颗粒骨打压植骨结合多孔非骨水泥臼杯在AAOSⅢ型髋臼大面积骨缺损翻修中的应用

背景：颗粒骨打压植骨是修复髋臼骨缺损的重要方法,对大面积髋臼骨缺损采用打压植骨结合非骨水泥臼杯重建仍然存在争议。目的：探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损的方法及近期疗效。方法：随访2005年6月至2010年4月收治的28例（28髋）AA0SⅢ型髋臼大面积骨缺损患者。男18例,女10例,年龄34-74岁,平均53．8岁。髋关节置换术后感染醐翻修9例,骨溶解及髋臼假体松动翻修19例。本组AAOSⅢ型髋臼骨缺损面积大,术中见髋臼骨缺损超过髋臼关节面的50％。全部采用同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术。术后定期随访,观察臼杯有无松动、植入骨与宿主骨整合情况,髋关节功能评分采用Harris评分。结果：28例均获得随访,术后随访时间为13-70个月,平均43个月。Harris评分由术前32-48分,平均41分,提高至末次随访时86-95分,平均90分。28例髋臼假体均固定牢固无松动征象,植入骨逐渐与宿主骨整合,无感染及坐骨神经损伤。结论：在获得臼杯初始稳定固定的情况下,大面积颗粒骨打压植骨（臼杯与宿主骨接触面积〈50％）结合多孔非骨水泥臼杯髋臼重建术修复AAOSⅢ型髋臼大面积骨缺损近期疗效较好,远期疗效尚待进一步随访。     

Revision total hip arthroplasty without bone graft of high-grade acetabular defects

Mixed results have been reported with bulk and cancellous bone graft to fill defects during acetabular revision arthroplasty. Jumbo cups have been used to maximize host bone contact, and if adequate initial stability can be achieved, this approach may provide a superior long-term outcome. We retrospectively reviewed a consecutive series of 107 acetabular revisions performed using jumbo cups without bone graft. Bone defects were assessed using a validated radiographic classification system that yielded 64 hips with significant bone defects for inclusion. Mean change in American Academy of Orthopaedic Surgeons lower extremity core and pain scores and in Short Form-12 scores showed increases of 22.01, 37.52, and 17.08 points, respectively. Postoperative radiographs consistently demonstrated host bone ingrowth into the jumbo acetabular shells, except for 3 failures. Careful incremental reaming up to a size that optimizes host bone support and contact may eliminate the need for bone graft in most acetabular revision arthroplasties.     

Trabecular metal used for major bone loss in acetabular hip revision

The purpose of this study was to evaluate the outcome of trabecular metal (TM) acetabular components used in revision hip arthroplasty with major bone deficiency. We retrospectively reviewed the records of 46 patients undergoing revision hip arthroplasty with severe acetabular bone loss. Clinical outcomes were assessed using Harris Hip Score, Western Ontario and McMaster Universities, and Short-Form 12. Mean follow-up was 50 months. All patients had Paprosky type IIc or III acetabular bone deficiency. Major complications included 1 infection, 2 dislocations, and 1 arterial bleeding. Average Harris Hip Score was 78.2. Short-Form 12 scores were within population-based age-matched averages. Western Ontario and McMaster Universities scores were mainly in the 2 lowest disability categories. Porous tantalum shows promising results in revision arthroplasty with severe acetabular bone loss.     

Structural Allograft Supporting a Trabecular Metal Cup Provides Durable Results in Complex Revision Arthroplasty

Background

Revision total hip arthroplasty (THA) is challenging specially in the presence of severe acetabular bone deficiency. We report the use of a highly porous revision shell augmented by structural allograft to provide structural support and coverage to the acetabular component.

大量同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯翻修髋臼大面积骨缺损的中期疗效

目的探讨同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼翻修大面积髋臼骨缺损的技术要点,并随访其中期临床和影像学疗效。方法随访2004年9月-2009年8月之间连续收治的采用同种异体颗粒骨打压植骨联合非骨水泥多孔髋臼杯翻修髋臼骨缺损面积大于整个髋臼关节面50％的27例（27髋）患者。按AAOS分类标准均为AAOSⅢ型骨缺损。按Paprosky分类标准,PaproskyⅡ型19例（19髋）,PaproskyⅢ型8例（8髋）。髋臼假体与宿主自体骨接触面积均小于50％;其中有19例患者的髋臼杯全完与异体骨接触。评价术前、术后的Harris评分,肢体长度。在X线片上评价髋关节旋转中心、髋臼侧透亮线、以及植骨融合情况,并判断髋臼有无松动和移位。用Kaplan-Meier生存分析评价髋臼假体的6年生存率。结果患者均完成随访,平均随访时间（6．4±1．4）年（4～9年）。术前Harris评分为（14．9±4．4）分（6-34分）,最后随访时的Harris评分为（85．6±8．1）分（67～98分）,差异具有统计学意义意义（t=22．181,P〈0．01）。术前肢体短缩（14．7±5．1）mm（6～24mm）,术后肢体短缩（0．2±3．4）mm（-9～12mm）,差异具有统计学意义（t=19．223,P〈0．01）。术后髋关节旋转中心均在Renawat三角内。所有病例术后1～1．5年植入的异体骨均与宿主骨融合。无髋臼假体松动或失败。髋臼假体的6年生存率为100％（95％可信区间为0．95～1．0）。结论髋臼AAOSⅢ型、PaproskyⅡ型甚至部分Ⅲ骨缺损,只要髋臼顶及前、后柱3个方向均存在大部分的骨皮质及一定的支撑作用,即便骨缺损面积大于髋臼关节面的50％,仍可采用同种异体骨颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术进行修复,并可取的满意的中期疗效。     

2- to 10-year follow-up study of acetabular revisions using allograft bone to repair bone defects

The failure rates of revision of acetabular components have been high; however, long-term success has been reported with the use of particulate allografts or autografts with large-diameter prosthetic cups to correct bone deficiencies when host-cup contact is at least 30% to 50%. The purpose of this study was to review 2- to 10-year follow-up data on complex acetabular revisions in which contact between allograft bone and the prosthetic cup was at least 50%. In the 47 hips monitored clinically and radiographically for a mean of 5 years, results were classified as excellent in 37%, good in 26%, fair in 17%, and poor in 19%. The mean Harris hip score was 82.5 (range, 39–100). The prosthetic cups migrated in 3 hips, but 2 stabilized within 1 year. Three cups had complete radiolucent lines without migration; the lines did not correlate with location of the allografts. Although bone ingrowth into porous surfaces from allografts is debatable, the results of the study show that massive allograft reconstruction of the acetabulum can provide both immediate and long-term stability of the prosthetic cup and restore bone stock.     

Revision of the acetabular component without cement after total hip arthroplasty. A concise follow-up, at fifteen to nineteen years, of a previous report

We previously reported our results at a minimum of three and seven years after use of a porous-coated acetabular metal shell in a consecutive series of 138 revision total hip arthroplasties. The current report presents the longer-term outcomes of these procedures, at fifteen to nineteen years postoperatively. A total of twenty metal shells (14%) underwent repeat revision. Seven of the repeat revisions were performed because of recurrent dislocation, seven were done at the time of femoral revision surgery, and six were done because of infection. Nineteen of the revised shells were well fixed, and one was aseptically loose. Of the sixty-seven hips in which the acetabular component survived for more than fifteen years after the index operation, two (3%) required a change of the modular acetabular liner because of wear or osteolysis. Nine (16%) of the fifty-seven hips with at least fifteen years of radiographic follow-up had an osteolytic lesion of >1 cm in diameter. The fifteen-year survival rate of the metal shells, with failure defined as revision because of loosening or as radiographic evidence of loosening, was 97%. Revision total hip arthroplasty with this cementless acetabular component has been followed by excellent component survivorship at fifteen years; the most common reasons for repeat revision were recurrent dislocation and infection.     

High placement of noncemented acetabular components in revision total hip arthroplasty. A concise follow-up, at a minimum of fifteen years, of a previous report

We previously reported the average ten-year results associated with the use of porous-coated noncemented acetabular shells that were placed at a high hip center at the time of revision total hip arthroplasty in thirty-four patients (thirty-six hips) with severe acetabular bone loss. We now report the average 16.8-year results for twenty-one patients (twenty-three hips). Of the original cohort of forty-four patients (forty-six hips), thirty-nine patients (forty-one hips; 89%) retained the shell. Two shells (4.3%) were revised because of aseptic loosening, and three (6.5%) were revised because of infection. Six femoral components were revised because of femoral osteolysis, and seven were revised because of aseptic loosening without osteolysis. On the basis of our results after an average duration of follow-up of 16.8 years, we believe that the placement of an uncemented acetabular component at a high hip center continues to be an excellent technique for revision total hip arthroplasty in selected patients with severe acetabular bone loss.     

Porous tantalum shells and augments for acetabular cup revisions

Purpose

The purpose of this study was to evaluate early functional results of revision hip arthroplasty with pelvic bone loss revised with porous tantalum (PT) acetabular components.

Methods

Twenty-five consecutive patients (25 hips) with loose acetabular components after total hip arthroplasty with a minimum of Paprosky IIa pelvic bone loss treated with PT cups with and without modular augments were retrospectively reviewed. Clinical outcomes were assessed using Harris hip score, and Western Ontario and McMaster Universities scores. Mean follow-up was 20.5 months and no patient was lost during follow-up.

Results

The average Harris hip score, and Western Ontario and McMaster Universities scores improved from 40 and 36 preoperatively to 79 and 73 postoperatively, respectively. No statistically significant differences in functional outcome scores were found between the group with moderate (Paprosky IIa, b) and severe (Paprosky IIc or more) acetabular bone loss. At the most recent radiographic evaluation, 24 cups demonstrated no lucent lines and 1 cup had lucent lines but remained well fixed. One cup was revised for traumatic dislocation but was found well fixed at open reduction. There were no septic or aseptic failures in this series.

Conclusion

While awaiting longer-term follow-up studies, trabecular metal components show sufficient primary stability and appear suitable for revision hip arthroplasty with acetabular bone loss.     

Outcomes of Acetabular Reconstructions for the Management of Chronic Pelvic Discontinuity: A Systematic Review

BackgroundA number of articles have been published reporting on the clinical outcomes of various acetabular reconstructions for the management of chronic pelvic discontinuity (PD). However, no systematic review of the literature has been published to date comparing the outcome and complications of different approaches to reconstruction.MethodsThe US National Library of Medicine (PubMed/MEDLINE) and EMBASE were queried for publications from January 1980 to January 2019 using keywords pertinent to total hip arthroplasty, PD, acetabular dissociation, clinical or functional outcomes, and revision total hip arthroplasty or postoperative complications.ResultsOverall, 18 articles were included in this analysis (569 cases with chronic PD). The overall survival rate of the acetabular components used for the treatment of chronic PD was 84.7% (482 of 569 cases) at mid-term follow-up, whereas the most common reasons for revision were aseptic loosening (54 of 569 hips; 9.5%), dislocations (45 of 569 hips; 7.9%), periprosthetic joint infection (30 of 569 hips; 5.3%), and periprosthetic fractures (11 of 569 hips; 1.9%). Both pelvic distraction technique (combined with highly porous shells) and custom triflanges resulted in less than 5% failure rates (96.2% and 95.8%, respectively) at final follow-up. Also, highly effective in the treatment of PD were cup-cages and highly porous shells with and/or without augments with 92% survivorship free of revision for aseptic loosening for both reconstruction methods. Inferior outcomes were reported for conventional cementless shells combined with acetabular plates (72.7%) as well as ilioischial cages and reconstruction rings (66.7% and 60.6% survivorship, respectively).ConclusionThe current literature contains moderate quality evidence in support of the use of custom triflange implants and pelvic distraction techniques for the treatment of chronic PD, with a less than 5% all-cause revision rate and low complication rates at mean mid-term follow-up. Cup-cages and highly porous shells with or without augments could also be considered for the treatment of PD because both resulted in greater than 90% survival rates. Finally, there is still no consensus regarding the impact of different types of acetabular reconstruction methods on optimizing the healing potential of PD, and further studies are required in this area to better understand the influence of PD healing on construct survivorship and functional outcomes with each reconstruction method.     

Revision of the acetabular component without cement after a previous acetabular reconstruction with use of a bulk femoral head graft in patients who had congenital dislocation or dysplasia. A follow-up note

BACKGROUND: Revision of an acetabular component that has failed after a total hip arthroplasty in which a bulk femoral head autogenous graft or allograft was used as a structural graft for acetabular reconstruction is an uncommon but complex and challenging procedure. We previously reported the results for seventy hips at an average of 16.5 years after a total hip arthroplasty in which an acetabular reconstruction had been performed with a femoral head graft. In the present study, we evaluated a subset of nine hips from that series that had a subsequent revision of the acetabular component without cement. The purpose of the current study was to assess the usefulness of the bone graft in this revision. METHODS: The nine patients (nine hips) were followed clinically and radiographically for an average of seventy-six months (range, sixty-one to 114 months) after the index revision. In six hips the autogenous femoral head graft previously had been bolted to the lateral side of the ilium, and in one hip the femoral head allograft had been affixed in this manner. In the two remaining hips, the allograft had been placed within the acetabulum. The hips were classified according to the extent of acetabular bone loss, with use of criteria described previously. Three hips had stage-I bone loss; four, stage-II; and two, stage-IIB. A porous-coated hemispherical acetabular component was inserted without cement and fixed with screws in each hip. At least 70 percent of the porous coating was in contact with viable bone. RESULTS: At the time of the latest follow-up after the index revision, all nine acetabular components were functioning well without loosening or osteolysis and none had been revised. The average Harris hip score was 77 points (range, 61 to 98 points) compared with 49 points (range, 27 to 96 points) preoperatively. One hip had had revision of the femoral stem, and another had had exchange of the acetabular liner because of recurrent dislocations. There was no additional resorption of the residual bulk graft that was in contact with the metal shell in any hip. CONCLUSIONS: In this small series of complex acetabular revisions, the healed bulk graft provided valuable additional bone stock for the support of an acetabular component that was inserted without cement. Insertion of the acetabular component into the available bone, which consisted in major part of host bone and in minor part of united revascularized bulk graft, resulted in a well functioning hip after an intermediate duration of follow-up. In all except two hips, the enlarged bone stock allowed insertion of a larger acetabular component than had been used previously.     

Periprosthetic acetabular bone loss using a constrained acetabular component

We describe two patients with a constrained acetabular component who required treatment for recurrent dislocation showing postoperative periprosthetic acetabular bone loss. These hips required revision surgery and demonstrated considerable bone loss caused by the migrated acetabular component. Impingement may have occurred with increased stress at the bone-prosthesis interface, and the sharp ends of screws with a metal shell may have gradually plowed up the acetabular bone. These failures illustrate the potential risk of using a constrained acetabular component.     

Impaction grafting of the acetabulum with ceramic bone graft substitute

Background and purpose Loss of bone stock remains a challenge in revision hip surgery. Grafting with allograft is well established, but there are problems with availability, cost, infection, antigenicity, reproducibility, and stability of the created construct. BoneSave is a biphasic porous ceramic consisting of sintered 80% tricalcium phosphate and 20% hydroxyapatite. In vitro and in vivo studies, including its use mixed with allograft, have shown good results in impaction grafting. This is the first reported series of its use alone in impaction grafting of the acetabulum.

Methods We conducted a retrospective review of a cohort of 43 consecutive patients undergoing impaction grafting of contained acetabular defects by multiple surgeons at a single centre. All patients received uncemented acetabular components. They were followed up radiographically, together with self-reported satisfaction scale (SAPS), Oxford hip score (OHS), and Short-Form 12 (SF12) health survey. Kaplan-Meier survivorship analysis was performed with revision of the acetabular component, revision of any part of the construct, and reoperation as endpoints.

Results The fate of all cases was known. Mean follow-up was 4 years. 5 patients died during follow-up, with their constructs in situ. The survivorship of the acetabular component was 98% (95% CI: 85–100) at 7 years. 1 acetabular component was revised for infection and there was 1 radiographic acetabular failure. The median OHS was 36 (6–48), the median SF12 PCS was 36 (14–57), the median SAPS was 75 (0–100), and the median SF12 MCS was 50 (23–64). The graft material had incorporated in all 3 zones of the acetabulum in 33 out of 37 cases with complete radiographic follow-up.

Interpretation Medium-term results show that BoneSave alone is a reliable material for impaction grafting of contained defects in the acetabulum at revision surgery.     

Acetabular revision using a total acetabular allograft

The most challenging aspect of an acetabular revision is the management of severe bone loss, which compromises implant fixation and stability. We present a case of failed acetabular revision with extensive bone loss (Paprosky Type 3b) in a 50-year-old woman with rheumatoid arthritis, which was treated using total acetabular allograft. At a follow-up of 1 year and 3 months, the allograft had united with the host bone. This is the first report of the use of a total acetabular allograft for revision total hip arthroplasty in India. The total acetabular allograft allows the placement of the component closer to the normal hip center, provides initial stability for the acetabular component, and restores bone stock to the host pelvis.     

打压植骨结合金属网重建髋臼严重骨缺损

目的 评价打压植骨结合金属网重建严重骨缺损髋臼的中期临床效果,分析Paprosky骨缺损分型在评价骨缺损时的重要性.方法 1998年12月至2007年12月采用打压植骨技术结合使用金属网片和(或)金属网杯进行严重髋臼缺损重建63例(67髋),所有患者均为AAOS Ⅲ型混合型缺损.其中58例患者(61髋)获得了完整随访,平均63个月.Paprosky Ⅱ B 19例(20髋),Paprosky Ⅱ C 27例(28髋),Paprosky Ⅲ A 12例(13髋).术前Harris髋关节评分平均41.7分(21～52分).术后随访时进行临床疗效、影像学及并发症等评估.结果 58例(61髋)患者Harris髋关节评分术后平均89.2分(81～98分),术后优良率达93%,除3例发生聚乙烯髋臼从网杯中脱出外,其余55例患者髋臼无影像学松动.1例使用金属网杯患者髋臼旋转中心未能恢复正常.3例术后脱位患者,其中2例手法复位,1例切开复位,均获成功.术后发生感染1例(1.6%),经二期翻修打压植骨成功治愈.结论 异体骨打压植骨配合金属网是处理严重髋臼骨缺损的理想技术.建议在使用打压植骨技术对严重髋臼缺损重建时,采用AAOS分型结合Paprosky分型方法对缺损的严重程度进行评价.金属网杯不适用于严重髋臼骨缺损的打压植骨重建.     

Primary total hip arthroplasty with a porous-coated acetabular component. A concise follow-up of a previous report

We previously reported the seven-to-ten-year results of the use of a porous-coated acetabular metal shell in a consecutive series of 204 primary total hip arthroplasties. In the present study, we evaluated the longer-term outcomes of these arthroplasties, at fifteen to eighteen years. One hundred and thirty-six (96%) of the 142 hips available for study retained the original acetabular metal shell. Three of the 142 metal shells failed secondary to aseptic loosening. Ten hips (7%) required a change of the modular acetabular liner because of excessive wear or for the treatment of osteolysis. The fifteen-year rate of survival of the metal shell, with failure defined as revision because of loosening or radiographic evidence of loosening, was 99%. The rate of survival of cementless acetabular reconstructions was excellent at fifteen years, although osteolysis and reoperations were noted to occur much more frequently as the duration of follow-up increased. The majority of the complications were related to wear of the polyethylene liner.     

Acetabular reconstruction with impacted morcellized cancellous bone autograft and cemented primary total hip arthroplasty: a 10- to 17-year follow-up study

During the period 1979 through 1986, 69 acetabular reconstructions in 63 patients were performed with the use of autologous morcellized bone-grafts because of acetabular bone stock loss. Nine cases (10 hips) were lost to follow-up. Eleven patients (12 hips) died <10 years after surgery; none had a revision. The results for the remaining 43 patients (47 hips) were reviewed at an average interval of 12.3 years (range, 10-17 years). No preoperative Harris hip score was available. The average Harris hip score at follow-up was 88 (range, 60-100). Radiographically, all grafts united. One hip developed a deep infection. Three other hips (6%) were revised because of aseptic loosening of the acetabular component. An additional 3 acetabular components were considered radiographic failures. Excluding the infected case, the overall survival rate of these acetabular reconstructions with a revision as endpoint was 94% at an average follow-up of 12.3 years. Reconstruction of acetabular bone stock loss with autologous morcellized bone-grafts is an attractive technique with a good potential for long-term success.     

Favorable results of acetabular reconstruction with impacted morsellized bone grafts in patients younger than 50 years: a 10- to 18-year follow-up study of 34 cemented total hip arthroplasties

We report a long-term review of 41 acetabular reconstructions using impacted morsellized bone grafts and a cemented total hip arthroplasty (THA) in patients younger than 50 (22-49; average 38) years. Reconstruction was performed in 23 primary THA (19 patients) and 18 revision THA (17 patients). 3 patients were lost to follow-up and 3 (4 hips) died within 10 years of surgery; none had a revision. Thus, 34 hips (30 patients) were reviewed with an average follow-up of 13 (10-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component 7 and 11 years after surgery. One additional cup was revised after 12 years during a femoral stem revision due to wear and matching problems, but was well fixed. The survival rate of the acetabular reconstruction technique was 94% (95% CI: 90-98%).     

Massive acetabular bone loss: Limits of trabecular metal cages

Massive acetabular bone loss (more than 50% of the acetabular area) can result in insufficient native bone for stable fixation and long-term bone ingrowth of conventional porous cups. The development of trabecular metal cages with osteoconductive properties may allow a more biological and versatile approach that will help restore bone loss, thus reducing the frequency of implant failure in the short-to-medium term. We report a case of massive bone loss affecting the dome of the acetabulum and the ilium, which was treated with a trabecular metal cage and particulate allograft. Although the trabecular metal components had no intrinsic stability, they did enhance osseointegration and incorporation of a non-impacted particulate graft, thus preventing failure of the reconstruction. The minimum 50% contact area between the native bone and the cup required for osseointegration with the use of porous cups may not hold for new trabecular metal cups, thus reducing the need for antiprotrusio cages. The osteoconductive properties of trabecular metal enhanced allograft incorportation and iliac bone rebuilding without the need to fill the defect with multiple wedges nor protect the reconstruction with an antiprotrusio cage.     

Cementless acetabular revision for aseptic failure of cemented hip arthroplasty

This study is a 5- to 11-year retrospective followup of 40 hips in 33 patients with cementless acetabular revision for aseptic failure of a cemented total hip arthroplasty. A porous coated, Harris-Galante acetabular component was used in all revisions. Thirty-eight of the 40 hips received acetabular bone grafting at revision. The mean Harris Hip Score improved from 51 points just before the index cementless revision to 87 points at the most recent followup. Twenty-nine of 40 (73%) hips were classified as having a good or excellent result. Radiolucencies were observed in seven of the 40 (18%) hips at the most recent followup, but none of these radiolucencies were complete or progressive. Five of the 40 (13%) hips were rated as failures and required repeat revision. Two (5%) of these failures were caused by aseptic loosening, with both hips having severe acetabular bone damage at the time of the index revision. This failure rate for aseptic loosening was less than that reported for cemented acetabular revision, thereby confirming the efficacy of cementless acetabular components in revision hip surgery in the intermediate term.