Acetabular bone grafting in primary total hip arthroplasty]

A group of 108 hips in 102 patients (81 females and 21 males; average age: 66.9 years) operated at our Centre between 1989 and 1998 was evaluated. There were 76 hips with idiopathic arthritis, 21 hips with rheumatoid arthritis, 2 hips with post-traumatic lesions and 9 cases of dysplastic arthritis of the hip. Cemented total hip arthroplasty was performed in all cases (62 Weller prostheses, 28 Charnley prostheses, 12 Ultima-Straight prostheses and 6 Centrament prostheses). In the presented material three different kinds of bone grafting were performed: "impaction bone grafting" with autogenous cancellous bone grafts in cases of bone cysts and cavitary lesions (57 cases); augmentation of thin sclerotic or protrusive acetabulums with autogenous cancellous bone grafts with or without allogenous cancellous bone grafts (26 and 16 cases respectively); and reconstruction of the roof of the acetabulum with autogenic cortico-cancellous bone grafts 9 cases). In 17% cases autogenous and allogenous bone grafts were used simultaneously and in 83% autogenous bone grafts only were employed. Acetabular bone grafting was necessary to create proper bone substrate for endoprostheses implantation. Evaluation of results was based on criteria proposed by a joint committee of The Hip Society, SICOT and AAOS. A mean of 83.5% points were achieved in the Harris Hip Score. Aseptic loosening was observed in 15 sockets and 9 stems. Bone grafts didn't heal in 25 hips, of which 14 had loose sockets. These results are comparable to those in primary total hip arthroplasties without acetabular bone grafting. The results in the presented paper support the opinion that acetabular bone grafting is a useful tool in reconstructive surgery of the hip and allows to achieve good results in technically difficult acetabuli.     

Effect of osteonecrosis on bone density and its management on the results of revision arthroplasty of the hip]

128 hips after revision arthroplasty in 115 patients which had been operated in our Ward in 1990-2001 were retrospectively evaluated. There were 99 women and 16 men with mean age: 68.9 years old. The mean time of follow-up was 28.6 months (form 3 to 120 months). In 98 hips there were aseptic loosening of the both elements of the prosthesis, in 13 hips there were aseptic loosening of the stem, in 17 hips there were aseptic loosening of the cup only. Cement total hip rearthroplasty was made in 112 cases and cementless total hip rearthroplasty was made in 16 hips. In presented material there were used the acetabular bone grafts in 114 cases, and the femoral bone grafts in 97 cases--all with allogenic frozen bone grafts. The additional implants were used in 31 cases (meshwork, wire, screw). The bone defects in acetabulum and femoral stem was based on Paprovsky classification. There were good and excellent results in 90% and poor or bad results in 10% according to clinical and radiological evaluation. Mean clinical result was 78.5 p. in Harris Hip Score. The radiological results were poor in 13 hips (according to criterion proposed by joined committee of The Hip Society, SICOT and AAOS). Osteointegration of bone allografts was radiologically confirmed in 81% of cases. Complication rates is 20%. There is no correlation between the type of acetabular or femoral bone defects and results of revision hip arthroplasty. Poor results are correlated with use of SKT or Weller stem. Wagner femoral osteotomy and the lack of bone allografts healing.     

Total hip reconstruction using frozen femoral head allografts in patients with acetabular bone loss

Major acetabular bone loss associated with failed total hip replacements can be managed successfully using frozen femoral heads as structural allografts during revision surgery. In 29 cases followed for an average period of 3.9 years, all of the grafts showed radiographic evidence of union. Five hips showed clinical or radiographic evidence for acetabular loosening. Three of these hips required reoperations for symptomatic loosening. In two of these, sufficient bone stock was present to permit another revision without further bone grafting. Twenty-five of the remaining 26 hips were functioning satisfactorily with a mean Harris score of 84 points. In view of the major bone loss following multiple previous operative procedures in these young patients, the results of revisions using structural femoral head allografts were clearly superior to those with resection arthroplasty, the most likely alternate solution. Graft resorption, lack of posterior coverage, and incomplete cement mantle contributed to the failures.     

人工全髋关节置换术中自体骨重建髋臼骨缺损的临床研究

目的探讨人工全髋关节置换术中用自体结构性植骨重建髋臼骨缺损的疗效。方法患者共26例29髋,自体股骨头植骨23髋、自体髂骨取骨6髋。骨缺损以打磨的髋臼假体骨床半球面积计算,骨缺损最大者有1602mm2,最小390mm2,平均每例缺损874mm2。全部采用非骨水泥型髋臼假体、2～3枚螺钉固定髋臼假体。临床评价采用Harris评分,X线观察移植骨愈合、骨和假体间骨长入和髋臼假体的稳定情况等。结果随访6个月～8年6个月,平均随访时间为（4.2±1.7）年,本组Harris评分平均从（52.2±16.7）分提高到（86.7±6.2）分（P〈0.05）。所有病例髋臼假体稳定、周围无放射透亮影,假体髋臼骨面均有骨长入,移植骨愈合。X线片显示移植骨愈合时间3～6个月,平均为5.1个月。本组尚无术后翻修病例。结论采用自体骨进行结构性植骨或混合少量异体骨重建髋臼顶、前和后侧壁缺损（AAOS）髋臼缺损中Ⅱ、Ⅲ型缺损）,经过近中期随访,移植骨全部愈合良好,获得满意的疗效。     

Revision total hip arthroplasty using a Kerboull-type acetabular reinforcement device with bone allograft: minimum 4.5-year follow-up results and mechanical analysis

We retrospectively reviewed 40 hips in 36 patients who had undergone acetabular reconstruction using a titanium Kerboull-type acetabular reinforcement device with bone allografts between May 2001 and April 2006. Impacted bone allografts were used for the management of American Academy of Orthopaedic Surgeons Type II defects in 17 hips, and bulk bone allografts together with impacted allografts were used for the management of Type III defects in 23 hips. A total of five hips showed radiological failure at a mean follow-up of 6.7 years (4.5 to 9.3), two of which were infected. The mean pre-operative Merle d'Aubigné score was 10 (5 to 15) vs 13.6 (9 to 18) at the latest follow-up. The Kaplan-Meier survival rate at ten years, calculated using radiological failure or revision of the acetabular component for any reason as the endpoint, was 87% (95% confidence interval 76.3 to 97.7). A separate experimental analysis of the mechanical properties of the device and the load-displacement properties of bone grafts showed that a structurally hard allograft resected from femoral heads of patients with osteoarthritis should be preferentially used in any type of defect. If impacted bone allografts were used, a bone graft thickness of < 25 mm was acceptable in Type II defects. This clinical study indicates that revision total hip replacement using the Kerboull-type acetabular reinforcement device with bone allografts yielded satisfactory mid-term results.     

Fate of bone grafts in acetabular roof reconstructions assessed by roentgenography and scintigraphy

Autogeneic bone grafts--26 femoral heads, four femoral and two iliac bone grafts--were used in 32 total hip arthroplasties, mainly on patients with complete dislocation of the hip, to reconstruct deficiencies of the acetabular roof by a standardized procedure. At the follow-up examination after 24 to 101 months (median, 52 months), roentgenography demonstrated lateral resorption of the graft in 20 of 32 hips, but resorption involved bone support of the socket in only three of the hips. Analysis of serial roentgenograms showed that resorption was not a function of time. Complete incorporation of the grafts was observed in 27 hips; partial incorporation was shown in three. Roentgenographically, two grafts were not incorporated. None of three grafts of a cortical nature was incorporated. Graft uptake of radioactive tracer was found by 99mTc-diphosphonate emission scintigraphy in 16 of 21 hips, but did not correlate with progressive bone resorption, nonunion, or loss of bone structure. High quality serial roentgenograms showing good bone detail provided the best information about the integrity of the acetabular roof reconstructions.     

Acetabular reconstruction using morcellised bone with ring support--medium-term results at three to nine years

Marked acetabular bone loss in revision hip arthroplasty is challenging. Reconstruction or reinforcement rings may be used in moderate or severe cases with morcellised bone graft to restore bone stock. We report a single surgeon series of 45 hips over a 5-year period. There were 6 complex primary and 39 revision hip arthroplasties with a mean follow-up of 85 months (range: 42-106). Mean age at surgery was 75.6 years (range: 31-95). Contour (Smith & Nephew) titanium acetabular rings were used in all cases. At time of assessment 12 patients had died; of the 30 alive patients (33 hips), 23 patients (26 hips) were available for clinical evaluation. Forty of 45 grafts healed uneventfully with good graft incorporation, 2 were radiologically loose and both were infected. No loosening occurred in the absence of infection. Based on this experience, we recommend this as a safe and effective technique with low complication rates.     

Use of bipolar endoprosthesis and bone grafting for acetabular reconstruction

Reconstruction operations for severe acetabular defects using bone grafting and a bipolar hemiarthroplasty retrospectively reviewed in 81 hips between 1983 and 1985. The most common indication was failed total hip arthroplasty. Bone grafts consisted of cancellous bone, bone blocks, and wafer-type grafts used singly or in combination. The follow-up period was 12 to 36 months postoperatively (mean, 16 months). There were 22 perioperative complications (27%) and 13 postoperative complications (16.7%). A majority of hips showed some graft resorption and component migration that worsened with time. There were four graft failures with subluxation of the component, one prosthesis dislocation, and one component disassembly. Ten hips had revision (13.3%) for a variety of reasons. Nevertheless, clinically, most patients (83%) believed the procedure had improved their condition. Reconstruction for severe acetabular defects can be achieved successfully using this technique, but long-term follow-up evaluation is needed to fully assess the role of this procedure in relation to other available options.     

Clinical outcome and periprosthetic bone remodelling of an uncemented femoral component with taper design

We followed 48 consecutive patients (50 hips) with osteoarthritis who received a primary total hip replacement using a tapered stem with hydroxylapatite coating (Cerafit Multicone H-A.C.) and a press-fit cup. Mean follow-up was 3 years, mean patient age was 54.7 years, and mean preoperative Harris hip score was 57. Quantitative evaluation of periprosthetic bone remodelling was assessed 1 year after the index operation using computed tomography (CT). Clinical and radiological follow-up was obtained in all hips. The mean Harris hip score at follow-up was 96. Forty-nine hips were clinically rated good or excellent. No thigh pain was reported. Radiographs showed stable fixation by bone ingrowth in all hips. Fifteen hips were eligible for CT. Three years after operation, mean decrease of overall bone mineral density (BMD) was 14.2% and mean decrease of cortical BMD 15.5% in the metaphyseal portion. In the diaphyseal portion, mean decrease of overall BMD was 10.0% and mean decrease of cortical BMD 7.7%. Minimal changes were observed at the level of the tip of the stem. Clinical and radiological outcome using a tapered femoral stem with hydroxylapatite coating compares favourably with other reports. Osteodensitometry shows limited proximal femoral bone resorption.     

Modular acetabular reconstructive cup in acetabular revision total hip arthroplasty at a minimum ten year follow-up

Purpose

Modular acetabular reconstructive cups have been introduced in an attempt to offer initial rigid fixation by iliac lag screws and ischial pegs, to support bone grafts with a flanged metal socket, and to restore original hip center in acetabular revision. The purpose of this study was to clarify minimum ten year follow-up results of this cup system with morsellised allografts in revision cases.

Methods

We retrospectively investigated 54 acetabular revisions at a mean of 11 years (range, ten to 14 years). The indications were Paprosky’s type 2B (eight hip), 2C (eight hips), 3A (23 hips), 3B (nine hips), and 4 (six hips).

Results

Using aseptic loosening as the endpoints, the survival rate was 89.3 % (95 % CI 81–98). Radiographically, one type 3A hip, three type 3B hips and one type 4 hip showed aseptic loosening while no type 2 hips or no cemented cups showed loosening.

Conclusions

The modular reconstructive cups for acetabular revision showed bone stock restoration and stable implantation.     

Femoral segment graft is a suitable alternative to stabilize pelvic osteotomies in developmental dysplasia of the hip: a comparative study

The aim of this study was to compare bone healing in pelvic osteotomy patients with osteotomy gaps filled with a femoral segment resected (FSR) graft with bone healing in patients with an iliac tricortical autograft (ITA) in treatment of developmental dysplasia of the hip. Sixty-three hips were treated using FSR grafts. Sixty-one hips were treated using ITA. The mean operation time and blood loss were significantly reduced in the FSR graft group, but graft union time was extended in the FSR graft group compared with that in the ITA group. The FSR graft was found to be safe and effective in treatment of developmental dysplasia of the hip and serves as an advantageous alternative to ITA.     

Acetabular revision with impacted grafting and a reinforcement ring: 42 patients followed for a mean of 10 years

We analyzed the outcome of 42 cemented cup revisions (40 patients) with morselized bone grafts and a reinforcement ring after median 10 (7-16) years. The acetabular component migrated a mean of 7 (5-8) mm in 5 hips. The migration stopped after 2 years except in 1 hip, the only one revised because of mechanical loosening. 3 other hips were revised because of infection. Among the other 38 hips (36 patients), the Merle d'Aubigné score increased from 9 to 15 points.     

Die Hakendachschale in der Revision schwieriger gelockerter Hüftprothesenpfannen

The long-term results of acetabular revision after total hip arthroplasty (THA) with the use of a reinforcement ring with hook were evaluated. The study included 57 cases of surgery dating back 10 years or more. Of a total of 54 patients (57 operated hips), 18 patients (19 hips) died during the 10-year period and 2 patients (2 hips) were completely lost to follow-up. At the time of the revision surgery, the mean age of the remaining 34 patients (36 hips) was 62.5 years (range: 47-80). A THA revision was done in 25 cases and an acetabular revision only in 11 cases. The most common acetabular defect was a combined segmental and cavitary defect (n = 19), and in three cases there was pelvic discontinuity. Autologous or homologous cancellous bone grafts were used to fill acetabular cavities in 17 hip joints. Structured bone grafts, predominantly homologous bone, were used in ten cases for acetabular reconstruction. At a mean follow-up of 11.4 years (range: 10-14.5) three hip joints (8%) had undergone further revision. The revisions were done for aseptic loosening of the acetabular component in two cases and a septic loosening of both components in one case. Three further cases (8%) revealed signs of acetabular loosening. Two of these three patients were symptomatic but refused further revision surgery. In the 33 unrevised hip joints, a good or excellent clinical result with a d'Aubingé score of more than 14 points was found in 30 cases (92%). Osseous acetabular reconstruction with the use of a reinforcement ring leads to favorable results compared to other techniques. In the authors' opinion, this technique is preferable to those using oversized cups without osseous reconstruction of the acetabulum.     

Acetabular revision with impacted grafting and a reinforcement ring: 42 patients followed for a mean of 10 years

We analyzed the outcome of 42 cemented cup revisions (40 patients) with morselized bone grafts and a reinforcement ring after median 10 (7-16) years. The acetabular component migrated a mean of 7 (5-8) mm in 5 hips. The migration stopped after 2 years except in 1 hip, the only one revised because of mechanical loosening. 3 other hips were revised because of infection. Among the other 38 hips (36 patients), the Merle d'Aubigné score increased from 9 to 15 points.     

Impaction grafting for acetabular deficiency in total hip arthroplasty for developmental hip dysplasia

The pathological anatomy in neglected developmental dysplasia of the hip often demands some sort of reconstructive surgery to augment the acetabular bone stock during total hip arthroplasty. We have reviewed 11 hips in 10 patients with osteoarthritis secondary to developmental hip dysplasia who underwent cemented total hip arthroplasty using impaction grafting of the acetabulum with a morselized femoral head autograft, to bring the socket down to the anatomical hip center. The mean age at the index procedure was 43.4 years (ranging from 29 to 60 years) and the mean follow-up period was 3.8 years (ranging from 2 to 7 years). Postoperative functional evaluation according to the Merle d'Aubigné and Postel score modified by Charnley revealed very satisfactory results. Radiographic review showed incorporation of all grafts. One socket is radiographically loose. No major complications have been encountered. There have been no reoperations. We believe that acetabular impaction grafting is a valuable alternative in dealing with osteoarthritic hips secondary to developmental hip dysplasia.     

髋臼内陷症的全髋关节置换术

目的 探讨全髋关节置换术治疗髋臼内陷症的手术操作方法和临床疗效.方法 2003年6月至2008年5月,采用全髋关节置换术治疗髋臼内陷症31例35髋,男16例18髋,女15例17髋;年龄36～71岁,平均52.2岁.手术均采用后外侧入路,股骨头取出困难时采用逆行取出法,分别处理髋臼环和髋臼底,取自体松质颗粒骨修复骨缺损,采用压配方式植入非骨水泥型全髋关节假体.术后1、3、6、12个月门诊随访,以后每年随访1次,随访时采用Harris髋关节评分评估髋关节功能,摄X线片观察假体是否有松动和再次内陷,植骨是否愈合.结果 全部病例随访19～152个月,平均46.5个月.1例患者术后第2天出现右下肢深静脉血栓,经抗凝处理后痊愈;1例术后2个月出现轻度大腿痛,无特殊处理,术后6个月消失,无其他并发症发生.术前Harris髋关节评分平均(48.9±6.5)分,末次随访增至平均(91.2±5.7)分,较术前平均改善42.3分.X线片显示所有假体均获得骨性稳定,无松动和再次内陷,术后平均6个月植骨愈合.结论 对于内陷髋臼,采用不同于普通全髋关节置换的手术技术,外移髋臼至旋转中心,用植骨修复骨缺损,选择非骨水泥型假体重建髋臼,可获得较好的临床效果,髋臼松动和再次内陷发生率低.

Abstract：

Objective To evaluate the clinical outcome of total hip arthroplasty (THA) for protrusio acetabuli. Methods Between 2003 to 2008, 31 patients(35 hips) with protrusio acetabuli were treated with THA, including 16 males (18 hips) and 15 females (17 hips). The age ranged from 36 to 71 years (average age 52.2 years). The femoral heads were moved out with retrograde method when necessary via posterior-lateral hip incision. The acetabular loops and bottoms were prepared respectively. Auto-bone grafting was used to repair acetabular defects and cementless prostheses were planted with press-fit skills. At follow-up visit,the hip functions were evaluated by Harris score. The loosening, re-protrusion and the union of graft bone was judged by X-ray. Results The mean follow-up was 46.5 months (19-152 months). One patient developed DVT on the second day post-operatively who recovered well after anticoagulation treatment. One patient complained of gentle thigh pain which disappeared at 6 months. No other complication was found. The mean Harris scores had improved from 48.9±6.5 pre-operatively to 91.2±5.7 post-operatively. All prostheses acquired bone stabilization with no sign of loosening and re-protrusion and the grafts bone were healed at a mean 6 months according to X-ray. Conclusion THA with acetabular bone grafting and cementless component for protrusio acetabuli have acquired excellent results and prevented loosening and re-protrusio effectively.     

Cavitary acetabular defects treated with morselized cancellous bone graft and cementless cups

The use of impacted morselized cancellous bone grafts in conjunction with cementless hemispherical acetabular cups for treatment of AAOS type II acetabular cavitary deficiencies was evaluated in a retrospective study of 23 primary and 24 revision total hip arthroplasties, at a mean follow-up of 7.9 and 8.1 years, respectively. All primary hips received autografts, while all revision hips received allografts. Modified Harris Hip Scores for primary and revision hip replacements increased from a pre-operative mean of 37 and 47 to a postoperative mean of 90 and 86, respectively. All 23 autografts and 23 out of 24 cancellous allografts were radiographically incorporated without evidence of resorption. There were no instances of infection, component migration, or cases requiring subsequent acetabular revision. We conclude that impacted morselized cancellous bone-graft augmentation of cementless cups is a viable surgical option for AAOS type II cavitary acetabular defects.     

颗粒打压植骨结合骨水泥型髋臼杯在髋关节发育不良髋臼重建中的应用

目的探讨颗粒打压植骨结合骨水泥型髋臼杯在CroweⅡ、Ⅲ型髋关节发育不良（DDH）中应用的早期疗效。方法2005年3月至2008年3月,采用颗粒打压植骨重建髋臼结合骨水泥型髋臼杯治疗11例DDH继发骨性关节炎的患者。女10例,男1例,年龄43～58岁,平均49．4岁;CroweⅡ型9例,Crowem型2例,疼痛病史5～30年,术前Harris评分28～55分,平均45．3分。术后定期随访进行影像学评价和Harris评分。结果本组患者临床随访4～36个月,平均18个月,全部患者髋关节功能恢复良好,无感染、神经损伤、脱位等并发症。术后Harris评分90～98分,平均94．1分,术后随访影像学上显示植骨均与宿主骨愈合,最后一次随访无植骨吸收髋臼假体松动、移位。结论颗粒打压植骨结合骨水泥型髋臼杯治疗CroweⅡ、Ⅲ型DDH患者早期效果可靠。     

应用非骨水泥髋臼或金属髋臼支架行髋关节翻修术的临床研究

目的 评估非骨水泥髋臼及金属髋臼支架加植骨修复髋臼骨缺损的效果.方法 我院自2001年9月至2008年9月应用髋臼翻修支架行髋关节翻修术22例(24髋).其中Lima非骨水泥人工翻修髋臼2例(2髋),Kerboull 支架2例(2髋),GAP 髋臼翻修支架18例(20髋).男性6例(6髋),女性16例(18髋).平均年龄62岁(34～79岁).感染性松动2例(2髋),无菌松动20例(22髋).平均随访时间48个月(18～84个月),对其进行临床和影像学评估.Harris评分术前平均为56分(44～75分).结果 末次随访时22例患者Harris评分平均为89分(78～94分).优良率为95.5%(21/22).三种髋臼翻修支架的外展角满意,髋臼旋转中心基本得到了重建.髋臼翻修支架及其聚氯乙烯臼无明显移位,假体周围无透亮线,髋臼植骨愈合良好.结论 应用非骨水泥髋臼或髋臼支架修复髋臼侧巨大骨缺损,重建了髋臼正常旋转中心、提供了翻修假体的初期稳定性、避免了所植骨在血管化时期的过度机械负重,是翻修髋臼巨大骨缺损的可靠方法.     

Results of total hip reconstruction using acetabular mesh in patients with central acetabular deficiency

Fifty-three patients (54 hips) treated with cemented total hip reconstruction with the aid of an acetabular mesh made of Vitallium (Howmedica Inc., Rutherford, New Jersey), a cobalt-chrome molybdenum alloy, to reinforce the medial cement for deficient bone stock in the central acetabular region, were evaluated at an average follow-up period of 6.8 years (range, five to ten years). Thirty of these patients (30 hips) were treated with revision operations for either failed cup arthroplasty (ten hips), failed endoprosthesis (six hips), or failed total hip arthroplasty (14 hips) and presented difficult problems for acetabular reconstructions. Although none of the hips required reoperations for acetabular loosening, three patients showed roentgenographic evidence of acetabular component migration, and three others showed signs of impending failure of fixation of the acetabular component. The overall mean Harris hip rating improved from a mean of 43 points preoperatively to 87 points at follow-up evaluations. The extent of bone loss in the central acetabular region had the greatest influence on the results of acetabular fixation at the follow-up evaluation. None of the hips with intact medial acetabular cortex had roentgenographic evidence of failure of fixation, while 14% of the hips with medial cortical defects measuring less than 1 cm, and 75% of the hips with larger defects developed acetabular component loosening. The results of total hip reconstruction using acetabular mesh were unsatisfactory in patients with moderate or severe central acetabular bone loss and defects through the medial wall.(ABSTRACT TRUNCATED AT 250 WORDS)