Allogeneic cancellous bone graft and a Burch-Schneider ring for acetabular reconstruction in revision hip arthroplasty.

BACKGROUND: There is an ever-increasing number of failed hip arthroplasties associated with massive deficiency of acetabular bone stock consisting of a segmental or cavitary defect. This study was undertaken to evaluate the long-term results after use of morselized cryopreserved allogeneic bone graft and an antiprotrusio cage to treat such a deficiency. METHODS: From January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with an acetabular defect classified as type IIl or IV according to the American Academy of Orthopaedic Surgeons system were operated on with use of a Burch-Schneider ring and morselized cryopreserved allogeneic cancellous bone graft. Thirty-eight patients (thirty-eight hips) were available for clinical and radiographic follow-up examinations at an average of 7.3 years (range, 4.2 to 9.4 years) after surgery. RESULTS: All measured clinical parameters had improved significantly by the time of the follow-up examination (p < 0.0001). Radiographs confirmed that none of the thirty-eight hips had any measurable migration or displacement of the acetabular component and that osseous consolidation occurred only within the grafted area in all patients. CONCLUSION: Acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone graft and the Burch-Schneider ring can be highly successful in managing massive acetabular deficiencies in revision hip arthroplasty.     

Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency.

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening.     

Acetabular reconstruction using a roof reinforcement ring with hook for total hip arthroplasty in developmental dysplasia of the hip-osteoarthritis minimum 10-year follow-up results

The outcome of 33 total hip arthroplasties using an acetabular reinforcement ring with hook for osteoarthritis associated with developmental dysplasia of the hip was reevaluated after a minimal follow-up of 10 years (average, 10.8 years). Most cases comprised Crowe type II (22 hips) and type III (7 hips) dysplasia. The mean D'Aubigné score increased from 7 to 15 points. Three revisions (9%) were performed for aseptic loosening, 2 of them had a structural autograft. None of the unrevised 30 acetabular reconstructions showed definite radiographic signs of loosening. These results compare favorably with the literature and the acetabular reinforcement ring with hook presents a versatile tool for acetabular bone stock deficiencies.     

Revision Total Hip Arthroplasty Using a Cementless Cup Supporter and Iliac Autograft: A Minimum of 15-Year Follow-Up

Background

Bone deficiency in revision total hip arthroplasty is a surgical challenge. The Murata-Chiba cup supporter (MC support ring) is an acetabular component supporter for a cementless porous-coated cup. The purpose of this study is to examine the clinical and radiographic outcomes of reconstruction of acetabular bone deficiency using iliac autografts supported by an MC support ring in a revision setting with minimum 15-year follow-up.

Use of the Charnley mini-offset bore acetabular component in severe acetabular dysplasia. A preliminary report

Nine total hip arthroplasties were performed in seven patients using the Charnley mini-offset bore acetabular component to assess its effectiveness in cases of severe deficiency of acetabular bone "stock." Preoperative diagnoses included seven chronically dislocated hips and two previously failed arthroplasties. The follow-up period averaged 49 months. Pain relief was dramatic in all patients, and all had increased ambulatory capacity after operation. No clinical loosenings or deep infections were encountered. The small outside diameter (36 mm) of this acetabular component requires only minimal bone removal from the acetabular bed. Its eccentrically positioned bore allows for adequate polyethylene thickness in the weight-bearing area. It also takes advantage of the low frictional torque of a small femoral head system.     

Uncemented total hip arthroplasty with superior acetabular deficiency. Femoral head autograft technique and early clinical results

A technique for primary uncemented total hip arthroplasty in the presence of a superolateral acetabular deficiency is described. The resected femoral head is used as an autograft. Matching reamers are used to ream the pseudoacetabulum and femoral head. Lag screw fixation is then performed and reaming of the graft and host bone simultaneously allows placement of an uncemented acetabular component. The hip center of rotation is returned to its anatomic center, the medial wall and subchondral bone are maintained, maximal contact and rigid fixation is obtained between femoral head autograft and host bone, and press fit of an uncemented cup is achieved. This method was applied to 10 consecutive hips in seven patients who had superior migration of the femoral head. The results were compared to those of 44 uncomplicated primary uncemented total hip arthroplasties during the same time period. While operative time and blood loss were increased in the bone graft cases, the early clinical results were equivalent to those of routine uncemented total hip arthroplasties.     

Acetabular component revision with frozen massive structural pelvic allograft: average 5-year follow-up

We evaluated the use of a hemipelvic acetabular transplant in 20 revision hip arthroplasties with massive acetabular bone defects. We report 65% good intermediate-term results at a mean follow-up of 5 years (4-10 years). A cemented cup (without a reinforcement ring) was entirely supported by the allograft in all procedures. There were 7 failures (5 aseptic loosening and 2 deep infections). Two dislocations occurred but did not require acetabular revision. There were 2 cases in which moderate acetabular migration occurred but then stabilised and did not progress. Thirteen of 20 acetabular reconstructions did not require revision. We believe that these are satisfactory intermediate-term results for massive acetabular defects too large for reconstruction with other standard techniques.     

Acetabular reconstruction using a cementless cup and hydroxyapatite granules: 3- to 8-year clinical results

We investigated 17 patients undergoing consecutive revision or conversion total hip arthroplasties with a cementless cup for acetabular bone defects. Patients were all women and the average age at the time of surgery was 61.2 years. All bone defects were filled and packed with porous hydroxyapatite (HA) granules. The average follow-up was 5.6 years (range, 3-8 years). The average Merle d'Aubigné functional hip score was 15.6 at the latest follow-up vs 11.6 before surgery. No patients needed additional revision surgery. In 4 cases in which a superior deficiency had been covered with HA granules, the cup migrated superior to the host bone but without any detrimental effect. The remaining 13 cases showed no migration of the cup. We conclude that acetabular reconstruction with a cementless cup and HA granules seems to provide encouraging intermediate results.     

LD hip arthroplasty. Design concepts and first clinical trials of a new modular system.

The new LD modular hip arthroplasty is made of Ti6A14V. The acetabular component has a hemispheric expansive metallic ring and a polyethylene nucleus in the shape of a cone segment. Since June 1988, when the clinical trials began, 352 arthroplasties have been performed with 112 total hip arthroplasties among them. Only 60 noncemented total hip arthroplasties, with the longest follow-up evaluation reaching 24 months, were analyzed. Patients with revision operations were excluded. The results have been evaluated using the Merle D'Aubigne scoring scale. Good results were found in 86% of cases. Pain improved markedly at three months in the postoperative period. At six months, the Trendelenburg sign was negative in 76% and positive in 12%. The Duchenne sign was positive in 11%. Major complications included three dislocations, two acetabular component revisions caused by initial malposition, one external popliteal nerve palsy, one deep infection, and two periprosthetic fractures. No acetabular migrations have been found. There are six femoral sinkings of less than 1 cm. Heterotopic ossifications Grade II-III appear in 24% of cases. The results to date are evaluated clinically and radiologically. The acetabular design has proved efficient, and the femoral components show a low incidence of stress shielding.     

Revision total hip arthroplasty using impaction bone grafting with cemented nonpolished stems and Charnley cups

This article reports the results of 181 cemented revision total hip arthroplasties in which impacted morcellized allograft and cement was used for reconstitution of acetabular and femoral bone deficiencies. There were 173 acetabular and 79 femoral reconstructions. The mean follow-up was 4.0 years. The overall survival rate was 97.2%. Evidence of revascularization of the impacted allograft was shown in 29 of 30 (97%) randomly selected bone scintigraphies. Radiographic evidence of allograft incorporation was observed in 128 of 173 (74%) acetabula and 48 of 73 (61%) femora. Stem subsidence occurred in all types of femoral bone deficiencies and was not time dependent (P = .17). The acetabular components showed significant migration with increased bone deficiency (P = .0003). Impaction bone grafting has shown promising results in revision total hip arthroplasty but is not recommended in type 3 acetabular defects.     

Failures after revision hip arthroplasties with threaded cups and structural bone allografts: Loosening of 13/18 cases after 1-4 years

Uncemented threaded, smooth cup acetabular components and structural deep-frozen bone allografts harvested from femoral heads during arthroplasties were used for reconstruction of the acetabulum in 18 revision hip arthroplasties. Autogenous bone grafts were also used in every case. The mean follow-up time was 2.5 (1-4) years. Loosening of the prosthetic component occurred in 13 cases. In 8 cases revision of the acetabular component has already been performed, and 5 cases remain to be reoperated. The use of uncemented, threaded cups in combination with reconstruction of bone defects with structural allografts cannot be recommended in acetabular revisions.     

Low-friction arthroplasty in patients younger than 40 years old: 20- to 25-year results

A total of 67 low-friction arthroplasties were performed from 1971 through 1978 in patients <40 years old and followed an average of 21.7 years. There have been 33 cup loosenings and 17 stem loosenings. The average rate of wear of the cup was 0.12 mm/y for the entire series and 0.16 mm/y for the revised cups. Although the preoperative diagnosis leading to low-friction arthroplasty commonly reflected some deficiency in bone structure, particularly in the acetabulum, there were no primary osteoarthrosis cases. The femoral stem proved to be durable, but acetabular cups gave poorer results in younger patients than in older patients. The 2 major factors limiting the longevity of the cemented cup were acetabular bone quality and wear.     

人工全髋关节置换术中髋臼骨缺损的重建

目的 探讨人工全髋关节置换术中各种髋臼骨缺损的特点与重建方法.方法 1998年5月至2008年8月对获得随访的行初次全髋关节置换或翻修的37例(37髋)髋臼缺损患者的临床资料进行回顾性分析,依据AAOS分型采取颗粒性或结构性植骨、生物或骨水泥髋臼假体以及钛网或加强环置入等方法对骨缺损进行重建.术前Harris评分(42±8)分.术后采用Harris评分判断髋关节的功能改善情况,复查X线片了解移植骨愈合及假体在位情况.结果 AAOS Ⅰ型9例,Ⅱ型13例,Ⅲ型15例.颗粒性植骨24例,结构性植骨6例,混合性植骨7例;生物型假体21例,骨水泥型假体16例.平均随访时间53.7个月.术后Harris评分(87±5)分,与术前比较,差异具有统计学意义(P<0.05).移植骨在最后一次复查时均已愈合或基本愈合.结论 对于AAOS Ⅰ型、Ⅱ型等简单的髋臼骨缺损,颗粒性或结构性植骨结合生物型髋臼假体就可以获得很好的初始稳定性,而对于AAOSⅢ型等较严重的缺损,则应行结构性植骨或附加钛网及加强环等重建髋臼.其短、中期疗效是令人满意的.     

Revision total hip arthroplasty. Current role of polymethylmethacrylate

In 29 consecutive failed total hip arthroplasties revised during a 15-month period, cement fixation was used in 14 and cementless fixation in 11. A combination of the two techniques was used in four patients. Analysis of the indications for one or the other fixation type showed that the quality of bone stock and the location of bone deficiency were the most important criteria. The use of a fixation technique that suited the method of bone repair, i.e., autografts, allografts, or a combination of the two, was all-important. Cement technique alone was generally used when bone stock was intact and healthy. Cement was also used in combination with protrusio screens and allografts for gross acetabular deficiencies. Cementless, porous ingrowth technique, together with autografts, was preferred for femoral deficiencies or minor acetabular deficiencies. Bipolar prostheses with compressed, fragmented allografts were used as salvage procedures in gross acetabular deficiencies in older patients, especially when the femoral component did not need to be exchanged.     

Bank bone grafts in revision hip arthroplasty for acetabular protrusion

In 23 revision hip arthroplasties in which acetabular protrusion was encountered, homologous bone grafting was used to reconstruct or reinforce the medial wall of the acetabulum. Loosening of the acetabular component was the cause of the protrusion in all the cases. Postoperative follow-up showed a solid bone socket around the acetabular cup in all the cases and no signs of loosening at 3-years' follow-up.     

Bank bone grafts in revision hip arthroplasty for acetabular protrusion

In 23 revision hip arthroplasties in which acetabular protrusion was encountered, homologous bone grafting was used to reconstruct or reinforce the medial wall of the acetabulum. Loosening of the acetabular component was the cause of the protrusion in all the cases. Postoperative follow-up showed a solid bone socket around the acetabular cup in all the cases and no signs of loosening at 3-years' follow-up.     

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.     

Cancellous impaction bone grafting of acetabular defects in complex primary and revision total hip arthroplasty

The reconstruction of major acetabular bone defects during revision, conversion, and primary total hip arthroplasties (THAs) is challenging. We reviewed a consecutive series of 168 THAs (108 revisions, 8 conversions, and 52 primary THAs) performed by 1 surgeon (S.B.G.) between 1997 and 2008 using impaction bone grafting for acetabular reconstruction. Autograft, cancellous allograft croutons, and demineralized bone matrix were used to fill bone defects as needed. The acetabular bone deficiency was classified according to the American Academy of Orthopaedic Surgeons: type I, segmental deficiency with significant rim defect; type II, cavitary defects medially or posteriorly; type III, combined cavitary and segmental deficiency; type IV, pelvic discontinuity; and type V, arthrodesis. According to this method, 56 hips had type I, 31 hips had type II, 48 hips had type III, and 27 hips had type IV deficiencies. Of the 168 patients, 19 subsequently died of causes unrelated to the THA, and 11 were lost to follow-up. All patients had at least 2 years of follow-up. Average Harris Hip Score improved from 45.5±17.9 preoperatively to 81.1±16.5 postoperatively (P<.05) for revision THAs, from 40.0±11.3 preoperatively to 85.0±12.8 postoperatively (P<.05) for conversion THAs, and from 42.3±14.9 preoperatively to 85.0±12.0 postoperatively (P<.05) for primary THAs. All impaction grafted bone (allograft, autograft, or a combination) incorporated radiographically, thus restoring bone stock. Complications included 1 early infection, which was managed successfully with debridement and liner exchange, and 2 late infections that were managed successfully with staged revision. Two revisions required subsequent re-revision for late loosening. Two hip dislocations occurred, 1 of which required surgical treatment to place a constrained liner.     

Acetabular reconstruction with a threaded prosthesis for failed total hip arthroplasty.

The MEC-Ring threaded acetabular component was used in 35 patients for revision of failed cemented hip arthroplasties, and 32 have been observed for two to four years (mean, 2.5 years). With only a short-term follow-up period, 44% of patients have already required revision for failure of the MEC-Ring acetabular component. Patients with especially poor acetabular bone stock that had had structural bone graft had a significantly higher rate of failure. The authors developed a technique of supine oblique roentgenograms that allowed better visualization of the component-bone interface. Eighty-six percent of patients had radiolucencies, and 67% of these were progressive. The presence of progressive radiolucencies, component migration, or both was associated with a higher failure rate. Progressive radiolucencies were also associated with a worse pain score in patients whose arthroplasties have not failed. The MEC-Ring threaded component is not recommended for revision hip arthroplasty, especially in cases with poor acetabular bone stock.     

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.