Ganz reinforcement ring for reconstruction of acetabular defects in revision total hip arthroplasty

BACKGROUND: In revision total hip arthroplasty, bone loss due to loosening and migration of the acetabular component makes fixation of a new implant difficult. The purpose of this study was to evaluate the clinical and radiographic outcomes of the use of the Ganz reinforcement ring with nonstructural allograft in the reconstruction of acetabular defects. METHODS: Sixty-one acetabular revisions performed with use of the Ganz reinforcement ring and nonstructural allograft, between 1989 and 1992, in fifty-seven patients with aseptic loosening met our selection criteria. Eleven hips in eleven patients were lost to follow-up, leaving fifty hips available for evaluation five years or more following surgery. According to the American Academy of Orthopaedic Surgeons classification, twenty-four acetabular defects were Type II, twenty-four were Type III, and two were Type IV. Clinical and radiographic evaluations were carried out at a mean of six and nine years after surgery. Twelve more patients were lost to follow-up before the most recent evaluation. RESULTS: The mean Merle d'Aubigné composite score increased significantly compared with the preoperative score (p < 0.001). There were seven failures: six cases of aseptic loosening and one case of septic arthritis. Graft incorporation and bone remodeling occurred in all hips but three in which the ring fixation had been inadequate at the time of surgery. The Kaplan-Meier survivorship rate, with use of revision or loosening of the component as the criterion of failure, was 81% at ten years. Inadequate fixation of the implant at the time of surgery was the only multivariate predictor of failure (p = 0.003). CONCLUSIONS: Patients treated with acetabular revision with a Ganz reinforcement ring had reconstitution of periacetabular bone stock as well as good clinical and radiographic results, provided that the ring had been fixed adequately at the time of surgery. This procedure may not be the preferred approach for reconstructing segmental defects of the medial wall or pelvic discontinuity.     

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.     

Revision total hip arthroplasty for large medial (protrusio) defects with a rim-fit cementless acetabular component

Seventeen patients (19 hips) with protrusio acetabuli resulting from a failed total hip arthroplasty, large medial bone defect, and an intact bony rim were treated with an oversized cementless acetabular component and medial morcelized allograft. An average of 55% of the revision component was not supported by host bone. At an average follow-up of 2.8 (range 2-6) years, none of the acetabular components required revision for loosening. The average cup position preoperatively was 10.5 mm medial to Köhler's line and postoperatively was 6.8 mm lateral to Köhler's line. Despite very large medial defects, reconstructions with this technique remained stable.     

Revision of a cemented acetabular component to a cementless acetabular component. A ten to fourteen-year follow-up study.

BACKGROUND: Although cementless acetabular components are routinely used in revision hip surgery, few investigators have evaluated the retention and efficacy of these components in the long term. In the current study, the clinical and radiographic outcomes of a series of arthroplasties performed by one surgeon with a cementless acetabular component were assessed at a minimum of ten years. METHODS: From 1986 through 1988, sixty-one consecutive revision total hip arthroplasties were performed in fifty-five patients because of aseptic failure of one or both components of a prosthesis in which both components had been cemented. Twenty-eight patients (thirty-two hips) were alive at a mean of 12.9 years (range, 11.5 to 14.3 years) after the operation. In all of the patients, the acetabular component was revised to a porous-coated Harris-Galante component inserted without cement, and the femoral component was revised to an Iowa component affixed with contemporary cementing techniques. The hips were evaluated clinically and radiographically at a minimum of ten years subsequent to the index revision. No hips were lost to follow-up. RESULTS: None of the acetabular components required revision because of aseptic loosening. Two hips (3%) demonstrated radiographic evidence of aseptic loosening of the acetabular component. The polyethylene liner was exchanged during the follow-up period in eight hips. CONCLUSION: After a minimum of ten years of follow-up, cementless acetabular fixation in revision hip arthroplasty had produced durable results that were markedly better than those reported for acetabular fixation with cement.     

全髋置换术中应用髋臼内壁环形截骨术治疗成人髋臼发育不良

目的评价全髋置换中应用髋臼内壁环形截骨固定非骨水泥髋臼杯治疗成人髋臼发育不良的疗效。方法对29例髋臼发育不良继发骨性关节炎患者(29髋)在全髋置换术中应用髋臼内壁环形截骨术。手术指征为术前X线髋臼覆盖率70%。非骨水泥髋臼杯全部安放在真臼位置,附加操作:软组织松解17髋,治疗性股骨截骨2髋,结构性植骨1髋,股骨短缩3髋。手术前后进行临床及X线参数评价。结果患者均获得随访,时间4~8年。Harris评分从术前36~75(68.4±8.49)分提高到85~100(92.2±4.05)分(P0.05);其中优25髋,良4髋。影像学观察髋臼内壁截骨处愈合时间3~5个月,术后6~12个月时骨重塑。X线检查显示没有无菌性松动和透亮线,真臼固定稳定。结论在非骨水泥全髋置换术治疗髋关节发育不良中,应用髋臼内壁环形截骨术可以提供良好的髋臼位置、足够的髋臼覆盖及保留足够内壁厚度,并且无需植骨。     

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。     

Use of constrained acetabular components for hip instability: an average 10-year follow-up study

The short-term efficacy of using constrained acetabular components for hip instability in the total hip arthroplasty construct has been documented. However, long-term concerns including late dislocation, loosening of components, and osteolysis have not been addressed. The authors evaluated, at an average 10.3-year follow-up, 101 tripolar constrained components (Stryker Howmedica Osteonics) used in the total hip arthroplasty construct. At final follow-up, 6 hips had dislocated or had failure of the constrained component, 5 of which were revised. In addition, 4 hips were revised for aseptic loosening of the acetabular component, 4 hips were revised for aseptic femoral loosening, and 1 hip was revised for acetabular osteolysis. Considering the complexity of the cases, this component has provided durable fixation and hip stability at this intermediate-term follow-up.     

Cementless acetabular fixation in patients 50 years and younger at 10 to 18 years of follow-up

The purpose of the study was to evaluate the 10- to 18-year follow-up of cementless acetabular fixation in patients 50 years and younger. We retrospectively reviewed a consecutive group of 118 patients (144 hips) in whom primary total hip arthroplasty had been performed by 2 surgeons using a cementless acetabular component. Two (1.4%) cementless acetabular components were revised because of aseptic loosening. Twenty-four hips (16.7%) were revised for any mechanical failure of the acetabular component mostly related to acetabular liner wear and osteolysis. The average linear wear rate was 0.19 mm per year, which was higher than our previous reports with cemented acetabular fixation. The fiber mesh ingrowth surface of the cementless acetabular component in this study was superior to cemented acetabular components in terms of fixation. However, the high rates of wear and osteolysis have led to poor overall acetabular component construct survivorship.     

Porous-ingrowth revision acetabular implants secured with peripheral screws. A minimum twelve-year follow-up

BACKGROUND: During revision total hip arthroplasty, the acetabular component is often secured with screws to ensure initial press-fit stability. The purpose of the present study was to assess a series of acetabular revisions involving the use of a porous-coated acetabular component that was stabilized with peripheral screws and to evaluate the results in relation to the acetabular bone deficiencies that were present at the time of the revision procedure. METHODS: From 1987 to 1991, 203 consecutive acetabular revisions were performed. In 142 hips, a severe acetabular bone deficiency that did not require an allograft was reconstructed with a porous-coated acetabular cup that was secured with a minimum of two peripheral screws. After an average duration of follow-up of 13.2 years, 134 hips were reviewed clinically and radiographically. The procedure was considered to be a clinical failure if the component was revised or if the postoperative clinical scores were poorer than the preoperative scores. RESULTS: At the time of the most recent follow-up, 127 (95%) of the 134 hips were stable and clinically successful. The other seven hips (5%) were considered to have failed. Five of these seven hips failed because of an infection, and two failed because of aseptic loosening. Five (19%) of the twenty-seven hips with a Paprosky type-3A defect (a defect in which 30% to 50% of the host acetabulum is missing) failed. CONCLUSIONS: Revision total hip arthroplasty with use of a porous-coated acetabular component that is fixed with peripheral screws can provide long-term durability in hips with severe acetabular defects that do not require the use of an allograft (Paprosky type-1 and type-2 defects). We recommend that when an acetabular implant with peripheral screws is used for the treatment of a more severe (type-3) defect, the cup should be augmented with structural allograft to improve initial stability, or other implants should be utilized.     

Incorporation of allograft for acetabular reconstruction: Single photon emission CT in 21 hip arthroplasties followed for 2.5-5 years

We studied 21 hips in 20 patients who had acetabular reconstruction with a femoral head allograft in primary (n 2) and secondary (n 19) total hip arthroplasty. The fate of the graft was evaluated by serial bone SPECTs (single photon emission computed tomography). With a mean follow-up period of 37 (30-60) months, 14 of the 21 hips showed evidence of incorporation at earliest 13 (6-18) months after operation. There was no correlation between the fate of allograft and the compatibility of A, B, 0 blood typing between host and donor, the use of bone cement in the fixation of acetabular component, or loosening of the acetabular component.     

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.     

Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years.

BACKGROUND: Anterolateral acetabular bone deficiency is one of the technical problems associated with total hip arthroplasty in patients with developmental hip dysplasia. The purpose of this study was to evaluate the results of one method of acetabular reconstruction for hip dysplasia-placement of an uncemented socket in conjunction with a bulk femoral head autograft. METHODS: Forty-four hips in thirty-five patients (twenty-nine female and six male; average age, thirty-nine years) with developmental hip dysplasia were treated with primary total hip arthroplasty with use of an uncemented porous-coated titanium cup fixed with screws and an autogenous bulk femoral head graft. The patients were followed clinically in a prospective fashion for five to 12.3 years (mean, 7.5 years), and radiographs were analyzed retrospectively. RESULTS: Four acetabular components were revised: two, because of severe polyethylene wear and osteolysis; one, because of aseptic loosening; and one, because of fracture of the acetabular shell. The mean Harris hip score for the unrevised hips improved from 51 points preoperatively to 91 points postoperatively. No unrevised socket had definite radiographic evidence of loosening. Forty-three of the forty-four hips had no radiographic evidence of resorption of the graft or had radiographic evidence of resorption limited to the nonstressed area of the graft lateral to the edge of the cup. CONCLUSIONS: This method of reconstruction provided reliable acetabular fixation and appeared to restore acetabular bone stock in patients with developmental hip dysplasia. We use this technique for patients with moderate anterolateral acetabular bone deficiency requiring total hip arthroplasty.     

Catastrophic fracture of a stable metal acetabular component

Various modes of failure of primary and revision total hip arthroplasty have been well documented in the literature over the past 30 years. Concerns over polyethylene wear, osteolysis, and hypersensitivity reactions leading to component loosening and early revision have been evaluated and reported in the literature. Routine follow-up is important to monitor for postoperative issues that might lead to the subsequent need for revision.This article describes a case of a 64-year-old man who initially presented 11 years prior with an intertrochanteric fracture, which failed secondary to varus alignment and femoral head osteonecrosis. The fixation was converted to a total hip replacement using the S-ROM system (DePuy, Warsaw, Indiana). Subsequently, the patient was lost to follow-up after primary total hip arthroplasty and presented with a catastrophic fracture of the metal acetabular cup system. The failure was suggested by clinical presentation and confirmed by imaging studies showing a fractured acetabular shell with femoral head prosthesis resting in the superolateral ileum. The contributing factors that resulted in mechanical failure were polyethylene wear and component fracture. The acetabular component was revised with an in-growth cementless trabecular metal multihole cup (Zimmer, Warsaw, Indiana) with bone grafting of acetabular defects.Routine assessments help educate patients and allow careful monitoring by physicians while establishing a radiographic timeline for the identification, progression, or lack of postoperative complications.     

Assessment of bone grafts used for acetabular augmentation in total hip arthroplasty. A study using roentgenograms and bone scintigraphy

Total hip arthroplasty was performed in 13 hips with acetabular bone grafts for secure component fixation. The incorporation and healing of acetabular bone grafts were investigated with the aid of roentgenograms, planar bone scans, and a newer scintigraphic technique, three-dimensional single photon emission computed tomography (SPECT). Conventional roentgenograms proved unreliable in evaluating bone graft reconstitution because of overlapping trabecular bone patterns of the graft and iliac wing. There was no evidence of graft failure or acetabular loosening. Bone grafts in the late follow-up group (four to seven years postoperation) exhibited normal radionuclide activity, whereas grafts less than one year postsurgery demonstrated patterns of increased activity. SPECT was helpful in producing an anatomic reconstruction of the acetabulum. The observation that bone grafts exhibited normal biological viability is crucial for ensuring secure acetabular component fixation on a long-term basis.     

The fate of revised uncemented acetabular components in patients with rheumatoid arthritis

The results of patients with rheumatoid arthritis who had revision hip arthroplasty have been studied infrequently. The purpose of this study was to review the authors' clinical and radiographic experiences and outcomes with revision hip arthroplasty. Revision total hip arthroplasties were done on 28 patients (30 hips). All hips had morselized bone grafting and four hips had bulk allografts for segmental defects. The mean age of the patients at the time of surgery was 50 years (range, 20-74 years). Patients were followed up for 4 to 15 years (mean, 7 years). At the latest followup, 14 hips (13 patients) of the 30 hips (47%) had good and excellent Harris hip score ratings. Mechanical failures included six hips (five patients) that had revision arthroplasty and two hips (two patients) that had resection arthroplasty. Six other hips (five patients) had poor Harris hip score ratings. The Kaplan-Meier survivorship curve for failure of the acetabular component revealed an 89% chance of survivorship curve for failure of the acetabular component revealed an 89% chance of survival at 60 months and a 44% chance of survival at 108 months. Based on the results of this study, revision hip arthroplasty for acetabular loosening with a cementless acetabular prosthesis has a low rate of success in patients with rheumatoid arthritis.     

Radiographic and clinical analysis of cementless acetabular fixation in total hip arthroplasty

Tofruetancloc nthisoitpnru sac.rttih oOrnorpig ltaiensctahylln y(i,qTuH emAa)jfoo irrs a Td HweteAelrli-o etrseatctaehbdnliiqs huheeidpsutilized bone cement for fixation,but loosening rate ofthe acetabular component was very high because ofbone cement tec…     

THA Revisions Using Impaction Allografting With Mesh Is Durable for Medial but Not Lateral Acetabular Defects

Background

Most acetabular revisions are managed with cementless hemispherical or elliptical metal implants relying on bone ingrowth. Nonetheless, loss of acetabular bone stock and inability to achieve secure component fixation represent challenges in the setting of revision total hip arthroplasty. Impaction bone grafting (IBG) using allograft represents one option for treatment of this problem. However, cup migration and bone graft resorption are limitations when IBG is used for large segmental defects, and the precise role of IBG as well as the use of mesh (and the kinds of defects for which mesh does not work well) in this setting remains unknown.

Questions/purposes

We therefore evaluated patients undergoing acetabular revision surgery using IBG and a cemented cup in large bone defects to determine (1) the frequency with which the hip center could be restored in hips with Paprosky 3A and 3B defects and in hips with or without the use of metallic mesh during surgery; (2) survivorship of IBG acetabular-revision reconstructions in patients with severe Paprosky 3A and 3B defects; and (3) risk factors for failure of the reconstruction, including the use of mesh and defect severity (3A versus 3B).

Methods

Between 1997 and 2009, we performed 226 acetabular revisions using IBG. During that time, indications for using IBG in this setting included Paprosky 3A and 3B defects without pelvic discontinuity. Of these, 204 (90.2%) were available for followup at a minimum of 5 years (mean, 10 years; range, 5–17 years). There were 100 hips with an intraoperative bone defect of Paprosky 3A and 104 with a 3B. Medial or rim acetabular uncontained defects were treated with medial and/or lateral metallic mesh in 142 hips. We determined the postoperative radiological cup position and acetabular reconstruction of the hip center according to Ranawat in both groups. We assessed the appearance of cup loosening and the possible risk factors with regression analysis.

Results

Mean postoperative acetabular abduction angle and vertical, horizontal, and hip rotation center distances improved (p < 0.001 in all parameters). Nine hips showed radiological loosening in the group with bone defect 3A and 16 in Group 3B. The survival rate for loosening at 15 years was 83% (95% confidence interval [CI], 71%–95%) for Group 3A and 73% (95% CI, 60%–84%) for Group 3B (p = 0.04). The survivorship for loosening when using mesh or not at 15 years was: no mesh 89% (95% CI, 74%–99%), medial mesh 85% (95% CI, 72%–97%), lateral mesh 80% (95% CI, 67%–91%), and medial and lateral meshes 54% (95% CI, 31%–76%) (p = 0.008). After controlling the most relevant confounding variables we found that the most important factor associated with loosening was lateral mesh use (p = 0.008; hazard ratio, 2.942; 95% CI, 1.328–6.516).

Conclusions

IBG provides an improvement in reconstruction of the hip rotation center in acetabular revision surgery. Although results are good for contained or medial large defects, hips with a rim or lateral segmental defect may need other options for reconstruction of these challenging surgeries.

Level of Evidence

Level III, therapeutic study.     

Revision of failed acetabular cups with extensive structural allografts

AIM: Structural allografts are used with encouraging results for revision of failed total hip arthroplasty and in the surgery of bone tumours. The aim of the present study is to describe the clinical and radiological results achieved with structural allografts in revision of a total hip arthroplasty. MATERIAL AND METHODS: 15 patients (12 female and 3 male patients) were revised with an acetabular defect situation of type 3 A or 3 B according to the Paprosky classification. Five fresh-frozen acetabula, nine distal femora and one proximal tibia were used for acetabular reconstruction. The rigid graft fixation was performed with 2 > or = AO screws. In one case a cemented acetabular ring was implanted, four cementless cups and ten cemented polyethylene acetabular components were used. The mean follow-up was 7.9 years (1.6-11.0 years). RESULTS: A stable osseointegration of fifteen transplanted structural allografts was achieved in thirteen cases. Two allografts (one aseptic loosening, one deep infection) failed to osseointegrate. In one case the migration of a cementless cup was registered. Revision surgery of this female patient was performed successfully with a cemented reconstruction ring. The mean Harris hip score at the latest follow-up was 81.4 points (70-99 points). CONCLUSION: For reconstruction of acetabular bone stock and restoration of the bone anatomy structural allografts can be recommended. The use of cementless cups in combination with structural grafts is to be evaluated as critical.     

Failure of an uncemented non-porous metal-backed prosthesis with augmentation using impacted allograft for acetabular revision 12- to 17-year results

We have reviewed 29 patients (30 hips) who had undergone revision total hip arthroplasty using a Freeman metal-backed acetabular component and acetabular impaction allografting. The mean follow-up was for 153 years (12 to 17). Five patients (5 hips) died with the prosthesis in situ and four (4 hips) were lost to follow-up. Twelve hips had failed and in the remaining nine there were minor symptoms. The mean time to failure requiring further surgery was nine years. Excluding patients who were lost to follow-up or had died, 72% of the hips were radiologically loose at the last review. The commonest pattern in those requiring revision was failure of the reinforcement ring in adduction with remodelling of the medial wall. Of the nine patients who had not undergone revision, one with bilateral replacements had no current radiographs and only three of the remaining seven replacements had no radiological signs of loosening. The short-term results for this technique have been reported to be satisfactory, but in the long term they are not. The factors associated with failure include the design of the prosthesis, which has been implicated in disappointing long-term results when used in primary arthroplasty, but not with the frequency of failure found in this series. It seems that the reliance on peripheral screw fixation over a bed of allograft without bridging the graft does not provide sufficient stability to allow incorporation of the graft.     

A stemmed acetabular component in the management of severe acetabular deficiency

We evaluated the use of a stemmed acetabular component in the treatment of severe acetabular deficiency during revision and complex primary total hip arthroplasty. There were 31 hips of which 24 were revisions (20 for aseptic loosening, four for infection) and the remainder were complex primary arthroplasties. At a mean follow-up of 10.7 years (6 to 12.8), no component had been revised for aseptic loosening; one patient had undergone a revision of the polyethylene liner for wear. There was one failure because of infection. At the latest follow-up, the cumulative survival rate for aseptic loosening, with revision being the end-point, was 100%; for radiographic loosening it was 92% and for infection and radiographic loosening it was 88%. These results justify the continued use of this stemmed component for the reconstruction of severe acetabular deficiency.