Pelvic reconstruction for massive acetabular insufficiency

Joint reconstruction for pelvic discontinuity because of massive acetabular insufficiency presents a significant surgical challenge. Using retrograde-inserted Steinmann pins to rebuild the dome may be associated with early implant failure because of insufficient mechanical stability and neurovascular injury resulting from pin misplacement. Retrograde pins cannot be placed completely across the pelvic defect. We hypothesized that large Steinmann pins placed anterograde under direct vision from the iliac crest completely across the acetabular column and floor defects would minimize the risk of early failure, and could be placed safely without the use of fluoroscopy in combination with a posterior hip approach. The purpose of our study was to review the mechanical failure and complication rates of nine patients (10 hips) treated between 1996 and 2002 for pelvic discontinuity using this pin placement technique to reinforce a cemented roof ring hip reconstruction done via a posterior approach. None of the patients had implant loosening or failure, there were no neurovascular complications, and no perioperative deaths. One patient required cup revision for recurrent dislocation. All patients were bedridden or wheelchair-bound before surgery, but regained independent household walking by 6 weeks postoperatively. Reinforcing the acetabulum with a lattice girder of anterograde pins provides safe and effective hip reconstruction.     

Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor

BACKGROUND: Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis. METHODS: Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score. RESULTS: The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction. The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp. CONCLUSIONS: Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograft-related complication.     

髋臼转移瘤的外科治疗

目的 回顾性总结髋臼周围转移瘤的治疗经验.方法 对2000年7月至2007年7月收治的43例髋臼转移瘤患者进行随访.术前21例有明确原发灶,10例活检证实转移瘤,其余12例术后病理证实为转移瘤.12例为孤立性转移灶,31例为多发骨转移.采用刮除术35例,整块切除8例.重建方式包括骨水泥型全髋置换或网杯加固髋臼+全髋置换12例,带翼网杯+全髋置换16例,斯氏针骨水泥加固髋臼顶、网杯+全髋置换7例,可调试半骨盆假体置换8例.结果 患者均平稳度过围手术期.术前疼痛评分平均7.2分,术后41例患者疼痛缓解及恢复行走能力,疼痛评分平均3.5分.术后功能评分平均24.5分.术中平均出血量1600 ml.6例患者出现局部复发.各种原因共死亡14例患者.并发症包括2例伤口感染、1例多器官功能衰竭、2例假体脱位.结论 髋臼转移瘤手术目的是缓解疼痛,并根据髋臼周围的骨质破坏情况具体选择重建方法,维持及恢复髋关节的活动度和稳定性.     

Major reconstruction for periacetabular metastasis: early complications and outcome following surgical treatment in 40 hips

We performed 40 total hip arthroplasties with pelvic reconstruction in 37 patients with metastatic periacetabular tumor. 3 patients underwent bilateral periacetabular reconstructive surgery and 2 of these had bilateral procedures at the single operation. There were 8 Harrington class I, 7 class II, and 25 class III lesions. A modified Harrington procedure was employed. All patients showed improvements in hip pain, analgesic use, ambulation and mobility postoperatively. 1 prosthetic dislocation occurred after a fall at home 2 months following surgery. 2 patients had pulmonary emboli during the femoral procedure, 1 of whom died during surgery. There were no prosthetic loosenings. Preoperative CT and/or MRI are important for the study of metastatic involvement of acetabular bone. Durability of reconstruction requires appropriate use of acetabular mesh, Steinmann pins, acetabular reinforcement rings and long-stem femoral prostheses. Careful patient selection may improve quality of life. A sequential bilateral procedure should be considered for some patients.     

Total femoral arthroplasty for salvage of end-stage prosthetic disease

The complications and outcomes in patients who had total femoral arthroplasty for salvage of a severely compromised femur were studied. The clinical scenarios included numerous revision total hip or knee arthroplasties, failed periprosthetic fractures, or recurrent infection treated with multiple radical debridement surgeries. Fifty-nine patients (average age, 73.7 years) were identified. At an average 4.8 years followup, adequate pain relief was achieved and Harris hip pain scores averaged 33.8 of 44 points, and knee pain scores averaged 42.8 of 50 points. Good function was achieved with 98% of patients able to ambulate and 43% using no assistive device or a cane only. There were 18 complications or subsequent surgeries. Infection and dislocation occurred in eight patients and seven patients, respectively. Total femoral arthroplasty for salvage of a severely compromised femur provides acceptable results even in the most difficult of cases.     

Patient survival after hip arthroplasty for metastatic disease of the hip

BACKGROUND: The hip joint is a common location for metastatic disease. Actual as well as impending fractures at this site are frequently due to mechanical instability after tumor invasion and are usually treated surgically with hip arthroplasty. The objective of this study was to analyze survival and influences on survival after hip arthroplasty for metastatic hip disease. METHODS: Two hundred and ninety-nine patients who had undergone a total of 306 hemiarthroplasty or total hip arthroplasty procedures for treatment of a pathologic or an impending pathologic hip fracture between 1969 and 1996 at our institution were included in this study. Data that had been acquired prospectively within the total joint registry of our institution were reviewed retrospectively. RESULTS: The median duration of survival after the arthroplasty was 8.6 months. The duration of survival was significantly associated with the site of the fracture, location of the primary tumor, and time from the diagnosis of the primary tumor to the surgery for the fracture (p < or = 0.05). The time from the diagnosis to the arthroplasty was a significant independent predictor of survival. CONCLUSIONS: Patients undergoing hip arthroplasty for metastatic disease have a limited life expectancy, with only 40% (120) of the 299 patients in our series still alive at one year after the surgery. By identifying prognostic factors regarding life expectancy, this study provides surgeons and oncologists with information with which to weigh risks and benefits of hip arthroplasty for individual patients preoperatively.     

Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis

The mortality and morbidity after hip and knee arthroplasty were reviewed retrospectively during a 3-year period in 14 patients who had chronic renal failure and who were receiving hemodialysis. The patients had a primary total hip or knee replacement, or a revision arthroplasty or resection arthroplasty. Four of the patients (29%) died in the hospital during the postoperative period. One of the seven patients (14%) having a primary joint replacement died, whereas three of the seven patients (86%) having a revision or resection died. Every patient had multiple medical comorbidities, and every patient had a complication. The results indicate that arthroplasty procedures, especially revisions and resections, in this patient population are associated with a high rate of complications and death, and that in-depth informed consent should be provided for all patients contemplating these procedures. Meticulous treatment of medical comorbidities is mandatory. Finally, data in the literature and in the current report question whether joint arthroplasty procedures should be done in patients with end-stage renal disease who are receiving hemodialysis.     

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.     

Contemporary Ceramic Total Hip Arthroplasty in Patients with Cerebral Palsy: Does It Work?

BackgroundAdult patients with cerebral palsy (CP), who have advanced degenerative arthritis of the hip, have been treated with resection arthroplasty and arthrodesis. Although total hip arthroplasty (THA) has also been used as one of the alternative options, there are few studies on contemporary bearings used in THA. Therefore, we evaluated the results of the contemporary ceramic-on-ceramic THA in adult patients with CP.MethodsFrom January 2005 to December 2007, five adult CP patients (5 hips) underwent THA using contemporary ceramic-on-ceramic bearings. All patients were able to stand or ambulate with intermittent use of assistive devices at home. We retrospectively reviewed the series to determine the results of THA in terms of pain relief, improved function, and durability of prosthesis.ResultsThere were 3 men and 2 women with a mean age of 35.9 years. All patients had pain relief without decline in mobility postoperatively. One hip was dislocated, which was treated successfully with closed reduction and an abduction brace for 2 months. There was no ceramic fracture, loosening, or osteolysis during the mean follow-up of 6.8 years (range, 5.8 to 8.3 years).ConclusionsCementless THA using contemporary ceramic-on-ceramic bearings is a useful option for the treatment of advanced degenerative arthritis of the hip in ambulatory adults with CP.     

新型复合重建技术重建髋臼周围肿瘤切除后骨缺损

目的 评价新型复合重建技术对髋臼周围肿瘤切除后骨缺损的重建效果.方法 2001年3月至2007年3月,对23例髋臼周围肿瘤患者行切除复合重建,其中男性16例,女性7例,平均年龄43岁(16～78岁).肿瘤类型:原发性恶性骨与软组织肿瘤17例,其中软骨肉瘤7例、成骨肉瘤4例、尤文肉瘤2例、恶性纤维组织细胞瘤2例、恶性神经鞘瘤1例、滑膜肉瘤1例;骨巨细胞瘤2例;侵袭性骨母细胞瘤1例;转移瘤3例,其中甲状腺癌1例、乳腺癌l例、卵巢癌1例.术后对肿瘤控制和功能结果进行评定.结果 原发性恶性骨盆肿瘤中Ⅰ A期1例,Ⅰ B期5例,ⅡA期3例,ⅡB期8例,3例良性骨肿瘤均为Ⅲ期,原发瘤患者平均随访时间36.8个月(9～73个月);3例转移瘤患者生存期9.6～36.6个月.肿瘤局部复发4例,肺转移5例,死亡5例,术后无深部感染和皮肤坏死.深静脉血栓2例;坐骨神经不全损伤1例,股骨头假体脱位2例,螺钉松动3例,肢体短缩3例,其中植入物相关并发症发生率为21.7%,术后6个月MSTS功能评分平均为68%;随访5年以上的6例患者MSTs功能评分平均为62%.结论 新型复合重建技术可有效重建髋臼周围肿瘤切除后骨缺损同时可以较好恢复髋关节功能,术后并发症少.     

Sciatic nerve reconstruction: limb preservation after sarcoma resection

Limb salvage for extremity sarcoma has become the standard of care when possible. This review attempts to determine the outcome of sciatic nerve reconstruction after surgical tumor resection. The authors' objective was to determine the clinical value of extremity salvage with such a defect. Five patients (two male, three female) were selected from a department database at The University of Texas M.D. Anderson Cancer Center between 1995 and 1999 who met the following criteria: lower limb tumor resection involving a gap in the sciatic nerve with subsequent nerve autograft reconstruction. An additional patient who underwent primary sciatic nerve neurorrhaphy was also included. The average tumor size was 203 cm2. The most common tumor histology was spindle cell sarcoma. The average autograft length was 13 +/- 3.2 cm with one to four cables employed. Currently, 3 patients are still alive. Four of the 5 patients who received sciatic autonerve grafts reported partial distal sensory recovery subjectively. The patient who underwent primary neurorrhaphy has both motor and sensory innervation 42 months after surgery. Although not ideal for all patients, sciatic nerve reconstruction is a viable option for those willing to undergo limb preservation. Notable limitations to daily activity do not appear to be present, and patients are able to ambulate with or without assistive devices. With aggressive rehabilitation, some patients are able to function quite well with this bioprosthesis. Patients should consider, however, that their extremity is on loan. Substantial wound complications or infections may ultimately lead to amputation.     

Reconstruction of the pelvis after tumor resection in children and adolescents

Thirty patients younger than 19 years with malignant bone tumors of the pelvis were treated by limb salvage surgery between 1970 and 1998. Functional and oncologic results were reviewed retrospectively. In 10 patients the defect was reconstructed by an endoprosthesis and in 20 patients reconstruction by autologous grafts (n = 7), allograft and prosthesis combinations (n = 2), bone cement reconstruction (n = 1), iliosacral arthrodesis (n = 1), modified Girdlestone procedure (n = 3), or resection without reconstruction (n = 6) was done. Three and one-half reoperations per patient were necessary postoperatively after allograft reconstruction, 2.5 reoperations per patient were necessary after endoprosthetic reconstruction, and 0.8 reoperations per patient were necessary after other or no reconstruction. After a mean followup of 52 months (range, 2-241 months), 17 patients were alive, 15 of whom were continuously disease-free, and 13 patients had died of their disease. Functional ratings were 81% after autograft, 73% after allograft, and 60% after endoprosthetic reconstruction. Defect reconstruction varied according to the type of resection. Type I resections were best reconstructed by biologic methods. Endoprosthetic reconstruction after periacetabular resection with the advantage of preservation of a functional hip and body integrity was associated with a high rate of complications and reoperations. Its role compared with allograft reconstruction, modified Girdlestone procedure, or no reconstruction requires additional investigation.     

Total hip arthroplasties in patients less than forty-five years old

We studied the cases of eighty-one patients (108 total hip arthroplasties), ranging in age from fourteen to forty-five years, at an average of 4.5 years after the index operation and evaluated them with regard to six major factors: age, disease, Charnley category, prior operations, length of time since arthroplasty, and quality of the arthroplasty with regard to cementing technique and component position. After two to five years 78 per cent were satisfactory, but after five years or more only 72 per cent were satisfactory. Patients who were less than thirty years old had poorer results. Good technique yielded 93 per cent satisfactory clinical results. The patients in this study with the worst prognosis for success following total hip arthroplasty were less than thirty years old, had osteonecrosis or osteoarthritis as the primary disease, and had a less than optimum reconstruction. Patients who were alcohol-abusers or who had had a prior hip infection or a prior acetabular cup or femoral hemiarthroplasty also had a poor prognosis. Patients who had the arthroplasty for collagen disease or were thirty years old or older, or both, and had a good technical reconstruction had the best prognosis.     

Major reconstruction for periacetabular metastasis: Early complications and outcome following surgical treatment in 40 hips

We performed 40 total hip arthroplasties with pelvic reconstruction in 37 patients with metastatic periacetabular tumor. 3 patients underwent bilateral periacetabular reconstructive surgery and 2 of these had bilateral procedures at the single operation. There were 8 Harrington class I, 7 class II, and 25 class III lesions. A modified Harrington procedure was employed. All patients showed improvements in hip pain, analgesic use, ambulation and mobility postoperatively. 1 prosthetic dislocation occurred after a fall at home 2 months following surgery. 2 patients had pulmonary emboli during the femoral procedure, 1 of whom died during surgery.There were no prosthetic loosenings. Preoperative CT and/or MRI are important for the study of metastatic involvement of acetabular bone. Durability of reconstruction requires appropriate use of acetabular mesh, Steinmann pins, acetabular reinforcement rings and long-stem femoral prostheses. Careful patient selection may improve quality of life. A sequential bilateral procedure should be considered for some patients.     

Acetabular reconstruction with bone impaction grafting and a cemented cup: 20 years' experience.

Acetabular bone stock loss compromises the outcome in primary and revision total hip arthroplasty. In 1979, a biologic method was introduced with tightly impacted cancellous allografts in combination with a cemented polyethylene cup for acetabular reconstruction. With this technique, it is possible to replace the loss of bone and to repair normal hip mechanics and hip function with a standard implant. Based on the authors' 20 years experience, a review of the long-term data is presented in primary total hip arthroplasty with preexisting acetabular bone stock loss, primary total hip arthroplasty in rheumatoid arthritis, patients who had bone impaction when younger than 50 years, and in acetabular revisions. The survival rate with revision of the cup for aseptic loosening as the end point was 94% at 10 to 17 years, 90% at 10 to 18 years, 91% at 10 to 17 years, and 92% at 10 to 15 years. From biopsy specimens from humans and histologic data in animal experiments the incorporation of these impacted bone chips was proven. The acetabular bone impaction technique using large morselized bone chips (range, 0.7-1 cm) and a cemented cup is a reliable technique with favorable long-term outcome.     

Hip arthroplasty in patients with Paget's disease

In individuals with Paget's disease, the pelvis and upper femur are the areas of the skeleton most frequently involved. Associated deformities and alterations in bone quality can complicate total hip arthroplasty when required for degenerative joint changes, and can compromise outcome. A review of reported series shows that patients with Paget's disease may present unique problems during the preoperative assessment, intraoperative treatment, and postoperative followup. Preoperative determination of disease activity and assessment of the cause of hip symptoms is important. Intraoperatively, deformity such as coxa vara, femoral bowing, acetabular protrusio, and bony enlargement may cause alterations in implant choice or fixation method used and the patient may even require corrective osteotomy. Excessive bleeding and bone quality changes may complicate these efforts additionally. Postoperative problems include heterotopic bone formation, and in those patients in whom the underlying disease is highly active or poorly controlled, rapid postoperative bone resorption is possible. Results of cemented arthroplasty in patients with Paget's disease have been reported as comparable with but slightly worse than the results reported for unselected patients who underwent hip arthroplasty. The long-term results of uncemented implants in patients with Paget's disease remains to be established.     

Major reconstruction for periacetabular metastasis: Early complications and outcome following surgical treatment in 40 hips

We performed 40 total hip arthroplasties with pelvic reconstruction in 37 patients with metastatic periacetabular tumor. 3 patients underwent bilateral periacetabular reconstructive surgery and 2 of these had bilateral procedures at the single operation. There were 8 Harrington class I, 7 class II, and 25 class III lesions. A modified Harrington procedure was employed. All patients showed improvements in hip pain, analgesic use, ambulation and mobility postoperatively. 1 prosthetic dislocation occurred after a fall at home 2 months following surgery. 2 patients had pulmonary emboli during the femoral procedure, 1 of whom died during surgery.There were no prosthetic loosenings. Preoperative CT and/or MRI are important for the study of metastatic involvement of acetabular bone. Durability of reconstruction requires appropriate use of acetabular mesh, Steinmann pins, acetabular reinforcement rings and long-stem femoral prostheses. Careful patient selection may improve quality of life. A sequential bilateral procedure should be considered for some patients.     

Early pain relief and function after posterior minimally invasive and conventional total hip arthroplasty. A prospective, randomized, blinded study

BACKGROUND: Few prospective randomized studies have demonstrated benefits of minimally invasive total hip arthroplasty when compared with conventional total hip arthroplasty. We hypothesized that patients treated with a posterior mini-incision would have better results than those treated with a posterior long incision with regard to the achievement of established goals for pain relief and functional recovery permitting hospital discharge by the second postoperative day. METHODS: Sixty of 231 eligible patients were randomized (with thirty in each group) to have a total hip arthroplasty performed through either a posterior mini-incision (10 +/- 2 cm) or a traditional long incision (20 +/- 2 cm). After completion of the total hip arthroplasty, the mini-incision group underwent extension of the skin incision to 20 cm. Patients were evaluated on the basis of self-determined pain scores, requirements for pain medicine, need for assistive gait devices, and time until discharge. Gait analysis provided objective functional assessment. RESULTS: The average hospital stay was 63.2 +/- 13.3 hours in the mini-incision group and 73.6 +/- 23.5 hours in the long-incision group (p = 0.04). More patients with a mini-incision were discharged by the second postoperative day (p = 0.003) and more were using just a single assistive device at the time of discharge (p = 0.005). As scored on a verbal analog scale of 0 to 10 points, patients with a mini-incision had less pain on each postoperative day and the pain score remained significantly lower at the time of discharge (mean, 2.2 +/- 1.0 points compared with 3.1 +/- 0.9 points in the long-incision group; p = 0.002). After hospital discharge, there were no clinical differences in pain or function between the two groups of patients. CONCLUSIONS: Compared with conventional total hip arthroplasty performed through a posterior incision, posterior minimally invasive total hip arthroplasty resulted in better early pain control, earlier discharge to home, and less use of assistive devices. Subsequent evaluations at six weeks and three months showed equivalency between the clinical results in the two groups. LEVEL OF EVIDENCE: Therapeutic Level I.     

The management of malignant bone tumors in children and adolescents

A series of 205 pediatric patients affected by osteosarcoma, Ewing's sarcoma, fibrosarcoma, and malignant fibrous histiocytoma of bone were treated from 1978 to 1988. Ninety-eight percent of the patients received chemotherapy and 63% had a surgical resection. Sixty-five percent of all patients were alive at 30 months and were considered disease free. The functional results after surgery were evaluated according to the Musculoskeletal Tumor Society score. In all diaphyseal resections and resections of the upper extremity and pelvis, the results were excellent or good in 60% of the cases. In resections of the proximal femur, distal femur, or proximal tibia and reconstruction with nonexpansible prostheses, the results were excellent or good in 75%. On the other hand, when arthrodeses of the lower extremity were used, only 14% of cases had a good result. This correlates with the resulting lack of articulation and serious limb shortening seen with progression of skeletal growth.     

Pelvic limb-salvage surgery for malignant tumors

Thirteen patients with primary malignant tumors of the pelvis underwent internal hemipelvectomy. The diagnoses were: Ewing's sarcoma 7, osteosarcoma 4, chondrosarcoma 1, and malignant fibrous histiocytoma 1. No megaprostheses or massive allografts were used for reconstruction. Six patients underwent resection only with no reconstruction, 5 had strut grafts inserted to restore the pelvic ring, 1 had an autoclaved autograft of the acetabulum and 1 had an ilio-femoral arthrodesis. No patients were lost to follow-up. Nine patients died from their disease after an average of 23 months (range 2 to 72 months). The 4 survivors (3 free of disease) have an average follow-up of 84 months (range 60 to 120 months).