The Survival and Fate of Acetabular Reconstruction With Impaction Grafting for Large Defects

Background  

Impaction bone grafting has been used for acetabular reconstruction in revision surgery. However, most series do not establish differences in survival in revisions with differing severity of bone loss.     

Massive Bone Defect Compromises Postoperative Cup Survivorship of Acetabular Revision Hip Arthroplasty with Impaction Bone Grafting

We evaluated 66 acetabular revision arthroplasties using cemented cup with impaction bone grafting (IBG) to detect the extent that bone defect affects the outcome. We defined the maximum acetabular defect distance (MADD), which indicates the greatest depth of the grafted layer. Cup survival analysis with aseptic loosening as the endpoint revealed that the “MADD ≤ 20 mm” group showed higher survivorship than the “MADD > 20 mm” group (95% vs. 74%, P = 0.034), and that the simple-wall-defect group (none or one mesh used) showed higher survivorship than the complex-wall-defect group (two meshes used) (96% vs. 73%, P = 0.044). A favorable indication for acetabular IBG reconstruction is cases in which those cups can be placed at ≤ 20 mm MADD with a simple wall defect.     

颗粒骨打压植骨技术在治疗髋臼骨缺损中的应用

目的介绍颗粒状松质骨打压植骨技术对髋臼骨缺损的重建方法。方法应用该技术对23例髋臼侧假体翻修患者及4例陈旧性髋臼骨折行人工全髋关节置换患者进行植骨,植骨块来源于深低温冰箱梯度降温后的冷冻干燥骨。术后进行临床评估及X线评估。结果术后平均随访3．1年,Harris评分平均提高36分,无1例假体需要再次翻修,有3例在X线上出现髋臼侧透亮带。结论打压植骨技术可以有效治疗髋臼骨缺损,应注重对颗粒松质骨的制备,植骨床的准备及对植骨块的紧密打压和固定。     

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.     

应用双极人工股骨头和骨移植进行髋臼假体翻修术

目的分析双极人工股骨头和嵌压植骨联合应用对合并巨大骨缺损的髋臼侧假体进行翻修术的临床疗效.方法 1988年3月～2000年11月期间利用双极人工股骨头对合并巨大骨缺损的23例24髋进行髋臼侧假体翻修术.其中男15例,女8例,平均年龄48岁,平均随访6.4年.翻修术的原因中假体松动21髋,骨溶解2髋,感染1髋.髋臼骨缺损根据AAOS分类,Ⅰ型3髋,Ⅱ型6髋,Ⅲ型15髋.自体骨移植2髋,异体骨移植8髋,混合移植14髋.临床评价采用Harris评分,并在X线片上对髋臼假体的移位、移植骨的愈合与吸收、髋臼形态的塑形以及再次翻修等进行分析.结果 Harris评分术前为49分,术后1年为78分,最后随访时间为76分.髋臼假体向上内方向移位19髋,向上外方向移位5髋.并发症中异位骨化12髋,感染1髋,复发性脱位1髋.因感染和髋臼假体严重移位采用非骨水泥型髋臼假体行再次翻修术2髋.结论双极人工股骨头和嵌压植骨联合应用对合并巨大骨缺损的髋臼侧假体进行翻修术具有髋臼形态塑形良好、移植骨愈合率高以及髋臼假体不需要坚强内固定等优点,可作为一种特殊情况下的髋臼侧假体翻修术;其缺点是髋臼假体移位.     

Favorable Early Results of Impaction Bone Grafting With Reinforcement Mesh for the Treatment of Paprosky 3B Acetabular Defects

Background

We present the early institutional experience with the use of impaction bone grafting, mesh augmentation, and cement fixation of an all-polyethylene cup for the treatment of Paprosky 3B acetabular defects during revision total hip arthroplasty.

颗粒打压植骨联合金属钛网用于中度 髋臼缺损髋翻修的早期研究

目的：对应用颗粒松质骨打压植骨联合金属钛网于伴有中度髋臼骨缺损的全髋关节翻修术中髋臼重建方法进行早期临床效果分析;比较该方法用于不同类型骨缺损的效果差异。 研究对象及方法：整理筛选我院2008年7月-2015年3月间金属钛网联合颗粒骨打压植骨技术行髋臼骨缺损重建的19例（19例髋,男8,女11）。骨缺损采用Paprosky分型：IIB型7例,IIC型11例,IIIA型1例。术后定期复查髋部X线,并于复查时行髋关节恢复情况的评估。 研究结果：19例均获得临床及影像结果的完整随访,平均随访时长4.7年。除去一例行再次翻修,所有患者髋臼旋转中心均得到了良好重建;移植骨状况良好,和宿主骨不同程度的整合;影像学资料未见明显假体松动。HHS评分由翻修前平均47.51分提高至末次随访时平均90.3分。术后假体4.7年以再次翻修为研究终点的生存率为94.7%。SF-36生活质量评分得到了提高。IIB和IIC型之间对比无统计学差异。 研究结论：金属钛网联合颗粒松质骨打压植骨用于伴有骨缺损的髋关节翻修,适用于Paprosky IIB和IIC型髋臼缺损,两者疗效相当,早期临床效果良好。 关键词：全髋关节翻修术;金属钛网;髋臼缺损;颗粒打压植骨     

The Results of Acetabular Impaction Grafting in 129 Primary Cemented Total Hip Arthroplasties

Between 1995 and 2003, 129 cemented primary THAs were performed using full acetabular impaction grafting to reconstruct acetabular deficiencies. These were classified as cavitary in 74 and segmental in 55 hips. Eighty-one patients were reviewed at mean 9.1 (6.2–14.3) years post-operatively. There were seven acetabular component revisions due to aseptic loosening, and a further 11 cases that had migrated > 5 mm or tilted > 5° on radiological review — ten of which reported no symptoms. Kaplan–Meier analysis of revisions for aseptic loosening demonstrates 100% survival at nine years for cavitary defects compared to 82.6% for segmental defects. Our results suggest that the medium-term survival of this technique is excellent when used for purely cavitary defects but less predictable when used with large rim meshes in segmental defects.     

Impaction Bone Grafting with Low Dose Irradiated Freeze‐Dried Allograft Bone for Acetabular Reconstruction

ObjectiveReconstruction of acetabular defects has been extremely challenging in both primary and revision total hip arthroplasty (THA). Impaction bone grafting (IBG) can restore the acetabulum bone mass and anatomically reconstruct the acetabulum. Our study aimed to report the short and medium‐term clinical and radiographic outcomes of IBG for acetabular reconstruction in the cemented THA in the Chinese population.MethodsThis was a single‐center retrospective review enrolling 57 patients between May 2013 and July 2019. The patients with acetabular defects were treated with IBG, using low dose irradiated freeze‐dried allograft bone with or without autograft bone, in the cemented THA performed by one senior surgeon. Harris hip score (HHS), standard pelvis anterior–posterior radiograph and lateral hip radiograph were obtained before operation and at 1 week, 3 months, 12 months, and yearly. Graft osteointegration was evaluated by Oswestry''s criteria, and complication was documented at the last follow‐up. Independent sample ANOVA test and Pearson chi‐square tests are used for statistical analysis.ResultsThere were 61 hips in 57 patients. The average follow‐up time was 35.59 months (5–77 months). According to AAOS classification, a total of 18 hips were identified as segmental bone deficiency (type I), with 21 and 22 hips for cavitary bone deficiency (type II) and the combined bone deficiency (type III), respectively. The average HHS was improved from 44.49 (range: 32–58) preoperatively to 86.98 (range: 78–93) postoperatively. Graft osteointegration was satisfactory (Oswestry score ≥2) in all patients. No dislocation occurred in the 57 patients (61 hips) during follow‐up. Although one cup migrated, no revision, re‐revision, radiographic loosening, graft bone lysis, or postoperative complications were detected at the final follow‐up.ConclusionsIBG with low‐dose irradiated freeze‐dried allograft bone in acetabular bone defect reconstruction is a reliable technique for restoring acetabular bone defects in THA.     

Impaction Bone Grafting Combined with Titanium Mesh for Acetabular Bone Defects Reconstruction in Total Hip Arthroplasty Revision: A Retrospective and Mini‐Review Study

ObjectiveTo investigate the application of impaction bone grafting (IBG) combined with Ti‐alloy mesh for acetabular bone defect reconstruction in total hip arthroplasty (THA) revision and follow up the clinical outcomes and imaging findings.MethodsThe clinical and imaging data of patients who were admitted to our hospital from January 2000 to December 2020 and underwent acetabular bone defects reconstruction using IBG combined with titanium mesh were retrospectively analyzed. Preoperative and post‐revision Oxford and Harris scores, and post‐revision complications were evaluated. Radiographs were used to determine center of rotation (COR) of the hip joint, transparency line, bone graft fusion, and bone mineral density (BMD) around the hip joint.ResultsSignificant improvement was observed in both Oxford and Harris scores (P < 0.05). The radiographs taken at the last follow‐up examination showed no significant differences in the acetabulum COR, offsets, inclination angle, mean ratio of vertical value, and BMD analysis between the post‐revision side and contralateral side (P > 0.05). The follow‐up data showed restoration of the mesh implant and graft bone fusion.ConclusionsThe application of IBG combined with titanium‐alloy mesh in revision THA patients with acetabular defects was found to provide satisfactory outcomes. However, large‐scale studies are still needed to further elucidate the long‐term outcomes.     

11-Year Mean Follow-Up of Acetabular Impaction Grafting With a Mixture of Bone Graft and Hydroxyapatite Porous Synthetic Bone Substitute

Background

We report an 11-year mean follow-up of the effectiveness of bone impaction grafting with bone and hydroxyapatite (HA) for large, uncontained acetabular defects in primary and revision hip surgeries.

Reconstruction of Acetabular Defects With Impaction Grafting in Primary Cemented Total Hip Arthroplasty Produces Favorable Results: Clinical and Radiographic Outcomes Over 6.4 Years on Average

BackgroundCemented primary total hip arthroplasty (THA) associated with acetabular reconstruction (AR) involving impacted bone grafting has been employed successfully in the revision of cavitary defects but the results are reportedly less predictable for segmental defects. The objective of the study is to evaluate the clinical and radiographic results of patients who had presented cavitary, segmental, and combined acetabular defects and received THA/AR involving impacted morselized cancellous bone autografts followed by rigorous postoperative management.MethodsClinical outcomes were assessed retrospectively of 154 patients who had been submitted to 169 THA/AR procedures performed by a single surgeon over a 15-year period. The Harris Hip Score system was applied to 103 patients, and the degree of acetabular migration was determined from radiograph images of 91 AR procedures, of which 40 were segmental/combined and 51 were cavitary reconstructions.ResultsThe frequency of aseptic acetabular loosening was 3% while that of thromboembolic events was 4.1%. According to Harris Hip Score, 87.4% of outcomes were classified as excellent/good after an average follow-up period of 6.4 years irrespective of the type of acetabular defect. Horizontal and/or vertical acetabular migrations and changes in angular tilt were observed in all ARs, although the minor movements detected did not undermine the structural stability of the reconstructions or the functional capacity of patients.ConclusionThe described THA/AR technique can be used effectively in the reconstruction of segmental/combined and cavitary acetabular defects. The success of the technique as applied to segmental/combined defects was attributed in part to the rigorous rehabilitation protocol with temporary postoperative weight-bearing restriction.     

Mid-term Follow-up of the Direct Anterior Approach in Acetabular Revision Hip Arthroplasty Using a Reconstruction Cage With Impaction Grafting

BackgroundSevere acetabular bone loss is often treated with reconstruction cages and impaction grafting using allograft bone. Accurate implant positioning is crucial for successful clinical and radiological outcomes. The direct anterior approach (DAA) is a standard approach for primary total hip arthroplasty (THA) that is being used more frequently for revision THA. The aim of this study was to report midterm clinical and radiological outcomes of acetabular revision arthroplasty using the DAA to address large acetabular defects by using a reconstruction cage and impaction grafting.MethodsAcetabular cup revisions were performed in 64 patients (64 hips) with severe acetabular bone loss. All patients received reconstruction cages with impaction grafting via the DAA. The stem was also revised in 22 patients. Complications, radiological, and functional outcomes were assessed.ResultsSix of the 64 patients were revised at a mean follow-up of 27.6 months (range, 11-84 months), two each for implant failure, infection, and recurrent dislocation. One hip showed the radiological failure of the implant, but the patient was asymptomatic and was not revised. The median Western Ontario McMasters Osteoarthritis Score (WOMAC) for the cohort overall improved significantly (P < .01) by the latest follow-up compared with preoperative scores.ConclusionGood midterm outcomes can be obtained with the DAA for acetabular cup revisions done to address severe acetabular bone loss by using reconstruction cages and impaction grafting. The number of complications was within the expected range for this type of revision procedure at midterm follow-up, and dislocation rates were low.     

Reconstruction of the Shallow Acetabulum With a Combination of Autologous Bulk and Impaction Bone Grafting Fixed by Cement

Background

Acetabular bone deficiency, especially proximal and lateral deficiency, is a difficult technical problem during primary total hip arthroplasty (THA) in developmental dysplasia of the hip (DDH). We report a new reconstruction method using a medial-reduced cemented socket and additional bulk bone in conjunction with impaction morselized bone grafting (additional bulk bone grafting method).

Questions/purposes

In a population of patients with acetabular dysplasia undergoing THA using a medial-reduced cemented socket and additional bulk bone with impacted morselized bone grafting, we evaluated (1) the radiographic appearance of bone graft; (2) the proportion of cups that developed loosening and subsequent revision; and (3) clinical results (outcome scores and complications).

Methods

Forty percent of 330 THAs for DDH performed at one center between 1999 and 2009 were defined as shallow dysplastic hips. The additional bulk bone grafting method was performed on 102 THAs with shallow acetabulum (31% for DDH) at one center between 1999 and 2009. We used this approach and technique for shallow acetabuli when a cup protruded from the lateral acetabular edge in preoperative templating. The other 132 dysplastic hips without bone grafting had THA performed at the same periods and served as a control. Acetabuli were defined as shallow when the depth was less than or equal to one-fifth of the pelvic height (cranial-caudal length on radiograph). The additional bulk bone grafting technique was as follows: the resected femoral head was sectioned at 1 to 2 cm thickness, and a suitable size of the bulk bone graft was placed on the lateral iliac cortex and fixed by poly-l-lactate absorbable screws. Autologous impaction morselized bone grafting, with or without hydroxyapatite granules, was performed along with the implantation of a medial-reduced cemented socket. We defined an “incorporated” graft as remodeling and trabeculation including rounding off of the protruding edge of a graft beyond the socket. Radiographic criteria used for determining loosening were migration or a continuous radiolucent zone between the prosthesis/bone cement and host bone. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) and the Merle d’Aubigne and Postel score; complications were tallied from chart review. The followup was 10 ± 3 years (range, 6–15 years).

Results

One acetabular component (1%) with severe shallow and steep acetabuli showed definite radiographic evidence of loosening and was revised. Clinically, the mean JOA score for the hips treated with additional bulk bone grafting THA in this study improved from 39 ± 10 points preoperatively to 95 ± 5 points postoperatively (p < 0.05, paired t-test). The mean Merle d’Aubigne and Postel score for the hips improved from 7 ± 2 points to 17 ± 1 points (p < 0.05, paired t-test). Complications included a Trendelenburg sign in one hip, dislocation in one, and transient partial sciatic nerve palsy in one. Within 3 years 6 months postoperatively, 101 of 102 additional bulk bone grafting cases showed successful bone remodeling and bone graft reorientation without collapse on radiographs. Partial resorption of the additional bone graft on the lateral side was observed in two hips (2%) with socket abduction angles of < 35°.

Conclusions

Achieving stable acetabular fixation is often challenging in the dysplastic hip, especially shallow acetabulum, and a variety of techniques have been described. Early results of combining bulk graft with impaction of morselized graft are promising. Although each surgical technique was well established, further investigation for clinical results of a combination of these techniques might be necessary to confirm longer term outcomes.

Level of Evidence

Level IV, therapeutic study.