Isolated Acetabular Revision With Ceramic-on-Ceramic Bearings Using a Ceramic Head With a Metal Sleeve

The purpose of this study is to evaluate results of isolated acetabular revision with ceramic-on-ceramic bearings using a ceramic head with a metal sleeve. A retrospective review of fifty-three hips was performed. The mean patient age was 49.9 years and the mean follow-up period was 5.7 years. The mean modified Harris hip score improved from 47.5, pre-operatively, to 84.7 at the time of last follow-up (P < 0.001). Two patients reported squeaking of the hip. Three patients experienced loosening cup, necessitating re-revision surgery. There was a significant difference of acetabular bone defect between loose cup group and stable cup group (P = 0.018). There were no ceramic fractures and no osteolysis. The survival rate of the acetabular cup at the mid-term follow-up was 94.3%. In conclusion, ceramic head with a metal sleeve can be a reliable option for isolated acetabular revision.     

Cementless Total Hip Arthroplasty in Patients with Osteonecrosis After Kidney Transplantation

This study was to determine the mid- to long-term survivorship of cementless metal-on-metal THA in 52 patients (74 hips) who underwent THA for osteonecrosis of the femoral head with a cementless THA. The mean follow-up was 10.2 years. The mean age at operation was 42.1 years (range, 25–62 years). The survivorship analysis with revision as the end point estimated a 96.6% chance of THA survival during 16.4 years. The average Harris hip score at last follow-up was 89.2 points (range, 74–100). Two patients (two hips) required revision surgery for extensive acetabular osteolysis at 9 years and acetabular liner dissociation at 2 years. The survival rates of cementless THA in these patients are encouraging. However, the possibility of metallic wear related complications are raising concern.     

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.     

Stability of Revision Acetabular Components Using the Rim-Fit Technique

Use of the rim-fit technique in revision acetabular surgery was reviewed for 20 hips in 18 patients. Defects at revision surgery included isolated medial segmental and global cavitary deficiencies with largely intact peripheral rim. A cementless acetabular component is placed to achieve a press-fit against the bony acetabular rim after morselized allograft and/or autograft was placed behind the cup. The average follow-up period was 68.3 months (5.7 years) (range, 27-112 months). Cup migration was assessed using digital radiography. Average vertical migration was 1.02 mm superiorly, and average horizontal migration was 0.8 mm medially. The abduction angle changed on average by 0.25°. Use of the rim-fit technique for treatment of cavitary acetabular defects is associated with component stability and minimal component migration.     

Use of Jumbo Cups for Revision of Acetabulae With Large Bony Defects

Several methods of treatment are available for acetabular revision associated with bone loss. Jumbo cups (minimum diameter of 62 mm in women, 66 mm in men, or 10 mm larger than the normal contralateral acetabulum) are often useful for large defects. The purpose of this study is to report a large jumbo cup series with an average 10-year follow-up. A total of 196 jumbo cups in 186 patients with a minimum of 2-year follow-up were available for review. Harris hip score improved from 44 preoperatively to 72 postoperatively. Survivorship was 98% at 4 years and 96% at 16 years. Five revisions and two resection arthroplasties were performed for failure. In conclusion, porous jumbo cup acetabular revision with supplemental screw fixation provides good to excellent intermediate- and long-term outcomes.     

Acetabular revision with morsellised allogenic bone graft and a cemented metal-backed component

Failure of total hip arthroplasty with acetabular deficiency occurred in 55 patients (60 hips) and was treated with acetabular revision using morsellised allograft and a cemented metal-backed component. A total of 50 patients (55 hips) were available for clinical and radiological evaluation at a mean follow-up of 5.8 years (3 to 9.5). No hip required further revision of the acetabular component because of aseptic loosening. All the hips except one had complete incorporation of the allograft demonstrated on the radiographs. A complete radiolucent line of > 1 mm was noted in two hips post-operatively. A good to excellent result occurred in 50 hips (91%). With radiological evidence of aseptic loosening of the acetabular component as the end-point, the survivorship at a mean of 5.8 years after surgery was 96.4%. The use of impacted allograft chips in combination with a cemented metal-backed acetabular component and screw fixation can achieve good medium-term results in patients with acetabular bone deficiency.     

大量同种异体颗粒骨打压植骨结合多孔非骨水泥臼杯翻修髋臼大面积骨缺损的中期疗效

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翻修大面积髋臼骨缺损的技术要点,并随访其中期临床和影像学疗效。方法随访2004年9月-2009年8月之间连续收治的采用同种异体颗粒骨打压植骨联合非骨水泥多孔髋臼杯翻修髋臼骨缺损面积大于整个髋臼关节面50％的27例（27髋）患者。按AAOS分类标准均为AAOSⅢ型骨缺损。按Paprosky分类标准,PaproskyⅡ型19例（19髋）,PaproskyⅢ型8例（8髋）。髋臼假体与宿主自体骨接触面积均小于50％;其中有19例患者的髋臼杯全完与异体骨接触。评价术前、术后的Harris评分,肢体长度。在X线片上评价髋关节旋转中心、髋臼侧透亮线、以及植骨融合情况,并判断髋臼有无松动和移位。用Kaplan-Meier生存分析评价髋臼假体的6年生存率。结果患者均完成随访,平均随访时间（6．4±1．4）年（4～9年）。术前Harris评分为（14．9±4．4）分（6-34分）,最后随访时的Harris评分为（85．6±8．1）分（67～98分）,差异具有统计学意义意义（t=22．181,P〈0．01）。术前肢体短缩（14．7±5．1）mm（6～24mm）,术后肢体短缩（0．2±3．4）mm（-9～12mm）,差异具有统计学意义（t=19．223,P〈0．01）。术后髋关节旋转中心均在Renawat三角内。所有病例术后1～1．5年植入的异体骨均与宿主骨融合。无髋臼假体松动或失败。髋臼假体的6年生存率为100％（95％可信区间为0．95～1．0）。结论髋臼AAOSⅢ型、PaproskyⅡ型甚至部分Ⅲ骨缺损,只要髋臼顶及前、后柱3个方向均存在大部分的骨皮质及一定的支撑作用,即便骨缺损面积大于髋臼关节面的50％,仍可采用同种异体骨颗粒骨打压植骨结合多孔非骨水泥臼杯髋臼重建术进行修复,并可取的满意的中期疗效。     

Acetabular revision total hip arthroplasty using an impacted morselized allograft and a cementless cup: minimum 10-year follow-up

This study was undertaken to analyze the clinical and radiologic results of acetabular revision arthroplasty using an impacted morselized allograft and a cementless cup and was performed on 71 hips of 62 patients who were followed up for a minimum of 10 years (10 years to 14 years 8 months; mean, 12 years). The acetabular bone defects were classified using the American Academy of Orthopaedic Surgeons Committee on the Hip and Paprosky classifications. Cementless hemispherical cups were inserted via a press-fit technique, using an impacted morselized allograft. The mean Harris hip score at the last follow-up visit was 92. Only 3 cases were re-revised, and the 12-year survival rate was thus 95.8%. The study shows that acetabular revision arthroplasty using an impacted morselized allograft and a cementless cup is an excellent treatment option.     

Acetabular Cup Revision With the Use of the Medial Protrusio Technique at an Average Follow-up of 6.6 Years

A significant rim defect encountered during revision surgery can make stable cementless cup fixation difficult. One approach to this problem is to medialize the acetabular cup to improve the degree of rim contact. In this study, we investigate this technique, termed the medial protrusio technique, for acetabular fixation in revision hip arthroplasty. A retrospective review of 25 patients (25 hips) who underwent medialization was performed. Clinical and radiographic evaluation was performed. At an average follow-up of 6.6 years, the overall patient function and satisfaction were good to excellent, with a mean Harris hip score of 85.2. This demonstrates that the medial protrusio technique can be a valuable option in addressing acetabular cup failure.     

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. A 15- to 20-year follow-up

This study presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients, at a mean of 16.5 years follow-up (15 to 20). The Kaplan-Meier survivorship for the cup with end-point revisions for any reason, was 79% at 15 years (95% confidence interval (CI); 67 to 91). Excluding two revisions for septic loosening at three and six years, and one revision of a well-fixed cup after 12 years in the course of a femoral revision, the survivorship was 84% at 15 years (95% CI; 73 to 95). At review there were no additional cases of loosening, although seven acetabular reconstructions showed radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.7 cm to 1.0 cm) and a cemented cup, is a reliable technique of reconstruction, when assessed at more than 15 years.     

Structural Allograft Supporting a Trabecular Metal Cup Provides Durable Results in Complex Revision Arthroplasty

Background

Revision total hip arthroplasty (THA) is challenging specially in the presence of severe acetabular bone deficiency. We report the use of a highly porous revision shell augmented by structural allograft to provide structural support and coverage to the acetabular component.

Results of cemented metal-backed acetabular components: A 10-year-average follow-up study

The clinical and radiographic results of 86 primary total hip arthroplasties performed in 74 patients from 1983 to 1987 with a cemented metal-backed acetabular component and a cemented collared straight femoral stem with a 32-mm head were reviewed at a mean follow-up of 10.1 years. Seven patients (9.2%) underwent acetabular component revision at a mean of 9.0 years after implantation; an additional 24 components (31.6%) demonstrated evidence of radiographic loosening, resulting in a total failure rate of 40.8%. Periacetabular radiolucencies were noted in Charnley zones at the following rates: 34.2% in zone I, 18.4% in zone II, and 27.6% in zone III. In addition, 18.4% and 38.2% of implants demonstrated evidence of migration and excessive polyethylene wear. Excessively vertical cup placement (>49° inclination) at the time of initial arthroplasty was statistically correlated with polyethylene wear, implant migration, and fixation failure. A trend of increasing implant failure was also noted with decreasing polyethylene liner thickness. Periacetabular cement mantle thickness was not statistically correlated with subsequent component loosening or failure. Results of Kaplan-Meier survivorship analysis using revision as an endpoint showed 93.6% survivorship at 10 years and 88.4% at 12 years. The mean modified Harris hip scores were 46.9 preoperatively and 81.8 at final follow-up. The significant overall rates of radiographic loosening, migration, polyethylene wear, and implant revision confirm the suspected trend of increasing failure rates of cemented metal-backed acetabular components over time.     

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.     

Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty

Bone loss represents one of the greatest challenges in revision joint surgery. A retrospective review was conducted of both radiographic and clinical outcomes of eleven patients who underwent revision arthroplasty using a long extensively porous coated cylindrical femoral component. All patients' femurs presented with severe proximal femoral bone loss (Paprosky class IIIB and IV). With a mean follow-up of 8 years (2 to 14) we report no femoral revisions and one acetabular revision to a constrained cup secondary to instability. All patients were clinically and radiographically stable. We did not observe any issue with proximal stress shielding or component loosening. The article reports that in patients with severe proximal femoral bone loss, extensively porous-coated non-modular stems are a viable option offering stable and predictable outcomes.     

Midterm survivorship of a press-fit, plasma-sprayed, tri-spike acetabular component

Press-fit acetabular cups without screw holes can limit migration of particulate wear debris and reduce risk of acetabular osteolysis and device loosening. The Tri-Spike cup (Biomet, Inc, Warsaw, Ind) includes a titanium alloy plasma spray porous surface and does not require screw fixation. We retrospectively examined the incidence of cup loosening and acetabular osteolysis after implantation of 45 cups (44 patients) with mean follow-up of 7.3 years (range, 4-9 years). Only one patient (one cup) had evidence of less than 1 mm of retroacetabular radiolucency at 3 years (nonprogressive), which was found to remain firmly fixed during revision of the aseptically loosened femoral component. No cups were removed or revised at latest follow-up. Projected Kaplan-Meier survivorship at 9 years was 100% for cup loosening/revision and 97.8% for radiolucency.     

Minor column structural acetabular allografts in revision hip arthroplasty

A minor column (shelf) allograft is used for uncontained defects that involve less than 50% of the acetabulum. The prospectively collected records and radiographs of 47 patients (51 hips) who had undergone minor column structural acetabular allograft reconstruction during revision hip arthroplasty were reviewed. The purpose was to identify the long-term results (minimum 5 years) and factors that may influence longevity of the allograft and predispose the patient to subsequent acetabular component failure. The mean duration of followup was 119 months (range, 68-195 months). There was one perioperative death and six patients were lost to followup. Eleven patients (22%) required additional surgery. Three acetabular cups could not be revised successfully, despite multiple attempts, and the patients were treated with Girdlestone excisions. Eight patients underwent successful revision surgery with only three requiring a repeat structural allograft. Survival time for the acetabular cup as determined by Kaplan-Meier analysis was 153 months (95% confidence interval; range, 136-169 months). Cup failure was associated with more operative procedures performed before revision surgery (mean, 3.2 procedures), and failure to restore the vertical center of hip rotation to within 12 to 14 mm of the predicted value. The acetabular abduction angle was not a predictor for failure. The current study shows that good results can be achieved with structural acetabular allograft reconstruction with mid-term to long-term implant survival (cup aseptic survival, 80.4% and allograft re-construction survival, 94.1%), especially if there is restoration of near normal hip biomechanics.     

Circumferential osteotomy of the medial acetabular wall in total hip replacement for the late sequelae of childhood septic arthritis of the hip

We performed 52 total hip replacements in 52 patients using a cementless acetabular component combined with a circumferential osteotomy of the medial acetabular wall for the late sequelae of childhood septic arthritis of the hip. The mean age of the patients at operation was 44.5 years (22 to 66) and the mean follow-up was 7.8 years (5 to 11.8). The mean improvement in the Harris Hip Score was 29.6 points (19 to 51) at final follow-up. The mean cover of the acetabular component was 98.5% (87.8% to 100%). The medial acetabular wall was preserved with a mean thickness of 8.3 mm (1.7 to 17.4) and the mean length of abductor lever arm increased from 43.4 mm (19.1 to 62) to 54.2 mm (36.5 to 68.6). One acetabular component was revised for loosening and osteolysis 4.5 years postoperatively, and one had radiolucent lines in all acetabular zones at final review. Kaplan-Meier survival was 94.2% (95% confidence interval 85.8% to 100%) at 7.3 years, with revision or radiological loosening as an end-point when two hips were at risk. A cementless acetabular component combined with circumferential medial acetabular wall osteotomy provides favourable results for acetabular reconstruction in patients who present with late sequelae of childhood septic hip arthritis.     

2- to 10-year follow-up study of acetabular revisions using allograft bone to repair bone defects

The failure rates of revision of acetabular components have been high; however, long-term success has been reported with the use of particulate allografts or autografts with large-diameter prosthetic cups to correct bone deficiencies when host-cup contact is at least 30% to 50%. The purpose of this study was to review 2- to 10-year follow-up data on complex acetabular revisions in which contact between allograft bone and the prosthetic cup was at least 50%. In the 47 hips monitored clinically and radiographically for a mean of 5 years, results were classified as excellent in 37%, good in 26%, fair in 17%, and poor in 19%. The mean Harris hip score was 82.5 (range, 39–100). The prosthetic cups migrated in 3 hips, but 2 stabilized within 1 year. Three cups had complete radiolucent lines without migration; the lines did not correlate with location of the allografts. Although bone ingrowth into porous surfaces from allografts is debatable, the results of the study show that massive allograft reconstruction of the acetabulum can provide both immediate and long-term stability of the prosthetic cup and restore bone stock.     

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.     

Does Revision of an Acetabular Shell With Insertion of an Uncemented Constrained Liner Confer Benefit Over Cementing Into a Well-Ingrown Shell?

BackgroundDuring revision total hip arthroplasty (THA), a constrained acetabular liner (CAL) may be inserted to enhance hip stability. It is unclear, however, whether cementation of a CAL into a retained cup offers an advantage compared to revision of the acetabular cup and insertion of an uncemented CAL. The purpose of our study was to compare outcomes and survivorship between the 2 methods.MethodsWe identified a total of 177 patients who underwent revision THA with a specific CAL at our center between July 2004 and May 2019 (114 cup revisions and insertion of an uncemented CAL, 63 cementations of a CAL into a retained cup). Kaplan-Meier (KM) survival analysis was performed for implant survival free from aseptic failure of the CAL for both cohorts.ResultsThe average follow-up time was 7.2 and 7.02 years for the cemented and uncemented cohort, respectively (P = .55). Five patients (7.93%) in the cemented CAL group experienced failure of the CAL, whereas 10 patients (8.77%) in the uncemented CAL cohort experienced failure (P = .21). Kaplan-Meier (KM) survival analysis demonstrated comparable survivorship at 10 years (P = .055).ConclusionThe results of our study suggest comparable survivorship between cementing a CAL into a retained cup and inserting an uncemented CAL in a revised acetabular cup. As a result of these findings along with the benefits associated with cementing a CAL, we encourage surgeons to readily consider this option in the management of recurrent instability.