Delayed neuropathy of the sciatic nerve after total hip replacement with an acetabular reinforcement ring

AIM: Lesions of the sciatic or femoral nerve after THR are typical complications. Delayed neuropathies of the sciatic or femoral nerve are rare conditions. CASE REPORT: We report the case of a delayed neuropathy of the sciatic nerve after THR with reconstruction of the acetabulum with an acetabular reinforcement ring. After electrophysiologic evaluation we performed a revision of the sciatic nerve. Intraoperatively we found an impingement of the sciatic nerve between the dorsal aspect of the acetabular reinforcement ring and scar tissue. After revision of the nerve, resection of the scar tissue and interposition of a fat pad the patient was out of any complaints but reported some sensory deficits of the first toe. CONCLUSION: Using acetabular reinforcement rings for reconstruction of acetabular defects care has to be taken of the correct position. In anatomically cramped positions a protruding of the dorsal edge of the ring may cause a lesion of the sciatic nerve.     

Impingement of the iliopsoas muscle after revision of a loosened acetabular cup with an acetabular reinforcement ring

Impingement of the iliopsoas muscle due to a protruding acetabular component is an uncommon cause of pain after total hip arthroplasty. We report the case of a 59 year old female patient who developed groin pain one year after revision arthroplasty and reconstruction of the acteabular defect with an acetabular reinforcement ring due to a loosened cup. THERAPY AND FOLLOW UP: After revision of the right hip via an anterior approach we used bone cement to smooth the anterior edge of the acetabular reconstruction ring and created a smooth rim for the iliopsoas tendon. At follow up 2 years later the patient was satisfied with the result, she complained about very rare recurrent groin pain, without any need for further treatment.     

Complications of ilioischial reconstruction rings in revision total hip arthroplasty

The complications, management, and outcome of a consecutive series of 61 ilioischial reconstruction rings performed by 1 surgeon over a 15-year period are reported. Structural corticocancellous allografts were used in 48 cases. Twenty-seven cases had no complications, 9 had medical complications, and 5 had complications related to femoral revision. Other complications included 4 sciatic and 2 peroneal nerve palsies, 4 rings that lost fixation, 1 possibly loose ring, 3 fractured flanges, 3 loose cups, 7 dislocations, and 3 deep infections. Success, defined as a stable reconstruction with no further acetabular revision and bone graft incorporation, was 76%. We recommend a constrained acetabular liner to avoid dislocation in selected cases, slotting the ischial flange into bone for further ring stability and protection of the sciatic nerve.     

Radiological evaluation of allograft reconstruction in acetabulum with Ganz reinforcement ring in revision total hip replacement

Background  

In revision total hip replacement (THR), cages and rings are commonly used for the reconstruction of bone defects that are due to mechanical loosening of the acetabular cup and migration of the femoral head prosthesis. The purpose of this study was to evaluate the radiological results of the use of Ganz reinforcement rings with bone allografts in acetabular revision THR.     

髋臼翻修过程中固定螺钉安全区的解剖学研究

目的 探讨评估髋臼翻修过程中假体同定螺钉的安全区域,测试四象限系统的有效性.方法 2006年12月至2008年1月,制备11例(22髋)正常国人冷冻骨盆髋标本,剔除肌肉组织后每例标本固定在仰卧位置,安装假体前后拍摄X线片,测量髋臼旋转中心的位置变化.右侧半髋用于评估超大(Jumbo)髋臼假体和高中心髋臼假体同定螺钉的安全区.左侧半髋用于评估3种重建加强环固定螺钉的安全区(臼内区和臼外区).结果 超大髋臼假体前上象限和前下象限发生了神经或血管损伤.高中心髋臼时除了后上象限后半部和后下象限以外其余象限均发生了神经或血管损伤.Müller重建环在前上象限(臼内12(和臼外区)发生了神经或血管损伤.Ganz重建环在前上象限(臼内区和臼外区)和臼顶区发生了神经或血管损伤,Butch-Schneider重建网笼在前上象限(臼内区和臼外区)和坐骨同定钉(当出骨长度大于15 mm时)发生了神经或血管损伤.结论 应用Jumbo非骨水泥假体和重建环时可以参照初次全髋关节置换时叙述的安全区.高中心髋臼手术时,我们常用的阴象限方法需要改进,前上象限及后上象限前部和臼顶区为不安全区域.     

Revision surgery in pelvic discontinuity: an analysis of seven patients

The technical aspect and clinical outcome of seven patients with pelvic discontinuities in acetabular revision surgery after a mean followup of 96 months were analyzed. The surgical treatment consisted of three consecutive steps beginning with mechanical stabilization of the two acetabular columns, followed by bony acetabular reconstruction by filling the osteolytic defect with allograft chips covered with autologous bone to achieve a contained defect after healing of the autograft, and anchorage of the cup using an acetabular reinforcement ring (five with a hook, two without a hook). Complications included a partial ischial nerve lesion, one intraoperative femoral shaft fracture, and one recurrent dislocation. One patient had revision surgery 12 months after the first revision surgery because of aseptic loosening, and in one patient two prominent screws had to be removed. The clinical improvement according to the Harris hip score was 40.1 points on average (preoperative, 33 points; postoperative, 73.1 points). At the final followup all acetabular components were stable and the pelvic discontinuity had healed. Despite the technical feasibility of such revisions and the acceptable clinical results, the complication rate is high. Early diagnosis of acetabular loosening to minimize the osteolytic loss of bone stock is important.     

Long-term results of primary hip total prosthesis with acetabulum reinforcement ring

The Müller acetabular reinforcement ring has proven very useful, especially in total hip revision when the bone of the acetabulum is of poor quality or deficient. However, the acetabular reinforcement ring may also be indicated in primary total hip replacement, especially in the case of poor quality bone in the acetabular bone stock, e.g. in chronic polyarthritis or protrusio acetabuli, or of deficient morphology of the acetabulum, e.g. in hip dysplasia. We analysed the results recorded in 145 patients operated on between 1977 and April 1983. Each of these patients had received a total hip prosthesis for the first time, with the polyethylene cup supplemented by an acetabular reinforcement ring. This patient group cannot be compared with the usual patient populations reported on in connection with primary hip replacement, since most of our 145 patients had several risk factors and had undergone previous surgery on up to seven occasions on the hip ultimately replaced by a prosthesis. Radiological analysis did not show a significant correlation between malposition of the acetabular reinforcement ring and signs of loosening, except when the acetabular component had been implanted in a most atypical manner. The infection rate was 4.8%, but it must be borne in mind that from 1977 to 1983 there was no routine prophylaxis with antibiotics. The incidence of aseptic loosening of the acetabular reinforcement ring necessitating revision was 0.7% after a mean follow-up of 7.7 years (range 5.5-11 years).(ABSTRACT TRUNCATED AT 250 WORDS)     

The use of motor-evoked potentials to monitor sciatic nerve status during revision total hip arthroplasty

Sciatic nerve palsy is an uncommon complication after total hip arthroplasty (THA) but can cause permanent functional impairment in the extremity. The goal of this study was to identify specific intraoperative maneuvers that may increase the risk of sciatic nerve injury during revision THA. Motor-evoked potentials (MEPs) were used in combination with electromyography (EMG) monitoring during revision THA in 27 consecutive patients to identify intraoperative events that cause conduction abnormalities through the sciatic and peroneal nerves. MEP monitoring required general anesthesia and a neurophysiologist in the operating room throughout the procedure. Significant electrical events occurred, most commonly during acetabular reconstruction. Hip flexion should be avoided during posterior acetabular retraction when using the posterior approach with posterior dislocation. The position of the sciatic nerve should be clearly identified when complex structural acetabular augmentation with allograft is performed during revision THA. MEP monitoring was used as a research tool for this study. However, we do not use MEP monitoring in our revision THA clinical practice.     

Bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis, seventy eight revisions using bone allografts with or without metal reinforcements

Purpose

The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA).

Methods

We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices.

Results

In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications.

Conclusions

Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.     

Revision arthroplasty--acetabular aspect: cementless acetabular bone reconstruction

The increasing occurrence of aseptic loosening, often accompanied by extensive acetabular defects, confronts the surgeon with severe difficulties. Multisegmental acetabular defects can be treated by bone grafting and metal antiprotrusion support rings. With these techniques, pelvis defects can be reconstructed to achieve a stable and permanent fixation of the acetabular component. Since 1983, more than 850 patients underwent revision surgery of the acetabular component using a reinforcement ring. Forty-one consecutive cases were available for follow-up, including clinical and radiographic examination as well as evaluation of patient history on average 7.3 years after operation. We report the follow-up results of these cases, which demonstrate that this kind of revision surgery guarantees a solid and stable situation at the acetabular component.     

Clinical and Radiological Outcome of Acetabular Reconstruction Rings in Complex Primary and Revision Total Hip Arthroplasty

BackgroundAcetabular reconstruction in complex primary and revision total hip arthroplasty (THA) with bone loss poses a great challenge. We aim to evaluate the medium-term clinical and radiological outcome of reconstruction rings used in these difficult situations. MethodsWe retrospectively reviewed a consecutive series of acetabular reconstructions with Muller ring or Bursh-Schneider cage from January 2009 to December 2016. The reconstruction rings were used in 66 hips (65 patients). There were 41 complex primary THA and 25 revision THA. The mean follow-up period was 76 months (range, 37–167 months). Clinical evaluation includes the assessment of Harris hip score, visual analogue scale (VAS) score, limb length discrepancy, and activities of daily living. The radiographs were analyzed for any signs of loosening, osteolysis, acetabular migration, and heterotopic ossification.ResultsThe overall survival rate was 95% for revision in aseptic loosening and 87% for any reason at an average follow-up of 6.3 years. Twelve patients died and 9 patients were lost to follow-up leaving 45 patients for final functional analysis. Among the 45 patients, excellent to good results were seen in 33 patients, fair results were seen in 5 patients, poor results were seen in seven patients. Two patients had aseptic loosening and another two patients developed deep chronic infection awaiting two-stage revision.ConclusionReconstruction rings still place a role in the armamentarium for complex acetabular reconstruction. It helps to reliably restore the bone stock, have an acceptable survival rate and satisfactory functional outcome at medium to long-term follow-up.     

Retroperitoneal Hematoma : An Unusual Cause of Pain After Total Hip Arthroplasty

Pain following total hip arthroplasty due to impingement of the iliopsoas is a recognized complication of the procedure with a reported incidence as high as 4.3%. The pain is most often due to direct mechanical irritation of the iliopsoas due to a malpositioned or oversized acetabular cup. Definitive treatment of iliopsoas impingement often requires surgical revision or iliopsoas tenotomy, although many cases remain undiagnosed or are managed conservatively. We present an unusual case of pain after total hip arthroplasty due to a large retroperitoneal hematoma secondary to acetabular cup irritation of the iliopsoas tendon. This case represents a potentially important complication of undiagnosed or conservatively managed iliopsoas impingement, particularly in patients taking anticoagulants or antiplatelet medications.     

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

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

Retroperitoneal hematoma: an unusual cause of pain after total hip arthroplasty

Pain following total hip arthroplasty due to impingement of the iliopsoas is a recognized complication of the procedure with a reported incidence as high as 4.3%. The pain is most often due to direct mechanical irritation of the iliopsoas due to a malpositioned or oversized acetabular cup. Definitive treatment of iliopsoas impingement often requires surgical revision or iliopsoas tenotomy, although many cases remain undiagnosed or are managed conservatively. We present an unusual case of pain after total hip arthroplasty due to a large retroperitoneal hematoma secondary to acetabular cup irritation of the iliopsoas tendon. This case represents a potentially important complication of undiagnosed or conservatively managed iliopsoas impingement, particularly in patients taking anticoagulants or antiplatelet medications.     

Acetabular anti-protrusio rings and cages in revision total hip arthroplasty

Uncemented hemispherical porous-coated acetabular components work well for the great majority of acetabular component revisions. Unfortunately, when bone loss is so severe that little contact between a porous-coated socket and native bone can be achieved, high rates of failure of uncemented porous-coated sockets have been reported. When circumstances are encountered in which porous-coated hemispherical sockets are unlikely to succeed, acetabular reinforcement devices have advantages over cemented polyethylene sockets alone. The ability of antiprotrusio rings and cages, now used to augment socket fixation to the pelvis, facilitate extensive pelvic bone grafting, and prevent early socket migration, have led to renewed interest in these devices as useful tools in the orthopedic surgeon's armamentarium to manage some of the most challenging acetabular reconstruction problems. This article discusses the rationale for selected use of acetabular reinforcement devices, the reported results of using acetabular reinforcement rings and cages in revision total hip arthroplasty, and the circumstances in which these devices may be considered for acetabular reconstruction at the present time.     

Mueller roof reinforcement rings. Medium-term results.

Short term results of cemented acetabular reconstruction with the use of the Mueller reinforcement ring in 30 hips in 29 patients have been reported previously. The indications for reinforcement were primary and postrevision segmental, cavitary, and combined acetabular deficiencies. The current study reports the medium term clinical and radiologic results of 20 of the 29 patients who were surgically treated (18 primary and eight postrevision hips) and who underwent followup with detailed clinical and radiographic analysis within an average of 9 years (range, 7-12 years). In the latest followup, there has been a statistically insignificant decrease in clinical scores compared with those obtained immediately after surgery; the changes probably are a result of the patients' aging. The radiologic scores at the latest followup were lower, although not statistically significant, than those at the short term followup. The causes of the three ring failures that occurred 5, 8, and 8.5 years after surgery and required revision arthroplasty were either acute trauma or tuberculous arthritis. Three additional hips (two primary and one revision) had evidence of loosening in the ring and socket associated with symptomatology and were considered as hips with impending revision. The rate of success of primary implantation was 94% at 7 years, 86% at 10 years, and 86% at 12 years and was not statistically different from that of revision implantation, which was 86% in all three followup periods. In this small series this surgical technique was successful and effective and followed by good medium term clinical and radiographic results in primary and revision implantation in segmental, cavitary, or complex acetabular deficiencies and in osteoporotic or deficient acetabular bone.     

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.     

Azetabuläre Defektrekonstruktion in der Revisionschirurgie der Hüfte

The treatment of periprosthetic bone defects of the acetabulum is a therapeutic challenge in hip revision surgery. The aims are the biological reconstruction of osseous acetabular defects and the restoration of a load-bearing acetabular bone stock as well as restoring the physiological joint biomechanics and achieving primary and load-stable fixation of the revision graft in the vital pelvic bone. The biological reconstruction of the acetabular bone stock should include what is referred to as “down-grading” of the acetabular defect situation in case a repeat revision procedure becomes necessary. Nowadays, a large variety of grafts and reconstruction procedures are available for the reconstruction of acetabular defects. The choice of suitable materials (osseous or metallic) for the restoration of a load-bearing acetabular bone stock is currently the subject of controversial discussion. This article reviews the various options for the reconstruction of acetabular bone defects taking into consideration the current findings in the scientific literature.     

Acetabular reinforcement in total hip replacement

In 21 cases of severe secondary protrusio acetabuli with extensive or total destruction of the acetabular cortical structures, the double anchorage of conventional polyethylene cups with nine Müller acetabular reinforcement rings and 12 Burch-Schneider anti-protrusio reinforcement cages was carried out. They were applied in combination with reconstructive surgery of cancellous bone in three primary total hip replacements and in 18 revision operations for loosened acetabular cups following total arthroplasties. Indication for and technique of the acetabular reinforcement are described. The radiological and clinical results in 21 patients followed up were satisfactory. They confirm the efficiency of these screw-fixed reinforcement implants for the solid fixation of the plastic cup in patients with extreme acetabular deficiencies.     

Cemented hip revision surgery in severe acetabular defects using a semirigid acetabular reinforcement ring--a 5- to 25-year follow-up study

Between 1978 and 1998, a total of 38 consecutive acetabular component revisions were performed in 38 patients. Average age was 67 years, and 87% of patients had severe uncontained segmental acetabular defects of more than 50%. We describe the operative technique of acetabular component revisions performed with bone grafting and a steel, semirigid acetabular reinforcement ring (Eichler), and long-term results are presented. After an average of 11.2 years follow-up, 1 cup was revised after 0.8 years for mechanical loosening, but the ring remained stably fixed. Remodeling (partial) of autografts occurred in all cases. The average HHS was 72.5. The Eichler reinforcement ring is a viable option for segmental acetabular defects in revision hip surgery, allows for restoration of pelvic bone, and makes future revisions feasible.