Acetabular prosthetic protrusion and sepsis: case report and review of the literature

Acetabular prosthetic protrusio is an unusual complication of total hip arthroplasty that develops from erosion of the medial acetabular wall and intrapelvic migration of the implant. This report reviews 3 cases of severe intrapelvic prosthetic migration where acute or chronic sepsis was associated with the condition. All subjects were female and involved the left hip. In each case, debridement of the intrapelvic implant was required with an intra-abdominal approach. After successful eradication of infection, 2 patients have a well-functioning reimplanted prosthesis, and 1 was left with a Girdlestone arthroplasty. Literature review revealed that 11 of 16 similar prosthetic protrusion cases had chronic sepsis, of which, 10 were female and 9 involved the left hip. Chronic infection should be considered when intrapelvic prosthetic migration occurs after total hip arthroplasty.     

Arthrodesis for failed arthroplasty of the hip

The results of Girdlestone arthroplasty after failure of total hip arthroplasty have been found to be functionally poor in the physiologically young patient. The authors have evaluated 14 patients who were treated by hip arthrodesis following repeated failed arthroplasty. The average number of previous procedures was 2.6. Seven were infected prior to arthrodesis. A modified A.O. technique was used in all cases and was followed by hip spica immobilization. The average age of the patients was 38 years. All but one were men. Thirteen of the patients healed their arthrodesis primarily. Pain relief was excellent and most patients were able to return to their original jobs, in contrast to the results in patients with Girdlestone arthroplasty. Osteotomy or arthrodesis is preferred to total hip arthroplasty in the young, active patient with unilateral osteoarthritis. Arthrodesis is also possible and has a high rate of functional success after failed arthroplasty, infected or noninfected.     

Transabdominal approach for intrapelvic migration of a total hip prosthesis component

We report a patient with severe intrapelvic migration of the acetabular component after total hip arthroplasty. Preoperative drip infusion pyelography showed a medial shift in the ureter caused by the migrated acetabular component. Preoperative angiography showed that the right external iliac artery was compressed and shifted medially by the migrated acetabular component. At revision surgery, the migrated acetabular component was successfully removed through a transabdominal (transperitoneal) approach, with the assistance of a general surgeon, and reconstruction was performed through a transtrochanteric approach. We concluded that the transabdominal approach was a useful approach for removing a severely migrated acetabular component. Received: December 19, 2000 / Accepted: March 5, 2001     

Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003

Total hip replacement has an important role in the treatment of acetabular fractures. Immediate total hip arthroplasty is only indicated for some rare cases but late reconstruction is performed more frequently and may follow failed non-operative or operative treatment of the original acetabular fracture. INTRODUCTION: The purpose of this study is to determine the results of the use of total hip replacement for the treatment of acetabular fractures and to compare the results of the early and late reconstruction group. MATERIALS AND METHODS: 121 acetabular fractures treated with total hip arthroplasty between 1983 and 2003 at the University Hospitals Gasthuisberg in Leuven, Belgium were retrospectively studied. The patients were divided into two groups. In the "early reconstruction group" total hip arthroplasty was performed as primary treatment of the acetabular fracture. In the "late reconstruction group": total hip arthroplasty was performed following failed operative or non-operative treatment of the acetabular fracture. The indications for total hip arthroplasty and the surgical technique in both the early and late reconstruction group were compared. Secondly, complications were reviewed in both groups and a functional scoring system was applied for each patient. RESULTS: Primarily there was a significant difference in the age of the patient population of each group with a predominance for older patients in the early reconstruction group. Secondly, less revisions were performed in the early reconstruction group: 8% compared to 22% in the late reconstruction group. DISCUSSION: The results obtained in our patient groups were compared to the results found in literature by a Medline search. In general, our results were comparable to the results found in literature but a remarkable difference was found between different authors. CONCLUSION: Total hip replacement for acetabular fractures is rarely indicated in the acute phase. After failed treatment of an acetabular fracture, total hip replacement has to be considered as a salvage procedure. In both cases, one may not forget total hip arthroplasty is a severe intervention associated with a high number of complications.     

Intrapelvic cyst formation after hip arthroplasty with a carbon fibre-reinforced polyethylene socket

Carbon fibre-reinforced polyethylene cups were inserted in total hip arthroplasties for both hips of a male patient. Ten years after the arthroplasty of the right hip, an intrapelvic cyst was observed. The cyst was connected to the inner acetabular wall. The endoprosthetic cup showed gross loosening with a marked osteolysis of the acetabulum. Revision arthroplasty with allograft bone and an uncemented endoprosthesis was successfully performed. The fibrotic tissue at the bone-cement interface showed numerous histiocytic cells with cytoplasmic infiltrates of carbon and polyethylene particles. The left hip was also later revised for loosening, but no cyst formation was observed on that side.     

Retroperitoneal migration of a septically loose femoral component

Migration of total hip arthroplasty components is generally associated with a medial acetabular wall defect and may cause various intrapelvic complications. This is often a result of the destructive bone loss that takes place with infection. To our knowledge, this is the first report that presents complete intrapelvic migration of a femoral stem of total hip arthroplasty due to septic loosening with an intact medial acetabular wall.     

钽金属臼杯重建髋臼骨缺损的近期疗效

 目的 探讨应用钽金属臼杯对不同类型髋臼骨缺损进行重建的近期疗效。方法 回顾性分析2009年8月至2012年4月在全髋关节置换术中使用钽金属臼杯重建髋臼骨缺损的连续21例患者的病例资料,男6例,女15例;年龄24~78岁,平均(53.7±16.2)岁。初次全髋关节置换5例：Crowe Ⅳ型髋关节发育不良2例、髋关节感染后遗高位脱位畸形2例、类风湿关节炎1例;全髋关节翻修16例：全髋关节置换术后感染二期翻修2例、髋臼金属炎性假瘤3例、假体无菌性松动11例。骨缺损Paprosky分型Ⅰ型9例,Ⅱa型4例,Ⅱb型5例,Ⅱc型1例,Ⅲa型1例,Ⅲb型1例。观察术后髋臼假体周围透光线、假体位置、生存率、并发症及Harris髋关节评分。结果 全部病例随访6~40个月,平均20.1个月。末次随访时PaproskyⅠ型患者的Harris髋关节评分(87.2±7.4)分,高于术前(41.1±6.3)分;Ⅱ型(79.8±11.8)分,高于术前(38.4±12.5)分;Ⅲ型为79分,高于术前24分。随访期间钽金属臼杯固定良好,未出现松动及移位,假体生存率100%。按照Anderson骨长入影像学评价标准,髋臼杯均出现不同程度骨长入。1例于DeLee-Charnley髋臼3区出现透光线,4个月后消失;1例于髋臼1区出现假体周围间隙,随访6个月未进展。1例于术后4周出现后脱位。结论 应用钽金属臼杯重建PaproskyⅠ、Ⅱ型髋臼骨缺损,能实现早期与宿主骨整合,近期疗效好。     

Intrapelvic complications after total hip arthroplasty failure

BACKGROUND: Severe total hip arthroplasty failure with central migration of prosthetic components is uncommon. If perforation of the medial acetabular wall occurs, injuries of intrapelvic structures may result. DATA SOURCES: A meta-analysis of the English literature was performed. A human pelvic cadaver was used to demonstrate the proximity of intrapelvic structures to a centrally dislocated cup. RESULTS: Fifty cases of intrapelvic injury were identified. Structures involved most frequently were the external iliac artery and the bladder. The most common types of complication included fistula formation, development of a false aneurysm, and hemorrhage. The human cadaver pelvis demonstrated the proximity of intrapelvic vessels, the bladder, the ureter, the vagina, the deferent duct, the sigmoid colon, the rectum, and the sciatic nerve to an intrapelvically intruded prosthesis. CONCLUSIONS: Failed total hip replacements should be considered to cause damage to pelvic viscera.     

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.     

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.     

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。     

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.     

External iliac arteriovenous fistula following total hip arthroplasty. A case report

An external iliac arteriovenous fistula developed 3 years after revision of the acetabular component of a total hip arthroplasty in a patient with rheumatoid arthritis. The mechanism of this complication, which also produced disseminated intravascular coagulopathy, was chronic erosion of the iliac artery from a large bolus of bone cement and/or the protrusio shell that were used to reconstruct a severe acetabular protrusio. Care must be taken to avoid intrapelvic intrusion of hardware or cement during acetabular reconstruction to avoid immediate and late injury to the iliac vessels.     

Septische Lockerung eines Wagner-Revisionsschaftes durch Mycobacterium tuberculosis.

Only a few cases of specific tuberculous infections of total hip arthroplasties have been published. We report the case of a 66-year-old male patient who received a cementless total hip arthroplasty due to osteoarthritis of the left hip in 1990. Four years later, revision arthroplasty with a Wagner revision stem was performed because of aseptic loosening. In 1995 revision of a loosened acetabular cup was necessary. In 1996 we saw the patient for the first time in our outpatient unit. He complained of increasing pain in the region of the left hip. X-rays showed loosening of the Wagner stem. Aspiration of the synovial fluid of the left hip revealed an infection with mycobacterium tuberculosis (radioimmunoassay). There were no signs of tuberculous infection in the patient's history. Treatment consisted of removal of the prosthesis followed by antituberculosis chemotherapy for 12 months with rifampicin, ethambutol, isoniazid, and pyrazinamide. In April 2001 revision of the left hip joint and implantation of a MRP titanium revision stem and reconstruction of the acetabulum with an acetabular reconstruction ring was done. Until today the patient exhibits no signs of recurrence of the tuberculous infection.     

Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old

BACKGROUND: Acetabular bone deficiency can present a challenge during total hip arthroplasty, especially in young patients. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes of primary and revision acetabular reconstruction with use of an impaction bone-grafting technique and a cemented polyethylene cup in young patients who had preexisting acetabular bone deficiency. METHODS: Forty-two consecutive acetabular reconstructions were performed in thirty-seven patients who were younger than fifty years old (average, 37.2 years old). The impaction bone-grafting technique was used for twenty-three primary and nineteen revision acetabular reconstructions. Twenty-eight patients (thirty-one hips) were available for review after a minimum duration of follow-up of fifteen years. Clinical and radiographic results were assessed, and survivorship analysis was performed with the Kaplan-Meier method. RESULTS: Eight hips were revised at a mean of twelve years (range, three to twenty-one years) after a primary reconstruction (four hips) or revision reconstruction (four hips). The revision was performed because of aseptic loosening of the acetabular component in four hips and because of culture-proven septic loosening in two. Two additional cups (both in hips that had had a revision reconstruction) were revised, during revision of the femoral stem, because of wear (one hip) or because of persistent intraoperative instability (one hip). Twenty-eight hips (in twenty-five patients) had retention of the acetabular component for a minimum of fifteen years. The mean Harris hip score for that group was 89 points. Twenty-six of these twenty-eight hips had no or slight pain. Kaplan-Meier analysis revealed a twenty-year survival rate of 80% (95% confidence interval, 67% to 94%) with acetabular revision for any reason as the end point and of 91% (95% confidence interval, 80% to 100%) with acetabular revision because of aseptic loosening as the end point. CONCLUSIONS: Acetabular reconstruction with use of impaction bone-grafting and a cemented polyethylene cup is a reliable and durable technique that is associated with good long-term results in young patients with acetabular bone-stock defects.     

Intrapelvic migration of a well-fixed femoral stem after removal of an acetabular cup

Failure of total hip arthroplasty with central migration of prosthetic components is uncommon. Various pelvis and visceral complications have been reported from intrapelvic migration of the acetabular cup or the cement or from the heat generated by methylmethacrylate polymerization. To our knowledge, we are the first to report intrapelvic migration of a femoral stem causing ipsilateral lower-extremity swelling, pressure sores, and severe bowel symptoms after the removal of the acetabular component.     

人工全髋关节置换术中非感染性髋臼骨缺损的治疗策略

目的探讨人工全髋关节置换术在治疗非感染性髋臼骨缺损中的应用。方法 2000年1月至2010年1月间40例非感染性髋臼骨缺损初次行全髋关节置换患者,其中CroweⅢ、Ⅳ型先天性髋关节脱位18例,髋关节感染后融合14例,陈旧性髋臼骨折8例。内移髋关节旋转中心17例,结构性植骨13例,颗粒松质骨打压植骨10例;有14例应用钛网,9例重建钢板,7例加强杯固定。术前术后进行临床评估及X线评估。结果本组手术全部成功,术后无感染发生。本组40例患者随访8～42个月,平均（10.4±2.1）个月,随访时无假体松动,关节无疼痛,患者对手术结果满意,髋关节功能较术前明显改善,术前平均Harris评分为（58.4±6.1）分,术后为（88.6±3.1）分;术后平均Harris评分较术前提高明显,两者比较差异有统计学意义（P〈0.05）。结论对非感染性髋臼节段性和混合性骨缺损进行大块植骨并辅以颗粒骨,并选用牢固的钉板系统固定,将髋臼重建在真臼位置,并尽量采用非骨水泥型臼杯,通过不同的重建方法可以获得良好的髋关节功能。     

Coxarthrosis after traumatic hip dislocation in the adult

Sixteen percent of patients with uncomplicated hip dislocations have posttraumatic arthritis develop. Incidences as high as 88% are reported for patients with dislocations associated with severe acetabular fractures. The surgical treatment of patients with posttraumatic arthritis includes arthroscopy, arthrodesis, osteotomy, and arthroplasty. Although arthroplasty offers the best solution for the painful arthritic hip in the older or inactive patient, the treatment of an active patient in the prime of life with severe osteoarthritis of the hip is problematic. In the younger, active patient, it may be prudent to consider alternative treatment in an attempt to avoid, or delay, total hip arthroplasty. Although improving the longevity of primary arthroplasty is desirable, measures to prevent or delay the onset of the osteoarthritis seem more appropriate. Arthroscopic lavage, debridement and chondral abrasion, and osteochondral fragment removal after dislocation may have a role in the treatment of young patients with the early stages of coxarthrosis. Any patient with isolated posttraumatic arthritis of the hip who has a life expectancy greater than 30 years may be a candidate for hip arthrodesis. The ideal candidates for hip arthrodesis are only laborers younger than 35 years of age. Osteotomy of the hip for posttraumatic arthritis remains an appealing alternative for many patients because of the long-term failures of total hip arthroplasty. The clinical results of osteotomy are variable and do not match the results of a total hip arthroplasty. However, primary arthroplasty may fail, and revision arthroplasty is routinely more difficult and shorter lived than the primary operation.     

Clear cell chondrosarcoma of the proximal femur with intrapelvic extension

Clear cell chondrosarcoma is a rare tumor that can be easily confused with benign tumors. The aim of this report is to present a case that is rare, initially diagnosed as aneurysmal bone cyst and then chondroblastoma, and has an interesting extension pattern. A 41-year-old male patient was treated for an apparently benign cystic lesion of the right proximal femur by intralesional excision and bone grafting. The pathological diagnosis was aneurysmal bone cyst. Two years later, the patient presented with a pathological fracture at the same site and a total hip arthroplasty was performed. The pathological specimen was diagnosed as chondroblastoma. Three years later, clinical and radiological examination of the patient revealed a large mass located on the intrapelvic side of the acetabulum. There was no evidence of distant metastases. Both tumors were resected with a wide margin on the femoral side and a marginal margin on the intrapelvic side. The extremity was reconstructed with a resection-type total hip prosthesis. Again, the pathological diagnosis was chondroblastoma. The patient developed a deep infection that was treated by antibiotic therapy and surgical debridement. One year later, there was recurrence of the femoral and intrapelvic masses and right hemipelvectomy was performed; the specimen was reported as clear cell chondrosarcoma. Since then, the patient has been leading an active life, and there is no evidence of local recurrence or distant metastasis. Clinically and pathologically, clear cell chondrosarcoma may be confused with benign bone tumors. This caused a delay in the final diagnosis of this patient and he received inadequate surgical treatment, leading to a hemipelvectomy. We also found that the intrapelvic mass seemed to have developed independently on the intrapelvic side of the acetabulum. We were unable to find an exact explanation for this finding and postulated that tumor cells might have been seeded into the inner wall of the acetabulum during acetabular preparation of the total hip prosthesis.