Failed periacetabular osteotomy leads to acetabular defects during subsequent total hip arthroplasty

The modified Spitzy shelf acetabuloplasty for the dysplastic hip

Aims

Although there are various pelvic osteotomies for acetabular dysplasia of the hip, shelf operations offer effective and minimally invasive osteotomy. Our study aimed to assess outcomes following modified Spitzy shelf acetabuloplasty.

Methods

Between November 2000 and December 2016, we retrospectively evaluated 144 consecutive hip procedures in 122 patients a minimum of five years after undergoing modified Spitzy shelf acetabuloplasty for acetabular dysplasia including osteoarthritis (OA). Our follow-up rate was 92%. The mean age at time of surgery was 37 years (13 to 58), with a mean follow-up of 11 years (5 to 21). Advanced OA (Tönnis grade ≥ 2) was present preoperatively in 16 hips (11%). The preoperative lateral centre-edge angle ranged from -28° to 25°. Survival was determined by Kaplan-Meier analysis, using conversions to total hip arthroplasty as the endpoint. Risk factors for joint space narrowing less than 2 mm were analyzed using a Cox proportional hazards model.

Results

The mean Merle d'Aubigné clinical score improved from 11.6 points (6 to 17) preoperatively to 15.9 points (12 to 18) at the last follow-up. The survival rates were 95% (95% confidence interval (CI) 91 to 99) and 86% (95% CI 50 to 97) at ten and 15 years. Multivariate Cox regression identified three factors associated with radiological OA progression: age (hazard ratio (HR) 2.85, 95% CI 1.05 to 7.76; p = 0.0398), preoperative joint space (HR 2.41, 95% CI 1.35 to 4.29; p = 0.0029), and preoperative OA (HR 8.34, 95% CI 0.94 to 73.77; p = 0.0466).

Conclusion

Modified Spitzy shelf acetabuloplasty is an effective joint-preserving surgery with a wide range of potential indications.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

METHODS

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

RESULTS

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

CONCLUSION

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A minimally invasive periacetabular osteotomy improves the radiographic parameters and functional outcomes in the treatment of developmental dysplasia of the hip in adolescents and adults: surgical technique and early results

PURPOSE

To introduce West China Hospital periacetabular osteotomy (WCH PAO) for acetabular dysplasia in adolescent and young adult patients and evaluate the early clinical results of WCH PAO.

METHODS

A retrospective analysis of 34 patients with developmental dysplasia of the hip was performed from October 2019 to April 2021. Baseline data with surgical time and perioperative blood-loss volume were retrieved from medical record systems. The lateral center-to-edge angle (LCEA), acetabular inclination (AI), hip disability and osteoarthritis outcome score (HOOS), University of California Los Angeles (UCLA), and modified Harris hip score (mHHS) were compared preoperatively and postoperatively.

RESULTS

All patients had significant postoperative radiology improvements, including LCEA and AI. The LCEA was improved from 12.9 to 33.2°, and the AI was decreased from 27.2 to 8.5°. In addition, hip functional outcomes, including HOOS, UCLA and mHHS, were improved. The UCLA was improved from 3.9 to 6.3, and the HOOS was decreased from 71.0 to 10.5. The Harris hip score improved from 50.8 before surgery to 87.4 after surgery. The mean operative time was 155 min (range 120 to 190 min), and the mean intra-operative blood loss was 580.2 ± 285.5 ml. Furthermore, no major complications, including nerve injury or bone nonunion, occurred in the cohort study.

CONCLUSION

WCH PAO is a minimally invasive surgical method for acetabular dysplasia in adolescent and young adult patients who that simplifies the surgical procedure and decreases the incidence of complications related to osteotomy.

Total hip arthroplasty after rotational acetabular osteotomy for developmental dysplasia of the hip: a retrospective observational study

Background

Total hip arthroplasty after osteotomy is more technically challenging than primary total hip arthroplasty, especially concerning cup placement. This is attributed to bone morphological abnormalities caused by acetabular bone loss and osteophyte formation. This study aimed to investigate the clinical and radiological outcomes of total hip arthroplasty after rotational acetabular osteotomy compared with those of primary total hip arthroplasty, focusing mainly on acetabular deformity and cup position.

Methods

The study included 22 hips that had undergone rotational acetabular osteotomy and 22 hips in an age- and sex-matched control group of patients who underwent total hip arthroplasties between 2005 and 2020. We analyzed cup abduction and anteversion; lateral, anterior, and posterior cup center–edge angle; hip joint center position; femoral anteversion angle; and presence of acetabular defect using postoperative radiography and computed tomography. Operative results and clinical evaluations were also analyzed.

Results

The clinical evaluation showed that the postoperative flexion range of motion was lower in total hip arthroplasty after rotational acetabular osteotomy than in primary total hip arthroplasty, although no significant difference was noted in the postoperative total Japanese Orthopedic Association hip score. The operative time was significantly longer in the rotational acetabular osteotomy group than in the control group, but there was no significant difference in blood loss. The lateral cup center–edge angle was significantly higher and the posterior cup center–edge angle was significantly lower in the total hip arthroplasty after rotational acetabular osteotomy, suggesting a posterior bone defect existed in the acetabulum. In total hip arthroplasty after rotational acetabular osteotomy, the hip joint center was located significantly superior and lateral to the primary total hip arthroplasty.

Conclusions

In total hip arthroplasty after rotational acetabular osteotomy, the cup tended to be placed in the superior and lateral positions, where there was more bone volume. The deformity of the acetabulum and the high hip center should be considered for treatment success because they may cause cup instability, limited range of motion, and impingement.

Total hip arthroplasty after periacetabular osteotomy versus primary total hip arthroplasty: a propensity-matched cohort study

BACKGROUND

Controversy still exist regarding the outcomes of total hip arthroplasty (THA) after periacetabular osteotomy (PAO). The purpose of this study was to compare the clinical and radiologic outcomes of THA after PAO with primary THA based on balanced baseline characteristics with propensity score matching.

METHODS

Using propensity score matching, 1:2 matched cohort to facilitate comparison between patients who underwent primary cementless THA with or without previous PAO. Then, we compared the operative time, blood loss, complications, postoperative clinical score, cup size, position, and alignment of acetabular cup, and degree of bony coverage on cup between the two groups.

RESULTS

Thirty-five patients with 37 hips who underwent THA after PAO were successfully matched to 70 patients with 74 hips who underwent primary THA. The operative time and blood loss in THA after PAO were significantly longer and larger than those in primary THA (P < 0.001 and = 0.0067, respectively). Clinical score showed no difference between the groups (P > 0.05). For THA after PAO, the cup size and bony coverage were larger (P = 0.0014 and < 0.001, respectively), and the hip center was significantly higher and laterally (P < 0.001 and < 0.001, respectively) comparing primary THA.

CONCLUSION

This study demonstrated longer operative time and larger blood loss without difference in the postoperative clinical score or complications between THA after PAO and primary THA. Furthermore, THA after PAO provided larger cup size and superolaterally positioned cup center without difference in the cup inclination or anteversion comparing primary THA.

Is cup positioning easier in DDH patients previously treated with Bernese periacetabular osteotomy?

Background

Acetabular orientation changes after periacetabular osteotomy (PAO) lead to technical change when performing subsequent total hip arthroplasty (THA). There is no unified consensus regarding the solution for acetabular component installation after PAO. In the current study, we performed computed tomography (CT)-based simulation of acetabular component installation and compared the acetabular defect and component position following THA after PAO and the same patient before PAO.

Methods

From January 2014 to December 2018, pelvic models of 28 patients (28 hips) underwent PAO and with the risk factors to develop secondary osteoarthritis. The acetabular reconstruction process was simulated using 3D models from CT data, and the acetabular component coverage was calculated in 3D space based on the measurement and algorithm we proposed. We evaluated the anterior, posterior, superior, inferior acetabular sector angle (ASA), the medial wall thickness (MWT), and the distance from the hip center to the plane of pubic symphysis and ossa sedentarium in the study group (post-PAO group) and control group (pre-PAO group). In addition, we investigated the changes in the acetabular component covering and size between the two groups.

Results

A-ASA and I-ASA values were significantly smaller in the post-PAO group than in the pre-PAO group. The S-ASA and distance values were significantly bigger in the post-PAO group. Compared to the pre-PAO group, the post-PAO group has a bone defect in the anterior and inferior medial. However, the post-PAO group has to elevate the cup to improved component coverings.

Conclusion

Acetabular defection following simulation of cup installation after PAO was significantly changed compared to those without PAO. Elevation of hip joint centers as much as 4 mm and increase acetabular cup anteversion were therapeutic options for DDH patients following THA after PAO

Association between total hip arthroplasty following periacetabular osteotomy and acetabular component overhang

BACKGROUND

There is limited understanding of anterior acetabular component overhang, which induces groin pain, in post-periacetabular osteotomy (PAO) hips during conversion to total hip arthroplasty (THA). The aim of the study were to determine the following: (1) the differences in the amount of acetabular component overhang among pre-PAO hips and post-PAO hips in simulating THA; (2) the factors associated with the amount of component overhang in THA following PAO; (3) whether high component placement with elevation of the hip center by 10 mm reduces the amount of component overhang compared to the anatomical component position in THA following PAO.

METHODS

Computer-based simulations of acetabular component implantation were performed using preoperative and postoperative CT data from 30 patients undergoing PAO. Implantation was performed thrice in each patient: in pre-PAO hips (anatomical component position) and post-PAO hips (anatomical and high component position). Component overhang was measured on the axial plane, which passes through the component center.

RESULTS

Overhang was greater in post-PAO hips [mean (SD) overhang: 5.2 (2.9) mm, pre-PAO hips: 10.2 (4.6) mm, post-PAO hips-mean difference, 5.0 mm; p < 0.001]. A smaller distance between the pubic osteotomy and the acetabulum, and greater overhang in pre-PAO hips was independent factors associated with increased overhang in post-PAO hips. Overhang was smaller with the high component position than with the anatomical component position in post-PAO hips [mean (SD) overhang-3.5 mm (2.9) with high component position among post-PAO hips; mean difference, 6.6 mm; p < 0.001). Ten post-PAO hips with the anatomical component position had overhang of at least 12 mm (the likely threshold for groin pain). Of these, 9 hips had reduced overhang (< 12 mm) with the high component position.

CONCLUSIONS

Acetabular component overhang was more severe in THA following PAO than in THA without prior PAO. Pubic osteotomy should be performed closer to the acetabular rim to prevent severe overhang in potential THA conversion cases. A high component position decreased the risk of severe overhang.

Acetabular custom-made implants for severe acetabular bone defect in revision total hip arthroplasty: a systematic review of the literature

PURPOSE

The management of acetabular bone loss is a challenging problem in revision total hip arthroplasty (rTHA). The aim of this systematic review is to summarize and critically analyze indications, complications, clinical and radiological outcomes of custom-made acetabular components in rTHA.

METHODS

A systematic review of English literature was performed on Medline. Retrospective or prospective studies with minimum 2 years of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Rates of intra- or post-operative complications, aseptic loosening (AL), periprosthetic joint infection (PJI), reoperations and re-revisions rates were extrapolated.

RESULTS

18 articles with a level of evidence of IV were included. Six hundred and thirty-four acetabular custom components (627 patients) with a mean FU of 58.6 ± 29.8 months were analyzed. The studies showed good clinical and functional outcomes. Custom-made acetabular components allowed a stable fixation with 94.0 ± 5.0% survival rate. The estimated rate of re-operations and re-revisions were 19.3 ± 17.3% and 5.2 ± 4.7%, respectively. The incidence of PJI was 4.0 ± 3.9%.

CONCLUSIONS

The acetabular custom-made implants represent a reliable solution for pelvic discontinuity and particular cases of bone loss classified as Paprosky Type IIIA-B or type III-IV according to American Academy of Orthopaedic Surgeons system where the feature of the defect cannot be handled with standard implants. This strategy allows to fit the implant to the residual host bone, bypassing the bony deficiency and restoring hip biomechanics. Satisfactory clinical and radiological outcomes at mid-term follow-up are reported in literature.

Long-Term Outcomes of Eccentric Rotational Acetabular Osteotomy Combined With Femoral Osteotomy for Hip Dysplasia

BACKGROUND

This study aimed at investigating the clinical outcomes of eccentric rotational acetabular osteotomy (ERAO) combined with intertrochanteric valgus osteotomy (ITVO) over a period of more than 10 years.

METHODS

This is a case-control study of 39 patients (40 hips) who underwent ERAO combined with ITVO for hip dysplasia (ITVO group). Patients were matched for age, sex, follow-up period, and preoperative joint stage to 78 patients (80 hips) who underwent ERAO alone (ERAO group). We compared the clinical and radiographic outcomes and the survival rates between the groups.

RESULTS

The Harris Hip Score at the final follow-up was significantly lower in the ITVO group than in the ERAO group. The postoperative center edge angle, acetabular head index, and minimum joint space were significantly smaller in the ITVO group than in the ERAO group. The survival rates for the conversion to total hip arthroplasty end point were not significantly different between groups. However, survival rates for the Harris Hip Score < 80 end point were significantly poorer in the ITVO group than in the ERAO group.

CONCLUSION

The long-term results of ERAO combined with ITVO were not satisfactory from a hip function perspective. ERAO combined with ITVO should be indicated in only young active patients with pre-osteoarthritis and initial stages of osteoarthritis.