The results of acetabular impaction grafting in 129 primary cemented total hip arthroplasties

Long-term outcomes of acetabular impaction grafting with cemented cups and trabecular metal for revision hip arthroplasty: a follow-up study

INTRODUCTION

Revision hip arthroplasty in the presence of complex acetabular deficiencies is challenging. Cement, allograft, reconstruction rings and porous trabecular metal now provide versatile options for acetabular fixation and restoration of acetabular offset. We compare acetabular impaction bone grafting (AIBG) and trabecular metal (TM) cups at long-term follow-up.

METHODS

53 patients who underwent revision hip arthroplasty were retrospectively reviewed from local joint registry data. 36 patients were revised using AIBG and 17 with TM. Median clinical follow-up was 9.57 (2.46-18.72) years and 9.65 (7.22-12.46) years, respectively. 82% of the TM group and 63% of the AIBG group were ⩾ Paprosky 2C. Re-revision was considered failure. Radiographs demonstrating 5 mm of femoral head migration and 5° of acetabular component inclination change were considered loose.

RESULTS

Patients receiving AIBG were younger (68 vs. 74 years) with a longer interval from initial arthroplasty to revision (17 vs. 13 years). Revisions in both groups were indicated most commonly for failed cementing (AIBG 88.9% vs. TM 70.5%). No TM reconstructions underwent re-revision, with only 1 failing at 6.3 years, compared with 9 AIBG re-revisions. When revising for sepsis, 33% of AIBG revisions failed.

CONCLUSIONS

AIBG demonstrated high failure rates at long-term follow-up when compared to TM constructs. We recommend the use of AIBG in small cavitary defects only. We strongly advise against its use in the setting of significant bony defects and for prosthetic joint infection.

Partial retention of the acetabular cement mantle in aseptic revision hip arthroplasty: is it a viable option?

INTRODUCTION

Choosing the most appropriate reconstruction method when addressing a cemented cup at hip revision surgery can be a difficult decision. The aim of this study is to look into the practice and results of retaining a well-fixed medial acetabular cement mantle while removing loose superolateral cement. This practice goes against a preconceived principle that if some of the cement is loose it must all be removed. So far, no significant series looking at this is available in the literature.

METHODS

We assessed a cohort of 27 patients in our institution where this practice was carried out and assessed their outcomes clinically and radiographically.

RESULTS

Of the 27 patients, 24 had follow-up ⩾2 years (2.9-17.8, mean 9.3 years). There was 1 subsequent revision for aseptic loosening at 11.9 years, 1 first-stage revision of both stem and cup for infection at 1 month, and 2 patients died without a 2-year review. 2 patients did not have radiographs available for review. 2 of the 22 patients with radiographs available had changes in lucent lines, which were not clinically significant.

CONCLUSION

Based on these results we conclude that retaining well-fixed medial cement during socket revision is a viable reconstruction option in carefully selected cases.

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

Objective

To 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.

Methods

The 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.

Results

Significant 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.

Conclusions

The 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.

Acetabular impaction grafting with mesh for acetabular bone defects: a systematic review

INTRODUCTION

In conjunction with impaction bone grafting (IBG), metal meshes have been proposed to minimise defects of the medial and superolateral walls in order to convert combined complex uncontained segmental defects into contained cavitary defects to facilitate IBG.

METHODS

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to March 2019 utilising keywords pertinent to total hip arthroplasty (THA), acetabular impaction bone grafting, clinical or functional outcomes, revision THA, or postoperative complications.

RESULTS

7 articles were found to be suitable for inclusion in the present study. The mean modified Coleman methodology score for methodological deficiencies of the studies was 45.3 (range 38-59). Severe acetabular bone loss was present in 56% of cases having moderate bone loss in 18%, and mild in 26%. The all-cause reoperation rate was 7.4%, while the all-cause revision rate of the acetabular component was 6.2%.

CONCLUSIONS

IBG with mesh is effective for selected patients with acetabular bone defects. Most patients with moderate bone loss as well as selected patients with large superolateral defects can be successfully treated with IBG combined with mesh. There is limited data to show that IBG with mesh might be associated with decreased survival rates in patients with severe lateral defects (Paprosky IIIA) combined with ischial or medial wall osteolysis who require combined medial and lateral meshes. In addition, patients with severe superomedial migration of the cup (Paprosky IIIB) should not be treated with IBG and mesh.

A Review and Description of Acetabular Impaction Bone Grafting: Updating the Traditional Technique

Restoring acetabular bone loss in revision hip arthroplasty is a major challenge for the orthopaedic surgeon. This paper discusses the traditional cemented technique of impaction bone grafting as applied to the acetabulum, as well as the evolution of the technique to employ uncemented implants. Some of the recent published literature regarding these techniques is reviewed and the personal experiences of the senior author with these techniques are also reported.

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

BACKGROUND

Cemented 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.

METHODS

Clinical 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.

RESULTS

The 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.

CONCLUSION

The 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.

Functional and radiological outcomes after treatment with custom-made acetabular components in patients with Paprosky type 3 acetabular defects: short-term results

BACKGROUND

Severe acetabular defects require special treatment with either impaction bone grafting, metal augmented cups or cup-cage constructs. Even these options are often not adequate, especially in hips with Paprosky type 3 defects with loss of anterior and posterior columns. This study investigates the clinical and radiological outcomes of custom-made acetabular components (© Materialise NV, Leuven, Belgium) for Paprosky type 3 defects.

METHODS

Sixteen patients were eligible for this trial, nine of whom agreed to be included. All of them completed one year of follow-up. The Harris hip score and the Oxford hip score were used to compare pre- and postoperative functional outcomes. Radiological follow-up comprised anteversion and inclination of the implanted cup and offset measurements in both hips (femoral, medial, ischial offset and center of rotation). Statistical analyses were performed with IBM SPSS Statistics.

RESULTS

The mean follow-up time of the nine patients was 12.2 months (range: 10-18). The Oxford hip score and Harris hip score improved from 19.8 and 50.1 to 29.4 and 68.8, respectively (p = 0.009 and 0.01). There were complications in three cases (33.3%), which led to one re-revision (11.1%). Radiologic follow-up showed restoration of the height of the center of rotation and of the global offset. Significant difference was detected in the femoral offset.

CONCLUSIONS

The functional and radiological outcomes are promising. However, long-term outcomes still need to be examined.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Conversion from a failed proximal femoral nail anti-rotation to a cemented or uncemented total hip arthroplasty device: a retrospective review of 198 hips with previous intertrochanteric femur fractures

Background

At present, it is unclear which device (uncemented or cemented total hip arthroplasty [UTA or CTA, respectively]) is more suitable for the conversion of a failed proximal femoral nail anti-rotation (PFNA). The aim of this review was to assess the outcomes of failed PFNAs converted to a UTA or CTA device in elderly individuals with intertrochanteric femoral fractures (IFFs).

Methods

Two hundred fifty-eight elderly individuals (258 hips) with IFFs who underwent a conversion to a UTA or CTA device following failed PFNAs during 2007–2017 were retrospectively identified from the China Southern Medical Centre (CSMC) database. The primary endpoint was the Harris Hip Score (HHS); secondary endpoint was the key orthopaedic complication rate.

Results

The median follow-up was 65 months (60–69 months). Significant distinctions were observed (87.26 ± 16.62 for UTA vs. 89.32 ± 16.08 for CTA, p = 0.021; 86.61 ± 12.24 for symptomatic UTA vs. 88.68 ± 13.30 for symptomatic CTA, p = 0.026). A significant difference in the overall key orthopaedic complication rate was detected (40.8% [40/98] vs. 19.0% [19/100], p = 0.001). Apparent distinctions were detected in terms of the rate of revision, loosening, and periprosthetic fracture (11.2% for UTA vs 3.0% for CTA, p = 0.025; 13.2% for UTA vs 5.0% for CTA, p = 0.043; 10.2% for UTA vs 3.0% for CTA, p = 0.041, respectively).

Conclusion

For elderly individuals with IFFs who suffered a failed PFNA, CTA devices may have a noteworthy advantage in regard to the revision rate and the rate of key orthopaedic complications compared with UTA devices, and CTA revision should be performed as soon as possible, regardless of whether these individuals have symptoms.

Bone impaction grafting with trabecular metal augments in large defects in young patients: unravelling a new perspective in surgical technique

Background

Acetabular reconstruction with bone impaction grafting in large defects has yielded conflicting results.

Methods

This was a retrospective study of a case series of five patients with a young age (≤50 years) at the time of surgery who had large acetabular defects reconstructed by bone impaction grafting and trabecular metal augments. The mean follow-up was 79 months. We describe the surgical technique in detail.

Results

Improvement was significant on the WOMAC and SF-36 scales (p < 0.05). The radiographs taken at the last follow-up examination showed no migration of the polyethylene cup (p = 0.31) or differences in the abduction angle (p = 0.27) compared to the radiographs from the immediate postoperative period. One patient presented two dislocation episodes as a complication.

Conclusion

The combination of trabecular metal augments with the bone impaction grafting technique in young patients with large acetabular defects provides satisfactory results in the long term and restores the bone stock.

Post-operative hip centre restoration and migration after impaction bone grafting in revision and complex primary hip arthroplasty

INTRODUCTION/OBJECTIVES

Although impaction grafting proved efficacy in the reconstruction of acetabular defects in primary and revision hip arthroplasty, its role in large segmental defects is still debatable. Our objective is to determine hip centre restoration and last follow-up migration after acetabular reconstruction with impaction grafting in different types of acetabular defects.

METHODS

This is a single-centre retrospective radiographic study of (107) total hip arthroplasty (42 primary and 65 revision) in (104) patients using impaction grafting. The available radiographs were examined for normal, preoperative, immediate postoperative, and last follow-up vertical (Y) and horizontal (X) hip centre. Maximum acetabular defect distance (MADD), presence, and size of the mesh were recorded.

RESULTS

In type I and II AAOS defects, the post-operative hip centre was not significantly different from the normal hip centre on the contralateral healthy side. In type III defects, there was a significant variation between the normal hip centre and the post-operative hip centre (P value 0.034 and 0.001 for Y and X, respectively). At 44-month follow-up of 36 hips, 31 (86%) hips migrated. The mean migration ± SD was 5.72 ± 3.7, 2, 4.15 ± 1.2, and 11.26 ± 3.9 mm for types I, II, and III, respectively (P value 0.211). Hips with MADD > 15 mm, especially with large mesh sizes migrate significantly more (P value = 0.042, 0.037, and 0.039, respectively).

CONCLUSION

Hip centre restoration was better, and migration was less for type I and II AAOS rather than for type III. Other options for reconstruction should be considered.

Favorable Results of Primary Total Hip Arthroplasty With Acetabular Impaction Bone Grafting for Large Segmental Bone Defects in Dysplastic Hips

BACKGROUND

The aim of the present study was to assess midterm results after acetabular impaction bone grafting (IBG) in primary total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with large acetabular segmental defect.

METHODS

Primary THA with IBG for DDH with large acetabular segmental defect was performed in 40 hips of 38 patients. The average age was 61.6 years (range: 33-82 years), and the average follow-up period was 7.5 years (range: 3-10.3 years). The Merle d'Aubigné and Postel hip score and complications were assessed. For radiological assessment, postoperative location of the hip rotation center, the socket inclination angle, and the socket center-edge angle were assessed. Kaplan-Meier survival analysis was performed with the end points of any type of reoperation and aseptic acetabular loosening.

RESULTS

The mean Merle d'Aubigné and Postel hip score improved from 10.4 points to 16.2 points at the final follow-up. Reoperation was performed in 1 case for acute infection without loosening. In 39 out of 40 hips (97.5%), the center of hip rotation was located beneath the "high hip center." The average socket inclination angle was 39.3° (range: 30°-54°), and the average socket center-edge angle was -11.8° (range: -23° to 9°). Survival rate of acetabular component at 8 years with the end point of any reoperation and of aseptic loosening was 96.6% (95% confidence interval: 89.9%-100%) and 100%, respectively.

CONCLUSION

Acetabular IBG represents one of the useful options for restoring a normal hip center and acetabular bone stock in primary THA for DDH with large acetabular defect.

Results using Trabecular Metal™ augments in combination with acetabular impaction bone grafting in deficient acetabula

We examined whether the use of trabecular metal wedges to fill segmental defects is an effective method of socket reconstruction when used in combination with impaction grafting and implantation of a cemented socket. Fifteen hips in 14 patients underwent impaction grafting in combination with a TM wedge with a minimum of two years follow-up. All patients had their defects assessed using the Paprosky classification. Patients were reviewed with x-rays and migration of the implant was measured. Outcome scores were also collected. Mean follow-up was 39 months (25-83). The mean age at surgery was 67.8 (49-85) years. Seven of the patients had previously undergone impaction grafting with the use of a stainless steel rim mesh to constrain the graft. None of the patients had failed either clinically or radiologically.

Clinical and radiographic outcomes of acetabular impaction grafting without cage reinforcement for revision hip replacement: a minimum ten-year follow-up study

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan-Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.