Effectiveness of Constrained Liner Use During Harrington Hip Reconstruction in Oncology Patient

Dislocation rate after hip arthroplasty due to metastatic bone disease: a retrospective cohort study evaluating the postoperative dislocation risk across different articulating solutions

BACKGROUND AND PURPOSE

Joint stability after hip replacement (HR) in patients with metastatic bone disease (MBD) is of special importance. Dislocation is the second leading cause of implant revision in HR, while survival after MBD surgery is poor with an expected 1-year survival of around 40%. As few studies have investigated the dislocation risk across different articulation solutions in MBD, we conducted a retrospective study on primary HR for patients with MBD treated in our department.

PATIENTS AND METHODS

The primary outcome is the 1-year cumulative incidence of dislocation. We included patients with MBD who received HR at our department in 2003-2019. We excluded patients with partial pelvic reconstruction, total femoral replacement, and revision surgery. We assessed the incidence of dislocation with competing risk analysis with death and implant removal as competing risks.

RESULTS

We included 471 patients. Median follow-up was 6.5 months. The patients received 248 regular total hip arthroplasties (THAs), 117 hemiarthroplasties, 70 constrained liners, and 36 dual mobility liners. Major bone resection (MBR), defined as resection below the lesser trochanter, was performed in 63%. The overall 1-year cumulative incidence of dislocation was 6.2% (95% CI 4.0-8.3). Dislocation stratified by articulating surface was 6.9% (CI 3.7-10) for regular THA, 6.8% (CI 2.3-11) for hemiarthroplasty, 2.9% (CI 0.0-6.8) for constrained liner, and 5.6% (CI 0.0-13) for dual mobility liners. There was no significant difference between patients with and without MBR (p = 0.5).

CONCLUSION

The 1-year cumulative incidence of dislocation is 6.2% in patients with MBD. Further studies are needed to determine any real benefits of specific articulations on the risk of postoperative dislocation in patients with MBD.

Operative management of metastatic disease of the acetabulum: review of the literature and prevailing concepts

Metastatic disease of the periacetabular region is a common problem in orthopaedic oncology, associated with severe pain, decreased mobility, and substantial decline of the quality of life. Conservative management includes optimisation of pain management, activity modification, and radiation therapy. However, patients with destructive lesions affecting the weight-bearing portion of the acetabulum often require reconstructive surgery to decrease pain and restore mobility. The goal of surgery is to provide an immediately stable and durable construct, allowing immediate postoperative weight-bearing and maintaining functional independence for the remaining lifetime of the patient. A variety of surgical techniques have been reported, most of which are based upon cemented total hip arthroplasty, but also include porous tantalum implants and percutaneous cementoplasty. This review discusses the various reconstructive concepts and options, including their respective indications and outcome. A reconstructive algorithm incorporating different techniques and strategies based upon location and quality of remaining bone is also presented.

Functional and Survival Outcomes of Patients following the Harrington Procedure for Complex Acetabular Metastatic Lesions

Background: The Harrington surgical technique makes it possible to manage complex, extensive bone lesions using pins and cement to consolidate bone for acetabular cup positioning. However, it may be associated with a high reoperation rate, and the functional results of this surgery are not precisely described in the literature. Methods: In a monocentric retrospective study including all patients operated on using the Harrington procedure associated with THA between 2005 and 2020, we aimed to assess preoperative and postoperative function, reoperation-free survival, and overall survival. Results: Functional improvement was significant for Parker scores (preoperative: 3.6 ± 2.0; 6-month follow-up: 6.6 ± 3.2; 12-month follow-up: 7.6 ± 2.1) and Musculoskeletal Tumor Society (MSTS) scores (preoperative: 31.1 ± 16.2%; 6-month follow-up: 67.7 ± 30.6%; 12-month follow-up: 82.4 ± 24.0%). Of the 21 patients included, the reoperation-free survival rate was 76.1% [CI 95%: 58.1–99.7] at six and twelve months, with the main complications being pin migration (50.0%) and infection (25%). The patient overall survival rate was 76.2% [95% CI: 59.9–96.7] at six months and 61.9% [95% CI: 59.9–96.7] at 12 months. Discussion: These results underlined significant functional improvements following a conventional Harrington procedure, with acceptable reoperation rates.

Acetabular reconstruction after advanced acetabular metastasis resection: Modified Harrington technique with a Kerboull reinforcement device

The surgical treatment of acetabular bone metastases rests on total hip arthroplasty (THA). In the event of major bone defects, the reconstruction may prove challenging. Two complicating factors are the need to obtain a mechanically stable acetabulum and the unfeasibility of using an autograft to increase the bone stock. The technique described in 1981 by Harrington involves implanting steel rods to reinforce the pelvis before sealing the prosthetic cup. We have now been using this technique for several years, and based on our accumulated experience we introduced several substantial modifications. The most important among them is the use of a Kerboull acetabular reinforcement device (KARD) in addition to the iliac pins. This reinforcement of the acetabulum, which is widely used for THA, serves as the basis for guiding the reconstruction, while also facilitating the sealing of the prosthetic cup. Furthermore, we use centrally threaded rods to avoid secondary displacement. Finally, we routinely use a dual-mobility cemented cup to decrease the risk of dislocation. Here, we describe our acetabular reconstruction technique based on a modified Harrington technique, which is used for acetabular reconstruction in patients with advanced acetabular metastases managed at our French referral centre.

Outcomes of Hip Reconstruction for Metastatic Acetabular Lesions: A Scoping Review of the Literature

(1) Background: Management of metastatic periacetabular lesions remains a challenging area of orthopaedics. This study aims to evaluate and summarize the currently available reconstructive modalities, including their indications and outcomes. (2) Methods: A scoping review was carried out in accordance with PRISMA guidelines. Medline, EMBASE, and Cochrane were searched for relevant articles. (3) Results: A total of 18 papers met inclusion criteria encompassing 875 patients. The most common primary malignancy was breast (n = 230, 26.3%). Reconstruction modalities used were total hip arthroplasty (n = 432, 49.1%), the Harrington procedure (n = 374, 42.5%), modular hemipelvic endoprotheses (n = 63, 7.2%) and a reverse ice-cream cone prosthesis (n = 11, 1.25%). (4) Conclusions: Advances in implant design including use of dual mobility or flanged cups, tantalum implants, and modular hemipelvic endoprostheses allow for larger acetabular defects to be addressed with improved patient outcomes. This armamentarium of reconstruction options allows for tailoring of the procedure performed depending on patient factors and extent of periacetabular disease.

Survival of the GAP II cage in the management of metastatic disease of the acetabulum

AIMS

The aim of this study was to assess the clinical and radiological outcomes of an antiprotrusio acetabular cage (APC) when used in the surgical treatment of periacetabular bone metastases.

METHODS

This retrospective cohort study using a prospectively collected database involved 56 patients who underwent acetabular reconstruction for periacetabular bone metastases or haematological malignancy using a single APC between January 2009 and 2020. The mean follow-up was 20 months (1 to 143). The primary outcome measure was implant survival. Postoperative radiographs were analyzed for loosening and failure. Patient and implant survival were assessed using a competing risk analysis. Secondary parameters included primary malignancy, oncological treatment, surgical factors, length of stay in hospital, and postoperative complications.

RESULTS

A total of 33 patients (59%) died during the study period at a mean of 15 months postoperatively (1 to 63). No patient had radiological evidence of loosening or failure. Acetabular component survival was 100%. Three patients (5.4%) had further surgery; one (1.8%) underwent revision of the femoral component for dislocation, one required debridement with implant retention for periprosthetic joint infection, and one required closed reduction for dislocation. Using death as a competing risk, at 100 months, the probability of revision was 0.036 and the risk of death was 0.84.

CONCLUSION

With appropriate patient selection, the antiprotrusio cage offers good implant survival, with a reasonable perioperative complication rate in this high-risk group of patients when managing metastatic disease or haematological malignancy around the acetabulum. Cite this article: Bone Joint J 2022;104-B(4):504-509.

Acetabular reconstruction in oncological surgery: A systematic review and meta-analysis of implant survivorship and patient outcomes

BACKGROUND

Reconstruction of the hip for peri-acetabular oncological disease remains a challenge. The objective of this study was to summarize the evidence and identify techniques utilized for primary and metastatic tumors of the acetabulum and hemipelvis.

METHODS

A systematic review of the published literature was carried out in accordance with PRISMA guidelines. MEDLINE, EMBASE and Cochrane databases identified relevant articles. Quality was assessed using the Newcastle-Ottawa Scale. The study was registered on PROSPERO.

RESULTS

53 papers were included, 16 were suitable for meta-analysis. 909 patients had primary and 1140 metastatic disease. 1094 patients underwent reconstruction with conventional total hip arthroplasty (with or without cup-cage or cement augmentation) or modifications of the Harrington procedure, collectively termed 'non-complex'. 928 patients underwent 'complex' reconstructions with either a modular hemipelvic, saddle, reverse snow-cone, custom-made or 3D-printed endoprosthesis. The most common complication was deep infection (11%) followed by dislocation (5%). Mean MSTS scores were 61.9% for 'non-complex' versus 63.2% for 'complex' reconstruction. Meta-analysis suggested increased mortality for primary (OR 3.14; 95% CI 1.15-8.54) and trends toward reduced mortality for metastatic disease (OR 0.93; 95% CI 0.26-3.29) following 'complex' versus 'non-complex' reconstruction. Reoperation rates were higher following 'complex' reconstruction for metastatic disease (OR 1.90; 95% CI 0.66-5.46) and similar for primary disease (OR 0.98; 95% CI 0.45-2.14).

CONCLUSIONS

Peri-acetabular tumors are associated with high rates of morbidity and mortality. Decisions regarding implant selection are multi-factorial with recent increase in the use of custom-made and 3D-printing technologies. Multiple factors contribute to the oncological outcome and patient function. Further research is required in order to guide optimal practice.

Emerging Concepts in the Surgical Management of Peri-Acetabular Metastatic Bone Disease

The pelvis is a common site of metastatic bone disease. Peri-acetabular lesions are particularly challenging and can cause severe pain, disability and pathologic fractures. Surgical management of these lesions has historically consisted of cementoplasty for contained lesions and Harrington reconstructions for larger, more destructive lesions. Due to the limitations of these procedures, a number of novel procedures have been developed to manage this challenging problem. Percutaneous techniques—including acetabular screw fixation and cementoplasty augmented with screws—have been developed to minimize surgical morbidity. Recent literature has demonstrated a reliable reduction in pain and improvement in function in appropriately selected patients. Several adjuncts to the Harrington procedure have been utilized in recent years to reduce complication rates. The use of constrained liners and dual mobility bearings have reduced the historically high dislocation rates. Cage constructs and porous tantalum implants are becoming increasingly common in the management of large bony defects and destructive lesions. With novel and evolving surgical techniques, surgeons are presented with a variety of surgical options to manage this challenging condition. Physicians must take into account the patients’ overall health status, oncologic prognosis and anatomic location and extent of disease when developing an appropriate surgical plan.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases

INTRODUCTION

The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival.

HYPOTHESIS

The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies.

METHODS

Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)].

RESULTS

Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer.

CONCLUSION

Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Is an Acetabular Cage and Cement Fixation Sufficiently Durable for the Treatment of Destructive Acetabular Metastases?

BACKGROUND

Destructive bony acetabular metastases cause pain, pathological fractures, and loss of mobility. Although multiple fixation options are available, we have favored a rigid stainless steel partial pelvic cage for acetabular fixation in these patients; however, little is known about the durability of this approach. QUESTION/PURPOSES: (1) How common was loss of fixation in a small series of metastatic acetabular defects treated with an acetabular cage and cemented total hip replacement? (2) What is the implant survival free from reoperation or revision at 2 and 4 years using a competing-risks survivorship estimator in patients thus treated? (3) What complications were associated with the treatment? (4) What level of postoperative mobility was achieved?

METHODS

Between 2006 and 2017, we treated all acetabular metastases that needed surgical intervention, not amenable to conventional cemented THA alone with our single technique of acetabular partial pelvic cage and cemented total hip replacement. We treated 47 hips in 46 patients whose acetabular metastasis led to acetabular collapse or who were unresponsive to nonoperative measures of radiation therapy and analgesia. Routine followup occurred at 3 and 12 months; 17 of 46 patients (37%) died before 1 year, and all other patients were followed beyond 1 year. Only one patient who remains alive has not been seen in the past 5 years. Loss of fixation was determined by radiological or clinical signs of cage loosening. Survivorship free from reoperation or revision at 2 and 4 years was determined using competing-risks analysis. We did not assess patient-reported outcomes, but we did have data on the proportion of patients who were able to ambulate in the community and if so, what assistive devices they used, which we obtained by chart review.

RESULTS

One patient experienced cage loosening identified 8 years postoperatively as a result of local disease progression and has been managed with observation. No patients underwent revision for loss of acetabular fixation. The cumulative incidence of reoperation or revision was 8% at 2 years (95% CI, 3.6-12.6) and 16% at 4 years (95% CI, 9.2-23.2). Four patients had postoperative dislocations, of which three underwent reoperation. One patient developed a postoperative deep infection and underwent reoperation. One patient died within 30 days of surgery. Only one patient did not ambulate in the community postoperatively; 23 ambulated independently, 10 with the use of a walking stick and 12 using a walker.

CONCLUSIONS

In this small series, we found this approach sufficiently durable to continue its use for patients with acetabular metastases with collapse or those not responding to nonoperative measures. However, comparison studies are needed to determine whether it is superior or inferior to other available alternatives.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BACKGROUND

Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified.

METHODS

A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed.

RESULTS

At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed.

CONCLUSION

This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.