Intermediate to Long-Term Follow-up of Cementing Liners into Well-Fixed Acetabular Components

Long-Term Outcomes of Cementing Highly Cross-Linked Polyethylene Liners Into Well-Fixed Acetabular Shells in Revision Total Hip Arthroplasty

BACKGROUND

Cementing a new liner into a secure, well-positioned metallic shell can be a less-invasive strategy in revision total hip arthroplasty (THA). This study aimed to report the mean 14-year outcomes of cementing highly cross-linked polyethylene (XLPE) liners into well-fixed acetabular shells in revision THAs.

METHODS

This study reviewed a single-surgeon series of cementing XLPE liners into well-fixed acetabular components. Of the 52 hips (51 patients) evaluated, 48 hips (47 patients) that satisfied a minimum follow-up of 10 years were included. The Harris Hip score was used for clinical evaluation. Final hip radiographs were used to determine the extent of acetabular osteolysis and stability of the components. The mean age at index operation was 53 years (range, 32 to 72). The mean follow-up duration was 14 years (range, 10 to 18).

RESULTS

The mean Harris Hip score improved from 58 points (range, 23-81) preoperatively to 91 points (range, 45-100) at the final evaluation (P < .001). A total of 3 acetabular rerevisions were performed, all for aseptic loosening of the outer shell. One postoperative dislocation occurred, but it was successfully treated with a closed reduction. Final radiographs showed a significant reduction in acetabular osteolysis (P < .001). Implant survivorship free from any rerevision was 93.3% (95% confidence interval, 85.9-100%) at 14 years.

CONCLUSION

Cementing an XLPE liner into a well-fixed acetabular shell in revision THA demonstrated excellent clinical and radiographic outcomes at a mean of 14 years postoperatively. This technique could be a safe and durable option in the absence of XLPE liners compatible with preimplanted shells.

Long-Term Survivorship of Cemented and Uncemented Polyethylene Liner Exchange

BACKGROUND

Revision surgery is usually required for complications associated with total hip arthroplasty (THA). Significant morbidity can be associated with revision THA and thus some may only revise the liner of the original metal back component if it is found to be well fixed. We compare the long-term survivorship of cemented and uncemented head-liner THA exchange surgeries and possible causes.

METHODS

Between 2000 and 2018, we reviewed cases from our arthroplasty database who underwent THA revision for head-liner exchange. We stratified our cohort into 2 groups: cemented and uncemented liners. Patients were followed clinically and radiographically to determine survivorship of the exchanges for both cemented and uncemented liners. Implant survivorship was measured using a competing risk analysis considering death and patients lost to follow-up as competing risks.

RESULTS

A total of 84 patients (85 hips) underwent head-liner exchange surgery during the study period (21 cemented and 64 uncemented liners). The mean follow-up time was 6.9 years, with 75.3% and 24.7% of patients having been revised due to non-dislocation and dislocation causes, respectively. Two cemented liners (9.5%) and 11 uncemented liners (17.2%) required revision. The survival analysis of all head-liner revision was 86.4% at 18 years. Survival estimates liner exchanges due to dislocation versus non-dislocation groups were 57.3% versus 82.7% respectively (P = .034).

CONCLUSION

The present study shows improved survivorship of head-liner exchanges performed due to non-dislocation etiology compared to dislocation etiology, but no difference in survivorship between cemented and uncemented head-liner exchange.

LEVEL OF EVIDENCE

Level III.

[Partial or full component exchange in hip revision? : The relevance of off-label use and mix & match]

Off-label use is frequently practiced in hip revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended (i.e. large bone and soft tissue defects, obesity). Patients may also benefit from selective application of mix & match in hip revision, when the exchange of one component only is necessary and the invasiveness of surgery can be reduced. Currently, there are no formal guidelines for these situations. Therefore, within a recent EFORT initiative, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in revision hip and knee arthroplasty.

Liner Dissociation and Acetabular Erosion Treated by Implant Retention and Dual-Mobility Liner Cementation: A Case Report

CASE

A 56-year-old woman underwent a left total hip arthroplasty (THA) after developing avascular necrosis after chemotherapeutic treatment of breast cancer. She presented approximately 2 years after index THA with left groin pain and complaints of instability. Imaging revealed pseudodislocation of the ceramic femoral head with erosion through the acetabular component. Intraoperative evaluation revealed a dissociated polyethylene liner, damaged acetabular locking mechanism, metallosis, and well-fixed and aligned components. Treatment consisted of component retention, bone grafting, and dual-mobility liner cementation into the acetabular component.

CONCLUSIONS

The two-year follow-up demonstrated a pain-free, well-functioning hip, bone graft incorporation, and no evidence of loosening.

Pseudotumor and delayed recurrent dislocation after total hip arthroplasty with a modular femoral neck: A case report

RATIONALE

Pseudotumor formation after hip arthroplasty is a rare complication that can occur not only at the head-neck junction but also at the modular neck-stem junction. Dislocation is a challenging and common complication of primary and revision total hip arthroplasty compared with other complications. Similarly, the association between pseudotumors and delayed recurrent dislocation remains unclear.

PATIENT CONCERNS

We report the case of a 73-year-old woman with pseudotumor formation after total hip arthroplasty combined with a modular femoral neck. A delayed recurrent dislocation occurred in this case. Approximately 4weeks after the first revision surgery, redislocation occurred.

DIAGNOSIS

The patient was eventually diagnosed with delayed recurrent artificial hip dislocation combined with a periprosthetic pseudotumor of the right hip.

INTERVENTIONS

During the first revision surgery, a thickened, indurated cyst measuring 8×3×8cm with a red-brown wall containing brown fluid was completely excised. A cemented stem, combined with a BIOLOX Forte ceramic head, was implanted. Approximately 4weeks after surgery, redislocation occurred, and we cemented an elevated rim liner on the acetabular component with a metal head.

OUTCOMES

At the last follow-up, 49 months after revision surgery, the patient was asymptomatic with a Harris hip score of 90. The patient had a satisfactory prognosis after treatment.

LESSONS

The application of the modular-neck stem should be cautiously performed, particularly for modular prostheses containing different alloys. Pseudotumors and insufficient soft-tissue tension both contribute to hip instability, which may eventually lead to delayed repeated dislocation. In addition, femoral offset must be considered. Cement-liner technology may be used for aging patients who are less active. This case report, focusing on pseudotumors and delayed recurrent dislocations, aimed to identify factors that may support this diagnosis, which is easy to miss. Consequently, it can provide further details on the treatment process and alert orthopedic surgeons to this infrequent but important cause of delayed recurrent dislocation.

EFORT recommendations for off-label use, mix & match and mismatch in hip and knee arthroplasty

Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

Total Hip Arthroplasty in a Patient with Mucopolysaccharidosis Type IVB

Introduction. Morquio syndrome or mucopolysaccharidosis (MPS) type IV is a rare autosomal recessive lysosomal storage disease, characterized by abnormal metabolism of glycosaminoglycans associated with specific skeletal deformities, also known as dysostosis multiplex. Case Presentation. We present the case of a 23-year-old patient with advanced osteonecrosis of the femoral head (ONFH) on both sides due to Morquio syndrome. A diagnosis of mucopolysaccharidosis type IVB was made after extensive genetic profiling. The patient had the condition for a long time. At 7 years old, the patient was treated with bilateral pelvic Salter's osteotomy. Afterward, the patient was able to walk freely but could never take part in sports. At 22 years old, pain in the hip increased, and magnetic resonance imaging showed a bilateral femur head necrosis. Hence, the patient underwent cementless total hip arthroplasty (THA). Intraoperatively, a periprosthetic fracture occurred. Therefore, revision surgery with internal fixation was performed on the next day. Postoperatively, a weight-bearing restriction of 20 kg on the left leg was imposed for 6 weeks. The patient made a full recovery and was able to move without residual complaints. Annual orthopedic evaluation in patients treated with surgical intervention is recommended. Discussion. Orthopedic challenges for mucopolysaccharidoses and corresponding bone alterations, known as dysostosis multiplex, involving trunk and limbs with typical radiological findings have been well described. The hip is invariably involved, with dysplasia affecting the femoral neck (coxa valga), femoral epiphysis (loss of sphericity, osteonecrosis), and a flared hypoplastic iliac wing. Symptomatic therapy consists, on the one hand, of a surgical procedure and, on the other hand, a variety of supportive measures. However, the management of joint replacement in lysosomal storage diseases has not been well reported. All patients with MPS should be considered at high risk for surgical intervention requiring anesthesia because of airway and cardiac disease manifestations. In the case of a need for THA, we recommend cemented stem fixation because of the overall poor bone quality in patients with Morquio syndrome.

"Off-label" Usage of an Oxidized Zirconium Femoral Head in Revision of a Total Hip Arthroplasty with Mechanically Assisted Crevice Corrosion and a Legacy Taper

We present a case of a 72-year-old male with a history of a late 1980s metal-on-polyethylene total hip arthroplasty who presented with unilateral leg vascular compromise, joint pain, and stiffness and subsequently underwent revision for adverse local tissue reaction secondary to mechanically assisted crevice corrosion. His stable and extensively porous coated femoral implant had a legacy taper with no currently manufactured option for a non–Co-alloy femoral head. After shared decision-making with the patient, we opted to use an oxidized zirconium femoral head from another manufacturer with a similar taper during his revision surgery and documented that his vascular compromise resolved and his serum Co was undetectable 3 years after the revision.

Cementation of the highly cross-linked polyethylene liner into a well-fixed acetabular shell to treat patients with recurrent dislocation after total hip arthroplasty

Cementation of a highly cross-linked polyethylene liner into a well-fixed acetabular shell provided a good durability for liner wear. However, its efficacy in treating recurrent instability due to malposition cup is less reported. The aim of this study is to evaluate the outcome of this surgical technique to treat hip instability. From 2009 to 2019, we have identified 38 patients who had been surgically treated for recurrent instability, including cementation liner (N = 20) and revision cup (N = 18) procedures. Patients were followed for a mean of 45.66 months. We have recorded and analyzed all causes of implant failure including recurrent instability. Clinical outcomes were assessed including complication and Harris Hip Score (HHS) preoperatively and at the latest follow-up. Revision-free survivorship for any cause was 95.0% at 1 year, and 84.4% at 5 years in cementation liner group and 88.9% at 1 year and 5 years in revision cup group. Mean Harris hip score improved from 48.3 points preoperatively to 79.5 points at the last follow-up in cementation liner group and mean HHS improved from 43.3 points preoperatively to 77.2 points in revision cup group. There were two implant failures in each group, including one is due to persistent hip instability and the other is due to periprosthetic joint infection in the cementation liner group and two implant failure are due to persistent hip instability in the revision cup group. Functional scores and implant survival were similar in both groups. We demonstrated that orientation correction via the cementation of the polyethylene liner into well-fixed acetabular shell is a promising option to treat and prevent instability. Level of Evidence: Therapeutic Level IV.