JBJS | Bulk Structural Autogenous Grafts and Allografts for Reconstruction of the Acetabulum in Total Hip Arthroplasty. Sixteen-Year-Average Follow-up*

The Journal of Bone & Joint Surgery, Volume 79, Issue 2

Articles | February 01, 1997

Bulk Structural Autogenous Grafts and Allografts for Reconstruction of the Acetabulum in Total Hip Arthroplasty. Sixteen-Year-Average Follow-up*

ANDREW A. SHINAR, M.D.†; WILLIAM H. HARRIS, M.D.‡, BOSTON, MASSACHUSETTS

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Investigation performed at the Orthopaedic Biomechanics Laboratory and the Hip and Implant Unit of the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston

The Journal of Bone & Joint Surgery. 1997; 79:159-68

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Abstract

Acetabular reconstruction with bulk structural autogenous grafts and allografts from the femoral head in complex total hip arthroplasty was highly successful at an average of five years postoperatively but was much less so by 11.8 years. To assess the longer-term fate of such grafts, we reviewed the results of eighty-one consecutive total hip arthroplasties performed by the senior one of us with use of these grafts. Nine hips in nine patients who had died and two hips that were infected in two patients were excluded. Therefore seventy hips (sixty-two patients) were included in this study. The average duration of follow-up was 16.5 years (range, 14.1 to 21.4 years).Sixty-one arthroplasties were performed to treat various forms of congenital dysplasia. Fifteen arthroplasties, ten of which were revision operations, were performed with allograft, and fifty-five were performed with autogenous graft. The average age of the patients at the time of the index operation was 45.2 years (range, sixteen to sixty-nine years). All of the sockets, which had an average outer diameter of forty millimeters (range, thirty-four to fifty millimeters), were inserted with cement. The average coverage of the acetabular component by the bulk graft was 49 per cent (range, 15 to 100 per cent).All of the grafts united. At the latest follow-up examination, twenty-five acetabular components (36 per cent) had been revised for aseptic loosening, eighteen (26 per cent) had radiographic evidence of loosening, and twenty-seven (39 per cent) were rigidly fixed and in place. The average Harris hip score for the hips in which the implant remained rigidly fixed was 74 points, while that for the hips in which the implant was loose but had not been revised was 69 points.Nine of the fifteen acetabular components supported by allograft and sixteen (29 per cent) of the fifty-five supported by autogenous graft were revised (p = 0.03). However, the total rate of acetabular components that were either loose or revised was ten of fifteen and thirty-three (60 per cent) of fifty-five, respectively. This difference was not significant (p = 0.4), with the numbers available.Regression analysis revealed that a younger age at the time of the operation and the extent of coverage of the acetabular component by the graft were associated with the need for revision. Twenty-one (78 per cent) of the twenty-seven acetabular components that remained rigidly fixed were supported by graft over less than 50 per cent of the contact area, while only nine (36 per cent) of the twenty-five that were revised were so supported (p < 0.05). None of the nine acetabular components with 30 per cent of the contact area or less covered by graft were revised.In nineteen of the twenty-two revisions of the acetabular component performed after the index operation, the socket was inserted without cement; the average outer diameter of the socket was fifty-three millimeters (range, forty to fifty-eight millimeters).Both the structural autogenous grafts and the structural allografts used in acetabular reconstruction in total hip replacement functioned well for the initial five to ten years. By an average of 16.5 years, nine of the fifteen hips treated with allograft and sixteen (29 per cent) of the fifty-five treated with autogenous graft had been revised. The greater the extent of the coverage of the acetabular component by the graft, the greater the rate of late failure.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Severely deficient acetabular bone stock presents a challenge to surgeons who perform reconstructive procedures about the hip. Coventry⁶ initially recommended foregoing reconstruction for patients with such a problem. Charnley and Feagin⁴ stated that total hip arthroplasty should be avoided in patients who have total congenital dislocation of the hip. Others^9,22 have advocated intentional fracture of the medial wall of the acetabulum. One of us and colleagues^18,20 proposed acetabular reconstruction with autogenous graft from the femoral head. However, a review of the results revealed that, by an average of seven years, 9 per cent (four) of the forty-seven acetabular components had been revised and an additional 13 per cent (six) were loose¹⁴. By an average of 11.8 years, both rates had approximately doubled, to 20 per cent (nine of forty-six hips) and 26 per cent (twelve), respectively³².

The results of allografting parallel those of autogenous grafting. In one study³¹, the rate of revision at an average of four years was 11 per cent (three of twenty-seven hips), and an additional 7 per cent (two) of the components were loose. By an average of six years, the rates had approximately doubled, to 21 per cent (eight of thirty-eight hips) and 11 per cent (four), respectively. By an average of ten years, the rates had risen to 33 per cent (ten of thirty hips) and 13 per cent (four)³¹.

Other authors have demonstrated similar initial success¹¹ followed by failure after additional follow-up¹², while some have maintained that use of a bulk structural graft can be successful^3,15. The aim of the present study was to assess the long-term results of acetabular reconstruction with bulk structural autogenous grafts and allografts from the femoral head in total hip arthroplasty.

*One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund or foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the William H. Harris Foundation, Boston, Massachusetts.

†Associated Orthopedists of Detroit, 19505 East Eight Mile Road, St. Clair Shores, Michigan 48080. E-mail address for Dr. Shinar: ashinar@pol.net.

‡Orthopaedic Biomechanics Laboratory, GrJ 1126, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114.

†Associated Orthopedists of Detroit, 19505 East Eight Mile Road, St. Clair Shores, Michigan 48080. E-mail address for Dr. Shinar: ashinar@pol.net.

‡Orthopaedic Biomechanics Laboratory, GrJ 1126, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114.

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Fig. 1 Graph of the percentage of acetabular components that were supported by autogenous graft (diamonds) or by allograft (squares) and that were not revised, plotted against time.

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Fig. 2 Graph of the percentage of acetabular components that were supported by autogenous graft (diamonds) or by allograft (squares) and that remained rigidly fixed, plotted against time.

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Fig. 3 Kaplan-Meier²⁸ survivorship curves representing the rate of survival, with revision as the end point, for the hips with an autogenous graft (diamonds) and those with an allograft (squares), plotted against time. The I-bars represent the 95 per cent confidence intervals.

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Figs. 4-A through 4-E: Radiographs of a thirty-three-year-old woman who had total congenital dislocation of the left hip. Fig. 4-A: Preoperative frog-leg lateral radiograph of the hip.

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Fig. 4-B: Anteroposterior radiograph made after application of an autogenous graft from the femoral head, which covered 40 per cent of the forty-millimeter cemented cup and was fixed with two bolts.

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Fig. 4-C: Anteroposterior radiograph, made 2.9 years postoperatively, showing displacement of the socket associated with mild superior and lateral resorption of the graft.

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Fig. 4-D: Radiograph made after revision with a forty-millimeter cup inserted with cement. The graft appeared to be well vascularized.

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Fig. 4-E: Radiograph made after a repeat revision with a forty-six-millimeter cup inserted without cement 13.2 years after the first revision. The graft appeared to be well vascularized. Note the preservation of the lateral lip of the graft at sixteen years after the initial grafting procedure. This is a crucial element for support of a replacement inserted without cement.

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Figs. 5-A, 5-B, and 5-C: Radiographs of a forty-two-year-old woman who had severe dysplasia of the left hip and mild dysplasia of the right hip. Fig. 5-A: Preoperative anteroposterior radiograph of the pelvis.

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Fig. 5-B: Anteroposterior radiograph of the left hip, made immediately after reconstruction with an autogenous graft from the femoral head that covered 30 per cent of the forty-four-millimeter cup and was fixed with two bolts.

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Fig. 5-C: Anteroposterior radiograph of the left hip, made twenty-one years postoperatively. There was complete incorporation and lack of resorption of the graft. The Harris hip score was 82 points.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

We reviewed the results of acetabular reconstruction with a bulk structural graft performed by the senior one of us (W. H. H.) in eighty-one consecutive hips in seventy-three patients, from October 29, 1973, to November 24, 1980. All surviving patients who had not had a revision were interviewed in person (ten hips) or were surveyed with use of a questionnaire followed by a telephone interview (thirty-three hips). All interviews were conducted by an experienced orthopaedic surgeon who had not been involved in the operation or the care of the patients. Radiographs were made and a Harris hip score¹⁷ was determined for all hips. For the hips that were revised, the most recent radiographs before the revision were evaluated and the surgeon who performed the revision was contacted. We included four patients (four hips) who were not alive at the time of the review but either had had an acetabular revision or had had radiographs made and a Harris hip score determined after more than fourteen years of follow-up. Nine patients (nine hips) were excluded because they had died less than fourteen years postoperatively and they had not had an acetabular revision. Two hips (two patients) in which a resection had been done because of infection were also excluded. Thus, seventy hips (sixty-two patients) were included in this study. The average duration of follow-up was 16.5 years (range, 14.1 to 21.4 years). No patient was lost to follow-up.

Sixty-one procedures were done to treat various forms of congenital dysplasia, and nine were done to treat sequelae from a fracture or dislocation of the hip, a fracture of the acetabulum or femoral neck, mucopolysaccharidosis, infection, or tuberculosis. Twenty hips had had a total of twenty-five previous procedures.

The preoperative radiographs demonstrated group-I dysplasia of ten of the fifty-two hips that had autogenous grafting for dysplasia or dislocation (all primary procedures), group-II dysplasia of seven, group-III dysplasia of eleven, and group-IV dysplasia of twenty-four, according to the classification of Crowe et al.⁷.

Nine of the fifteen hips that were treated with an allograft were originally diagnosed with congenital dysplasia. Seven of the fifteen hips had had nineteen previous procedures other than total hip replacement. Ten of the fifteen index procedures were revision operations. According to the classification of acetabular deficiency presented by The American Academy of Orthopaedic Surgeons Committee on the Hip⁸, five of these ten hips had type-IIIA deficiency; three, type-IIIB; and two, type-IV. The original failed arthroplasty had been performed to treat osteoarthrosis secondary to congenital dysplasia in eight of the ten hips.

The average age of all of the patients at the time of the index operation was 45.2 years (range, sixteen to sixty-nine years). The average age of the forty-eight patients (fifty-five hips) who had an autogenous graft was 47.1 years (range, sixteen to sixty-nine years), and the average age of the fourteen patients (fifteen hips) who had an allograft was 38.7 years (range, twenty-one to sixty-five years); this difference was significant (p = 0.04, Student t test). The average weight of the sixty patients for whom it was known was fifty-nine kilograms (range, 38.2 to 81.8 kilograms). The average weight of the patients who had an autogenous graft was sixty kilograms (range, 47.3 to 81.8 kilograms), and the average weight of the patients who had an allograft was fifty-eight kilograms (range, 38.2 to 75.0 kilograms); with the numbers available, this difference was not significant (p = 0.4).

The techniques that were used have been described previously^18,20. In addition to the usual posterolateral incision, an anterior incision was made for twenty-eight of the fifty-five autogenous graft procedures and for five of the fifteen allograft procedures. Bolts were used to fix all but two grafts, which were intra-acetabular grafts that were contained by the osseous confines of the pseudoacetabulum.

The amount of coverage of the socket by the graft was determined on postoperative anteroposterior radiographs by comparison of the mediolateral dimension of the portion of the socket that was covered by the graft with the mediolateral dimension of the entire socket. Computerized tomography scans were not available, so it was not possible to assess fully the amount of coverage in three dimensions. The average coverage was 49 per cent (range, 15 to 100 per cent) for the whole series but 45 per cent (range, 15 to 95 per cent) for the autogenous grafts and 62 per cent (range, 35 to 100 per cent) for the allografts (p = 0.001, Student t test). Fifty-five grafts were fixed to the lateral aspect of the ilium, and fifteen were intra-acetabular. Nine of the intra-acetabular grafts were allografts.

All of the sockets were all-polyethylene; all were inserted with cement; and, except for one Charnley cup (Thackray, London, England), all were made by Howmedica (Rutherford, New Jersey). The average outer diameter of the seventy sockets was forty millimeters (range, thirty-four to fifty millimeters), and the averages in the two subgroups were similar. Union of the graft was determined by the presence of osseous trabeculae across the graft-host junction.

The femoral component was inserted with cement with use of so-called first-generation techniques for the eleven replacements performed before 1976 and with use of so-called second-generation techniques¹⁹ for the fifty-nine performed from 1976 to 1980. Thirty-eight custom miniature stems, seventeen HD-2 (Harris Design-2) stems, seven CAD (computer-assisted design) stems, six Harris stems, one calcar replacement (all Howmedica), and one Charnley stem (Thackray) were inserted. Fifty-five components had a twenty-two-millimeter-diameter femoral head and fifteen had a twenty-six-millimeter-diameter head.

Antibiotic prophylaxis and trochanteric osteotomy were used in all hips.

The fixation of the acetabular component was considered to have failed if the component had migrated two millimeters or more, if a continuous radiolucent line had developed²³ at the cement-bone interface, or if the cement had cracked. Resorption of the graft was estimated by comparison of the area occupied by graft on the most recent anteroposterior radiograph of the pelvis with that on the immediate postoperative radiograph. Vascularity of the graft was determined from the operative notes on the revision procedure and was graded as full, partial, or non-vascular.

The data were analyzed with Kaplan-Meier²⁸ survivorship curves and multiple regression analyses.

Results

Introduction | Materials and Methods | Results | Discussion | References

All of the grafts united. Twenty-five (36 per cent) of the seventy acetabular components were revised for aseptic loosening. Resorption of the graft was believed to be responsible for the failure of nineteen (76 per cent) of them. The other six were loose but without major resorption. Of the forty-five components that were not revised, eighteen had radiographic evidence of loosening. Therefore, twenty-seven (39 per cent) of the seventy components were rigidly fixed and in place at the time of the latest follow-up examination.

The over-all combined rate of revision and loosening was 61 per cent (forty-three hips). Kaplan-Meier survivorship analysis²⁸ revealed a 65 per cent rate of survival (95 per cent confidence interval, 55 to 75 per cent), with revision as the end point, at an average of 16.5 years. Resorption of the graft was mild (less than 33 per cent) in thirty-five of the hips that were not revised, moderate (33 to 50 per cent) in three, and severe (more than 50 per cent) in seven.

The average Harris hip score for the hips in which the component remained rigidly fixed was 75 points (range, 29 to 97 points), and the average score for the hips in which the component was loose was 69 points (range, 9 to 92 points).

Acetabular components that were supported by allograft were revised at a greater rate (nine of fifteen) than those that were supported by autogenous graft (sixteen of fifty-five; 29 per cent) (p = 0.03, Student t test). However, the total rate of revised and loose components that were supported by allograft (ten of fifteen) was not significantly different from the total rate of revised or loose components that were supported with autogenous graft (thirty-three of fifty-five; 60 per cent) (Figs. 1 and 2). Whether the allografts were used for a primary or a revision procedure did not influence the rate of revision or loosening; similarly, the preoperative diagnosis (dysplasia compared with other diagnoses) did not influence these rates in either the hips with an autogenous graft or those with an allograft. Kaplan-Meier survivorship analysis²⁸, with revision as the end point, demonstrated a 73 per cent rate of survival for the hips with an autogenous graft and a 40 per cent rate of survival for those with an allograft at an average of 16.5 years (Fig. 3).

The extent of the coverage of the acetabular component by the graft influenced the result of the reconstruction. Twenty-one (78 per cent) of the twenty-seven acetabular components that remained rigidly fixed were supported by graft over less than 50 per cent of the contact area, while only nine (36 per cent) of the twenty-five that were revised (Figs. 4-A, 4-B, 4-C, 4-D through 4-E) were so supported (p < 0.05, chi-square test). None of the nine acetabular components that had 30 per cent of the contact area or less supported by graft were revised (Figs. 5-A, 5-B, and 5-C), although two were loose at the latest follow-up examination. Of the twenty-nine acetabular components supported by graft over more than 50 per cent of the contact area, only five remained rigidly fixed.

The average coverage of the acetabular cup by the allograft was 62 per cent (range, 35 to 85 per cent) in the ten hips in which the component was loose or revised, whereas it was 64 per cent (range, 40 to 100 per cent) in the five hips in which the component was still rigidly fixed. The average coverage by the autogenous graft was 49 per cent (range, 20 to 95 per cent) for the thirty-three components that were loose or revised and only 36 per cent (range, 15 to 70 per cent) for the twenty-two components that were still rigidly fixed (p = 0.03, Student t test).

Failure of both types of graft was more common in younger patients. The average age at the time of the index operation of the patients who had an allograft (38.7 years) was less than that for the patients who had an autogenous graft (47.1 years) (p = 0.04, Student t test). Of the patients who had an autogenous graft, those in whom the component remained rigidly fixed had an average age of fifty years, whereas the average age was 48.4 years for those in whom the component was loose but not revised and 41.6 years for those in whom the component was revised. The difference between the age of the patients in whom the component was rigidly fixed and the age of those in whom it was revised was significant (p = 0.03, Student t test). The average age at the time of the index operation of the five patients with an allograft and in whom the component remained rigidly fixed was 48.8 years, compared with 33.6 years for the nine patients in whom the component was revised and the one patient in whom it was loose but not revised (p = 0.05, Student t test).

There was a trend of increased weight of the patient at the time of the index operation being associated with the rate of revision among the patients who had an autogenous graft (p = 0.07, Student t test). There was no such association in the group that had an allograft.

A younger age at the time of the index operation was significantly and detrimentally related to the rate of revision (p = 0.02, Student t test). Although, when analyzed in a continuous fashion, age was a significant factor in revision, it was not possible to determine a discrete age threshold below which revision became significantly more likely. The variables of weight, amount of coverage of the acetabular component with the graft, or type of graft were not significant when age was factored out. When the same analysis was performed for loosening with or without revision, none of these factors was significant. With the numbers available, the preoperative classification of Crowe et al.⁷ did not have a significant effect on the rate of revision among the fifty-two autogenous grafts that were used to treat various forms of dysplasia.

Nineteen of the twenty-two acetabular revisions performed after the index operation were done without cementing of the socket and without the addition of a structural graft. Also, the average size of the nineteen components was fifty-three millimeters (range, forty to fifty-eight millimeters), in contrast to forty millimeters for the components used for the index operation. The remaining three revisions, done with cementing of the cup (average outer diameter, 43.3 millimeters), were performed between December 1978 and October 1981, before the development of cups designed to be inserted without cement. In another revision, a bipolar prosthesis and additional bulk and particulate graft were placed by another surgeon. Only two hips had a resection arthroplasty. According to the twenty-two operative notes that included a description of vascularity of the graft at the time of the revision, the graft was found to be well vascularized in eighteen hips, partially vascularized in one, and non-vascular in three. All three non-vascular grafts were allografts used in revision procedures.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

We sought to determine the long-term results of acetabular reconstruction with a bulk structural autogenous graft or allograft from the femoral head in total hip arthroplasty. Our early results with the autogenous grafts were encouraging but were followed by later failures^14,31,32. The rate of revision at an average of 16.5 years (29 per cent; sixteen of fifty-five) was only moderately higher than that at 11.8 years (20 per cent; nine of forty-six), but the total rate of revision or loosening at an average of 16.5 years was 60 per cent (thirty-three of fifty-five). These figures are similar to the over-all combined rate of acetabular revision (13 per cent; eleven of eighty-four) and loosening (50 per cent; forty-two of eighty-four) in a series of eighty-four cemented acetabular components in sixty-three patients who were followed for an average of eighteen years⁴⁰. The patients in that study were not specifically selected for acetabular deficiency but were selected for an age of less than fifty years. The average age of forty-two years at the time of the index arthroplasty in that series is the closest, among the ages in published long-term studies of which we are aware, to the average age of 47.1 years for the patients who had an autogenous graft in our study.

Most authors have reported excellent early or intermediate results with the use of structural autogenous grafts from the femoral head^{13,15,21,26,30,34,42}. Commonly, however, they have done so for patients in whom the acetabular component was covered by a smaller amount of graft. Our data suggest that bulk grafts play a minor role in the longevity of the component if they support 30 per cent of the acetabular component or less. Wolfgang⁴² reported that the rate of acetabular revision in his series was 2 per cent (one of forty-two components) at 5.7 years, but 57 per cent (twenty-four) of the forty-two cups had 30 per cent coverage by the graft or less. No patient had more than 50 per cent coverage⁴². Many other authors have reported similar success at the time of intermediate-term follow-up, but the percentage of coverage by the graft was similarly low in their patients^15,26,34. The relevance of the successful results with bulk grafts reported by some authors is questionable as they did not report the amount of coverage by the graft^13,21,30.

In the present study, nine acetabular components (13 per cent) had 30 per cent coverage by the graft or less and none of them had been revised at an average of 16.5 years. In contrast, only 17 per cent of the components with more than 50 per cent coverage by the bulk graft were in place and rigidly fixed at an average of 16.5 years.

Gross and Catre¹⁵ thought that their results were better than those reported from our institution¹⁴ because screws rather than bolts had been used to fix the graft in their patients. We do not agree. All of the grafts in our series united, and those in several other reported series^26,29,31,34 either united or did not migrate. Non-union of the graft is uncommon⁵. The bolts in our series that broke did so only after major resorption of the graft, well after union had occurred.

Our data revealed that failure of fixation of the component is associated with the percentage of its coverage by bulk autogenous graft. However, regression analysis demonstrated that the age at the time of the operation was an even stronger factor in failure of fixation of the acetabular component.

The bulk structural allografts were associated with a substantially higher rate of revision at 15.4 years (nine of fifteen, with one additional loose component) than the bulk autogenous grafts at 16.6 years (sixteen [29 per cent] of fifty-five, with seventeen additional loose components). The results with bulk structural allografts and cups inserted with cement have generally been substantially worse than those with autogenous grafts¹⁶.

The reports of good results with bulk structural autogenous grafts that covered less than 35 per cent¹, as much as 40 per cent¹⁶, and even as much as 50 per cent³⁸ of the contact area of porous cups that had been inserted without cement have all been based on short-term follow-up. Other than those reported on by Chandler and Penenberg^2,3, acetabular components inserted without cement have performed poorly when supported by bulk allografts. Rates of failure of 15 per cent (seven of forty-six) to 65 per cent (thirteen of twenty) with follow-up of only two to four years have been reported^10,25,33,43, regardless of the type of allograft used. Use of bulk structural allografts in conjunction with threaded cups^10,24,38 or with bipolar prostheses^10,30,38 has yielded similarly poor results, often with short-term follow-up.

One advantage of bulk grafts was demonstrated by the fact that nineteen revision operations without cement were possible after the index reconstructions and substantially larger components could be inserted without cement and were supported by revascularized graft. Still, for most patients, we do not believe that the effect of augmented bone stock justifies the rate of revision and the total rate of loosening and revision associated with bulk autogenous grafts (29 and 60 per cent, respectively) or the rate of revision (nine of fifteen) associated with bulk allografts by an average of 16.5 years when reconstruction without cement is possible. We prefer to insert an acetabular component without cement and without a bulk graft, but when such reconstructions are not possible bulk grafts are still the best alternative.

For revision operations, we currently insert acetabular components without cement^27,36,41 and commonly place the cup at a high hip center^35,37 because we recognize that bulk structural graft is not needed if there is at least 70 per cent coverage by host bone and since greater coverage of the cup by host bone is achieved if cement is not used. Silverton et al.³⁹ reported, at a mean of 8.9 years, the intermediate-term results of 115 revision acetabular reconstructions performed without bulk grafting; there were no repeat revisions for aseptic loosening except in one patient who had radiation necrosis of the pelvis. In complex primary procedures, we place the cup without cement at either a high hip center or the anatomical hip center, depending on where the best amount and configuration of viable native bone is.

In retrospect, we would not have used a graft for fifty-one of the seventy hips reported on here if we had treated them at the present time. Only 39 per cent (twenty-seven) of the seventy acetabular components remained rigidly fixed at an average of 16.5 years postoperatively. Even this low rate, however, is skewed in favor of grafting. Seven (26 per cent) of the twenty-seven components that remained rigidly fixed had 30 per cent coverage by the graft or less, and only five (19 per cent) had more than 50 per cent coverage. Thus, when grafts are used to provide the major support of the acetabular component, they perform even less well. We presently use structural bone graft only in rare instances in which the native bone stock is inadequate for reconstruction performed without cement and with contemporary techniques, including use of a small acetabular component inserted without cement, a high hip center if needed, and particulate grafting.

References

Introduction | Materials and Methods | Results | Discussion | References

Barrack, R. L., and |and |Newland, C. C.: Uncemented total hip arthroplasty with superior acetabular deficiency. Femoral head autograft technique and early clinical results. J. Arthroplasty,5: 159-167, 1990.5159 1990 [PubMed]

Chandler, H. P.: Use of allografts and prostheses in the reconstruction of failed total hip replacements. Orthopedics,15: 1207-1218, 1992.151207 1992 [PubMed]

Chandler, H. P., and Penenberg, B. L.: Bone Stock Deficiency in Total Hip Replacement: Classification and Management. Thorofare, New Jersey, Slack, 1989.

Charnley, J., and |and |Feagin, J. A.: Low-friction arthroplasty in congenital subluxation of the hip. Clin. Orthop.,91: 98-113, 1973.9198 1973 [PubMed]

Conn, R. A.; Peterson, L. F. A.; Stauffer, R. N.; and |and |Ilstrup, D.: Management of acetabular deficiency; long-term results of bone grafting the acetabulum in total hip arthroplasty. Orthop. Trans.,9: 451-452, 1985.9451 1985

Coventry, M. B.: Indications and selection of patients for total hip replacement. Part I. Selection of patients for total hip arthroplasty. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 23, pp. 136-142. St. Louis, C. V. Mosby, 1974.

Crowe, J. F.; Mani, V. J.; and |and |Ranawat, C. S.: Total hip replacement in congenital dislocation and dysplasia of the hip. J. Bone and Joint Surg.,61-A: 15-23, Jan. 1979.61-A15 1979

D'Antonio, J. A.; Capello, W. N.; Borden, L. S.; Bargar, W. L.; Bierbaum, B. F.; Boettcher, W. G.; Steinberg, M. E.; Stulberg, S. D.; and |and |Wedge, J. H.: Classification and management of acetabular abnormalities in total hip arthroplasty. Clin. Orthop.,243: 126-137, 1989.243126 1989 [PubMed]

Dunn, H. K., and |and |Hess, W. E.: Total hip reconstruction in chronically dislocated hips. J. Bone and Joint Surg.,58-A: 838-845, Sept. 1976.58-A838 1976

Emerson, R. H., Jr.; Head, W. C.; Berklacich, F. M.; and |and |Malinin, T. I.: Noncemented acetabular revision arthroplasty using allograft bone. Clin. Orthop.,249: 30-43, 1989.24930 1989 [PubMed]

Fredin, H. O., and |and |Unander-Scharin, L. E.: Total hip replacement in congenital dislocation of the hip. Acta Orthop. Scandinavica,51: 799-802, 1980.51799 1980

Fredin, H.; Sanzén, L.; Sigurdsson, B.; and |and |Unander-Scharin, L.: Total hip arthroplasty in high congenital dislocation. 21 hips with a minimum five-year follow-up. J. Bone and Joint Surg.,73-B(3): 430-433, 1991.73-B(3)430 1991

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