JBJS | Revision of the Acetabular Component without Cement After a Previous Acetabular Reconstruction with Use of a Bulk Femoral Head Graft in Patients Who Had Congenital Dislocation or Dysplasia. A Follow-up Note*

The Journal of Bone & Joint Surgery, Volume 81, Issue 12

Articles | December 01, 1999

Revision of the Acetabular Component without Cement After a Previous Acetabular Reconstruction with Use of a Bulk Femoral Head Graft in Patients Who Had Congenital Dislocation or Dysplasia. A Follow-up Note*

B. SONNY BAL, M.D.†; TED MAURER, 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, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston

The Journal of Bone & Joint Surgery. 1999; 81:1703-6

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Abstract

Background: Revision of an acetabular component that has failed after a total hip arthroplasty in which a bulk femoral head autogenous graft or allograft was used as a structural graft for acetabular reconstruction is an uncommon but complex and challenging procedure. We previously reported the results for seventy hips at an average of 16.5 years after a total hip arthroplasty in which an acetabular reconstruction had been performed with a femoral head graft. In the present study, we evaluated a subset of nine hips from that series that had a subsequent revision of the acetabular component without cement. The purpose of the current study was to assess the usefulness of the bone graft in this revision.Methods: The nine patients (nine hips) were followed clinically and radiographically for an average of seventy-six months (range, sixty-one to 114 months) after the index revision. In six hips the autogenous femoral head graft previously had been bolted to the lateral side of the ilium, and in one hip the femoral head allograft had been affixed in this manner. In the two remaining hips, the allograft had been placed within the acetabulum.The hips were classified according to the extent of acetabular bone loss, with use of criteria described previously. Three hips had stage-I bone loss; four, stage-II; and two, stage-IIIB.A porous-coated hemispherical acetabular component was inserted without cement and fixed with screws in each hip. At least 70 percent of the porous coating was in contact with viable bone.Results: At the time of the latest follow-up after the index revision, all nine acetabular components were functioning well without loosening or osteolysis and none had been revised. The average Harris hip score was 77 points (range, 61 to 98 points) compared with 49 points (range, 27 to 96 points) preoperatively. One hip had had revision of the femoral stem, and another had had exchange of the acetabular liner because of recurrent dislocations. There was no additional resorption of the residual bulk graft that was in contact with the metal shell in any hip.Conclusions: In this small series of complex acetabular revisions, the healed bulk graft provided valuable additional bone stock for the support of an acetabular component that was inserted without cement. Insertion of the acetabular component into the available bone, which consisted in major part of host bone and in minor part of united revascularized bulk graft, resulted in a well functioning hip after an intermediate duration of follow-up. In all except two hips, the enlarged bone stock allowed insertion of a larger acetabular component than had been used previously.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

We present a follow-up report of a small series of hips that had an acetabular revision without cement after the failure of a cemented acetabular component that had been supported against a bulk femoral head allograft or autogenous graft. These hips are a subset of an earlier series of seventy hips, in which nearly two-thirds (thirty-three) of fifty-five acetabular components that had been supported with an autogenous graft were loose at 16.5 years and nearly one-third (sixteen) of the fifty-five needed an acetabular revison⁴. Of the fifteen hips that had received an allograft, nine needed a reoperation. However, the graft united to the host bone in all of the hips.

In the present study, we assessed the usefulness of this residual healed bulk graft in augmenting the acetabular bone stock as well as the efficacy of insertion of the acetabular component without cement during an acetabular revision.

*One or more of the authors has 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, foundation, educational institution, or other nonprofit organization with which one or more of the authors is 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.

†Jackson County Orthopaedics, Incorporated, 801 N.W. St. Mary's Drive, Suite 101, Blue Springs, Missouri 64104.

‡Orthopedic Institute of Illinois, 303 North Kumpf Boulevard, Peoria, Illinois 61605.

§Orthopaedic Biomechanics Laboratory, GrJ 1126, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114. E-mail address: wharris@partners.org.

†Jackson County Orthopaedics, Incorporated, 801 N.W. St. Mary's Drive, Suite 101, Blue Springs, Missouri 64104.

‡Orthopedic Institute of Illinois, 303 North Kumpf Boulevard, Peoria, Illinois 61605.

§Orthopaedic Biomechanics Laboratory, GrJ 1126, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114. E-mail address: wharris@partners.org.

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Figs. 1-A, 1-B, and 1-C: Anteroposterior radiographs of one of the nine patients. Fig. 1-A: Radiograph made after a right total hip arthroplasty with use of cement for the treatment of congenital dislocation, performed in 1977. Note the superior placement of the acetabular component and the deficient acetabulum.

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Fig. 1-B Radiograph made after revision with use of a bulk femoral head allograft secured to the lateral surface of the ilium and an acetabular component inserted with cement and supported against the graft. The arrow indicates the graft-host bone interface.

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Fig. 1-C Radiograph made after repeat revision, performed ten years after the first revision. The acetabular cement had cracked, leading to aseptic loosening of the cup. For the second revision, the host bone and the healed bulk graft were reamed and a porous-coated metal cup was inserted into the host bone and the residual bulk graft. The arrow indicates the healed graft-host bone interface. Most of the acetabular shell was against host bone. The presence of the allograft made this second revision easier than it would have been if the procedure had been attempted without it.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between April 1984 and February 1989, fourteen patients (fifteen hips) in whom a bulk femoral head graft had been used previously to support an acetabular component inserted with cement had revision with an acetabular component inserted without cement. Of this group, nine patients (nine hips) were available for follow-up at an average of seventy-six months (range, sixty-one to 114 months) after the index revision. Six autogenous grafts and three allografts had been used in the nine hips. The six autogenous grafts and one of the three allografts had been bolted to the lateral side of the ilium²; the remaining two allografts had been placed within the acetabulum. The acetabular host bone and the bulk graft had united in each hip, as evidenced by the presence of continuous osseous trabeculae at the graft-host bone interface. There had been partial resorption of the superior and lateral parts of two of the six autogenous grafts and of all three allografts. All nine patients were women, and congenital dysplasia or dislocation had been the original cause of the hip disease in all of them. The average age of the patients at the time of the index revision was fifty years (range, twenty-six to sixty-one years), and the average weight was fifty-eight kilograms (range, fifty-two to seventy-one kilograms). Three hips were classified as group A and six, as group B, according to the criteria of Charnley¹.

Seven of the index revisions were performed because of aseptic loosening; one, because of extensive pelvic osteolysis; and one, for reimplantation after a resection arthroplasty that was done because of a late deep infection.

The index revision was the first acetabular revision in six hips, the second in two hips, and the third in one hip. Five patients had revision of the acetabular component only, and the other four had revision of the femoral component as well. A trochanteric osteotomy was used for the operative exposure in each hip.

After the host acetabulum and the healed bulk graft had been reamed with hemispherical reamers, there was bleeding from five of the six bulk autogenous grafts and from two of the three bulk allografts. No bleeding was noted from the two remaining bulk grafts, but there appeared to be sufficient bleeding from the host bone to support bone ingrowth in these hips.

The extent of the acetabular bone loss in each hip was determined according to previously reported criteria⁵. The three hips that had a stage-I defect needed reaming only, and the four that had a stage-II defect needed filling of the defect (which was mild or moderate) with particulate bone graft after reaming. The two remaining hips, which had a stage-IIIB defect with major loss of the bone stock in the medial wall, dome, and anterior and posterior columns, needed extensive particulate bone graft.

Each acetabular component was implanted with use of a so-called line-to-line fit and was fixed with self-tapping screws (average number of screws, 3.4; range, two to six). At least 70 percent of the metal shell was supported by viable bone (either viable host bone or viable host bone and bulk graft) (Figs. 1-A, 1-B, and 1-C).

All reconstructions were performed by the senior one of us (W. H. H.), at the same institution, with use of the Harris-Galante porous-coated acetabular component (Zimmer, Warsaw, Indiana). Six patients were examined by the senior one of us at the time of follow-up, and three patients completed a detailed questionnaire and had current radiographs made elsewhere. The follow-up radiographs, which included Judet radiographs, were compared with all previous radiographs.

Results

Introduction | Materials and Methods | Results | Discussion | References

At an average of seventy-six months (range, sixty-one to 114 months) after the index revision, none of the acetabular components had been revised, were loose, or were associated with pelvic osteolysis. Two hips had had a reoperation: one had had a revision of the femoral stem because of aseptic loosening and the other, exchange of the acetabular liner because of recurrent dislocations. No additional resorption of the bulk grafts was apparent on radiographic examination. None of the bulk grafts had fragmented or migrated.

The average Harris hip score³ at the time of the latest follow-up was 77 points (range, 61 to 98 points) compared with 49 points (range, 27 to 96 points) preoperatively. Five patients reported no hip pain, one had slight pain, and two had mild pain. The one patient who had moderate pain had a loose femoral component.

At the time of the latest follow-up, one hip had a continuous radiolucent line at the implant-bone interface of the metal acetabular shell as seen on one radiograph and three had a nearly continuous radiolucent line around the shell.

In all except two hips, the outer diameter of the acetabular component that had been inserted without cement was larger than that of the acetabular component that had been inserted with cement in the previous operation. Of the other two hips, one had an acetabular component with an outer diameter that was the same (forty millimeters) as that of the acetabular component used in the previous operation and the other had a component with an outer diameter that was two millimeters smaller (forty-six compared with forty-eight millimeters).

Five patients (six hips) in the original group of fourteen patients (fifteen hips) were not followed for at least five years; one patient had died at eighteen months with a well functioning prosthesis, two patients had had a resection arthroplasty because of a late deep infection, and one patient had had a femoral revision elsewhere because of painful aseptic loosening of the femoral component at four years. The remaining patient (two hips) refused to send radiographs but provided clinical data; that patient had a Harris score of 91 points for one hip and 88 points for the other hip.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

A bulk structural graft to support an acetabular component inserted during a total hip replacement generally is used in patients who have a major deficiency of the acetabular bone stock. Union of the bulk autogenous or allogenic graft to the pelvis almost always is achieved. However, the rate of loosening of the acetabular component increases over time if the graft provides more than 30 percent of the structural support for the component.

In the current study, we evaluated whether a bulk graft used during a previous arthroplasty performed with cement provided useful additional support in a subsequent revision of the acetabular component without cement in nine hips. After a minimum of five years (average, seventy-six months; range, sixty-one to 114 months), none of the acetabular shells had been revised, were loose, or were associated with pelvic osteolysis. The outer diameter of the acetabular component that was inserted during the revision was larger than that of the one used at the time of the bone-grafting in seven of the nine hips.

The findings in this small series suggest that, in addition to the advantage that bulk grafting provides when needed for an initial acetabular reconstruction in a hip with major acetabular deficiency, it provides the secondary advantage of facilitating a subsequent revision if that becomes necessary. This information may be useful when revision of a loose cemented acetabular component is being considered in patients who had a previous acetabular reconstruction with a bulk autogenous graft or allograft.

References

Introduction | Materials and Methods | Results | Discussion | References

Charnley, J.: Low Friction Arthroplasty of the Hip. Theory and Practice. New York, Springer, 1979.

Garbuz, D.; Morsi, E.; Mohamed, N.; and Gross, A. E.: Classification and reconstruction in revision acetabular arthroplasty with bone stock deficiency. Clin. Orthop.,324: 98-107, 1996.32498 1996 [PubMed]

Harris, W. H.: Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J. Bone and Joint Surg.,51-A: 737-755, June 1969.51-A737 1969

Shinar, A. A., and Harris, W. H.: Bulk structural autogenous grafts and allografts for reconstruction of the acetabulum in total hip arthroplasty. Sixteen-year-average follow-up. J. Bone and Joint Surg.,79-A: 159-168, Feb. 1997.79-A159 1997

Tanzer, M.; Drucker, D.; Jasty, M.; McDonald, M.; and Harris, W. H.: Revision of the acetabular component with an uncemented Harris-Galante porous-coated prosthesis. J. Bone and Joint Surg.,74-A: 987-994, Aug. 1992.74-A987 1992

Topics

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Charnley, J.: Low Friction Arthroplasty of the Hip. Theory and Practice. New York, Springer, 1979.

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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B. SONNY BAL, TED MAURER, WILLIAM H. HARRIS; Revision of the Acetabular Component without Cement After a Previous Acetabular Reconstruction with Use of a Bulk Femoral Head Graft in Patients Who Had Congenital Dislocation or Dysplasia. A Follow-up Note*. The Journal of Bone & Joint Surgery. 1999 Dec;81(12):1703-6.

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