JBJS | Total Hip Arthroplasty with Insertion of the Acetabular Component without Cement in Hips with Total Congenital Dislocation or Marked Congenital Dysplasia*

The Journal of Bone & Joint Surgery, Volume 81, Issue 3

Articles | March 01, 1999

Total Hip Arthroplasty with Insertion of the Acetabular Component without Cement in Hips with Total Congenital Dislocation or Marked Congenital Dysplasia*

MICHAEL J. ANDERSON, M.D.†; WILLIAM H. HARRIS, M.D.‡, BOSTON, MASSACHUSETTS

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Investigation performed at the Orthopaedic Biomechanics Laboratory and the Adult Reconstructive Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston

The Journal of Bone & Joint Surgery. 1999; 81:347-54

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Abstract

Background: End-stage osteoarthritis secondary to total congenital dislocation or severe congenital dysplasia of the hip (class B or C according to the system of Eftekhar or type 2 or 3 according to the system of Hartofilakidis et al.) in adults presents special problems with regard to reconstruction of the hip. The purpose of the present study was to assess the intermediate-term results associated with the use of a porous ingrowth acetabular component for the treatment of these difficult cases.Methods: We performed a prospective study of a consecutive series of twenty-one patients (twenty-four hips) who had had a primary total hip arthroplasty with use of a hemispherical acetabular component that was inserted without cement and fixed with screws. No patient was lost to follow-up. Three patients (four hips) died, of causes unrelated to the total hip arthroplasty, before a minimum duration of follow-up of five years. None of these patients had had revision. Of the remaining eighteen patients (twenty hips), fifteen were women and three were men. Ten hips had total dislocation, and ten had severe dysplasia.Results: After an average duration of follow-up of eighty-three months (range, sixty-four to 102 months), the average Harris hip score was 90 points (range, 68 to 97 points). No patient had revision, loosening, or migration of the acetabular component; pelvic osteolysis; or a continuous radiolucent line at the mesh-bone interface of the acetabular component. The average rate of polyethylene wear was 0.08 millimeter per year (range, zero to 0.21 millimeter per year).Conclusions: The porous ingrowth acetabular component that was used in the present study functioned well at the time of the intermediate-term follow-up of this group of patients who had marked congenital dysplasia or total dislocation of the hip. The use of this component decreased the need for structural acetabular grafts. This component appears to perform as well as larger components of this design that have been assessed after similar durations of follow-up.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Osteoarthritis of the hip secondary to severe congenital dysplasia or total congenital dislocation (class B or C according to the system of Eftekhar⁶ [Fig. 1] or type 2 or 3 according to the system of Hartofilakidis et al.¹⁵) presents difficult problems with regard to reconstruction of the hip in adults^4,10-12,14. Charnley and Feagin stated that a total hip arthroplasty should be avoided in patients who have total congenital dislocation of the hip³. One of us (W. H. H.) previously advocated the use of autogenous grafts or allografts from the femoral head to augment limited pelvic bone stock^9,13. The initial results achieved with these techniques were excellent; however, by seven years after the operation, five of forty-seven acetabular components had already been revised and five of the remaining forty-two were radiographically loose⁷. These results continued to deteriorate with time, and, by an average of sixteen years, 60 percent (thirty-three) of fifty-five acetabular components in patients who had been managed with a bulk autogenous graft from the femoral head were loose²². Failure of fixation of the acetabular component was rare before five years, a finding that emphasizes the insensitivity of evaluations performed after follow-up periods of less than five years.

In 1984, we began to reconstruct the acetabulum in these difficult cases with use of a hemispherical component designed to be inserted without cement and fixed with screws (Harris-Galante Porous Acetabular Component; Zimmer, Warsaw, Indiana) if at least 70 percent of the porous surface was covered by host bone. If more than 30 percent of the surface of the component was uncovered, a bulk graft was fixed to the pelvis and a component that was designed to be inserted with cement was used instead.

The purpose of the present study was to assess, after a minimum duration of follow-up of five years, the results of total hip arthroplasty performed with use of a porous ingrowth acetabular component in patients who had total congenital dislocation or marked congenital dysplasia of the hip.

*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. 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.

†Blount Orthopaedic Clinic, 625 East St. Paul Avenue, Milwaukee, Wisconsin 53202.

‡Adult Reconstructive Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114.

†Blount Orthopaedic Clinic, 625 East St. Paul Avenue, Milwaukee, Wisconsin 53202.

‡Adult Reconstructive Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114.

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FIG1:: Fig. 1 Drawing showing the stages of dislocation of the hip, from dysplasia to complete dislocation, according to the system of Eftekhar⁶. Class-A hips were not included in the present study. (Reprinted, with permission, from: Eftekhar, N. S.: Total Hip Arthroplasty. Vol. 2, p. 927. St. Louis, Mosby, 1993.)

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FIG2-A:: Figs. 2-A and 2-B: Anteroposterior radiographs of a woman who had a total hip replacement, at the age of fifty-six years, because of total congenital dislocation of the right hip with major deformity of the femoral head and severe osteoarthritis in the region of the false acetabulum. Fig. 2-A: Preoperative radiograph.

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FIG2-B:: Fig. 2-B Radiograph made eight years after total hip replacement was performed with use of a hemispherical acetabular component that was inserted without cement and fixed with screws. The interface between the acetabular component and the host bone is excellent. No pelvic osteolysis is evident.

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FIG3-A:: Figs. 3-A and 3-B: Anteroposterior radiographs of a woman who had a total hip replacement, at the age of thirty-eight years, because of total congenital dislocation of the left hip. The case of this patient, who had a high, complete dislocation, illustrates the general rule that, even though the bone mass in the region of the true acetabulum is severely hypoplastic, this region still has the greatest bone mass anywhere in the hemipelvis for the acetabular reconstruction. Fig. 3-A: Preoperative radiograph of the pelvis and hips.

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FIG3-B:: Fig. 3-B Radiograph made nine years after total hip replacement was performed with use of a small acetabular component that was inserted without cement and fixed with screws. The appearance and function of the acetabular reconstruction were excellent.

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FIG4-A:: Figs. 4-A and 4-B: Anteroposterior radiographs of a woman who had a total hip replacement, at the age of forty-two years, because of severe dysplasia of the left hip (class B according to the system of Eftekhar⁶). Fig. 4-A: Preoperative radiograph. There is evidence of healing at the site of a previous valgus subtrochanteric osteotomy of the femur.

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FIG4-B:: Fig. 4-B Radiograph made six years after total hip replacement was performed with use of a hemispherical acetabular component that was inserted without cement and fixed with screws. The acetabular reconstruction functioned well, and the radiographic appearance of the hip was excellent.

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FIG5-A:: Figs. 5-A, 5-B, and 5-C: Anteroposterior radiographs of a woman who had bilateral congenital dislocation of the hip. The patient was managed with a subtrochanteric osteotomy in the left hip at the age of eighteen years and a total replacement of the right hip at the age of fifty-three years. Fig. 5-A: Radiograph of the pelvis and hips, made after the subtrochanteric osteotomy and before the total hip replacement.

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FIG5-B:: Fig. 5-B: Radiograph of the right hip, made after total hip arthroplasty was performed with use of a hemispherical titanium acetabular component that was inserted without cement and fixed with screws. The acetabular bone stock was augmented with a bulk autogenous graft from the femoral head, which was fixed to the pelvis with bolts. Seventy-five percent of the surface of the acetabular component was in contact with host bone. A custom-made CDH femoral component was inserted with cement, and the greater trochanter was advanced.

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FIG5-C:: Fig. 5-C: Radiograph of the right hip, made ten years after the total hip arthroplasty. The graft has united and is well preserved. The interface between the acetabular component and the host bone is excellent. The trochanter has united, and the femoral component remains well fixed.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

The present study included only patients who had osteoarthritis of the hip secondary to total congenital dislocation or severe dysplasia (class B or C according to the system of Eftekhar⁶ or type 2 or 3 according to the system of Hartofilakidis et al.¹⁵) as these conditions represent the more complex problems that are encountered during total hip arthroplasty⁴. Because hips with mild dysplasia (class A) do not represent as difficult a challenge and usually can be treated with customary total hip arthroplasty techniques, they were not included in the present study. As noted earlier, we required at least 70 percent of the mesh to be covered by host bone in order to allow for the use of an acetabular component that was designed to be inserted without cement.

The first twenty-one consecutive patients (twenty-four hips) in whom a hemispherical acetabular component was inserted without cement for the treatment of osteoarthritis secondary to total congenital dislocation (Figs. 2-A, 2-B, 3-A and 3-B) or severe congenital dysplasia (Figs. 4-A and 4-B) constituted the original study group. Three patients (four hips) died of unrelated causes before a minimum duration of follow-up of five years. None of these three patients had loosening or revision of the acetabular component or symptoms in the region of the reconstruction. The remaining eighteen patients (twenty hips) form the basis of the present study. Ten hips had total dislocation (Figs. 2-A and 3-A), and ten had severe dysplasia (Fig. 4-A). No patient was lost to follow-up. Five patients (six hips) returned for a follow-up examination, and thirteen patients (fourteen hips) completed a detailed written questionnaire. The questionnaires included the Short Form-36 (SF-36)²⁶ and the questions used to determine the Harris hip score⁸. The range of motion of the hip was estimated on the basis of the ease of tying the shoe, as described in previous reports from the Mayo Clinic¹⁶ and by one of us (W. H. H.) and Rubash¹⁸. Data regarding limb-length discrepancy were obtained from the preoperative records and at the time of the most recent clinical visit. Current radiographs were available for all patients.

The average age of the patients at the time of the index operation was fifty-two years (range, twenty-five to eighty-seven years), and the average weight was 57.7 kilograms (range, 40.9 to 75.0 kilograms). Fifteen patients were women and three were men.

Because of the marked distortion of the anatomy about the hip in many of these patients⁹, wide exposure was generally necessary¹³. Osteotomy of the greater trochanter was performed in seventeen hips. In the remaining three hips, the procedure was performed through a posterior approach without trochanteric osteotomy but with excision of both the anterior and the posterior aspects of the capsule.

Care was taken to preserve the medial wall, the anterior and posterior columns, and the dome; often, the initial reaming was performed with use of small acetabular reamers (thirty-eight or forty millimeters in outer diameter). In three hips, the pelvic bone stock was supplemented with an autogenous graft from the femoral head to provide additional coverage of the socket (Figs. 5-A, 5-B, and 5-C), but in all three hips at least 75 percent of the mesh of the component was in direct contact with host bone. The extent of coverage of the shell was assessed intraoperatively by direct observation of the percentage of the shell that was not covered laterally by bone. In one additional hip, there was a thin, weak osteophyte in the region of the acetabulum. The presence of this osteophyte increased the amount of contact between the host bone and the component to more than 75 percent, but, because the structural integrity of the osteophyte was suspect, the region was reinforced with a bulk autogenous graft from the femoral head. Thus, four bulk grafts were used, but only three were in direct contact with the porous surface. In the sixteen hips that were not treated with a bulk graft, the average coverage of the acetabular component by host bone (as determined on the basis of the immediate postoperative anteroposterior radiograph) was 90 percent (range, 75 to 100 percent). In all hips, the acetabular component that was inserted was nominally the same size as the last reamer that had been used (so-called line-to-line sizing). The acetabular component was secured with screws in every hip.

Because of the hypoplastic acetabular bone stock in our patients, most of the acetabular components in the present study were small. The outer diameter of the acetabular component was forty millimeters in ten hips, forty-two millimeters in one hip, forty-four millimeters in one hip, forty-six millimeters in seven hips, and forty-eight millimeters in one hip. The diameter of the femoral head was twenty-two millimeters in seventeen hips, twenty-six millimeters in two hips, and twenty-eight millimeters in one hip. The minimum polyethylene thickness (present in ten hips) was five millimeters; in all other hips, the thickness of the polyethylene was six millimeters or more.

Eight hips had had a previous operation. These procedures had included acetabular osteotomy (three hips), femoral osteotomy (three hips), open reduction (one hip), and arthrodesis (one hip).

All radiographs that had been made preoperatively, immediately postoperatively, at each follow-up interval, and at the time of the most recent examination were assessed. The interface between the porous surface and the bone was graded on the postoperative radiographs with respect to the presence or absence of radiolucent lines in the three zones described by DeLee and Charnley⁵. According to the criteria previously described by Schmalzried and one of us (W. H. H.)²⁰, any linear radiolucency that was observed on the immediate postoperative radiograph was termed a gap, whereas any radiolucency appearing in a region where no gap had existed previously was termed a radiolucent line. The fate of each gap was determined by comparison of its appearance on the immediate postoperative radiograph with that on radiographs made at an intermediate interval (approximately two years postoperatively) and at all subsequent intervals. The locus of the center of the hip was calculated with reference to the interteardrop line¹⁹.

Fifteen of the twenty femoral components were inserted with cement; of these, twelve were of the CDH Precoat design (Zimmer) and three were custom-made CDH Precoat stems (Zimmer) that had been reduced in size on the basis of the preoperative radiographs. The remaining five stems were Harris-Galante Porous components (HGP; Zimmer); four of these components were twelve centimeters long, and the fifth was thirteen centimeters long. No subtrochanteric femoral shortening was performed in this series.

Polyethylene wear was measured according to the method of Livermore et al.¹⁷.

Results

Introduction | Materials and Methods | Results | Discussion | References

The average duration of follow-up was eighty-three months (range, sixty-four to 102 months). The average Harris hip score⁸ was 90 points (range, 68 to 97 points) at the time of the most recent examination compared with 37 points (range, 21 to 56 points) preoperatively. Ninety percent (eighteen) of the twenty patients had a good or excellent result according to the previously described criteria⁸. No patient had loosening, migration, or revision of the acetabular component; a complete radiolucent line around the acetabular component; pelvic osteolysis; or a subsequent operation on the acetabular side.

The average rate of polyethylene wear for the seventeen hips that had received a twenty-two-millimeter-diameter femoral head was 0.08 millimeter per year (range, zero to 0.21 millimeter per year). The number of hips (three) that had been treated with a head of another size was too small to provide useful data on polyethylene wear.

One femoral component—a small, custom-made stem that had been inserted with cement for the treatment of osteoarthritis secondary to congenital dislocation—was revised because of aseptic loosening. No other femoral component was revised for any reason.

All five femoral components that had been inserted without cement appeared to have ingrowth of bone on the most recent radiographs, but two were associated with femoral osteolysis. Femoral osteolysis also was noted in one hip with a well fixed stem that had been inserted with cement; the lesion was observed in the area of a defect in the cement mantle.

One patient, who had had a complex revision operation as the index procedure, sustained a postoperative dislocation of the hip prosthesis; the dislocation was treated with closed reduction, and no additional dislocations occurred. Another patient had mild femoral and sciatic nerve palsies, which resolved nearly completely. A third patient had a reoperation because of marked restriction of motion secondary to severe heterotopic ossification (class IV according to the system of Brooker et al.²). Radiographs of the remaining nineteen hips (that is, the hips that did not have a reoperation for the treatment of heterotopic ossification) revealed class-III ossification in two hips, class-II ossification in ten, and no evidence of ossification in seven. No hip had a deep infection.

Fifteen of the seventeen hips that had had a trochanteric osteotomy had union at the osteotomy site. In one of the other two hips, the trochanter migrated. In the remaining hip, the fate of the trochanter, which had been placed against a proximal femoral allograft, could not be clearly determined on the basis of the most recent radiograph.

Nineteen gaps were observed on the immediate postoperative radiographs of twelve hips. Only one gap was located in zone II; the other eighteen gaps were located in zones I and III. Only one gap, which was two millimeters thick, exceeded one millimeter in thickness. No gap increased in size. At the time of the most recent assessment, thirteen gaps were unchanged and six had disappeared.

There was a total of twenty-seven new radiolucent lines around eleven components. No radiolucent line was more than 0.5 millimeter thick. Only one radiolucent line was located in zone II; the other twenty-six radiolucent lines were located in either zone I (twelve) or zone III (fourteen). No hip had a continuous radiolucent line.

All four bulk autogenous grafts united, and no graft had evidence of failure or resorption. No screw bent or broke. No hip had dissociation of the fiber-metal mesh from the acetabular shell.

Sufficient data regarding limb-length discrepancy were available for seventeen of the twenty hips. The preoperative limb-length discrepancy ranged from ten centimeters of shortening to five centimeters of lengthening. Ten hips were on the side of the longer limb, four were on the side of the shorter limb, and three were in patients who had no limb-length discrepancy. All ten longer limbs were shortened, and six were found to be equal in length to the contralateral limb postoperatively. Three of the four shorter limbs were lengthened, and the fourth was shortened by 1.5 centimeters. Two of the three involved limbs of patients who had no limb-length discrepancy were lengthened by one centimeter.

Although we would have preferred to perform the acetabular reconstruction in the region of the true acetabulum in all twenty-four hips that were included in the original study group, the quality of the available bone stock in nine hips (38 percent) made it necessary to place the hip center at least thirty-five millimeters proximal to the interteardrop line. These nine hips were arbitrarily designated as having a high hip center. In the twenty hips that form the basis of the present study, the center of the hip was placed an average of twenty-eight millimeters (range, five to sixty-six millimeters) proximal to the interteardrop line. In the nine hips with a high hip center, the average lateral placement of the center of the hip was thirteen millimeters (range, seven to nine millimeters), one millimeter less than the normal value¹⁹.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The porous ingrowth acetabular component that was used in the present study functioned well at the time of the intermediate-term follow-up of this group of patients who had marked congenital dysplasia or total dislocation of the hip. The use of this component decreased the need for structural acetabular grafts. This component appears to perform as well as larger components of this design that have been assessed after similar durations of follow-up^21,24. In addition, the results of the present study were better than those of a similar study by Gerber and one of us (W. H. H.)⁷, in which patients who had a severe acetabular deficiency were managed with a bulk autogenous graft or allograft from the femoral head and insertion of the acetabular component with cement. In that study, ten (21 percent) of forty-seven cemented acetabular components had become loose and five of the ten had been revised after an average duration of follow-up of approximately seven years⁷. These data support our hypothesis that bulk autogenous grafting or allografting usually is not needed for the stable fixation of acetabular components that are designed to be inserted without cement and fixed with screws, provided that at least 70 percent of the component is covered by host bone. Nevertheless, longer-term follow-up studies are needed. In the present study, three hips were treated with a bulk graft even though at least 70 percent of the interface was covered by host bone. The purpose of bone-grafting in these young patients was not to provide structural support to the hip, but, rather, to provide additional pelvic bone stock in the event that a subsequent revision became necessary.

The rate of polyethylene wear when these small components were utilized with twenty-two-millimeter-diameter femoral heads was consistent with the rates that have been reported in association with twenty-two-millimeter-diameter heads that have been used for total hip arthroplasties performed with cement¹⁷. Although the low weight of the patients in the present study may have played a role in limiting the rate of wear, most previous studies of total hip replacement have not demonstrated any association between the weight of the patient and the rate of wear.

Although radiolucent lines were seen in at least one zone of eleven hips, a progressive radiolucent line was seen in only fourteen (10 percent) of the 147 zones that were evaluated on the latest follow-up radiographs. At the time of the most recent follow-up, no patient had a radiolucent line in all three zones and no patient had a continuous radiolucent line.

In contrast to the findings of previous intermediate-term studies in which pelvic osteolysis was commonly observed around other types of acetabular components that had been inserted without cement^1,23,25, none of the patients in the present study had evidence of pelvic osteolysis after an average duration of follow-up of seven years. This finding may be related to the low weight of the patients, the intermediate duration of follow-up, or other factors. In the present small series of twenty hips, we could detect no association between the height of the hip center and the rate of polyethylene wear or the development of radiolucent lines. We also could detect no association between the rate of wear and the development of femoral osteolysis in the present study, in which several types of femoral components were used.

Complications were common in association with these difficult cases. The complications included two trochanteric nonunions, one nerve palsy (which resolved), and one dislocation. In addition, one hip had a reoperation for the treatment of limited motion secondary to severe heterotopic ossification.

References

Introduction | Materials and Methods | Results | Discussion | References

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