JBJS | The Fate of Stable Femoral Components Retained During Isolated Acetabular Revision : A Six-to-Twelve-Year Follow-up Study

The Journal of Bone & Joint Surgery, Volume 84, Issue 2

Scientific Article | February 01, 2002

The Fate of Stable Femoral Components Retained During Isolated Acetabular Revision : A Six-to-Twelve-Year Follow-up Study

Joseph T. Moskal, MD; Francis H. Shen, MD; Thomas E. Brown, MD

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Investigation performed at the Roanoke Orthopaedic Center, Roanoke, Virginia

Joseph T. Moskal, MD
Roanoke Orthopaedic Center, 4064 Postal Drive SW, Roanoke, VA 24018

Francis H. Shen, MD
Thomas E. Brown, MD
Department of Orthopaedic Surgery, University of Virginia, P.O. Box 800159, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Stryker Howmedica Osteonics) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2002; 84:250-255

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Abstract

Background: The decision as to whether to revise a well-fixed femoral component in hips requiring isolated acetabular revision is challenging. The purpose of the present study was to determine the long-term results of, and the complications associated with, retention of a stable and well-fixed femoral component during isolated acetabular revision.

Methods: We retrospectively reviewed the clinical and radiographic results for thirty-one patients (thirty-two hips) who underwent isolated revision acetabuloplasty without removal of a well-fixed femoral component. The reason for acetabular revision was aseptic loosening in thirty-one hips and malposition in one hip. Of the thirty-two femoral components, twenty-one were cemented and eleven were cementless. The average duration of follow-up from the time of the index revision was 8.1 years (range, 6.4 to 12.5 years), and the average duration of total service of the femoral component was seventeen years (range, seven to twenty-five years) from time of the initial implantation. The average age of the patients at the time of the index revision was sixty-six years (range, twenty-nine to eighty-seven years).

Results: Thirty-one (97%) of the primary femoral components were judged to be stable and well fixed at the latest follow-up evaluation. One femoral component (3%) was revised because of aseptic loosening, eight years after the index acetabular revision and seventeen years after the initial total hip arthroplasty. Radiographic evaluation of the thirty-one femoral components that were not revised demonstrated no evidence of loosening or subsidence. There were no dislocations, nerve palsies, or intraoperative fractures associated with retention of the femoral component. Twenty-seven (84%) of the acetabular components were judged to be stable at the latest follow-up evaluation.

Conclusion: In hips treated with isolated acetabular revision, a well-fixed femoral component can be retained successfully without adversely affecting the acetabular exposure; the placement, position, or stability of the acetabular component; or the ability to restore bone stock. The data from the present study support the decision to retain a well-fixed femoral component when the acetabular component needs to be revised.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Currently, most revision procedures in patients who have had a total hip arthroplasty are performed because of aseptic loosening. Although the pathophysiology of osteolysis is likely to be the same at the acetabular and femoral component interfaces^1-5, the rates and consequences of bone loss at these interfaces are often quite different. Clinically, this variation results in different rates of failure^6-10 for femoral and acetabular components, regardless of the method of fixation^11-15. As a result, the surgeon may be faced with a loose acetabular component and a well-fixed femoral stem. In series ranging in size from 139 to 215 hips, isolated loosening of the acetabular component has been reported to account for as many as 27% of all revision total hip arthroplasties performed^16,17. To our knowledge, however, there have been no reports in which retained femoral components have been followed for a minimum of six years after isolated acetabular revision.

Although the revision of a stable and well-fixed femoral component may facilitate the acetabular revision, long-term clinical results have demonstrated that primary femoral components are superior to revision components^18-22. Removal of a well-fixed femoral component can result in destruction of bone stock, making reimplantation difficult or impossible. It also increases operative time, blood loss, and cost. Retaining a well-fixed stem would decrease the morbidity associated with the complications of increased bone loss, intraoperative fracture, and femoral perforation^11,23,24. Retaining a well-fixed femoral prosthesis would therefore be advantageous if it did not compromise the isolated revision acetabuloplasty and/or the clinical outcome.

Previously, the senior author (J.T.M.) and colleagues reported on the preliminary results of isolated acetabular revision after an average duration of follow-up of 4.8 years (range, three to nine years)²⁵. The findings of that study suggested that revision acetabuloplasty could be performed without removing or revising a stable, well-fixed femoral component and that retention of the femoral component did not compromise the final outcome of the acetabular reconstruction. The purpose of the current study was to determine the fate of, and complications associated with, well-fixed femoral components that are left in place at the time of revision of the acetabular component.

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Fig. 1-A:: Figs. 1-A through 1-D A man who underwent a total hip arthroplasty with cemented femoral and acetabular components at the age of twenty-nine years because of traumatic osteoarthrosis. Nine years after the initial total hip arthroplasty, an isolated grade-III acetabular revision was performed at our institution because of aseptic loosening of the acetabular component. During the operation, the femoral component was found to be stable and was not revised. Fig. 1-A Preoperative radiograph demonstrating a type-III³² combined segmental and cavitary deficiency. The cemented monoblock femoral component was well fixed.

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Fig. 1-B:: Fig. 1-B Radiograph made four years after the revision (a grade-III reconstruction performed with use of both structural and morselized allograft). The components appear to be stable.

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Fig. 1-C:: Fig. 1-C Radiograph made six and one-half years after the revision, demonstrating a radiolucent area in Gruen zone 2 and changes consistent with femoral osteolysis at the bone-cement interface, findings that had not been apparent on previous radiographs.

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Fig. 1-D:: Fig. 1-D Radiograph made eight years after the revision, demonstrating progressive loosening of the femoral component. The femoral component had been in situ for a total of seventeen years since the time of the initial total hip arthroplasty.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From December 1987 to December 1993, 171 consecutive revision total hip arthroplasties were performed in 159 patients by the senior author²⁵. Thirty-two hips (19%) in thirty-one patients required revision of only the acetabular component because of either aseptic loosening (thirty-one hips) or malposition (one hip). There were twenty women and eleven men. The average age of the patients at the time of the index revision was sixty-six years (range, twenty-nine to eighty-seven years).

Twenty-one femoral components were monoblock devices with a fixed head size and neck length. The remaining eleven femoral components had a modular femoral head with a Morse taper. Twenty-one femoral components were cemented, ten were porous-coated, and one was hydroxyapatite-coated. The uncemented femoral components were determined to be osseointegrated and stable before surgery on the basis of the radiographic criteria described by Engh et al.²⁶. The cemented femoral components were noted to be well fixed with no radiographic evidence of loosening according to the criteria of Harris and McGann²⁷.

All acetabular components were revised to porous-coated hemispheric cups (Porous-Coated Anatomic Two-Piece Cluster Cup; Stryker Howmedica Osteonics, Rutherford, New Jersey). The average diameter of the acetabular component implanted at the time of the index revision was 61 mm (range, 52 to 74 mm). The average time from the isolated revision acetabuloplasty to the latest follow-up examination was 8.1 years (range, 6.4 to 12.5 years). The modified direct lateral approach was used for twenty (63%) of the thirty-two hips²⁸; however, more extensile approaches were used for hips with substantial ilioischial structural deficiency or pelvic dissociation²⁵. The acetabular reconstructions were graded with use of the method described by Borden and Greenky²⁹ and Hungerford et al.³⁰.

Routine anteroposterior radiographs of the pelvis and proximal aspect of the femur and true lateral radiographs of the hip were made and reviewed before surgery, immediately after surgery, at three and six months, and at yearly intervals thereafter. The prosthetic components and the acetabular defects were evaluated with use of radiographic criteria described previously^31-35. The angle of the cup and the distance from the acetabular component to Kohler’s line and the teardrop were measured and compared on serial radiographs^12,16. Linear migration of the acetabular component was defined as a change of >2 mm in either the medial or the superior direction, or both¹⁶. Rotational migration was defined as a change of >3° in the theta angle, which is the angle formed by the horizontal line drawn through the teardrops and the plane of opening of the cup¹⁹.

All patients received intravenous antibiotics and warfarin postoperatively according to our previously described protocol²⁵. Clinical evaluations, including determination of leg-length inequality, function, range of motion, and the Harris hip score³⁶, were performed at each yearly follow-up examination.

No patient was lost to follow-up. Five patients (five hips) died during the follow-up period from causes unrelated to the index procedure. Data from the yearly follow-up evaluations preceding the deaths were included in the study.

Results

Introduction | Materials and Methods | Results | Discussion | References

Thirty-one (97%) of the thirty-two primary femoral components were judged to be stable and well-fixed at the latest follow-up evaluation. One hip (3%) required a femoral revision eight years after the index procedure and seventeen years after the initial total hip arthroplasty (Figs. 1-A, 1-B, 1-C, and 1-D). Ninety-eight months after the index procedure, radiographs demonstrated changes at the bone-cement interface that were consistent with osteolysis and that met the criteria established by Harris and McGann for possible loosening of the femoral component²⁷. At that point, the patient underwent repeat revision with use of uncemented femoral and acetabular components, despite a good clinical result as indicated by a Harris hip score of 86 points.

Of the thirty-one stable femoral components, twenty (63% overall) were cemented, ten (31% overall) were porous-coated, and one (3% overall) was hydroxyapatite-coated. At the time of writing, these components had been followed for an average of seventeen years (range, seven to twenty-five years) since the time of implantation and for an average of 8.1 years (range, 6.4 to 12.5 years) since the time of the index procedure.

Loss of proximal femoral density was observed on the radiographs of four hips (13% overall); in two of these hips, the femoral component was extensively porous-coated and demonstrated evidence of proximal stress-shielding³⁷. Six hips (19% overall) demonstrated rounding of the calcar femorale. Five hips (16% overall) demonstrated focal osteolysis^5,38-42 proximal to the lesser trochanter in Gruen zone 1 (three hips) and zone 7 (two hips). There was no evidence of metaphyseal or diaphyseal endosteal osteolysis or cavitation distal to zones 1 and 7. The lesions did not span more than one Gruen zone, and the average size was 5 ¥ 15 mm². Annual radiographs demonstrated that the progression of the individual focal osteolytic defects was slow (<1.0 mm/year).

All eleven uncemented femoral components (including ten porous-coated components [31% overall] and one hydroxyapatite-coated component [3% overall]) remained osseointegrated, all demonstrated endosteal spot welds⁴³, and none had circumferential radiolucent lines or signs of subsidence²⁶. Similarly, the twenty cemented femoral components that were not revised showed no evidence of definite loosening (radiographic evidence of migration of the component or the cement) or probable loosening (a complete radiolucent zone)²⁷. All thirty-one femoral components that were not revised remained well fixed, and there were no potential or pending revisions.

The grading system popularized by Borden and Greenky²⁹ and Hungerford et al.³⁰ was used to quantitate the magnitude of the acetabular defect as it related to the degree and quality of fixation within host bone. Four (13%) of the thirty-two acetabuli had little or no bone defect and required no bone graft (a grade-I reconstruction), sixteen (50%) required morselized filler graft even though the prosthesis was stable on host bone (a grade-II reconstruction), and twelve (38%) required structural allografting to stabilize the prosthesis (a grade-III reconstruction). In all thirty-two hips, regardless of the complexity of the reconstruction and the size of the osseous defect, the acetabular revision was performed without removal of the femoral component. At the latest follow-up evaluation, performed at an average of 8.1 years after the index procedure, twenty-seven (84%) of the acetabular components were judged to be stable, with no need for additional operative treatment, and five (16%) were considered to have failed. Four of the five hips with a failed acetabular component required a second revision operation.

There were no dislocations, nerve palsies, early or late infections, or intraoperative fractures. The average Harris hip and pain scores were 44 and 14 points, respectively, before the index procedure and 81 and 42 points, respectively, at the most recent follow-up examination. The average leg-length inequality was 14 mm (range, 0 to 40 mm) preoperatively and 3 mm (range, 0 to 12 mm) postoperatively. One clinical deep-vein thrombosis occurred despite the routine use of perioperative warfarin, but there were no documented cases of pulmonary embolization.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The total number of revision procedures has risen in accordance with the increasing duration of follow-up after total hip arthroplasty and the increase in life expectancy⁴⁴. In 1999, more than 150,000 total hip arthroplasties were performed in the United States alone⁴⁵. Approximately 20% of these procedures were revision operations.

Thirty-two of the 171 consecutive revision hip arthroplasties that were reviewed at the time of the present study consisted of an isolated cementless acetabular revision. Because only the loose acetabular component was revised, it was possible to follow the primary femoral components for an average of 8.1 years (minimum, 6.4 years) after the acetabular revision, or for an average of seventeen years (range, seven to twenty-five years) after the initial procedure. At the time of the most recent follow-up evaluation, thirty-one (97%) of the primary femoral components and twenty-seven (84%) of the revision acetabular components remained stable and well fixed.

Although a clinical failure occurred in six (19%) of the thirty-two hips, only one failure was secondary to loosening of the femoral component. In that case, the performance of an isolated acetabular revision extended the service life of the primary femoral component by an additional eight years, resulting in a total service life of seventeen years. Increased loosening of total hip components has been noted in patients who are less than fifty-five years of age^46-48 as well as in those who have avascular necrosis⁴⁹ or traumatic osteoarthrosis⁵⁰. Given these risk factors, a femoral loosening rate of 3% is quite low^51,52.

The radiographic findings in the group of thirty-one femoral components that were not revised included signs of proximal focal osteolysis^41,53, rounding of the calcar femorale, and loss of proximal femoral density. Despite these findings, all eleven uncemented femoral components remained osseointegrated and stable, all demonstrated endosteal spot welds⁴³, and none had circumferential radiolucent lines or signs of subsidence²⁶. Similarly, the twenty cemented femoral components that were not revised remained stable and well fixed without evidence of circumferential radiolucent lines, loosening, migration, or subsidence²⁷.

The other five clinical failures in the present study were due to loosening of the revised acetabular cup. One of the acetabular failures occurred in the previously described patient with the loose femoral component. The second clinical failure occurred in a patient who had rotational migration of the acetabular component at twenty-two months. The component stabilized without intervention and remained nonprogressive during the subsequent nine-year follow-up period. The other three clinical failures occurred in the group of hips that had had a high-risk, grade-III reconstruction. Visual inspection at the time of repeat revision acetabuloplasty demonstrated that the grafts were well incorporated, and no further structural allografting was necessary. The repeat revisions also were done without removal of the femoral component, which remained well fixed.

In the present study, five hips—including four of the twelve that had a grade-III reconstruction—were treated with repeat revision because of loosening. We believe that this rate of loosening is independent of the femoral component and that the increased morbidity and cost associated with the revision of a well-fixed femoral component is therefore not warranted. In our series, retention of the femoral component did not limit the acetabular exposure or the surgeon’s ability to place and secure the bone graft or the acetabular component in an appropriate manner; thus, little benefit would have been gained by removing a well-fixed femoral component in this situation. Lastly, some authors have considered restoration of bone stock to be the major goal of complex acetabular revisions and have believed that a two-stage revision may be required after some grade-III reconstructions36,54,55. In the four hips in the present study that had a repeat revision after a grade-III reconstruction, incorporation of the structural allograft helped to restore bone stock and simplified the second revision so that only a grade-II reconstruction was required. With failure defined as revision or definite loosening, survivorship analysis demonstrated that the probability of survival of the acetabular component at ninety-seven months after revision was 84% (95% confidence interval, 68% to 93%). The rate of repeat revision of the acetabular component was 13% (four of thirty-two) at the time of the latest follow-up evaluation, 6.4 to 12.5 years postoperatively. These rates are comparable with those reported in other studies, ranging in size from 115 to 139 hips, in which revision total hip arthroplasties were performed with use of porous-coated hemispheric acetabular cups^12,16,22.

Few complications were noted in the current series. There were no nerve palsies or intraoperative fractures, and the rate of dislocation remained at 0% at the time of the latest follow-up evaluation. Most (63%) of the isolated acetabular revisions were performed through a standard modified direct lateral approach. This approach may have contributed in part to the low rate of dislocation because it avoids the need to deflect soft tissue posteriorly. With a posterior approach, extensive elevation and reflection of soft tissue is required in order to mobilize the femur adequately to gain sufficient acetabular exposure. We believe that retention of the femoral component is not necessarily associated with an increased rate of dislocation provided that satisfactory intraoperative stability is obtained. The presence of the femoral component did not influence the selection of the surgical approach.

In conclusion, retention of a well-fixed femoral component during acetabular revision does not compromise acetabular reconstruction and is associated with continued good clinical results of the femoral component. Revision of a well-fixed femoral component on the sole basis of the length of service of the implant is not warranted.

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Introduction | Materials and Methods | Results | Discussion | References

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