Type III acetabular defect revision with bilobed components: five-year results

The impact of retaining the femoral stem in revision total hip arthroplasty: a systematic review, meta-analysis, and meta-regression

INTRODUCTION

The management of well-fixed femoral stems in revision total hip arthroplasty (rTHA) remains a subject of debate, with concerns over potential complications arising from stem retention. This study aimed to investigate the re-revision rates due to aseptic loosening of the stem, overall re-revision rates, dislocation rates, and factors influencing these outcomes in rTHA with a retained well-fixed femoral stem.

MATERIALS AND METHODS

A systematic search was conducted across several databases including PubMed, EMBASE, and CENTRAL to identify pertinent publications from their inception through 2023. We specifically focused on studies that reported outcomes of rTHA with retained well-fixed femoral stems. The study designs incorporated in our research encompassed both cohort studies and case series studies. Thirty-five studies involving isolated acetabular revision and retaining the stem were included, representing a total of 3497 patients. Data extraction was tailored to the study questions. Meta-analyses, meta-regression, and subgroup analyses were conducted to evaluate the outcomes and their relationship with various factors. Pooled results, meta-regression, and subgroup analyses were performed using random-effects models. To assess and reduce bias, we employed Egger's test and the trim and fill method.

RESULTS

The meta-analysis included 3497 patients with a mean follow-up of 9.28 years. The 10-year risk of re-revision after retaining femoral stem using highly cross-linked polyethylene was 1.7% (95% CI 1.1%-2.3%; I2: 60%) for stem aseptic loosening and 8.8% (95% CI 6.2%-11.4%; I2: 78%) overall re-revision. Dislocation risk was 5.7% (95% CI 4.1-7.0%; I2: 61%). Ceramic heads showed lower stem failure risk than metal heads in long-term follow-ups (P < 0.001). The posterolateral approach in revision surgery resulted in better long-term outcomes compared to the direct lateral approach (P < 0.001). Follow-up duration, timeline of study, Harris Hip Score, type of stem fixation, femoral head material, BMI, age, stem age, and surgical approach were evaluated as influential factors on these outcomes.

CONCLUSION

The re-revision rate due to aseptic loosening of the retained stem during rTHA was found to be significantly low, supporting the idea of retaining well-fixed stems during rTHA. The overall re-revision and dislocation rates also presented comparable or better outcomes to prior studies. A range of factors, including the use of highly cross-linked polyethylene and ceramic femoral heads, was found to influence these outcomes.

LEVEL OF EVIDENCE

IV.

PROSPERO REGISTRATION NUMBER

CRD42022351157.

Design, fabrication, and structural safety validation of 3D-printable biporous bone augments

The use of commercial products such as a cup and liner for total hip arthroplasty for patients with severe bone defects has a high probability of failure. In these patients the cup alone cannot cover the bone defect, and thus, an additional augment or cage is required. In this study, we designed three-dimensional (3D) printable bone augments as an alternative to surgeries using reinforcement cages. Thirty-five sharp-edged bone augments of various sizes were 3D printed. A biporous structure was designed to reduce the weight of the augment and to facilitate bone ingrowth. Two types of frames were used to prevent damage to the augment’s porous structure and maintain its stability during printing. Furthermore, two types of holes were provided for easy augment fixation at various angles. Fatigue tests were performed on a combination of worst-case sizes derived using finite element analysis. The test results confirmed the structural stability of the specimens at a load of 5340 N. Although the porosity of the specimens was measured to be 63.70%, it cannot be said that the porous nature was uniformly distributed because porosity tests were performed locally and randomly. In summary, 3D-printable biporous bone augments capable of bonding from various angles and bidirectionally through angulation and bottom-plane screw holes are proposed. The mechanical results with bone augments indicate good structural safety in patients. However, further research is necessary to study the clinical applications of the proposed bone augment.

Graphic abstract

Early outcomes of using custom-made augments in revision total hip arthroplasty

INTRODUCTION

The continuing high demand for revision total hip arthroplasty (RTHA) requires not only additional economic costs, but also the search for new, effective methods to manage the reconstruction of acetabular bone loss. This study focuses on the assessment of the clinical and radiographic outcomes after RTHA using custom-made augments (CMA) in the short-term follow-up period.

MATERIALS AND METHODS

We retrospectively analyzed the results of using CMAs in 19 patients (20 hips). The average follow-up period was 41.3 months. All surgery was performed on defect types III and IV as per the Gross and Saleh classification.

RESULTS

There was a statistically significant difference when comparing the Oxford Hip Score before RTHA of 15.0 (Std. deviation-5.9) and after RTHA of 36.3 (Std. deviation-6.3) (p = 0.01). All implants were radiologically stable. CMA has demonstrated a good ability to restore position of hip centre of rotation (HCOR). In the postoperative period, two patients (2 hips) had dislocations. Only one of two patients underwent re-revision due to dislocation.

CONCLUSION

Treatment of uncontained loss of bone stock in RTHA using CMA shows promising clinical and radiographic results at short-term follow-up period; however, dislocation rate is 10% in this study.

Acetabular reconstruction using porous metallic material in complex revision total hip arthroplasty: A systematic review

Bone defects during acetabular revision of total hip arthroplasty raise a problem of primary fixation and of durable reconstruction. Bone graft with direct cemented fixation or in a reinforcement cage was long considered to be the gold standard; however, failures were reported after 10 years' follow-up, especially in segmental defect of the roof or pelvic discontinuity. In such cases, metallic materials were proposed, to ensure primary fixation by a roughness effect with added screws, and especially to avoid failure due to bone resorption in the medium term. We report a systematic literature analysis, addressing the following questions: (1) What materials are available and can be used with dual mobility (DM) designs? Apart from Trabecular Metal™ (TM), in which a DM cup can be cemented for sizes≥56mm, 4 other porous metals are available (Tritanium™, Trabecular Titanium™, Conceloc™, Regenerex™ and Gription™) although only the first 3 can be associated to DM. (2) Can the cost of these materials be estimated and compared to allograft with reinforcement cage? Considering simply the cost of the implant itself, compared to reconstruction by graft+cage+cemented cup (€2100), TM incurs an extra cost of €534, but with €1434 not covered by the French healthcare insurance. The cost of custom implants (apart from hemi-pelvis) ranges between €4200 and €8500, with only €4749 cover. (3) Do metallic materials ensure better survival than allograft+cage, according to severity of bone loss? Metallic reconstruction is claimed (with a low level of evidence) to reduce the risk of iterative loosening, but with a higher rate of dislocation, probably due to the lack of DM in many series. (4) What are the advantages and drawbacks of modular and custom metallic reconstructions? Modular reconstructions do not require 3D preoperative planning, but incur the risks of complications inherent to modularity. Custom implants can deal with more extensive defects, but require 5 to 8 weeks' production and are difficult to implant for the larger ones and/or when revision is limited to the acetabulum. (5) In what indications are these materials irreplaceable? Prior failure of allograft+cage in Paprosky type III defect with or without pelvic discontinuity shows the greatest benefit from metallic reconstruction, conditional on certain technical tricks. Only reconstructions using TM have more than 10 years' follow-up; other materials will need close monitoring. Failures in allograft with reinforcement cages occurred after about 10 years, and TM will need longer follow-up to prove its effectiveness. The high risk of dislocation should enable DM to be used, especially for small-diameter metallic reconstructions.

3D surgical printing for preoperative planning of trabecular augments in acetabular fracture sequel

We describe the methodical and possibilities of 3D surgical printing in preoperative planning for a total hip arthroplasty in acetabular deformity after acetabular fractures, showing a case of a 43-year-old with posttraumatic arthritis after both column fracture of the left acetabulum that was treated non operatively, supporting the do it yourself mode.

Reconstruction of acetabulum in revision total hip arthroplasty for pelvic discontinuity: report of a difficult case requiring four revision arthroplasty

Background

Massive bone defects of the acetabulum with pelvic discontinuity are one of the major problems in revision total hip arthroplasty. Several techniques have been described for repair of acetabular defect; however, reconstruction of acetabulum with massive bone defect is still a major problem. We describe a patient who required four revision total hip arthroplasty during a 24-year period.

Findings

The acetabulum with pelvic discontinuity was successfully reconstructed by stabilization of the posterior column with a plate commonly used for fracture treatment, and stabilization of the anterior column by reinforcement device commonly used for acetabular reconstruction. Fixation of both acetabular columns provided significant improvement of component stability.

Conclusions

In the case of pelvic discontinuity with massive acetabular bone defect, reconstruction by stabilizing both acetabular columns using reconstruction plate and KT plate is one of the better surgical options.

Trabecular Metal Use in Paprosky Type 2 and 3 Acetabular Defects: 5-Year Follow-Up

BACKGROUND

The reconstructive challenge of achieving a stable acetabulum in revision total hip arthroplasties in the presence of major osteolytic lesions has led to debate about the most appropriate surgical strategy to minimize implant-related failures. Trabecular metal (TM) implants have become popular but ongoing surveillance of their performance is required.

METHODS

We reviewed the clinical and radiological outcome of a consecutive series of 52 patients (55 hips) who had undergone revision total hip arthroplasty for Paprosky type 2 or 3 acetabular defects with TM revision acetabular shells between 2002 and 2008.

RESULTS

Four implant failures occurred (2 infections and 2 dislocations). Eleven patients from this cohort died (representing 12 hips) before the 5-year follow-up period giving us a follow-up of 78.2%. Implant survival at 5 years was 92% (95% confidence interval: 80.2%-96.9%). There were no cases of radiological loosening. The mean Oxford hip score was 34 (range, 5-48) at a mean follow-up of 63 months (range, 34-105 months).

CONCLUSIONS

We conclude that the use of TM revision shells for complex acetabular reconstruction yields satisfactory results.

Satisfying outcomes scores and survivorship achieved with impaction grafting for revision THA in young patients

BACKGROUND

The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far.

QUESTIONS/PURPOSES

The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

METHODS

During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate.

RESULTS

The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%-95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%-100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised.

CONCLUSIONS

IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Revision hip arthroplasty using impacted cancellous bone and cement: a long-term follow-up study

Acetabular bone deficiency is one of the many challenging problems encountered in revision hip arthroplasty. A variety of surgical options and techniques are available including impaction bone grafting. We present our long-term experience of 68 consecutive cups in 64 patients, using impacted cancellous bone grafting with bone cement. With a mean follow-up of 10.5 year (IQR 7.5-12.9) after revision surgery, three implants had undergone further revision. Three patients had subsequent femoral peri-prosthetic fractures, and none of these three required further acetabular revision. Survival of the acetabular components was 95.5 % for all causes and 100 % for aseptic loosening as the end point, with a further four patients showing radiographic, but asymptomatic loosening. A significant correlation was found between previous revision and re-revision (early failure) (p = 0.01) as well as progression of lytic lesion and re-revision (p = 0.01). The median Harris hip score at final follow-up was 79.5 (IQR 67.9-80.4). The use of impacted morcellised allograft bone with a cemented cup is an effective technique to achieve longevity and restoration of bone stock in acetabular revision arthroplasty. Our series has shown good clinical and radiological outcome with survivorship of the prosthesis exceeding 95 % at 10 years.

Reconstruction of the rotation center of the hip after oblong cups in revision total hip arthroplasty

BACKGROUND

The preoperative bone defect and the reconstruction of the center of rotation of the hip are critical in acetabular revision surgery. Uncemented oblong cups are employed in order to manage these issues. We analyzed the clinical results and rates of revision of two different uncemented oblong cups, the reconstruction of the center of rotation of the hip, as well as the rate of radiological loosening and possible risk factors.

MATERIALS AND METHODS

Forty-five patients (46 hips) underwent acetabular revision surgery using two different uncemented oblong cups. We assessed the clinical results and the survival rate for revision and aseptic loosening. Intraoperative bone loss was classified according to Paprosky, and acetabular reconstruction was assessed according to Ranawat. The mean follow-up was 7.2 years (range 4-11 years).

RESULTS

There were four re-revisions (three due to aseptic loosening); the survival rate for re-revision due to aseptic loosening was 60.1 % at seven years. The mean distance between the center of the femoral head prosthesis and the approximate center of the femoral head improved from 21.5 to 10.2 mm. Thirteen cups showed radiological loosening; the survival rate for radiological loosening at seven years was 40.54 %. A smaller postoperative horizontal distance was correlated with cup loosening.

CONCLUSIONS

Although optimal acetabular reconstruction can be achieved by using oblong uncemented cups in revision hip surgery, the clinical and radiological results are not encouraging. Excessive medialization of the cup may increase the rate of loosening.

Multiple Acetabular Revisions in THA - Poor Outcome Despite Maximum Effort

A consecutive series of 52 acetabular revisions was evaluated retrospectively. Inclusion criteria for all patients were at least one former exchange of the acetabular component. Reconstruction was performed with reliable techniques and implants other than extensively porous coated device (e.g. tantalum). The mean follow up was 5.63 (0.01-14.05) years. Cumulative survival at 14.05 years with removal of the acetabular component due to aseptic loosening or the worst case criterion (removal of the acetabular component for any cause and/or lost to follow-up) as the end point was 66.38 (95 % C.-I.: 47.80-84.96) % and 58.42 (95 % C.-I.: 41.01-75.83) %, respectively. The cumulative survival rate with mechanical failure of the acetabular reconstruction as the endpoint was significantly lower in patients with two or more previous revisions in comparison to those with only one former procedure (log rank test: p=0,0112 respectively). The mean Merle d'Aubignée-score improved from 7.3 (0-14) preoperatively to 10.6 (0-17) points at latest follow up examination.Survival of acetabular reconstructions with common techniques and implants is decreasing with the number of previous revisions. This may cause major concerns with regard to the rising number of patients needing repeated revisions. Maximizing durability of primary THA, precise preoperative planning as well as improved techniques and implants for revision may decrease this problem in the long term.

Revisions of extensive acetabular defects with impaction grafting and a cement cup

BACKGROUND

Loosening of acetabular components often leads to bony defects. Management of extensive acetabular bone loss in hip revision arthroplasty can be a tremendous challenge.

QUESTIONS/PURPOSES

We asked whether a reconstruction with impacted bone grafts will provide a durable and pain-free function in extensive acetabular defects. We specifically determined the (1) survival rates with the end point of revision for any reason, aseptic revision, and radiographic loosening; (2) visual analog scale (VAS) pain score, Harris hip score (HHS), and the Oxford Hip Questionnaire score (OHQS); (3) number of repeat revisions; (4) complications; and (5) radiographic loosening, wear, and radiolucencies.

PATIENTS AND METHODS

We retrospectively followed 25 patients (27 hips) with extensive acetabular defects. No patient was lost to followup. Two patients died during followup. Minimum followup was 3 years (mean, 8.8 years; range, 3-14.1 years).

RESULTS

Three patients (three hips) underwent repeat revision surgery and another two patients (two hips) had radiographically loose hips. The 10-year survival rate was 88% (95% confidence interval, 74.2%-100%) with the end point acetabular revision for any reason and 95% (95% confidence interval, 86.0%-100%) with the end point acetabular revision for aseptic loosening. The mean HHSs were 55 points before surgery and 72 points postoperatively.

CONCLUSIONS

Acetabular reconstruction with impaction bone grafting and a cemented cup is a reliable technique with a 10-year survival rate of 88% in patients with extensive acetabular deficiencies.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

[Standardized reconstruction of acetabular bone defects using the cranial socket system]

OBJECTIVE

Management of primary or secondary acetabular bone loss (D'Antonio type I-IV ). Implantation and stable fixation using a cementless, cranially extended oval press-fit cup to restore painless joint function and loading capacity.

INDICATIONS

Septic or aseptic loosening of the acetabular component after total hip arthroplasty. Acetabular bone loss after tumor resection. Primary acetabular bone defects in developmental dysplasia of the hip.

CONTRAINDICATIONS

Persistent deep infection. Bone defects including the parts of the iliac bone adjoining the sacrum (fixation of the stem in the ilium is not possible any more).

SURGICAL TECHNIQUE

Complete exposure of the acetabular defect using a standard approach. Removal of the loose cup. Excision of soft and granulation tissue from the acetabular ground and the rim. Reaming of the acetabulum with sequentially larger hemispheric reamers until an adequate bony bed is created for the insertion of the cranial socket. Eccentric cranial sockets without a craniolateral flap are preferable for use in type I and II defects with teardrop lysis mostly involving the craniolateral acetabulum, if a trihedral press-fit fixation can be achieved. Supplementary screw fixation through the acetabular ground, is possible. If a type III defect is present, the authors recommend the use of cranial sockets with an anatomic flap in order to increase primary stability by supplementary screw fixation. This is especially recommended for the management of deficiencies in the medial or posterior wall. If there is pelvic discontinuity (type IV), adequate acetabular reconstruction with primary stability of the component can only be achieved by a supplementary intramedullary structured stem fixed in the dorsal part of the ilium.

POSTOPERATIVE MANAGEMENT

Partial loading of the operated limb with 10 kg for a period of 6-12 weeks. Then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training.

RESULTS

A total of 50 cup revisions using the ESKA cranial socket system were clinically and radiologically analyzed with an average follow-up of 65.7+/-28.5 months (26-123 months). Defects were classified according to D'Antonio. There were 21 type II, 23 type III, and six type IV defects. The Harris Hip Score increased from 40 preoperatively to 68.3 points postoperatively. Four patients had recurrent hip dislocation requiring replacement of the inlay. In four cases of aseptic loosening, the acetabular component had to be revised. With revision of the acetabular component as an endpoint, implant survival was 92% after an average of 5.4 years.

Anatomic and physiologic rationale for various technologies for primary total hip arthroplasty

A number of patients have anatomic or physiologic variations that may adversely affect the performance of a primary total hip arthroplasty. Various technologies have been utilized in an attempt to improve the outcomes for these patients; however, some of these potential solutions are controversial. The authors examined the complete body of literature for scientific evidence regarding the use of these new technologies. The anatomic and physiologic anomalies that were studied include extra-articular deformities, developmental dysplasia, Perthes disease, Type C femoral bone, acetabular bone deficiency, femoral rotational abnormalities, variations that increase the risk of hip dislocation, sickle cell anemia, and extremely small or large bone sizes. This article presents the current scientific evidence and imparts an unbiased view of the use of various technologies to provide individualized solutions for patients who have anatomic or physiologic variations.

Clinical and radiographic assessment of cementless acetabular revision with morsellised allografts

The aim of this study was to evaluate the clinical and radiographic results of cementless acetabular revision with deep frozen morsellised allografts. Sixty-one patients (65 hips) underwent acetabular revision using cementless components and deep frozen morsellised allografts. Fifty-seven hips (53 patients) were reviewed at a mean of 105.1 months (range 72-180 months) after revision. The study group included 29 males and 24 females with a mean age of 46.4 years. One cup underwent further revision for aseptic loosening and two were defined as radiographic failures. The mean time for allograft incorporation was 12.5 months (range 6-24 months) after index surgery. The mean Harris hip score of the patients improved from 61.1 points preoperatively to 91.6 points postoperatively. Linear and cavitary osteolysis was observed in two and 12 hips, respectively. The acetabular revision using cementless components with deep frozen morsellized allografts provides favourable clinical and radiographic results, although the initial disease and age may adversely affect the outcomes.