Long-Term Outcome of Acetabular Reconstruction Using a Kerboull-Type Acetabular Reinforcement Device with Hydroxyapetite Granule and Structural Autograft for AAOS type II and III Acetabular Defects

Pelvic discontinuity: a challenge to overcome

Pelvic discontinuity (PD) has been a considerable challenge for the hip revision arthroplasty surgeon. However, not all PDs are the same. Some occur during primary cup insertion, resembling a fresh periprosthetic fracture that separates the superior and inferior portions of the pelvis, while others are chronic as a result of gradual acetabular bone loss due to osteolysis and/or acetabular implant loosening.

In the past, ORIF, various types of cages, bone grafts and bone cement were utilized with little success. Today, the biomechanics and biology of PD as well as new diagnostic tools and especially a variety of new implants and techniques are available to hip revision surgeons. Ultraporous cups and augments, cup-cage constructs and custom triflange components have revolutionized the treatment of PD when used in various combinations with ORIF and bone grafts. For chronic PD the cup-cage construct is the most popular method of reconstruction with good medium-term results.

Dislocation continues to be the leading cause of failure in all situations, followed by infection. Ultimately, surgeons today have a big enough armamentarium to select the best treatment approach. Case individualization, personal experience and improvisation are the best assets to drive treatment decisions and strategies.

Cite this article: EFORT Open Rev 2021;6:459-471. DOI: 10.1302/2058-5241.6.210022

Mid-term result of acetabular reconstruction using a Kerboull-type acetabular reinforcement device with hydroxyapatite impaction

The aim of this study is to investigate the mid-term results of 29 hips in 26 patients who underwent acetabular reconstruction using a Kerboull-type acetabular reinforcement device and impaction with hydroxyapatite (HA) granules. The acetabular bone defects were AAOS type II for six hips and type III for 23 hips. The mean Merle d’Aubigné clinical scores were significantly improved after operation. Six hips developed implant migration and breakage, and five of six hips were revised after an average of 5.5 (range 2.0–8.8) years. All hips with thickness of the grafted HA less than 10 mm were stable. As the HA became thicker, the failure rate were significantly increased. The Kaplan–Meier survival rates at 10 years were 73.2%, with 100% and 67.0% for AAOS type II and III defect respectively as the end point was failure condition. Reconstruction using a Kerboull-type acetabular reinforcement device and impaction with HA granules was an alternative method in the absence of adequate allografts.

Bone integration in acetabular revision hip arthroplasty using equine-derived bone grafts: a retrospective study

PURPOSE

During the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction.

METHODS

Records of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed.

RESULTS

Of the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components.

CONCLUSIONS

Results of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

Acetabular reconstruction for primary and revision total hip arthroplasty using Kerboull-type acetabular reinforcement devices-case-control study with factors related to poor outcomes of surgery

Kerboull-type acetabular support rings (KT) and allogenic bone graft were used for severe periacetabular bone loss with primary and revision total hip arthroplasty (THA). The purpose of this case-control study is to evaluate the risk factors related to poor outcomes of surgery.Sixty patients underwent primary THA and revision THA using allogenic bone graft with KT for large acetabular deficiency. These patients were retrospectively evaluated postoperatively and followed-up by radiograph. The minimum follow-up period was 4 years and averaged 7 years. A radiological failure was defined by the following criteria:Expected risk factors were defined as female, age >75 years, body mass index (BMI) >25%, medical history of hypertension, renal failure, liver steatosis, diabetes, hyperlipidemia, cardiac infarction, smoking, American Academy of Orthopedic Surgery (AAOS) classification III or IV, bleeding>500 mL, time of surgery >3hours, high hip center-type KT, inclination of KT >45 degrees, screw angle >25 degrees, morselized bone graft, Kawanabe's classification stage 3 or 4 and revision surgery. Nineteen hips (31.6%) revealed radiological failure according to our criteria, and revision THA was performed in 2 hips (3.3%). In the statistical analysis, morselized bone graft and high hip center-type KT were identified as factors of poor outcomes of surgery.

Acetabular reinforcement rings associated with allograft for severe acetabular defects

Acetabular revisions with severe bone defects can be challenging procedures. Several grading systems have been set into place to help the surgeon adequately gauge the degree of bone loss within the acetabulum. Internationally innovative research in orthopedics and bio-engineering has helped with progression of successful techniques and rings to re-establish the normal anatomy of the hip. The purpose of this review is to evaluate the outcomes of the different acetabular reinforcement rings in the setting of severe acetabular defects. A successive report of relevant data from the literature of multiple techniques will be provided. The procedures include the cup-cage, the Müller ring, the Ganz Ring, the Kerboull acetabular reinforcement device (KARD), the graft augmentation prosthesis (GAP) ring, and the Burch-Schneider ring. The main focus of this overview is rings only; other devices such as trabecular augments, custom-made cages, or oblong cups are not discussed. Furthermore, a special emphasis on the surgical technique of the KARD is also given. Procedures using these rings are usually associated with bone grafts either bulk or morselized. When considering the available data on these various rings used for reconstruction of the severely damaged acetabulum, the cup-cage, the KARD, and the Burch-Schneider ring appear to be reliable options for more successful long-term outcomes.

Revision total hip arthroplasty using the Kerboull acetabular reinforcement device for Paprosky type III defects involving the inferior margin of the acetabulum: a minimum five-year follow-up study

Aims

The purpose of this retrospective study was to evaluate the minimum five-year outcome of revision total hip arthroplasty (THA) using the Kerboull acetabular reinforcement device (KARD) in patients with Paprosky type III acetabular defects and destruction of the inferior margin of the acetabulum.

Patients and Methods

We identified 36 patients (37 hips) who underwent revision THA under these circumstances using the KARD, fresh frozen allograft femoral heads, and reconstruction of the inferior margin of the acetabulum. The Merle d'Aubigné system was used for clinical assessment. Serial anteroposterior pelvic radiographs were used to assess migration of the acetabular component.

Results

At a mean follow-up of 8.2 years (5 to 19.3), the mean Merle d'Aubigné score increased from 12.5 (5 to 18) preoperatively to 16.5 (10 to 18) (p < 0.0001). The survival rate at ten years was 95.3% (sd 4.5; 95% confidence interval (CI) 86.4 to 100) and 76.5% (sd 9.9, 95% CI 57.0 to 95.9) using aseptic loosening and radiological loosening as the endpoints, respectively.

Conclusion

These results show that the use of the KARD with reconstruction of the inferior margin of the acetabulum in revision THA is associated with acceptable clinical results and survival at mid-term follow-up with, however, a high rate of migration of the acetabular component of 21.6%. Cite this article: Bone Joint J 2018;100-B:725-32.

Revision Total Hip Arthroplasty Using the Kerboull Acetabular Reinforcement Device and Structural Allograft for Severe Defects of the Acetabulum

BACKGROUND

The purpose of this study is to review our experience with Kerboull reinforcement device combined with bulk allograft for management of severe acetabular defects.

METHODS

We investigated the results of revision total hip arthroplasty (THA) in 65 hips of 59 patients (10 male, 49 female) with Paprosky type 3A or 3B acetabular bone defects. Functional outcome was assessed using the Merle d'Aubigne hip score. Post-operative radiographs were examined for evidence of cup loosening. The mean age at revision THA was 59.1 years (23-85) and mean follow-up duration was 11.2 years (2-15).

RESULTS

The Merle d'Aubigne hip score improved from 10.6 points (5-15) before surgery to 17.1 points (15-18) (P < .05) at the time of last investigation. In this series, mean coverage of the bone graft was 83.0% (34.6-100) of the loading portion in the horizontal plane on radiography immediately after revision. However, consolidation of the bone graft was completed within 12 months for all cases. There were 4 radiological failures due to acetabular aseptic loosening at a mean of 10.8 years (8-13) after index surgery; all 4 cases demonstrated massive bone loss that no part of the rounded plate could be placed on the host bone. Kaplan-Meier analysis showed that the 15.2-year survival rate was 85.1% (95% confidence interval 71-99) with re-revision surgery for any reason as the end point.

CONCLUSION

Despite massive bone defects, we achieved favorable results for revision THA using bulk allograft and the Kerboull reinforcement device.

Revision Total Hip Arthroplasty Using a Cementless Cup Supporter and Iliac Autograft: A Minimum of 15-Year Follow-Up

BACKGROUND

Bone deficiency in revision total hip arthroplasty is a surgical challenge. The Murata-Chiba cup supporter (MC support ring) is an acetabular component supporter for a cementless porous-coated cup. The purpose of this study is to examine the clinical and radiographic outcomes of reconstruction of acetabular bone deficiency using iliac autografts supported by an MC support ring in a revision setting with minimum 15-year follow-up.

METHODS

Fifty-nine consecutive revision total hip arthroplasties (57 patients) using the MC support ring were followed for a minimum of 15 years. Nine hips had American Academy of Orthopaedic Surgeons type II deficiency and 24 had type III defects of the acetabulum. Clinical outcomes were evaluated using the Harris hip score. Radiographic evaluation included assessment for loosening and bone graft incorporation. Kaplan-Meier survival analysis was performed.

RESULTS

At a minimum 15-year follow-up (mean, 17.6 years), 32 patients (33 hips) were alive, 17 patients (18 hips) were deceased, and 8 patients (8 hips) were lost to follow-up. The mean Harris hip score improved from 44.3 to 77.2 at final follow-up. Four hips required reoperation due to deep infection (2 hips) and liner dissociation (2 hips), but no acetabular components were revised for aseptic loosening. Incorporation of the bone graft occurred in all cases. One unrevised patient had radiographic failure. Survivorship at 15 years with re-revision or radiographic failure as the end point was 90.6% (95% confidence interval, 83.0%-98.8%).

CONCLUSION

The reconstruction of acetabular bone deficiency using autografts supported by an MC support ring provided satisfactory clinical and radiological results at 17.6 years postoperatively.

Temporary total hip arthroplasty-like spacer for treating an infected periprosthetic femoral fracture using a long stem: A case report

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Total hip arthroplasty-like spacer using a long stem facilitated the eradication of infection.

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Total hip arthroplasty-like spacer allowed a good range of motion without pain.

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Our method is simple and effective for treating an infected periprosthetic femoral fracture.

Introduction

Infected periprosthetic femoral fractures are among the most complex and significant complications of total hip arthroplasty (THA). We report the novel use of a temporary THA-like spacer for treating an infected periprosthetic femoral fracture after revision surgery using a long stem.

Case presentation

We present a 72-year-old woman sustained a left infected periprosthetic femoral fracture after revi - streptococci in the culture sample. On suspicion of a periprosthetic joint infection, we planned a two-stage procedure. We used a temporary THA-like spacer comprising the removed femoral long stem, which was autoclaved and then reimplanted, and applied a new polyethylene acetabular liner. Both components were cemented in place with antibioticloaded bone cement, without applying strong pressure. Pain control waseasily achieved postoperatively because the fracture had been stabilized early. The THA-like spacer was stable, and allowed a good range of motion without pain. She was allowed to move with a wheelchair and was walk with partial weight bearing without pain. Seven week after the initial THAlike spacer placement, we performed a revision THA after successful control of infection. At the 1-year follow-up, the patient remained free of infection.

Conclusions

Temporary antibiotic-loaded cement-coated THA-like spacer using a long stem facilitated the eradication of infection, fracture stabilization, and enables partial weight bearing without pain.

Kerboull-type plate in a direct anterior approach for severe bone defects at primary total hip arthroplasty: technical note

Introduction: For cases with extensive acetabular bone defects, we perform surgery combining the Kerboull-type (KT) plate and bone graft through direct anterior approach (DAA) in primary total hip arthroplasty (THA) requiring acetabular reconstruction as minimally invasive surgery. This paper provides the details of the surgical procedure.

Methods: The basic structure of the Kerboull-type plate is a cruciform plate. Since the hook of the Kerboull-type plate has to be applied to the tear drop, a space for it was exposed. The tear drop is located in the anterior lower region in surgery through DAA in supine position. It was also confirmed by fluoroscopy as needed. The bone grafting was performed using an auto- or allogeneic femoral head for bone defects in the weight-bearing region of the hip joint.

Results: Of 563 patients who underwent primary THA between 2012 and 2014, THA using the KT plate through DAA was performed in 21 patients (3.7%). The mean duration of postoperative follow-up was 31.8 months. The mean operative time was 188.4 min, and the mean blood loss was 770 g. The patients became able to walk independently after 2.4 days on average (1–4 days). On clinical evaluation, the modified Harris Hip Score was 45.6 ± 12.4 before surgery, and it was significantly improved to 85.3 ± 8.97 on the final follow-up.

Discussion: DAA is a true intermuscular approach capable of conserving soft tissue. Since it is applied in a supine position, fluoroscopy can be readily used, and it was very useful to accurately place the plate.

Safe zone for transacetabular screw fixation using a Kerboull cross-plate: A CT-scan templating prospective study

BACKGROUND

Implantation of Kerboull acetabular reinforcement cross-plates (Kerboull plate) carries a risk for injury to vascular structures and pelvic organs. To our knowledge, there is no study assessing anatomical assessment related to this risk with this specific design. Therefore, we performed a prospective study to answer the following four questions: 1) What is the minimum distance and angle between the plate and iliac vessels? 2) What is the distance between the plate and the inner cortex of the ilium? 3) What is the ratio of views with muscle tissue present on the inner surface of the ilium? 4) What are the boundaries of the safe zone for transacetabular screw fixation for a Kerboull plate?

HYPOTHESIS

A safe zone for fixation screws would be defined by a narrow range of insertion angles.

MATERIALS AND METHODS

This is a CT-based 3D templating prospective study. Simulations were performed for 18 patients fitted with a Kerboull plate. An original Kerboull plate (Stryker, Mahwah, NJ, USA) was placed at a 45° abduction angle relative to the X-axis (alignment A) and the palette was placed vertically to the X-axis (alignment B). We measured the distance from the centre of the plate to the inner surface of the cortex of the ilium, the shortest distance to vessels and the angle of existing vessels, and the ratio of muscles on the inner surface of the ilium.

RESULTS

The shortest distance to the vascular structures increased with increasing angle of insertion of the fixation screws, 85.8±12.1mm for A and 111.4±12.0mm for B at 45°. The distance to the inner cortex was further increased for screws inserted in posterior direction. At insertion angles ≥40°, the screws passed through muscle before invading the pelvis in most cases. However, at anterior-posterior angle (AP angles) ≤-10°, the risk of direct insertion of screws into the sacroiliac joint increased.

DISCUSSION

The safe zone for transacetabular screws would be insertion at an angle≥40°, with an AP angle between 0° and -10° (slight posterior direction).

LEVEL OF EVIDENCE

Level IV prospective diagnostic study.

Metallosis after Exchange of the Femoral Head and Liner following Ceramic Acetabular Liner Dissociation in Total Hip Arthroplasty with a Modular Layered Acetabular Component

The type of bearing material that should be used in revision surgery after the failure of ceramic-on-ceramic total hip arthroplasty (THA) remains controversial. In the case of ceramic fracture, the residual ceramic particles can cause consequent metallosis when metal implants are used for revision THA. On the other hand, in the case of THA failure without ceramic fracture, revision THA with a metal femoral head provides satisfactory results. We report an unusual case of progressive osteolysis due to metallosis that developed after revision THA for ceramic liner dissociation without a liner fracture performed using a metal femoral head and polyethylene liner. The residual metal debris and abnormal pumping motion of the polyethylene liner due to the breakage of the locking system or the aspherical metal shell being abraded by the ceramic head seemed to be the cause of the progressive osteolysis.