Is Restoration of Hip Center Mandatory for Total Hip Arthroplasty of Protrusio Acetabuli?

Characterizing acetabular defects and need of major reconstruction during total hip arthroplasty in patients with acetabular protrusion- a retrospective study

Purpose

Total hip arthroplasty (THA) in patients with acetabular protrusion can be challenging due to the lack of acetabular bone support. Some patients may require a major reconstructive procedure to aid in the fixation of the acetabular components. The purpose of the study was to characterize the type of acetabular defects in patients with protrusion and to assess the need for major reconstruction.

Methods

This was a retrospective study of 125 THAs performed at a single tertiary center from 2010 to 2020 by a single surgeon in patients with acetabular protrusion. Demographics, operative details and radiographic details were recorded. THAs in which a structural graft, cage or augment were used for acetabular reconstruction were considered to have undergone a major reconstructive procedure and a classification system was proposed to identify patients requiring major reconstruction.

Results

10 (8 %) THAs required a major reconstruction in our cohort (2- augment, 8- structural allograft. There was significant difference in acetabular defects based on the etiology. Major reconstruction was more common when the diagnosis was sequalae of tuberculosis or post-traumatic arthritis. Simple cavitatory defects seldom required a major reconstruction while combined defects and medial wall deficiency increased the risk of requiring a major reconstruction.

Conclusion

The severity of defects varied considerably with majority of patients having cavitatory type of defect which can be successfully managed without the need of any major reconstructive measures. A simple classification based on the type of defect and medial wall competency appeared to be useful in identifying patients who may need a major reconstructive procedure during THA.

Perioperative Considerations for Hip Arthroplasty in Patients with Rheumatoid Arthritis

Due to its distinct features, rheumatoid arthritis (RA), an inflammatory autoimmune disorder, poses challenges in planning for surgical interventions. This review includes available evidence regarding perioperative considerations in management of RA patients, with a focus on hip surgery. RA can affect multiple joints, with development of extra-articular manifestations; therefore, preoperatively, comprehensive medical assessments, including cardiovascular or pulmonary evaluation must be considered in addition to surgical considerations. Modification of medications capable of controlling RA-related disease activity is critical, and requires collaboration with rheumatologists. Surgical considerations include the choice of surgical approach, implant selection, and problems related to weakened soft tissues, fragile bone density, and bony deformity such as protrusio acetabuli. Careful monitoring and more active rehabilitation are recommended for RA patients due to higher risk of postoperative complications. For achievement of optimal outcomes, use of a multidisciplinary perioperative approach is required for patients with RA.

Long-Term Outcomes of Primary Cemented Total Hip Arthroplasty with Acetabular Bone Graft for Protrusio Acetabuli: Minimum 10-Year Follow-Up

Background: This study reports the long-term survivorship of primary total hip arthroplasty (THA) for protrusio acetabuli. Methods: Patients undergoing THA utilising cement and bone graft acetabular reconstruction for protrusio acetabuli in a university teaching hospital during the period 2003 to 2014 were included. Kaplan-Meier survival estimates were calculated with 95% confidence intervals (CI) up to 15 years following surgery. PROMs were collected pre- and post-operatively for hip-specific function (Oxford Hip Score [OHS]) and health-related quality of life (HRQoL) using the EQ-5D-3L. Results: 129 consecutive THAs (96 patients) performed for protrusio acetabuli were identified (median age 69, IQR 61-75; female 115 [89.1%]; 38 [29.5%] inflammatory arthritis) with a mean follow-up of 15.7 years (range: 10.1-20.1 years). At the final follow-up, fifty-six (43.4%) patients had died and there were eleven (8.5%) reoperations, of which eight (6.2%) involved the revision of the acetabular component. The fifteen-year Kaplan-Meier any-reoperation survival estimate was 91.3% (95% CI 85.9-97.0). When considering all-cause acetabular revision only, the 15-year survival estimate was 93.1% (95% CI 88.2-98.3). The median pre-operative OHS improved significantly from baseline to 1 year post-THA, beyond the minimal important change (mean difference 28, 95% CI 25-30, p < 0.001). Similarly, there were clinically relevant improvements in HRQoL at 1 year post surgery (mean difference 0.10, 95% CI 0.06-0.15, p < 0.001). Conclusions: This study demonstrates that primary cemented THA utilising acetabular bone graft for reconstruction in patients with protrusio acetabuli was associated with 15-year survival rates of 93.1% and clinically relevant improvements in hip-specific function and HRQoL.

P, Kalia RB. Total Hip Arthroplasty in Protrusio Acetabuli: A Systematic Review

Protrusio acetabuli, or abnormal protrusion of the femoral head into the acetabulum, requires performance of a total hip arthroplasty (THA) for which various reconstruction techniques and outcomes have been described. The aim of this systematic review is to provide a comprehensive analysis of the current evidence, evaluate treatment efficacy, compare surgical techniques, and identify topics for future research along with improving evidence-based decision-making, improving patient outcomes in the management of this condition. A thorough systematic review of the PubMed, Embase, Cochrane Library databases, and Scopus library was conducted, and articles describing techniques of THA for treatment of protrusion acetabuli were extracted. The initial search generated 751 results. After exclusion, 18 articles were included. Of these, eight were prospective studies and 10 were retrospective. Surgery was performed on 783 hips with a mean age of 60 years; 80% of females who mostly had inflammatory arthritis were followed up for 8.86 years (range, 2-15.4 years). Good outcomes have been achieved with THA using uncemented cups with bone graft; however, no conclusion could be drawn with regard to the femoral side. It can be concluded that the concept of restoration of the anatomical hip center of rotation is paramount for good outcome and better survival of the implant is important when using uncemented cups with a bone graft. In addition, screw augmentation for fixation is not recommended unless absolutely necessary. The most common complications were aseptic loosening and heterotopic ossification. While the former required revision, conservative management was administered for the latter.