Bone grafting in total hip replacement for acetabular protrusion

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Bone grafting in total hip replacement for acetabular protrusion

Citation for published version (APA):

Slooff, T. J. J. H., Huiskes, H. W. J., Horn, van, J. R., & Lemmens, A. J. (1984). Bone grafting in total hip

replacement for acetabular protrusion. Acta Orthopaedica Scandinavica, 55(6), 593-596.

https://doi.org/10.3109/17453678408992402

DOI:

10.3109/17453678408992402

Document status and date:

Published: 01/01/1984

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Acta

Orthop.

Scand

55,593-596, 1984

Bone grafting in total hip replacement

for acetabular protrusion

Total hip replacement combined with acetabuloplasty was performed in 43 hips in 40 patients with protrusion secondary to arthrosis, rheumatoid arthritis or trauma. Depending on the acetabular defect, the acetabuloplasty encompassed reinforcement of the medial wall with bone grafts, vitallium meshes, protrusio rings and cups. The clinical and radiographic results were uniformly good on average 2 years postoperatively. All grafts appeared to be united and incorporated, without evidence of resorption. The only patient suffering from pain had radiographic signs of progressive varus migration of the femoral component.

A variety of surgical techniques have been de-

scribed to restore the lack of bone support in

acetabular protrusion secondary to disease or a

failed arthroplasty. Metal devices to redistrib-

ute the stresses and to reinforce the medial

wall were developed by Eichler (1973), Harris

&

Jones (1975) and Schneider (1980). The ap-

plication of acrylic cement was suggested by

Sotelo-Gana

&

Charnley (1978), whereas Par-

ker

&

Hastings (1974) and McCollum

&

Nun-

ley (1978) preferred bone grafts; the autogen-

ous femoral head can be used for previously

unoperated hips, or else autogenous iliac bone

or allografts.

This paper describes the results of total hip

replacement combined with acetabuloplasty

for acetabular protrusion.

Patients and methods

During the period January 1978January 1983, 43 hips had total hip replacement and bone grafting for protrusion of the acetabulum secondary to arthrosis (23 hips), rheumatoid arthritis (15 hips), and trauma

(5 hips); 21 of these arthroplasties were primary pro- cedures and 22 were secondary to failure of previous arthroplasties (16 total hip replacements, four surface replacements, and two hemiarthroplasties).

There were 29 females and 11 males; three patients had bilateral operations; and the age range was 21-82 years (Table 1).

In all cases the indications for surgery were pain, progressive functional disability and radiographic evidence of progressive destruction of bone stock, re-

Tom J. J. H.

Slooff

Rik Huiskes

Jim van Horn

Albert J. Lemmens

Departments of Orthopaedics and Radiology, Sint Radboud Hospital, University of Nij- megen, NG6500 HB Nij- megen, The Netherlands

sulting in protrusion a s assessed by Kohler’s line and disruption of Shenton’s line.

The presence of infection was excluded by clinical investigation, serial ESR and pre- and intra-oper- ative aerobic and anaerobic cultures.

Surgical techniques

The severity of the distortion of the normal anatomy and the size and location of the bone stock deficiency were assessed radiographically. The acetabulum was prepared carefully, notably in cases where bone cement from previous arthroplasties had to be re- moved. In the case of a defect in the medial wall, a cortico-cancellous graft was pressed into the acetabulum to close the gap. After curetting the acetabulum, the graft was surrounded by a wall of cancellous bone chips, moulded and impacted by using the socket trial prosthesis. In this way the acetabular cup was positioned more laterally and distally. Anchorage holes were punched in the acetabular roof and in the graft, which was then covered with a metal mesh. After irrigation with cooled Ringer so- lution and drying the socket, the prosthesis was ce-

Table 7. Etiology of acetabular protrusion in 43 reconstructed hips

Primary procedure Secondary procedure

No. Age No. Age

Arthrosis 10 62(49-79) 13 56(31-81)

Rheumatoid

arthritis 9 44(21-65) 6 56(45-68)

Trauma 2 36(31-41) 3 SS(31-82)

Total 21 22

Acta Orthop Downloaded from informahealthcare.com by Technical University of Eindhoven on 04/27/11

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594 T. J. J. H. Slooff et al.

Figure 1, A 36-year-old woman with rheumatoid arthritis was operated for progressive protrusion of her right hip. A shows Kbhler's line and disrupted Shenton's line 2 years after total hip replacement combined with bone grafting and vitallium mesh.

B shows lateralization and distalization of the acetabular component, no lucent lines, and homogeneous structure of the graft.

mented in position (Figures 1 and 2). In three hips the grafting procedure was supplemented with an Eichler protrusio ring. In cases of protrusions secondary to rheumatoid arthritis and osteoporosis, the use of protrusion cups with a n uninterrupted rim proved to be very helpful to provide firm support of the acetabular component.

In all cases standard implants were used. When using protrusio rings, the smaller types of acetabular components were required.

The femoral component was placed in routine fashion, using a n intramedullary plug and a cement syringe to obtain a solid cement layer. Both components were cemented with Gentamicin-PalacoE (Manufactured by E. Merck, Darmstadt, W. Ger- many) in revision arthroplasties, while in previously unoperated hips bone cement without antibiotics was used.

The postero-lateral approach provided sufficient exposure in all c a m , except that trochanteric os-

teotomy was necessary in three hips because of the extent of the protrusion and the restricted hip motion; these three cases were all re-operated for failed arthroplasty .

Autogenous femoral heads were used as bone grafts in 21 cases. These were supplemented with cortico-cancellous bone from the posterior iliac crest in 11 cases. In revisions of total hip arthroplasties, allografts were used, combined with autogenous chips from the posterior iliac crest (Table 2).

The average operation time was prolonged ( 2 4 % h) in comparison with routine total hip replacement. This was mainly due to the necessity to remove the prosthesis components and the bone cement, the preparation of the graft, and the reconstruction of the acetabulum. For the same reason the mean blood loss increased from 700 to 1800 cc.

Postoperative care included anticoagulation the- rapy, systemic antibiotics during the next 5 days, passive motion exercises after 24 h, ambulation with partial weight-bearing after 6 weeks and full weight- bearing at 3 months.

FOIIOW-UP

All patienta were reviewed in September 1983; the average follow-up period was 23 (6-68) months. No complications occurred during the follow-up period. All patients were followed up by routine examination and with serial roentgenograms in anterior-posterior and oblique-lateral projections.

This study focussed on the behaviour of the bone graft. As a parameter for its adaption, the presence of pain during weight-bearing on the affected side and radiographic signs of incorporation of the graft were recorded. These signs encompassed the absence of progressive lucent lines between the pre-existing bone and the graft, the absence of resorption of the graft, and the absence of further protrusion as assessed by Kohler's line. In addition, the radiographic homogeneity of the graft was considered.

Table 2. Methods for reconstruction in 43 cases operated for acetabular protrusion

Postero-lateral approach Trochanteric osteotomy Autogenous graft: femoral head

43 3 21 iliac crest 11 22 12 18 33 Figure 2. A 42-year-old male was reoperated because of

progressive, medial migration of total hip prosthesis (A). grafting, vitallium mesh and protrusio cup, B shows a radio- dense line at the previous interface. no radiolucent lines, and

~ l l ~ ~ ~ f t Combination of grafts protrusio~cup V,tallium mesh

Eight months after revision arthroplasty including bone Protrusio-ring 3

homogeneous structure of the graft.

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Bone grafting in THR

595 Results

All patients but one were pain-free; this pa-

tient was unable to put his full weight on the

affected hip, and radiographically the femoral

component had migrated in varus position; the

graft did show signs of union. In only five cases

was a radiolucent line evident between the

bone cement and the graft. The presence of

this line was regarded a s normal as it was less

than 1 mm in width in all five cases. Radi-

ographic examination showed union of the

grafts in all cases.

In all cases a homogeneous structure deve-

loped between 2 and 4 months after the oper-

ation. Progression of the protrusion and re-

sorption of the grafts were not found. The

average consolidation time varied between 3

and

4 months, apparently regardless of type of

graft.

Discussion

The technical procedure of total hip repla-

cement combined with acetabuloplasty for pro-

trusion has been well described (Harris

&

Jones 1975, Salvati et al. 1975,

McCollum

&

Nunley 1978, 1980, Schatzker et al. 1979,

Schneider 1980). All authors stress the nec-

essity of repairing and reinforcing the medial

wall of the acetabulum and recommend that

the acetabulum should be placed in the normal

anatomical position. This is important in order

to restore normal leg length,

to improve the

range of motion, and

to shift the weight-

bearing areas under the acetabular roof

(Schatzker et al. 1979).

To reconstruct the ace-

tabulum, autogenous bone as well a s allografts

seemed to be adequate, although metal rein-

forcements may be helpful; in three cases pro-

trusio rings of the Eichler type and in 33 cases

vitallium rigid mesh were used. There are

several reasons for using this mesh: in cases of

protrusion the acetabulum is weakened,

first

by the disease, second by the surgical trauma

in preparing the acetabulum, and third by the

wear of a loose prosthesis.

From analyses of Jacob

et al. (19761,

Pe-

dersen et al. (19821,

Pekman

&

Brown (1983)

and Crowninshield et al. (19831,

it is known

that in the absence

of subchondral bone the

stress levels in the bone cement and the trabe-

cular bone are increased. On the basis of these

computerized stress analyses, one may assume

that in our cases the addition of a metal mesh

to the reconstructed acetabulum reduced the

stresses. A further reason for using

a metal

mesh is the thermal conductivity of the metal,

which reduces the thermally induced oste-

ocyte-necrosis and vascular damage (Huiskes

1979).

Finally, by using a metal mesh, the

contact surface between cement and bone graft

is reduced, which may decrease the adverse

side effects of the cement (Willert et al. 1974).

In spite of the good clinical results that have

been reported using bone grafts in combination

with total hip replacement (Parker

&

Hastings

1974,

Harris

&

Jones 1975,

Salvati e t al. 1975,

Heywood 1980, McCollum

et al. 1980 and

Marti

&

Besselaar 1983),

little is known about

the behaviour and fate of the grafts that have

been covered with polymethylmethacrylate.

However, with reference to the experimental

work of Roffmann et al. (1982,

1983)

and the

clinical investigation of McCollum et al. (1980),

it seems reasonable to continue this technique

of reconstruction.

References

Crowninshield, R. D., Brand, R. A. & Pedersen, D. R.

(1983) A stress analysis of acetabular recon- struction in protrusio acetabuli. J . Bone Joint Surg. 65-A, 495499.

Eichler, J. (1973) Ein Vorschlag zur operativen Be-

handlung der F’rotrusio Acetabuli. Arch. Orthop. Unfall-Chir. 75, 76-80.

Harris,

W.

H. & Jones, W. N. (1975) The use of wire mesh in total hip replacement. Clin. Orthop.106,

Heywood, A. W. B. (1980) Arthroplasty with a solid bone graft for protrusio acetabuli. J . Bone Joint Surg. 62-B, 332-336.

Huiskes, R. (1979) Some fundamental aspects of human joint replacement. Analysis of stresses and heat conduction in bone prosthesis structures.

Acta Orthop. Scand. Suppl. 185.

Jacob, H. A. C., Huggler, A. H. & Dietschi, C. (1976) Mechanical function of subchondral bone as ex-

perimentally determined on the acetabulum of the human pelvis. J . Biomech. 9,625-627.

117-121.

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596 T. J. J. H. Slooff et al.

Marti, R. K. & Besselaar, P. P. (1983) Bone grafts in primary and secondary total hip replacement. In:

Progress in cemented total hip surgery and reui- sion. pp. 107-130. Excerpta Medica, Elsevier Science Publishers, Amsterdam.

McCollum, D.E. & Nunley, J . A . (1978) Bone grafting in acetabular protrusio. A biologic buttress. In: The Hip: Proceedings of the sixth open scientific meeting of the Hip Society, pp.

124-146. C. V. Mosby, St. Louis.

McCollum, D. E., Nunley, J . A. & Harrelson, J. M. ( 1980) Bone grafting in total hip replacement for acetabular protrusion. J . Bone Joint Surg. 62-A,

1065-1073.

Parker, S. M. & Hastings, D. C. (1974) Protrusio acetabuli in rheumatoid arthritis. J. Bone Joint Surg. Pedersen, D. R., Crowninshield, R. D., Brand, R. A. & Johnston, R. C. (1982) An axisymmetric model of acetabular components in total hip arthroplasty. J. Biomech. 15, 305-315.

Pekman, W. M. 8c Brown, Th. D. (1982) A finite ele- ment analysis of acetabular reconstruction following metastatic bone loss. In: Biomechanics Sym- posium, (Ed: Woo, S. L. Y.). A.M.D., Vol. 56, pp.

43-44. ASME. New York.

56-B, 587.

Roffman, M., Silberman, M. & Mendes, D. G. (1982) Viability and osteogenicity of bone graft coated with methylmethacrylate cement. Acta Orthop. Scand. 53,513-519.

Roffman, M., Silberman, M. & Mendes, D. G. (1983) Incorporation of bone graft covered with methyl- methacrylate onto acetabular wall. Acta Orthop. Scand. 54,580-583.

Salvati, E. A., Bullough, P. & Wilson, P. D., Jr. (1975) Intrapelvic protrusion of the acetabular com- ponent following total hip replacement. Clin. Or- Schatzker, J., Hastings, D. E. & Broom, R. J. (1979)

Acetabular reinforcement in total hip replace- ment. Acta Orthop. Z’raumat. Surg. 94, 135-141. Schneider, R. (1980) Die Armierung der Pfanne bei

der Totalendoprothese der Hufte. Unfallheilk. 83,

482-488.

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action of bone to methylmethacrylate after hip ar- throplasty. J. Bone Joint Surg. 56-A, 1368-1382. thop. 11, 212-227.