Acetabular Bone Grafting Research Articles

Simultaneous open reduction and internal fixation and total hip arthroplasty for the treatment of osteoporotic acetabular fractures.

Surgical treatment of acetabular fractures in elderly people is challenging. The main aim of this study is to evaluate retrospectively the indications, results and the complications of simultaneous open reduction and internal fixation (ORIF) and acute total hip replacement (THR) in the management of displaced acetabular fractures. This study was performed in an academic level I trauma centre. From January 2011 to December 2014, a consecutive series of 18 patients (eight females), with average age of 66years (range 35-81years) who had displaced acetabular fractures were included in our study. All patients underwent ORIF and simultaneous acute THR. The average duration of follow up was 21.7months (range 12-36months). At the latest follow up, all patients could walk independently. Thirteen patients (72.7%) had excellent Harris hip scores HHS, five, patients (27.7%) had good results. All fractures were healed and the acetabular autologous bone grafts were well incorporated. There were no delayed unions or non-unions. Two patients (11%) had heterotropic bone formation which did not affect the activity of the patients. There were no signs of loosening of the acetabular cups however one patient had 2mm medial migration of the cup. No vertical migration was observed, and there were no signs of loosening around the femoral stem. ORIF and simultaneous THR is a good option for the treatment of certain types of acetabular fractures particularly in elderly population.

A cemented cup with acetabular impaction bone grafting is more cost-effective than an uncemented cup in patients under 50 years.

Acetabular deficiencies in young patients can be restored in several ways during total hip arthroplasty. Currently, cementless cups are most frequently used. Impaction bone grafting of acetabular defects is a more biological approach, but is it cost-effective in young patients on the long term? We designed a decision model for a cost-utility analysis of a cemented cup with acetabular impaction bone grafting versus an uncemented cup, in terms of cost per quality-adjusted life year (QALY) for the young adult with acetabular bone deficiency, in need for a primary total hip arthroplasty. Outcome probabilities and effectiveness were derived from the Radboud University Nijmegen Medical Centre and the Norwegian Hip Register. Multiple sensitivity analyses were used to assess the contribution of the included variables in the model's outcome. Cemented cups with impaction bone grafting were more cost-effective compared to the uncemented option in terms of costs per QALY. A scenario suggesting equal primary survival rates of both cemented and uncemented cups still showed an effect gain of the cemented cup with impaction bone grafting, but at higher costs. Based on this model, the first choice of treatment of the acetabular bone deficient osteoarthritic hip in a young patient is reconstruction with impaction bone grafting and a cemented cup.

Clinical and radiographic evaluation of cemented socket fixation concomitant to acetabular bone grafting fixed with absorbable hydroxyapatite-poly-l-lactide composite screws

BackgroundThe durability of uncalcined and unsintered hydroxyapatite-poly-l-lactide composite screws is unclear when used for the fixation of acetabular bone graft in total hip arthroplasty under full-weight conditions. We have used this type of screw for the fixation of acetabular bone graft in cemented or reverse-hybrid total hip arthroplasty since 2003. Hence, we conducted a follow-up study to assess the safety and efficacy of these screws when used for cemented socket fixation. MethodsIn this study, 98 patients (106 cases) who underwent fixation of acetabular bone graft in cemented or reverse-hybrid total hip arthroplasty using hydroxyapatite-poly-l-lactide composite screws were followed up for over 5 years and evaluated clinically and radiographically. The patient population comprised 10 men and 88 women with a mean age of 60.3 years (range, 41–81 years) at the time of surgery. The original diagnosis for primary total hip arthroplasty was secondary osteoarthritis in 97 cases and high hip dislocation in nine cases. ResultsThe mean follow-up period was 7.6 years (range, 5–11 years). No patient in this series required revision surgery, and no radiographical loosening occurred during the follow-up period. The mean Japanese Orthopaedic Association score improved from 48 (range, 7–73) preoperatively to 87 (range, 50–100) at the final follow-up. Radiographically bone graft consolidation was confirmed in all cases, and no apparent osteolysis around the cemented socket or composite screws was detected. Kaplan–Meier survival analyses with socket revision surgery for any reason, socket loosening, and appearance of a radiolucent line >1 mm in any zone as the endpoints yielded survival rates of 100%, 100%, and 86.8% at 5 years, and 100%, 100%, and 81.0% at 10 years, respectively. ConclusionThis absorbable screw seems to have no negative effects on the mid-term clinical results of cemented socket fixation.

The biological approach in acetabular revision surgery: impaction bone grafting and a cemented cup.

Acetabular impaction bone grafting (IBG) in combination with a cemented cup in revision total hip arthroplasty (THA) is a proven and well-recognised technique which has been used in clinical practice for more than 35 years. Nowadays, with cemented prostheses tending to lose a larger part of the THA market every year in primary and revision cases, and many young surgeons being only trained in implanting uncemented prostheses, this technique is considered by many as technically demanding and time consuming, making its use less appealing. Despite this image and many new innovative techniques using uncemented implants in acetabular revisions over the last 25 years, IBG with a cemented cup is still one of the few techniques that really can reconstitute bone and respects human biology. In this era of many biologically-based breakthroughs in medicine, it is hard to explain that the solution of most orthopaedic surgeons for the extensive bone defects as frequently seen during acetabular revision surgery, consists of implanting bigger and larger metal implants. This review aims to put the IBG method into a historical perspective, to describe the surgical technique and present the clinical results.

Long-term results of the uncemented acetabular component in a primary total hip arthroplasty performed for protrusio acetabuli: a fifteen year median follow-up.

Protrusio acetabuli is an uncommon finding that can be seen in patients undergoing primary total hip arthroplasty for arthritis. Uncemented fixation of the acetabular component and bone grafting of the protrusio defect is commonly used as a reconstruction method and has shown good mid-term results. The long-term outcome of these reconstructions warrants further study. The objective of this study was to determine the results of primary total hip arthroplasty (THA) with use of an uncemented acetabular component for protrusio acetabuli in patients followed for a minimum of ten years. Sixty-five hips in 53 patients had a primary THA with uncemented acetabular component for the protrusio acetabuli between 1984 and 2001. There were 53 procedures performed in females (82%) and 12 in males (18%). The mean age at the procedure was 66 years. Acetabular floor reconstruction with use of bone graft was performed in 58 hips (89%). Four patients (five hips) were lost to follow-up less than ten years after the procedure and 25 patients (31 hips) had died during the follow-up period. The median follow-up of living patients that did not have revisions for acetabular component was 15.4 years (range, ten to 24 years). During the study duration, six hips underwent acetabular component revision: aseptic loosening (three hips), polyethylene wear (two hips), and recurrent instability (one hip). The median Harris hip score for the living patients who did not have an acetabular component revision improved from 55 points pre-operatively to 82 points at the latest follow-up. At 15 years, the estimated survival rate from revision was 70% for the THA: 85.4% for the acetabular component, and 83% for the femoral component. Five unrevised acetabular components had evidence of non-progressive radiolucency. In patients undergoing THA with acetabular protrusio, fixation of an uncemented hemispherical shell and use of bone graft as necessary provided satisfactory clinical and radiographic results as well as satisfactory survivorship rates at a median follow-up of 15 years.

Acetabular re-revision with impaction bone grafting and a cemented polyethylene cup; a biological option for successive reconstructions.

For the revision of failed acetabular components impaction bone grafting (IBG) with a cemented cup is a well known technique. Claims have been made that this is a biological reconstruction technique, restoring the bone stock loss and thereby facilitating future revisions. However, there are no scientific data proving this claim. In this study, we present the clinical and radiographic outcome of 11 consecutive acetabular re-revisions in 10 patients with again IBG and a cemented polyethylene cup observed in a previously reported cohort of 62 acetabular IBG revisions. All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. The mean follow-up after re-revision was 10 years (5-15) and 28 years (26-30) after the primary revision. No patients were lost to follow-up. The mean HHS improved from 37 (12-49) points to 71 (40-95) points at final follow-up. Survival with further cup revision for any reason as endpoint was 91% (95% confidence interval (CI) 51 to 99) at 10 years. When excluding one early cup re-revision for malpositioning 3 weeks postoperative, survivorship with further cup revision for aseptic loosening as endpoint was 100% (95% CI 37-100) at 10 years. Survival with further cup re-operation for any reason as endpoint was 82% (95% one-sided CI 45-95). In all surviving re-revisions trabecular incorporation was observed without radiolucent lines. This study shows that, due to restoring the bone stock, even successive acetabular reconstructions using IBG and a cemented cup are possible with satisfying 10 years survivorship.

Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty

The procedure of bone allografting associated with a reinforcement device is widely used for acetabulum revision. However in absence of biologic fixation of the allograft, failure of the reconstruction may occur. We made the hypothesis that it would be possible to load these grafts with bone marrow derived mesenchymal stem cells (MSC) to rescue the osteogenic capacity of an allogenic dead bone and therefore enhance incorporation of allografts with the host bone and decrease the number of failures related to the allograft. We identified 60 patients who had undergone acetabular component revision for aseptic failure of cemented implants associated with massive periacetabular osteolysis and Paprosky type 3A or 3B classification (without pelvic discontinuity) between 1996 and 2001. The study group of 30 patients received MSCs in the allograft and at the host graft junction. The average total number of MSCs received by each patient was 195,000 cells (range 86,000-254,000 cells). The control group of 30 patients had no MSCs in the allograft. Patients were matched for the size of periacetabular osteolysis (Paprosky type 3A or 3B). We compared the evolution of the allografts and evaluated cup migration and revision of the hips as end points at a minimum of 12 years or until failure. Better radiographic graft union rates and less allograft resorption were observed with allografts loaded with stem cells. Allograft resorption was significantly decreased in the group with allograft loaded with MSCs (1.2 cm(2) -range 0-2.3 cm(2)-of resorption on radiographs in the group with MSCs; versus 6 cm(2), range 2.1-8.5 cm(2) in the group without MSCs). The rate of mechanical failure was highest (p = 0.01) among the 30 patients with allograft without stem cells (9/30; 30 %) compared with no failures for patients with allograft loaded with stem cells. Revision of the cup was necessary in nine patients in the control group. No revision was performed in the 30 patients of the study group with MSCs. For acetabular defect reconstruction, loading the allograft with MSCs has resulted in a lower rate of failure as compared with allograft without MSCs.

Impaction grafted bone chip size effect on initial stability in an acetabular model: Mechanical evaluation

IntroductionAcetabular bone defect reconstruction is an increasing problem for surgeons with patients undergoing complex primary or revision total hip replacement surgery. Impaction bone grafting is one technique that has favourable long-term clinical outcome results for patients who undergo this reconstruction method for acetabular bone defects. Creating initial mechanical stability of the impaction bone graft in this technique is known to be the key factor in achieving a favourable implant survival rate. Different sizes of bone chips were used in this technique to investigate if the size of bone chips used affected initial mechanical stability of a reconstructed acetabulum. MethodologyTwenty acetabular models were created in total. Five control models were created with a cemented cup in a normal acetabulum. Then five models in three different groups of bone chip size were constructed. The three groups had an acetabular protrusion defect reconstructed using either; 2–4 mm3, 10 mm3 or 20 mm3 bone chip size for impaction grafting reconstruction. The models underwent compression loading up to 9500 N and displacement within the acetabular model was measured indicating the initial mechanical stability. ResultsThis study reveals that, although not statistically significant, the largest (20 mm3) bone chip size grafted models have an inferior maximum stiffness compared to the medium (10 mm3) bone chip size. InterpretationsOur study suggests that 10 mm3 size of bone chips provide better initial mechanical stability compared to smaller or larger bone chips. We dismissed the previously held opinion that the biggest practically possible graft is best for acetabular bone graft impaction.

Acetabular impaction bone grafting in total hip replacement

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Spinopelvic Dissociation as a Complication of Iliac Crest Bone Graft Harvest Using an Acetabular Reamer

Descriptive case report. To report spinopelvic dissociation as a complication of autogenous bone graft harvest with the use of an acetabular reamer. Iliac crest bone graft harvest has been previously described in orthopedic literature with overall complication rates of 0% to 39%. Complications are inconsistently separated into "minor" and "major" groups, commonly reporting hematoma, infection, and injury to the superior gluteal artery or nerve. No reports of spinopelvic dissociation, a well known injury in the traumatic setting, have been reported. We report the case of 1 patient who presented with spinopelvic dissociation after autogenous bone graft harvest with the use of an acetabular reamer. We present a unique case in which fracture through the reamer harvesting site led to complete disruption of the posterior pelvic ring on the operative side. Subsequent attempted closed management led to failure through the osteoporotic anterior pelvic ring on the operative side and the posterior pelvic ring on the contralateral side, leading to progressive instability, disability, and pain. This was successfully addressed with lumbopelvic fusion and 2-year follow-up is presented. The potential hazard of acetabular reamer bone graft harvest is discussed, and primary operative fixation of harvest-related fractures is suggested.

Use of HA–PLLA Composite Screws to Fix Acetabular Bone Graft in Cemented THA: Absorption Pattern of Screws in Six Patients

We used a composite of uncalcined and unsintered hydroxyapatite (u-HA) particles and poly-l-lactide (PLLA) to fix the acetabular bone graft in total hip arthroplasty (THA) in a clinical trial in six patients, and followed them for over 10 years. The patients were evaluated clinically and radiologically to assess the safety and efficacy of the screws and the characteristics of their absorption. No patient in this series experienced revision or radiographic loosening during the follow-up period. The configurations of the HA–PLLA composite screws were confirmed on early post-operative radiographs in every case, whereas they appeared obscure on radiographs within 5 years after surgery, and only osteosclerotic traces remained in the screw positions at the final follow-up. Some screw heads were covered with bone within 3 months of surgery, and some screw heads migrated laterally with breakage, but were absorbed in situ within 5 years. The screws seemed to have no negative effect on the mid-term clinical results of the THAs.

Mid-term results of acetabular reconstruction using a Kerboull-type acetabular reinforcement device

The purpose of this study was to investigate the mid-term results of 32 acetabular reconstructions performed using a Kerboull-type acetabular reinforcement device and bone graft between June 1997 and January 2009. The mean age of the patients at the time of surgery was 71.4 years (range 55-85). Patients were followed-up for a mean of 7.5 years (range 2.1-13.7). The acetabular bone defects according to the American Academy of Orthopaedic Surgeons system was type III for 29 hips and type IV for three hips. Bulk allografts were performed in 30 hips and morselised autografts (iliac bone) were performed in two hips. Clinical evaluations were made according to the criteria of Postel/Merle d'Aubigné. The mean pre-operative Postel/Merle d'Aubigné hip score was 7.0 ± 2.9, and the final follow-up hip score was 12.6 ± 2.8. Six hips showed radiographic loosening, and two hips required further revision. A Kaplan-Meier analysis showed that the five-year and ten-year survival rates were 96.9% and 92.3%, respectively, using further revision of the acetabular device as an end point. Acetabular reconstruction using a Kerboull-type acetabular reinforcement device and bone graft gives satisfactory mid-term results.

Large Acetabular Defects Can be Managed with Cementless Revision Components

Optimal techniques for acetabular revision in the setting of major pelvic osteolysis have not been established. Bilobed components, structural grafts, and reinforcement cages have demonstrated 10-24% midterm failure rates. While cementless hemispherical components have been utilized to treat large acetabular defects, most reports have not focused specifically on patients with extensive deficiencies. We report midterm clinical scores, component revisions, and complications following focal bone grafting and cementless acetabular revision in cases with major periacetabular osteolysis. We identified 30 patients (32 hips) who underwent cementless acetabular revision to treat massive acetabular bone loss at an average followup of 53 months. We excluded three patients lost to followup and two patients who died prior to minimum 24 month followup. Harris Hip Scores were assessed before and after surgery. Postoperative radiographs were evaluated for graft incorporation and component migration. Component revision and component migration are reported as failures. Mean Harris Hip Score improved from 52.5 (range, 17.7-90.7) to 87.3 (range, 25.3-100) points. Three hips (9%) were revised for aseptic loosening. Three components (10.7%) demonstrated radiographic migration, but were not revised. Complete graft incorporation was seen in 17 cases (68%). There were five major complications (14%). Cementless acetabular fixation and bone grafting result in clinical scores and survivorship comparable to other options at midterm followup, with potential for biological fixation. Level IV, clinical research study. See the Guidelines for Authors for a complete description of levels of evidence.

Early results of whole femoral head allograft with articular cartilage for acetabular impaction grafting in revision hip replacements

Extensive bone loss associated with revision hip surgery is a significant orthopaedic challenge. Acetabular reconstruction with the use of impaction bone grafting and a cemented polyethylene cup is a reliable and durable technique in revision situations with cavitatory acetabular bone defects. Some use cancellous graft alone whilst others morselise the whole femoral head after removal of articular cartilage. This paper asks, if it really necessary to use pure cancellous graft? Forty-two acetabular revisions using impacted morselized bone graft without removal of articular cartilage and a cemented cup were studied retrospectively. The mean follow-up was 3 years (range, 2-5.6 years). Clinical and radiographic assessment was made using the Oxford hip score, Hodgkinson's criteria (1988) for socket loosening and the Gie classification (1993) for evaluation of allograft consolidation and remodelling. Forty (95%) sockets were considered radiologically stable (type 0, 1, 2 demarcations) and two (5%) sockets were radiologically loose (Type 3 demarcation). There was no socket migration in our series. Twenty-seven(64%) cases showed good trabecular remodelling (grade 3). Twelve (29%) cases showed trabecular incorporation (grade 2). Only three (7%) cases showed poor allograft incorporation (grade 1). Average pre-operative Oxford hip score was 41 and postoperative hip score was 27. There have been no socket re-revisions (100% survival) at an average of 3 years. Early radiological and clinical survival results with retaining articular cartilage of femoral head allografts are similar and comparable to other major studies for acetabular impaction bone grafting in revisions. Minimal loss of allograft mass is 40% in obtaining pure cancellous graft. When there is a limited supply and demand of allograft, saving up to 40% of the material is a valuable and cost-effective use of scarce resources.

Autogenous bulk structural bone grafting for reconstruction of the acetabulum in primary total hip arthroplasty: average 12-year follow-up.

The purpose of the present study was to assess the clinical and radiographic results of primary cemented total hip arthroplasty with acetabular bone grafting. Twenty patients (21 hips) were included in the current study: two males and 18 females with a mean age at surgery of 54.5 years (range 40-66 years). The mean duration of follow-up was 12 years (range 8-15 years). The diagnosis for all hips at surgery was secondary osteoarthritis due to developmental dysplasia. The degree of subluxation as categorized according to the classification of Crowe et al. was 11 hips in group I, 6 in group II, and 4 in group III. The Harris hip score was used for clinical evaluation. Standard anteroposterior radiographs were used for radiographic evaluation. The mean Harris hip score improved from 45.0 (range 24-60) before surgery to 90.4 (range 77-100) at the final follow-up. The mean proportion of the socket covered by the bone graft was 23.1% (range 9.8-42.3%). At the final follow-up, three sockets showed radiological evidence of loosening. No revision surgery was undertaken during the investigation period since those patients had only mild pain and did not request surgery. Autogenous bulk structural bone grafting for reconstruction of the acetabulum yielded favorable results during a mean follow-up of 12 years, provided that the proportion of coverage of the graft was less than 50%.

Long-term Outcome of Shelf Grafts in Total Hip Arthroplasty for Developmental Hip Dysplasia

Primary total hip arthroplasty (THA) in patients with osteoarthrosis secondary to developmental hip dysplasia is often complex due to anterolateral acetabular bone deficiency. The use of femoral head (shelf) autograft during the index arthroplasty provides nonimmunogenic, osteoconductive support with the potential for enhanced bone stock should revision surgery be required. Few long-term studies document the outcome of the use of shelf grafts in primary THA or quantify the need for further bone graft at revision surgery. A retrospective analysis was conducted of a single surgeon's series of 31 THAs performed in 25 patients with developmental hip dysplasia. Postoperative biplanar radiographic analysis was performed at 3 and 6 months and annually thereafter for a mean of 14 years (range, 8-18 years). Grafts were assessed for union, resorption, and displacement. The need for acetabular bone graft at revision surgery was recorded. Bony union was observed in 93% of cases; fibrous union developed in the remaining 7%. There was no graft displacement. In 71% of cases, less than one-third of the graft had resorbed; one-third to one-half had resorbed in the remaining 29% of cases. Of 10 patients revised (all for loosening of the acetabular component), 2 required structural allograft for inadequate bone stock. Femoral head autograft allows effective acetabular coverage with excellent rates of union, exhibits minimal graft resorption in the long-term, and rarely requires further acetabular allograft in revision surgery.

Total Hip Arthroplasty in Acetabular Protrusio

Protrusio is a central acetabular defect resulting from migration of the femoral head medial to Kohler's line. Protrusio can develop in association with a number of conditions that affect the metabolism or mechanical behavior of the periacetabular bone. Total hip arthroplasty (THA) for acetabular protrusio requires reconstruction of the contained cavitary defect. The acetabular rim is generally intact. The defect can be effectively treated with a lateralized cementless porous-coated component supported on the peripheral acetabular bony rim. Morsellized autograft is used to fill the medial defect. However, if the rim is inadequate to provide mechanical support for a cementless cup due to bone loss or osteoporosis, cementless cup reconstruction can result in medial migration. If rim support is inadequate, a reconstruction cage is a more appropriate option to gain fixation to the pelvis above and below the acetabulum. Total hip arthroplasty for protrusio can also affect both offset and leg length, so careful preoperative templating is important to help determine implant position. Results of THA with medial acetabular bone grafting for protrusio acetabuli have been favorable, with success rates similar to conventional THA.

Long-Term Results of Cemented Total Hip Arthroplasty in Developmental Dysplasia With Acetabular Bulk Bone Grafts After Improving Operative Techniques

We present the long-term results (mean follow-up, 11.8 years; range, 6.3-15.4 years) of cemented total hip arthroplasty with acetabular bulk bone grafting in 147 dysplastic hips using improved surgical techniques. Operations were performed through a direct lateral approach with partial trochanteric osteotomy to avoid nonunion of the greater trochanter. Bioresorbable poly( l-lactide) screws were used for fixation of the acetabular bone grafts to prevent any possible delayed remodeling. Preoperative planning using computer simulation was performed to estimate the optimal size and position of the acetabular component. Analysis predicted rates of survival of the acetabular component of 96% and 91% at 15 years, with revision for aseptic loosening and radiologic loosening as the end points, respectively. Our results indicate excellent long-term clinical and radiographic survivorship of a cemented acetabular component with bulk autograft for acetabular dysplasia.

Long-Term Results of Cemented Total Hip Arthroplasty for Dysplasia, With Structural Autograft Fixed With Poly- l-Lactic Acid Screws

This study reviewed a series of cemented total hip arthroplasty (THA) for dysplasia, with structural autograft fixed with poly- l-lactic acid screws. Grafted bone union was confirmed radiologically in every case, and there were no cases of early collapse or extravasation of grafted bone. Kaplan-Meier survivorship analysis of socket revision, radiologic loosening of the socket, and the appearance of a radiolucent line greater than 1 mm in the graft-socket interface as the end points indicated survival rates of 99%, 97.1%, and 63.5% at 10 years and 96.6%, 90.2%, and 56.1% at 15 years, respectively. The results of this study indicated that poly- l-lactic acid screws are safe and useful for the fixation of acetabular bone graft concomitant to cemented THA with a careful rehabilitation program.

Impaction bone grafting for acetabular reconstruction: mean 5.5-year results in Japanese patients

We performed a retrospective outcome study on 23 consecutive acetabular reconstructions involving impaction bone grafting in Japanese patients. Two hips had cavitary defects, and 21 hips had combined segmental and cavitary defects. The mid-term follow-up was performed at a mean of 5.5 years postoperatively. The mean Merle d'Aubigné and Postel hip score had improved from 11.5 to 15.7 points at the final follow-up. Two hips showed migration at 30 months after surgery, and one of these was a candidate for re-revision due to symptomatic cup migration. The Kaplan-Meier survival rate of the cup, with loosening and re-operation as the end points, was 91.3 and 95.7% at 5 years, respectively. Acetabular impaction bone grafting is a reproducible technique in which surgeons should strictly follow the recommended technical procedure.