Pelvic Osteolysis Research Articles

Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement.

Thirty-five patients who had had a primary total hip replacement with a porous-coated acetabular component inserted without cement had a revision procedure to treat pelvic osteolysis. The mean age at the time of the revision operation was forty-nine years (range, twenty-nine to eighty-five years). Forty-six distinct pelvic osteolytic lesions were noted radiographically around the thirty-five cups. These lesions ranged in size from 0.5 by 0.5 centimeter to 6.3 by 2.7 centimeters (mean, 2.6 by 1.7 centimeters). Fourteen of the thirty-five patients had no or only slight occasional pain at the time of diagnosis of the pelvic osteolysis, fifteen patients had pain attributed to a loose femoral component, one had pain related to a spontaneous fracture of the greater trochanter, and one had pain related to recurrent subluxation. The remaining four patients had pain in the groin despite radiographically stable implants. All of the metal-backed porous-coated acetabular components were stable according to the preoperative radiographs, and the stability was confirmed at the time of the revision. The metal shell was left in place and the acetabular liner was exchanged in all thirty-five patients. The osteolytic lesions were debrided, and thirty-four of the forty-six lesions were filled with allograft bone chips. The patients were evaluated a minimum of two years (range, two to five years; mean, 3.3 years) after the revision operation, and all thirty-five sockets were found to be radiographically stable. The bone grafts appeared to have consolidated, and none of the osteolytic defects had progressed. One-third of the lesions were no longer visible on radiographs, regardless of whether or not they had been filled with bone graft. The remaining lesions had decreased in size. It appears that, in the short-term, exchange of the liner and debridement of the granuloma, with or without use of allograft bone chips in the osteolytic defect, is a reasonable alternative to revision of the socket provided that the metal shell is solidly fixed at the time of the revision operation. If the metal shell has been markedly damaged by the femoral head, the locking mechanism for the polyethylene liner is not intact, or a satisfactory replacement liner is not available, then revision of the porous-coated acetabular component is indicated. These results must be considered preliminary. Since osteolysis may take several years to redevelop after a revision, additional follow-up is required.

Progressive bilateral pelvic osteolysis in a patient with McKee—Farrar metal—metal total hip prostheses

As accumulating evidence indicates that polyethylene plays a central role in periprosthetic osteolysis, there is a renewed interest in alternatives such as metal—metal bearings. Several long-term studies report encouraging results with the McKee—Farrar total hip arthroplasty, but there is a paucity of data on the incidence, severity, and pathogenesis of osteolysis in metal—metal bearing total hip arthroplasties. This study presents a patient who had progressive bilateral pelvic osteolysis associated with his McKee—Farrar metal—metal total hip prostheses. His left hip was revised after 13.5 years of service. The tissues revealed no gross metal staining and fewer inflammatory constituents than are typically found in metal—polyethylene bearing hips. His right hip was still functioning after 22.5 years of service, although the acetabular component was loose by that point. An arthrogram of this hip demonstrated communication of the joint with the iliac osteolysis. The development of osteolysis in both hips followed a pattern similar to that seen in metal—polyethylene total hip arthroplasties. Bearing wear could not be detected in either of the hips. Accumulating evidence indicates that particulate debris of appropriate size and number is capable of fueling periprosthetic inflammation. Specific to this study, consideration should be given to particles of cobalt—chromium alloy, polymethyl methacrylate bone—cement, and barium sulfate. Other factors that should be considered are increased joint fluid pressure, soluble inflammatory mediators, and the effective joint space. When bone becomes part of the effective joint space, it is exposed to particulate debris, soluble factors, and potentially increased joint fluid pressures, which may promote localized bone resorption. It must be kept in mind that the development of osteolysis is multifactorial. Although bearings with better wear characteristics are desirable, the elimination of polyethylene will not eliminate osteolysis.

Hybrid Total Hip Arthroplasty

A consecutive series of 125 hybrid total hip arthroplasties were performed in 120 patients by a single surgeon and were observed for an average of 8.6 years (range, 7-11 years). There were 38 men and 82 women with an average age of 71 years (range, 25-87 years) at the time of surgery. The diagnoses included primary and secondary osteoarthritis in 112 patients, osteonecrosis in 5 patients, and rheumatoid arthritis in 3 patients. All acetabular components were modular and had a Ti shell fixed with an average of 3 screws. The cemented femoral component was either Precoat or Precoat Plus with a 28-mm modular CoCr femoral head. The patients were prospectively observed clinically using the Harris hip score and radiographically using the Hip Society methods. Of the 125 total hip arthroplasties, 123 were followed for the entire observation period. The average preoperative Harris Hip Score was 37 (range, 15-55) and at the latest followup was 92 (range, 65-100). One acetabular component was revised for recurrent dislocations 3 years after surgery, and 1 stem was revised for mechanical loosening and 1 stem was radiographically loose. There was no evidence of cup migration of more than 1 mm. There were no radiolucencies around any of the screws. Two sockets had polyethylene wear of 2 mm. Localized pelvic osteolysis was noted in 5 hips (4%). The results of this study suggested that hybrid total hip replacement is an excellent procedure for reconstruction of the arthritic hip with minimal evidence of polyethylene wear and pelvic osteolysis.

Relationship between polyethylene wear, pelvic osteolysis, and clinical symptomatology in patients with cementless acetabular components: A framework for decision making

The purpose of this study is to assess the relationship between acetabular component polyethylene wear, pelvic osteolysis, and clinical symptoms to determine when operative intervention should occur and to predict the degree of difficulty of the revision. Fifty-four revisions of failed cementless acetabular components were performed in 52 patients. All cases demonstrated polyethylene wear radiographically, and in 43 cases (80%), osteolysis of the pelvis was seen. Symptoms of groin or buttock pain were seen in 45 of 54 cases (83%). Preoperative staging of the disease process included one patient with wear radiographically but neither symptoms nor lysis (stage I), 10 patients with wear and pain (stage IIA), 8 patients with wear and lysis but no pain (stage IIB), and 35 patients with wear, lysis, and pain (stage III). Patients in stages I and IIA could be revised with cementless components without structural allograft. Patients in stages IIB and III required structural allograft in 79% and cemented components in 53%. Cemented components were used when there was less than 50% contact between host—bone and prosthesis. Polyethylene wear alone (stage I) is an indication of impending failure, and when symptoms develop (stage IIA), revision should be undertaken. The development of radiographic lysis is a critical event, and as soon as osteolysis develops (stage IIB or III), revision should be undertaken immediately. From the perspective of the revision surgeon, there is great value in the early intervention for polyethylene wear and pelvic osteolysis.

Acetabular revision using a bone-ingrowth total hip component in patients who have acetabular bone stock deficiency

The clinical and radiologic results of acetabular revision using a porous titanium-mesh metal-backed acetabular component fixed to the pelvis with screws were studied in 30 consecutive patients (32 hips) who had moderate or severe acetabular bone loss. All of the acetabula were classified as type III or IV according to the American Association of Orthopaedic Surgeons' acetabular grading system. Particulate autologous or allogenic bone—graft was used in 75% of the reconstructions. The mean follow-up period was 69 months (range, 46–109 months). Three acetabular components (9%) were rerevised for aseptic loosening at an average of 64 months, including one patient who had a primary diagnosis of radiation necrosis of the ilium. The average Harris hip score for the remaining 29 hips rose from 46 to 81. The radiologic failure rate was 3% (1 of 29 unrevised hips) for a total failure rate of 12%. No pelvic osteolysis was seen with this implant. Revision of acetabula that have moderate or severe bone deficiency by a bone-ingrowth acetabular component fixed with screws and bone—graft appears to be successful in restoring bone stock and providing a stable, pain-free reconstruction.

Porous-coated acetabular components with screw fixation. Five to ten-year results.

The results of 136 consecutive primary total hip arthroplasties performed by one surgeon with the Harris-Galante-I porous-coated acetabular component were reviewed at a mean of seven years (range, five to ten years). In all hips, the outer diameter of the acetabular component was the same as the diameter of the final reamer used in the preparation of the acetabulum. However, this reamer was used only briefly at the rim of the acetabulum, and therefore the components had so-called press-fit stability. A mean of four screws (range, three to six screws) were used for additional fixation of the component. The clinical evaluation was performed with use of the Harris hip score. Standardized anteroposterior radiographs of the pelvis were assessed for migration of the component, radiolucent and radiodense lines, linear wear of the polyethylene, and osteolysis. No acetabular component had been revised for loosening and none were radiographically loose at the time of the most recent follow-up evaluation. There were no complications related to the use of the screws, and no screw had bent or broken. A non-progressive radiolucent line was seen in one acetabular zone in thirty-four hips (25 per cent) and in two acetabular zones in six hips (4 per cent). No hip had a radiolucent line in all three acetabular zones. The mean rate of linear wear of the polyethylene was 0.1 millimeter per year. There was no dissociation of the acetabular liner from the metal shell. Two hips (1 per cent) had asymptomatic osteolysis in the ischium and adjacent to the rim of the acetabular component; this was treated with grafting at the site of the lesion and exchange of the femoral head and the worn polyethylene liner. Five femoral components inserted without cement and one inserted with cement were revised because of loosening. The data suggest that, at a mean of seven years, fixation of this porous-coated component was uniformly excellent. The low prevalence of radiolucent lines and the absence of loosening are probably related, in part, to the technique of implantation. The low prevalence of polyethylene wear and pelvic osteolysis is a notable improvement compared with the results of arthroplasty with other porous-coated acetabular components. Although the results of the present study are encouraging, longer follow-up is necessary to determine the prevalence of late loosening and osteolysis.

The Nicolas Andry Award

A prospective randomized clinical trial comparing cemented to cementless total hip arthroplasty has been ongoing at the author's institution since 1987. All parameters assessed showed that there was no statistically significant difference in any of the health related quality of life measures used when patients with cement were compared with patients without cement at any of the followup periods as many as 4 years later. The improvement was dramatic and sustained. No components (cemented or cementless) have been revised to date (average, 4.8 years). A radiographic analysis showed probable loosening of the cemented socket in 24% and presumed minimal pelvic osteolysis in 8%. The cementless sockets showed a greater frequency and severity of pelvic osteolysis (14%). The cemented femoral component was judged to be possibly loose in 10%; however, none were considered probably loose. The patients who had cementless femoral components were doing extremely well with the components showing very little subsidence or proximal stress protection noted. Osteolysis on the femoral side was not seen in any of the cementless stems. Total hip replacement gives comparable clinical results when health related quality of life measures are analyzed; however, metal backed cemented acetabular components have a high rate of radiographic failure. Short-term stability of a non-cemented porous coated titanium stem, however, gave excellent clinical and radiographic results.

Paper #14 Total hip revision for pelvic osteolysis — The value of early intervention

Paper #14 Total hip revision for pelvic osteolysis — The value of early intervention

Increasing prevalence of femoral lysis in cementless total hip arthroplasty

A follow-up study was made of 94 primary total hip arthroplasties in 86 patients with a Harris—Galante (Zimmer, Warsaw, IN) porous-coated femoral component implant to determine the change in prevalence of femoral lysis and its clinical significance. At a mean follow-up period of 53 months (range, 16–86 months), femoral lysis was present in 31% of the femurs. In the first report of this condition, the incidence was 3%. The mean patient age was 54 years (range, 30–69 years). The most common diagnosis was osteoarthritis (62 hips). Of the 29 hips with femoral lysis, 11 were graded as extensive. Of the 14 hips in which the femoral component was defined as loose, 12 had femoral osteolysis; however, the mean Harris hip score among those with lysis was not reduced in those with femoral osteolysis (88 compared with 90 the entire group). Pelvic osteolysis, in contrast, was present in only one hip, around a screw. In this series, femoral lysis was a major complication, whether the femoral component was stable or not, and the prevalence of lysis increased sharply over time.

The relationship between the design, position, and articular wear of acetabular components inserted without cement and the development of pelvic osteolysis.

The relationship between the design, position, and articular wear of acetabular components inserted without cement and the development of pelvic osteolysis.

Revision Total Hip Arthroplasty: The Acetabular Component.

Intermediate and long-term results of revision total hip arthroplasty performed with the use of a cemented acetabular component have been disappointing, with high rates of radiographic and clinical failure. Other methods of acetabular revision involving the use of threaded cups and bipolar implants have also met with high failure rates. Although the long-term results of revision arthroplasty with uncemented acetabular components, especially in terms of polyethylene wear and pelvic osteolysis, are not yet available, the intermediate results have been excellent.

Orthopedics and Sports Medicine

There are potential long-term problems with anterior cruciate ligament reconstruction, even in those who have had a successful result. Arthroplasty of the elbow has been evolving. Infection after total joint arthroplasty is a potentially disastrous complication.

The relationship between the design, position, and articular wear of acetabular components inserted without cement and the development of pelvic osteolysis.

Between 1983 and 1987, an acetabular component with a unique chamfered-cylinder design was inserted without cement in 134 hips. With use of this design, initial stability is achieved through a cylindrical interference fit with the peripheral rim of the acetabulum, without the need for pegs, spikes, or screws. At an average of sixty-four months (range, forty to ninety-six months) after implantation, follow-up data were available for 113 hips (ninety-three patients). No component had been revised for loosening or was radiographically loose. However, the prevalence of balloon-like osteolysis of the pelvis was 17 per cent (nineteen hips). This bone loss was generally not associated with pain or other symptoms. Ten of the nineteen hips that were associated with pelvic osteolysis (including six of the nine that were associated with osteolysis of the ilium) had been reconstructed with use of an acetabular component that had no holes in the shell (that is, the shell was completely solid). This finding indicates that, while elimination of holes through the acetabular shell may have advantages, it will not prevent pelvic osteolysis. The osteolysis of the ilium was associated with a lateral opening of the acetabular component of more than 50 degrees (p < 0.0001). All of the hips in this series had insertion of a porous-ingrowth femoral resurfacing component made of titanium alloy. These components are no longer used. Revision of the femoral side due to osteolysis provided a unique opportunity to inspect directly forty-two clinically well functioning acetabular components. All of the polyethylene liners and acetabular shells were found to be rigidly fixed. Inflammatory tissue at the periphery of the implant-bone interface resulted in circumferential resorption of periacetabular bone despite rigid fixation of the component. This is direct evidence that a process of bone resorption similar to that reported at the cement-bone interface of cemented acetabular components can occur at the implant-bone interface of components inserted without cement. At the reoperation, a communication that had led to the pelvic osteolysis was found through areas of bone resorption at the periphery of the implant-bone interface. These areas were essentially cystic and were filled with a mixture of fluid and friable, yellow-tan tissue. It appeared that the osteolytic process had expanded into the soft cancellous bone and marrow while being contained by the denser cortical shell of the pelvic bones.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe osteolysis of the pelvic in association with acetabular replacement without cement.

We reviewed the cases of fourteen patients (fifteen lesions) who had osteolysis following the replacement of the acetabulum without cement. Nine women and five men, seventeen to sixty-seven years old, were involved in the study. One woman had bilateral pelvic osteolysis. Eight of the fifteen index acetabular reconstructions were done with a titanium-alloy implant and seven, with a chromium-cobalt-alloy implant. Eleven of the fifteen acetabular components had holes in the metal shell that may have acted as a conduit through which wear debris could gain access to the implant-bone interface, but only two of the acetabular components had been fixed with screws. In these two acetabular components, all available screw holes were not filled. The polyethylene liner was eight millimeters thick or less in twelve of the fifteen acetabular components; all of the liners were ten millimeters thick or less. The diameter of the head of eleven of the fifteen femoral components was thirty-two millimeters. Fourteen of the fifteen femoral components were placed without cement, and all but one was radiographically stable. The duration from the index operation to the appearance of pelvic osteolysis ranged from fifty-three to eighty-four months (mean, sixty-five months). At the time of the diagnosis, the patients were functioning well clinically, and all but three had a Harris hip score of 90 points or better, despite extensive destruction of bone in some instances. Since these patients were functioning well, the pelvic osteolysis was diagnosed radiographically at a regular follow-up examination. Only one patient had evidence of migration of the acetabular component on serial radiographs.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive pelvic osteolysis in the Gorham-Stout syndrome

Massive osteolysis is a very rare tumour-like lesion usually affecting young adults. There are 132 reported cases which we have reviewed, including 31 single cases of pelvic involvement. The term "massive osteolysis" is based on the typical radiological findings, such as increasing translucency and loss of bone density. The diagnosis of the Gorham-Stout syndrome must be confirmed by the microscopic finding of intramedullary vascular structures. Our patient was a 23 year old white Caucasian, who had the full clinical signs of Gorham-Stout syndrome. She had achieved 2 normal pregnancies and deliveries in spite of her massive pelvic osteolysis.