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The Journal of Bone & Joint Surgery, Volume 83, Issue 6

Articles | June 01, 2001

Allogeneic Cancellous Bone Graft and a Burch-Schneider Ring for Acetabular Reconstruction in Revision Hip Arthroplasty

E. Winter, MD, PhD; M. Piert, MD, PhD; R. Volkmann, MD; F. Maurer, MD, PhD; C. Eingartner, MD; K. Weise, MD, Prof; S. Weller, MD, Prof

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Investigation performed at Berufsgenossenschaftliche Unfallklinik, Trauma Center, University of Tuebingen, Tuebingen, Germany
E. Winter, MD, PhD
R. Volkmann, MD
F. Maurer, MD, PhD
C. Eingartner, MD
K. Weise, MD, Prof
S. Weller, MD, Prof
Berufsgenossenschaftliche Unfallklinik, Trauma Center, University of Tuebingen, Schnarrenbergstrasse 95, 72076 Tuebingen, Germany

M. Piert, MD, PhD
Department of General Surgery, University of Tuebingen, Hoppe-Seyler Strasse 3, 72076 Tuebingen, Germany

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:862-867

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Abstract

Background: There is an ever-increasing number of failed hip arthroplasties associated with massive deficiency of acetabular bone stock consisting of a segmental or cavitary defect. This study was undertaken to evaluate the long-term results after use of morselized cryopreserved allogeneic bone graft and an antiprotrusio cage to treat such a deficiency.

Methods: From January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with an acetabular defect classified as type III or IV according to the American Academy of Orthopaedic Surgeons system were operated on with use of a Burch-Schneider ring and morselized cryopreserved allogeneic cancellous bone graft. Thirty-eight patients (thirty-eight hips) were available for clinical and radiographic follow-up examinations at an average of 7.3 years (range, 4.2 to 9.4 years) after surgery.

Results: All measured clinical parameters had improved significantly by the time of the follow-up examination (p < 0.0001). Radiographs confirmed that none of the thirty-eight hips had any measurable migration or displacement of the acetabular component and that osseous consolidation occurred only within the grafted area in all patients.

Conclusion: Acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone graft and the Burch-Schneider ring can be highly successful in managing massive acetabular deficiencies in revision hip arthroplasty.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

A major concern in failed hip arthroplasty is the presence of severe deficiency in pelvic bone stock^1-5. Unfortunately, there is no single technique that is likely to provide a solution to span the full spectrum of possible acetabular defects. However, contained acetabular defects can generally be treated by grafting and insertion of a hemispherical acetabular component with use of screws and no cement^6-9.

A valuable alternative to augmentation of the deficient acetabulum is the placement of a hemispherical acetabular component. It is secured with screws and no cement onto the superior margin of the acetabular defect, resulting in a standard hip center as described by Woolson and Adamson¹⁰ or in a high hip center as described by Dearborn and Harris¹¹. Another option is to fill the superior part of the acetabular defect with metal in the form of an oblong acetabular component¹². As a result, the superior hemisphere of this implant remains securely in contact with the host bone above, allowing the establishment of a normal hip center. When an oblong cup is used, it is necessary to remove additional bone in order to accommodate the shape of this implant. Still another alternative is the use of bulk allograft, but the rate of failure of such grafts has been shown to increase over time^13,14. Because of this problem some authors have advocated the use of an acetabular reinforcement ring instead.

In the early 1980s, the Burch-Schneider¹⁵ ring was introduced. It is equipped with peripheral flanges, which are screwed onto the periacetabular pelvic bone in order to provide additional stability. Originally, it was common practice to fill the residual bone defects with cement when this device was used, but this technique frequently led to loss of bone stock and to secondary loosening of the antiprotrusio ring^1,16-21. Recently, the use of either autograft or allograft in combination with the reinforcement ring has been proved successful in long-term follow-up studies^1,22-25. However, it has been questioned whether use of transplanted cryopreserved allogeneic bone grafts can lead to vital acetabular bone stock. While several authors have reported failure of acetabular reconstruction performed with cryopreserved allogeneic bone graft^26,27, others have described cryopreserved allogeneic cancellous grafts as being successful^1,25,28-32. This study was undertaken to evaluate the long-term clinical and radiographic results after use of morselized cryopreserved allogeneic bone graft and a Burch-Schneider antiprotrusio cage to manage severe acetabular deficiencies in revision hip arthroplasty.

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Fig. 1-A:: Anteroposterior and axial radiographs of the hip of a sixty-eight-year-old woman, made nine years after a total hip arthroplasty performed with cement, showing a type-III combined defect³³.

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Fig. 1-B:: Anteroposterior and axial radiographs of the hip of a sixty-eight-year-old woman, made nine years after a total hip arthroplasty performed with cement, showing a type-III combined defect³³.

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Fig. 1-C:: Fig. 1-C Radiograph made six months after a revision hip arthroplasty with use of morselized cryopreserved cancellous allograft bone, a Burch-Schneider reinforcement ring, and a cup inserted into the ring with cement.

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Fig. 1-D:: Fig. 1-D Radiograph made five years after revision hip arthroplasty, showing the position of the implants to be unchanged and trabeculation of the osseous structures of the area in which the graft was implanted.

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Fig. 2:: Diagram of a bilateral acetabular reconstruction, showing the radiographic parameters with which migration is analyzed. Line A = reference line through the teardrop figure, Line B = perpendicular reference line through the teardrop figure, Line C = line through the axis of the antiprotrusio cage, HM = horizontal migration, VM = vertical migration, and AI = acetabular index.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patient Study Group

During the period from January 1, 1988, to January 1, 1994, forty-one patients (forty-one hips) with a severe acetabular defect (type III or IV according to the American Academy of Orthopaedic Surgeons system described by D’Antonio et al.³³) after a hip arthroplasty that had been performed because of coxarthrosis were operated on consecutively by the senior one of us (S.W.). The type and extent of the acetabular deficiencies had been determined from preoperative radiographs and intraoperative assessments. The failure of the arthroplasty had been determined to be aseptic in all patients. Of the forty-one patients, two died of unrelated causes four and six years after the surgery and one was unavailable for the follow-up examination. The remaining thirty-eight patients were assessed clinically and radiographically before the operation and at an average of 7.3 years (range, 4.2 to 9.4 years) afterward.

There were twenty-four women and fourteen men, with an average age of seventy-six years (range, forty-nine to eighty-three years) at the time of the index operation. There were twenty-one right and seventeen left hips. Thirty-four patients had a type-III deficiency and four patients had a type-IV deficiency³³. In twenty-seven patients, the femoral stem had to be revised as well because of aseptic loosening.

Operative Technique and Rehabilitation Program

The revision arthroplasty was performed in an operating room with vertical laminar airflow. The lateral transgluteal approach was used in all patients. First, the failed acetabular component was exposed and removed. The full extent of the defect became apparent only after the entire acetabulum had been debrided of cement and scarred capsular tissue with use of curets, osteotomes, and hemispherical reamers in order to achieve a well-vascularized recipient bed. Care was taken not to increase the size of the existing defect. Then, cryopreserved allogeneic cancellous bone from the bone bank was morselized (chip size, approximately 1 cm³). The bone was obtained from femoral heads stored at -80°C according to standard bone-bank guidelines. Depending on the size of the defect, cancellous bone from as many as three femoral heads was used. The cancellous chips were pressed into the acetabular cavity and carefully condensed. The flanges of the Burch-Schneider reinforcement ring (Protek AG, Bern, Switzerland) were bent into shape in order to comply with the specific anatomy of the acetabular region. The ring was then positioned by buttressing its inferior flange into the ischium, preferably with screws. The superior flange of the metal ring was fixed to the ilium with cancellous-bone screws. This should result in a stable composite (consisting of the load-bearing host bone, allograft, and implant) with a compressed bone graft located beneath the ring. A polyethylene cup was then cemented into the metal cage in a correct position with a thin (2 to 3-mm) film of cement. In order to avoid too much penetration of cement through the porous ring, the bone graft had to be well compressed (Figs. 1-A, 1-B, 1-C, and 1-D).

Patients were managed with bed rest for one week postoperatively when only the acetabular component had been revised and for two weeks when both components had been replaced. Intensive physical therapy was begun on the first postoperative day. The patients were advised to avoid flexion of the affected hip joint beyond 90° and to avoid forced rotation, especially forced internal rotation. Slight abduction was ensured for the first fourteen days with use of a wedged pillow. Partial weight-bearing of 20 kg for at least six weeks was recommended. Clinical and radiographic follow-up examinations were performed at three months, six months, and one year after the operation and then once a year.

Clinical Follow-up Examination

Thirty-eight patients (thirty-eight hips) were assessed clinically and radiographically before the operation and at an average of 7.3 years (range, 4.2 to 9.4 years) after it. Clinical follow-up studies were performed with use of the guidelines described by Johnston et al.³⁴. These guidelines consist of a comprehensive list of questions and examinations to determine the degree of pain, level of activity, ability to put on shoes and socks, ability to ascend and descend stairs, ability to change from a sitting to a standing position, walking capacity, ability to walk without support, and ability to walk with support. Additionally, the Harris hip score³⁵ was used to grade the clinical results, and the patients expressed their subjective impression of the result as very satisfied, satisfied, or dissatisfied.

The physical examination included an assessment of the range of hip motion before the operation and at the time of follow-up. In addition, the difference in limb length was recorded at the time of the follow-up examination. Preoperative data (derived from the patient’s records and questionnaires) were compared with the parameters evaluated at the time of the follow-up examination.

Radiographic Evaluation

All thirty-eight patients had a detailed radiographic examination at the time of the clinical follow-up to determine whether there had been migration of the acetabular implant as well as to assess the grafted area. The acetabular index, horizontal migration, and vertical migration were measured according to the methods described by Peters et al.²⁵ (Fig. 2) on immediate postoperative and final follow-up radiographs.

The bone-implant interface was also examined for radiolucent lines. The bone graft was determined to be either incorporated or not incorporated on the basis of the appearance of trabecular remodeling within the grafted area, which was assumed to have occurred when the graft density and architecture equaled those of the surrounding native bone^36-38. The three zones delineated by DeLee and Charnley³⁹ were used to report the location of any radiolucency and to give some indication of its extent. Furthermore, we analyzed whether the reinforcement ring had tilted by comparing the shape of the ring on the radiographs made shortly after the operation with that on the radiographs made at the time of follow-up.

Statistical Methods

Continuous paired observations (for example, range of hip motion) were analyzed before and after treatment with use of the paired t test. Ordinal data (for example, degree of pain) were tested for homogeneity of the marginal distributions of the corresponding transition matrices according to the Mann-Whitney test for ordinal independent observations as generalized by Agresti⁴⁰. This involved generating contingency tables and evaluating whether the differences in the marginal distributions of these tables significantly differed from zero to estimate the probability of how extensively the preoperative and postoperative severity of a condition differed.

Results

Introduction | Materials and Methods | Results | Discussion | References

Clinical Results

Fourteen patients were very satisfied with the surgical result, twenty-two were satisfied, and two were dissatisfied. The clinical parameters of pain, level of activity, ability to put on shoes and socks, ability to ascend and descend stairs, ability to change from a sitting to a standing position, walking capacity, and ability to walk with and without support all had significantly improved at the time of the follow-up examination (p < 0.0001), even in the two patients who were dissatisfied. The range of motion of the affected hip had also improved significantly (p < 0.005) in all patients. At the time of the follow-up examination, the average measured increase in limb length on the side of the operation was 0.8 cm (range, 0.5 to 3.0 cm) and the average Harris hip score³⁵ was 82.6 points (range, 58.2 to 94.9 points). Eleven (29%) of the patients had an excellent score (90 to 100 points); fourteen (37%), a good score (80 to 89 points); nine (24%), a fair score (70 to 79 points); and four (11%), a poor score (less than 70 points).

Radiographic Results

With regard to migration of the acetabular implants, no significant differences between the immediate postoperative and follow-up values were detected with respect to the acetabular index, horizontal migration, or vertical migration (Fig. 2). No tilting of the reinforcement ring was found. These findings indicate that no measurable migration occurred in any patient.

At the time of the follow-up examination, complete trabeculation and integration of the graft were observed in each of the three acetabular zones defined by DeLee and Charnley³⁹. The morphology of the graft appeared to match that of the surrounding native bone radiographically. This was interpreted as a sign of mature woven-bone formation within the region of the graft.

Complications

Few perioperative complications were observed. In one patient, the loosened acetabular cup dislocated deeply into the lesser pelvis during the revision operation. Despite this, we were able to remove the cup using the lateral approach. In another patient, an intraoperative fracture of a cancellous-bone screw in the ilium occurred. There were eleven general postoperative complications, including two cases of bronchitis; two cases of gastritis; five urinary-tract infections; and, despite treatment with low-dose heparin, two cases of deep venous thrombosis without severe sequelae. All eleven complications were successfully treated. Local postoperative complications included six hematomas, three of which were surgically drained, and two subcutaneous inflammatory reactions, which were treated nonoperatively. Revision surgery was required in one patient with a deep infection, but it was possible to preserve the implant. One early postoperative dislocation occurred. After relocation followed by conservative treatment (two weeks of bed rest and application of an anti-rotation cast), no additional dislocation took place.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The presence of a severe multisegmental acetabular defect is an indication for an acetabular reconstruction with use of a metal reinforcement ring and bone graft^23,25,41-43. Many authors have recommended use of the Burch-Schneider reinforcement ring with superior and inferior flanges, which can be secured to the ilium and ischium^{21,23,25,44,45}. This method provides initial stability and allows early weight-bearing. The ring also protects the graft implanted beneath it from excessive mechanical stress and yet promotes the bone-remodeling process. A close fit between the graft and the acetabulum, together with mechanical stability, is regarded as a crucial precondition for the remodeling of the allograft^1,28,29,46.

The studies performed by Haentjens et al.⁴⁷, Schatzker et al.²¹, and Zehntner and Ganz⁴³ illustrated the limits of utilizing the smaller Müller support ring in patients with an extensive acetabular defect. They reported high rates of implant migration of up to 44% in series ranging in size from twenty-five to fifty-six patients and followed for 7.2 to eight years postoperatively. The authors attributed this problem to the design limitations of the smaller Müller support ring. Since the Müller device is fixed only to the ilium and is not buttressed by the inferior pelvic bone, it should be used only to treat small defects in the acetabular roof or in the anterior or posterior column or to treat isolated cavitary defects.

No patient in our study had a neurovascular complication, and none of the general postoperative complications that were encountered led to any permanent sequelae. With regard to the local postoperative complications, one patient had a serious infection, which could be treated without removal of the implant. We were concerned about the occurrence of six hematomas, three of which required surgical drainage. Only one dislocation was observed in the thirty-eight patients. We attribute the low dislocation rate to our use of the lateral approach and a strict rehabilitation program.

None of the patients had any measurable migration or displacement of the acetabular component. A review of the literature revealed rates of loosening of the Burch-Schneider reinforcement ring as high as 12% after an average follow-up period of five years^1,21,23. In all patients in our study group, osseous consolidation according to the criteria described by Azuma et al.³⁶, Kondo and Nagaya³⁷, and Morsi et al.³⁸ occurred entirely within the grafted area.

Peters et al.²⁵ reported impressive restoration of the acetabulum in a group of twenty-eight patients who had undergone acetabular reconstruction with a Burch-Schneider ring and allogeneic cancellous bone graft. They noted, after an average of 2.8 years of follow-up, that the average thickness of the medial wall bone stock improved significantly, from 1.9 mm before surgery to 10.1 mm after revision (p < 0.01).

In 1999, Paprosky and Sekundiak¹⁸ stated that the role of acetabular reconstruction cages should, at present, be defined as only a short-term treatment and that follow-up studies still need to be performed in order to determine the worthiness of this procedure. Surprisingly, they listed only three references to support their view. At least seventeen studies concerning the outcome of the use of acetabular rings, with an average duration of follow-up of as long as 9.4 years, were published between 1984 and 1998^{1,20-25,28,30,31,41-44,47-49}. Paprosky and Sekundiak proposed that the use of an acetabular reconstruction ring should be considered not as an alternative but rather as an adjunctive procedure. In contrast, our results indicate that the use of an acetabular reconstruction ring with morselized cryopreserved cancellous bone allograft can be considered as a reliable procedure to treat massive acetabular deficiencies.

Paprosky and Sekundiak¹⁸ concluded that allogeneic bone grafts provide only osteoconductive potential. Several authors^21,23-25,30 have stated that autograft and morselized cryopreserved allograft are of equal value in the reconstruction of acetabular defects. Slooff et al.³² noted that autograft and deep-frozen allograft bone chips were equally effective. Gross et al.²⁹ reported successful results with use of morselized deep-frozen and irradiated allograft bone in the treatment of acetabular defects. Herr et al.⁵⁰ showed, in their experimental studies, that the cryopreservation of cancellous allografts at -80°C preserved the osteoinductive bone morphogenetic protein-isotypes. Recently, an [¹⁸F]fluoride-ion positron-emission-tomography (PET) study conducted at our institution verified the presence of active metabolism in areas of morselized cryopreserved allogeneic bone grafts even years after revision hip arthroplasty, clearly indicating intact bone perfusion and vitality in allografted areas^51,52.

In summary, acetabular reconstruction with use of morselized cryopreserved allogeneic cancellous bone grafts and an acetabular support ring with fixation at both the ilium and the ischium appears to be a viable method of managing massive acetabular deficiencies and appears to be able to successfully restore vital bone stock. It is clear that longer-term evaluation will be needed in order to completely assess this procedure.

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