The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 5

Scientific Articles | May 01, 2004

Cementing a Liner into a Stable Cementless Acetabular Shell: The Double-Socket Technique

Paul E. Beaulé, MD, FRCSC¹; Edward Ebramzadeh, PhD¹; Michel LeDuff, MA¹; Rajiv Prasad, MD¹; Harlan C. Amstutz, MD¹

¹ Joint Replacement Institute, Orthopaedic Hospital/University of California at Los Angeles, 2400 South Flower Street, Los Angeles, CA 90007. E-mail address for P.E. Beaulé: pbeaule@laoh.ucla.edu

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Los Angeles Orthopaedic Hospital Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Joint Replacement Institute at Orthopaedic Hospital, Los Angeles, California

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 May 01;86(5):929-934

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Abstract

Background: During revision hip replacement surgery, the cementless acetabular shell is often well fixed but the locking mechanism may be ineffective. Cementing a new liner into the existing acetabular shell (the double-socket technique) can provide a simple solution. The purposes of the present study were to review our initial clinical results and to define the potential limitations of this technique.

Methods: Thirty-two hips with a preexisting well-fixed acetabular socket that had been in situ for an average of 8.6 years were treated with the insertion of a new polyethylene liner (seventeen hips) or a metal liner (fifteen hips) with use of cement. The indication for this technique was a deficient locking mechanism in twenty-two hips and the unavailability of a matching liner in ten hips. Anteroposterior radiographs of all hips were analyzed by a single independent reviewer.

Results: The mean duration of follow-up was 5.1 years. Six hips required a reoperation after a mean of 29.7 months; the reasons for the reoperations included aseptic failure of the acetabular construct (four hips), instability (one hip), and sepsis (one hip). The University of California at Los Angeles hip scores improved significantly (p < 0.001) compared with the preoperative values; specifically, the mean score improved from 6.2 to 9.1 for pain, from 6.3 to 8.3 for walking, from 6.2 to 7.8 for function, and from 4.7 to 5.8 for activity. The prevalence of dislocation was 22%. Kaplan-Meier analysis with revision as the end point revealed a five-year survival rate of 78% (95% confidence interval, 55% to 91%).

Conclusions: The double-socket technique is a good alternative to acetabular socket removal for suitable candidates who have a well-fixed cementless socket with an inner diameter that is larger than the outer diameter of the cemented liner. This technique preserves acetabular bone stock and permits conversion to alternate bearing surfaces. We believe, however, that removal of a well-fixed acetabular shell or the use of a constrained liner should be strongly considered for patients with a history of hip instability.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Treatment of the acetabulum at the time of revision hip arthroplasty may pose major challenges related to bone loss, which often necessitates the insertion of a large cementless socket or a cage with or without the use of allograft bone^1-4. The advent of cementless fixation of acetabular components and the introduction of modularity have made it possible for the surgeon to perform a fairly straightforward revision in cases of excessive polyethylene wear and/or osteolysis by exchanging the liner without removing a stable acetabular shell^5,6. However, in cases of a defective locking mechanism or incompatibility of the liner with the implanted acetabular shell, the extraction of a well-fixed cementless acetabular shell can be difficult and can compound the bone loss that is sometimes present secondary to osteolysis. This not only compromises the fixation of a new acetabular shell but also increases the morbidity associated with the surgery.

During revision hip arthroplasty, it has been the practice of the senior author (H.C.A.) to replace the acetabular shell only when it is loose, in an attempt to preserve bone stock and to limit operative morbidity⁷. One surgical option, as reported by Heck and Murray⁸ and others⁹, is to insert a liner into the preexisting well-fixed cementless acetabular shell with use of cement. This option potentially preserves acetabular bone stock and limits blood loss and operative time.

The purposes of the present study were to review our initial clinical results following the insertion of a liner into a stable cementless acetabular shell with use of cement and to define the potential limitations of this technique.

Materials and Methods

Materials and Methods | Results | Discussion | References

Subjects

The records of all patients who had undergone revision hip surgery at our center and who had been followed for a minimum of two years were reviewed. Between 1982 and 2001, thirty-two hips (thirty patients) underwent a revision procedure during which a new liner was cemented into a preexisting well-fixed cementless acetabular socket either because of a defective locking mechanism (twenty-two hips) or because a corresponding liner was not available (ten hips) (Figs. 1-A and 1-B). We refer to this technique as the double-socket technique. The study group included fifteen women and fifteen men. The mean age of the patients at the time of the first hip replacement was 45.1 years (range, twenty to eighty-four years). The initial diagnoses are listed in Table I. The primary arthroplasty was a total hip replacement in sixteen hips and a metal-on-polyethylene surface arthroplasty in sixteen hips. The reason for revision surgery was aseptic loosening of the femoral component in twenty-five hips, recurrent dislocation in three, extensive osteolysis in two, wear of the polyethylene bearing liner in one, and fracture of an alumina femoral head in one. Two types of acetabular shells were left in situ at the time of revision surgery. The first type, present in eight hips, was made of titanium mesh and was manufactured by Zimmer (Warsaw, Indiana). The second type, present in twenty-four hips, had a porous beaded surface and was manufactured by DePuy (Warsaw, Indiana) (eighteen hips) or an unknown manufacturer (six hips). These thirty-two sockets had been in situ for an average of 8.6 years.

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Fig. 1-A and 1-B: Anteroposterior radiograph of the hip of a forty-four-year-old woman, made thirteen years after the initial procedure. The patient needed femoral revision surgery. Removal of the acetabular cup would have been extremely challenging because of the already complex acetabular reconstruction. Fig. 1-B Anteroposterior radiograph made thirteen months after the double-socket procedure, at which time the UCLA scores were 10 for pain, 10 for walking, 10 for function, and 7 for activity. The patient returned to teaching.

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TABLE I Data on the Thirty Patients (Thirty-two Hips)

Age at revision surgery*(yr)	53.7 ± 13.6
Weight*(kg)	78.2 ± 17.6
Male:female ratio	1:1
Charnley class (n = 32)†
A	40%
B	53%
C	7%
Etiology (n = 32)†
Osteoarthritis	22%
Osteonecrosis	19%
Developmental dysplasia	25%
Tumor	3%
Legg-Calvé-Perthes disease	6%
Slipped capital femoral epiphysis	6%
Arthrokatadysis	3%
Juvenile rheumatoid arthritis	10%
Rheumatoid arthritis	3%
Pigmented villonodular synovitis	3%

The data are given as the mean and the standard deviation.The data are given as the percentage of hips.

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TABLE I Data on the Thirty Patients (Thirty-two Hips)

Age at revision surgery*(yr)	53.7 ± 13.6
Weight*(kg)	78.2 ± 17.6
Male:female ratio	1:1
Charnley class (n = 32)†
A	40%
B	53%
C	7%
Etiology (n = 32)†
Osteoarthritis	22%
Osteonecrosis	19%
Developmental dysplasia	25%
Tumor	3%
Legg-Calvé-Perthes disease	6%
Slipped capital femoral epiphysis	6%
Arthrokatadysis	3%
Juvenile rheumatoid arthritis	10%
Rheumatoid arthritis	3%
Pigmented villonodular synovitis	3%

The data are given as the mean and the standard deviation.The data are given as the percentage of hips.

The mean age of the patients at the time of the index procedure was 53.7 years (range, thirty-one to eighty-five years). The mean time between the latest hip surgery (either primary or revision) and the index procedure was 7.5 years (range, 0.7 to 15.3 years). Seventeen hips received a new polyethylene liner (Zimmer [ten hips] or DePuy [seven hips]), and fifteen received a new metal bearing liner. Of the fifteen metal bearing liners, seven had grooves on the backside (Corin Medical, Cirencester, United Kingdom), three had a polyethylene backing (Centerpulse, Austin, Texas), and five had a porous beaded surface (Wright Medical Technology, Arlington, Tennessee). The outside diameter of the polyethylene liners ranged from 42 to 54 mm. The outside diameter of the metal bearing liners ranged from 37 to 54 mm. The average difference between the inside diameter of the cementless shell and the outside diameter of the cemented liner was 4.7 mm (range, —4 to 11 mm). The median femoral head size after reconstruction was 32 mm (range, 28 to 44 mm) (Table II).

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TABLE II Relevant Sizes of the Components of the Acetabular Construct

	Median	Standard Deviation	Range
Outside diameter of shell (mm)	59	4.3	49 to 66
Inside diameter of shell (mm)	51	4.5	42 to 57
Outside diameter of liner (mm)	46	4.5	37 to 54
Difference between inside diameter of shell and outside diameter of liner (mm)	5	3.1	-4 to 11
Head size (mm)	32	5.4	28 to 44

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TABLE II Relevant Sizes of the Components of the Acetabular Construct

	Median	Standard Deviation	Range
Outside diameter of shell (mm)	59	4.3	49 to 66
Inside diameter of shell (mm)	51	4.5	42 to 57
Outside diameter of liner (mm)	46	4.5	37 to 54
Difference between inside diameter of shell and outside diameter of liner (mm)	5	3.1	-4 to 11
Head size (mm)	32	5.4	28 to 44

All patients had a preoperative workup to rule out infection, which included aspiration of the hip, a white blood-cell count and differential, and determination of the erythrocyte sedimentation rate and the serum level of C-reactive protein. All revisions were performed through a posterior approach.

The decision to retain a cementless socket was made on the basis of radiographic and intraoperative criteria. The radiographic criteria were the absence of a radiolucent line measuring >1 mm in any two zones as described by DeLee and Charnley¹⁰, the absence of any radiographically measurable shift of the component, and the absence of material failure such as mesh dissociation. Intraoperatively, an attempt was made to remove all screws in order to properly assess socket stability. In all cases but one, we were able to remove all of the screws. The intraoperative criteria for retention of the socket were the absence of movement at the bone-socket interface when direct maximum hand pressure was repetitively applied three times to the edge of the socket in four quadrants with use of a metallic pusher and satisfactory component positioning as determined on the basis of a stable range of motion with the trial revision femoral component in place (>90° of flexion with the hip in neutral abduction and rotation, >45° of internal rotation with the hip in 90° of flexion and 5° to 10° of abduction, and >15° of external rotation with the hip in full extension).

Surgical Technique

Once the original polyethylene liner had been removed, an attempt to remove all screws was made. Any fibrous membrane around the acetabulum and screw-holes was removed. Once stability was confirmed and component positioning was believed to be satisfactory, the inner surface of the socket was roughened with use of a carbide burr if the socket did not have screw-holes (fifteen hips). In cases in which the polyethylene or metal liner did not have grooves, the backside was roughened with use of a small burr, usually resulting in the creation of at least four cruciate grooves measuring approximately 2 mm in depth and width. The interface area was cleansed and dried. Simplex cement (Howmedica, Rutherford, New Jersey) was mixed and was manually pressurized in its late phase, followed by insertion of the liner. The liner was oriented in the same plane as the socket in twenty-six hips and was reoriented by adding approximately 10° of anteversion in six. The decision to change the orientation was based on intraoperative hip instability.

Postoperative Regimen

Patients were given adjusted-dose warfarin for prophylaxis against deep-vein thrombosis for a period of three weeks and indomethacin (100 mg on the first day and 25 mg three times per day for seven days) to prevent heterotopic ossification. All patients were permitted to bear weight as tolerated with crutches for the first six weeks and then progressed to walking without assistive devices with the aid of physical therapy.

Clinical and Radiographic Evaluation

Patients were evaluated at six weeks, four months, one year, and then yearly. At a mean of 5.1 years (range, 2.0 to 8.7 years) after the index procedure and a mean of 14.1 years (range, 8.1 to 24.0 years) after the insertion of the existing cementless socket, no patient had been lost to follow-up. At each visit, the patients were evaluated with the University of California at Los Angeles (UCLA) hip scores for pain, walking, function, and activity¹¹. Anteroposterior and modified table-down lateral radiographs made at the time of discharge were used as a basis for comparison during the follow-up period. Migration of the acetabular shell was estimated by measuring the position of the implant with respect to fixed pelvic landmarks (the interteardrop line and the teardrop) on immediate postoperative and subsequent radiographs¹². Radiolucent lines at the prosthesis-bone interface were recorded in the three zones described by DeLee and Charnley¹⁰. Stability of the socket was defined according to the radiographic criteria of Udomkiat et al.¹³, which included (1) no occurrence of radiolucent lines after two years, (2) no progression of radiolucent lines after two years, (3) no radiolucent lines involving all three zones, (4) no radiolucent lines measuring =2 mm wide in any zone, and (5) no migration.

Statistical Analysis

Survival estimates with revision as the end point were calculated with use of the method of Kaplan and Meier¹⁴. Differences in survival curves were evaluated with use of the log-rank test.

Results

Materials and Methods | Results | Discussion | References

Clinical Results

Six of the thirty-two hips required a reoperation at a mean of 29.7 months (range, six to sixty-seven months) following the index procedure; the reasons for the reoperations included aseptic failure of the construct (four hips), instability (one hip), and sepsis (one hip). The five-year survival rate with revision as the end point was 78% (95% confidence interval, 55% to 91%). The UCLA hip scores improved significantly (p < 0.001) compared with the preoperative values; specifically, the mean score improved from 6.2 to 9.1 for pain, from 6.3 to 8.3 for walking, from 6.2 to 7.8 for function, and from 4.7 to 5.8 for activity. At the time of the latest follow-up, none of the retained sockets demonstrated radiographic signs of loosening according to the criteria of Udomkiat et al.¹³.

Aseptic Failures

Four of the six rerevisions were performed because of the failure of either the cemented liner or the acetabular socket. Two hips failed at the liner-cement interface; the dissociation in the first hip occurred at thirteen months secondary to a fall, and the dissociation in the second hip occurred at 5.5 years with no history of trauma. The first hip was revised with the insertion of a new, smaller-diameter polyethylene liner with cement. The outer diameter of the index liner had been 4 mm greater than the inner diameter of the socket. In the second hip, the cemented liner had the smallest outer diameter in the series (37 mm). The socket was revised to a cementless acetabular shell.

One patient sustained a fracture of the polyethylene liner 3.3 years after the index procedure. The liner had been gamma sterilized in air and had had a shelf life of greater than five years. A new polyethylene liner was cemented into the well-fixed shell, and the femoral head was exchanged. The hip was functioning well at the time of the most recent follow-up, four years after the revision.

There was only one case of aseptic loosening of a preexisting cementless socket (Harris-Galante I; Zimmer). This socket had been in situ for thirteen years at the time of the index procedure, and loosening occurred 2.1 years after the index procedure. We had been unable to remove all of the screws from the socket at the time of revision of the femoral component, when the new liner was cemented into the acetabular shell. The socket had had no radiolucent lines at the time of the index procedure.

Complications

Seven (22%) of the thirty-two hips had an episode of posterior dislocation; all but one of these dislocations occurred within the first year. One hip was revised for instability at six months. The femoral head and liner were exchanged, and the liner was reoriented. All of the other dislocations were treated with closed reduction, with one hip being treated with a spica cast for three months. No hip had a recurrence of dislocation. There were two infections: one occurred at 2.1 years and required two-stage revision surgery, and the other occurred at one month and resolved after débridement and administration of antibiotics. There were no neurovascular injuries.

Discussion

Materials and Methods | Results | Discussion | References

The purpose of the present study was to evaluate the results of cementing a new liner into a preexisting well-fixed cementless socket. The advantages of this so-called double-socket technique, in which the socket is left in place and a new liner is inserted with cement, are that (1) it is technically straightforward, thereby limiting operative morbidity, (2) it does not compromise acetabular bone stock, thereby obviating the need for major bone grafts, and (3) it permits conversion to alternate bearings. The disadvantages of this technique are that (1) there is a limited capability to change component orientation and (2) two new interfaces are created (one between the shell and the cement and the other between the cement and the liner).

The concept of cementing a polyethylene liner into a metal shell is not a new one. The senior author (H.C.A.) and colleagues reported on this technique in a canine study in which the implant-prosthesis interface was not adversely affected by the construct¹⁵ and has been used in clinical practice by others^8,9. This technique also has been used in hips with acetabular cages or reconstruction rings and has been associated with a very low dissociation rate^2,16-18. Gill et al. reviewed sixty-three hips that had been revised with the Bürch-Schneider anti-protrusio cage and reported only one case of dissociation of the liner after a mean duration of follow-up of 8.5 years². Kerboull et al. reported on sixty hips that had been revised with the Kerboull acetabular reinforcement device and reported no cases of dissociation after a mean duration of follow-up of ten years¹⁶.

In the present study on our initial clinical experience with the cementation of a liner into a preexisting shell, four (13%) of the thirty-two hips required revision secondary to failure of the construct. Two failures occurred at the liner-cement interface: in one case the outer diameter of the cemented liner was 4 mm greater than the inner diameter of the preexisting socket and the liner became loose after a fall, and in the other case the cemented liner had the smallest outside diameter in the series (37 mm). These two failures most likely can be attributed to the small fixation area between the acetabular shell and the liner. These failures illustrate a potential pitfall of this technique, namely, an inadequate cement mantle and a small fixation area. There was one case of aseptic loosening of the cementless socket, which occurred twenty-five months after the index operation and a total of fifteen years after the initial implantation of the socket. At the time of the revision, only one of the two screws from the original insertion could be removed. The shell was stressed, but apparently the one remaining screw prevented proper assessment of socket fixation, which was presumably fibrous. In such situations, it may be advisable to reinsert more screws as adjuvant fixation if the socket appears to be well fixed and some of the original screws cannot be removed. The last failure was a fracture of an oxidized polyethylene liner in a hip that had been reconstructed with a so-called jumbo (40-mm) femoral head¹⁹ for the treatment of recurrent instability. The relative thinness of the liner (4 mm), combined with the time-dependent degradation of the material properties and wear resistance of polyethylene subsequent to sterilization by gamma irradiation in air, led to its increased brittleness^20,21. Although the initial failure rate in the present study was high, this finding reflects both our learning curve and the limitations of this technique as well as the importance of proper material quality.

Dislocation was a major problem in this series, occurring in seven (22%) of the thirty-two hips. Four of the seven dislocations occurred in hips that had been converted from a surface arthroplasty to a total hip replacement. Because of the larger head size that is used at the time of a surface arthroplasty, the orientation of the acetabular shell is not as critical; however, when a surface arthroplasty is converted to a total hip replacement, the smaller head size may render the hip unstable. In addition, the greater mismatch between the outer diameter of the head and the outer diameter of the socket may have contributed to the instability by not providing adequate capsular restraint^19,22. Selective use of a so-called jumbo femoral head¹⁹ as well as newer technologies such as offset or constrained acetabular liners²³ may reduce the dislocation rate in the future.

On the basis of our initial clinical experience, the insertion of a liner into a well-fixed socket with use of cement appears to be an effective technique for revision hip surgery. We believe that this technique provides a straightforward alternative to removal of a well-fixed socket because of a deficient locking mechanism or the unavailability of matching liners. However, removal of a well-fixed acetabular shell or the use of a constrained liner should be considered for patients with a history of hip instability.

References

Materials and Methods | Results | Discussion | References

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Garbuz D, Morsi E, Gross AE. Revision of the acetabular component of a total hip arthroplasty with a massive structural allograft. Study with a minimum five-year follow-up. J Bone Joint Surg Am.1996;78: 693-7.78693 1996 [PubMed]

Hozack WJ, Mesa JJ, Carey C, Rothman RH. Relationship between polyethylene wear, pelvic osteolysis, and clinical symptomatology in patients with cementless acetabular components. A framework for decision making. J Arthroplasty.1996;11: 769-72.11769 1996 [PubMed][CrossRef]

Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am.1997;79: 1628-34.791628 1997 [PubMed]

Schmalzried TP, Fowble VA, Amstutz HC. The fate of pelvic osteolysis after reoperation. No recurrence with lesional treatment. Clin Orthop.1998;350: 128-37.350128 1998 [PubMed]

Amstutz HC, Ma SM, Jinnah RH, Mai L. Revision of aseptic loose total hip arthroplasties. Clin Orthop.1982;170: 21-33.17021 1982

Heck DA, Murray DG. In vivo construction of a metal-backed, high-molecular-weight polyethylene cup during McKee-Farrar revision total joint arthroplasty. A case report. J Arthroplasty.1986;1: 203-6.1203 1986 [CrossRef]

LaPorte DM, Mont MA, Pierre-Jacques H, Peyton RS, Hungerford DS. Technique for acetabular liner revision in a nonmodular metal-backed component. J Arthroplasty.1998;13: 348-50.13348 1998 [PubMed][CrossRef]

DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop.1976;121: 20-32.12120 1976 [PubMed]

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Martell JM, Pierson RH 3rd, Jacobs JJ, Rosenberg AG, Maley M, Galante JO. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am.1993;75: 554-71.75554 1993

Udomkiat P, Wan Z, Dorr LD. Comparison of preoperative radiographs and intraoperative findings of fixation of hemispheric porous-coated sockets. J Bone Joint Surg Am.2001;83: 1865-70.831865 2001

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Kim WC, Amstutz HC, O'Carroll PF, Hedley AK, Coster I, Schmidt I. Porous ingrowth in canine resurfacing hip arthroplasty: analysis of results with up to a 2-year follow-up. In: The hip proceedings of the twelfth open scientific meeting of the Hip Society. St. Louis: CV Mosby; 1984. p 211-43.211 1984

Kerboull M, Hamadouche M, Kerboull L. The Kerboull acetabular reinforcement device in major acetabular reconstructions. Clin Orthop.2000;378: 155-68.378155 2000 [PubMed][CrossRef]

Perka C, Ludwig R. Reconstruction of segmental defects during revision procedures of the acetabulum with the Burch-Schneider anti-protrusio cage. JArthroplasty.2001;16: 568-74.16568 2001 [CrossRef]

Zehntner MK, Ganz R. Midterm results (5.5-10 years) of acetabular allograft reconstruction with the acetabular reinforcement ring during total hip revision. J Arthroplasty.1994;9: 469-79.9469 1994 [CrossRef]

Beaulé PE, Schmalzried TP, Udomkiat P, Amstutz HC. Jumbo femoral head for the treatment of recurrent dislocation following total hip replacement. J Bone Joint Surg Am.2002;84: 256-63.84256 2002

McKellop H, Shen FW, Lu B, Campbell P, Salovey R. Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene. A hip simulator study. J Bone Joint Surg Am.2000;82: 1708-25.821708 2000

Otfinowski J, Pawelec A. Changing crystallinity of polyethylene in the acetabular cups of Weller hip prostheses. J Bone Joint Surg Br.1995;77: 802-5.77802 1995 [PubMed]

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Topics

systemic infection ; gait ; fracture ; bone screws ; dislocations ; femur ; head of femur ; hip region ; hip joint ; metals

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Paul E. Beaulé, Edward Ebramzadeh, Michel LeDuff, Rajiv Prasad, Harlan C. Amstutz; Cementing a Liner into a Stable Cementless Acetabular Shell: The Double-Socket Technique. The Journal of Bone & Joint Surgery. 2004 May;86(5):929-934.

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