Abstract
Most acetabular revisions can be managed with a hemispherical component with screw fixation.
Areas of segmental bone loss that preclude acetabular component stability may be managed with structural allograft or second-generation porous metal augments.
Acetabular cages have a limited application but can be a useful tool in the management of massive bone loss and pelvic discontinuity.
The demand for primary total hip arthroplasty is expected to increase over the next several decades. As a result, the demand for revision total hip arthroplasty will also increase. The burden of revision total hip arthroplasty is expected to increase in the United States by 137%, from 40,800 procedures in 2005 to 96,700 procedures by 20301. The most common indications for revision total hip arthroplasty are mechanical loosening of implants, hip instability, and infection, with the acetabular component involved in >50% of revisions2. Acetabular bone loss often results from osteolysis, stress-shielding, and/or component migration. The operative management of acetabular bone loss poses one of the greatest challenges in revision total hip arthroplasty. This article reviews the clinical evaluation and preoperative planning, classification system, and operative techniques used in the management of acetabular bone loss in revision total hip arthroplasty.
The success of the revision arthroplasty depends on a careful clinical evaluation and preoperative planning. Candidates for a revision total hip arthroplasty generally present in one of two manners. One group of patients is asymptomatic but has radiographic evidence of substantial and progressive wear with or without osteolysis. Bone loss associated with such wear may threaten future reconstructive options. The other group of patients has signs and symptoms related to the failure of a total hip replacement. The focus of the preoperative evaluation in the second group is to identify a clear cause of the patient's symptoms.
History and Physical Examination
The importance of obtaining a thorough and accurate history and physical examination cannot be overstated. A detailed account of all prior surgical procedures and their outcomes is obtained. It is particularly important to identify prior postoperative complications such as prolonged wound drainage, infection, and hip dislocation. If the postoperative symptoms had occurred prior to the index procedure, the sources of pain extrinsic to the hip should be investigated. If the patient's symptoms have persisted since the time of the index procedure, the possible causes include deep infection, failed component osseointegration, component impingement, and soft-tissue irritation. If the symptoms commence after a postoperative interval with no symptoms, then wear, osteolysis, infection, and aseptic loosening are more strongly considered.
The details of the location, quality, duration, and frequency of the pain are also investigated. Symptoms specifically related to the acetabular component manifest as groin or deep gluteal pain that becomes worse with a straight-leg-raising test (a positive finding on the Stinchfield test)3. Component loosening often presents as so-called start-up pain that occurs with the commencement of standing and walking and subsides with the continuation of the same activity. Severe pain at rest and night pain may indicate infection. Important elements of physical examination include inspection of the skin as well as assessment of hip motion, strength, gait pattern, leg length, and neurovascular status. It is also critical to examine systems extrinsic to the hip to investigate other sources of pain such as lumbar spine pathology, hernias, or vascular claudication.
Radiographic and Laboratory Evaluation
In addition to standard radiographs, advanced imaging studies are often helpful in the preoperative planning process. In many cases, computed tomography (CT) more accurately diagnoses component malpositioning and assesses the true volume of acetabular bone loss, often underestimated on the radiographic evaluation4. Intrapelvic components or cement may require an intrapelvic approach to identify, mobilize, and protect the relevant vasculature at the time of revision. Angiography or CT-magnetic resonance angiography has been suggested in these situations, but there are no data showing that these tests are either helpful or necessary.
Laboratory evaluation, including white blood-cell count, C-reactive protein, and erythrocyte sedimentation rate, should be a routine part of the preoperative planning process for all revision hip arthroplasty candidates. When clinical and/or laboratory data suggest the possibility of deep infection, a preoperative hip aspiration should be done with fluid sent for cell count, cell differential, and culture results5. These data serve as a means of better predicting the likelihood of deep infection. Advanced imaging studies, such as indium-labeled white blood-cell scintigraphy and positron emission tomography, may be useful for the same purpose6. Even for patients with a low preoperative probability of infection, routine anaerobic, aerobic, and fungal cultures of intraoperative fluid and tissue samples are obtained.
Preoperative Planning
Achieving desirable outcomes and avoiding complications with revision arthroplasty depends on careful preoperative planning. Preoperative consultation with a medical specialist helps to stratify the patient's medical risk and to optimize the status of his or her medical comorbidities.
Acquiring previous operative reports and implant records is also essential. This information allows the surgeon to obtain specialized instruments for the particular implant used in the primary arthroplasty, to allow for the efficient removal of the components. Prior operative reports also allow the surgeon to ensure that all of the appropriate modular parts to be used with retained components are available at the time of surgery. Effective communication among the orthopaedic surgeon, operating-room staff, device representative, and anesthesia team allows for efficient technical execution and is one of the most critical aspects of the preoperative planning process. Lastly, preoperative use of templates on radiographs allows the surgeon to consider several reconstructive options and predict the most appropriate surgical plan.
The main functions of orthopaedic classification systems are to facilitate communication among physicians, to provide an organizational framework for the purposes of research and education, and to help to guide decisions regarding management. The two most commonly used classification systems for bone loss associated with acetabular revision are the American Academy of Orthopaedic Surgeons (AAOS) classification system described by D'Antonio et al.7,8 and the classification system of Paprosky et al.9.
AAOS Classification System
The AAOS classification system was described by D'Antonio et al.7,8 and is the most commonly used classification system in the literature. It organizes acetabular bone loss by pattern and location, but does not account for the quantity of bone loss. Type-I acetabular bone loss involves segmental deficiencies. These defects are uncontained and involve part of the supportive acetabular hemisphere or medial wall. Type-II acetabular bone loss involves cavitary deficiencies (Fig. 1). Such defects involve contained areas of bone loss without breaching the supportive hemispheric acetabular rim. Both type I and type II are subdivided by the location of bone loss, including peripheral (rim), superior, anterior, posterior, and central (medial wall). A type-I central defect involves full-thickness loss of the medial wall. A type-II central defect involves either a partial-thickness loss of the medial wall or a protrusio deformity with an intact rim. Type-III acetabular bone loss involves combined segmental and cavitary defects. Type-IV bone loss involves severe deficiency of the anterior and posterior columns, resulting in pelvic discontinuity. Type-V bone loss involves hips with obliterated anatomy that causes difficulty locating the true acetabulum.
Classification System of Paprosky et al.
The classification system of Paprosky et al.9 (Table I) is a more elaborate framework that organizes acetabular bone loss patterns in a manner that attempts to guide management. The premise of this classification system is that inherent component stability depends on an initial press-fit. The surgeon uses a trial component intraoperatively to assess the supportive nature of the remaining acetabular bone stock. A trial component with full inherent stability does not change position when the surgeon pushes its rim or performs a trial reduction. A trial component with partial inherent stability does not change position with removal of the inserter, but it does not withstand the force of pushing on the rim or the performance of a trial reduction. A trial component with no inherent stability changes position with the simple act of removing the inserter.
The classification system of Paprosky et al. also associates specific radiographic findings, such as the direction of acetabular component migration and the location and/or severity of osteolysis, with expected intraoperative findings (Fig. 2, Table I). This allows the surgeon to predict the location and severity of bone loss and prepare for the most appropriate management options. A type-I defect involves minimal bone loss with an undistorted acetabular rim and full inherent trial stability. A type-II defect has three subtypes, all of which involve a distorted acetabular rim that still allows for trial stability (Fig. 3). A type-III defect has two subtypes, both of which involve an unsupportive acetabular rim that provides partial or no trial implant stability.
As for other hip reconstructive procedures, an adequate operative exposure is important for successful and efficient technical execution. In acetabular revision, a stepwise approach is undertaken. A standard extensile posterior or modified Hardinge approach may be used through a prior incision. After deep exposure is achieved, scar and pseudocapsule are excised and the femur is mobilized. At this point, if the existing femoral component is modular, the femoral head is removed.
If femoral revision is planned for loosening, the existing femoral stem is removed to improve the acetabular exposure. If the existing femoral component is well fixed, deep retractors are placed and acetabular visualization and access are assessed. If inadequate exposure is obtained, further measures are necessary. If the existing femoral component is a cemented stem with design features that allow for easy removal, it is tapped out to improve exposure. After acetabular reconstruction, the femoral stem is then reinserted or recemented into the previous cement mantle10,11.
If the previous femoral component is a well-fixed cementless stem or a well-fixed cemented stem with a roughened surface, a precoating, or another feature that precludes easy removal, component removal is avoided. In such cases, trochanteric osteotomy techniques, such as a trochanteric slide or trochanteric osteotomy, may be used to enhance the acetabular exposure12. Once sufficient acetabular visualization is achieved, the acetabular liner and fixation screws are removed and the fixation of the acetabular component is assessed. If the component is loose, it is removed and the margins of the remaining bone stock are defined. After the quality, quantity, and location of the remaining pelvic columns, acetabular rim, and medial wall are assessed, reconstructive options are considered.
The ultimate reconstructive goal in acetabular revision is long-term, stable fixation of a well-positioned component. Biological fixation refers to reconstructive options that achieve osseointegration of the component. Nonbiological fixation refers to reconstructive options that achieve mechanical stability without osseointegration13. Constructs that achieve biological fixation are preferred because of superior durability14,15, but osseointegration is more difficult to achieve in hips with massive bone loss.
Prerequisites for the achievement of osseointegration are twofold. First, stable initial fixation with minimal micromotion (<50 μm) promotes bone formation within the pores of the implant16. Excessive micromotion (>150 μm) leads to bone resorption and fibrous tissue infiltration, ultimately leading to component loosening17. Second, a minimum percentage of surface area contact between the component and viable host bone is required for osseointegration. Most surgeons believe the minimum value is 50%, as measured by the degree of component coverage on the anteroposterior radiograph. Realistically, the area of contact between the component and bone is a complex three-dimensional interaction that cannot be measured on a two-dimensional radiograph. Furthermore, other factors are likely to influence the percentage of contact necessary for osseointegration. Such factors include the size of the component, the quality and location of the bone at the areas of contact, and the type of metal used to manufacture the component18.
The following subsections review the indications, techniques, and outcomes of the reconstructive options currently used in acetabular revision.
Use of Isolated Acetabular Liner Exchange with or without Bone-Grafting
Patients presenting with a well-fixed and well-oriented acetabular component and with acetabular osteolysis are candidates for an isolated acetabular liner exchange with or without bone-grafting19. Such patients often are asymptomatic and are identified on a routine follow-up examination. The goals of this operative intervention are to prevent full-thickness liner wear with associated catastrophic failure, stop the pathological osteolytic process, and possibly allow for reconstitution of bone stock. Acetabular liner exchange with or without bone-grafting is indicated for patients experiencing substantial symptoms with radiographic evidence of periprosthetic osteolysis. Asymptomatic patients with evidence of periprosthetic osteolysis may be followed over time with serial radiographs. Such patients showing progressive osteolysis that may threaten future reconstructive options should undergo early operative intervention.
After adequate exposure is achieved, the acetabular liner is removed with care, minimizing damage to the acetabular component and its locking mechanism. Fixation screws are then removed from the inner surface of the acetabular component, after which the component is stressed to verify that it is well fixed. Next, reactive tissue is debrided as much as possible from the underlying osteolytic defects with a curet through the screw holes. Access to these defects may be improved by fashioning a cortical window superior to the acetabular component, allowing for a more thorough debridement of the lining of the osteolytic lesion20. We prefer to access the osteolytic defects through the screw holes if possible. For larger lesions and lesions that are incompletely accessible through the screw holes, we use a superolateral cortical window to improve the access. For larger lesions, our practice is to fill areas of bone loss with allogeneic crushed cancellous bone graft. Other options include demineralized bone matrix and bone-graft substitutes. A modern acetabular liner is then inserted into the acetabular component, with use of the existing locking mechanism, or is fixed to the component with cement21.
The results of isolated liner exchange for the management of wear-related osteolysis have been excellent22,23. Although many surgeons place bone graft in osteolytic defects as part of their operative technique, studies have failed to demonstrate that this intervention improves the surgical results24,25. In addition, the optimal bone-graft material or combination of materials has not been established.
Postoperative dislocation can be a troublesome issue after isolated acetabular liner exchange26. Patients should be warned of this potential complication as part of the informed consent. Evidence has suggested that use of a modified Hardinge approach may reduce the dislocation risk27. Our approach to minimization of this complication is to use the modified Hardinge approach, implant the largest possible femoral head component to optimize the head-neck ratio, and instruct the patients regarding basic hip precautions for the first six postoperative weeks. We do not use an abduction pillow or brace in the postoperative period, although these are reasonable options for patients with other risk factors for dislocation.
Use of a Cementless Hemispherical Component
In most patients, bone loss encountered at the time of acetabular revision can be managed with a standard cementless hemispherical component. When initial stability and sufficient component-bone contact is achieved, the construct reliably results in osseointegration and long-term durability28-30. The initial fixation is often supplemented with transacetabular screws, and contained osseous defects may be filled with cancellous bone allograft or a commercially available bone-graft substitute31-33.
After adequate acetabular exposure is obtained, the sufficiency of a cementless hemispherical cup is determined by evaluating the quantity and location of the remaining bone stock. Initial stability may be achieved with several patterns of bone loss. Substantial medial bone loss is tolerated as long as the remaining peripheral bone allows for an adequate rim fit. Similarly, areas of segmental acetabular wall deficiency are tolerated as long as the remaining peripheral rim adequately supports the component.
Other techniques may be used with a cementless hemispherical component to address hips with moderate bone deficiency. In an acetabulum with moderate peripheral rim deficiency, the surgeon is sometimes able to achieve initial fixation by wedging the component between the anterior and posterior pelvic columns. Superior bone deficiency may be addressed by achieving fixation in a superior position, elevating the center axis of the hip34,35. More extensive bone loss may also be successfully managed with the use of an extra-large so-called jumbo cup, defined as a component with an outer diameter of ≥66 mm (Fig. 4). In some hips with moderate to severe bone loss, this technique allows for the achievement of initial stability and, at the same time, increases the total surface area of component-bone contact36,37.
The surgeon is sometimes faced with the decision of achieving stability with a standard hemispherical component at a high hip center or using a structural graft or metal augment to achieve stability with a component placed at the normal hip center. In this setting, the better option depends on the quality and quantity of the remaining bone stock, the stability that is achieved with the component in either scenario, and the surface area of contact between the component and host bone. We prefer to reestablish the normal hip center whenever possible, although we use the high-hip-center technique if the option allows for superior prosthetic stability and contact with host bone.
A recent advance in acetabular revision was the advent of second-generation porous acetabular components. One example is porous tantalum or Trabecular Metal (Zimmer, Warsaw, Indiana). This type of porous surface seems more biocompatible with osteoblasts and allows for a construct with porosity that exceeds that of other commonly used porous surfaces38. These factors allow for osseointegration that is stronger and more rapid than other porous materials and may also reduce the minimum component-bone contact necessary for osseointegration39. In addition, through an increased material elasticity and coefficient of friction, these types of surfaces enhance the initial fixation of the acetabular component40. The beneficial characteristics of these porous components have allowed for the achievement of biological constructs in the setting of difficult acetabular revisions involving massive bone loss41,42.
Use of Structural Allograft
In hips with substantial segmental acetabular bone loss, the support structure necessary for hemispherical component stability is lost. Such deficiencies pose a difficult challenge in acetabular revision. Structural allograft is one tool that has been successfully used to address this situation (Fig. 5). The advantages of structural allograft include the potential for restoration of the normal hip center and the potential to restore bone stock for future revisions. The disadvantages include technical difficulty and an increased complication rate43. Complications specific to the use of structural allograft include unsuccessful osseointegration of the graft into the host bone and graft resorption. In addition, failure of the structural allograft may lead to implant failure. Such failures are more often seen when the structural allograft supports >50% of the acetabular component44.
In most hips, the location of the segmental bone loss is superoanterior or superoposterior and the remaining bone allows for sufficient component-bone contact (Paprosky type II). In this setting, the structural allograft, termed a shelf graft or minor column graft45, serves to provide support that allows for full stability with use of a hemispherical component. For hips with massive segmental bone loss with or without pelvic discontinuity (Paprosky type III), structural allograft may be used in conjunction with other devices that achieve mechanical stability. In this setting, the structural allograft, termed a major column graft46, is used only to restore bone stock and to direct the hip center to a normal position.
The results of reconstructions involving minor column grafts have shown moderate success and survival. At ten years, the survival of the acetabular component has been reported to be 78%, with failures associated with multiple previous operations and with the inability to restore the hip center44. In a study of major column grafts, eighteen (55%) of thirty-three reconstructions remained intact at an average of seven years. Of the remaining fifteen hips that needed further revision, seven had an intact graft that was used during the subsequent reconstruction and eight involved failure of both the component and the graft. The use of a reinforcement ring to support the graft was associated with increased survival of the reconstruction47.
Use of Metal Augments
Structurally important segmental acetabular bone loss may also be managed by modifying the acetabular component, an attractive alternative to the use of bulk allograft. Initially, this strategy was approached through the design and use of oblong acetabular components, bilobed acetabular components, and custom acetabular components. The goal with such prostheses is to match the shape of the distorted acetabulum to maximize bone support, component stability, and component-bone contact. Yet, in practice, oblong and bilobed components often have a mismatch with the shape of the distorted acetabulum. Custom components solve the problem of mismatch, but are expensive, require extensive preoperative planning, and take a long time to produce. Despite these disadvantages, such components have shown promising results in certain settings47-49.
A recently developed alternative to such devices is the use of special porous metal augments. These modular systems involve several choices of augments that can be sized, oriented, and positioned to closely match the dimensions of segmental acetabular defects (Figs. 6 and 7). In addition, the augments are composed of porous metal, providing the benefits of the material that have been discussed above. The augments can be used alone or in combination and allow the surgeon to tailor the construct to the needs of each individual acetabular revision.
After extensive acetabular exposure is achieved, a standard reamer is carefully used to define the normal hip center and to identify the areas of structural bone deficiency. With the trial component in place, the most appropriately shaped and sized augment is fitted to fill the defect and provide support to the trial. The segmental defect may be gently prepared with a reamer to better accommodate the augment. The metal component is then fixed to the acetabular defect with screws. Next, the second-generation porous metal revision shell is impacted in place. The stability of the hemispherical component is enhanced with several screws and with cement between the contact area of the cup and the augment. In addition, the augment may be filled with morselized bone graft. With time, osseointegration is achieved between the component-bone and augment-bone interfaces. Short-term results of the use of the modular augment system have been quite promising, with a low rate of aseptic loosening and improvement in clinical scores42,50,51.
Use of Impaction Grafting
Impaction grafting is another technique that may be applied in the management of acetabular bone loss in revision total hip arthroplasty. Although initially described with use of a cemented acetabular component, the technique may also be used with a cementless component. One of the attractions of impaction grafting is the potential for graft incorporation and restoration of lost bone stock. Histological analysis of human specimens has suggested revascularization of the graft, resorption of the graft by osteoclasts, and remodeling into a new osseous trabecular structure52. Another attraction is its versatility in managing both contained and segmental patterns of bone loss. The disadvantages of the technique include its higher technical difficulty and the unknown fate of the allograft bone (Fig. 8).
After extensive acetabular exposure is achieved, osseous landmarks and deficits are defined. As with other reconstructive techniques, the goal with impaction grafting is to restore the anatomic hip center34,35. In areas of segmental bone loss, overlying soft tissues are carefully elevated off the pelvis. A flexible stainless-steel mesh is then cut with scissors and fashioned to fit the open borders of the segmental defects in order to contain them. The mesh is then secured at its edges to the pelvis with screws. A trial acetabular component may be applied to the planned position of the acetabular component to aid in the positioning of the wire mesh. Medial wall meshes do not require screw fixation if a stable fit is achieved.
Small holes are drilled into sclerotic areas of the remaining bone stock in order to improve surface contact and promote vascularity. Next, the socket is filled with cancellous allograft chips, which are carefully impacted in layers. The cancellous allograft chips are 7 to 10 mm in size to optimize the initial stability of cemented cups with impaction grafting53. Impactors of progressively smaller sizes are used to impact the graft until the impactor that is sized for the acetabular component is reached. Next, cement is pressurized into the graft bed and the polyethelene component is placed and held in position until the cement has hardened. Alternatively, a cementless component may be implanted and the fixation augmented with screws54.
Outcomes of the impaction-grafting technique in acetabular revision have been encouraging. Schreurs et al. recently reported twenty to twenty-five-year results of the impaction-grafting technique for acetabular revision in fifty-eight patients55. The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the end point was 75% at twenty years. The survivorship for the acetabular component with revision for aseptic loosening as the end point was 87% at twenty years. Recent data have also suggested that the technique is less successful with massive bone loss56.
In North America, cementless components have been the most common method of acetabular reconstruction. In this setting, implant contact of <50% with the host bone has been associated with failure of the construct57. Leopold et al. found a survival rate of 84% at 11.5 years in 138 cementless acetabular revisions, of which 110 involved grafting with a mixture of autograft and allograft bone58. Particulate graft has also been used in combination with extra-large acetabular components to address large segmental defects, with favorable results shown over an eight to ten-year follow-up period59,60. For massive combined segmental and cavitary defects, impaction grafting may also be used with a cage construct. The cage provides a scaffold for a stable component while protecting the graft material to allow for incorporation and bone stock reconstitution. Although the failure rate of this type of reconstruction has been reported to be as high as 12% at five years, radiographic evidence of graft remodeling and incorporation has been shown61,62.
Use of an Acetabular Cage and Custom Triflange Component
Acetabular cages and custom triflange components are tools that can be used in certain situations with the most difficult acetabular revisions. In hips with massive bone loss and pelvic discontinuity, an acetabular cage or custom triflange component may be used to bridge the discontinuity and stabilize the pelvis. An acetabular cage provides a foundation for a cemented liner (Fig. 9). A custom triflange component is custom-designed to optimize the position of the flanges with respect to the patient's remaining bone stock, and a liner is secured to the cup by means of a locking mechanism63. Historically, the problem with these constructs is that they lack potential for biological fixation and thus are doomed to fatigue failure64,65. To address this limitation, cages and custom triflange components have recently been designed and manufactured with ingrowth surfaces, although the impact of this design feature on the failure rate has yet to be determined.
Acetabular cages provide short-term stabilization. In this setting, the device provides fixation and stability during the period of time that another device (such as a hemispherical cup) achieves long-term biological osseous ingrowth (Fig. 10). Acetabular cages have been successfully used for this purpose in constructs involving major column structural allografts66. The most extreme example of this construct is an acetabular cage in association with an acetabular transplant. Such a construct relies on ultimate graft incorporation for long-term fixation. Failure of graft incorporation with remodeling and resorption leads to eventual cage fatigue and construct failure.
A more recent concept in the application of acetabular cages is the so-called cup-cage construct. This technique is used in hips with massive bone loss with or without pelvic discontinuity. A second-generation porous cup is fixed to the remaining acetabulum with partial stability. An acetabular cage is then applied on top of the cup in order to provide short-term stability. An acetabular liner is cemented into the cage. With this construct, the cage provides short-term stability, which allows the underlying cup to achieve osseointegration and long-term fixation. Early results with this technique have shown promise67.
The management of acetabular bone loss is one of the more challenging aspects of revision hip arthroplasty. Optimization of patient outcomes depends on careful preoperative examination, radiographic evaluation, and preoperative planning. Bone loss classification allows the surgeon to predict and plan for all reconstructive possibilities. Acetabular access and visualization through a careful exposure allows effective reconstruction. Most acetabular revisions are managed with a cementless, hemispherical component. Hips with more extensive bone loss preclude the initial stability of a hemispherical component and may also lack the component-bone contact necessary for osseointegration. Such hips are managed with other tools, such as structural allograft, porous metal augments, and acetabular cages.
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