Technical factors for success with metal ring acetabular reconstruction

doi:10.1054/arth.2001.27669

The Journal of Arthroplasty

Volume 16, Issue 8, December 2001, Pages 961-969

https://doi.org/10.1054/arth.2001.27669 Get rights and content

Abstract

Sixty-four hips in 62 patients were revised with a Mueller ring (28 hips), Ganz ring (18 hips), and Burch-Schneider cage (18 hips) under the direction of a single surgeon. A polyethylene cup was cemented into the metal support of all hips. Average follow-up was 4.6 years (range, 2.0-6.7 years). Six rings were revised because of aseptic loosening, and 5 others were radiographically loose, for a mechanical failure rate of 11 of 64 (17%). Acetabular metal ring supports failed by migration when defects of ≥60% of the superior weight-bearing bone were filled by only cement or particulate graft. At the time of surgery, the superior rim of the metal support should be against host–bone for 60% of its support, and if not, the use of bulk allograft, rather than particulate graft, is required. Dislocation was the second failure mechanism identified, and this occurred in 15 hips (23%), with reoperation required in 5 hips (8%). A constrained liner should be used in patients with nonunion of the trochanter and preoperative abductor weakness that grades fair/minus or worse as measured by the side-lying abduction test.

Section snippets

Materials and methods

Between September 1992 and July 1997, 439 revision THAs were performed, and of these, there were 287 revisions of the acetabulum. Metal reinforcement supports were used in 64 of 287 (22.3%) acetabular revisions. These operations were performed under the direction of a single surgeon in all 64 hips in 62 patients. A Mueller ring was used in 27 patients with 28 hips with the center of rotation elevated >2 cm and a cavitary defect that was ≤2.5 × 2.5 cm. A Ganz ring was used in 18 patients with 18

Clinical assessment

The Harris hip scores of 56 hips without revision of the metal reinforcement at last follow-up (56 of 64 [88%]) averaged 78.9 ± 14.2 (range, 26-98), which improved from the average preoperative score of 41.4 ± 13.7 (range, 19-78; P =.000). For the 8 hips in which the metal reinforcement was revised, the last follow-up Harris hip score before revision of the metal reinforcement averaged 38.1 ± 19.6 (range, 15-62). The final average Harris hip score for each type of metal reinforcement used was

Discussion

There were 2 important findings in this study. First, the amount of bone support in the ilium, which is the superior weight-bearing area of the reinforcement ring, is a crucial factor for stability of the ring and cup composite and prevention of migration. Second, dislocation is prevalent in complex revision surgery because muscle deterioration commonly is present in hips with multiple operations. The strength of the abductor complex, which is the gluteus medius and upper head of the gluteus

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Cited by (78)

Treatment of Severe Acetabular Defects With an Antiprotrusio Cage and Trabecular Metal Augments - Clinical and Radiographic Results After a Mean Follow-Up of 6.6 Years
2023, Journal of Arthroplasty
Large acetabular bone defects present a serious challenge in revision total hip arthroplasty. The off-label use of antiprotrusio cages in combination with tantalum augments is a promising treatment option in these difficult situations.
Between 2008 and 2013, 100 consecutive patients underwent acetabular cup revision with a cage-augment combination in Paprosky 2 and 3 defect types (including pelvic discontinuities). There were 59 patients available for follow-up. The primary endpoint was the explantation of the cage-and-augment construct. The secondary endpoint was acetabular cup revision for any reason. Also, radiographic and functional outcomes (Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score) were evaluated. Implant survival rates were determined using a Kaplan–Meier analysis. The significance level was set at P < .05.
Explantation-free survivorship of the “Cage-and-Augment” system was 91.9% after a mean follow-up of 6.2 years (range, 0 to 12.8). All 6 explantations were due to periprosthetic joint infection (PJI). The overall revision-free implant survival rate was 85.7%, including 6 additional liner revisions due to instability. In addition, 6 early PJI occurred, which were successfully treated with debridement, irrigation, and implant retention. We did observe one patient who had radiographic loosening of the construct without necessity for treatment.
The combination of an antiprotrusio cage with tantalum augments is a promising technique in treating large acetabular defects. A major risk of PJI and instability due to large bone and soft tissue defects needs special attention.
Tantalum Augments Combined with Antiprotrusio Cages for Massive Acetabular Defects in Revision Arthroplasty
2020, Arthroplasty Today
Tantalum components have gained popularity for the management of Paprosky type IIIA and IIIB defects during revision total hip arthroplasty. Although the use of antiprotrusio cages solely shows suboptimal results, there are certain defects that still require their use. We hypothesized that combining tantalum augments and an antiprotrusio cage would (1) improve radiographic stability, (2) enhance survivorship, (3) decrease complications, and (4) improve clinical outcomes.
We retrospectively reviewed 20 patients with Paprosky type IIIA or IIIB defects who underwent revision of the acetabular component with a highly porous tantalum augment and an antiprotrusio cage combination. Preoperative and postoperative radiographs, survivorship free from aseptic component revision, and the Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and Short Form-36 scores were analyzed. The mean follow-up was 2.8 years.
At the most recent follow-up, no antiprotrusio cages had migrated and all tantalum augments had radiographic evidence of osseointegration. In addition, only 2 components were revised for aseptic etiologies and only 1 was loose. Both were revised secondary to failures of the inferior flange of the antiprotrusio cage. All clinical outcome scores significantly improved postoperatively. Finally, the risk of major postoperative complications was noted to be 10%.
In summary, a tantalum augment combined with an antiprotrusio cage in Paprosky IIIA and IIIB defects with divergent anatomy not amenable to a hemispherical socket provides a reliable technique to restore the anatomic hip center and prevent superior migration and provides a bony ingrowth surface. Longer term follow-up is required before the technique is widely adapted.
Level IV, therapeutic studies.
Midterm Results of a Contemporary, Porous-Coated Acetabular System in Patients Undergoing Primary Total Hip Replacement for Degenerative Hip Disease: A Prospective, Multicenter Study
2020, Journal of Arthroplasty
A contemporary, porous-coated acetabular implant designed for uncemented insertion was introduced in Europe and Australia in 2007. A similar previous acetabular system was found in several studies at 10 to 15-year follow-up to demonstrate accelerated polyethylene wear, osteolysis, and early failure. The current study was conducted to determine the midterm safety and effectiveness of this contemporary acetabular system using highly crosslinked polyethylene and ceramic liners at 5-year follow-up.
A prospective, nonrandomized study was conducted at 8 sites in Canada and the United States. All 148 study participants received a contemporary acetabular shell with proprietary porous coating. The primary outcome was the requirement for revision surgery at 5 years postoperatively. Secondary outcomes included a survival analysis, patient-reported outcome measures, radiographic failure, and postoperative adverse events.
At 5-year follow-up there was 1 cup revised for deep infection. No cups were revised for loosening and none were found to be radiographically loose. The overall survival rate with reoperation for any reason was 97.1%. The success rate was 96.8% for polyethylene and 100% for ceramic with no difference in the success rate between either bearing surface (P = 1.0). The mean patient-reported outcome measures all improved significantly between preoperative and 5-year postoperative scores (P < .001).
Results from this 5-year, multicenter, prospective study indicate excellent survivorship for this acetabular system when used with crosslinked polyethylene or ceramic bearing surfaces.
Low Revision Rates at More Than 10 Years for Dual-Mobility Cups Cemented Into Cages in Complex Revision Total Hip Arthroplasty
2020, Journal of Arthroplasty
Instability and aseptic loosening are the two main complications after revision total hip arthroplasty (rTHA). Dual-mobility (DM) cups were shown to counteract implant instability during rTHA. To our knowledge, no study evaluated the 10-year outcomes of rTHA using DM cups, cemented into a metal reinforcement ring, in cases of severe acetabular bone loss. We hypothesized that using a DM cup cemented into a metal ring is a reliable technique for rTHA at 10 years, with few revisions for acetabular loosening and/or instability.
This is a retrospective study of 77 rTHA cases with severe acetabular bone loss (Paprosky ≥ 2C) treated exclusively with a DM cup (NOVAE STICK; Serf, Décines-Charpieu, France) cemented into a cage (Kerboull cross, Burch-Schneider, or ARM rings). Clinical scores and radiological assessments were performed preoperatively and at the last follow-up. The main endpoints were revision surgery for aseptic loosening or recurring dislocation.
With a mean follow-up of 10.7 years [2.1-16.2], 3 patients were reoperated because of aseptic acetabular loosening (3.9%) at 9.6 years [7-12]. Seven patients (9.45%) dislocated their hip implant, only 1 suffered from chronic instability (1.3%). Cup survivorship was 96.1% at 10 years. No sign of progressive radiolucent lines were found and bone graft integration was satisfactory for 91% of the patients.
The use of a DM cup cemented into a metal ring during rTHA with complex acetabular bone loss was associated with low revision rates for either acetabular loosening or chronic instability at 10 years.
Long-Term Results of Acetabular Reconstruction Using Ganz Acetabular Rings
2018, Journal of Arthroplasty
Our study examines the long-term results of acetabular reconstruction using the Ganz acetabular reinforcement ring (GRR) in total hip arthroplasty.
Between 1998 and 2001, 135 hips (119 revision and 16 primary arthroplasties) were consecutively implanted with a GRR at our hospital. The average age was 65 years (range, 26-90). Clinical and radiographic evaluations were carried out. Long-term survivorship was estimated using a competing risks analysis, and multivariate survivorship using Cox regression model was used to identify risk factors for implant failure.
At a mean follow-up of 16 years (range, 15-18), 3 patients were lost to follow-up and 19 had implant failure: 4 aseptic loosenings without re-revision, 4 septic, and 11 aseptic re-revisions. Survival was estimated at 86% after 16 years (95% confidence interval [CI], 78.5%-90.9%) using radiographic loosening or revision for any reason as the end point. Using aseptic loosening as the end point, the survival was estimated at 91.2% after 16 years (95% CI, 84.5%-95.0%). Multivariate analysis revealed that age at surgery was a significant risk factor for failure of the GRR. With acetabular revision or loosening as the end point, patients ≤60 years had 71.6% (95% CI, 53%-82.8%) and older patients had 92.2% (95% CI, 84%-96.2%) probability of implant survival after a mean 16-year follow-up. The median Harris Hip Scores and Western Ontario and McMaster Universities Osteoarthritis Index scores were 77 and 64.5, respectively, and mean Numerical Pain Rating Scale score was 1.6 at final follow-up.
Our long-term study showed acceptable survival and functional results using the GRR in older patients, while young patients had less favorable survival.
Acetabular Revision using Trabecular Metal Augments for Paprosky Type 3 Defects
2018, Journal of Arthroplasty
Citation Excerpt :
Radiographic failure rates of 45% have been reported at 7 years of follow-up [19]. The rate of acetabular revision is as high as 25% at 12 years of follow-up [20]. Poor long-term results are typically seen in patients in whom the bulk allograft is supporting more than 50% of the cementless acetabular component [21,22].
Trabecular Metal (TM) augments are one option when reconstructing bone loss during acetabular side revision surgery.
We studied 38 consecutive patients with Paprosky type 3 defects that were revised using a TM shell and one or more augments over a 6-year period. There were 29 Paprosky type 3A defects and 9 Paprosky type 3B defects. The mean age of the patients at the time of surgery was 68.2 years (range 48-84). The mean length of follow-up was 36 months (range 18-74).
The mean preoperative short form 12 health survey improved from 27.7 before operation to 30.1 at the time of final follow-up (P = .001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 53 preoperatively to a mean of 78.8 at final follow-up (P < .0001). There was evidence of radiographic loosening in 7 of the cup-augment constructs. One patient developed a deep infection requiring re-revision. Two patients required revision for aseptic loosening.
The use of TM in complex acetabular reconstruction is associated with good outcome in the short to medium term.

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^*: Funds were received in partial or total support of the research material described in this article from the Orthopedic Research Institute at Good Samaritan Hospital, Los Angeles, California.

^**: Reprint requests: Lawrence D. Dorr, MD, The Arthritis Institute at Centinela Hospital, 501 East Hardy Street, 3rd Floor, Inglewood, CA 90301.

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Original ArticlesTechnical factors for success with metal ring acetabular reconstruction*,**

Abstract

Section snippets

Materials and methods

Clinical assessment

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Orthop Clin North Am

Orthop Clin North Am

Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency

J Bone Joint Surg Br

The use of reinforcement rings to reconstruct deficient acetabula

J Bone Joint Surg Br

Metal ring supports for deficient acetabular bone in total hip replacement

Instr Course Lect

Low-friction arthroplasty of the hip: theory and practice

Original Articles
Technical factors for success with metal ring acetabular reconstruction*,**