Orthopedics

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Feature Article 

Long-term Results of Bulk Femoral Head Autograft in Cementless THA for Developmental Hip Dysplasia

Shu Saito, MD; Takao Ishii, MD; Sei Mori, MD; Kunihiro Hosaka, MD; Naho Nemoto, MD; Yasuaki Tokuhashi, MD

Abstract

We evaluated the fate of bulk femoral head autograft in cementless total hip arthroplasty (THA) for developmental hip dysplasia. Of 87 hips (80 patients) studied, 37 hips (32 patients) were available for follow-up at a mean of 18.5 years (range, 15-24 years) postoperatively. The mean age of these 32 patients at the index procedure was 53.8 years (range, 40-65 years). The initial diagnosis was osteoarthritis in all 32 patients. The degree of acetabular dysplasia according to Crowe classification was type I in 18 hips (48.6%), type II in 14 (37.8%), type III in 5 (13.5%).

The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%-45%). Trabecular bridging across the graft–host interface was seen at a mean of 4 months (range, 2-6 months) postoperatively. Trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months (range, 12-36 months) postoperatively. There was no evidence of collapse and bony resorption of the grafted bone in the weight-bearing portion. Acetabular component fixation was stable in all hips at final follow-up. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 for a late postoperative deep infection and 1 for dissociation of the polyethylene liner. The survival rate was 94.5% (95% confidence interval, 91.3-96.5) for the acetabular component at 18.5 years of follow-up.

This study found that bulk femoral head autograft in cementless THA for developmental hip dysplasia produces excellent long-term results.

The need for better durability and longevity in total hip arthroplasty (THA) in high-demand patients is a constant challenge. Primary THA in patients with osteoarthritis secondary to developmental dysplasia of the hip is often complex due to anterolateral acetabular bone deficiency. The use of bulk femoral head autograft during THA provides nonimmunogenic, osteoconductive support with the potential for enhanced bone stock. However, the long-term benefits of this technique remain controversial. Harris et al1 originally described the use of femoral head bone grafting for severe acetabular deficiency for THA. However, they advised against bulk femoral head autograft for developmental dysplasia of the hip owing to high rates of postoperative resorption and collapse of the grafted bone.2,3

Recently, several long-term studies documented excellent outcomes with the use of bulk femoral head autograft in either primary uncemented4-7 or cemented cups.8,9 Since 1985, we have performed bulk femoral head autograft in cases of osteoarthritis with developmental dysplasia of the hip or where bony coverage of the acetabular component was <70%. The goal of our study was to examine the long-term results of bulk femoral head autograft for developmental dysplasia of the hip in cementless THA.

We retrospectively reviewed 87 hips (80 patients) treated with THA using cementless socket fixation to the original acetabulum and acetabular defects reconstructed by grafting bulk femoral heads between July 1985 and December 1995. Thirty-eight patients (39 hips) died, and 10 patients (11 hips) were lost to follow-up. Therefore, of the 87 THAs, 37 hips in 32 patients were available for >15 years.

Total hip arthroplasties were performed using a posterior approach without resecting the greater trochanter. For all cases, the host bony coverage of the acetabular component was <70%, and shelf bulk femoral head autograft was performed. Using the obuturator foramen as a landmark, reaming was started with a 4-mm under-reamer. Reaming stopped at 5 to 10 mm from the inner cortex. The femoral head was cut one-half with a bone saw to match the convexity of the pseudoacetabulum for accurate contact to the pseudoacetabular floor and multiple small drill holes were made to the subchondral surface. Multiple small drill holes were made to the pseudoacetabular floor…

Abstract

We evaluated the fate of bulk femoral head autograft in cementless total hip arthroplasty (THA) for developmental hip dysplasia. Of 87 hips (80 patients) studied, 37 hips (32 patients) were available for follow-up at a mean of 18.5 years (range, 15-24 years) postoperatively. The mean age of these 32 patients at the index procedure was 53.8 years (range, 40-65 years). The initial diagnosis was osteoarthritis in all 32 patients. The degree of acetabular dysplasia according to Crowe classification was type I in 18 hips (48.6%), type II in 14 (37.8%), type III in 5 (13.5%).

The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%-45%). Trabecular bridging across the graft–host interface was seen at a mean of 4 months (range, 2-6 months) postoperatively. Trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months (range, 12-36 months) postoperatively. There was no evidence of collapse and bony resorption of the grafted bone in the weight-bearing portion. Acetabular component fixation was stable in all hips at final follow-up. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 for a late postoperative deep infection and 1 for dissociation of the polyethylene liner. The survival rate was 94.5% (95% confidence interval, 91.3-96.5) for the acetabular component at 18.5 years of follow-up.

This study found that bulk femoral head autograft in cementless THA for developmental hip dysplasia produces excellent long-term results.

The need for better durability and longevity in total hip arthroplasty (THA) in high-demand patients is a constant challenge. Primary THA in patients with osteoarthritis secondary to developmental dysplasia of the hip is often complex due to anterolateral acetabular bone deficiency. The use of bulk femoral head autograft during THA provides nonimmunogenic, osteoconductive support with the potential for enhanced bone stock. However, the long-term benefits of this technique remain controversial. Harris et al1 originally described the use of femoral head bone grafting for severe acetabular deficiency for THA. However, they advised against bulk femoral head autograft for developmental dysplasia of the hip owing to high rates of postoperative resorption and collapse of the grafted bone.2,3

Recently, several long-term studies documented excellent outcomes with the use of bulk femoral head autograft in either primary uncemented4-7 or cemented cups.8,9 Since 1985, we have performed bulk femoral head autograft in cases of osteoarthritis with developmental dysplasia of the hip or where bony coverage of the acetabular component was <70%. The goal of our study was to examine the long-term results of bulk femoral head autograft for developmental dysplasia of the hip in cementless THA.

Materials and Methods

We retrospectively reviewed 87 hips (80 patients) treated with THA using cementless socket fixation to the original acetabulum and acetabular defects reconstructed by grafting bulk femoral heads between July 1985 and December 1995. Thirty-eight patients (39 hips) died, and 10 patients (11 hips) were lost to follow-up. Therefore, of the 87 THAs, 37 hips in 32 patients were available for >15 years.

Total hip arthroplasties were performed using a posterior approach without resecting the greater trochanter. For all cases, the host bony coverage of the acetabular component was <70%, and shelf bulk femoral head autograft was performed. Using the obuturator foramen as a landmark, reaming was started with a 4-mm under-reamer. Reaming stopped at 5 to 10 mm from the inner cortex. The femoral head was cut one-half with a bone saw to match the convexity of the pseudoacetabulum for accurate contact to the pseudoacetabular floor and multiple small drill holes were made to the subchondral surface. Multiple small drill holes were made to the pseudoacetabular floor to facilitate invasion of fibrovascular repair tissue from the iliac bone marrow into the grafted bone. The subchondral surface of the graft was impacted in the pseudoacetabular floor, and the graft was fixed securely to the host with two 4.5-mm cancellous screws penetrating outer and inner walls of the iliac bone. The re-reaming was started with a 2-mm under-reamer, and excessive amounts of grafted bone were removed by reamer.

The acetabular components were fixed by 3 to 5 screws without cement. The outer diameter of the acetabular components averaged 52.7 mm (range, 46-60 mm). The diameter of the prosthetic femoral head was 28 mm in all hips. Harris-Galante I cups (Zimmer Inc, Warsaw, Indiana) were used in 18 hips, Harris-Galante II cups (Zimmer Inc) in 12 hips, and Duraloc cups (DePuy Inc, Warsaw, Indiana) in 7 hips. Postoperative rehabilitation included nonweight-bearing ambulation for the first 6 weeks, followed by gradually increased weight bearing for another 6 weeks. All patients were examined at 1, 3, and 6 months postoperatively, and every 6 or 12 months thereafter. Standardized radiographs were used, including an anteroposterior (AP) view of the bilateral hips and a lateral view of the index hip. Acetabular component fixation was evaluated by the method described by Tompkins et al.10

The percentage of horizontal coverage with graft bone was determined on postoperative AP radiographs. The degree of coverage angle (CA) is the angle between the original lateral edge of the acetabulum and the lateral edge of the acetabular component (Figure 1). The percentage coverage was determined using the following formula: (CA/180)×100%. Incorporation and remodeling of grafted bone were analyzed according to the methods described by Knight et al.11 Survivorship was analyzed (Kaplan-Meier) with the endpoint defined as a revision surgery and radiographic loosening. SPSS version 13 was used (SPSS Inc, Chicago, Illinois).

Figure 1: Percentage of horizontal coverage by graft bone
Figure 1: The percentage of horizontal coverage by graft bone was determined on postoperative AP radiographs. The degree of coverage angle (CA) is the angle between the original lateral edge of the acetabulum and the lateral edge of the acetabular component.

Results

Thirty-seven hips in 32 patients were monitored for >15 years: 3 hips in 3 men, and 34 hips in 29 women. In 16 patients, only the right hip was involved; in 11, only the left hip was involved; and in 5, both hips were involved. The mean age of the 32 patients at the index procedure was 53.8 years (range, 40-65 years), and the mean length of follow-up was 18.5 years (range, 15-24 years). The initial diagnosis was osteoarthritis in all patients. All THAs were performed as unilateral procedures. The degree of acetabular dysplasia according to Crowe classification12 was type I in 18 hips (48.6%), type II in 14 (37.8%), and type III in 5 (13.5%).

One patient had a late postoperative deep infection 10 years postoperatively and required revision of both the acetabular and femoral components. Dissociation of the polyethylene liner was observed in 1 patient 12 years postoperatively and required revision of the polyethylene liner and the articular head. The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%-45%). The mean percentage of horizontal coverage was similar for the Crowe dislocation types: type I, 38% (range, 32%-51%); type II, 36% (range, 28%-45%); type III, 33% (range, 28%-36%).

Bony union of the shelf graft occurred in all cases. Trabecular bridging across the graft–host interface was seen in all hips at a mean of 4 months (range, 2-6 months) postoperatively. Disappearance of the acetabular bone graft interface line was noted in all hips at a mean of 9 months (range, 4-17 months) postoperatively. Trabecular reorientation was seen in all hips at a mean of 27 months (range, 12-36 months) postoperatively.

The period of trabecular reorientation was similar for the Crowe dislocation types. There was no evidence of collapse, displacement, or bony resorption of the grafted bone in the weight-bearing portion (Figure 2). Rounding off of the protruding edge of the graft beyond the cup or a change in graft density in areas where the graft was not stressed was considered an indicator of revascularization. A broken screw was observed in 1 hip with fixation of the graft bone at 4 years postoperatively (Figure 3).

Figure 2A: Immediately postoperative AP radiograph of the left hip Figure 2B: The graft bone shows trabecular reorientation
Figure 2: Immediately postoperative AP radiograph of the left hip. Bulk femoral head autograft was performed on the acetabular edge (A). Anteroposterior radiograph of the same hip 20 years after implantation. The graft bone shows trabecular reorientation, and no collapse, displacement, or resorption is found in the weight-bearing portion (B).

Figure 3A: Bulk femoral head autograft was performed on the acetabular edge Figure 3B: The graft bone shows trabecular reorientation
Figure 3: Immediately postoperative AP radiograph of the right hip. Bulk femoral head autograft was performed on the acetabular edge (A). Anteroposterior radiograph of the right hip 4 years after implantation. A broken screw was observed with fixation of the graft bone. The graft bone shows trabecular reorientation (B).

Radiographic evaluation showed acetabular component fixation was stable in all hips at final follow-up. There were no clear signs of loosening, radiolucent line, or focal osteolysis of the acetabular component. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 acetabular component for a late postoperative deep infection and 1 polyethylene liner and an articular head for dissociation of the polyethylene liner. The survival rate at 18.5 years was 94.5% (95% confidence interval [CI], 91.3-96.5) for the acetabular components.

Discussion

Primary THA with developmental dysplasia of the hip often provides inadequate coverage of the acetabular component. Surgical options for obtaining adequate bone coverage for stable fixation of the acetabular component have included use of a small cup with medial or high anatomic center.10-12 Another option is augmented bone grafts prepared from resected femoral heads or an allograft to the defective acetabulum. Bulk femoral head autograft offers advantages: the cup may be placed in an anatomic position rather than a high hip position, it provides support for the acetabular component, and, if incorporated, it provides beneficial bone stock for any revision surgery.

Harris et al1 originally described the use of femoral head bone grafting for severe acetabular deficiency for THA. However, they advised against bulk femoral head autograft for developmental dysplasia of the hip owing to high rates of postoperative resorption and collapse of the grafted bone.2 Moreover, Shinar and Harris3 reported 36% of acetabular components had been revised for aseptic loosening and 26% had radiographic loosening. Based on these clinical experiences, many surgeons abandoned bone grafting and have recommended medial or high setting of the acetabular component and use of a small acetabular component without bone grafting. Ito et al13 reported an excellent outcome at an average 10.6-year follow-up despite medial and high settings of the noncemented sockets in THA. Li et al14 and Sun et al15 reported favorable results choosing a small cementless acetabular component with its medial hip center.

However, considering future potential loosening of the acetabular components in association with periprosthetic bone loss, revision surgery to restore hip function would become more difficult in these patients. Recently, several long-term studies documented excellent outcomes with the use of bulk femoral head autograft in either primary uncemented4-7 or cemented cups.8,9 Akiyama et al9 indicated excellent long-term clinical and radiographic survivorship of a cemented acetabular component with bulk autograft for developmental dysplasia of the hip using poly-L-lactic acid screws. They indicated the survival rate of 96.6% and 90.2% at 15 years with socket revision and radiologic loosening as the endpoints, respectively.

Conclusion

In our study, trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months postoperatively. There was no evidence of collapse, displacement, or bony resorption of the grafted bone in the weight-bearing portion. The acetabular component fixation was stable in all hips at final follow-up, and the survival rate at 18.5 years was 94.5% (95% CI, 91.3-96.5) for the acetabular components.

References

  1. Harris WH, Crothers O, Oh I. Total hip replacement and femoral-head bone-grafting for severe acetabular deficiency in adults. J Bone Joint Surg Am. 1977; 59(6):752-759.
  2. Mulroy RD Jr, Harris WH. Failure of acetabular autogenous grafts in total hip arthroplasty. Increasing incidence: a follow-up note. J Bone Joint Surg Am. 1990; 72(10):1536-1540.
  3. Shinar AA, Harris WH. Bulk structural autogenous grafts and allografts for reconstruction of the acetabulum in total hip arthroplasty. Sixteen-year-average follow-up. J Bone Joint Surg Am. 1997; 79(2):159-168.
  4. Shetty AA, Sharma P, Singh S, Tindall A, Kumar SV, Rand C. Bulk femoral-head autografting in uncemented total hip arthroplasty for acetabular dysplasia: results at 8 to 11 years follow-up. J Arthroplasty. 2004; 19(6):706-713.
  5. Hendrich C, Engelmaier F, Mehling I, Sauer U, Kirschner S, Martell JM. Cementless acetabular reconstruction and structural bone-grafting in dysplastic hips. Surgical technique. J Bone Joint Surg Am. 2007; 89(Suppl 2 Pt 1):54-67.
  6. Nousiainen MT, Maury AC, Alhoulei A, Backstein DJ, Gross AE. Long-term outcome of shelf grafts in total hip arthroplasty for developmental hip dysplasia. Orthopedics. 2009; 32(9). pii: orthosupersite.com/view.asp?rID=42838. doi: 10.3928/01477447-20090728-15.
  7. Kim M, Kadowaki T. High long-term survival of bulk femoral head autograft for acetabular reconstruction in cementless THA for developmental hip dysplasia [published online ahead of print March 23, 2010]. Clin Orthop Relat Res. 2010; 468(6):1611-1620.
  8. Goto K, Akiyama H, Kawanabe K, So K, Morimoto T, Nakamura T. Long-term results of cemented total hip arthroplasty for dysplasia, with structural autograft fixed with poly-L-lactic acid screws [published online ahead of print June 24, 2009]. J Arthroplasty. 2009; 24(8):1146-1151.
  9. Akiyama H, Kawanabe K, Iida H, Haile P, Goto K, Nakamura T. Long-term results of cemented total hip arthroplasty in developmental dysplasia with acetabular bulk bone grafts after improving operative techniques [published online ahead of print July 4, 2009]. J Arthroplasty. 2010; 25(5):716-720.
  10. Tompkins GS, Jacobs JJ, Kull LR, Rosenberg AG, Galante JO. Primary total hip arthroplasty with a porous-coated acetabular component. Seven-to-ten-year results. J Bone Joint Surg Am. 1997; 79(2):169-176.
  11. Knight JL, Fujii K, Atwater R, Grothaus L. Bone-grafting for acetabular deficiency during primary and revision total hip arthroplasty. A radiographic and clinical analysis. J Arthroplasty. 1993; 8(4):371-382.
  12. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am. 1979; 61(1):15-23.
  13. Ito H, Matsuno T, Minami A, Aoki Y. Intermediate-term results after hybrid total hip arthroplasty for the treatment of dysplastic hips. J Bone Joint Surg Am. 2003; 85(9):1725-1732.
  14. Li B, Gong Y, Zhang L, Liu J, Li S. Total hip arthroplasty for the treatment of developmental dysplasia of the hip in adults [in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008; 22(6):646-648.
  15. Sun JY, Hao YF, Yang PY, Yang YS. Total hip replacement for the treatment of Crowe IV congenital hip dislocation using small acetabular components combined with medial protrusio technique. Zhongguo Gu Shang. 2009; 22(6):407-409.

Authors

Drs Saito, Ishii, Mori, Hosaka, Nemoto, and Tokuhashi are from the Department of Orthopedic Surgery, Nihon University School of Medicine, Tokyo, Japan.

Drs Saito, Ishii, Mori, Hosaka, Nemoto, and Tokuhashi have no relevant financial relationships to disclose.

Correspondence should be addressed to: Shu Saito, MD, Department of Orthopedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi, Kamimachi, Itabashi-Ku, Tokyo 173-8610 Japan (ssaito@med.nihon-u.ac.jp).

doi: 10.3928/01477447-20101221-15

10.3928/01477447-20101221-15

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