Acetabular Revision with Impacted Morselized
Cancellous Bone Graft and a Cemented Cup in
Patients with Rheumatoid Arthritis
A Concise Follow-up, at Eight to Nineteen Years, of a Previous Report*
By B. Willem Schreurs, MD, PhD, Jaap Luttjeboer, MD, Truike M. Thien, MD, Maarten C. de Waal Malefijt, MD, PhD, Pieter Buma, PhD, Ren´e P.H. Veth, MD, PhD, and Tom J.J.H. Slooff, MD, PhD
Investigation performed at the Department of Orthopaedics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
Abstract: We previously reported our results at a minimum of three years after thirty-five revisions of total hip
arthroplasty acetabular components in twenty-eight patients with rheumatoid arthritis. The revisions were performed with use of impacted morselized bone graft and a cemented cup. This update report presents the results at eight to nineteen years after the surgery, which, to our knowledge, is the longest follow-up available in the literature. No patient was lost to follow-up. Since our previous report, there were two additional cup failures due to aseptic loosening, at ten and sixteen years postoperatively. Kaplan-Meier analysis showed the probability of survival of the acetabular component at twelve years to be 80% (95% confidence interval, 65% to 95%) with removal of the cup for any reason as the end point and 85% (95% confidence interval, 71% to 99%) with aseptic loosening as the end point. Cup revisions performed with cement and use of impaction bone-grafting in patients with rheumatoid arthritis led to acceptable long-term prosthetic survival rates. This technique is attractive from a biological standpoint because of the possibility of maintaining acetabular bone stock.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Background
W
e previously reported the outcomes in a nonselected consecutive series of twenty-eight patients with rheuma-toid arthritis in whom a total of thirty-five total hip acetabular components had been revised with use of impacted morselized cancellous bone graft and a cemented cup1. The mean duration of follow-up in that study was 7.5 years (range, three to fourteen years). The mean age of the patients at the time of the index revision procedure was fifty-seven years (range, thirty-one to seventy-three years).
In our previous study1
, Kaplan-Meier analysis showed that the probability of survival of the acetabular component at eight years was 85% (95% confidence interval, 73% to 97%) with removal of the cup for any reason as the end point and 90% with
revision due to aseptic loosening as the end point. The overall radiographic survival rate of the cup, including the failures that led to repeat revision after the appearance of radiographic signs of loosening, was 87% at eight years.
The purpose of the present study was to update the clinical and radiographic results of our previous report after a mean duration of follow-up of 11.2 years (range, eight to nineteen years) after the surgery, as complications such as aseptic loosening and osteolyses tend to occur more frequently with longer follow-up.
Methods
T
his study was approved by our institutional review board. Between January 1983 and April 1997, thirty-fiveconsec-*Original Publication
Schreurs BW, Thien TM, de Waal Malefijt MC, Buma P, Veth RP, Slooff TJ. Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am. 2003;85:647-52.
Disclosure:The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Stryker Howmedica, Montreux, Switzerland) paid or directed in any one year, or agreed to pay or direct, benefits of less than $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
utive acetabular revisions were performed with use of the ace-tabular impaction bone-grafting technique and a cemented cup in twenty-eight patients with rheumatoid arthritis (including two patients with juvenile rheumatoid arthritis) (Table I). The indication for revision was aseptic loosening of the acetabular component in thirty-one hips, traumatic loosening of the cup in two, septic loosening in one, and recurrent dislocation in one. All patients were prospectively followed annually or biannually for at least eight years, or until repeat revision or death.
The surgical technique has been previously described1
. Acetabular defects were classified according to the clas-sification of the American Academy of Orthopaedic Surgeons (AAOS) Committee on the Hip2
(Table I). Radiographic incor-poration was defined as equal radiodensity of the graft and host bone, with a continuous trabecular pattern throughout as de-scribed by Conn et al.3
. Radiolucent lines of >2 mm in width were identified in the three zones described by DeLee and Charnley4
. Radiolucent lines were defined as stable or as progressive in time.
At the time of the last review in 20031
, all living patients with a surviving cup were seen for clinical and radiographic examination, and a Harris hip score was assigned. All patients who died during the follow-up period had been followed on a regular basis until their death, and the data on those patients were included in this report. A pain score for the revised joint and a score for overall patient satisfaction were obtained, with the use of visual analogue scales, for all surviving patients.
Failure was defined clinically as the need for revision of the acetabular component for any reason. Radiographic failure was defined as radiolucent lines in all three DeLee-Charnley
zones, or migration of ‡5 mm in any direction relative to the interteardrop line as seen on the anteroposterior pelvic radiograph.
The Kaplan-Meier estimates of the time to revision of the acetabular component for any reason, the time to revision due to aseptic loosening, and the time to radiographic failure were calculated separately. In order to study the effect of the patients with bilateral surgery on these results, we performed the anal-ysis both using all data and using the data on the first surgery only. This preliminary analysis showed that the estimates were similar in terms of the 95% confidence intervals. The Kaplan-Meier estimates and 95% confidence intervals presented in this report were derived in the analyses using all data.
Source of Funding
This study was performed without external funding; however, the costs of professional medical statistical advice were paid by our research fund.
Results Clinical Results
A
t the time of the final review, no patient had been lost to follow-up and eight patients (ten hips) had died of causes not related to the revision procedure. The mean preoperative Harris hip score, which was available for only nine hips, was 43 points (range, 9 to 68 points). At the time of the final review, the eighteen surviving hips (in fourteen living patients) that had not had a repeat revision had a mean Harris hip score of 79 points (range, 56 to 100 points). Frequently, disabling problems due to rheumatoid arthritis in other joints lowered the hip score. One patient (one hip) had moderate pain, four patients (five hips) had mild pain, and the remaining patients had no or slight pain. The mean visual analogue score (on a scale of 0 to 100, with 0 indicating no pain and 100 indicating unbearable pain) was 9.2 (range, 0 to 65) for hip pain at rest and 10.6 (range, 0 to 65) for pain when using the hip joint. The mean visual analogue score for satisfaction (on a scale of 0 to 100, with 0 indicating not satisfied at all and 100 indicating complete satisfaction) was 83.9 (range, 50 to 100). Of the fourteen patients (eighteen hips), two used a wheelchair, two used a rolling walker, and two used a cane for walking longer distances.Repeat Revisions of the Acetabular Component
Eight of the acetabular reconstructions were revised, with two of the revisions performed since the time of the previous report. Two repeat revisions were performed, at 0.7 and 1.3 years postoperatively, because of culture-proven septic loosening; neither of these cups was loose radiographically. Five revisions were performed, at 2.6, 3.5, 3.8, 9.8, and 16.3 years after the surgery, because of aseptic loosening of the cup. Four of the five aseptic failures occurred in hips with a reconstruction of a combined cavitary-segmental defect; one occurred in a hip with a reconstruction of a cavitary defect. The eighth repeat cup revision was performed 12.3 years after the reconstruction, during a femoral revision procedure due to aseptic loosening of the stem. The cup was revised because of polyethylene wear and
TABLE I Patient Demographics
No. of
Patients No. of Hips No. in series 28 35 Sex
F 26 32
M 2 3
Type of defects according to the AAOS classification
Cavitary 12 (34%) Combined 23 (66%) Deaths during follow-up period
(last available data included)
8 10 Repeat revision during
follow-up period*
8 Due to septic loosening 2 at 0.7 and 1.3 yr Due to aseptic loosening 5 at 2.6, 3.5, 3.8,
9.8, and 16.3 yr Due to wear and matching
problems
1 at 12.3 yr *The duration of follow-up ranged from eight to nineteen years.
647
TH EJO U R N A L O FBO N E& JO I N T SU R G E R YdJ B J S.O R GVO L U M E9 1 - AdNU M B E R3dMA R C H2 0 0 9
AC E TA B U L A RRE V I S I O N W I T HBO N EGR A F T A N D ACE M E N T E D CU P I NPAT I E N T S W I T H RH E U M AT O I DAR T H R I T I S
to be compatible with the new femoral component. However, this cup was well fixed both clinically and radiographically. Revisions of the Stem
Six patients (six hips) underwent a femoral stem revision, two because of deep sepsis and four because of aseptic loosening. Radiographic Results
Radiographic follow-up was complete for thirty-three hips. The radiographs were examined to determine the extent of the re-construction, demarcation lines around the implants, migration of the cup, and failure. The extent of the graft reconstructions varied in technical difficulty, from filling of cavitary defects only to reconstruction of combined segmental-cavitary defects with very large grafts (Fig. 1).
Six cups had radiographic evidence of loosening, with radiolucent lines in three zones; five of these hips underwent repeat revision because of the aseptic loosening. The other pa-tient did not have a repeat revision because she had only mild symptoms and was in poor medical condition. Of the hips with
the cup still in situ, one had progressive radiolucent lines in two zones and three had progressive radiolucent lines in one zone. Two hips had a nonprogressive radiolucency in zone 3, which had been observed immediately after the surgery.
Complications
Osteosynthesis was performed for treatment of a peri-prosthetic fracture of the femur that had been detected shortly after the index revision procedure in one patient. This stem was seen to be loose at the final radiographic review, but a revision procedure was not recommended because the patient had minimal symptoms. One hip underwent a reoperation five days after the index surgery because of a postoperative sciatic nerve palsy in combination with a hematoma. There was complete recovery of nerve function following the decom-pression. In another patient, a longer-neck femoral compo-nent was inserted to increase the offset of the femoral implant, two years after the acetabular reconstruction, because of re-current dislocations of the hip. No more dislocations occurred. One patient sustained a traumatic fracture of the femur at the
Fig. 1
Radiograph, made seventeen years postoperatively, of a thirty-five-year-old man with rheumatoid arthritis who had loosening of a cemented cup in each hip. (The original ra-diographs may be seen in our previous report1.) On the left side, there was complete protrusion of the cup into the pelvis. Both hips were reconstructed with impaction bone-grafting. A small piece of metal mesh was used to close a limited medial wall defect in the right hip; this is an example of filling of a relatively simple cavitary defect. In the left hip, the large protrusio was contained with metal mesh and filled with cancellous bone graft. Metal mesh was then placed into the graft bed, and the cup was cemented in place. (This technique of placing the metal mesh on top of the graft is no longer used.) Both cups were still in situ without radiographic loosening at the time of the present study. A small amount of axial migration of the left cup was noted in the first few months after the operation, but it did not progress subsequently. Clinically, both hips were functioning well at the last review.
level of the tip of the femoral stem at six years following the index surgery. The fracture healed after open reduction and plate fixation.
Component Survival
Kaplan-Meier analysis showed the probability of survival of the acetabular component at twelve years to be 80% (95% confi-dence interval, 65% to 95%) with removal of the cup for any
reason as the end point (Fig. 2-A). Excluding the two cases of septic cup loosening and the revision because of polyethylene wear, the probability of cup survival was 85% (95% confidence interval, 71% to 99%) at twelve years with revision due to aseptic loosening as the end point (Fig. 2-B). With radio-graphic failure as the end point, the probability of survival at twelve years was 73% (95% confidence interval, 54% to 92%) (Fig. 2-C).
Fig. 2-A
Fig. 2-B
Kaplan-Meier survival curves up to fifteen years postoperatively with the end points of revision for any reason (Fig. 2-A), revision due to aseptic loosening (Fig. 2-B), and radiographic failure (Fig. 2-C). The broken lines indicate the 95% confidence bands.
649
TH EJO U R N A L O FBO N E& JO I N T SU R G E R YdJ B J S.O R G VO L U M E9 1 - AdNU M B E R3dMA R C H2 0 0 9 AC E TA B U L A RRE V I S I O N W I T HBO N EGR A F T A N D ACE M E N T E D CU P I NPAT I E N T S W I T H RH E U M AT O I DAR T H R I T I SConclusions
A
lthough the number of patients in our study is not large, we believe that our findings are important. The series was consecutive and the follow-up was complete, there was no selection bias because we always used impaction bone-grafting in hip revisions, and the reconstructions were performed for a variety of acetabular defects.We are aware of only two other reports on the outcome of acetabular revisions in patients with rheumatoid arthritis5,6
. We and the other two groups1,5,6
have shown that the outcomes of cup revisions in patients with rheumatoid arthritis were infe-rior to those in patients without rheumatoid arthritis who were treated with the same techniques and followed for a compa-rable duration7-9
. At a mean of seven years after the surgery, the overall survival rate with aseptic loosening as the end point was 90% in our series and was similar to the survival rate after fully cemented revisions in a previous report5
. However, there was a striking difference in the radiographic failure rates, calculated with use of the same criteria, between our study and the pre-vious study5
. Raut et al.5
observed an overall radiographic survival rate of the acetabular component of 64% at a mean of seven years. In contrast, at a mean of twelve years, our study showed an overall radiographic survival rate of 73%. Impor-tantly, the only report available (to our knowledge) on the outcomes of acetabular revisions with use of a noncemented
cup in patients with rheumatoid arthritis (thirty cups in twenty-eight patients) showed a rate of survival of the ace-tabular component of only 44% at nine years after the surgery6
. In conclusion, the application of impacted morselized bone graft in combination with a cemented cup is an attractive option for reconstruction of acetabular bone stock in revision total hip arthroplasty in patients with rheumatoid arthritis. In comparison with other techniques in patients with rheumatoid arthritis, this method appeared to yield more favorable results, and we continue to use it for acetabular revisions in patients with rheumatoid arthritis.n
B. Willem Schreurs, MD, PhD Jaap Luttjeboer, MD
Truike M. Thien, MD
Maarten C. de Waal Malefijt, MD, PhD Pieter Buma, PhD
Ren´e P.H. Veth, MD, PhD Tom J.J.H. Slooff, MD, PhD
Department of Orthopaedics, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen,
The Netherlands. E-mail address for B.W. Schreurs: B.Schreurs@orthop.umcn.nl
References
1.Schreurs BW, Thien TM, de Waal Malefijt MC, Buma P, Veth RP, Slooff TJ. Acetabular revision with impacted morselized cancellous bone graft and a ce-mented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am. 2003;85:647-52.
2. D’Antonio JA, Capello WN, Borden LS, Bargar WL, Bierbaum BF, Boettcher WG, Steinberg ME, Stulberg SD, Wedge JH. Classification and management of ace-tabular abnormalities in total hip arthroplasty. Clin Orthop Relat Res. 1989;243:126-37.
3.Conn RA, Peterson LFA, Stauffer RN, Ilstrup D. Management of acetabular de-ficiency; long-term results of bone-grafting the acetabulum in total hip arthroplasty. Orthop Trans. 1985;9:451-2.
4.DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20-32.
5.Raut VV, Siney PD, Wroblewski BM. Cemented revision Charnley low-friction arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 1994;76:909-11.
6.Mont MA, Domb B, Rajadhyaksha AD, Padden DA, Jones LC, Hungerford DS. The fate of revised uncemented acetabular components in patients with rheuma-toid arthritis. Clin Orthop Relat Res. 2002;400:140-8.
7. Schreurs BW, Slooff TJ, Buma P, Gardeniers JW, Huiskes R. Acetabular reconstruction with impacted morsellised cancellous bone graft and cement. A 10- to 15-year follow-up of 60 revision cases. J Bone Joint Surg Br. 1998; 80:391-5.
8. Raut VV, Siney PD, Wroblewski BM. Cemented revision for aseptic acetabular loosening. A review of 387 hips. J Bone Joint Surg Br. 1995;77: 357-61.
9. Etienne G, Bezwada HP, Hungerford DS, Mont MA. The incorporation of mor-selized bone grafts in cementless acetabular revisions. Clin Orthop Relat Res. 2004;428:241-6.
