Acetabular Revision with Impacted Morselized Cancellous Bone Graft and a Cemented Cup in Patients with Rheumatoid Arthritis

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1 646 COPYRIGHT Ó 2009 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Acetabular Revision with Impacte Morselize Cancellous Bone Graft an a Cemente Cup in Patients with Rheumatoi 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. e Waal Malefijt, MD, PhD, Pieter Buma, PhD, René P.H. Veth, MD, PhD, an Tom J.J.H. Slooff, MD, PhD Investigation performe at the Department of Orthopaeics, Rabou University Nijmegen Meical Centre, Nijmegen, The Netherlans Abstract: We previously reporte our results at a minimum of three years after thirty-five revisions of total hip arthroplasty acetabular components in twenty-eight patients with rheumatoi arthritis. The revisions were performe with use of impacte morselize bone graft an a cemente cup. This upate report presents the results at eight to nineteen years after the surgery, which, to our knowlege, is the longest follow-up available in the literature. No patient was lost to follow-up. Since our previous report, there were two aitional cup failures ue to aseptic loosening, at ten an sixteen years postoperatively. Kaplan-Meier analysis showe the probability of survival of the acetabular component at twelve years to be 80% (95% confience interval, 65% to 95%) with removal of the cup for any reason as the en point an 85% (95% confience interval, 71% to 99%) with aseptic loosening as the en point. Cup revisions performe with cement an use of impaction bone-grafting in patients with rheumatoi arthritis le to acceptable longterm prosthetic survival rates. This technique is attractive from a biological stanpoint because of the possibility of maintaining acetabular bone stock. Level of Evience: Therapeutic Level IV. See Instructions to Authors for a complete escription of levels of evience. Backgroun We previously reporte the outcomes in a nonselecte consecutive series of twenty-eight patients with rheumatoi arthritis in whom a total of thirty-five total hip acetabular components ha been revise with use of impacte morselize cancellous bone graft an a cemente cup 1. The mean uration of follow-up in that stuy was 7.5 years (range, three to fourteen years). The mean age of the patients at the time of the inex revision proceure was fifty-seven years (range, thirty-one to seventy-three years). In our previous stuy 1, Kaplan-Meier analysis showe that the probability of survival of the acetabular component at eight years was 85% (95% confience interval, 73% to 97%) with removal of the cup for any reason as the en point an 90% with revision ue to aseptic loosening as the en point. The overall raiographic survival rate of the cup, incluing the failures that le to repeat revision after the appearance of raiographic signs of loosening, was 87% at eight years. The purpose of the present stuy was to upate the clinical an raiographic results of our previous report after a mean uration of follow-up of 11.2 years (range, eight to nineteen years) after the surgery, as complications such as aseptic loosening an osteolyses ten to occur more frequently with longer follow-up. Methos This stuy was approve by our institutional review boar. Between January 1983 an April 1997, thirty-five consec- *Original Publication Schreurs BW, Thien TM, e Waal Malefijt MC, Buma P, Veth RP, Slooff TJ. Acetabular revision with impacte morselize cancellous bone graft an a cemente cup in patients with rheumatoi arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am. 2003;85: Disclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. A commercial entity (Stryker Howmeica, Montreux, Switzerlan) pai or irecte in any one year, or agree to pay or irect, benefits of less than $10,000 to a research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immeiate family, is affiliate or associate. J Bone Joint Surg Am. 2009;91: oi: /jbjs.g.01701

2 647 TABLE I Patient Demographics No. of Patients No. of Hips No. in series Sex F M 2 3 Type of efects accoring to the AAOS classification Cavitary 12 (34%) Combine 23 (66%) Deaths uring follow-up perio 8 10 (last available ata inclue) Repeat revision uring 8 follow-up perio* Due to septic loosening 2 at 0.7 an 1.3 yr Due to aseptic loosening 5 at 2.6, 3.5, 3.8, 9.8, an 16.3 yr Due to wear an matching problems 1 at 12.3 yr *The uration of follow-up range from eight to nineteen years. utive acetabular revisions were performe with use of the acetabular impaction bone-grafting technique an a cemente cup in twenty-eight patients with rheumatoi arthritis (incluing two patients with juvenile rheumatoi arthritis) (Table I). The inication for revision was aseptic loosening of the acetabular component in thirty-one hips, traumatic loosening of the cup in two, septic loosening in one, an recurrent islocation in one. All patients were prospectively followe annually or biannually for at least eight years, or until repeat revision or eath. The surgical technique has been previously escribe 1. Acetabular efects were classifie accoring to the classification of the American Acaemy of Orthopaeic Surgeons (AAOS) Committee on the Hip 2 (Table I). Raiographic incorporation was efine as equal raioensity of the graft an host bone, with a continuous trabecular pattern throughout as escribe by Conn et al. 3. Raiolucent lines of >2 mm in with were ientifie in the three zones escribe by DeLee an Charnley 4. Raiolucent lines were efine as stable or as progressive in time. At the time of the last review in , all living patients with a surviving cup were seen for clinical an raiographic examination, an a Harris hip score was assigne. All patients who ie uring the follow-up perio ha been followe on a regular basis until their eath, an the ata on those patients were inclue in this report. A pain score for the revise joint an a score for overall patient satisfaction were obtaine, with the use of visual analogue scales, for all surviving patients. Failure was efine clinically as the nee for revision of the acetabular component for any reason. Raiographic failure was efine as raiolucent lines in all three DeLee-Charnley zones, or migration of 5 mm in any irection relative to the intertearrop line as seen on the anteroposterior pelvic raiograph. The Kaplan-Meier estimates of the time to revision of the acetabular component for any reason, the time to revision ue to aseptic loosening, an the time to raiographic failure were calculate separately. In orer to stuy the effect of the patients with bilateral surgery on these results, we performe the analysis both using all ata an using the ata on the first surgery only. This preliminary analysis showe that the estimates were similar in terms of the 95% confience intervals. The Kaplan- Meier estimates an 95% confience intervals presente in this report were erive in the analyses using all ata. Source of Funing This stuy was performe without external funing; however, the costs of professional meical statistical avice were pai by our research fun. Results Clinical Results At the time of the final review, no patient ha been lost to follow-up an eight patients (ten hips) ha ie of causes not relate to the revision proceure. 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 ha not ha a repeat revision ha a mean Harris hip score of 79 points (range, 56 to 100 points). Frequently, isabling problems ue to rheumatoi arthritis in other joints lowere the hip score. One patient (one hip) ha moerate pain, four patients (five hips) ha mil pain, an the remaining patients ha no or slight pain. The mean visual analogue score (on a scale of 0 to 100, with 0 inicating no pain an 100 inicating unbearable pain) was 9.2 (range, 0 to 65) for hip pain at rest an 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 inicating not satisfie at all an 100 inicating complete satisfaction) was 83.9 (range, 50 to 100). Of the fourteen patients (eighteen hips), two use a wheelchair, two use a rolling walker, an two use a cane for walking longer istances. Repeat Revisions of the Acetabular Component Eight of the acetabular reconstructions were revise, with two of the revisions performe since the time of the previous report. Two repeat revisions were performe, at 0.7 an 1.3 years postoperatively, because of culture-proven septic loosening; neither of these cups was loose raiographically. Five revisions were performe, at 2.6, 3.5, 3.8, 9.8, an 16.3 years after the surgery, because of aseptic loosening of the cup. Four of the five aseptic failures occurre in hips with a reconstruction of a combine cavitary-segmental efect; one occurre in a hip with a reconstruction of a cavitary efect. The eighth repeat cup revision was performe 12.3 years after the reconstruction, uring a femoral revision proceure ue to aseptic loosening of the stem. The cup was revise because of polyethylene wear an

3 648 Fig. 1 Raiograph, mae seventeen years postoperatively, of a thirty-five-year-ol man with rheumatoi arthritis who ha loosening of a cemente cup in each hip. (The original raiographs may be seen in our previous report 1.) On the left sie, there was complete protrusion of the cup into the pelvis. Both hips were reconstructe with impaction bonegrafting. A small piece of metal mesh was use to close a limite meial wall efect in the right hip; this is an example of filling of a relatively simple cavitary efect. In the left hip, the large protrusio was containe with metal mesh an fille with cancellous bone graft. Metal mesh was then place into the graft be, an the cup was cemente in place. (This technique of placing the metal mesh on top of the graft is no longer use.) Both cups were still in situ without raiographic loosening at the time of the present stuy. A small amount of axial migration of the left cup was note in the first few months after the operation, but it i not progress subsequently. Clinically, both hips were functioning well at the last review. to be compatible with the new femoral component. However, this cup was well fixe both clinically an raiographically. Revisions of the Stem Six patients (six hips) unerwent a femoral stem revision, two because of eep sepsis an four because of aseptic loosening. Raiographic Results Raiographic follow-up was complete for thirty-three hips. The raiographs were examine to etermine the extent of the reconstruction, emarcation lines aroun the implants, migration of the cup, an failure. The extent of the graft reconstructions varie in technical ifficulty, from filling of cavitary efects only to reconstruction of combine segmental-cavitary efects with very large grafts (Fig. 1). Six cups ha raiographic evience of loosening, with raiolucent lines in three zones; five of these hips unerwent repeat revision because of the aseptic loosening. The other patient i not have a repeat revision because she ha only mil symptoms an was in poor meical conition. Of the hips with the cup still in situ, one ha progressive raiolucent lines in two zones an three ha progressive raiolucent lines in one zone. Two hips ha a nonprogressive raiolucency in zone 3, which ha been observe immeiately after the surgery. Complications Osteosynthesis was performe for treatment of a periprosthetic fracture of the femur that ha been etecte shortly after the inex revision proceure in one patient. This stem was seen to be loose at the final raiographic review, but a revision proceure was not recommene because the patient ha minimal symptoms. One hip unerwent a reoperation five ays after the inex surgery because of a postoperative sciatic nerve palsy in combination with a hematoma. There was complete recovery of nerve function following the ecompression. In another patient, a longer-neck femoral component was inserte to increase the offset of the femoral implant, two years after the acetabular reconstruction, because of recurrent islocations of the hip. No more islocations occurre. One patient sustaine a traumatic fracture of the femur at the

4 649 Fig. 2-A Fig. 2-B Kaplan-Meier survival curves up to fifteen years postoperatively with the en points of revision for any reason (Fig. 2-A), revision ue to aseptic loosening (Fig. 2-B), an raiographic failure (Fig. 2-C). The broken lines inicate the 95% confience bans. level of the tip of the femoral stem at six years following the inex surgery. The fracture heale after open reuction an plate fixation. Component Survival Kaplan-Meier analysis showe the probability of survival of the acetabular component at twelve years to be 80% (95% confience interval, 65% to 95%) with removal of the cup for any reason as the en point (Fig. 2-A). Excluing the two cases of septic cup loosening an the revision because of polyethylene wear, the probability of cup survival was 85% (95% confience interval, 71% to 99%) at twelve years with revision ue to aseptic loosening as the en point (Fig. 2-B). With raiographic failure as the en point, the probability of survival at twelve years was 73% (95% confience interval, 54% to 92%) (Fig. 2-C).

5 650 Fig. 2-C Conclusions Although the number of patients in our stuy is not large, we believe that our finings are important. The series was consecutive an the follow-up was complete, there was no selection bias because we always use impaction bone-grafting in hip revisions, an the reconstructions were performe for a variety of acetabular efects. We are aware of only two other reports on the outcome of acetabular revisions in patients with rheumatoi arthritis 5,6.We an the other two groups 1,5,6 have shown that the outcomes of cup revisions in patients with rheumatoi arthritis were inferior to those in patients without rheumatoi arthritis who were treate with the same techniques an followe for a comparable uration 7-9. At a mean of seven years after the surgery, the overall survival rate with aseptic loosening as the en point was 90% in our series an was similar to the survival rate after fully cemente revisions in a previous report 5. However, there was a striking ifference in the raiographic failure rates, calculate with use of the same criteria, between our stuy an the previous stuy 5.Rautetal. 5 observe an overall raiographic survival rate of the acetabular component of 64% at a mean of seven years. In contrast, at a mean of twelve years, our stuy showe an overall raiographic survival rate of 73%. Importantly, the only report available (to our knowlege) on the outcomes of acetabular revisions with use of a noncemente cup in patients with rheumatoi arthritis (thirty cups in twenty-eight patients) showe a rate of survival of the acetabular component of only 44% at nine years after the surgery 6. In conclusion, the application of impacte morselize bone graft in combination with a cemente cup is an attractive option for reconstruction of acetabular bone stock in revision total hip arthroplasty in patients with rheumatoi arthritis. In comparison with other techniques in patients with rheumatoi arthritis, this metho appeare to yiel more favorable results, an we continue to use it for acetabular revisions in patients with rheumatoi arthritis. n B. Willem Schreurs, MD, PhD Jaap Luttjeboer, MD Truike M. Thien, MD Maarten C. e Waal Malefijt, MD, PhD Pieter Buma, PhD René P.H. Veth, MD, PhD Tom J.J.H. Slooff, MD, PhD Department of Orthopaeics, Rabou University Nijmegen Meical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlans. aress for B.W. Schreurs: B.Schreurs@orthop.umcn.nl References 1. Schreurs BW, Thien TM, e Waal Malefijt MC, Buma P, Veth RP, Slooff TJ. Acetabular revision with impacte morselize cancellous bone graft an a cemente cup in patients with rheumatoi arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am. 2003;85: D Antonio JA, Capello WN, Boren LS, Bargar WL, Bierbaum BF, Boettcher WG, Steinberg ME, Stulberg SD, Wege JH. Classification an management of acetabular abnormalities in total hip arthroplasty. Clin Orthop Relat Res. 1989;243:

6 Conn RA, Peterson LFA, Stauffer RN, Ilstrup D. Management of acetabular eficiency; long-term results of bone-grafting the acetabulum in total hip arthroplasty. Orthop Trans. 1985;9: DeLee JG, Charnley J. Raiological emarcation of cemente sockets in total hip replacement. Clin Orthop Relat Res. 1976;121: Raut VV, Siney PD, Wroblewski BM. Cemente revision Charnley low-friction arthroplasty in patients with rheumatoi arthritis. J Bone Joint Surg Br. 1994;76: Mont MA, Domb B, Rajahyaksha AD, Paen DA, Jones LC, Hungerfor DS. The fate of revise uncemente acetabular components in patients with rheumatoi arthritis. Clin Orthop Relat Res. 2002;400: Schreurs BW, Slooff TJ, Buma P, Gareniers JW, Huiskes R. Acetabular reconstruction with impacte morsellise cancellous bone graft an cement. A 10- to 15-year follow-up of 60 revision cases. J Bone Joint Surg Br. 1998; 80: Raut VV, Siney PD, Wroblewski BM. Cemente revision for aseptic acetabular loosening. A review of 387 hips. J Bone Joint Surg Br. 1995;77: Etienne G, Bezwaa HP, Hungerfor DS, Mont MA. The incorporation of morselize bone grafts in cementless acetabular revisions. Clin Orthop Relat Res. 2004;428:241-6.