Use of homologous graft in hip arthroplasty reviews with acetabular component cementation

Abstracts

A artroplastia total do quadril representa um grande avanço no tratamento das enfermidades ortopédicas que acometem o quadril. A soltura asséptica desta prótese pode causar lesões e perdas ósseas, representando um grande desafio para a reconstrução cirúrgica destas artroplastias. Uma das alternativas para a reconstrução é o uso do enxerto ósseo de banco de ossos, podendo este ser usado em bloco ou na forma picada. Este estudo, baseado em uma revisão da literatura sobre enxertos ósseos, teve como objetivo uma análise quanto à reconstrução com enxertos em bloco e picado e sua integração. O enxerto picado mostrou melhores resultados quanto à integração quando se consegue estabilidade da reconstrução. Quando não conseguimos uma boa estabilidade, o enxerto em bloco associado aos anéis de reforço sobressai como a melhor opção.

Revisão; Acetábulo; Transplante homólogo

ORIGINAL ARTICLE

Use of homologous graft in hip arthroplasty reviews with acetabular component cementation

Fábio Stuchi Devito^I; Rudelli Sergio Andrea Aristides^II; Emerson Kiyoshi Honda^III; Alceu Gomes Chueire^IV

^IMaster in Medicine, contracted of the Department of Orthopaedics and Traumatology, Medical College, São José do Rio Preto-SP, former fellow of the Princess Elizabeth Orthopaedic Center Exeter

^IIPhD Professor, Consultant, Hip Group of the Department of Orthopaedics and Traumatology, Santa Casa de Misericórdia de São Paulo – "Fernandinho Simonsen" Building

^IIIHead of Hip Group, Department of Orthopaedics and Traumatology, Santa Casa de Misericórdia de São Paulo – "Fernandinho Simonsen" Building

^IVChairman of the Discipline of Orthopaedics and Traumatology, Medical College, São José do Rio Preto-SP

^{Correspondences to}

SUMMARY

Hip total arthroplasty represents a breakthrough in the treatment of orthopaedic illnesses affecting the hip. The aseptic loosening of this prosthesis may cause injuries and bone losses, representing a great challenge for the surgical reconstruction of those arthroplasties.One alternative to reconstruction is the use of bone graft sourced by bone bases, which may be used as a block or in pieces. This study, based on a literature review addressing bone grafts, had as an objective to analyze reconstruction with grafts in blocks and in pieces and its union. The graft in pieces showed better results concerning union when reconstruction stability is achieved. When a good stability cannot be achieved, the graft in block combined with reinforcement rings is highlighted as the best option.

Keywords: Revision; Acetabulum; Transplantation, homologous.

INTRODUCTION

Bone injuries caused by implants migration constitute cavities with bone structure loss, make prosthesis review difficult, and currently represent a great challenge for hip surgeons.

In this situation, some therapeutic alternatives must be selected, such as the use of large-dimension prosthesis in an attempt to fill that cavity; felling this gap with bone cement; acetabulum implantation with rotation center lift, arthroplastic resection and reconstruction with bone grafts ^(1,2).

The reconstruction with bone graft has been shown to be a very attractive method, in addition of being a biological solution, because it is possible to fix an acetabular bone injury, reestablish hip biomechanics and use a normal sized prosthesis ^(1,3).

Bone grafts can be divided into: autologous, homologous and heterologous. The incorporation process for a bone graft, whether homologous or autologous, is represented by a sequence of events caused by the graft and by the receptor. That graft’s receptor contributes to the formation of blood vessels and cells required for repairing the process. The graft serves as a support structure in which that receptor’s response will occur, being this phase named osteoconduction. The matrix of graft and growth factors and residual cells promote an intense cell activity in the receptor, which is necessary for bone formation, being this process named osteoinduction ⁽⁴⁾.

The use of bone grafts in review surgeries of hip arthroplasties with acetabular component cementation has been made with two methods according to the size of bone fragment: the minced form and/or the bone block^(1,2,3,5,6). Regarding the kind of reconstruction, the most used treatment method has been the minced and impacted graft associated to metal mesh (Figures 1A and 1B) or, the bone graft in blocks with or without reinforcement ring (Figures 2 A and 2 B).

The objective of this study was to assess a current trend towards the use of block and minced bone grafts in the medium and long term, in acetabular reviews of hip total prosthesis with acetabular component cementation, based on relevant studies on homologous bone graft use in acetabular reviews of cemented hip total prosthesis.

RESULTS

We found 135 articles published between 1966 and 2002.

We used 20 articles we regarded as the most important ones, addressing the use of block and minced graft, and both kinds.

DISCUSSION

Regarding bone union, it seems that it undoubtedly occurs. However, Jasty and Harris, in 1990, reported a high resorption rate in block grafts, evolving to 32% of reconstruction failure in six years of follow-up ⁽⁶⁾.

Some authors ^(6,7,8) make confusion, and, most of the times, do not distinguish the mechanisms of the expressions bone union and bone integration, which, in our point of view, represent quite different situations, where bone integration is essentially important for bone stock restoring and for a longer prosthesis durability ⁽⁹⁾.

It was Conn who determined the X-ray criteria for bone integration interpretation during X-ray follow-up. He regards a graft as integrated when radiodensity between the graft and the receptor bone is identical, and when a continuous trabecular matrix is formed on the graft- receptor interface, evidencing a new trabecular pattern, according to the loads applied on that region, then occurring bone reorganization. However, Azuma et al., in 1994, regarded a graft as incorporated when the sclerotic line, which is present on the graft-receptor interface, disappears, with normal density restoring ^(10,11).

However, those X-ray criteria for bone integration analysis are difficult to interpret, mostly in the presence of a metal mesh or an acetabular reinforcement ring. Only with a histological study we would be able to state or prove bone integration ^(1,5,10).

The vast majority of acetabular reconstructions with bone blocks do not present graft or acetabular component migration process^(6,7,8); this is because, at first, the bone block provides higher stability to the reconstruction when compared to a reconstruction made with small fragments. Acetabular reconstructions with minced graft often evidence acetabular component migration, or a change on acetabular bent angle. This happens because, when we use a minced graft in acetabular reconstructions, it is possible that an acetabular component migration, or a change on acetabular bent occurs, but that component is not loose ^{(1,5,9,11-14)}.

The small bone blocks serve as a support for the acetabular component and usually support less than 50% of the acetabular element. Some studies^(15,16) report up to 78.4% of acetabular element survival in a follow-up period of nearly 10 years. The large bone blocks used in massive bone injuries with acetabular element cementation and supporting more than 50% of the acetabular component present the worst results in this kind of reconstruction with the use of block grafts. They have a rate of up to 32% of reconstruction failure in a six-year follow-up, therefore, the use of a reinforcement ring is recommended for such cases ^(6,17).

Acetabular reconstructions with minced graft showed encouraging early results ^(1,5,9). A rate of 94% good results is reported in prosthesis reviews with minced and impacted graft in a mean follow-up time of 12 years and, even in patients below 50 years old, they presented a rate of 91% good results. In patients submitted to acetabular reconstruction in primary surgeries for prosthesis, they achieved similar results to those for review surgeries, the use of minced graft, in some autologous case, presented the same characteristics and revascularization and integration ability.

Some studies addressing block grafts in tumor and review surgeries ^(18,19) show a slow union, limited only to a few millimeters, leaving the central portion of the block with the presence of necrotic bone. The cortical bone shows an inflammatory response predominantly accompanied by osteoclast activity, causing a temporary enlargement of Haversian channels, resulting in mechanical laxity of the graft.

The histological analysis of biopsies taken in acetabular reconstructions with minced and impacted graft shows that, within a period of eight to nine months after review surgery, there already were signs of revascularization and immature bone formation ^(1,5,9,20). Donk et al., in 2002, reported the results of 24 biopsies performed 3 months to 15 years after review surgeries, and, in the first six months, there was a fast graft revascularization and immature bone formation. Subsequently, this newly-formed bone will undergo a remodeling process into lamellar bone, and, after ten years postoperatively, more than 90% of the graft is integrated^(1,20).

CONCLUSIONS

In cavitary defects, the use of grafts from bone libraries in its minced and impacted form represents the best way to apply that graft, as well as the best results.

In segmental defects, whenever transforming a segmental defect into a cavitary one with the aid of a reinforcement mesh, and achieving a good reconstruction stability are possible, the minced and impacted graft on acetabulum provides the best results.

When using a minced graft is impossible, the use of a block graft is an alternative.

REFERENCES

Received in: 03/29/06; approved in: 07/22/06

Study conducted at the Department of Orthopaedics and Traumatology, Medical Sciences College, Santa Casa de São Paulo – "Pavilhão Fernandinho Simonsen".

• 1. Slooff TJ, Buma P, Gardeniers JW, Schreurs W, Schimmel JW, Huiskes R. Revision of the acetabular component: bone packing. In: Callaghan JJ, Rosenberg AG, Rubash HE. Adult hip. New York: Lippincott-Raven; 1998. p.1449-60.
• 2. Leopold SS, Jacobs JJ, Rosenberg AG. Cancellous allograft in revision total hip arthroplasty. A clinical review. Clin Orthop Relat Res. 2000; 371:86-97.
• 3. Gross AE, Allan DG, Catre M, Garbuz DS, Stockley I. Bone grafts in hip replacement surgery. The pelvic side. Orthop Clin North Am. 1993; 24:679-95.
• 4. Muscolo DL, Ayerza MA. Allografts. In Callaghan JJ, Rosenberg AG, Rubash HE. Adult hip. New York: Lippincott-Raven; 1998. p.297-312.
• 5. Slooff TJ, Buma P, Schreurs BW, Schimmel JW, Huiskes R, Gardeniers J. Acetabular and femoral reconstruction with impacted graft and cement. Clin Orthop Relat Res. 1996; 324:108-15.
• 6. Jasty M, Harris WH. Salvage total hip reconstrution in patients with major acetabular bone deficiency using structural femoral head allografts. J Bone Joint Surg Br. 1990, 72:63-7.
• 7. Chagas AM, Camisa Júnior A, Dozza PR, Roos MV. O enxerto ósseo homólogo de banco em cirurgia de revisão com prótese total de quadril não cimentada. Rev Bras Ortop 1993; 28:309-14.
• 8. Garbuz D, Morsi E, Gross AE. Revision of the acetabular component on total hip artroplasty with a massive structural allograft. J. Bone Joint Surg Am. 1996; 78:693-7.
• 9. Schreurs BW, Slooff TJ, Gardeniers JW, Buma P. Acetabular reconstruction with bone impaction grafting and a cemented cup. "20 Years" experience. Clin Orthop Relat Res. 2001; 393:202-15.
• 10. Heekin RD, Engh CA, Vinh T. Morsellized allograft in acetabular reconstruction, a postmortem retrieval analysis. Clin Orthop Relat Res. 1995; 319:184-90.
• 11. Azuma T, Yasuda H, Okagaki K. Compressed allograft chips for acetabular reconstruction in revision hip artroplasty. J Bone Joint Surg Br. 1994; 76: 740-4.
• 12. Schimmel JW, Buma P, Versleyen D, Huiskes R, Slooff TJ. Acetabular reconstruction with impacted morselized cancellous allografts in cemented hip arthroplasty. A histological and biomechanical study on the goat. J Arthroplasty. 1998; 13: 438-48.
• 13. Ornstein E, Franzén H, Johnsson R, Sandquist P, Stefánsdóttir A, Sundberg M. Migration of the acetabular component after revision with impacted morselized allografts. Acta Orthop Scand. 1999; 70: 338-42.
• 14. Giensen EB, Lamerigts MP, Verdonschot N, Buma P, Schreurs BW, Huiskes R. Mechanical characteristics of impacted morsellised bone grafts used in revision total hip arthtroplasty. J Bone Joint Surg Br. 1999; 81:1052-7.
• 15. Gross AE. Revision arthroplasty of the acetabulum with restoration of bone stock. Clin Orthop Relat Res. 1999, 369:198-207.
• 16. Woodgate IG, Saleh HJ, Jaroszynski G, Agnidis Z, Woodgate MM, Gross AE. Minor column structural acetabular allografts in revision hip arthroplasty. Clin Orthop Relat Res. 2000; 371:75-85.
• 17. Gill TJ, Sledge JB, Müller ME. The management of severe acetabular bone loss using structural allograft and acetabular reinforcement devices. J. Arthroplasty. 2000; 15: 1-7.
• 18. Enneking WF, Mindell ER. Observations on massive retrieved human allografts. J. Bone Joint Surg Am. 1991; 73:1123-42.
• 19. Hooten JP, Engh CA, Heekin RD, Vinh TN. Structural bulk allografts in acetabular reconstruction. Analysis of two grafts retrieved at post-mortem. J Bone Joint Surg Br. 1996; 78:270-5.
• 20. Donk SV, Buma P, Slooff TJ, Gardeniers JW, Schereurs BW. Incorporation of morselized bone grafts: a study of 24 acetabular biopsy specimens. Clin Orthop Relat Res. 2002; 396:131-41.

Publication Dates

• Publication in this collection
  20 Dec 2006
• Date of issue
  2006

History

• Accepted
  22 July 2006
• Received
  29 Mar 2006