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Radiographic evaluation of 19 patients with Paprosky 3A and 3B submitted to acetabular review with trabecular metal wedge

ABSTRACT

Objective:

This study is aimed at evaluating the fixation of trabecular metal wedges in patients who underwent revision of total hip arthroplasty with large acetabular bone defects.

Methods:

The radiographs of 19 patients (21 hips), who underwent revision of total hip arthroplasty using trabecular metal wedges from September 2010 to December 2014 were evaluated. This study included only cases of Paprosky 3A and 3B. Preoperative and postoperative images were analyzed. Non-fixation of the implant was defined by the presence of angular variation of the component higher 10 degrees or displacement greater than 6 mm. Patients with follow-up times of less than 24 months or who did not attend the last two appointments were excluded from the study.

Results:

The mean follow-up time was 39.4 months (25-61). Fixation was achieved in all cases despite its complexity. There was only one case of dislocation that was treated with open reduction. One case developed infection, and was surgically approached on two occasions, with extensive debridement and intravenous antibiotics following protocol, with good evolution.

Conclusion:

The implanted trabecular metal wedges showed excellent results in the short- and medium-term and may represent another option in the reconstruction of large acetabular defects, sometimes replacing bone reconstruction that uses bone tissue banks or autologous graft.

Keywords:
Hip arthroplasty; Acetabulum; Prostheses and implants

RESUMO

Objetivo:

Avaliar a fixação das cunhas de metal trabeculado em pacientes submetidos a revisão de artroplastia do quadril com grandes defeitos ósseos acetabulares.

Métodos:

Foram avaliadas as radiografias de 19 pacientes, ou 21 quadris, submetidos a revisão de artroplastia do quadril com cunha de metal trabeculado de setembro de 2010 a dezembro de 2014. Foram incluídos somente os casos Paprosky 3 A E 3 B. Exames de imagem pré-operatórios e pós-operatório foram analisados. A não fixação do implante foi definida pela presença de variação angular do componente superior a 10 graus ou deslocamento superior a 6 mm. Pacientes com tempo de seguimento inferior a 24 meses ou aqueles que não compareceram às duas últimas consultas foram excluídos.

Resultados:

O tempo de seguimento médio foi de 39,4 meses (25-61). A fixação foi alcançada em todos os casos, apesar da complexidade. O único caso de luxação foi submetido a redução aberta. Um caso evoluiu com infecção, foi abordado cirurgicamente em dois momentos, com amplo desbridamento e uso de antibiótico venoso, conforme protocolo, e apresentou boa evolução.

Conclusão:

O implante em cunha de material trabeculado apresentou resultados excelentes em curto e médio prazos, pode ser mais uma opção nas reconstruções dos grandes defeitos acetabulares, por vezes substitui a reconstrução óssea com o uso de banco de ossos ou enxerto autólogo.

Palavras-chave:
Artroplastia de quadril; Acetábulo; Próteses e implantes

Introduction

Hip surgery reviews have become increasingly common in hip specialist practices, mainly associated with an exponential increase in total hip arthroplasty in Brazil and worldwide. It is estimated that 250,000 primary arthroplasties and 50,000 revision arthroplasties are performed annually in the United States.11 Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-97. Acetabular revision surgeries are generally classified according to the remaining bone stock, and the complexity of this procedure is a major challenge even for the more experienced surgeons (Fig. 1).

Fig. 1
Loosening of the acetabular component after reconstruction with Burch-Schneider acetabular reinforcement ring (3A defect).

When analyzing the history of revision surgery, the advancement in the area of acetabular defect filling materials has been extraordinary. Based on postoperative questionnaires, the clinical results have also shown a substantial improvement.

The preoperative understanding of bone defects is paramount for surgical planning. Among the several classifications in the literature, that by Paprosky et al.22 Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6 -year follow-up evaluation. J Arthroplasty. 1994;9(1):33-44. is one of the most used. In general, this classification assesses the presence or absence of osteolysis in three points: the ischium, the Kohler line, and the superior wall of the acetabulum.

The literature presents several options for the treatment of acetabular defects, each with positive and negative aspects. The technique involving acetabular reconstruction with trabecular metal is relatively new; its results have been more frequently published in recent years, especially in the complex Paprosky 3A and 3B defects, in order to re-establish the center of rotation of the hip.33 Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52.

4 Grappiolo G, Loppini M, Longo UG, Traverso F, Mazziotta G, Denaro V. Trabecular metal augments for the management of Paprosky type III defects without pelvic discontinuity. J Arthroplasty. 2015;30(6):1024-9.
-55 Steven BW, Raj B, Nigel JPH, Brewster T. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52.

Trabecular metal has been increasingly used in major hip surgery reference centers, both as an acetabular revision component, and as an option to fill acetabular defects. The high failure rate of traditional porous components when used in revision surgery can be explained not only by their physical and mechanical characteristics, but also by the difference in porosity when compared with trabecular metal, which in the latter can reach 75-80%.66 Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J Bone Joint Surg Br. 1999;81(5):907-14. This feature is very interesting, as it provides a much superior bone growth into the porosities when compared with traditional implants (Fig. 2).

Fig. 2
Electronic photomicrography demonstrating bone growth in the porous tantalum structure (Zimmer.com).

The trabecular metal wedge comes in several sizes and three shapes, which allows the filling of a wide diversity of bone defects.

This study is aimed to assess the fixation of trabecular metal implants in patients classified as Paprosky 3A and 3B who underwent total hip arthroplasty revision.

Methods

Between September 2010 and December 2014, 258 hip arthroplasty revisions were performed at the Hospital of Traumatology and Orthopedics. Of these, 19 patients (21 hips) were classified as Paprosky 3A or 3B, and underwent the trabecular metal wedge procedure aiming to reconstruct the bone defects. Follow-up time of less than 24 months and absence from the last two outpatient visits were the exclusion criteria.

The mean age of the patients was 56.8 years (35-76); 12 were males and seven, females. The mean follow-up time was 29.3 months (range: 14-55). The posterolateral access route was used in all patients. All patients underwent femoral component revision. In all cases, five fragments were collected for bacterial culture and antibiogram.

Patients were classified according to Paprosky et al.22 Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6 -year follow-up evaluation. J Arthroplasty. 1994;9(1):33-44. The results were analyzed using Student's t-test and considered significant when p < 0.05.

The criteria for the use of the trabecular metal wedge was lack of coverage (contact with the host bone) over 40%,77 Jasty M. Jumbo cups and morsalized graft. Orthop Clin N Am. 1998;29(2):249-54. or cases in which the initial stability of the component was not obtained and the wedges were used to stabilize the reconstruction system. In all cases, bone cement was used at the interface between the wedges, as well as between the wedges and the trabecular acetabular component.

In six patients under the age of 55 years, bone graft was used to restore the bone stock. In one case, an autologous graft was combined with bone tissue bank, and in five cases, only autologous graft from the posterior iliac crests was used.

No patients required postoperative drains. Patients were prescribed prophylactic subcutaneous low molecular weight heparin for 30 days.

The outpatient follow-up was performed according to the medical service's protocol, at three weeks, three months, six months, and one year postoperatively, and then annually thereafter. Patients were clinically evaluated according to the criteria of Merle D’Aubigné and Postel,88 D'Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36A(3):451-75. and radiologically with panoramic views of the pelvis and hip in anteroposterior and lateral views. With these complementary exams, osseointegration of the acetabular component was assessed according to the criteria set by Moore et al.99 Moore MS, McAuley JP, Young AM, Engh CA Sr. Radiographic signs of osseointegration in porous-coated acetabular components. Clin Orthop Relat Res. 2006;444:176-83. The presence of three or more has a positive predictive value of 96.9%. Wedge osseointegration failure was demonstrated when an angular variation greater than 10 degrees or component displacement greater than 6 mm were observed.1010 Abolghasemian M, Tangsataporn S, Sternheim A, Backstein D, Safir O, Gross AE. Combined trabecular metal acetabular shell and augment for acetabular revision with substantial bone loss: a mid-term review. Bone Joint J. 2013;95B(2):166-72. The position of the center of rotation in the pre- and postoperative period was assessed and compared with that of the contralateral hip.

Results

The mean number of previous surgeries was 1.3 (1-3), and the mean time since the last procedure was 10.68 years (6-17). Fig. 3 presents the division of cases studied according to the classification of Paprosky et al.22 Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6 -year follow-up evaluation. J Arthroplasty. 1994;9(1):33-44.

Fig. 3
Division of cases studied according to Paprosky's classification.

The center of rotation on preoperative radiographs was located at a mean of 38 mm (28-59) when compared with the contralateral side. In six cases, this parameter was not assessed due to contralateral arthroplasty (Fig. 4). In the postoperative period, two hips presented a center of rotation greater than 20 mm; however, these cases presented good clinical evolution.

Fig. 4
Bilateral revision of total hip arthroplasty. A, preoperative radiograph of the left hip showing severe acetabular defect (Paprosky 3B); B, perioperative imaging showing the use of trabecular metal wedge; C, panoramic postoperative radiograph of the pelvis.

All bacterial cultures collected during the procedures were negative.

Clinically, the patients were evaluated by the criteria of Merle D’Aubigne and Postel,88 D'Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36A(3):451-75. evolving from 6.67 points in the preoperative to 14.83 in the postoperative period. Student's t-test indicated that this difference was statistically significant (p < 0.0001).

The mean acetabular component size was 62 (54-74). An acetabular component coated with trabecular metal was used in all cases. All three types of wedges (semicircular, column support, and chock-shaped) were used; they are shown in Fig. 5.

Fig. 5
Types of wedges used for acetabular reconstruction.

The criteria for wedge instability were not observed, even in those that were not secured with screws, and used to promote the stability of the system in acetabular reconstruction (Fig. 6).

Fig. 6
Total hip arthroplasty revision. A, preoperative radiography showing severe acetabular defect (Paprosky 3B); B, perioperative photo showing the acetabular reconstruction with the aid of trabecular metal wedge (note the absence of screw fixation of the intermediate wedge); C, postoperative radiography.

All acetabular domes presented three or more fixation criteria. In all cases, 32 mm femoral heads were used.

Regarding complications, one patient presented postoperative dislocation and underwent surgical reduction. Another patient developed acute infection and underwent two surgical procedures for debridement and intravenous antibiotic application in accordance with the medical service protocol, presenting a satisfactory evolution. None of the complications resulted in loosening or instability of the acetabular component or of the trabecular metal wedge.

Discussion

The correct understanding of bone defects following total hip arthroplasty is a primary pillar of joint reconstruction. The increase in the number of revisions is directly proportional to the increase in the number of primary arthroplasties performed worldwide, especially in young patients. The various materials and new techniques available direct toward new ways of managing different acetabular bone defects. Several surgical options have been described, such as impacted grafts,1111 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. antiprotrusion rings,1212 Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME. Pelvic discontinuity in revision total hip arthroplasty. J Bone Joint Surg Am. 1999;81(12):1692-702.

13 Gross AE. Revision arthroplasty of the acetabulum with restoration of bone stock. Clin Orthop Relat Res. 1999;(369):198-207.

14 Saleh KJ, Jaroszynski G, Woodgate I, Saleh L, Gross AE. Revision total hip arthroplasty with the use of structural acetabular allograft and reconstruction ring: a case series with a 10 -year average follow- up. J Arthroplasty. 2000;15(8):951-8.
-1515 Gross AE, Goodman S. The current role of structural grafts and cages in revision arthroplasty of the hip. Clin Orthop Relat Res. 2004;(429):193-200. oblong components,1616 Berry DJ, Sutherland CJ, Trousdale RT, Colwell CW Jr, Chandler HP, Ayres D, et al. Bilobed oblong porous coated acetabular components in revision total hip arthroplasty. Clin Orthop Relat Res. 2000;(371):154-60.,1717 Chen WM, Engh CA Jr, Hopper RH Jr, McAuley JP, Engh CA. Acetabular revision with use of a bilobed component inserted without cement in patients who have acetabular bone- stock deficiency. J Bone Joint Surg Am. 2000;82(2):197-206. structured grafts,1818 Dewal H, Chen F, Su E, Di Cesare PE. Use of structural bone graft with cementless acetabular cups in total hip arthroplasty. J Arthroplasty. 2003;18(1):23-8. large components or jumbo cups,1919 Whaley AL, Berry DJ, Harmsen WS. Extra- large uncemented hemispherical acetabular components for revision total hip arthroplasty. J Bone Joint Surg Am. 2001;83A(9):1352-7. and acetabular components associated with trabecular metal wedges.2020 Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treatment of severe acetabular bone loss during revision hip arthroplasty. Clin Orthop Relat Res. 2004;(429):201-8.

21 Sporer SM, Paprosky WG. The use of a trabecular metal acetabular component and trabecular metal augment for severe acetabular defects. J Arthroplasty. 2006;21 6 (Suppl. 2):83-6.
-2222 Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467(1):199-205.

The literature indicates significant failure rates in reconstructions with structured graft, which are attributed to the slow bone incorporation, which in turn leads to the instability of the acetabular component.2323 Sporer SM, O'Rourke M, Chong P, Paprosky WG. The use of structural distal femoral allografts for acetabular reconstruction. Average ten- year follow- up. J Bone Joint Surg Am. 2005;87(4):760-5. Oblong prostheses tend to restore the center of rotation. Nonetheless, the literature describes a high failure rate.2424 Mäkinen TJ, Kuzyk P, Safir OA, Backstein D, Gross AE. Role of cages in revision arthroplasty of the acetabulum. J Bone Joint Surg Am. 2016;98(3):233-42. Reconstruction with antiprotrusion rings is an excellent option. However, some studies report a failure index associated with non incorporation of the graft, failure of the implant in promoting adequate biological fixation, and the need for a bone tissue bank for this procedure.1515 Gross AE, Goodman S. The current role of structural grafts and cages in revision arthroplasty of the hip. Clin Orthop Relat Res. 2004;(429):193-200. Regis et al.2525 Regis D, Sandri A, Bonetti I. Acetabular reconstruction with the Burch- Schneider antiprotrusion cage and bulk allografts: minimum 10 -year follow-up results. Biomed Res Int. 2014;2014:194076.,2626 Regis D, Sandri A, Bonetti I, Bortolami O, Bartolozzi P. A minimum of 10 -year follow-up of the Burch- Schneider cage and bulk allografts for the revision of pelvic discontinuity. J Arthroplasty. 2012;27(6):1057-63. reported that 9.23% of complications were related to aseptic loosening or breakage, higher in type 3B defects. A study published in 20121515 Gross AE, Goodman S. The current role of structural grafts and cages in revision arthroplasty of the hip. Clin Orthop Relat Res. 2004;(429):193-200. presented a survival rate of 72.2% after a minimum follow-up of 10 years. Beckmann et al.2727 Beckmann NA, Weiss S, Klotz MC, Gondan M, Jaeger S, Bitsch RG. Loosening after acetabular revision: comparison of trabecular metal and reinforcement rings. A systematic review. J Arthroplasty. 2014;29(1):229-35. published a comparative study between an antiprotrusion ring and trabecular metal that demonstrated a statistically lower rate of loosening with trabecular metal wedge when compared to the antiprotrusion ring in all degrees of acetabular defects, with an apparently greater benefit in severe cases.

The use of trabecular metal wedges has become attractive in revisions with large bone defects, mainly regarding the stability obtained in the reconstruction and the versatility in its use,2828 Meneghini RM, Meyer C, Buckley CA, Hanssen AD, Lewallen DG. Mechanical stability of novel highly porous metal acetabular components in revision total hip arthroplasty. J Arthroplasty. 2010;25(3):337-41. the nonrelation with graft resorption, and the absence of donor area morbidity or the need for a bone tissue bank as a source for filling bone defects.2727 Beckmann NA, Weiss S, Klotz MC, Gondan M, Jaeger S, Bitsch RG. Loosening after acetabular revision: comparison of trabecular metal and reinforcement rings. A systematic review. J Arthroplasty. 2014;29(1):229-35.,2929 Garbuz D, Morsi E, Gross AE. Revision of the acetabular component of a total hip arthroplasty with a massive structural allograft. Study with a minimum five- year follow- up. J Bone Joint Surg Am. 1996;78(5):693-7.

In 2006, Sporer and Paprosky2121 Sporer SM, Paprosky WG. The use of a trabecular metal acetabular component and trabecular metal augment for severe acetabular defects. J Arthroplasty. 2006;21 6 (Suppl. 2):83-6. published a series of 28 hips, classified only as Paprosky 3A or 3B, and did not report aseptic loosening. Borland et al.33 Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52. analyzed 24 patients after a mean follow-up of five years and reported one case of failure due to wedge rupture, which required a second revision. In 2015, Whitehouse et al.3030 Whitehouse MR, Masri BA, Duncan CP, Garbuz DS. Continued good results with modular trabecular metal augments for acetabular defects in hip arthroplasty at 7 to 11 years. Clin Orthop Relat Res. 2015;473(2):521-7. observed a wedge survival rate of 92% in ten years of follow-up. In 2009, Siegmeth et al.2222 Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467(1):199-205. published a retrospective study of 37 patients with two cases of aseptic loosening, both of which were classified as 3A. Van Kleunen et al.3131 Van Kleunen JP, Lee GC, Lementowski PW, Nelson CL, Garino JP. Acetabular revisions using trabecular metal cups and augments. J Arthroplasty. 2009;24 6 Suppl.:64-8. evaluated 97 patients who underwent this technique, and did not report this complication. Weeden et al.3232 Weeden SH, Schmidt RH. The use of tantalum porous metal implants for Paprosky 3A and 3B defects. J Arthroplasty. 2007;22 6 (Suppl. 2):151-5. analyzed 43 patients, only 3A and 3B defects, and reported a 98% survival rate in 2.8 years of follow-up. Lakstein et al.3333 Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE. Trabecular metal cups for acetabular defects with 50% or less host bone contact. Clin Orthop Relat Res. 2009;467(9):2318-24. reported an 8% failure rate in a four-year follow-up with the tantalum acetabular component when support/stability wedges were not used in contact failures greater than 50%. The present study assessed 19 patients, with a mean follow-up time of 39.4 months, and found a wedge fixation rate of 100% according to radiographic criteria.

According to Makinen et al.,2424 Mäkinen TJ, Kuzyk P, Safir OA, Backstein D, Gross AE. Role of cages in revision arthroplasty of the acetabulum. J Bone Joint Surg Am. 2016;98(3):233-42. the clinical outcome is directly related to preoperative bone loss. Borland et al.33 Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52. reported a significant improvement in the WOMAC (p < 0.0001) and SF-36 scores (p < 0.05). Siegmeth et al.2222 Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467(1):199-205. reported that the vast majority of patients presented a significant quality of life improvement. Grappiolo et al.44 Grappiolo G, Loppini M, Longo UG, Traverso F, Mazziotta G, Denaro V. Trabecular metal augments for the management of Paprosky type III defects without pelvic discontinuity. J Arthroplasty. 2015;30(6):1024-9. reported a Harris Hip Score of 40 preoperatively, vs. 90.5 postoperatively. Hasart et al.3434 Hasart O, Perka C, Lehnigk R, Tohtz S. Reconstruction of large acetabular defects using trabecular metal augments. Oper Orthop Traumatol. 2010;22(3):268-77. assessed only patients with Paprosky 3A and 3B defects, using the evaluation criteria of Merle D’Aubigne and Postel,88 D'Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36A(3):451-75. and reported an improvement from 6 to 13 points in the postoperative period. Similar increments to those found in the literature were observed in the present patients, with a preoperative mean of 6.67 vs. 4.83 in the postoperative period; the best parameter was improvement of pain.

In the present study, a bone graft was used in six cases, all younger than 55 years of age, in order to restore the lost bone stock (Fig. 7). Borland et al.33 Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52. used a similar technique in 24 patients, with a mean follow-up of five years and graft incorporation. Gunther et al.3535 Günther KP, Wegner T, Kirschner S, Hartmann A. Modular reconstruction in acetabular revision with antiprotrusion cages and metal augments: the cage-and-augment system. Oper Orthop Traumatol. 2014;26(2):141-55. evaluated 44 patients, with a mean follow-up of 38.8 months, and did not observe migration or loosening of implants with bone graft associated with trabecular metal wedges.

Fig. 7
Total left hip arthroplasty revision with acetabular reconstruction. A, preoperative radiograph showing severe acetabular defect on the left (Paprosky 3B); B, perioperative imaging showing the use of chock-shaped column support trabecular metal wedge; C, panoramic postoperative radiograph of the pelvis.

The improvement of the center of rotation is described as paramount for improvement in gait ability in the postoperative period, due to a better conditioning of the abductor muscles; it also causes less wear on the bearing surface and present a lower rate of aseptic loosening.3636 Visuri T, Koskenvuo M, Honkanen R. The influence of total hip replacement on hip pain and the use of analgesics. Pain. 1985;23(1):19-26.,3737 Delp SL, Wixson RL, Komattu AV, Kocmond JH. How superior placement of the joint center in hip arthroplasty affects the abductor muscles. Clin Orthop Relat Res. 1996;(328):137-46. Abolghasemian et al.1010 Abolghasemian M, Tangsataporn S, Sternheim A, Backstein D, Safir O, Gross AE. Combined trabecular metal acetabular shell and augment for acetabular revision with substantial bone loss: a mid-term review. Bone Joint J. 2013;95B(2):166-72. reported improvement in the location of the center of rotation in 79.4% of the hips. Siegmeth et al.2222 Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467(1):199-205. reported improvement in 91% of cases; one of the three cases in which the center of rotation was greater than 35 mm evolved with wedge loosening and underwent a second revision. Callado et al.3838 Callado VM, Kimura OS, Leal DC, Sousa Filho PG, Fernandes MBC, Freitas EH. Evaluation of the fixation of the trabecular metal wedge in patients undergoing revision of total hip arthroplasty. Rev Bras Ortop. 2014;49(4):364-9. reported a mean improvement in the center of rotation of 17 mm; in the preoperative period, 55.5% of the cases were above 35 mm. In the present study, the center of rotation was located 38 mm higher than the contralateral side; 77.7% of the cases measured in the pre-operative period were above 35 mm. In the postoperative period, two cases remained with a center of rotation greater than 20 mm, without clinical and radiographic repercussion until the last outpatient evaluation.

As complications, in the present study there was one case of dislocation and one case of infection treated with surgical debridement and venous antibiotic. Until the last follow-up assessment, none of the complications had led to loosening of the components. The authors believe that the case of dislocation was related to a patient who had been bedridden for almost two years while awaiting the procedure; this patient had a history of two previous procedures and severe impairment of the abductor muscles. The patient who developed acute infection was in his second surgery and had been diagnosed with severe rheumatoid arthritis. Callado et al.3838 Callado VM, Kimura OS, Leal DC, Sousa Filho PG, Fernandes MBC, Freitas EH. Evaluation of the fixation of the trabecular metal wedge in patients undergoing revision of total hip arthroplasty. Rev Bras Ortop. 2014;49(4):364-9. reported one case of infection in 23 Paprosky 3B cases. Van Kleunen et al.3131 Van Kleunen JP, Lee GC, Lementowski PW, Nelson CL, Garino JP. Acetabular revisions using trabecular metal cups and augments. J Arthroplasty. 2009;24 6 Suppl.:64-8. reported an infection rate of 8.2% in 97 cases. In their series, Siegmeth et al.2222 Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467(1):199-205. reported a 5.4% rate of complications. Borland et al.33 Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52. reported no complications in their series. The complication rate observed in the present study is consistent with the literature for such a complex sample.

Conclusion

The use of the trabecular metal wedges in revision surgeries for cases with severe bone defects (Paprosky 3A and 3B) present good clinical results and high survival in the short- and medium-terms, representing an alternative in complex joint reconstructions.

References

  • 1
    Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87(7):1487-97.
  • 2
    Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6 -year follow-up evaluation. J Arthroplasty. 1994;9(1):33-44.
  • 3
    Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52.
  • 4
    Grappiolo G, Loppini M, Longo UG, Traverso F, Mazziotta G, Denaro V. Trabecular metal augments for the management of Paprosky type III defects without pelvic discontinuity. J Arthroplasty. 2015;30(6):1024-9.
  • 5
    Steven BW, Raj B, Nigel JPH, Brewster T. Use of porous trabecular metal augments with impaction bone grafting in management of acetabular bone loss. Acta Orthop. 2012;83(4):347-52.
  • 6
    Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J Bone Joint Surg Br. 1999;81(5):907-14.
  • 7
    Jasty M. Jumbo cups and morsalized graft. Orthop Clin N Am. 1998;29(2):249-54.
  • 8
    D'Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36A(3):451-75.
  • 9
    Moore MS, McAuley JP, Young AM, Engh CA Sr. Radiographic signs of osseointegration in porous-coated acetabular components. Clin Orthop Relat Res. 2006;444:176-83.
  • 10
    Abolghasemian M, Tangsataporn S, Sternheim A, Backstein D, Safir O, Gross AE. Combined trabecular metal acetabular shell and augment for acetabular revision with substantial bone loss: a mid-term review. Bone Joint J. 2013;95B(2):166-72.
  • 11
    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.
  • 12
    Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME. Pelvic discontinuity in revision total hip arthroplasty. J Bone Joint Surg Am. 1999;81(12):1692-702.
  • 13
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Publication Dates

  • Publication in this collection
    Jan-Feb 2018

History

  • Received
    08 Sept 2016
  • Accepted
    24 Jan 2017
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br