Retention of a well-fixed acetabular component in the setting of massive acetabular osteolysis and pelvic discontinuity: A case report

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1 Washington University School of Meicine Digital Open Access Publications Retention of a well-fixe acetabular component in the setting of massive acetabular osteolysis an pelvic iscontinuity: A case report Murat Pekmezci San Francisco General Hospital (SFGH) an UCSF Library James Keeney Wilfor Hall Meical Center Amana Schutz Washington University School of Meicine in St. Louis John C. Clohisy Washington University School of Meicine in St. Louis Follow this an aitional works at: Part of the Meicine an Health Sciences Commons Recommene Citation Pekmezci, Murat; Keeney, James; Schutz, Amana; an Clohisy, John C.,,"Retention of a well-fixe acetabular component in the setting of massive acetabular osteolysis an pelvic iscontinuity: A case report." The Journal of Bone an Joint Surgery.91, (2009). This Open Access Publication is brought to you for free an open access by Digital Commons@Becker. It has been accepte for inclusion in Open Access Publications by an authorize aministrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.eu.

2 2232 COPYRIGHT Ó 2009 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Retention of a Well-Fixe Acetabular Component in the Setting of Massive Acetabular Osteolysis an Pelvic Discontinuity ACaseReport By Murat Pekmezci, MD, James Keeney, MD, Amana Schutz, PhD, an John C. Clohisy, MD Investigation performe at the Department of Orthopaeic Surgery, Washington University School of Meicine, St. Louis, Missouri The management of massive pelvic osteolysis can pose a substantial challenge when a revision total hip arthroplasty is performe. For patients with well-fixe, wellpositione acetabular components an with containe osteolytic efects, retention of the prosthesis with bone-grafting of the osteolytic lesions is an accepte surgical strategy 1-4. In contrast, in the setting of massive osteolysis with pelvic iscontinuity, the acetabular component is usually loose an must be revise. To our knowlege, the uncommon clinical scenario in which pelvic iscontinuity an massive osteolysis are associate with a well-fixe acetabular component has not been iscusse in the literature. In the following case report, we escribe the surgical treatment an clinical results of a patient with this challenging combination of problems. The patient was manage with acetabular component retention, open reuction an internal fixation of the iscontinuity, an morselize bonegrafting of the osteolytic bone efects. The patient was informe that ata concerning the case woul be submitte for publication, an she consente. Case Report Asixty-one-year-ol woman presente to us with rightsie groin pain nine years after a right primary total hip arthroplasty. The postoperative course ha been uncomplicate, an she ha remaine asymptomatic until eight months prior to the time of presentation. She ha no history of trauma. The pain was worse with activity an improve with rest. She ha no fever or other constitutional symptoms. The meical history was notable for obesity, coronary artery isease that require coronary artery bypass grafting six months prior to presentation, an a previous episoe of iverticulitis, which require a partial colectomy to manage acute intestinal obstruction. She also ha a history of cholecystectomy, multiple hernia repairs, an left hip an right knee replacements. She was retire, ivorce, an living alone. The cariovascular isease limite her to walking insie her home. On physical examination, she ha a well-heale posterolateral hip incision, a moerate limp, a positive Trenelenburg sign on the right sie, an relative shortening of the affecte extremity of 10 mm. The range of motion of the affecte hip was 90 of flexion, 30 of abuction, 10 of auction, 10 of internal rotation in extension, an 20 of external rotation in extension. Log-rolling of the right lower extremity elicite mil groin pain. The Harris hip score was 69 points at the time of presentation. Raiographic evaluation, incluing both anteroposterior an Juet raiographs, emonstrate massive periacetabular osteolysis an pelvic iscontinuity (Figs. 1-A an 1-B). The osteolysis was iffuse an involve the superolateral, posterior, meial, an inferior periacetabular regions. The superomeial aspect of the acetabular shell appeare to be integrate with the ilium. There was eccentricity of the articulation of the femoral hea, inicating substantial polyethylene wear. There was resorption of the proximal-meial aspect of the femoral neck, but the femoral component appeare to be stable without evience of osteolysis. Compute tomographic scans confirme the finings of extensive osteolysis an pelvic iscontinuity. Consistent with the plain raiographs, the acetabular component appeare to be well fixe to the ilium along the superior, posteromeial surface (Figs. 2- A an 2-B). Because of the symptoms of progressive hip pain with activity, an the finings of massive pelvic osteolysis an pelvic iscontinuity, we anticipate potential catastrophic failure of the construct an thus recommene surgical intervention. A spectrum of potential treatment options was iscusse. Given the low functional emans of the patient an the extent of the meical comorbiities, the surgeon an patient agree to a 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. No commercial entity pai or irecte, or agree to pay or irect, any benefits to any research fun, founation, ivision, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immeiate families, are affiliate or associate. J Bone Joint Surg Am. 2009;91: oi: /jbjs.h.01336

3 2233 Fig. 1-A Fig. 1-B Anteroposterior pelvic (Fig. 1-A) an iliac oblique (Fig. 1-B) raiographs emonstrate massive periacetabular osteolysis (white arrows) an pelvic iscontinuity (black arrow).

4 2234 Fig. 2-A Compute tomographic scan emonstrating massive periacetabular bone estruction at the level of the hip joint center. There is almost complete loss of all periacetabular bone at this level (white arrows) (Fig. 2-A). The superior posteromeial aspect of the acetabulum with osseous ingrowth supporting the component is well visualize (white arrow) (Fig. 2-B). Fig. 2-B

5 2235 Fig. 3 Nonarticular polyethylene wear ue to osseous abrasion (arrow) from the freely mobile ischium is emonstrate. The metallic shell appears to be well fixe an unamage. plan of reconstruction that minimize the magnitue of the proceure, to the extent possible. The hip revision was performe with the patient in the lateral ecubitus position uner general anesthesia, an the hip was expose through a Kocher-Langenbeck approach. The femoral component was well fixe an aequately positione. The acetabular component was well positione an well fixe to the superior, posteromeial pillar of the ilium as suggeste by the imaging stuies, but there was massive bone loss in the superolateral aspect of the acetabulum, the posterior column, the meial wall, the anterior column, an the ischium. The superolateral osteolytic lesion was containe, while the remaining lesions were uncontaine. Frank iscontinuity of the hemipelvis was present as emonstrate by free motion between the superior an inferior portions of the hemipelvis. The inferior, nonarticulating margin of the polyethylene liner showe major wear that was attribute to abrasion from the ajacent mobile ischium (Fig. 3). The metallic shell was not amage. These intraoperative observations inicate to us that acetabular component removal woul result in a massive uncontaine acetabular efect that woul require a major structural allograft an reconstructive cage. Since the acetabular component was well fixe an the patient ha low functional emans, we ecie to retain the acetabular component, perform open reuction an internal fixation of the posterior column, an place morselize allografts in the osteolytic lesions. The eficient posterior column was packe with morselize graft, an the iscontinuity was reuce an fixe with ouble plating with use of eight an twelve-hole 4.5-mm reconstruction plates (Figs. 4-A an 4-B). The remaining periprosthetic osteolytic areas were packe with morselize allograft. The reconstruction was complete with cementation of a 32-mm inner iameter, 10 lippe acetabular liner (Longevity; Zimmer, Warsaw, Iniana) an placement of a 32-mm-iameter femoral hea with a 12-mm neck length (DePuy, Warsaw, Iniana). A cemente liner was use because of the suboptimal liner locking mechanism of the retaine acetabular component. The postoperative course was uneventful. The patient walke using a touch-own weight-bearing gait for three months postoperatively. She was then avance to 50% partial weight-bearing for one month an to full weight-bearing four months after surgery. The patient was last seen twenty-eight months after surgery, an the hip was asymptomatic. The Harris hip score was 87 points. Raiographs mae at that time emonstrate apparent healing of the iscontinuity an incorporation of the morselize bone graft (Fig. 5). The acetabular component was well fixe with no sign of loosening or migration. Discussion Periacetabular osteolysis can range in severity from small containe lesions to massive uncontaineefects with pelvic iscontinuity. The primary treatment goal is to achieve bone stock restoration an stable acetabular fixation 4. When patients with massive pelvic osteolysis present with a loose cup, the ecision to procee with acetabular component revision is straightforwar. However, in the setting of a well-positione an osseointegrate cup, the optimal approach has not been conclusively establishe. Some authors have recommene

6 2236 Fig. 4-A Fig. 4-B The pelvic iscontinuity has been reuce an stabilize with ouble plating of the posterior column with use of two reconstruction plates (Fig. 4-A), an morselize bone graft has been place in the periacetabular osteolytic efects (Fig. 4-B). preservation of a well-fixe cup an grafting of the efect if the cup is moular an well fixe, has an intact locking mechanism, an is in acceptable position an if an appropriate polyethylene liner is available 1,2,5,6. Other authors have recommene the removal of a well-fixe cup at the time of revision, noting that this will enhance ientification of the extent of osteolysis an facilitate grafting of the efects 7-9. The management of pelvic iscontinuity has classically involve two options 10. For acute pelvic iscontinuity, primary apposition of the osseous surfaces an fixation with a pelvic reconstruction plate has been recommene 11. For pelvic iscontinuity associate with massive osteolysis where a fracture gap is typically present, the use of structural allograft or metal augments 12 may be consiere, often supporte by a reconstruction plate or a reinforcement cage. In our patient, although there was pelvic iscontinuity, the cup was well-fixe into the cephala portion of the posteromeial aspect of the acetabulum. The cup was in satisfactory position, an the liner coul be exchange 1. Since the locking mechanism was suboptimal, a cross-linke polyethylene liner was cemente into the acetabular shell to achieve stability at the interface 13. While retaining an acetabular shell in the presence of pelvic iscontinuity an massive osteolysis is controversial, component retention in the setting of an acute pelvic iscontinuity has been reporte in one small series 11. The management of a hip with concomitant massive periacetabular osteolysis, pelvic iscontinuity, an a well-fixe acetabular component is challenging. The case of our patient suggests that retention of the acetabular component with grafting an plate fixation of the surrouning pelvis is a treatment option for some patients. We emphasize that our patient ha extremely low functional emans an ha substantial comorbiities. Thus, one of our surgical goals was to avoi implant removal an major structural grafting (or metallic augments), if possible. Given this clinical situation, the surgical strategy of component retention, repair of the iscontinuity,

7 2237 Therefore, we cannot avocate this surgical technique for all patients with a similar implant failure pattern, but we present this approach as one option to be consiere. We believe that for these complex reconstructions, the surgical ecision-making process must be iniviualize an the surgeon must consier both the specific characteristics of the implant failure an the patient-specific factors. n Murat Pekmezci, MD Division of Orthopaeic Surgery, San Francisco General Hospital, 1001 Potrero Avenue, Room 3A36, San Francisco, CA Fig. 5 The anteroposterior pelvic raiograph mae at the time of the latest follow-up emonstrates a stable acetabular cup, bone graft incorporation, an healing of the pelvic iscontinuity. an bone-grafting of the osteolytic efects seeme appropriate. While this proceure has been associate with a goo clinical result at a relatively short follow-up interval of twenty-eight months, the long-term urability of this construct is unknown. James Keeney, MD Wilfor Hall Meical Center, Unite States Air Force, 2200 Bergquist Drive, San Antonio, TX Amana Schutz, PhD John C. Clohisy, MD Department of Orthopaeic Surgery, Washington University School of Meicine, 1 Barnes-Jewish Hospital Plaza, Suite WP, Campus Box 8233, St. Louis, MO aress for J.C. Clohisy: jclohisy@wustl.eu References 1. Chiang PP, Burke DW, Freiberg AA, Rubash HE. Osteolysis of the pelvis: evaluation an treatment. Clin Orthop Relat Res. 2003;417: Maloney WJ. Socket retention: staying in place. Orthopeics. 2000;23: Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associate with a stable acetabular component inserte without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997;79: Maloney WJ, Paprosky W, Engh CA, Rubash H. Surgical treatment of pelvic osteolysis. Clin Orthop Relat Res. 2001;393: Beaulé PE, LeDuff MJ, Dorey FJ, Amstutz HC. Fate of cementless acetabular components retaineuring revision total hip arthroplasty. J Bone Joint Surg Am. 2003;85: Hozack WJ, Mesa JJ, Carey C, Rothman RH. Relationship between polyethylene wear, pelvic osteolysis, an clinical symptomatology in patients with cementless acetabular components. A framework for ecision making. J Arthroplasty. 1996; 11: Chang JD, Yoo JH, Hur M, Lee SS, Chung YK, Lee CJ. Revision total hip arthroplasty for pelvic osteolysis with well-fixe cementless cup. J Arthroplasty. 2007;22: Mallory TH, Lombari AV Jr, Faa RA, Aams JB, Kefauver CA, Eberle RW. Noncemente acetabular component removal in the presence of osteolysis: the affirmative. Clin Orthop Relat Res. 2000;381: Puri L, Lapinski B, Wixson RL, Lynch J, Henrix R, Stulberg SD. Compute tomographic follow-up evaluation of operative intervention for periacetabular lysis. J Arthroplasty. 2006;21(6 Suppl 2): Paprosky WG, O Rourke M, Sporer SM. The treatment of acetabular bone efects with an associate pelvic iscontinuity. Clin Orthop Relat Res. 2005; 441: Springer BD, Berry DJ, Cabanela ME, Hanssen AD, Lewallen DG. Early postoperative transverse pelvic fracture: a new complication relate to revision arthroplasty with an uncemente cup. J Bone Joint Surg Am. 2005;87: Sporer SM, Paprosky WG. Acetabular revision using a trabecular metal acetabular component for severe acetabular bone loss associate with a pelvic iscontinuity. J Arthroplasty. 2006;21(6 Suppl 2): Kummer FJ, Aams MC, Dicesare PE. Revision of polyethylene acetabular liners with a cemente polyethylene cup: a laboratory stuy. J Arthroplasty. 2002;17: