9/27/2016. When All Else Fails: Harrington Hip Reconstruction. Wheelchair bound Peri-acetabular lesion on MRI Anterior and posterior column defects

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1 When All Else Fails: Harrington Hip Reconstruction Matthew J. Seidel, MD 24 September 2016 JA 84 M referred for L acetabulum lesion Hx of renal cell carcinoma Pain began one month ago Unable to bear weight No history of trauma 2 JA Wheelchair bound Peri-acetabular lesion on MRI Anterior and posterior column defects 3 1

2 4 TREATMENT OPTIONS Massive pelvic defects Non-operative Protected weight bearing, pain control, bisphosphonate Chemotherapy Radiation therapy Radiation and chemotherapies Cryoablation/radioablation Acetabuloplasty/cementoplasty Surgery 5 Who will benefit from Harrington reconstruction? 6 2

3 INDICATIONS Anterior/posterior column bone loss Functionally impaired Life expectancy exceeds recovery time Non-operative modalities unlikely to be effective Patient desires intervention Does not want to wait for custom implant or humanitarian use exemption 7 HARRINGTON HIP K.D. Harrington- Landmark JBJS article(1981) Reconstruction without periacetabular bone stock Proposed classification of bone defects Described reconstruction technique for type III 8 OPERATIVE MANAGEMENT Class III Reconstruction Harrington Custom implant Other options outside USA Resection arthroplasty Iliofemoral fusion 9 3

4 How is this reconstruction performed? 10 HARRINGTON Use familiar approach Varies by defect location Iliofemoral or posterior Radiolucent table helpful but not required 11 HARRINGTON You will need: 6.5/7.3 cannulated screw set Fully threaded Schanz pins Cemented acetabular component Constrained in almost all cases Standard femoral components 12 4

5 HARRINGTON Expose acetabulum / resect tumor Instrument both columns when possible Posterior column: Retrograde 6.5mm screw Anterior column: Antegrade Schanz pins Place tip medially to allow for cup Cement cup Trowel to prevent painful ridge Prevent intra-pelvic extravasation Gelfoam, etc Fluoroscopy to confirm positioning

6 16 IMAGING 17 JA At 1 year follow-up Community ambulator without assistive device No perceived functional limitation No pain medication use No evidence of recurrent disease 18 6

7 HS 84 M history of prostate cancer New onset R groin pain Radiation in the past Unable to ambulate, now in wheelchair 19 IMAGING

8 HS Ambulatory with walker at 3 months No narcotics Abductor weakness/pain 22 IMAGING 23 HS Discharges from PT by 6 months Ambulating in community with walker Sustains ground level fall 11 months post-op Deceased two months after revision Disease progression 24 8

9 IMAGING 25 IMAGING 26 CT 56 F renal cell carcinoma Prior radiation Local progression noted at one year f/u Ground level fall two months later Revision complicated by deep infection 27 9

10 28 29 PUBLISHED RESULTS Author Marco et al Tillman et al Tsagozis et al Kiatisevi et al Year No. Pts. Technique Measure Outcome Complication Modified Harrington Up/down Modified Harrington Antegrade Modified Harrington Retro screw Modified Harrington Retro screw ECOG Narcotic use Allan scale Revision Pain Ambulation ECOG MSTS VAS one level Decreased 2 pts 1 revised 2.7 pts 0.81 pts 1.4pts 70(27-87) 6.2mm 22% DVT, super infx, decubitus ulcer, one revision 10% hardware comp 32%- 13 dislocation, 7 deep infx, 4 loosening 22%- dislocation, super infx, foot drop, DVT(2) 30 10

11 OUR EXPERIENCE Number of patients: 23 Average age: 62.1y 41% female 43% prior radiation Renal, prostate, breast most common primaries Average follow-up: 343d 4 deceased due to progression of disease Ambulatory function improved in 83% None made worse 31 OUR EXPERIENCE 32 OUR EXPERIENCE Days(Avg) # patients Avg. Post-Op ECOG (Range) Avg. Pre-op ECOG(range) (0-4) 3.0(2-4) (0-4) 3.0(2-4) (0-4) 3.0(2-4) (0-4) 3.1(0-4) 33 11

12 COMPLICATIONS 4 re-operations in 3 patients 1 deep infection, 1 aseptic loosening, 1 periprosthetic fracture complicated by deep infection All received pre-operative radiation 1 dislocation requiring closed reduction 1 patient with local progression of disease 1 patient with bilateral DVT Majority of patients chronic trochanteric bursitis 34 CONCLUSIONS Reproducible results with Harrington technique Inexpensive and technically simple Long term results lacking Complications are challenging to treat Often worst following prior radiation More fixation probably better 35 12