Anterolateral bone deficiency in patients undergoing total hip arthroplasty for developmental dysplasia of the hip often compromises acetabular component coverage. Various reconstructive methods have been utilized to address such bone deficiency, including superior placement of the cup1-3, medialization of the cup4,5, and augmentation of bone stock with insertion of a bulk bone graft onto the anterolateral aspect of the acetabulum with subsequent implantation of a cemented or an uncemented cup6-13. The latter technique has the benefits of allowing a more anatomic cup position, early structural support for the acetabular component, and potentially increased pelvic bone stock if future operations are required14-17.
We previously reported the five to twelve-year results in forty-four consecutive hips with developmental dysplasia treated with an uncemented acetabular component and an autogenous femoral head graft at a single institution17. In that report, four acetabular components were revised but no unrevised component had radiographic evidence of loosening or associated graft resorption. The purpose of the current study was to determine the twenty-year survivorship of total hip arthroplasty with an uncemented socket used in conjunction with a bulk femoral head autograft in patients with anterolateral bone deficiency secondary to developmental dysplasia of the hip. A secondary goal was to evaluate the status of the autogenous femoral head graft and the remaining bone stock.
The study group included all patients who underwent total hip arthroplasty with an uncemented socket and bulk femoral head bone autograft for treatment of degenerative joint disease secondary to developmental dysplasia of the hip at a single, tertiary-care institution from 1985 to 2001. Institutional review board approval was obtained prior to initiation of the study.
Patients were identified through a total joint registry that has prospectively followed all patients with a total joint arthroplasty at our institution since 1969. Preoperative radiographs were assessed for the degree of acetabular dysplasia by measuring five indices of dysplasia: the levels of dislocation as classified by Crowe et al.18 and Hartofilakidis et al.19, the center-edge angle of Wiberg20, the acetabular angle21, and the acetabular roof (Tönnis) angle22. The percentage of coverage of the acetabular component by the autograft was assessed by determining the mean arc of coverage by the graft of the porous-coated surface of the acetabular component as measured on the anteroposterior radiograph. This was completed both immediately postoperatively and at the time of follow-up to determine graft resorption. Radiographic evidence of union was considered to be the disappearance of the femoral head-host bone interface. Radiolucent lines at the bone-implant interface were recorded according to the acetabular zones described by DeLee and Charnley23. Radiographic evidence of component loosening was considered to be migration or a change in the position of the component, screw fracture, or a complete radiolucent line at the bone-implant interface of ≥2 mm in all zones.
The original series included forty-four hips in thirty-five patients17; five (eight hips) died and therefore were excluded from the present study. None of the eight hips had been revised at the time of the patient’s death. One living patient (one hip) was lost to follow-up. We reviewed the results in thirty-five hips in twenty-nine patients (six with a staged bilateral procedure). The mean age at the time of the index surgical intervention was forty-three years (range, twelve to sixty-seven years), and twenty-five patients (86%) were female. According to the classification of dysplasia described by Crowe et al.18, seven hips (20%) were in Group I; five (14%), Group II; nineteen (54%), Group III; and four (11%), Group IV. According to the classification of Hartofilakidis et al.19, there were ten dysplastic hips (29%), twenty low dislocations (57%), and five high dislocations (14%). Our current indication for the use of a graft is Crowe Group-III dysplasia in a young patient. The graft is provisionally fixed with two Kirschner wires. This is followed by reaming with an appropriately sized reamer, and then the graft is secured to the pelvis. At that point, the real acetabular component is impacted into place. The average operative time was 216 minutes (range, 115 to 375 minutes). The operative approach was anterolateral in twenty hips, transtrochanteric in ten, and posterior in five. The mean duration of follow-up was 21.3 years (range, 13.1 to twenty-six years).
An Osteonics peripheral self-locking (PSL) acetabular cup (Howmedica Osteonics, Allendale, New Jersey) was used in twelve hips (34%); a Harris-Galante-I cup (Zimmer, Warsaw, Indiana), in thirteen (37%); a Harris-Galante-II cup (Zimmer), in eight (23%); an Osteonics Dual Geometry cup (Howmedica Osteonics), in one (3%); and an Osteonics Omnifit Spherical cup (Howmedica Osteonics), in one (3%). The mean cup diameter was 48 mm (range, 42 to 58 mm). All cups except the Osteonics Dual Geometry cup were fixed with supplementary screws. Thirty-one femoral components were uncemented, and four were cemented.
Kaplan-Meier survivorship analyses were performed with two end points: revision of the acetabular component due to aseptic etiologies and revision of the acetabular component due to aseptic etiologies or head and liner exchange24.
Source of Funding
There was no external funding for this study.
Survivorship Free from Revision of the Acetabular Component
At twenty years, there had been twelve acetabular revisions, eight of which occurred since our previous report17. The acetabular components were revised at an average of 12.8 years (range, 3.5 to 18.5 years) following the index surgical procedure. The survivorship free from acetabular revision at twenty years was 66% (Fig. 1). Of the twelve cup revisions, nine were shell and liner revisions for polyethylene wear and/or osteolysis, one was for aseptic acetabular loosening, one was for a fracture of an acetabular liner, and one was for late instability. Two patients had femoral revision due to osteolysis, but the acetabular component was well fixed and not revised.
Survivorship Free from Revision of the Acetabular Component or Head and Liner Exchange
At twenty years, two additional patients underwent isolated head and liner exchanges with retention of the acetabular component, resulting in fourteen revisions in total. The mean twenty-year survivorship free from aseptic revision of the acetabular component or head and liner exchange was 62% (Fig. 2).
The mean inclination angle was 43° (range, 25° to 65°). The mean arc of cup coverage by the graft was 30° (range, 14° to 76°). All bone grafts healed to the pelvis. At the time of the most recent follow-up, a mean of 16% (range, 0% to 100%) of the lateral overhanging part of the graft had been resorbed, but no identifiable resorption of the graft supporting the component itself was visible on anteroposterior radiographs. There was no difference in the mean resorption of the overhanging portion of the graft between revised and non-revised acetabular components (12% versus 18%, respectively; p = 0.32).
Clinical Status of Femoral Head Autograft and Bone Stock at Revision
At revision, the surgeons believed the grafts facilitated revision cup placement as no revision cases required additional structural grafts or metal augments. Seven of the twelve acetabular revisions included use of morselized bone graft against the medial wall. All of the surgeons’ operative notes concerning the revision procedures commented on the viability of the bone graft (as indicated by bleeding bone) as well as complete union of the bone graft. All revision procedures were completed with an uncemented acetabular component with supplemental screw fixation.
The mean preoperative Harris hip score (HHS) was 45.1 points (range, 20 to 74 points). At the time of the most recent follow-up, there was a significant increase in the mean Harris hip score to 80.1 points (range, 45.3 to 97.7 points) (p < 0.0001). Two patients developed a Vancouver type-B1 periprosthetic femoral fracture—one at four and one at eight years postoperatively; both were treated with open reduction and internal fixation.
The use of an autogenous femoral head graft with an uncemented acetabular component is an option that provides structural support and augments the pelvic bone stock in patients with developmental dysplasia of the hip treated with total hip arthroplasty. While there are numerous mid-term reports of this technique, there are minimal data on long-term outcomes. This mean twenty-year follow-up study of the subjects of our previous report17 demonstrated acceptable long-term results. The technique appeared to restore long-lasting acetabular bone stock in patients with developmental dysplasia of the hip.
There are limitations to the current study. The patients in this series had various levels of dysplasia, although all had lateral acetabular bone deficiency. Moreover, a variety of acetabular implants were utilized.
In our clinical opinion, the long-term viability of this technique depends primarily on three variables: (1) the acetabular fixation method (cemented versus uncemented), (2) the quantity of acetabular bone stock, and (3) the amount of the cup that is supported by the graft. Variable results have been noted with the use of cemented sockets (Table I). In general, early results have been favorable, with increasing revision rates due to graft collapse or socket loosening seen in some mid-term and long-term studies9,13,15,25-28.
In our series, use of an uncemented acetabular component in combination with an autogenous bone graft provided lasting fixation in a young patient population at a mean of more than twenty years. The survivorship in this report is decreased from the 91% rate in our previous study, in which there were no acetabular revisions for aseptic loosening at a mean of 7.5 years17. However, it is important to note that only one of the fourteen revisions was related to component loosening; the rest were related to polyethylene wear. The revisions, combined with an additional ten years of follow-up, may have contributed to the decrease in the HHS by a mean of 10 points since the time of our previous report. To our knowledge, our present study represents the longest reported follow-up of uncemented sockets used in combination with an autogenous bone graft (Table II). Barrack and Newland noted no failures in a series of ten hips followed for a mean of only three years6. At a mean of five years, Anderson and Harris reported no mechanical failures in twenty dysplastic hips29. Morsi et al. found that one of seventeen hips had been revised at a mean of 6.6 years30. Hintermann and Morscher noted two revisions in thirty-nine hips reconstructed with an autograft and uncemented cup31. Most recently, Kim and Kadowaki found a ten-year survival rate free of acetabular revision of 94%32.
In addition to providing initial structural support of the acetabulum, an autogenous femoral head graft restores acetabular bone stock. All femoral heads united as seen radiographically, and all of the patients who underwent revision surgery were found to have clinical evidence of autograft union. More importantly, the grafts had augmented the bone stock so no additional structural bone graft was needed at the time of revision surgery. However, the HHS had decreased by approximately 10 points compared with that in our prior report17.
Finally, surgeons must be aware that the amount of the cup that is supported by the graft may affect survivorship. Kobayashi et al. recommended that coverage of the socket by the graft not exceed 50%33. Mulroy and Harris recommended at least 70% coverage of the acetabular component by host bone to provide stability and allow adequate ingrowth on bone28. In our series, the mean arc of cup coverage by the graft was 30°. In contrast to the findings in prior reports28,33, there was no difference in the mean arc of cup coverage by the graft between the revised and non-revised acetabular components.
The management of acetabular replacement for developmental dysplasia of the hip depends on the severity of the dysplasia. Our clinical experience and current study indicate that an uncemented porous-coated socket fixed with screws in conjunction with a bulk femoral head autograft is a viable and durable method of reconstruction for hips with moderate dysplasia and anterolateral acetabular bone deficiency.
Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
* Original Publication
* Spangehl MJ, Berry DJ, Trousdale RT, Cabanela ME. Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years. J Bone Joint Surg Am. 2001 Oct;83(10):1484-9. Cited Here...
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
1. McQueary FG, Johnston RC. Coxarthrosis after congenital dysplasia. Treatment by total hip arthroplasty without acetabular bone-grafting. J Bone Joint Surg Am. 1988 ;70(8):1140–4.
2. Pagnano W, Hanssen AD, Lewallen DG, Shaughnessy WJ. The effect of superior placement of the acetabular component on the rate of loosening after total hip arthroplasty. J Bone Joint Surg Am. 1996 ;78(7):1004–14.
3. Russotti GM, Harris WH. Proximal placement of the acetabular component in total hip arthroplasty. A long-term follow-up study. J Bone Joint Surg Am. 1991 ;73(4):587–92.
4. Dorr LD, Tawakkol S, Moorthy M, Long W, Wan Z. Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia. J Bone Joint Surg Am. 1999 ;81(1):83–92.
5. Hartofilakidis G, Stamos K, Karachalios T, Ioannidis TT, Zacharakis N. Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am. 1996 ;78(5):683–92.
6. Barrack RL, Newland CC. Uncemented total hip arthroplasty with superior acetabular deficiency. Femoral head autograft technique and early clinical results. J Arthroplasty. 1990 ;5(2):159–67.
7. Garvin KL, Bowen MK, Salvati EA, Ranawat CS. Long-term results of total hip arthroplasty in congenital dislocation and dysplasia of the hip. A follow-up note. J Bone Joint Surg Am. 1991 ;73(9):1348–54.
8. Raut VV, Stone MH, Siney PD, Wroblewski BM. Bulk autograft for a deficient acetabulum in Charnley low-friction arthroplasty. A 2-9-year follow-up study. J Arthroplasty. 1994 ;9(4):393–8.
9. Ritter MA, Trancik TM. Lateral acetabular bone graft in total hip arthroplasty. A three- to eight-year follow-up study without internal fixation. Clin Orthop Relat Res. 1985 ;(193):156–9.
10. Shinar AA, Harris WH. Bulk structural autogenous grafts and allografts for reconstruction of the acetabulum in total hip arthroplasty. Sixteen-year-average follow-up. J Bone Joint Surg Am. 1997 ;79(2):159–68.
11. Silber DA, Engh CA. Cementless total hip arthroplasty with femoral head bone grafting for hip dysplasia. J Arthroplasty. 1990 ;5(3):231–40.
12. Wolfgang GL. Femoral head autografting with total hip arthroplasty for lateral acetabular dysplasia. A 12-year experience. Clin Orthop Relat Res. 1990 ;(255):173–85.
13. Rodriguez JA, Huk OL, Pellicci PM, Wilson PD Jr. Autogenous bone grafts from the femoral head for the treatment of acetabular deficiency in primary total hip arthroplasty with cement. Long-term results. J Bone Joint Surg Am. 1995 ;77(8):1227–33.
14. Farrell CM, Berry DJ, Cabanela ME. Autogenous femoral head bone grafts for acetabular deficiency in total-hip arthroplasty for developmental dysplasia of the hip: long-term effect on pelvic bone stock. J Arthroplasty. 2005 ;20(6):698–702.
15. Gerber SD, Harris WH. Femoral head autografting to augment acetabular deficiency in patients requiring total hip replacement. A minimum five-year and an average seven-year follow-up study. J Bone Joint Surg Am. 1986 ;68(8):1241–8.
16. Harris WH, Crothers O, Oh I. Total hip replacement and femoral-head bone-grafting for severe acetabular deficiency in adults. J Bone Joint Surg Am. 1977 ;59(6):752–9.
17. Spangehl MJ, Berry DJ, Trousdale RT, Cabanela ME. Uncemented acetabular components with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip: results at five to twelve years. J Bone Joint Surg Am. 2001 ;83(10):1484–9.
18. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am. 1979 ;61(1):15–23.
19. Hartofilakidis G, Stamos K, Ioannidis TT. Low friction arthroplasty for old untreated congenital dislocation of the hip. J Bone Joint Surg Br. 1988 ;70(2):182–6.
20. Wiberg G. Studies on dyplastic acetabula and congenital subluxation of the hip joint. With special reference to the complication of osteo-arthritis. Acta Chir Scand. 1939;83-Suppl 58.
21. Sharp IK. Acetabular dysplasia. The acetabular angle. J Bone Joint Surg Br. 1961 ;43(2):268–72.
22. Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. New York: Springer; 1987.
23. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976 ;(121):20–32.
24. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Statist Assn. 1958;53(282):457–81.
25. Gross AE, Catre MG. The use of femoral head autograft shelf reconstruction and cemented acetabular components in the dysplastic hip. Clin Orthop Relat Res 1994-298:60-6.
26. Inao S, Matsuno T. Cemented total hip arthroplasty with autogenous acetabular bone grafting for hips with developmental dysplasia in adults: the results at a minimum of ten years. J Bone Joint Surg Br. 2000 ;82(3):375–7.
27. Lee BP, Cabanela ME, Wallrichs SL, Ilstrup DM. Bone-graft augmentation for acetabular deficiencies in total hip arthroplasty. Results of long-term follow-up evaluation. J Arthroplasty. 1997 ;12(5):503–10.
28. Mulroy RD Jr, Harris WH. Failure of acetabular autogenous grafts in total hip arthroplasty. Increasing incidence: a follow-up note. J Bone Joint Surg Am. 1990 ;72(10):1536–40.
29. Anderson MJ, Harris WH. Total hip arthroplasty with insertion of the acetabular component without cement in hips with total congenital dislocation or marked congenital dysplasia. J Bone Joint Surg Am. 1999 ;81(3):347–54.
30. Morsi E, Garbuz D, Gross AE. Total hip arthroplasty with shelf grafts using uncemented cups. A long-term follow-up study. J Arthroplasty. 1996 ;11(1):81–5.
31. Hintermann B, Morscher EW. Total hip replacement with solid autologous femoral head graft for hip dysplasia. Arch Orthop Trauma Surg. 1995;114(3):137–44.
32. Kim M, Kadowaki T. High long-term survival of bulk femoral head autograft for acetabular reconstruction in cementless THA for developmental hip dysplasia. Clin Orthop Relat Res. 2010 ;468(6):1611–20. Epub 2010 Mar 23.
33. Kobayashi S, Saito N, Nawata M, Horiuchi H, Iorio R, Takaoka K. Total hip arthroplasty with bulk femoral head autograft for acetabular reconstruction in developmental dysplasia of the hip. J Bone Joint Surg Am. 2003 ;85(4):615–21.