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Is an Acetabular Cage and Cement Fixation Sufficiently Durable for the Treatment of Destructive Acetabular Metastases?

Rowell, Philip, MBBS, BSc, FRACS, FAOrthoA; Lowe, Martin, MBBS, BSc, FRACS, FAOrthoA; Sommerville, Scott, MBBS, FRACS, FAOrthoA; Dickinson, Ian, MBBS, FRACS, FAOrthoA

Clinical Orthopaedics and Related Research®: June 2019 - Volume 477 - Issue 6 - p 1459–1465
doi: 10.1097/CORR.0000000000000725
CLINICAL RESEARCH
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Background Destructive bony acetabular metastases cause pain, pathological fractures, and loss of mobility. Although multiple fixation options are available, we have favored a rigid stainless steel partial pelvic cage for acetabular fixation in these patients; however, little is known about the durability of this approach.

Question/purposes (1) How common was loss of fixation in a small series of metastatic acetabular defects treated with an acetabular cage and cemented total hip replacement? (2) What is the implant survival free from reoperation or revision at 2 and 4 years using a competing-risks survivorship estimator in patients thus treated? (3) What complications were associated with the treatment? (4) What level of postoperative mobility was achieved?

Methods Between 2006 and 2017, we treated all acetabular metastases that needed surgical intervention, not amenable to conventional cemented THA alone with our single technique of acetabular partial pelvic cage and cemented total hip replacement. We treated 47 hips in 46 patients whose acetabular metastasis led to acetabular collapse or who were unresponsive to nonoperative measures of radiation therapy and analgesia. Routine followup occurred at 3 and 12 months; 17 of 46 patients (37%) died before 1 year, and all other patients were followed beyond 1 year. Only one patient who remains alive has not been seen in the past 5 years. Loss of fixation was determined by radiological or clinical signs of cage loosening. Survivorship free from reoperation or revision at 2 and 4 years was determined using competing-risks analysis. We did not assess patient-reported outcomes, but we did have data on the proportion of patients who were able to ambulate in the community and if so, what assistive devices they used, which we obtained by chart review.

Results One patient experienced cage loosening identified 8 years postoperatively as a result of local disease progression and has been managed with observation. No patients underwent revision for loss of acetabular fixation. The cumulative incidence of reoperation or revision was 8% at 2 years (95% CI, 3.6–12.6) and 16% at 4 years (95% CI, 9.2–23.2). Four patients had postoperative dislocations, of which three underwent reoperation. One patient developed a postoperative deep infection and underwent reoperation. One patient died within 30 days of surgery. Only one patient did not ambulate in the community postoperatively; 23 ambulated independently, 10 with the use of a walking stick and 12 using a walker.

Conclusions In this small series, we found this approach sufficiently durable to continue its use for patients with acetabular metastases with collapse or those not responding to nonoperative measures. However, comparison studies are needed to determine whether it is superior or inferior to other available alternatives.

Level of Evidence Level IV, therapeutic study.

P. Rowell, M. Lowe, S. Sommerville, I. Dickinson, Orthopaedic Department, The Princess Alexandra Hospital, Woolloongabba, Queensland, Australia

S. Sommerville, I. Dickinson, The Wesley Medical Centre, Wesley Hospital, Auchenflower, Queensland, Australia

P. Rowell, 32 Coronation St, Bardon, Queensland, Australia 4065, Email: philipdrowell@gmail.com, philip.rowell@health.qld.gov.au

Each author certifies that neither he, nor any member of his or her immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at both The Princess Alexandra Hospital, Woolloongabba, Queensland, Australia, and Wesley Hospital, Auchenflower, Queensland, Australia.

Received August 22, 2018

Accepted February 25, 2019

© 2019 Lippincott Williams & Wilkins LWW
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