Abstract
Background
It remains controversial whether isolated acetabular component revision or both component revision surgeries should be performed in patients with stable femoral component. The present study aimed to evaluate the survival of patients with unrevised stable uncemented femoral stem who underwent isolated acetabular component revision.
Material and Methods
A retrospective analysis was conducted in patients who underwent isolated acetabular component revision and had stable uncemented femoral component during revision hip arthroplasty between February 1998 and December 2009. Demographic data of the patients included age, previous surgery, complications, duration between primary and revision surgery, and duration between revision and latest follow-up. Functional results were analyzed using Harris Hip Score (HHS).
Results
Fifteen hips of thirteen patients were included in the study with a mean age of 62.08 ± 12.9 years. Average time from THA to the isolated acetabular revision was 9.2 ± 3.48 years. Average follow-up time from revision to the latest follow-up was 12.39 ± 2.68 years, and femoral components had been followed for an average of 21.6 ± 4.06 years since the time of implantation. Average HHS of the patients were 53 before revision surgery and 81.9 at the last follow-up (p < 0.001). The 10-year survival rate of patients who underwent revision in the femoral component was 100%, whereas their 15-year survival rate was 93.3%. None of the acetabular components required revision.
Conclusion
Isolated revision of acetabular component may be considered if there is stable uncemented femoral component in revision THA. Acetabular reconstruction quality, acetabular and unrevised femoral component survival are not affected by retaining well-fixed femoral component.
Level of Evidence
4, retrospective cohort study.
Keywords: Revision hip arthroplasty, Isolated acetabular component, Femoral stem survival, Unrevised femoral component
Introduction
As the number of total hip arthroplasty (THA) procedures increases, the number of revisions also increases. Osteolysis and loosening are the most common diagnoses of patients who underwent revision of THA, and they generally occur in the acetabular component [1]. In clinical practice, surgeons could be faced with a well-fixed (stable) femoral component, a loose acetabular shell, and the dilemma of whether isolated acetabular component revision or both component revision surgeries should be performed.
Lower operation time, reduced blood loss, lower cost, and preserving bone stock are known advantages of isolated acetabular component revision, and the rate of component revision is reported to be 12%–30% [1–6]. On the contrary, retaining the femoral component can cause inadequate exposure, difficulty in soft tissue balancing, and increase the risk of postoperative dislocation [3, 7, 8]. Using polyethylene during revision surgery may also lead to osteolysis recurrence [9].
The study aimed to determine whether revision of an isolated acetabular component without the removal of a uncemented, well-fixed femoral stem could be successfully performed, to confirm the need for delayed revision of the femoral component, to evaluate whether polyethylene debris can affect uncemented femoral component for long-term survival, and to determine the functional results and postoperative complications in patients who have undergone isolated acetabular component revision.
Material and Methods
Patients
In the arthroplasty database of our institution, we retrospectively reviewed the data of all revision THA procedures performed between February 1998 and December 2009. Patients were included if they met the following criteria:
Isolated acetabular component revision during revision THA
Metal on polyethylene-bearing surface combination in primary and revision THA
Minimum 10-year follow-up after isolated acetabular component revision
Patients who met the following criteria were excluded:
Cemented femoral component
Femoral component revision prior to acetabular component revision
Revision THA for periprosthetic joint infection
Methods of Assessment
A retrospective study was performed using case files, plain X-rays, and digital radiographs from a picture archiving system. The demographic data of the patients included age, gender, previous surgery, surgical approaches, complications, indications for revision THA, duration between primary and revision surgery, and duration between revision and latest follow-up. Functional results were analyzed using Harris Hip Score (HHS). The end points were pain along the perifemoral radiolucencies or subsidence of > 5 mm indicating femoral component loosening and re-revision THA. Bone defects on the acetabulum were classified according to the Paprosky [10] classification based on the the radiographic evaluation and perioperative findings.
Preoperative pelvis and hip radiographs were evaluated to identify any perifemoral radiolucencies according to Gruen et al. [11] and periacetabular radiolucencies according to the system of Delee and Charnley [12]. All primary uncemented femoral components showed evidence of osseointegration and were judged to be stable prior to revision surgery based on the radiographic criteria described by Engh et al. [13]. Osteolysis was defined as a radiographic appearance of any focal bone resorption area > 1 mm in width that was not apparent on the radiograph obtained immediately after surgery [14]. The radiological criteria for loosening were as follows: positional change in the component, > 2 mm of radiolucency around the acetabular component, or an increase in the radiolucent area. Additionally, stabilities of the femoral components were evaluated with longitudinal traction and rotational forces during the acetabular cup revision.
Serum C-reactive protein (CRP), white blood cell count, percentage of polymorphonuclear leukocyte, erythrocyte sedimentation rate were investigated to rule out infection preoperatively. Intraoperative findings to rule out infection included persistence of purulence and peroperative frozen section. We also took samples for culture after opening the pseudocapsule. All the preparations were made preoperatively for probable periprosthetic hip infection and two-stage revision surgery. Two-stage revision surgery was performed if any sign and suspicion of infection.
Surgical and Follow-up Protocol
All operations were performed following the modified Hardinge approach using standard techniques on lateral decubitus position. After capsulectomy and soft tissue release, the hip was dislocated. The femoral head was removed and femoral component was pushed back posteriorly with a retractor to improve surgical exposure. Afterward, all acetabular cups, cement (as necessary), liners, and screws were removed. Bone defects were reconstructed using grafts if necessary. After the preparation of acetabular bone, acetabular component was impacted to the bone and secured with screws. The polyethylene liner was inserted according to the recommendations of the manufacturer for primary components. Cement was used to fix the polyethylene liner into the reconstruction ring with appropriate abduction and inclination. All femoral heads were changed. All patients had metal on polyethylene-bearing surface combination in both primary and revision THA. All patients received prophylactic intravenous antibiotics postoperatively for 24 h. Early postoperative radiographs were obtained in the postanesthesia unit. The initial outpatient follow-up was performed 2 weeks after surgery to assess for wound healing and for the patient’s response to the medical management. All patients were followed up regularly on the 3rd and the 6th weeks; 3, 6, and 12 months; and then, annually after surgery. Functional evaluation was performed using the HHS. All complications, including aseptic loosening, osteolysis, femoral head and stem fracture, dislocation, and periprosthetic joint infection, were recorded. Anteroposterior radiograph of the pelvis and proximal femur and true lateral radiographs of the hips were taken and reviewed preoperatively; immediately after the revision; 6 weeks, 3 months, and 6 months after surgery; and annually at follow-up visits.
Statistical Analysis
Statistical analysis was performed using Statistical Package for the Social Sciences software (SPSS for Microsoft, version 21.0). The revision of the retained femoral component or radiographic sign of femoral stem loosening was considered, and the endpoint was included in the clinical and radiographic analysis. A Kaplan–Meier survival analysis of the data on unrevised femoral stems was performed. A p value of < 0.05 was considered significant.
Results
In our institutional arthroplasty database, we identified 163 revision THA procedures. A total of 21 hips (13%) required revision in the acetabular component only, and 23 (14%) hips required revision in the femoral stem only. Two patients with ceramic-on-ceramic bearing and four with cemented femoral component were excluded. One patient died during the follow-up, and his last follow-up data and examination findings were included. Finally, 15 hips of 13 patients [8 women, 5 men] were included in the study. All patients with well-fixed uncemented femoral component underwent isolated acetabular revision (Fig. 1).
Fig. 1.
Anteroposterior radiograph of the right hip of a female patient, (a) preoperative radiograph when the patient was 47 years old, (b) 14 years after THA the acetabular component was loose, the polyethylene had a certain amount of wear and required revision, (c) 11 years after revision of the cup and 25 years with femoral component in place
The average age of the patients was 62.08 ± 12.9 at the time of the latest examination. The average time from THA to the isolated acetabular revision was 9.2 ± 3.48 years. The average follow-up time from acetabular revision to the latest follow-up was 12.39 ± 2.68 years, and the femoral components had been followed for an average of 21.6 ± 4.06 years since the time of implantation (Table 1). Index arthroplasty was performed in 7 hips (46.7%) with osteoarthritis, in 4 hips (26.7%) with dysplasia, in 1 hip (6.65%) with femoral head osteonecrosis, in 1 hip (6.65%) with rheumatoid arthritis, in 1 hip (6.65%) with ankylosing spondylitis, and in 1 hip (6.65%) with post-traumatic arthritis. Revision hip arthroplasty was performed in 10 hips (67%) with aseptic loosening, in 2 hips (13%) with pelvic protrusion, in 1 hip (7%) with acetabular component failure (fracture), and in 2 hips (13%) with excessive acetabular liner wear. The average diameter of the acetabular component implanted during the index revision was 56.93 ± 6.40 mm (range, 44–68 mm). The sizes of the femoral head used in revision surgery were 28 mm in 10 hips, 32 mm in 3 hips, and 36 mm in 2 hips. The average leg length inequality was 11.13 ± 10.54 mm (range 0–39 mm) preoperatively and 5.46 ± 7.78 mm (range 0–30 mm) postoperatively.
Table 1.
Demographic data of patients
| Number of the patients (hips) | 15 hips (2 bilateral); 13 patients |
| Male to female | 5/8 |
| Age | 62.08 ± 12.9 (range 40–83) |
| Index arthroplasty to revision (years) femoral component implantation (years) |
9.2 ± 3.48 (range 4–18) 21.6 ± 4.06 (range 16.3–28.3) |
| Follow-up (years) | 12.39 ± 2.68 (range 10–18) |
| Diagnosis of the primary arthroplasty | |
| Osteoarthritis | 7 (46.7%) |
| Development dysplasia of the hip | 4 (26.7%) |
| Avascular necrosis of the femoral head | 1 (6.65%) |
| Rheumatoid arthritis | 1 (6.65%) |
| Ankylosing spondylitis | 1 (6.65%) |
| Post-traumatic arthritis | 1 (6.65%) |
| Diagnosis of the revision arthroplasty | |
| Aseptic loosening | 10 (67%) |
| Pelvic protrusion | 2 (13%) |
| Acetabular component failure (fracture) | 1 (7%) |
| Excessive acetabular liner wear | 2 (13%) |
| Preoperative acetabular bone deficiency (paprosky type) | |
| Type 1 | 6 (40%) |
| Type 2A | 2 (13%) |
| Type 2B | 2 (13%) |
| Type 2C | 1 (6.5%) |
| Type 3A | 1 (6.5%) |
| Type 3B | 3 (21%) |
| Revision acetabular component diameter (mm) | 56.93 ± 6.40 mm (range 44–68 mm) |
| Femoral head used (mm) | |
| 28 mm | 10 (67%) |
| 32 mm | 3 (20%) |
| 36 mm | 2 (13%) |
| Acute complications | 1 (sciatic nerve paralysis) |
| Dislocations | 0 |
| Acetabular rerevisions for aseptic loosening | 0 |
| Acetabular reconstruction type | |
| Primary component | 8 (53%) |
| Reconstruction ring | 7 (47%) |
The acetabular bone deficiencies were classified according to the Paprosky classification. Acetabular defect type 1 was present in 6 hips (40%), type 2A in 2 hips (13%), type 2B in 2 hips (13%), type 2C in 1 hip (6.5%), type 3A in 1 hip (6.5%), and type 3B in 3 hips (21%). During the acetabular component revision, primary acetabular component was used in 8 hips (53%), while acetabular reconstruction ring was used in 7 hips (47%). Two acetabular components were cemented in primary hip arthroplasty procedure. The cemented acetabular components were revised using reconstruction ring. One cemented primary acetabular component was used in the revision procedure, while the other 7 primary acetabular components were cementless. No metallosis was observed during the revision arthroplasty. But fibrogranulamatous tissues were prominently observed in 4 cases and debrided completely. All the femoral stems were monoblock in our study. The femoral components of all patients were in satisfactory position and well fixed to the bone. So all femoral components were preserved. Pelvic bony defects were treated with morselized allograft in 8 (53%) patients. None of the patients had femoral bone grafting during the surgery.
Three patients presented radiolucence in Gruen zone 1 at the latest follow-up; however, the patients had no complaint. One patient presented radiolucent areas in Gruen zones 7, 8, and 9, which were considered to be loosening. However, the patient had minimal pain with long-distance walking and with no other clinical symptoms of loosening. This was probably due to the cylindrical fully porous-coated femoral stem and fitting in diaphysis. There was an absence of femoral stem subsidence. The 10-year survival rate of femoral component was 100%, while the 15-year survival rate was 93.3% (Fig. 2). None of the acetabular components required revision. The 10-year and 15-year survival rates of acetabular components were 100%, independent of the implant choice. The average HHSs of the patients were 53.20 ± 8.52 before the revision surgery and 81.86 ± 8.44 at the last follow-up (p < 0.001).
Fig. 2.
Kaplan–Meier survival curve for retained femoral components, with pain along perifemoral radiolucencies or subsidence of greater than 5 mm indicating femoral component loosening and re-revision THA as end points. The 10-year survival rate of femoral component was 100%, while 15-year survival rate was 93.3%
One patient experienced peroneal nerve injury postoperatively and resolved without sequelae. None of the patients developed dislocations, periprosthetic fracture, early or late infections, or deep-vein thromboses. Six patients walked normally without the need for an assistive device, such as a stick. Four patients used a stick as an assistive device. One patient (2 hips) was able to walk with a limited distance with a stick, and one patient had limited walking ability.
Discussion
Surgeons will have to determine whether loose component revision or both component revision surgeries should be performed during revision THA if one component is well fixed. Both component revision surgeries have some advantages: allow the use of different sizes and types of newer technology revision implants, allow better exposure of the surgical site, and have a lower dislocation rate [2, 15]. On the contrary, isolated acetabular revision has some potential superiorities, such as shorter surgical time, lower blood loss, lower costs, and a fewer complications with femoral component [4, 16]. However, keeping the stable and not loose femoral component in place may lead to inadequate acetabular exposure, cup malposition, and increased risk of postoperative dislocation [8]. We evaluated 16 isolated acetabular revision procedures and investigated the impact of isolated acetabular revision on the femoral component survival. Our retrospective study demonstrated that isolated acetabular component revision can provide acceptable functional outcome and has no negative effect on femoral component survival with the addition of a fewer postoperative medical complications.
Postoperative instability and dislocation are among the complications in revision THA. The incidence of postoperative dislocation ranges from 1 to 10%. It even reaches to 22%, especially higher in isolated acetabular component revision procedures than in both component revision surgeries [17–19]. Surgical approach is one of the risk factors for dislocations. The optimal surgical approach during the revision THA is controversial. Alberton [20] suggested that there was no significant association between surgical approach and postoperative dislocation rate. However, Park et al. [21] and Manning et al. [22] declared that only revision THA of acetabulum via the posterior approach has been associated with high rates of dislocation. Our surgical approach for primary and revision THA is the modified Hardinge approach, and there were no dislocations in our study during the follow-up period, which is in accordance with the data on the literature [21, 22]. The lack of postoperative dislocation may be associated with surgical technique and the experience of the surgeon.
Leaving the well-fixed femoral component in place is one of the controversial issues. The stable femoral component was pushed behind the posterior column after extracting the femoral head and excision of the neocapsule in our routine practice. This makes it possible to get access to the acetabular side and to reconstruct the bone defects. Preserving the stable femoral component did not complicate the revision THA. In our study, the implant survival at 12.4-year follow-up was 93.3%, which is similar to the results of the literature [3, 4, 23]. Unfortunately, one complication of sciatica paralysis occurred, which may have been caused by our technique. Forward or inferior displacement of the femoral component during the approach could be less iatrogenic [24].
The retained femoral component failed in 7% of our cases, which is comparable to the rate found in the literature [25, 26], and isolated acetabular component revision has not affected both acetabular and femoral component survival.
Considering the functional results, our study demonstrated the mean improvement of 28.9 points on the average HHS at 12.4 years of follow-up on isolated acetabular component revision. These results can be explained by the fact that the satisfactory functional results of revision procedures are lower than those of primary THA. The results in our study were lower than those in Cho et al. [27] and Lim et al.’s [28] studies. Because Cho et al. [27] reported a 33.4-point improvement in HHS at a 9.2-year follow-up on 29 isolated acetabulum revisions, while Lim et al. [28] reported an HHS of > 35 points at an average follow-up of 5.5 years on 269 acetabulum only revision procedures. The less improvement in the HHS might be due to the fact that our cohort group had lower preoperative HHS than the value reported in the literature. Therefore, the results were not likely to be limited by retention of the femoral stem, but our study still demonstrated an overall high level of patient satisfaction.
Our study has several limitations. First, this is a retrospective analysis, and none of the patients have undergone both component revision surgeries during total hip revision surgery. Second, the number of patients evaluated in the study was relatively small. Meanwhile, the length of follow-up (nearly 12.4 years), discussion on the fate of unrevised cementless femoral component, and the use of one exposure only (modified Hardinge) are the strengths of our study.
When we synthesize our results with those in the literature [28, 29], we concluded that the best method of treating patients with loose acetabular component only is to preserve the well-fixed uncemented femoral component. Leaving the stable femoral component decreases the surgery time, blood loss, and costs. Additionally, acetabular reconstruction quality and acetabular and unrevised femoral component survival are not affected by retaining the well-fixed femoral component. Moreover, the risk of dislocation does not increase if femoral anteversion is determined preoperatively. Otherwise, both components should be revised.
Conclusion
Our study confirms that isolated acetabular component revision may be performed in patients with well-fixed uncemented femoral stem, and unrevised femoral component survival are not affected by retaining stable uncemented femoral component.
Compliance with Ethical Standards
Conflict of interest
Mehmet Ekinci, Yucel Bilgin, Yasin Sayar, Omer Naci Ergin, Ahmet Salduz, Turgut Akgul and Irfan Ozturk declare that they have no conflict of interest.
Ethical standard statement
The current study was approved by the local ethical committee.
Informed consent
Informed consent was obtained from the patients in the study.
Footnotes
Publisher's Note
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Contributor Information
Mehmet Ekinci, Email: dr.ekincimehmet@gmail.com.
Yucel Bilgin, Email: yucelbilgin70@hotmail.com.
Yasin Sayar, Email: zal0105@gmail.com.
Omer Naci Ergin, Email: omnaer@gmail.com.
Ahmet Salduz, Email: ahmetsalduz@gmail.com.
Turgut Akgul, Email: trgtakgul@gmail.com.
Irfan Ozturk, Email: ozturkirfan@hotmail.com.
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