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BONE AUTOPLASTY OF ACETABULAR ROOF IN TOTAL ARTHROPLASTY FOR PATIENTS WITH DYSPLASTIC COXARTHROSIS Markov D.A., Zvereva K.P., Belonogov V.N., Bychkov A.E., Troshkin A.Yu.

Saratov City Clinical Hospital No.9, Saratov, Russia

 

Currently, dysplastic coxarthrosis takes the second place among degenerative and dystrophic diseases of the hip joint [1-3]. The incidence of the pathology varies from 25 to 77 % according to various data [1, 4]. The epidemiological component is presented by young women (age of 30-40) [1, 2, 5]. Disability and decrease in working capability are registered in 11.5 and 70 % of cases correspondingly [1, 2]. At the present time, the main technique for treatment of this pathology is total arthroplasty, which quickly removes intense pain syndrome and improves social adaptation [6, 7]. However the defects in the posterosuperior and anterosuperior borders of the acetabulum in dysplastic coxarthrosis with severe dysplasia significantly burdens the intervention and worsens the surgical outcomes, with increase in number of postsurgical complications. [3, 7, 8]. The most perspective variant of full coverage of the acetabular component is impaction bone plastics with fixation of the femoral head autograft in the supraacetabular region [7-9].

Objective – to analyze the results of total hip replacement with use of bone autoplasty of the acetabular roof in patients with dysplastic coxarthrosis of the type 1-2 according to Hartofilakidis.

 

MATERIALS AND METHODS

The retrospective analysis of the disease course in 34 patients with dysplastic coxarthrosis of the types 1 and 2 (Hartofilakidis) was conducted for estimation of efficiency of impact bone autografting of the acetabular roof. The patients were treated in Saratov Razumovskiy State Medical University in 2014-2016. The mean age of the patients was 39.2 ± 4.62 (95 % CI, 37.22-41.19 years). The gender distribution: 27 women and 7 men or 79 % / 21 %. All 34 patients (100 %) were the persons of working age, including 62 % (21 patients) of the persons with disability of the group 3.  

The inclusion criteria were: 1) dysplastic coxarthrosis of the types 1-2 according to Hartofilakidis; 2) coxarthrosis of the stages 3-4 according to X-ray examination; 3) intense pain syndrome and limited motions in the injured joint. The exclusion criteria: 1) osteoporosis according to radiological examination; 2) long term administration of glucocorticosteroids and anticonvulsants; 3) gastrointestinal diseases with malabsorption syndrome; 4) insulin-dependent diabetes mellitus; 5) kidney stone disease. All 34 patients received the cementless total hip replacement with the press-fit acetabular components and metal-polyethylene friction pair, with additional bone plasty of the acetabular roof with the femoral head spongious autograft.

 

Surgical technique

The patient is positioned on the healthy lateral side. Spinal dural anesthesia is conducted. After three times of surgical field preparation, the anteriolateral approach to the hip joint (according to Watson-Johnson) is made. Dissection of the skin subcutaneous fat and broad fascia was carried out with the standard technique. Dissection of the tendon of the middle gluteal muscle was performed in the safe zone, 2-3 cm from the place of attachment to the greater trochanter, for possibility of subsequent restoration of the abducent mechanism. The longitudinal dissection of the joint capsule and displacement of the femoral head were performed. The femoral head saw-line was realized at the level of the neck. Circumferential placement of 4 Homan retractors provided the adequate approach to the acetabulum. The sawn part of the femoral head was used for formation of the trapezoidal spongious autograft (Fig. 1).

Figure 1

Bone graft from head of the femur.

The acetabulum was cleaned from scar tissues. The bone scraper was used for removal of sclerotic parts in the roof. The ready autograft was placed onto the prepared bed and was fixed with 2-3 spongious screws (Fig. 2).

Figure 2

Bone graft in acetabular roof.

The special cutters (beginning from the minimal size of 36 mm) were used for preparation of the acetabulum with the autograft up to the bleeding bone. After that, the impaction of the press-fit acetabular component and the polyethylene insert were performed with adherence to the positioning rules (Fig. 3).

Figure 3

Inserted cup.

After opening the intramedullary channel of the femoral bone with use of the chisel, and after use of the rasps for reaching the necessary size, the femoral component was placed at the anteversion angle within 10-20°. The control head was used for testing the stability of the joint and for estimation of the range of movements. The metal head was positioned and reduced. After that, the wound was sutured in layer-by-layer manner.

The table 1 shows the characteristics of the endoprosthesis components in dependence on a manufacturing company.

Table 1

Stratification of implanted components

 

Postsurgical period

The postsurgical injection therapy included the antibiotic prevention with wide-spectrum drugs (cephalosporins of 3rd generation), administration of low-molecular heparin for prevention of clotting (Clexane) and prescription of non-steroidal anti-inflammatory drugs (ketolorac, nimesulid) for anti-inflammatory and analgetic purposes. Calcemin Advance was recommended for improvement in union of the autograft (for 2 months). As a part of limitations, the external rotation of the operated extremity and its flexion more than 90° in the hip joint was prohibited for 3 months. On the first day, the patients tried to sit and used the respiratory gymnastics. On the second day, the dosed (not more than 40 %) weight-bearing crutch ambulation was allowed. One and a half month after the surgery, the walking-stick was used. The additional support was cancelled if the X-ray examination showed any signs of the autograft survival 3 months later.

The estimation of results of surgical treatment was carried out with clinical and radiological examinations, VAS, Harris score and SF-36 one year after the surgery. The clinical examination included the estimation of range of movements in the operated joint and the difference in the length of the lower extremities. Estimation of pain intensity was estimated with VAS. SF-36 was used for analysis of life quality.

According to anterolateral and lateral X-ray images in 3, 6 and 12 months, we could assess the position of the endoprosthesis components, the condition of paraprosthetic bone tissue and good position of the autograft. The functional result of the treatment was estimated with modified Harris score: 90-100 points – excellent, 80-89 – good, 70-79 – satisfactory, < 70 – unsatisfactory.

The statistical analysis was conducted with Microsoft Excel AtteStat 2.5.1. The preparation of the variational series included the calculation of mean arithmetic, standard deviation and confidence intervals. Mann-Whitney non-parametric test was used for comparison of the mean values in relation to denial of the hypothesis of normal distribution of the variational series. The p value < 0.05 was statistically reliable.

The study was conducted on the basis of written consent and the approval from the ethical committee with compliance with Helsinki Declare – Ethical Principles for Medical Research with Human Subjects 2000, and the Rules for Clinical Practice in the Russian Federation confirmed by the Health Ministry of RF June 19, 2003, No.266).

 

RESULTS

The results of the surgical treatment were estimated in the clinical examination including inspection of postsurgical field, measurement of absolute and relative lengths of the extremities, and estimation of volume of movements in the hip joint with use of the angle meter. Edema, flushing, local temperature increase and fistulous tracts (the signs of inflammatory process) were not identified. 3 patients (8.8 %) showed the excessive length of the operated extremity, with the mean value of 0.13 ± 0.45 cm (95 % CI, 0.2-0.7 cm). The presurgical volume of movements showed the statistically significant differences from the values 1 year after arthroplasty (the table 2).

Table 2

Volume of motion in hip

One should note the normal values of internal rotation in patients with dysplastic coxarthrosis with significant limitation of other types of movements at the presurgical stage; it was possibly determined by anatomically excessive antetorsion of the femoral neck in such pathology.

The analysis of VAS score showed the decrease in the value in dependence on time of rehabilitation. It showed the decrease in intensity of pain in the patients after joint replacement. The significant increase was noted in the first three months. Possibly, it was associated with additional uptake of analgetics at the background of recovery of the anatomical center of rotation and balancing the muscular strength after the intervention. The figure 4 shows the time course of VAS.

Figure 4

Time course of VAS

The clinically identified improvement in the condition of the hip joint was confirmed by Harris score results. The mean values 12 months after total hip replacement (83.6 ± 6.56; 95 % CI, 81.4-85.8), showed the statistically significant differences from the presurgical values (26.1 ± 6.23; 95 % CI, from 23.9 to 28.2) (р < 0.01). The results were excellent in 8 patients, good – in 16, satisfactory – in 9, unsatisfactory – in 1 (Fig. 5).

Figure 5

Structure of Harris scale results.

The postsurgical X-ray images showed the impaction of the acetabular component into the true acetabulum (100 %) in all patients. The mean values of bone coverage of the prosthesis cup were 95.1 ± 3.79 % (95 % CI, from 93.8 % to 96.3 %), the lateral angle of inclination – 42.5⁰ ± 4.77⁰ (95 % CI, from 40.9⁰ to 44.1⁰). The condition of paraprosthetic tissue in DeLee-Charnley zones was excellent in 21 (62 %) patients, good –in 12 (35 %), unsatisfactory – in 1 (3 %). Adherence of the autograft in view of the flattening line of osteotomy was registered in 33 patients (97 %) 3 months after the surgery (Fig. 6).

Figure 6

X-ray images of a patient with dysplastic coxarthrosis of type 2 according to Hartofilakidis: a) before operation; b) after operation.

Figure 6a X-ray images of a patient with dysplastic coxarthrosis of type 2 according to Hartofilakidis before operation.	Figure 6b X-ray images of a patient with dysplastic coxarthrosis of type 2 according to Hartofilakidis after operation.

The stability of the femoral component in all 34 patients (100 %) showed the normal position of the prosthesis stem and absence of the osteolysis line with 2 mm width and more in Gruen zones.

One patient (3 %) showed the non-adherence of the spongious autograft and development of aseptic instability of the acetabular component according to the radiological examination 6 months after primary arthroplasty. It required for a single revision intervention with placement of the strengthening ring (Burch-Schneider).

The estimation of SF-36 showed the mean values of physical functioning, role functioning determined by physical condition. The intensity of pain syndrome after surgical treatment differed from the presurgical values (p < 0.05). However the values of life activity, social functioning and role functioning, which were determined by emotional state and mental health, did not differ significantly in the pre- and postsurgical periods. The table 3 presents the data.

    Table 3

Assessment of patient^’s quality of life according to SF-36

Note: * – statistically significant differences between the indicators at p < 0.05.

DISCUSSION

Total hip replacement is one of the most efficient treatment techniques of dysplastic coxarthrosis that allows fast elimination of intense pain and improving the joint functioning. However the available anatomical features of the acetabulum significantly burden the surgical intervention and decrease its efficiency.

One of the most perspective techniques for treatment of defects in anterosuperior and posterosuperior borders of the acetabulum is bone impaction plastics with the autograft from the segment of the sawn femoral bone. The standard techniques of examination were used for estimation of the efficiency. So, the main complaints and indications for total joint replacement were intense pain and the limited function of the joint. The special attention was given to these components after surgical  management.

According to the clinical examination, the volume of movements in the injured hip joint increased significantly and was within the normal range. The presurgical and postsurgical values of internal rotation were normal; it was possibly associated with anteversion of the femoral neck with hip dysplasia. The intensity of pain decreased by 83 % one year after total hip replacement, and the registered values about 1.38 points did not cause any worsening the social adaptation. The values of the physical component of SF-36 (influence of physical condition on daily activity after surgery) increased almost two times. It can be explained by the decrease in pain intensity and absence of contractures in the affected joint after surgery. The mental component of health was the same before and after surgery. This fact can be explained by adaptation of patients to long term pathology and their non-acceptance of hip dysplasia as a mutilating disease. The functional outcome according to Harris score showed the significant increase in the mean value from 26.1 to 83.6 points 12 months after total replacement. According to the clinical and radiological examinations, the rate of autograft non-survival and aseptic instability of the prosthetic cup was 1 case (3 %). It was associated with non-adherence to the postsurgical limitation mode.

 

CONCLUSION

The use of bone autograft from the sawn segment of the femoral head for total hip replacement is efficient for patients with dysplastic coxarthrosis of the types 1-2 (Hartofilakidis), completely covers the acetabular component, improves the results of surgical treatment and decreases the rate of aseptic instability of the prosthesis cup.

 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of clear or potential interests relating to publication of the article.