Отправить письмо автору 
Написать комментарий 
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
|
Cup |
Abs. n. |
% |
Stem |
Abs. n. |
% |
|
Smith & Nephew (R3) |
27 |
79 |
Smith & Nephew (SL) |
28 |
85 |
|
De Puy (Pinnacle) |
4 |
12 |
De Puy (Corail) |
3 |
9 |
|
Zimmer (Trilogy) |
3 |
9 |
Zimmer (Avenir) |
2 |
6 |
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
|
Index |
Time of testing |
|
|
before THR |
after THR |
|
|
Flexion |
56.5 ± 16.58* |
106 ± 9.9* |
|
Extension |
2.8 ± 2.06* |
8.9 ± 4.22* |
|
Adduction |
2.6 ± 3.07* |
9.6 ± 4.5* |
|
Abduction |
10.4 ± 6.89* |
21 ± 6* |
|
External rotation |
10.1 ± 6.57* |
22.4 ± 5.8* |
|
Internal rotation |
21 ± 6.36 |
21.6 ± 4.39 |
Note: * – statistically significant differences between the indicators at p < 0.05.
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 ofthe 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
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
|
Index |
Before surgery |
After surgery |
|
Physical component of health |
23.7 ± 1.74* |
50.4 ± 2.69* |
|
Mental component of health |
55.2 ± 0.99 |
58.1 ± 4.07 |
|
Physical functioning |
16.4 ± 6.27* |
89.2 ± 5.85* |
|
Role (physical) functioning |
14.3 ± 13.36* |
66.7 ± 12.91* |
|
Pain |
30.3 ± 8.58* |
81.7 ± 10.23* |
|
General health |
79 ± 3.74 |
87.8 ± 4.92 |
|
Life activity |
74.3 ± 7.32 |
85.8 ± 2.04 |
|
Social functioning |
85 ± 7.22 |
93.8 ± 6.85 |
|
Role (emotional) functioning |
90.5 ± 16.3 |
83.3 ± 16.67 |
|
Mental health |
84 ± 3.22 |
90 ± 4.89 |
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.
REFERENCES:
1. Denisov
AO. Dysplastic coxarthrosis against congenital hip dislocation and other
dysplastic coxarthrosis: clinical recommendations. St. Petersburg,
2013. 26 p. Russian (Денисов А.О. Диспластический коксартроз на фоне врожденного
вывиха бедра и другие диспластические коксартрозы: клинические рекомендации.
СПб., 2013. 26 с.)
2. Mazurenko
AV. Total hip arthroplasty with severe degree of dysplasia: Cand. med. sci.
diss. Saint Petersburg, 2013. 166 p. Russian (Мазуренко А.В. Тотальное
эндопротезирование тазобедренного сустава при тяжелой степени дисплазии: дис. …
канд. мед. наук. Спб., 2013. 166 с.)
3. Yang S,
Cui Q. Total hip arthroplasty in developmental dysplasia of the hip: Review of
anatomy, techniques and outcomes. World J
Orthop. 2012; 3(5): 42-48
4. Dokhov
MM, Levchenko KK, Petrov AB, Ivanov DV, Dol AV, Ulyanov VYu et al. Experimental
modeling of the prosthesis of the supraacetabular region of the hip bone as a
stage of prevention of early dysplastic coxarthritis. Modern Problems of Science and Education. 2017; 5. Available at:
http://science-education.ru/en/article/view?id=26876 (accessed 27.02.2018)
Russian (Дохов М.М., Левченко К.К., Петров А.Б., Иванов Д.В., Доль А.В., Ульянов В.Ю. и др. Экспериментальное моделирование протеза
надацетабулярной области тазовой кости как этап профилактики раннего
диспластического коксартроза //Современные проблемы науки и образования. 2017.
№ 5. Источник удаленного доступа: http://science-education.ru/ru/article/view?id=26876 (дата обращения: 27.02.2018)
5. Uluçay C,
Ozler T, Güven M, Akman B, Kocadal AO, Altıntaş F. Etiology of coxarthrosis in
patients with total hip replacement. Acta
Orthop Traumatol Turc. 2013; 47(5): 330-333
6. Khanduja
V. Total hip arthroplasty in 2017 – current concepts and recent advances
Indian. J Orthop. 2017; 51(4): 357-358
7. Maksimenko
DV, Vorotnikov AA, Malakhov SA, Shishkin DV, Konovalov EA. Variant of
acetabular roof plastics with its defects by structural autograft as a stage of
total cementless total hip replacement of coxarthritis. In: Modern technologies in traumatology and
orthopedics: the materials of conference. St. Petersburg:
Sintez Buk,
2010. P. 168-169. Russian (Максименко
Д.В., Воротников А.А., Малахов С.А., Шишкин Д.В., Коновалов Е.А. Вариант пластики
крыши вертлужной впадины при ее дефектах структурным аутотрансплантатом как
этап тотального бесцементного эндопротезирования коксартроза //Современные
технологии в травматологии и ортопедии: матер. конф. СПб.: Синтез Бук, 2010. С. 168-169)
8. Tikhilov
RM, Shapovalov VМ. Complex cases of primary arthroplasty of the hip
joint. Deformation of the acetabulum. Available at:
http://medbe.ru/materials/endoprotezirovanie-tbs/slozhnye-sluchai-pervichnoy-artroplastiki-tazobedrennogo-sustava-deformatsiya-vertluzhnoy-vpadiny/
medbe.ru (accessed 27.02.2018). Russian (Тихилов Р.М., Шаповалов В.М. Сложные
случаи первичной артропластики тазобедренного сустава. Деформация вертлужной
впадины. Источник удаленного доступа: http://medbe.ru/materials/endoprotezirovanie-tbs/slozhnye-sluchai-pervichnoy-artroplastiki-tazobedrennogo-sustava-deformatsiya-vertluzhnoy-vpadiny/medbe.ru (дата обращения
27.02.2018)
9. Peng Y, Yang L, Chen G, Gu L, Chen H. Autograft of femoral
head for
acetabular reconstruction in
total hip
arthroplasty for
developmental dysplasia of the hip
with complicated deformity. Zhonghua Wai Ke Za Zhi. 2014; 52(1):
25-29
Статистика просмотров
Ссылки
- На текущий момент ссылки отсутствуют.
