Long-Term Results of Bulk Femoral Head Autograft in Cementless THA for Developmental Hip Dysplasia

Abstract

We evaluated the fate of bulk femoral head autograft in cementless total hip arthroplasty (THA) for developmental hip dysplasia. Of 87 hips (80 patients) studied, 37 hips (32 patients) were available for follow-up at a mean of 18.5 years (range, 15–24 years) postoperatively. The mean age of these 32 patients at the index procedure was 53.8 years (range, 40–65 years). The initial diagnosis was osteoarthritis in all 32 patients. The degree of acetabular dysplasia according to Crowe classification was type I in 18 hips (48.6%), type II in 14 (37.8%), type III in 5 (13.5%). The mean percentage of horizontal coverage of the acetabular components with graft bone was 34% (range, 25%–45%). Trabecular bridging across the graft–host interface was seen at a mean of 4 months (range, 2–6 months) postoperatively. Trabecular reorientation of the grafted bone was seen in all hips at a mean of 27 months (range, 12–36 months) postoperatively. There was no evidence of collapse and bony resorption of the grafted bone in the weight-bearing portion. Acetabular component fixation was stable in all hips at final follow-up. Of the 37 hips (32 patients), 2 acetabular components required revision: 1 for a late postoperative deep infection and 1 for dissociation of the polyethylene liner. The survival rate was 94.5% (95% confidence interval, 91.3–96.5) for the acetabular component at 18.5 years of follow-up. This study found that bulk femoral head autograft in cementless THA for developmental hip dysplasia produces excellent long-term results.

Femoral Head Autograft Can Reliably Reconstruct Dysplastic Acetabula Through the Direct Anterior Approach for Total Hip Arthroplasty

“…This study demonstrates that reconstructing the true acetabulum in dysplastic hips (Crowe I-III) with FHA can be successfully accomplished via a DAA with significant improvements in clinical and radiographic outcomes. Although satisfactory clinical and radiographic outcomes have been demonstrated using similar techniques and indications through alternative surgical approaches [ [3] , [4] , [5] , [18] , [19] , [20] , [21] , [22] ], potential advantages of the DAA include (1) direct exposure of the anterolateral acetabular defect, that is, typical of dysplastic hips [ 28 ]; (2) the use of intraoperative fluoroscopy, which facilitates graft placement and fixation, component positioning, and restoration of LLDs [ [31] , [32] , [33] ]; (3) an expediated functional recovery with prior studies demonstrating improvements in early gait, reduced hospital LOS, minimal activity restrictions, a low dislocation rate, and reduced postoperative pain [ 20 , [24] , [25] , [26] ].…”

“…Despite conflicting historical concerns of long-term graft resorption [ 15 ], recent literature has been largely positive for FHA [ [3] , [4] , [5] , [18] , [19] , [20] , [21] , [22] ]. In the present series, there was radiographic evidence of graft incorporation in all patients at a mean time of 6.5 months, which is comparable to alternative surgical approaches [ 3 , 4 ], with no evidence of component loosening or graft collapse.…”

“…Despite conflicting historical concerns of long-term graft resorption [ 15 ], recent literature has been largely positive for FHA [ [3] , [4] , [5] , [18] , [19] , [20] , [21] , [22] ]. In the present series, there was radiographic evidence of graft incorporation in all patients at a mean time of 6.5 months, which is comparable to alternative surgical approaches [ 3 , 4 ], with no evidence of component loosening or graft collapse. Although the underlying etiology of higher survival rates of FHA in recent literature is unknown, it could be speculated to be from several technical factors including (1) initial graft and cup stability through press-fitting the cup and placement of vertical screws through the cup to capture both graft and host bone; (2) graft orientation such that the subchondral portion of the graft was in maximum contact with the acetabular defect [ 47 ]; (3) use of highly porous-coated titanium cups to enhance initial component stability and facilitate bone ingrowth [ 48 ]; (4) restoration of the anatomic hip center to allow for a more physiological load transfer to the implant-bone interface [ 5 ].…”

“…Acetabular bone deficiency in patients with hip dysplasia creates technical challenges when performing total hip arthroplasty (THA) and can often preclude conventional placement of the acetabular component. Several techniques to achieve stability and coverage of the acetabular component have been described, including creation of a high hip center [ 1 ], cup medialization [ 2 ], and reconstruction of the true acetabulum with the use of autograft, allograft, or metal augments [ [3] , [4] , [5] , [6] , [7] ]. Many of these strategies, however, come at the expense of hip biomechanics [ 8 ], acetabular bone stock, and/or can be associated with high rates of component loosening [ [9] , [10] , [11] ].…”

“…With improvements in surgical technique and the use of highly porous-coated acetabular components, several recent studies have shown promising long-term outcomes of bulk FHA in THA using posterolateral or direct lateral approaches [ [3] , [4] , [5] , [18] , [19] , [20] , [21] , [22] ]; however, limited data exist on its efficacy through a direct anterior approach (DAA). The DAA has become increasingly popular for THA, largely due to minimizing soft-tissue trauma through the use of true intermuscular planes [ 23 ].…”