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Biologic technique achieves good outcomes in patients with acetabular protrusio
Impaction grafting with autologous bone led to restored bone stock in young and middle-aged patients.
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A new surgical technique proved advantageous when used in patients with protrusio acetabuli, according to a presenter.
The condition can be either primary or secondary and graded as mild, moderate or severe. Patients with acetabular protrusion are often a challenge to treat due to problems with medial and proximal migration of the hip center, lack of bone medially and reduce peripheral support for the socket, Arun Mullaji, FRCS(Ed), MS, said at a recent meeting.
“Using an impacted morsellized autograft with a porous coated cementless socket is a technically straightforward solution,” he said. “It restores biologically the deficient medial floor, provides sound mechanical fixation, and prevents recurrence of protusio. Templating helps restore the biomechanics.”
A challenging surgery
There are two types of protrusio. The primary type is a rare idiopathic variety. More commonly, however, it is associated with rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget’s disease, Mullaji said.
The surgical technique he described at the meeting involves impaction grafting that uses morsellized autologous bone and a cementless porous-coated hemispherical cup without any acetabular rings or cages. Using cemented cups, Mullaji said, can be associated with long-term complications and a high incidence of loosening and recurrence of protrusio.
A preoperative radiograph shows a 55-year-old woman with severe protrusio of the right hip secondary to rheumatoid arthritis.
This radiograph is of the right hip 3 months after reconstruction with morsellized impacted autologous bone graft, cementless socket and stem.
Images: Mullaji A
For the study that Mullaji discussed, the technique was used in 30 patients with an average age of 46 years who had 2 years to 10 years follow-up.
“There are three aims to our reconstruction. The first is to restore biomechanics to the hip. The second is to provide a biologic solution to address the bone deficiency medially, and the third is to ensure long-term fixation without recurrence of protrusion,” Mullaji said.
Improved Harris hip score
Among the patients Mullaji and colleagues studied about half of them were women and the majority of the patients had moderate to severe grade protrusio. All of the patients had an improvement in their mean Harris hip scores from 52 points preoperatively to 85 points at a mean follow-up of 4 years.
Incorporation of the graft was shown in all cases of the study, Mullaji and colleagues noted in their abstract.
“There was no evidence or progression of the protrusion or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients,” according to Mullaji and colleagues.
At the meeting Mullaji said, “This technique is therefore applicable to all types of cups. The limitations are, however, if there is no rim support or a very large defect, one may need to use rings or cages.” – by Robert Linnehan
- Reference:
- Mullaji A. Paper #34. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 11-14, 2013; Orlando, Fla.
- For more information:
- Arun Mullaji, FRCS(Ed), MS, can be reached at Breach Candy Hospital, The Arthritis Clinic, 101 Cornelian, Cumballa Hill, Mumbai 400036, India; email: drarunmullajiclinic@gmail.com.
Disclosure: Mullaji receives consulting fees and royalties from DePuy Synthes Joint Reconstruction and he receives consulting fees from Biomet.