This chapter describes the indications, component design, surgical technique, and long-term results for acetabular reconstruction with a flanged acetabular component. The triflange cup is indicated in cases of massive acetabular bone loss that is not reconstructable with hemispheric implants. The prosthesis is custom matched to the patient’s anatomy and implanted by a standard posterior approach. Long-term results indicate that this technique provides pain relief and improves clinical function while reliably achieving implant stability on host bone.
The triflange cup is indicated in cases of massive acetabular bone loss, typically American Academy of Orthopaedic Surgeons type III or IV pelvic discontinuity defects, Paprosky type IIIA or IIIB defects, and cases of pelvic radiation osteonecrosis.
Design of the component, with particular attention to flange size and location, head center location, and cup face orientation, is critically important.
Several attempts at working with the design engineer on the component design may be necessary before all the elements of the design are optimal. Time spent ensuring satisfactory design will pay off with a component that fits intimately against host bone, is inherently stable, and is at less risk for dislocation.
Surgical technique is similar to other reconstructive procedures requiring extensile exposure. Operative time typically is reduced compared with techniques involving intraoperative fabrication and improvisation, such as cages and structural allograft.
Because the component accepts standard, off-the-shelf modular inserts, options such as alternative bearings, large head ball diameters, and constrained liners should be considered when appropriate.
The 1:1 hemipelvis model used to design the implant is sterilized and used during the procedure for reference.
Always insert the component iliac flange first. After the component is properly seated, screws are inserted starting with the ischial flange. If necessary to improve screw fixation, a cavitary lesion in the ischium can be filled with bone cement.
Locking screws may be used in the ischial and iliac flanges to further improve implant stability. Component design should always include one lag screw hole in each flange; the lag screw is inserted first and pulls the implant down into intimate contact with host bone.
Dislocation is the most common complication after triflange reconstruction. This can be reduced by close attention to cup face orientation and head center location when the implant is designed and by the use of constrained inserts in cases of poor abductor function.
The sciatic nerve must be identified and mobilized enough that the ischial flange can be correctly placed without traction or compression injury. An external neurolysis may be necessary.
Avoid significant traction on the superior gluteal nerve contained in the neurovascular bundle exiting the superior aspect of the sciatic notch.
Catastrophic pelvic bone loss as a result of osteolysis, infection, mechanical abrasion, or congenital deficiency is the most daunting challenge in hip reconstruction. To achieve successful acetabular reconstruction, the implant must be stable on viable host bone strong enough to accept the loads of ambulation. If the implant does not achieve adequate bony stability, the reconstruction is doomed to failure. Catastrophic bone loss compromises the amount of viable host bone and its strength.
The primary objective of any acetabular reconstruction must be stable fixation. Two general methods achieve this: achieve the stability by getting the implant to healthy bone by choosing an implant that matches the shape of the acetabular defect, or achieve stability by taking the implant to healthy bone beyond the defect by bridging the defect. Defect-matching methods, the most commonly used technique, typically involve implantation of a larger hemispherical cup. The defect shape is matched simply by reaming the defect until a hemispherical component is stably fixed on the remaining acetabular rim. Defect-matching techniques used for revision acetabuloplasty with less than catastrophic bone loss have had excellent results at long term. For defects that are too large or too eccentric for a hemispheric component, the surgeon may use an implant that is more closely matched to the defect in shape, such as an oblong cup. Results with oblong components have been excellent when the supporting bone is adequate. Failures occur when these implants are used in situations that exceed the indications of the implant, such as in cases of pelvic discontinuity. Alternatively, the defect can be converted to more a hemispheric configuration with the addition of structural allograft or trabecular metal augments. Although the long-term success rates of trabecular metal augments are not yet known, the published results with allograft show high rates of failure at long term.
Some defects are simply too massive to allow predictable stable fixation with defect-matching techniques. These defects must be “bridged” by the implant to bring the implant into stable contact with host bone. Although the goals of surgery remain the same, the objective of bridging techniques is to achieve stability on the pelvic bone beyond the acetabulum and the remnants of its rim.
These large defects are classified as American Academy of Orthopaedic Surgeons (AAOS) type III (contained) or IV (pelvic discontinuity) defects or Paprosky type IIIA or IIIB defects. Special considerations are made for acetabular reconstruction in the face of pelvic osteonecrosis caused by irradiation. This chapter discusses the use of triflange acetabular components to address these catastrophic defects. The design of the implants, the surgical technique, and the outcomes are reviewed.
The triflange cup is indicated in cases of severe acetabular bone loss that exceeds the limits of defect-matching techniques ( Table 41-1 and Fig. 41-1, A ). The authors consider the indications for the triflange cup as most but not all AAOS type III combined defects, all cases of pelvic discontinuity (AAOS type IV), and all cases of pelvic radiation osteonecrosis. According to the Paprosky classification of acetabular defects, the indications for the triflange cup include most Paprosky IIIA and IIIB defects.
|Study||Year||Hips||Mean Follow-up (range)||AAOS Defect||Failures|
|Christie et al||2001||59 revision THAs, 8 primary THAs||4.4 yr (2-9 yr)||III: 34 hips; IV: 33 hips||None|
|Joshi et al||2002||27 revision THAs||4.8 yr (4-6 yr)||All III||2 hips: 1 converted to girdlestone for infection, 1 re-revised to new triflange for dislocation|
|Holt and Dennis||2004||26 revision THAs||4.5 yr (2-7 yr)||III: 23 hips; IV: 3 hips||3 hips: 1 converted to girdlestone for loosening, 2 additional patients with hips with loosening have refused further surgery|
|DeBoer et al||2007||26 revision THAs||10 yr (7-13 yr)||All IV (pelvic discontinuity)||None|
The decision to use a triflange cup must be made preoperatively, well in advance of the procedure, because the component is custom designed and manufactured to fit the individual patient’s pelvis. Although major acetabular bone loss often is obvious, it is heralded by dissociation of the acetabular component from the acetabulum; dislocation of the component into the pelvis; resorption of allografts; and broken screws, plates, and antiprotrusio rings (see Fig. 41-1 ). In more subtle cases standard radiographic views of the pelvis, augmented by additional views (Judet, inlet/outlet), alert the surgeon to defect size and the presence of pelvic discontinuity. If the acetabular component has dislocated into the pelvis, or if the superior and inferior pubic rami are rotated relative to the ipsilateral iliac wing and the contralateral hip, a pelvic discontinuity must be assumed ( Fig. 41-2 ).
Additional imaging with three-dimensional computed tomography reconstruction may further help determine the extent of acetabular bone loss (see Fig. 41-1 ). If three-dimensional images do not provide enough information to fully evaluate the bone loss, a 1:1 hemipelvic model is created. This model will give the surgeon the best representation of the bone available to support the reconstruction. This model also can be used for a mock surgical procedure to evaluate whether a defect-matching technique can be used to reconstruct the acetabulum.
The triflange cup has proven to be a reliable option for patients with catastrophic bone loss. However, the time necessary to design and build the implant, the design complexity with required surgeon input, and the implant cost render it unsuitable when a simpler method of reconstruction will work. The three-dimensional reconstructions are highly effective in determining which cases of bone loss can be solved with defect-matching solutions.
The time necessary to design and manufacture the implant can be a relative contraindication. The implant requires a minimum of 6 to 8 weeks for the design, manufacture, and sterilization process. This time requirement can stretch to 4 to 6 months if the design process is delayed by revisions of the component design.
In patients in whom proceeding more quickly is important, an alternative solution such as an antiprotrusio cage may be selected. The antiprotrusio cage is a malleable metal defect-bridging device first introduced in 1974. It is most effective when combined with structural allograft. Because it is used for a variety of defects and individual pelvises, the cage must be made of deformable metal so the flanges can be bent and shaped intraoperatively to maximize contact with the host bone. This “one size fits all” design of an antiprotrusio cage often results in a compromised fit. The strength of the flanges is compromised to allow intraoperative adjustment. The absence of biologic fixation and flexible flanges leads to frequent component failure from flange or screw breakage and loss of fixation.
Infection is an absolute contraindication. Bone loss itself has not been a contraindication. No patient has been denied reconstruction with a triflange because of the severity of bone loss.
The design phase of the triflange cup is the most critical step in the surgical technique. Because the implant is custom made, surgeon input on bone removal, flange size and location, head center location, and cup face orientation is required before the implant is made. Because these decisions are made preoperatively, the operative time is reduced by eliminating the intraoperative improvisation and fabrication necessary when using cages and structural allografts. Careful consideration and contemplation of the various design decisions are necessary during the design phase, however, because no alterations are possible during surgery with the exception of the modular insert choices and the amount of bone removed.
The design process begins with a computed tomographic (CT) scan done on a modeling protocol. Having the radiology technician review the protocol with a design engineer from the manufacturer before the scan is often helpful. The CT scan should capture both hemipelvises. It should begin one slice above the ilium and end one slice below the ischium to ensure that the entire pelvis is captured. A standard CT artifact algorithm should be used to avoid enhancing metallic scatter in the scan region. To produce an adequately detailed model, slice thickness should not exceed 3 mm.
Once the scan is complete, it is sent to the manufacturer and a three-dimensional model is created. This complex task first requires the removal from the scan of the failed acetabular component, bone cement, screws, plates, and old grafts. Despite this complexity, the results are surprisingly accurate. The surgeon can then review the reconstructed hemipelvis on the computer (see Fig. 41-1, B ), or a 1:1 model can be constructed by stereolithography. The model is sent to the surgeon, who marks the thin, fragile periacetabular bone to be removed at surgery and draws the outline of the flange geometry on the model (see Fig. 41-1, C ). Remember, cup stability and fixation no longer come from the deficient rim of remaining acetabular bone but from the better bone of the ilium, ischium and pubis. The implant bridges the defect.
The iliac flange is the most important. The iliac bone is the best, and this flange has the largest surface available for contact. The authors generally plan for five to six screws in excellent bone through this flange. The ischial flange is the next most important flange. When using a posterior approach, this flange sits under the sciatic nerve. Consideration of the flange geometry is important. The ischial flange should extend far enough and be broad enough to accept three to four screws. The edges should be rounded and of low profile to avoid the possibility of sciatic nerve irritation. The pubic flange generally is small, roughly triangular in shape, and without a screw hole. It provides the “third leg on the stool” for stability.
The surgeon-marked pelvic model is returned to the manufacturer for the first pass at the construction of an implant model. At this point, the engineer should be notified if the surgical plan is to reestablish a near anatomic position of the head center or if head center will be raised (cephalad) or lowered (caudal). This will depend more on the planned retention or revision of the femoral component than on the acetabular bone loss.
The engineer returns the pelvic model with any areas of bone removed or machined (with acetabular reamers) marked in bright red for surgeon reference. The pelvic model is later sterilized and referenced intraoperatively. The model of the proposed triflange cup is sent along with the pelvic model. The surgeon reviews the size and location of the three flanges and changes are marked on the model for engineer referencing. Special attention should be made to the contour of the flanges and how the flanges will interact with the soft tissues. Smooth transitions and rounded edges are important where the sciatic nerve may pass. To maximize initial implant stability, the iliac flange should fit over the two planes formed by the gluteal ridge and the iliac screw holes should begin at the inferior edge of the remaining structurally sound ilium.
Over the past 2 years the authors have added locking screws to enhance the stability of the triflange cup/pelvic construct. The location of any locking screw holes is indicated on the model. One nonlocking screw hole should always be present in both the ischial and iliac flanges. This nonlocking lag screw will be inserted first and will pull the implant down into intimate contact with the bone surface before the locking screws are inserted.
Cup stability on the pelvic model is assessed. The flanges should fit intimately against the pelvic bone. The construct should feel stable to superior/inferior and anterior/posterior loading. Increasing the diameter of the central hemispherical portion often will greatly improve overall stability. Although the central hemispherical portion does not have to intimately contact the remaining acetabulum, the component should have inherent stability when placed on the model. The authors’ original designs attempted to fill the acetabular volume and have circumferential rim contact. The attempt to attain simultaneous rim and flange contact results in a component that is nearly impossible to insert without injury to the abductor muscles and superior gluteal nerve. The hemispherical portion of the cup should be of a large enough diameter that the cup resists any movement of the implant on the hemipelvis. Implants produced more recently have been designed with smaller central portions and have done as well clinically as the larger original designs. The cup likely derives its stability primarily from the flanges. The authors’ current designs are created without dome screw holes although a central, threaded dome hole is present to allow attachment of an impactor. The impactor handle can be helpful in manipulating the cup as it is positioned on the pelvis.
Head center location and the cup face orientation are critically important. The head center is chosen on the basis of patient-specific considerations, including leg-length discrepancy and planned retention or revision of the femoral component. The vertical head center is first selected by approximating the anatomic position of the head center with the superior aspect of the obturator foramen as a reference point. The remnants of the anterior and posterior columns help center the head in the coronal plane. The head center often is lateralized, which reduces possible femoral component impingement with the flanges. Lateralization of the head center has not affected long-term cup fixation. Cup face orientation is targeted at 35 to 40 degrees from the inter-teardrop line. Anteversion and abduction initially are established by using the plane of the obturator foramen as a guide. Throughout the design process, a full pelvic sawbones model is used as a reference.
In cases of pelvic discontinuity, the obturator foramen is not an accurate reference point because the inferior segment of the pelvis rotates away from the anatomic position around the pubic symphysis. In these cases the referenced sawbones model, the radiograph, and the iliac wing are used to establish cup face orientation. Establishing cup face orientation remains the most difficult part of the design process, precisely because the reference points often are so ambiguous.
Once the design is finalized, the pelvic and implant models are returned to the engineer to begin manufacture. The design process may go through several iterations before the design is satisfactory. The surgeon must take the time necessary to ensure that the component design is satisfactory before approving it.
Manufacture generally takes approximately 6 weeks after approval of a design. The central cup face and modular locking mechanism are created first. The flanges are then machined out of a titanium block. The screw holes are added. The pelvic side of the component is plasma sprayed and the hydroxyapatite coating is applied. The cup is then sterilized and shipped.
Whenever the pelvis must be exposed beyond the immediate acetabular rim, a more extensile approach must be used. The incision tends to be longer because the surgeon must be able to see enough of the bone beyond the acetabular deficiency to ensure good contact with healthy bone and see that the implant is seated at the planned position. Although the imposing size of the triflange cup may suggest that implantation will be difficult, the necessary exposure is identical to that used to place an antiprotrusio cage or a structural allograft. A standard posterior approach is used most often. This can be combined with an extended trochanteric osteotomy if necessary for femoral component revision.
After the incision is made, the soft tissue planes are reestablished. The tensor fascia is separated from the underlying gluteus medius and vastus lateralis fascia. The sciatic nerve must be identified and protected. It is located as it crosses over the ischium and then traced distally beneath the gluteus maximus insertion and into the hamstrings. Proximally it is traced into the sciatic notch. It must be identified and mobilized because the ischial flange fits intimately on the “sciatic” surface of the ischium. Because bone contact is critical for implant stability, the nerve must be mobilized enough that the flange can be correctly placed without traction or compression injury. This usually is easily accomplished, but the surgical planes may be confused and the nerve may be enveloped in scar. In this situation, identification of the nerve more distally (deep to the gluteus maximus insertion or directly over the ischium) and tracing it proximally are important. An external neurolysis occasionally is necessary.
Once the sciatic nerve is mobilized, a posterior arthrotomy is made. The periarticular scar is removed and the hip is mobilized. The hip is dislocated and the femoral component is inspected. If the femoral component is to be revised, it is removed at this stage. The authors often use an extended trochanteric osteotomy to facilitate femoral component revision. If the component is retained, it is mobilized and retracted anteriorly under the gluteus minimus and anterior to the acetabulum. The gluteus minimus and gluteus maximus are elevated off the ilium. Care is taken to avoid significant traction on the superior gluteal nerve contained in the neurovascular bundle exiting the superior aspect of the sciatic notch. Enough mobilization must occur to allow the iliac flange to slide under the muscle. A small pocket is then created anterior to the pubis for the pubic flange. From the lateral decubitus position the pubis usually is straight down toward the operating table.
The ischium must be exposed to allow placement of the ischial flange. The soft tissue is elevated off the remaining posterior column extending from the inferior edge of the sciatic notch past the ischium. This tissue must be taken as a sleeve. The dissection off the ischium includes part of the hamstring origin so that the ischial bone beneath is exposed.
The pelvic model is repeatedly referenced. It is sterilized preoperatively and kept in the sterile field for review during the procedure. The areas of the model marked in red denote bone that has been planned for removal or machining. The bone must be removed to match the pelvic model so that the implant will fit as planned.
Component position on the model should be reviewed before implantation. The iliac flange is inserted first. The leg is abducted and translated cephalad, relaxing the hip abductors. The iliac flange slides between the ilium and the gluteus minimus. Care should be taken to avoid undue traction on the superior gluteal nerve posteriorly. The component is then rotated so that the pubic flange slides into the pocket created anteriorly. The hip is then extended and the knee flexed to relax the posterior soft tissues. The ischial flange is then pushed into position. Care should be taken to avoid trapping the sciatic nerve under the flange. The nerve has been mobilized with the surrounding sleeve of soft tissue. Releasing the soft tissue at the inferior corner of the acetabulum often will create additional mobilization of the posterior sleeve.
The triflange cup is then gently impacted into its seated position. The model is again referenced to ensure that the flanges are at the design position. If the component does not seat as expected, it is most likely malrotated, the planned bone removal (areas marked in red on model) is not complete, or morselized bone graft placed in the medial defect is preventing the cup from seating. Because of the potential interference from the morselized graft, the authors place the graft after the cup is fixed into position. Large gaps usually are present posteriorly between the component and the pelvis where the acetabulum is deficient, which allows backfilling with graft without difficulty.
Once the cup is seated, the screws are inserted. The ischial screws are always inserted first. The bone of the ischium is most affected by osteolysis. A large cavitary defect in the ischium often is present and screw fixation is compromised. If necessary to improve fixation, a cavitary lesion in the ischium can be filled with bone cement. Screws placed through the hardened cement attain excellent fixation. The authors’ most recent modification to the triflange design is the use of locking screws in the ischial and iliac flanges. One screw hole in the ischium remains for a lag screw. The 6.5-mm lag screw is inserted first to pull the flange down. The locking screws are then inserted. Once all the ischial screws are inserted, the iliac screws are inserted.
During iliac screw insertion, care must be taken to avoid traction injury to the superior gluteal nerve. For the iliac screws above the most distal row, drilling and insertion can occur directly through the gluteus minimus and medius. A total of four to five iliac screws usually are placed. The lag screws are inserted first to pull the iliac flange into intimate contact with the ilium. Because the iliac bone usually is well preserved, these screws attain excellent purchase. Because the edges of the flange are obscured by the gluteus maximus and minimus, palpation is the most effective way to determine if the flange is well seated. Once the flange is well reduced, the locking screws are inserted. Morselized graft is then packed behind the cup. This graft does not contribute to cup support or fixation but may aid in remodeling of the acetabular defect over time.
The modular insert is then inserted. In patients with poor abductor function (denervation, detachment, or absent greater trochanter) a constrained liner is used. In other cases, large head ball diameters and alternative bearings are considered.
Component Implantation in Cases of Pelvic Discontinuity
In patients with pelvic discontinuity, the upper and lower halves of the hemipelvis may be rotated through the discontinuity. Because the pelvis was scanned and the model made with the patient supine, the relation between the two halves of the hemipelvis often changes when the patient is in the lateral decubitus position.
Although the sequence of implant insertion is unchanged because of this rotation, the flanges often do not initially seat at their design positions. The ischial screws must be inserted first and the ischial flange placed at its design position. With the ischial screws in place, the iliac flange often is rotated off the ilium, but as the first iliac lag screw is inserted the screw taking purchase into the ilium will rotate the flange with the connected inferior half of the hemipelvis into the correct orientation relative to superior half. The remaining iliac screws are then inserted.