A 59-year-old man presented with hip pain secondary to metastatic prostate carcinoma affecting multiple sites, including his left acetabulum. The patient’s prognosis was good, he was active, independent, with a good quality of life, so was offered surgical reconstruction. The Harrington method involves passing metal rods from the ileum to the ischium and pubis to create a scaffold for hip replacement. This is the gold standard for reconstruction of acetabular metastatic defects. However, this method is prone to failure by medialisation of the construct in the long term. We present our technique of employing a novel modification to the Harrington reconstruction that offers additional support medially with a suprapectineal plate. This construct is strong and durable enough to facilitate immediate weight-bearing and prevent long-term medialisation.
- cancer - see oncology
- hip prosthesis implantation
- prostate cancer
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Bone is the third most common site of metastatic disease after lung and liver. Pathological fractures from metastatic disease present a significant surgical challenge, particularly those involving the acetabulum. Advancement in oncological care means the prognosis and survivorship of patients with metastatic disease is continually improving. A robust, reliable method of acetabular reconstruction that allows early weight-bearing is therefore vital in the management of these patients.
Harrington originally described his reconstruction technique for advanced metastatic disease in the acetabulum in 1981.1 He suggested reinforcing the acetabulum with two groups of threaded pins that converge in the supra-acetabular region. The pins are cemented together with an acetabular support ring and a total hip replacement. This technique was further modified by Grimer, who suggested the use of three pins inserted from the iliac crest to pass in front of, behind and medial to the acetabulum.2 This forms a scaffold onto which cement can be applied, with or without reinforcement provided by a steel mesh. An acetabular component of a total hip replacement can be cemented into this construct. In this paper, we describe a modification of the Grimer method, in severe cases of hemipelvic metastatic disease. The use of a suprapectineal plate provides additional support particularly to the quadrilateral plate of the acetabulum. This functions as a buttress of the medial wall of the acetabulum and negates the need for cement or a steel mesh as outlined in Grimer’s paper. An acetabular component of a total hip replacement can be directly cemented into this construct. This is a biomechanically sound reconstruction that, in conjunction with total hip arthroplasty, allows immediate weight-bearing and a return to function.
We present a 59-year-old man with a background of histologically diagnosed carcinoma of the prostate with metastatic bone disease. A bone scan and cross-sectional imaging identified metastases in his thoracic spine and left acetabulum.
During an inpatient stay for chest pain and a suspected pulmonary embolism, the patient sustained a fall. Subsequent radiographs (figure 1) demonstrated a pathological fracture of his left acetabulum. He was transferred to our institution for further assessment and management. Despite his metastatic disease, the patient had a favourable prognosis, and a decision was made to offer him reconstructive surgery for his fracture. This involved the concept of ‘fix and replace’ surgery. This refers to fixation of his acetabular fracture with simultaneous total hip replacement in the same sitting. The rationale for this is to minimise morbidity and optimise postoperative full weight-bearing mobility.
A CT scan was obtained preoperatively which showed extensive bone loss around the acetabulum (figure 2).
A surgical plan was formed, and the Harrington Plus technique was employed. Harrington originally described the insertion of threaded pins to support a collapsing acetabulum in these situations. In this case, we elected to use a suprapectineal plate in order to augment our construct and allow full weight-bearing immediately postoperatively. Initially supine, the patient had a Stoppa approach to his acetabulum for the plate insertion, a lateral window to place the Harrington rods and then turned laterally to perform a total hip replacement. The final result can be seen in figure 3.
Plain radiographs, bone scan, CT scan and appropriate blood tests.
Myeloma screen normal.
PSA raised at 686.12.
The ‘Harrington Plus’ reconstruction to augment the patient’s failing acetabulum before a total hip replacement.
Outcome and follow-up
The patient remained in hospital for 7 days and was repatriated to a district general hospital. He recovered well with no immediate complications. The patient was able to fully weight-bear with crutches on discharge. He was followed up at 2 weeks locally and at 3 months with us. At his last follow-up, his pain was much improved. Unfortunately, his prostate cancer progressed, and he passed away 9 months postsurgery.
The treatment of pathological fractures of the acetabulum has been well described in the literature. Harrington first described a technique for their reconstruction in 1981.1 Since then, two authors have looked at the long-term results.3 4 Additionally, other authors have modified this technique in order to attempt to improve the strength and longevity of the construct.2 In the long term, the Harrington reconstruction has been known to fail by medialisation of the construct. Therefore, in patients with a good prognosis, this can be a problematic feature. Our technique in this case report directly addresses this problem. The incorporation of the suprapectineal plate provides a buttress to the medial wall of the acetabulum and prevents failure by medialisation previously experienced with the Harrington reconstruction. In the context of improving oncological care, and better prognoses in this patient group, it is vital to provide a strong and durable construct with good longevity.
We appreciate the additional morbidity associated with the use of the Stoppa approach in these cases. If the bone stock allowed for a triflange or cup cage, this would be appropriate and certainly offers a lower surgical insult. However, our patient did not have adequate bone stock for either of these techniques, thus our proposed solution.
As such, we place our indications for a Harrington Plus as the following, taking these into account we have completed four cases in 5 years; hence, the indications are rare.
Advanced bony metastatic involvement of the ischium. The ischium is a key inferior point for fixation of the triflange construct. With metastasis in the ischium, which is often involved early in pelvic metastatic disease, there are only 20–30 mm screw options available for fixation with a fairly horizontal direction of screw placement. This is limited by most cage systems.
Extensive metastasis in the ilium where the Harrington rods alone provide poor construct integrity.
Metastasis from a known aggressive primary; rapid advancement of bony lesion.
The primary aim of this technique is to allow ‘reliable longevity’ to an immediate postoperative full weight-bearing construct, by locking the anterior column into the posterior column sciatic buttress which is some of the most dense bone in the body and more resistant to metastatic disease.
We use this technique with caution in the following patients:
Very frail; if possible, we try to avoid the second positioning and extra surgical insult.
Patients with previous gynaecological/pelvic surgery/radiation to pelvis as there are often dense adhesions which increases surgical operative time and complication risk, such as bleeding, infection or hollow visceral organ breach.
Those with central ’hernia mesh' in situ, again because they cause dense adhesions.
Metastatic disease which is known to bleed such as renal metastasis for which we would use embolisation where possible.
Pathological fractures of the acetabulum in patients with metastatic bone disease and a good prognosis should be treated surgically.
The surgical aim should be to allow immediate full weight-bearing to reduce postoperative morbidity and continuity of quality of life.
The reconstructive construct should be robust and offer good longevity.
Our method offers a reliable, reproducible construct that confers the aforementioned advantages—stable, durable and good longevity beyond previous Harrington reconstructions that have failed by medialisation of the construct.
There is a greater surgical insult with this technique, and it should be performed with caution in certain patient groups.
Contributors All authors have contributed to the patients care, write-up and review of the manuscript. RC: contributed to the planning of the paper, patient’s care, design of the paper and write-up of the paper. D’JL: contributed to the planning of the paper, patient’s care, design of the paper and write-up of the paper. ADC contributed to the planning of the paper, patients care, design of the paper, write-up of the paper and the development of the technique.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.