Orthopedics · Medical Literature
Autologous impaction bone grafting of a cemented acetabular component in primary total hip arthroplasty in young patients: a randomized controlled trial.
Abstract
This randomized controlled trial (RCT) aimed to compare clinical and radiological outcomes of cemented acetabular component in primary total hip arthroplasty (THA) in patients aged under 60 years with and without autologous impaction bone grafting (IBG). A single-centre, triple-blinded RCT was conducted in patients aged 18 to 59 years undergoing primary THA without acetabular defects. Patients were randomized to receive either IBG or no IBG. Noninferiority of IBG was assessed for the primary endpoint, the Hip disability and Osteoarthritis Outcome Score (HOOS) sub-scale for activities of daily living (ADL) at one-year follow-up. Secondary outcomes included other patient-reported outcome measures (PROMs), perioperative outcomes, complications, and radiological outcomes. Radiographs assessed acetabular component and centre of rotation positioning, offset changes, and the presence of radiolucent lines in the bone-cement interface. A total of 131 patients were randomized. No significant group differences were found for the HOOS-ADL sub-scale at one year (mean difference 1.9 points (95% CI -4.85 to 8.7); p = 0.578), meeting the criteria for noninferiority. Furthermore, there was no effect of group on the scores for other PROMs. Surgery duration (+ 7.5 minutes; p < 0.001) and blood loss (+ 100 ml; p = 0.001) were significantly higher in the IBG group. Complication and revision rates were comparable. Radiologically, the IBG group had significantly fewer radiolucent lines in the bone-cement interface than the control group at one-year follow-up (p < 0.001). Compared with preoperatively, the postoperative position of the centre of rotation was less superior and medial in the IBG group (p = 0.024). The use of autologous IBG with a cemented acetabular component in primary THA in young patients is noninferior to standard cemented fixation regarding short-term clinical outcomes. IBG improves vertical position of the centre of rotation and early radiological fixation by reducing radiolucent lines around the cup, suggesting potential benefits for long-term acetabular component survival.
Clinical relevance
Cemented acetabular fixation in young patients (<60 years) undergoing primary THA carries heightened long-term revision risk, making optimization of initial fixation critical. This RCT directly addresses whether autologous impaction bone grafting (IBG) can improve radiological fixation quality without compromising short-term functional outcomes in this high-demand population. Given the increasing incidence of THA in younger patients and the substantial functional and economic burden of aseptic loosening and early revision, these findings are immediately relevant to surgical decision-making.
Key findings
1. Primary endpoint noninferiority confirmed: IBG was noninferior to standard cemented fixation for HOOS-ADL sub-scale at one-year follow-up (mean difference 1.9 points; 95% CI −4.85 to 8.7; p = 0.578), with no significant between-group difference in any other patient-reported outcome measure (PROM). 2. Operative time was significantly longer in the IBG group (+7.5 minutes; p < 0.001), and intraoperative blood loss was significantly greater (+100 mL; p = 0.001). 3. IBG significantly reduced the prevalence of radiolucent lines at the bone-cement interface at one-year follow-up compared with the non-IBG control group (p < 0.001), indicating superior early radiological fixation. 4. Postoperative center of rotation (COR) positioning was significantly less superior and less medial in the IBG group compared with preoperative measurements (p = 0.024), reflecting improved acetabular component positioning. 5. Complication and revision rates were comparable between groups at one-year follow-up, with no statistically significant difference reported. 6. The study enrolled 131 randomized patients (ages 18–59 years, no acetabular defects) in a single-centre, triple-blinded design, providing Level I evidence; however, the one-year follow-up limits conclusions regarding long-term implant survival.
Practice implications
In patients aged 18–59 years undergoing primary cemented THA without acetabular defects, surgeons should consider autologous IBG as an adjunct to cemented acetabular fixation, given its superior early radiological profile (fewer radiolucent lines, improved COR verticalization) without any detectable decrement in short-term functional outcomes. Clinicians must counsel patients and plan scheduling to account for a modest increase in operative time (~7.5 minutes) and blood loss (~100 mL), which may be relevant in patients with borderline hemoglobin or comorbidities affecting transfusion risk. Longer-term follow-up data are needed before IBG can be definitively recommended as a standard-of-care modification to reduce aseptic loosening and revision rates in this young, high-demand cohort.