Introduction. Impaction bone grafting (IBG) is a reliable technique for acetabular revision surgery with large segmental defects. However, bone graft resorption and cup migration are some of the limitations of this tecnique. We assess frequency and outcome of these complications in a large acetabular IBG series. Patients and Methods. We analysed 330 consecutive hips that received acetabular IBG and a cemented cup in revision surgery with large bone defects (Paprosky types 3A and 3B). Fresh-frozen femoral head allograft was morselized manually. The mean follow-up was 17 years (3–26). All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. Changes in different paremeters regarding cup position were assessed pre- and postoperatively and at the follow- up controls. Only variations greater than 5º and 3 mm were considered. Results. The mean Harris Hip Score improved from 48.3+8.5 to 84.6+12.8 at final follow-up. The radiological analysis showed cup migration in 42 hips. The mean appearance time was 4.3 years (range, 1–25). Migration was progressive and painful in 27 hips (67.5%) requiring cup revision. Lateral mesh was more frequently associated with migrated cups (p=0.034). Cup tilt was found in 37 out 42 migrated cups, however cranial migration was more frequent in progressive migrated cups (p=0.02). There were 34 re-revisions, 27 due to aseptic cup loosening, 6 due to dislocation and one due to infection. The survival rate for any cause at 16 years was 81.2% (95% Confidence Interval (CI): 74.0 to 88.4) and for aseptic cup loosening was 83.4% (95% CI: 76.2–90.6). In all surviving hips trabecular incorporation was observed without radiolucent lines. Conclusions. IBG continues to be a reliable technique for large defects in acetabular revision surgery. Bone graft resorption and cup migration was not frequent in this large series and one-third of cases were not progressive. Cup migration was more frequent in cases with a segmental roof defect in which a lateral mesh was used

Purpose. Cementless cup with structural allograft is one of option for acetabular revision in the cases which has severe bone loss. This study was performed to verify that the structural allograft with cementless cup could be one of good options for revision of acetabular cup with severe bone defect and to verify that the allograft resorption affect the stability of cementless acetabular cup. Materials and Methods. We reviewed 25 cases of 25 patients who underwent acetabular cup rvision using cementless porous coated hemispherical cup with structural allograft from May 1992 to July 2011 July 2011. There were nine males and sixteen females with an average age of 50.0 years. The average follow-up period was 76.7(28∼212) months. The clinical evaluation was performed using Harris Hip Score(HHS) and UCLA activity score. Radiologically, the degree of resorption of grafted bone, incorporation of allograft bone with normal bone, osteolysis and cup loosening were evaluated. Results. Clinically, the average Harris hip score was improved from 54 preoperatively to 93.4 at the last follow-up. The average UCLA activity score was also improved from 4.3 preoperatively to 6.4 at the last follow-up. Radiologically, the incorporation of allograft was accomplished in 11.4 months and the resorption of grafted bone was noted in 3 cases(12%), but the allograft resorption had not progressed to moderate degree even in long term follow-up. There was no cup loosening and average survivor rate was 100% in 6 years. There was no infection, allograft nonunion, osteolysis. Conclusion. Cementless cup with structural allograft in acetabular cup reconstruction can provide excellent mi-term results in both clinical and radiological aspects. Structural allograft can provide strong mechanical support for the bone ingrowth of cementless cup. The clinical result of this study auggest that cementless cup with structural allograft can be a good option for acetabular cup revision with severe bone defect. Resorption of structural allograft rarely occurred, and the resorption of structural allograft does not affect stablility of cup even in long term follow-up

Introduction. Cup malposition in hip arthroplasty and hip resurfacing is associated with instability, accelerated wear, and the need for revision. A recent study measuring cup orientation on conventional radiodiographs demonstrated an incidence of cup malpositioning of 50% according to the safe zone that they defined 1,2. A prior study of 105 conventionally placed cups using CT demonstrated a cup malpositioning incidence of 74%3. The current study similarly assesses the variation in cup position using conventional techniques as measured by CT. Methods. CT studies of 123 hips in 119 patients with total hip arthroplasties performed using conventional techniques were used for this study. The indications for the CT studies were for CT-based surgical navigation of the contralateral side or for assessment of periprosthetic osteolysis. An application specific software modules was developed to measure cup orientation using CT (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). The cup orientation was determined by first identifying Anterior Pelvic Plane Coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module then allowed for the creation of a plane parallel with the opening plane of the acetabulum. The orientation of the cup opening plane in the AP Plane coordinate space was calculated according to Murray's definitions of operative anteversion and operative inclination. Since these studies including images through the femoral condyles, femoral anteversion could be measured on these hips as well (Osirix v5.6, Pixmeo SARL, Bernex, Switzerland). Results. Cup orientation for the 123 hips is shown in Figure 1. Operative anteversion averaged 29.7 degrees with a standard deviation of 12.2 and a range of −24.4 to 57.5. Operative inclination averaged 37.5 degrees with a standard deviation of 7.7 and a range of 18.4 to 68.2. Femoral anteversion averaged 21.1 degrees with a standard deviation of 14.0 and a range of −20.5 to 60.9. Using 25 degrees of operative anteversion and 45 degrees of operative inclination as the center of a safe zone for example, 78 of 123 (63%) were more than 10 degrees off in either anteversion and inclination and 23 of 123 (19%) were more than 10 degrees off in both anteversion and inclination. Discussion and Conclusion. Most conventionally placed acetabular components are malpositioned. While the incidence of cup malorientation using conventional techniques is quite high, the incidence in our series appears to be lower than that reported by Saxler et al. It is curious that most experienced surgeons who perform total hip arthroplasty using conventional methods of cup alignment believe that their accuracy quite good. Yet, multiple objective studies of cup alignment demonstrate that accuracy is quite poor. Since cup malposition is so closely associated with instability, impingement, wear, bearing fracture, osteolysis and loosening, questions remain as to how conventional methods of cup alignment remain an acceptable standard of care in our field

Introduction. Optimal alignment of the acetabulum cup component is crucial for good outcome of Total Hip Arthroplasty (THA). A patient-specific instrumentation (PSI) for cup alignment manufactured by 3D printing might improve cup alignment in conventional THAs with patient's lateral decubitus position. In this study, we developed PSI for cup alignment which transferred preoperatively planned cup alignment to the operation room as a linear visual reference(Figure 1), then investigated its accuracy in terms of fitting of PSI on the bony surface and angle deviation between pre- and post-operative cup alignments. Methods. 3-Dimensional bone models created from CT images of both sides of 6 cadaveric specimens were used in the current study. In the first experiment (first 3 specimens and six hips), we designed PSI to fit on the acetabular rim, and we inserted a Kirschner wire (K-wire) through PSI after PSI's fitting. In the second experiment (remaining 3 specimens and six hips), after the same steps like the first experiment were done, we reamed and finally impacted plastic cups with the visual reference of the K-wire. Using postoperative CT images taken after both experiments, we measured deviation of the K-wire placement for the first experiment, and measured deviation of the cup placement from planned cup alignment. Results. The angle deviation of the K-wire alignment on the basis of radiographic inclination and anteversion angles was on average 2.2°±2.5° and 1.0°±1.3° respectively in the first experiment. The angle deviation of the cup alignment with the same definition was on average 2.88°±1.63° and 4.15°±2.56°. For one cadaveric specimen data for the first experiment were missing. Conclusion. We conclude that the accuracy of acetabular cup placement can be improved by the use of patient-specific cup orientation guides

Introduction. Revision Total Hip Arthroplasties (THA) have a significantly higher failure rate than primary THA's and the most common cause is aseptic loosening of the cup. To reduce this incidence of loosening various porous metal implants with a rough surface and a porous architecture have been developed which are said to increase early osteointegration. However, for successful osteointegration a minimal micromotion between the implant and the host bone (primary stability) is beneficial. It has not been previously determined if the primary stability for the new Gription® titanium cup differs from that of the old Porocoat® titanium cup. Material and Methods. In 10 cadaveric pelvises, divided into 20 hemipelvises, bilateral THA's were performed by an experienced surgeon (RGB) following the implant manufacturer's instructions and with the original surgical instruments provided by the company. In randomized fashion the well established Porocoat® titanium implant was implanted on one side of each each hemipelvis whereas on the corresponding opposite side the modified implant with a Gription® coating was inserted. Radiographs were taken to confirm satisfactory operative results. Subsequently, the hemipelvis and cups were placed in a biomechanical testing machine and subjected to physiological cyclic loading. Three-dimensonal loading corresponded to 30% of the load experienced in normal gait was imposed reflecting the limited weight bearing generally prescribed postoperatively. The dynamic testing took place in a multi-axial testing machine for 1000 cycles. Relative motion and micromotion were quantified using an optical measurement device (Pontos, GOM mbh, Braunschweig, Germany). Statistical evaluation was performed using the Wilcoxon signed-rank test. Results and conclusion. The standard Porocoat® titanium cups showed a mean relative motion with respect to the host bone of 54.74µm (Range 26.04 – 127.06µm), while the porous Gription® titanium cup displayed a relative motion with respect to the host bone of 49.77µm (Range 24.69 – 128.37µm). The Wilcoxon test did not reveal a significant difference between the two surfaces. The in-vitro biomechanical evaluation of both acetabular cups under a physiologic loading scenario showed no significant difference with regard to primary stability. Both the extensively tried and clinically successful Porocoat® titanium cup and the newer Gription® coated cup showed very little micromotion and both implants should therefore allow good osteointegration

Introduction:. Cup malposition in hip arthroplasty and hip resurfacing is associated with instability, accelerated wear, and the need for revision. A recent study measuring cup orientation on conventional radiodiographs demonstrated an incidence of cup malpositioning of 50% according to the safe zone that they defined. 1,2. A prior study of 105 conventionally placed cups using CT demonstrated a cup malpositioning incidence of 74%. 3. The current study similarly assesses the variation in cup position using conventional techniques as measured by CT. Methods:. We have performed CT-based navigation of hip arthroplasty and revision arthroplasty on a routine basis since 2003 and also use CT imaging to quantify periprosthetic osteolysis. In our image database from these, we have identified 98 hips and y patients who had a previously conventionally-placed cup on CT imaging. For each hip, cup orientation was determined in operative anteversion and operative inclination (according to the definitions of Murray) using an application specific software application (HipSextant Research Application 1.0.7, Surgical Planning Associates Inc., Boston, Massachusetts). This application allows for determination of the Anterior Pelvic Plane coordinates from a 3D surface model. A multiplanar reconstruction module allows for creation of a plane parallel with the opening plane of the acetabulum and subsequent calculation of plane orientation in the AP Plane coordinate space. Results:. 16 of 53 or 30.2% of hips in the control group were within 7.5 degrees of the safe zone center for both for both anteversion and inclination. 29 of 53 or 51.9% of hips in the control group were within 10 degrees of the safe zone center for both for both anteversion and inclination. Discussion and Conclusion:. Most conventionally placed acetabular components are malpositioned. While the incidence of cup malorientation using conventional techniques is quite high, the incidence in our series appears to be lower than that reported by Saxler et al. It is curious that most experienced surgeons who perform total hip arthroplasty using conventional methods of cup alignment believe that their accuracy quite good. Yet, multiple objective studies of cup alignment demonstrate that accuracy is quite poor. Since cup malposition is so closely associated with instability, impingement, wear, bearing fracture, osteolysis and loosening, questions remain as to how conventional methods of cup alignment remain an acceptable standard of care in our field

Introduction. Cup malposition in hip arthroplasty and hip resurfacing is associated with instability, accelerated wear, and the need for revision. The current study similarly assesses the variation in cup position using conventional techniques as measured by CT. Methods. We have performed CT-based navigation of hip arthroplasty and revision arthroplasty on a routine basis since 2003 and also use CT imaging to quantify periprosthetic osteolysis. In our image database, we have identified 91 hips in 87 patients (51 female, 36 male) who had a previously conventionally-placed cup on CT imaging. For each hip, cup orientation was determined in operative anteversion and operative inclination (according to the definitions of Murray) using an application specific software application (HipSextant Research Application 1.0.7, Surgical Planning Associates Inc., Boston, Massachusetts). This application allows for determination of the Anterior Pelvic Plane coordinates from a 3D surface model. A multiplanar reconstruction module allows for creation of a plane parallel with the opening plane of the acetabulum and subsequent calculation of plane orientation in the AP Plane coordinate space. Results. The conventionally placed cups ranged from −7.2° to 57.5° in operative anteversion (mean = 30.2°, SD = 11.6°) and 18.4° to 68.1° in operative inclination (mean = 37.6, SD = 8.2°). If a safe zone goal of 27 degrees of operative anteversion (± 10°) and 42 degrees of operative inclination (± 10°) is assumed, 29.7% of hips are out of the safe zone of operative anteversion, and 25.3% of hips are out of the safe zone of operative inclination. 45.1% of all hips are out of the safe zone in either operative anteversion, operative inclination, or both. If a goal of 20° of operative anteversion (± 10°) and 45° of operative inclination (± 10°) is assumed, 55.0% of hips are out of the safe zone in operative anteversion, 44.0% of hips are out of the safe zone in operative inclination, and 70.3% of hips are out of one or both safe zones. Discussion. Most conventionally placed acetabular components are malpositioned and the current study confirms prior reports of the incidence of cup malposition as measure both by CT and plain radiographs. It is curious that most experienced surgeons who perform total hip arthroplasty using conventional methods of cup alignment believe that their accuracy quite good. Yet, multiple objective studies of cup alignment demonstrate that accuracy is quite poor. Since cup malposition is so closely associated with instability, impingement, wear, bearing fracture, osteolysis and loosening, questions remain as to how conventional methods of cup alignment remain an acceptable standard of care in our field

In 2021, Vigdorchik et al. published a large multicentre study validating their simple Hip-Spine Classification for determining patient-specific acetabular component positioning in total hip arthroplasty (THA). The purpose of our study was to apply this Hip-Spine Classification to a sample of Australian patients undergoing THA surgery to determine the local acetabular component positioning requirements. Additionally, we propose a modified algorithm for adjusting cup anteversion requirements. 790 patients who underwent THA surgery between January 2021 and June 2022 were assessed for anterior pelvic plane tilt (APPt) and sacral slope (SS) in standing and relaxed seated positions and categorized according to their spinal stiffness and flatback deformity. Spinal stiffness was measured using pelvic mobility (PM); the ΔSS between standing and relaxed seated. Flatback deformity was defined by APPt <-13° in standing. As in Vigdorchik et al., PM of <10° was considered a stiff spine. For our algorithm, PM of <20° indicated the need for increased cup anteversion. Using this approach, patient-specific cup anteversion is increased by 1° for every degree the patient's PM is <20°. According to the Vigdorchik simple Hip-Spine classification groups, we found: 73% Group 1A, 19% Group 1B, 5% Group 2A, and 3% Group 2B. Therefore, under this classification, 27% of Australian THA patients would have an elevated risk of dislocation due to spinal deformity and/or stiffness. Under our modified definition, 52% patients would require increased cup anteversion to address spinal stiffness. The Hip-Spine Classification is a simple algorithm that has been shown to indicate to surgeons when adjustments to acetabular cup anteversion are required to account for spinal stiffness or flatback deformity. We investigated this algorithm in an Australian population of patients undergoing THA and propose a modified approach: increasing cup anteversion by 1° for every degree the patient's PM is <20°

Background. A few patients undergoing a total hip replacement need a subsequent revision of the cup. In some of these cases, the treating surgeon may be confronted with Unexpected Positive Intraoperative Cultures (UPIC). The exact incidence of this finding is unclear. Moreover, it is unknown what the clinical outcome of these patients is when the stem is left in situ. The aim of our study was to describe the incidence of UPIC in patients undergoing cup revision and to determine the need for total revision in this patient group during follow-up. Methods/design. In this retrospective multicenter cohort study, we included all consecutive patients that underwent a cup revision between 2015–2017 and had a minimal follow-up of 2 years. Patients were divided in 3 cohorts: i) no positive intra operative cultures; ii) one UPIC; iii) two or more UPIC. Cases in whom 2 or fewer cultures were obtained during cup revision were excluded from the analysis. Results. From the 334 evaluated cases, 77 were excluded because an inadequate number of cultures were obtained. From the total of 257 included cases, the incidence of UPIC was 16% (n=39). 21 cases had one (8%), and 18 cases had two or more UPIC (7%). After two years of follow up, implant survival in the no UPIC group was 88% (95% CI 0.83 – 0.93), in the one UPIC group 95% (95% CI 0.86 – 1.0), and in the two or more UPIC group 77% (95% CI 0.57 – 0.97). Survival analysis showed no statistically significant differences between the cohorts as determined by cox regressive analysis and log rank test (P = 0.19). Conclusion. The incidence of UPIC in patients who undergo cup revision is relatively high but does not seem to have a major influence on the need for total revision of the hip during a follow-up of 2 years

Introduction. Polyethylene (PE) wear is clearly linked to total hip arthroplasty (THA) failure, leading to osteolysis and decreasing survivorship rates. Dual mobility cups (DMC) are widely used to prevent or treat THA instability. However some studies have pointed PE wear risk as a “dual wear” risk. Hip wear simulation is usually used to understand factors influencing wear and to differentiate design, PE types and materials performances. To date, few works have been published studying dual mobility insert wear. Objectives. Our objective was to evaluate wear of DMC with comparison with a fixed single articulating hip design and to measure wear under same conditions (loading cycle, temperature, sterilization, material and surface roughness). Methods. The test bench includes one station for a control sample and one for dynamic test. Those are driven independently one from the other. Two electrical actuators applied the forces and two forces sensors putted on the fixing plate of the acetabular part gave the corresponding values. On the dynamic station, the angular movements are generated by an electric motor. Sleeves are installed on the bowls containing the testing liquid and on the supports of acetabular parts, in order to get a tight volume that excludes contaminant particles. Wear is measured by a gravimetric method. The simulator is stopped and implants have been removed from the simulators in order to achieve weighting and observations at 0.5, 1, 2, 3, 4 and 5 millions cycles. At the end, the sample PE insert and the control one are removed from their cup in the aim to measure the mass loss. Results. Under same conditions the gravimetric wear and the linear penetration of the head are perfectly comparable between a conventional and a dual mobility cup. Conclusion. In vitro, DMC wear is equal or less important than a standard single fixed cup and volumetric wear is lower than published data. Wear of the two joints of a DMC is not increased thanks to the recruitment phenomenon and the freedom induced by the concept

INTRODUCTION. Reaming of the acetabular cavity prior to cementless cup implantation aims to create a defined press-fit between implant and bone. The goal is to achieve full implant seating with the desired press-fit to reduce the risk of early cup loosening and the risk of excessive cup deformation. Current research concentrated on the spherical deviations of the reamed cavity compared to the reamer size, but the direct relationship between nominal press-fit, reamer geometry, cavity shape and bone-implant contact has not yet been investigated. The aim of this study was to determine the influence of the reaming process, the surface coating, and the implantation force on the achieved press-fit situation. METHODS. Fresh-frozen porcine acetabulae (n = 20) were prepared and embedded. Hemispherical reamers were used and the last reaming step was performed using a vertical drilling machine to ensure a proper alignment of the cavity axis. A hand-guided 3D laser scanner was used (HandySCAN 700, Creaform) to determine the reamer geometry and the cavity shape. Press-fit cups with two different surface coatings (Ø44 mm, Porocoat/Gription, DePuy Synthes) were implanted using a drop tower. The Porocoat cup was implanted with impacts from lower drop heights (low implantation force) and press-fits of 1 mm and 2 mm. The Gription cup, exhibiting a rougher surface, was implanted with low and high implantation forces and a press-fit of 1 mm. Bone-implant contact was analysed by the registration of the cup and cavity surface models, scanned prior to implantation, to the scan of the implanted cup. The cup surface was divided in areas with and without contact to the surrounding cavity. Overhang indicates that there was no adjacent cavity surface surrounding the implanted cup. The transition between contact and a gap at the cup dome was defined as contact depth and used as indicator for the cup seating. RESULTS. The peripheral cavity diameter was on average 0.94 ± 0.29 mm smaller than the reamer diameter due to the sub-hemispherical distribution of the cutting blades. This led to an increased effective press-fit in the peripheral area of the cavity. The contact area between cup and bone increased with the implantation force (p = 0.008) and ranged from 13.1 % to 27.8 %. The contact depth was larger for the smoother Porocoat coating (p = 0.008), a press-fit of 2 mm (p = 0.008) and a higher implantation force (p = 0.008). DISCUSSION. This study shows that, assuming similar implantation forces, an increased surface roughness of the cup coating increases the risk of an insufficient cup seating. For a given press-fit, higher implantation forces would be necessary to fully seat the cup in order to enhance the bone-implant contact. Implantation of a cup without a defined nominal press-fit could increase the contact area; however a high reaming accuracy and an increased friction coefficient of the cup coating are required to compensate for a reduction in initial fixation strength caused by reduced radial compressive forces. For any figures or tables, please contact authors directly

Introduction. Lumbar spine fusion in patients undergoing THA (total hip arthroplasty) is a known risk factor for hip dislocation with some studies showing a 400% increased incidence compared to the overall THA population. Reduced spine flexibility can effectively narrow the cup anteversion safe zone while alterations in pelvic tilt can alter the center of the anteversion safe zone. The use of precision cup alignment technology combined with patient-specific cup alignment goals based on preoperative assessment has been suggested as a method of addressing this problem. The current study assess the dislocation rate of THA patients with stiff or fused lumbar spines treated using surgical navigation with patient-specific cup orientation goals. Methods. Seventy-five THA were performed in 54 patients with a diagnosis of lumbar fusion, lumbar disc replacement, and scoliosis with Cobb angles greater than 40 degrees were treated by the senior author (SM) as part of a prospective, non-randomized study of surgical navigation in total hip arthroplasty. All patients were treated using a smart mechanical navigation tool for cup alignment (HipXpert System, Surgical Planning Associates, Inc., Boston, MA). Cup orientation goals were set on a patient-specific basis using supine pelvic tilt as measured using CT. Patients with increased pelvic tilt had a goal for increased cup anteversion and patients with decreased pelvic tilt had a goal for decreased cup anteversion (relative to the anterior pelvic plane coordinate system). Each patient's more recent outpatient records were assessed for history of dislocation, instability, mechanical symptoms, decreased range of motion or progressive pain. Additionally, last clinic radiographs were reviewed to confirm lumbar pathology in the form of spinal surgical hardware. Results. Seventy-five total hip arthroplasties with stiff lumbar spine were reviewed with and average follow up of 6.04 years. The average number of levels of lumbar fusion was 2.3 levels. Since the most recent follow up on all patients in this cohort no hip dislocations had occurred. Discussion and Conclusion. Fusion or stiffness of the lumbar spine is a known risk factor for instability following elective THA. The current study demonstrates that patient-specific planning of cup placement taking abnormal pelvic tilt into consideration combined with the use of accurate intra-operative cup alignment technology can be used to address this problem

We report the outcome of 320 primary Total Hip Arthroplasties (THA) with minimum 10-year follow-up (range 10–17 years, mean 12.6 years), performed by a single surgeon in Tauranga New Zealand, with the Exeter Contemporary Flanged all-polyethylene cup and Exeter femoral stem via a posterior approach. The aim of the study is to compare the results with the published results from the design centre and create a baseline cohort for further outcomes research in this centre. All patients were prospectively followed at 6 weeks, 1 year, 5 years, 10 years, (and 15 years when available). Of 333 cases that matched the inclusion criteria, 13 procedures in 12 patents were excluded because of concomitant bone grafting and/or supplementary cage fixation, leaving 320 primary THA procedures in 280 patients, including 26 bilateral procedures in 13 patients. Mean follow-up of the surviving cases was 12.6 (range 5.0-17.1) years. There were 12 revisions – 2 for fracture, 5 for instability, 1 for impingement pain and 4 for infection. There were no revisions for aseptic cup loosening. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 100% at 15.0 years (with minimum 40 cases remaining at risk). All-cause acetabular revision in 12 cases result in a Kaplan-Meier survival of 95.9% (95% CI: 93.5 to 98.3%). Cemented THA with the Exeter Contemporary Flanged cup and the Exeter stem is a durable combination with results that can be replicated outside of the design centre. The Exeter Contemporary Flanged cup has excellent survivorship at 15 years when used with the Exeter stem. Cemented THA with well-proven components should be considered the benchmark against which newer designs and materials should be compared

Introduction. Biological repair of acetabular bone defects after impaction bone grafting (IBG) in total hip arthroplasty could facilitate future re-revisions in case of failure of the reconstruction again using the same technique. Few studies have analysed the outcome of these acetabular re-revisions. Patients and Methods. We analysed 34 consecutive acetabular re-revisions that repeated IBG and a cemented cup in a cohort of 330 acetabular IBG revisions. Fresh-frozen femoral head allografts were morselized manually. All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. The mean follow-up after re-revision was 7.2 years (2–17). Intraoperative bone defect had lessened after the first failed revision. At the first revision there were 14 hips with Paprosky 3A and 20 with Paprosky type 3B. At the re-revision there were 5 hips with Paproky 2B, 21 with Paprosky type 3A and 8 with type 3B. Lateral mesh was used in 19 hips. Results. The mean Harris Hip Score improved from 45.4 (6.7) to 77.1 (15.6) at final follow-up. The radiological analysis showed cup migration in 11 hips. The mean appearance time was 25 months (3–72). Of these, migration in three cups was progressive and painful requiring re-revision. Cup tilt was found in all migrated hips. There were one dislocation requiring a cemented dual mobility cup associated with IBG and one infection resolved with resection-arthroplasty. Survival with further cup revision for aseptic loosening was 80.7% (95% Confidence Interval 57.4–100) at 11 years. In all surviving re-revisions trabecular incorporation was observed without radiolucent lines. Conclusion. Biological repair can be obtained by restoring the bone stock, even after successive acetabular reconstructions using IBG and a cemented cup

Proper positioning of the acetabular cup deters dislocation after total hip arthroplasty (THA) and is therefore a key focus for orthopedic surgeons. The concept of a safe zone for acetabular component placement was first characterized by Lewinnek et al. and furthered by Callanan et al. The safe zone concept remains widely utilized and accepted in contemporary THA practice; however, components positioned in this safe zone still dislocate. This study sought to characterize current mass trends in cup position identified across a large study sample of THA procedures completed by multiple surgeons. This retrospective, observational study reviewed acetabular cup position in 1,236 patients who underwent THA using computer-assisted navigation (CAS) between July 2015 and November 2017. Outcomes included acetabular cup position (inclination and anteversion) measurements derived from the surgical navigation device and surgical approach. The overall mean cup position of all recorded cases was 21.8° (±7.7°, 95% CI = 6.7°, 36.9°) of anteversion and 40.9° (±6.5°, 95% CI = 28.1°, 53.7°) of inclination (Table 1). For both anteversion and inclination, 65.5% (809/1236) of acetabular cup components were within the Lewinnek safe zone and 58.4% (722/1236) were within the Callanan safe zone. Acetabular cups were placed a mean of 6.8° of anteversion (posterior/lateral approach: 7.0°, anterior approach: 5.6°) higher than the Lewinnek and Callanan safe zones whereas inclination was positioned 0.9° higher than the reported Lewinnek safe zone and 3.4° higher than the Callanan safe zone (Figure 1,2). Our data shows that while the majority of acetabular cups were placed within the traditional safe zones, the mean anteversion orientation is considerably higher than those suggested by the Lewinnek and Callanan safe zones. The implications of this observation warrant further investigation. For any figures or tables, please contact the authors directly

Iliopsoas tendonitis after total hip arthroplasty (THA) can be a considerable cause of pain and patient dissatisfaction. The optimal cup position to avoid iliopsoas tendonitis has not been clearly established. Implant designs have also been developed with an anterior recess to avoid iliopsoas impingement. The purpose of this cadaveric study was to determine the effect of cup position and implant design on iliopsoas impingement. Bilateral THA was performed on three fresh frozen cadavers using oversized (jumbo) offset head center revision acetabular cups with an anterior recess (60, 62 and 66 mm diameter) and tapered wedge primary stems through a posterior approach. A 2mm diameter flexible stainless steel cable was inserted into the psoas tendon sheath between the muscle and the surrounding membrane to identify the location of the psoas muscle radiographically. CT scans of each cadaver were imported in an imaging software. The acetabular shells, cables as well as pelvis were segmented to create separate solid models of each. The offset head center shell was virtually replaced with an equivalent diameter hemispherical shell by overlaying the outer shell surfaces of both designs and keeping the faces of shells parallel. The shortest distance between each shell and cable was measured. To determine the influence of cup inclination and anteversion on psoas impingement, we virtually varied the inclination (30°/40°/50°) and anteversion (10°/20°/30°) angles for both shell designs. The CT analysis revealed that the original orientation (inclination/anteversion) of the shells implanted in 3 cadavers were as follows: Left1: 44.7°/23.3°, Right1: 41.7°/33.8°, Left2: 40/17, Right2: 31.7/23.5, Left3: 33/2908, Right3: 46.7/6.3. For the offset center shells, the shell to cable distance in all the above cases were positive indicating that there was clearance between the shells and psoas. For the hemispherical shells, in 3 out of 6 cases, the distance was negative indicating impingement of psoas. With the virtual implantation of both shell designs at orientations 40°/10°, 40°/20°, 40°/30° we found that greater anteversion helped decrease psoas impingement in both shell designs. When we analyzed the influence of inclination angle on psoas impingement by comparing wire distances for three orientations (30°/20°, 40°/20°, 50°/20°), we found that the effect was less pronounced. Further analysis comparing the offset head center shell to the conventional hemispherical shell revealed that the offset design was favored (greater clearance between the shell and the wire) in 17 out of 18 cases when the effect of anteversion was considered and in 15 out of 18 cases when the effect of inclinations was considered. Our results indicate that psoas impingement is related to both cup position and implant geometry. For an oversized jumbo cup, psoas impingement is reduced by greater anteversion while cup inclination has little effect. An offset head center cup with an anterior recess was effective in reducing psoas impingement in comparison to a conventional hemispherical geometry. In conclusion, adequate anteversion is important to avoid psoas impingement with jumbo acetabular shells and an implant with an anterior recess may further mitigate the risk of psoas impingement

Introduction. The direct anterior approach (DAA) for total hip arthroplasty continues to gain popularity. Consequently, more procedures are being performed with the patient supine. The approach often utilizes a special leg positioner to assist with femoral exposure. Although the supine position may seem to allow for a more reproducible pelvic position at the time of cup implantation, there is limited evidence as to the effects on pelvic tilt with such leg positioners. Furthermore, the DAA has led to increased popularity of specific softwares, ie. Radlink or JointPoint, that facilitate the intra-op analysis of component position from fluoroscopy images. The aim of this study was to assess the difference in cup orientation measurements between intra-op fluoroscopy and post-op CT. Methods. A consecutive series of 48 DAA THAs were performed by a single surgeon in June/July 2018. All patients received OPS. TM. pre-operative planning (Corin, UK), and the cases were performed with the patient supine on the operating table with the PURIST leg positioning system (IOT, Texas, USA). To account for variation in pelvic tilt on the table, a fluoroscopy image of the hemi-pelvis was taken prior to cup impaction, and the c-arm rotated to match the shape of the obturator foramen on the supine AP Xray. The final cup was then imaged using fluoroscopy, and the radiographic cup orientation measured manually using Radlink GPS software (Radlink, California, USA). Post-operatively, each patient received a low dose CT scan to measure the radiographic cup orientation in reference to the supine coronal plane. Results. Mean cup orientation from intra-op fluoro was 38° inclination (32° to 43°) and 24° anteversion (20° to 28°). Mean cup orientation from post-op CT was 40° inclination (29° to 47°) and 30° anteversion (22° to 38°). Cups were, on average, 6° more anteverted and 2° more inclined on post-op CT than intra-op. These differences were statistically significant, p<0.001. All 48 cups were more anteverted on CT than intra-op. There was no statistical difference between pre- and post-op supine pelvic tilt (4.1° and 5.1° respectively, p = 0.41). Discussion. We found significant differences in cup orientation measurements performed from intra-op fluoro to those from post-op CT. This is an important finding given the attempts to adjust for pelvic tilt during the procedure. We theorise two sources of error contributing to the measurement differences. Firstly, the under-compensation for the anterior pelvic tilt on the table. Although the c-arm was rotated to match the obturator foramen from the pre-op imaging, we believe the manual matching technique utilised in the Radlink software carries large potential errors. This would have consistently led to an under-appreciation of the adjustment angle required. Secondly, the manual nature of defining the cup ellipse on the fluoro image has previously been shown to underestimate the degree of cup anteversion. These combined errors would have consistently led to the under-measurement of cup anteversion seen intra-operatively. In conclusion, we highlight the risk of over-anteversion of the acetabular cup when using 2D measurements, given the manual inputs required to determine a result

Aims. Only a small number of studies exist that report the results of EBM-produced porous coated trabecular titanium cups in primary total hip arthroplasty (THA). This study aims to investigate the patient satisfaction level, clinical function and radiographic outcomes of the patients who underwent THA using an EBM-produced porous coated titanium cup. Patients and Methods. A total of 32 patients who underwent primary THA with using an EBM-produced porous coated titanium cup from five hospitals between May and December, 2012 were retrospectively reviewed. Five patients were lost prior to the minimum 6-year follow-up. Clinical and radiographic outcomes were analyzed with an average follow-up of 81.48 (range: 77.00–87.00) months. Results. The median HHS and SF-36 scores improved significantly while the WOMAC Osteoarthritis Index decreased significantly at the latest follow-up (p<0.001). Eighteen (66.7%) patients rated their satisfaction level as very satisfied, 6 (22.2%) as satisfied, 2 (7.4%) as neutral and 1(3.7%) as dissatisfied. No intraoperative or postoperative complications were identified, including aseptic cup loosening, hip dislocation, periprosthetic joint infection, periprosthetic fracture, nerve palsy, hematoma. At the latest follow-up, all cups were considered to have achieved fixation via bone ingrowth with three or more of the five signs occurring in the most recent X-ray. However, three cups revealed radiolucent lines with a width of less than 1 mm. These radiolucent lines were distributed in the DeLee-Charnley zone 1 in 1 patient, zone 3 in another patient and the area between zone1 and zone 2 in an additional patient. The latest postoperative centers of rotation were restored nearly to the anatomic center of rotation both vertically and horizontally and the acetabular cups obtained satisfactory orientation postoperatively. Conclusions. The mid-term follow-up of patients who underwent primary THA using EBM-produced porous coated titanium cups demonstrated favorable patient satisfaction, clinical function and adequate biological fixation. For any figures or tables, please contact authors directly

INTRODUCTION. Unlike current acetabular cups, this novel ceramic cup has a Ti/HA coating which removes the requirement for assembly into a metal shell which avoiding potential chipping/misalignment and reducing wall thickness [Figure 1]. This study examines the resistance of novel thin-walled, direct to bone fixation ceramic cups to critical impact loads. METHODS. Samples of the smallest (Ø46mm) and largest (Ø70mm) diameter ReCerf. TM. acetabular cups and corresponding femoral head implants were implanted into Sawbones foam blocks considered representative of pelvic cancellous bone. Two different positional configurations were tested and were considered worst case and the extremes of surgical compromise; P1 simulates the cup fully supported by the acetabulum with a high inclination angle (70°) and a vertical impaction axis (worst case loading near the cup rim) and. P2 simulates the cup implanted with a lower inclination (55°) but with the superior section unsupported by acetabulum bone [Figure 2]. For each size, three acetabular cups were tested in each position. The impact fixture was positioned within a drop weight rig above a bed of sand and ≈22mm of pork belly representative of soft tissues damping effect and the implant components aligned to achieve the defined impact point on the cup [Figure 2]. Lateral falls were tested on all available samples applying impact energy of 140J [1] and 3m/s impact velocity [2]. After the lateral fall test, each sample was tested under impact conditions equivalent to a frontal car crash considering a peak impact force of 5.7kN occurring 40ms from initial contact (able to produce acetabular fracture)[3]. RESULTS. None of the testing simulating a lateral fall produced fracture or any other damage to the ceramic acetabular cup. In 7 of the 12 tests, the impact force was sufficient to fracture the foam block representing the periprosthetic bone. The cups showed a good stability within the blocks, with a maximum recorded cup spinning angle relative to the acetabulum of 4.5˚. Subsequent testing simulating a car crash resulted in the fracture of two samples out of 12, one of the largest and one of the smallest ReCerf. TM. cups. In both instances, failure occurred very close to the inner edge. Of the remaining 10 samples no cup fractures were observed. All foam acetabulum blocks were severely damaged and 5 blocks fractured. The maximum recorded cup spinning angle following the car crash impact was 5.8˚. SIGNIFICANCE. Extreme testing scenarios presented here are not a regulatory requirement for manufacturers and have not previously been considered for ceramic acetabular components. Fracture is a possible failure mode of ceramics but this testing has proven that modern ceramics can withstand lateral falls and the large majority can withstand subsequent loading equivalent to head on car-crash; loading under which pelvic bone fracture and significant injury is far more likely to occur than implant fracture

Background. Accurate acetabular cup positioning is considered to be essential to prevent postoperative dislocation and improve the long-term outcome of total hip arthroplasty (THA). Recently various devices such as navigation systems and patient-specific guides have been used to ensure the accuracy of acetabular cup positioning. Objectives. The present study evaluated the usefulness of CT-based three-dimensional THA preoperative planning for acetabular cup positioning. Methods. This study included 120 hips aged mean 68.3 years, who underwent primary THA using CT-based THA preoperative planning software ZedHip® (LEXI, Tokyo Japan) and postoperative CT imaging (Fig.1). The surgical approach adopted the modified Watson-Jones approach in the lateral decubitus position and Trident HA acetabular cups were used for all cases. Preoperatively the optimum cup size and position in the acetabular were decided using the ZedHip® software, taking into consideration femoral anteversion and to achieve the maximum range of motion in dynamic motion simulation. Radiographic inclination (RI) was selected in the range between 40°∼45° and radiographic anteversion (RA) in the range between 5°∼25°. Three-dimensional planning images of the cup positioning were obtained from the ZedHip® software, and the distances between the edge of the implant and anatomical landmarks such as the edge of the anterior or superior acetabular wall were measured on the three-dimensional images and recorded (Fig.2). Intraoperatively, the RI and RA were confirmed by reference to these distances and the acetabular cup was inserted. Relative positional information of the implant was extracted from postoperative CT imaging using the ZedHip® software and used to reproduce the position of the implant on preoperative CT imaging with the software image matching function. The difference between the preoperative planning and the actual implant position was measured to assess the accuracy of acetabular cup positioning using the ZedHip® software. Results. Actual cup size corresponded with that of preoperative planning in 95% of cases (114 hips). Postoperative mean RI was 42.3° ± 4.2° (95% confidence interval (CI), 41.5° ∼ 43.0°) and mean RA was 16.1° ± 5.9° (95%CI, 15.0° ∼ 17.1°). Deviation from the target RI was 4.2° ± 3.7° (95%CI, 3.5° ∼ 4.9°) and deviation from the target RA was 4.0° ± 3.6° (95%CI, 3.4° ∼ 4.7°). Overall 116 hips (96.7%) were within the RI safe zone (30° ∼ 50°) and 108 hips (90.0%) were within the RA safe zone (5° ∼ 25°), and 105 hips (87.5%) were within both the RI and RA safe zones (Fig.3). Mean cup shift from preoperative planning was 0.0mm ± 3.0mm to the cranial side in the cranio-caudal direction, 2.1mm ± 3.0mm to the anterior side in the antero-posterior direction, and 1.7mm ± 2.1mm to the lateral side in the medio-lateral direction. Conclusion. The accuracy of acetabular cup positioning using our method of CT-based three-dimensional THA preoperative planning was slightly inferior to reported values for CT-based navigation, but obviously superior to those without navigation and similar to those with portable navigation. CT-based three-dimensional THA preoperative planning is effective for acetabular cup positioning, and has better cost performance than expensive CT-based navigation. For any figures or tables, please contact the authors directly