We evaluated the use of a stemmed acetabular component in the treatment of severe acetabular deficiency during revision and complex primary total hip arthroplasty. There were 31 hips of which 24 were revisions (20 for aseptic loosening, four for infection) and the remainder were complex primary arthroplasties. At a mean follow-up of 10.7 years (6 to 12.8), no component had been revised for aseptic loosening; one patient had undergone a revision of the polyethylene liner for wear. There was one failure because of infection. At the latest follow-up, the cumulative survival rate for aseptic loosening, with revision being the end-point, was 100%; for radiographic loosening it was 92% and for infection and radiographic loosening it was 88%. These results justify the continued use of this stemmed component for the reconstruction of severe acetabular deficiency

In patients with severe acetabular deficiency due to rheumatic arthritis (RA), the mid-term result of THA including a bone graft in the acetabular bed were analyzed. A total of 32 patients with 40 joints, comprising of 30 females and 2 males, were reviewed in this study. These patients had severe acetabular deficiency and were receiving THA for RA, including a bone graft in the acetabular bed. The average age at surgery was 58. 3 years and the average follow-up period was 6. 2 years. These patients had suffered from RA for 21 years on an average. The acetabular bed was filled with the chip bone and covered with the slice bone, followed by strong pressurization of the implanted bone and fixation of the cup with a screw. The patients were evaluated clinically using the Harris hip score, and radiologically using the Gruen radiographic analysis and the Sotelo-Garza and Charnley classification. In the clinical evaluation using score, the mean score improved from 39. 7 preoperatively to 82. 3 postoperatively. An improvement in pain, walking ability, ROM and ADL were observed. In the radiological evaluation using the Gruen analysis, more radiolucent lines tended to appear in the zone 1, of which none was progressive or indicated loosening. On the femoral side, more partially radiolucent lines of 1 mm or less tended to appear in the zone 4, of which none indicated osteolysis or loosening. The mean thickness of acetabular bed improved from 4. 3 mm preoperatively to 13. 5 mm postoperatively. During the follow-up period, no collapse of the implanted bone, dislocation of the cup or loosening was observed. Treatment with the bone graft method using slice bone and chip bone are used for acetabular deficiency in rheumatic hip joint in our department, this methods is considered to be an effective treatment, because it has provided a good initial fixation of cup and a good graft survival

Revision hip arthroplasty for severe acetabular deficiency is a technically challenging operation. Many different methods have been described for the management of acetabular deficiency. These include augmentation with bone cement, structural allografts, impaction grafting, support rings with graft and reconstruction with a high centre of rotation. The long term results of many of these methods were variable. We reviewed the outcome of a stemmed acetabular cup (McMinn cup, Link UK) used with morsellised bone graft for revision hip arthroplasty with severe acetabular deficiency. The implant was used only in the most severe cases of acetabular deficiency where it was impossible to achieve stable fixation using simpler methods. This device was used in only 13 out of 265 revision arthroplasties performed by the senior author. Between 1995 and 2002 13 acetabulae were reconstructed using a stemmed acetabular cup and non-structural morsellised bone graft. All were revision procedures with the number of previous operations on the same hip ranging between 1 and 4. 2 patients died from causes not related to surgery. 1 hip was revised for persistent discharge although no organisms were identified on repeated cultures. The mean follow-up of the remaining 10 hips was 72 months (range 46 – 108 months). All patients were satisfied with the results and their function improved significantly post-operatively. 8 of the 10 people report no pain from the hip and 2 reported slight or occasional pain which did not interfere with their activities at last follow-up. The mean Harris Hip Score was 84.6 (range 70 to 99.8). Radiological assessment showed regeneration of acetabular bone stock. Some X-Rays showed proximal migration of the cup but with no evidence of loosening at last follow-up. Acetabular reconstruction using the McMinn stemmed acetabular cup is a useful technique in revision hip arthroplasty with severe acetabular deficiency

The cranial cup is now a standardised implant in acetabular revision surgery. In order to illustrate the positive results of a standardised implant in acetabular revision surgery in comparison to other possibilities of reconstruction, we analysed results of all data in our study group. Aseptic loosening of implants often causes segmental and cavitary acetabular deficiency. Experiences gained in radical tumour surgery with reconstruction by custommade endoprostheses induced the development of the cranial cup for revision total hip arthroplasty. This new cementless revision cup has an oval shape and a special cranial flap, as well as an intramedullary rod if necessary. This type of cranial cup has been used since 1993. From 9/97 to 1/99, we implanted 30 cranial cups in revision hip surgery and collected all data of these patients prospectively. Clinical and x-ray follow-up was documented on a regular basis. Acetabular deficiency occurred twice in type 1, five times in type 2, twenty-two times in type 3 and once in type 4. The AAOS D’Antonio score was used. Cranial cups were implanted without cranial flap in 10 cases, with cranial flap in 20 cases and once using the intramedullary rod additionally. Only 28 patients were included in our last examination because one patient had died and one was bedridden because of a reason other than the hip. The Harris hip score increased from an average of 32 points preoperatively to 63 points postoperatively. Twenty-one patients are satisfied or very satisfied with their surgery. Radiograph examinations showed an average inclination angle of 42.5° in all cranial cups. Up to now there have been complications in four patients who suffered luxations, but only one required a change of inlay. One intraoperative injury of the urinary bladder had to be revised later. Three implants showed a change of position in x-ray. One was the patient with the urinary bladder injury and possible septic loosening, the second was a patient with extreme osteoporosis, and the third was a patient who did not receive an intramedullary rod for a type 4 lesions. Currently, these three patients do not have any complaints. We have always achieved primary stability. Morselised bone autografts or bone substitute materials were used to fill remaining defects. An intramedullary rod should be used in pelvis discontinuity and is obligatory to achieve the necessary stability. Developed from the experiences of custom-made tumour endoprostheses, the cranial cup with all possible variations is an appropriate intraoperative variable implant in revision acetabular surgery

We evaluated the use of bilobed acetabular components in the treatment of acetabular deficiency during revision and complex primary total hip replacements. 79 patients (83 hips) were operated upon between august 1990 and December 2005 64 patients were reviewed clinically and radiologically.7 patients had died from unrelated causes. 3 patients were followed up clinically and radiologically for one year and were doing well at their last appointments. 5 were lost in follow up. The mean follow up of patients was 5.5 year (range, 2–15 years). One patient was revised for aseptic loosening. The average post operative Harris hip score was 94.9 (range 74–100) at the last follow up appointments of 68 patients. Two patients developed deep wound infection and one patient dislocated three months post operatively, treated with a constrained liner. At the latest follow up the cumulative survival rate for aseptic loosening with revision being the end point is 97% at 15 years. These results support the use of bilobed of-the-shelf cups in the reconstruction of acetabular defects with intact anterior and posterior columns

Introduction. Different classification systems for acetabular deficiencies, including AAOS and Paprosky, are commonly used. Classification of these bone defects is often performed based on Xrays or CT images. Although the amount of bone loss is rarely measured quantitatively in these images, objective and quantitative data on the degree of bone loss could facilitate correct and consistent classification. Recently, a computerized CT-based tool was presented to quantitatively asses bone loss: TrABL (Total radial Acetabular Bone Loss). This study demonstrates on an extended patient population that TrABL combined with standard classification systems provides more detailed, quantitative information on bone defects. Methods. CT scans of 30 severe acetabular defects, classified Paprosky IIIA and IIIB, were collected and analysed with TrABL. The tool automatically calculated the total amount of bone that was missing around the acetabulum, seen from the hip's original rotation centre. Six anatomical regions were defined for which the degree of bone loss was expressed: anterosuperior, anteroinferior, inferior, posteroinferior, posterosuperior and medial. Results. Statistical analysis highlighted that total bone loss was highest in the posterosuperior region (63%±27%). Bone loss was lowest inferiorly. No statistical differences were found between the anterosuperior, anteroinferior, posteroinferior, and medial regions. The majority of the defects suffered at least 25% bone loss in more than half of the regions. All defects had at least one region with the same degree of bone loss. The quantitative 3D data of TrABL provided more information compared to general classification schemes. This information has shown to be crucial during implant selection and preoperative planning for multiple clinical cases. Conclusion. Classification of acetabular bone deficiencies into existing systems can be refined by the quantitative data provided by TrABL. As a result, the ease and consistency regarding the treatment selection for particular categories of challenging defects will increase

Introduction: The objectives of this study were to evaluate acetabular bone deficiency in revision THA with a simple classification on the anteroposterior pelvis radiograph and correlate the results of cementless hemispherical porous coated cup and cancellous bone graft reconstruction. Methods: 70 acetabular revisions reconstructed employing large ‘jumbo’ porous coated cups with cancellous allo-grafting were evaluated at a mean follow-up of 5 years (range 2 – 10 years). During this time period 7 additional acetabular reconstructions required impaction grafting, cage reinforcement and cemented cups. Pre- and postoperative measurements of acetabular bone loss and the position of the revision component were performed with respect to a previously described triangle defining the placement and size of an idealcup. Impaction bone allo-grafting techniques were employed to fill defects. A minimum of 40% implant contact to host bone, especially in the weight-bearing dome region was attained in all cases and a minimum of 2 screws supplemented fixation to the ilium. Clinical evaluation comprised the HSS score and a patient assessment questionnaire (PAQ). Radiographically, cups were examined for filling of defects, ingrowth, graft consolidation, and stability. Results: The mean HSS score improved from 18 to 33 out of a maximum of 40. The mean superior bone defect was 18 mm (range 10 – 25mm) and the mean medial bone defect was 7 mm (range 0 – 22mm). All the cement-less acetabular components were bone ingrown with the exception of one stable fibrous union. Allograft incorporation occurred at a mean of 7 months after surgery. Neither the status of Kohler’s line nor the Paprosky class correlated with eventual radiographic or clinical results. Discussion: We present a simple method of evaluation of acetabular bone deficiency on the A-P pelvis radiograph employing a triangle that locates the ideal center of rotation of the hip. Superior bone loss upto 25 mm and medial migration as much as 22 mm has been successfully reconstructed employing impacted, cancellous allograft, large porous coated hemispherical Cementless acetabular components and screw fixation with excellent outcomes at intermediate-follow-up. Larger defects necessitate complex reinforced cage reconstruction

Acetabular cages are necessary when an uncemented or cemented cup cannot be stabilised at the correct anatomic level. Impaction grafting with mesh for containment of bone graft is an alternative for some cases in centers that specialise in this technique.

At our center we use three types of cage constructs –

(A) Conventional cage ± structural or morselised bone grafting. This construct is used where there is no significant bleeding host bone. This construct is susceptible to cage fatigue and fracture. This reconstruction is used in young patients where restoration of bone stock is important.

(B) Conventional cage in combination with a porous augment where contact with bleeding host bone can be with the ilium and then by the use of cement that construct can be unified. The augment provides contact with bleeding host bone and if and when ingrowth occurs, the stress is taken off the cage.

(C) Cup Cage Construct – in this construct there must be enough bleeding host bone to stabilise the ultra-porous cup which functions like a structural allograft supporting and eventually taking the stress off the cage. This construct is ideal for pelvic discontinuity with the ultra-porous cup, i.e., bridging and to some degree distracting the discontinuity. If, however, the ultra-porous cup cannot be stabilised against some bleeding host bone, then a conventional stand-alone cage must be used.

In our center the cup cage reconstruction is our most common technique where a cage is used, especially if there is a pelvic discontinuity.

Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven cup-cage procedures with an average follow-up of 74 months (range, 24–135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any cause, including infection.

The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval, 83.1–97.4), and the 10-year survival rate was 85% (95% CI, 67.2–93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 pre-operatively to 13 post-operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the ischial flange and they remain stable.

Dysplastic acetabula were augmented during total hip replacement by superolateral autografts. In cases of primary arthroplasty these were taken from the excised femoral head and in revision surgery from the iliac crest. Two or (usually) three small grafts were used to facilitate revascularisation; they were fixed with lag screws to the roughened iliac bone above the acetabulum. We reviewed 84 hips (63 primary arthroplasties and 21 revisions) more than five years (mean 10.1) after operation. All but one of the grafts showed consolidation within three months and they had become structurally integrated with the iliac bone, as evidenced by the trabecular reorientation. Resorption, which has caused early socket failure when large bone grafts have been used, did not occur.

Revision hip arthroplasty in patients with massive acetabular bone deficiency has generally given poor long-term results. We report the use of an 'anti-protrusio cage', secured to the ischium and ilium, which bridges areas of acetabular bone loss, provides support for the acetabular socket, and allows pelvic bone grafting in an environment protected from excessive stress. Forty-two failed hip arthroplasties with massive acetabular bone loss were revised with the Burch-Schneider anti-protrusio cage and evaluated after two to 11 years (mean five years). There was failure due to sepsis in five hips (12%) and aseptic loosening in five (12%); the remaining 32 hips (76%) showed no evidence of acetabular component failure or loosening

This study was to analyze the minimum ten years clinical and radiological results of revision total hip arthroplasties using allogenic impaction bone graft and cemented cup in acetabular bone deficiency. Fifty two revision total hip arthroplasties that had been performed in forty nine patients between March 1992 and June 1997 and had followed more than minimum ten years were included in this study. The clinical and radiological results were evaluated by Harris hip score and roentgenography including anterior-posterior view of pelvis and lateral view of operated hip. The mean Harris hip score was 47 points preoperatively, 81 points at three years, 84 points at seven years, and 82 points at ten years after revision. In radiological evaluation, osseous union between grafted bone and host bone was seen within four months in 47 hips, a complete grafted bone-cement radiolucent line of two millimeter or more in at least one zone was seen in 5 hips at two years, 7 hips at seven years, and 2 hip at 10 years follow-up. We recommend the technique using allogenic impaction bone graft and cemented cup to reconstruct the acetabular cavitary defect in revision total hip arthroplasties

Introduction: The increasing utilization of total hip arthroplasty and the increasing life expectancy have brought an increasing incidence of revision hip arthroplasty. With severe acetabular, revision surgery with the use of standard cemented or press-fitted components is inadequate for fixation. In these cases the use of proximal femoral allograft can restore the deficiency.

Purpose: To present a new technique and preliminary results of revision total hip arthroplasty using proximal femoral allograft prosthetic composites for massive ace-tabular bone loss. The technique uses the natural vector of forces in the intertrochanteric region in an opposite direction at the acetabular defect.

Methods: From June 2000 to July 2001, seven patients underwent reconstruction of massive acetabular defects with proximal femoral allograft bone. The etiologies for bone loss were infection in 2 patients, aseptic loosening in 4 and acetabular protrusion in 2 patients. In 4 hips there were also femoral defects that was reconstructed with allograft. The average age of the patients was 69.8 years. All patients were wheel chair bound prior to surgery. Harris Hip Score was used to assess preoperative and follow-up function level.

Results: Harris Hip Score improved significantly in all patients. All patients are ambulatory at follow-up. Complications included 2 dislocation and 2 deep-vein thrombosis. No allograft resorbtion was noted at follow-up.

Conclusions: The proximal femoral allograft provides a solid construct for the acetabular cup in large acetabular bone defects. Although failure and complication rates might be higher than revision procedures with lesser bone defects, this reconstructive option for massive ace-tabular defects dramatically improves a patient’s function level.

Reconstruction of an acetabulum following severe bone loss can be challenging. The aim of this study was to determine the outcome of acetabular reconstruction performed using trabecular metal shell for severe bone loss.

Between June 2003 and June 2006 a total of 29 patients with significant acetabular bone stock deficiency underwent revisions using trabacular metal shell. According to Paprosky classification, there were 18 patients with grade IIIA and 11 patients with grade IIIB defects. Nineteen patients required augments to supplement the defects. Functional clinical outcomes were measured by WOMAC and Oxford hip. Detailed radiological assessments were also made.

At most recent follow up (average 5.5 years, range 3.5–8.5) the mean Oxford hip score improved from 12 preoperatively to 27.11 postoperatively and WOMAC score from 17.57 preoperatively to 34.14 postoperatively The osseointegration was 83% according to Moore's classification. There were two reoperations; one was for instability, and one for aseptic loosening. One patient has a chronic infection and one had a periprosthetic fracture, both treated conservatively.

Despite challenges faced with severe preoperative acetabular defects the early results using this technique in Grade III A and B is encouraging.

We evaluated 38 hip reconstructions in 36 patients at a mean follow-up of 5.9 years (range 4 to 9.1) after femoral head allografts had been used to augment severely deficient acetabular bone stock. The patients were all relatively young and had many previous operations. Their pre-operative Harris hip rating averaged 46 points (range 18 to 73). All the allografts united and there were no infections. However, 12 acetabular components (32%) became loose; six of these had needed revision using the healed allograft, and two hips had required resection arthroplasty. The 30 surviving hips had a mean Harris hip score of 82 points. Some radiographic evidence of graft resorption was seen in 23 hips, though this was mild in 17. The extent of cover provided by the allograft and the severity of graft resorption both correlated with acetabular loosening. Although structural allografts had allowed successful hip reconstructions in many of these patients with major bone loss, the failure rate had increased from zero at four years to 32% at six years; clearly they provide only a short-term solution.

Aim: The purpose of this study was to assess the results with use of an oval cementless acetabular component for revision total hip arthroplasty. Methods: 30 hips had an acetabular revision with an cementless oval acetabular component. No patient was lost to follow-up, but one died during the study period. All defects were classiþed during surgery according the AAOS classiþcation. All patients were evaluated radiographically and clinically and were followed for an average of thirty-six months (range, twenty four to fourty eight months). In 21 of the 30 hips no additional bone grafting was necessary. Results: There were 17 segmental defects (type 1), 12 combined defects (type III) and one case of pelvic discontinuity (type IV). At the time of follow-up, 27 (93.1%) of 29 cups were stable. One of the loosening affected the patient with pelvic discontinuity, the other a patient with a combined segmental defect including the medial wall. The average Harris Hip Score improved from 39 points (range: 15–73 points) preoperatively to 89 points (range 68–96 points) postoperatively. Complications included three dislocations without recurrency. The radiological follow-up examinations revealed good osteointegration of 27 implants. All postoperatively remaining defects were completly þlled in by bone at the follow up. Conclusion: The asymmetrical shape of the BOFOR enhanced the primary stabilty on the lateral columns with three point anchorage. We recommend this device when a patient has an oblong-shaped acetabular defect and the surgeon wants to correct an elevated hip center. However, the medial wall of the acetabulum (Kohlerñs line) should be intact.

Traditional radiographic criteria might underestimate or fail to detect subtle types of acetabular dysplasia. Acetabular sector angles (ASA) can measure the degree of anterior and posterior coverage of the femoral head on computed tomography (CT). This study aims to determine ASA values at different axial levels in a cohort of (1) asymptomatic, high-functioning hips without underlying hip pathology (controls); and (2) symptomatic, dysplastic hips that underwent periacetabular osteotomy (PAO). Thereby, we aimed to define CT-based thresholds for hip dysplasia and its subtypes. This is an IRB approved cross-sectional study of 51 high functioning, asymptomatic patients (102 hips) (Oxford Hip Score >43), without signs of osteoarthritis (Tönnis grade≤1), who underwent a CT scan of the pelvis (mean age: 52.1±5.5 years; 52.9% females); and 66 patients (72 hips) with symptomatic hip dysplasia treated with peri-acetabular osteotomy (PAO) (mean age: 29.3±7.3 years; 85.9% females). Anterior and posterior acetabular sector angles (AASA & PASA) were measured by two observers at three CT axial levels to determine equatorial, intermediate, and proximal ASA. Inter- and intra-observer reliability coefficient was high (between 0.882–0.992). Cut-off values for acetabular deficiency were determined based on Receiver Operating Characteristic (ROC) curve analysis, area under the curve (AUC) was calculated. The dysplastic group had significantly smaller ASAs compared to the Control Group, AUC was the highest at the proximal and intermediate PASA. Controls had a mean proximal PASA of 162°±17°, with a cut-off value for dysplasia of 137° (AUC: 0.908). At the intermediate level, the mean PASA of controls was 117°±11°, with a cut-off value of 107° (AUC 0.904). Cut-off for anterior dysplasia was 133° for proximal AASA (AUC 0.859) and 57° for equatorial AASA (AUC 0.868). Cut-off for posterior dysplasia was 102° for intermediate PASA (AUC 0.933). Measurement of ASA on CT is a reliable tool to identify dysplastic hips with high diagnostic accuracy. Posterior ASA less than 137° at the proximal level, and 107° at the intermediate level should alert clinicians of the presence of dysplasia

Aim. Aim of this monocentric, prospective study was to evaluate the safety, efficacy, clinical and radiographical results at 24-month follow-up (N = 6 patients) undergoing hip revision surgery with severe acetabular bone defects (Paprosky 2C-3A-3B) using a combination of a novel phase-pure betatricalciumphosphate - collagen 3D matrix with allograft bone chips. Method. Prospective follow-up of 6 consecutive patients, who underwent revision surgery of the acetabular component in presence of massive bone defects between April 2018 and July 2019. Indications for revision included mechanical loosening in 4 cases and history of hip infection in 2 cases. Acetabular deficiencies were evaluated radiographically and CT and classified according to the Paprosky classification. Initial diagnosis of the patients included osteoarthritis (N = 4), a traumatic fracture and a congenital hip dislocation. 5 patients underwent first revision surgery, 1 patient underwent a second revision surgery. Results. All patients were followed-up radiographically with a mean of 25,8 months. No complications were observed direct postoperatively. HHS improved significantly from 23.9 preoperatively to 81.5 at the last follow-up. 5 patients achieved a defined good result, and one patient achieved a fair result. No periprosthetic joint infection, no dislocations, no deep vein thrombosis, no vessel damage, and no complaint about limbs length discrepancy could be observed. Postoperative dysmetria was found to be + 0.2cm (0cm/+1.0cm) compared to the preoperative dysmetria of − 2.4 cm (+0.3cm/−5.7cm). Conclusions. Although used in severe acetabular bone defects, the novel phase-pure betatricalciumphosphate - collagen 3D matrixshowed complete resorption and replacement by newly formed bone, leading to a full implant integration at 24 months follow-up and thus represents a promising method with excellent bone regeneration capacities for complex cases, where synthetic bone grafting material is used in addition to autografts

Failure of total hip arthroplasty with acetabular deficiency occurred in 55 patients (60 hips) and was treated with acetabular revision using morsellised allograft and a cemented metal-backed component. A total of 50 patients (55 hips) were available for clinical and radiological evaluation at a mean follow-up of 5.8 years (3 to 9.5). No hip required further revision of the acetabular component because of aseptic loosening. All the hips except one had complete incorporation of the allograft demonstrated on the radiographs. A complete radiolucent line of > 1 mm was noted in two hips post-operatively. A good to excellent result occurred in 50 hips (91%). With radiological evidence of aseptic loosening of the acetabular component as the end-point, the survivorship at a mean of 5.8 years after surgery was 96.4%. The use of impacted allograft chips in combination with a cemented metal-backed acetabular component and screw fixation can achieve good medium-term results in patients with acetabular bone deficiency