Although total hip arthroplasty is highly successful for treatment of osteoarthrosis of hip joint, it is skill demanding surgery to perform and even more challenging in case of revision with bone defects. There are many options available for reconstruction of acetabular bony defects. Here, we evaluate the outcome of acetabular bony defect reconstructed with trabecular metal augments in short term. We performed, 22 revision total hip arthroplasties and 6 primary total hip arthroplasties (total 28 in 28 patients) using trabecular metal augments to reconstruct acetabular defect between 2011 to 2015. Out of these 28 patients, 18 were males and 10 were females. Mean age of these patients was 61.2 years (range: 46 years to 79 years). Pre-operative templating was done for all cases and need for trabecular metal augments was anticipated in all cases. All cases were classified according to Paprosky classification for acetabular bone defects. Out of 28 patients, 3 had type 2B, 1 had type 2C, 18 had type 3A and 6 had type 3B acetabular defects. Post operatively, all patients were followed at regular interval for their clinical and radiological outcome. An average follow up was 20.1 months (range: 6 months to 42.5 months). We assessed clinical outcome in the form of Herris hip score (HHS) and radiological outcomes in form of osteolysis in acetabular zones and osseointegration, according to the criteria of Moore. The average Harris hip score (HHS) was improved from 58.0 preoperatively to 87.2 postoperatively. The average degree of cup abduction at the final follow up was 44.29. The centre of rotation of the hip joint was corrected from average 38.90mm (range: 22.15mm to 66.35mm) above the inter-teardrop line preoperatively to average 23.85mm (range: 11.82mm to 37.69mm) above the inter-teardrop line postoperatively. Out of 28 patients, 18 patients had three or more signs of osseointegration, according to the criteria of Moore, at the time of final follow up. Rest of patients, had one or two signs of osseointegration (5 patients had one sign and 5 patients had two signs). We had no patient with migration or loosening of acetabular components. No patient has osteolysis of acetabulum in any zone. Trabecular metal augments provide good initial stability to acetabular cup as well as helpful to bring down the centre of rotation of the hip joint within limit of 35mm above the inter-teardrop line. They also facilitate osseointegration. Our study showed that the results of the trabecular metal augments in reconstruction of acetabular bony defects were successful even in short term. However, long term study is required for better evaluation

Introduction. Primary stability is an important factor for long-term implant survival in total hip arthroplasty. In revision surgery, implant fixation becomes especially challenging due the acetabular bone defects, which are often present. Previous studies on primary stability of revision components often applied simplified geometrical defect shapes in a variety of sizes and locations. The objectives of this study were to (1) develop a realistic defect model in terms of defect volume and shape based on a clinically existing acetabular bone defect, (2) develop a surrogate acetabular test model, and (3) exemplarily apply the developed approach by testing the primary stability of a pressfit-cup with and without bone graft substitute (BGS). Materials & Methods. Based on clinical computed tomography data and a method previously published [1], volume and shape information of a representative defect, chosen in consultation with four senior hip revision surgeons, was derived. Volume and shape of the representative defect was approximated by nine reaming procedures with hemispherical acetabular reamers, resulting in a simplified defect with comparable volume (18.9 ml original vs. 18.8 ml simplified) and shape. From this simplified defect (Defect D), three additional defect models (Defect A, B, C) were derived by excluding certain reaming procedures, resulting in four defect models to step-wise test different acetabular revision components. A surrogate acetabular model made of 20 PCF polyurethane foam with the main support structures was developed [2]. For the exemplary test, three series for Defect A were defined: Native (acetabulum without defect), Empty (defect acetabulum without filling), Filled (defect acetabulum with BGS filling). All series were treated with a pressfit-cup and subjected to dynamic axial load in direction of maximum resultant force during level walking. Minimum load was 300 N and maximum load was increased step-wise from 600 N to 3000 N. Total relative motion between cup and foam, consisting of inducible displacement and migration, was assessed with the optical measurement system gom Aramis (gom GmbH, Braunschweig, DE). Results. Total relative motion increased with increasing load, with a maximum of 0.63 mm for Native, 0.86 mm for Filled, and 1.9 mm for Empty. At load stage 1800 N, total relative motion in Empty was 11.0-fold increased in comparison to Native, but could be reduced to a 3.3-fold increase in Filled. Discussion. The objective of this study was to develop a simplified, yet realistic and modular defect model which could be used to step-wise test different treatment strategies. Applicability of the developed test setup was shown by assessing primary stability of a pressfit-cup in a native, empty, and filled situation. The presented method could potentially be used as a modular test setup to compare different acetabular revision components in a standardized way. For any figures or tables, please contact authors directly

Introduction. Modern acetabular cups require a convenient bone stock for sufficient cup fixation. Thereby, fixation stability is influenced by the chosen interference fit of the acetabular cup, the cup surface structure, circularity of the reamed acetabulum and by the acetabular bone quality. The ideal implantation situation of the cup is commonly compromised by joint dysplasia and acetabular bone defects. The aim of the present experimental study was to characterise implant fixation of primary acetabular cups in case of definite acetabular cavity defects. Materials and Methods. For the experimental determination bone substitute blocks (100 × 100 × 50 mm) made of polymethacrylimide (PMI) foam with a density of 7 pcf were used. The created acetabular defect situations were derived from the defect classification according to Paprosky. The defect geometries in the PMI foam blocks were realised by a CNC drilling machine. Thereby the defects are described in the dorso-ventral direction by the angle α and in medio-lateral direction by the angle β (given as angle combination α/β) related to the centre of rotation of the reamed cavity. For the lever-out tests the defect types IIb and IIIa (each with different α and β angles) were considered and compared to the intact fixation situation. Therefore, a macrostructured titanium cup (Allofit, Zimmer GmbH, Wintherthur, Switzerland) with an outer diameter of 56 mm were displacement-controlled (v = 20 mm/min) pushed into the 2 mm diametric under reamed PMI-foam cavities. Three cups were inserted until the cup overhang pursuant to surgical technique was reached. Subsequently the cups were displacement-controlled (v = 20 mm/min) levered out via a rod which was screwed into the implant pole by perpendicular displacement (U. axial. ) of the rod in direction of the defect aperture. The lever-out moments were calculated by multiplying the first occurring force maximum (F. max. ) with the effective lever arm length (l. lever. ), whereby moments caused by the deadweight of the rod were considered. Primary stability was defined by the first maximum lever-out moment. Results. The calculated lever-out moments were in a range from 15.5 ± 1.4 Nm to 1.4 ± 0.5 Nm. Defects with a 90° dorso-ventral opening angle showed 57 ± 17% lower lever-out moments. Defects with a 120° dorso-ventral opening angle showed 80 ± 6% lower lever-out moments compared to the cup fixation into intact cavities. Moreover, medio-lateral angles greater than 20° reduced the lever-out moment by 79 ± 12% compared to the intact cavities. Conclusion. The determined lever-out moments underline the reduction of fixation stability of acetabular cup by loss of circumferential rim and absent of superior wall support of the acetabular bone. Thereby, the fixation stability is influenced by the degree of dorso-ventral and medio-lateral defect manifestation. Hence, the fixation stability depends on the cavity surface and in particular the surface of the bone-implant interface in the fixation zone of the acetabular cup Thus, dorso-ventral defect sizes with greater opening angle than 60° and medio-lateral defect sizes greater than 20° are critically for sufficient fixation of primary acetabular cup implants

Reconstruction acetabular surgery with bone stock loss is still a difficult and challenging problem for the orthopaedic surgeon. The goals of acetabular revision are: stable bone coverage that can support the new acetabular component, restoration of the anatomy and bone stock for future revisions, equalization of leg length and restoration of the centre of hip motion. These goals are difficult to achieve when the pelvic defect is particularly severe. We examine the case of a female 73 years old who underwent a third revision arthroplasty of the hip joint because of extensive bony defect of the acetabular cavity (massive protrusio defect-type III –D’Antonio- combined segmental/cavitary acetabular defect). The femoral component which was revised in a previous operation with a mega stem (type Kotz), was radiologically stable and symptomless. Preoperative radiological assessment was performed using standard radiographic views, Judet views and CT scan. The surgical approach that we used was a slight modification of the previous incision achieving a better visualization of the entire acetabulum and iliac wing. The loose acetabular cup as well as soft tissue and debris were removed from the acetabulum. The large acetabular defect was filled with a massive allograft (tibial plateau) properly cut and shaped. The stability of the allograft was achieved fixing the allograft to the iliac bone with screws. A large amount of particulate allograft bone was placed in the depths of the acetabular defect restoring a proper level of the acetabular floor. Then a Burke-Schneider cage was firmly seated and fixed with screws in the prepared acetabular bed. A polyethylene cup was cemented into the acetabular shell. The superior part of the Kotz femoral prosthesis was also revised with a new one. Postoperatively we din not have any complications, the graft incorporation was successful with a satisfactory functional result. We believe that the use of structural allograft bone is essential for the reconstruction of large segmentalace-tabular defects. The results however are less predictable because of important technical difficulties and sometimes serious complications occur

Aims. Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects. Methods. We performed a retrospective review at a single institution of patients undergoing revision THA by a single surgeon. We identified 49 consecutive patients with large acetabular defects where the biphasic BGS was applied, with no other products added to the BGS. After placement of metallic acetabular implants, the BGS was injected into the remaining bone defects surrounding the new implants. Patients were followed and monitored for functional outcome scores, implant fixation, radiological graft site remodelling, and revision failures. Results. Mean follow-up was 39.5 months (36 to 71), with a significant improvement in post-revision function compared to preoperative function. Graft site remodelling was rated radiologically as moderate in 31 hips (63%) and strong in 12 hips (24%). There were no cases of complete graft site dissolution. No acetabular loosening was identified. None of the patients developed clinically significant heterotopic ossification. There were twelve reoperations: six patients developed post-revision infections, three experienced dislocations, two sustained periprosthetic femur fractures, and one subject had femoral component aseptic loosening. Conclusion. Our series reports bone defect restoration with the sole use of a biphasic injectable BGS in the periacetabular region. We did not observe significant graft dissolution. We emphasize that successful graft site remodelling requires meticulous recipient site preparation. Cite this article: Bone Jt Open 2022;3(12):991–997

Introduction. Acetabular bone defects are still challenging to quantify. Numerous classification schemes have been proposed to categorize the diverse kinds of defects. However, these classification schemes are mainly descriptive and hence it remains difficult to apply them in pre-clinical testing, implant development and pre-operative planning. By reconstructing the native situation of a defect pelvis using a Statistical Shape Model (SSM), a more quantitative analysis of the bone defects could be performed. The aim of this study is to develop such a SSM and to validate its accuracy using relevant clinical scenarios and parameters. Methods. An SSM was built on the basis of segmented 66 CT dataset of the pelvis showing no orthopedic pathology. By adjusting the SSM's so called modes of shape variation it is possible to synthetize new 3D pelvis shapes. By fitting the SSM to intact normal parts of an anatomical structure, missing or pathological regions can be extrapolated plausibly. The validity of the SSM was tested by a Leave-one-out study, whereby one pelvis at a time was removed from the 66 pelvises and was reconstructed using a SSM of the remaining 65 pelvises. The reconstruction accuracy was assessed by comparing each original pelvis with its reconstruction based on the root-mean-square (RMS) surface error and five clinical parameters (center of rotation, acetabulum diameter, inclination, anteversion, and volume). The influence of six different numbers of shape variation modes (reflecting the degrees of freedom of the SSM) and four different mask sizes (reflecting different clinical scenarios) was analyzed. Results. The Leave-one-out study showed that the reconstruction errors decreased when the number of shape variation modes included in the SSM increased from 0 to 20, but remained almost constant for higher numbers of shape variation modes. For the SSM with 20 shape variation modes, the RMS of the reconstruction error increased with increasing mask size, whereas the other parameters only increased from Mask_0 to Mask_1, but remained almost constant for Mask_1, Mask_2 and Mask_3. Median reconstruction errors for Mask_1, Mask_2, and Mask_3 were approximately 3 mm in Center of Rotation (CoR) position, 2 mm in Diameter, 3° in inclination and anteversion, as well as 5 ml in volume. Discussion. This is the first study analyzing and showing the feasibility of a quantitative analysis of acetabular bone defects using a SSM-based reconstruction method in the clinical scenario of a defect or implant in both acetabuli and incomplete CT-scans. Validation results showed acceptable reconstruction accuracy, also for clinical scenarios in which less healthy bone remains. Further studies could apply this method on a larger number of defect pelvises to obtain quantitative measures of acetabular bone defects

Aim: Impaction bone grafting is an established technique for the restoration of bone loss at revision hip surgery. Preformed stainless steel meshes have been recently introduced to augment graft containment. We present our results of acetabular impaction grafting at a mean of 4 years, with particular reference to the use of preformed steel meshes.

Methods: 72 consecutive total hip replacements (7 primary and 65 revision) in 69 patients underwent acetabular impaction grafting with morsellised fresh frozen allograft through a posterior approach. In 47 cases there were uncontained defects (46 segmental or combined deficiencies, one pelvic discontinuity) necessitating the use of a preformed steel mesh, secured with multiple small fragment screws to contain the impacted bone graft. All the operations were done by the senior author in a district general hospital.

Results: At mean follow-up of 4 years (range 18 to 92 months), no case has been lost to follow up. The Merle d’Aubigne Postel hip scores averaged 5.3 (pain), 4.2 (walking ability), and 5.3 (range of movement). (Charnley group A -26 patients, group B -19, group C -24). There were no peri-operative deaths or deep infections. There have been no revisions for septic or aseptic loosening. There were 2 cases of early post operative dislocation which stabilised after closed reduction. One case of recurrent disclocation required cup revision. There was one case of radiographic loosening without cup migration. This patient remains pain free and there are no plans for revision. In all other cases, radiographs suggest graft incorporation, with no significant radiolucent lines, acetabular component or mesh migration. There have been no complications relating to the use of the preformed mesh.

Conclusion: The results of this study are encouraging. By using preformed metallic meshes it is possible to manage all cases of acetabular loss, irrespective of severity, encountered during total hip replacement with acetabular impaction grafting.

Aims: A main condition in succesfull rearthroplasty of acetabular component is the way of stabilizing this component in physiological site, with a full support on bone. Segmental and cavitary acetabular defect are often caused by aseptic loosening of the implants. The use of bulky corticocancellous grafts, which would be loaded is recommended. Methods: Acetabular roof reconstruction technique for revision cemented THA, according to Zuk is presented in a series 42 patients (19 male and 23 female aged 56– 68 yr). No screws and bone pins were used for cortico-cancellous graft þxation. Results: In 22 patients autogenic graft was sufþciently remodeled within 12 months, in 16 cases with frozen allogenic graft it lasted 20 months on average. Longer remodeling time depended on the size of acetabular defect, coexisting conditions and postoperative complication. In 2 cases an autolysis of the graft occurred; one patient underwent prolonged corticosteroid therapy before; the other one was exposed extensively to chemical substances prior to surgery. Aseptic loosening of the acetabular roof in this cases followed. Conclusions: Reconstruction of acetabular roof defect in this method is relatively simple and can diminish complication rate bounded with potential electrolysis harmfull effect. A mean remodeling time of reconstructed acetabular bone roof with this method was equal as with stabilized graft (pins and screws)

Aims. Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction. Methods. Between 2014 and 2023, 79 patients with a mean follow-up of 33 months (SD 22; 9 to 103) were included. Functional outcome was measured using the Harris Hip Score and EuroQol five-dimension questionnaire (EQ-5D). PPR revisions were defined as an endpoint, and subgroups were analyzed to determine risk factors. Results. Implantation was possible in all cases with a 2D centre of rotation deviation of 10 mm (SD 5.8; 1 to 29). PPR revision was necessary in eight (10%) patients. HHS increased significantly from 33 to 72 postoperatively, with a mean increase of 39 points (p < 0.001). Postoperative EQ-5D score was 0.7 (SD 0.3; -0.3 to 1). Risk factor analysis showed significant revision rates for septic indications (p ≤ 0.001) as well as femoral defect size (p = 0.001). Conclusion. Since large acetabular defects are being treated surgically more often, custom-made PPR should be integrated as an option in treatment algorithms. Monoflange PPR, with primary iliac fixation, offers a viable treatment option for Paprosky III defects with promising functional results, while requiring less soft-tissue exposure and allowing immediate full weightbearing. Cite this article: Bone Jt Open 2024;5(8):688–696

The use of trabecular metal (TM.) shells supported by two TM augments in the footing technique has been described as a potential option for the treatment of Paprosky 3B acetabular defects. The aim of this study was to assess the mid implant survivorship and radiological and clinical outcomes after acetabular revision using this technique. We undertook a retrospective, double-centre series of 39 hips in 39 patients (15 male, 24 female) treated with the footing technique using a TM shell supported by two TM augments, for severe acetabular bone loss between 2007 and 2020. The mean age at the time of surgery was 62,9 (28 to 86) years. The mean follow-up was 5,4 (1,5 to 15) years. The cumulative mid survivorship of the implant with revision for any cause was 89%. 3 hips (7,6%) required further revision due to aseptic loosening, and 1 (2,8%) required revision for infection. The mean Harris Hip Score improved significantly from 48 (29 to 65) preoperatively to 79 points (62 to 98) at the latest follow-up (p < 0.001). The reconstruction of Paprosky 3B acetabular defects with TM shells and two augments in footing-technique showed excellent mid-term results. This technique appears to be a viable option for treating these defects

The objective of this study was to assess the clinical and radiological results of patients who were revised using a new generation custom-made triflange acetabular component (CTAC) for component loosening and large acetabular defect (Paprosky 3A and 3B) after previous total hip arthroplasty (THA). New generation CTACs involve the use of patient-specific drill guides and incorporate three-dimensional printed bone models, enhancing precision during surgical implantation. Data were extracted from a single centre prospective database of patients with large acetabular defects who were treated with a new generation CTAC. Patients were included if they had a minimum follow-up of five years. The modified Oxford Hip Score (mOHS), EurQol EuroQoL five-dimension three-level (EQ-5D-3L) utility, and Numeric Rating Scale (NRS), including visual analogue score (VAS) for pain, were gathered at baseline, and at two- and five-year follow-up. Reasons for revision, and radiological and clinical complications were registered. Trends over time are described and tested for significance (p<0.05). A total of 49 (70%) of 70 patients with a mean age of 73.5 years (SD 7.7) had a complete follow-up of 5 years. A significant improvement was found in HOOS, mOHS, EQ-5D-3L utility and NRS, VAS pain rest and activity between baseline and final follow-up. Complications included 8 cases with loosening screws, 4 with bony fractures, 4 periprosthetic infections and 2 cases with dislocation. One patient with bilateral pelvic discontinuity had revision surgery due to recurrent dislocations. No revision surgery was performed for screw failure or implant breakage. New generation CTAC in patients with THA acetabular loosening and massive acetabular bone loss (Paprosky 3A and 3B) can result in stable constructs and significant improvement in functioning and health-related quality of life at five years’ follow-up

Osteolysis, fractures, and bone destruction caused by osteomyelitis or metastasis can cause large bone defects and present major challenges during acetabular reconstruction in total hip arthroplasty. We sought to evaluate the survivorship and radiographic outcomes of an acetabular reconstruction consisting of a polyethylene liner (semi-constrained) embedded in cement filling bone defect(s) reinforced with screws and/or plates for enhanced fixation (HiRISC). Retrospective chart review of 59 consecutive acetabular reconstructions as described above performed by 4 surgeons in a single institution (10/18/2018-1/5/2023) was performed. After radiographs and operative reports were reviewed, cases were classified following the Paprosky classification for acetabular defects. Paprosky type 1 cases (n=26) were excluded, while types 2/3 (n=33) were included for analysis. Radiographic loosening was evaluated up to latest follow-up. Mean follow-up was: 487 days (range, 20–1,539 days). Out of 33 cases, 2 (6.1%) cases were oncological (metastatic disease) and 22 (66.7%) had deep infection diagnosis (i.e., periprosthetic joint infection [PJI] or septic arthritis). In total, 7 (21.2%) reconstructions were performed on native acetabula (3 septic, 4 aseptic). At a mean follow-up of 1.3 years, 5 (15.2%) constructs were revised: 4 due to uncontrolled infection (spacer exchange) and 1 for instability. On follow-up radiographs, only 1 non-revised construct showed increased radiolucencies, but no obvious loosening. When compared to patients with non-revised constructs, those who underwent revision (n=5) were significantly younger (mean 73.8 vs. 60.6 years, p=0.040) and had higher body mass index (24.1 vs. 31.0 Kg/m. 2. , p=0.045), respectively. Sex, race, ethnicity, American-Society-of-Anesthesiologist classification, infection diagnosis status (septic/aseptic), and mean follow-up (449.3 vs. 695.6 days, respectively, p=0.189) were not significantly different between both groups. HiRISC construct may be a viable short-term alternative to more expensive implants to treat large acetabular defects, particularly in the setting of PJI. Longer follow up is needed to establish long term survivorship

In primary total hip arthroplasty (THA) for patients with Crowe II or higher classes developmental dysplasia of the hip (DDH) or rapidly destructive coxopathy (RDC), the placement of the cup can be challenging due to superior and lateral acetabular bone defects. Traditionally, bone grafts from resected femoral heads were used to fill these defects, but bulk graft poses a risk of collapse, especially in DDH with hypoplastic femoral heads or in RDC where good quality bone is scarce. Recently, porous metal augments have shown promising outcomes in revision surgeries, yet reports on their efficacy in primary THA are limited. This study retrospectively evaluated 27 patients (30 hips) who underwent primary THA using cementless cups and porous titanium acetabular augments for DDH or RDC, with follow-up periods ranging from 2 to 10 years (average 4.1 years). The cohort included 22 females (24 hips) and 5 males (6 hips), with an average age of 67 years at the time of surgery. The findings at the final follow-up showed no radiographic evidence of loosening or radiolucency around the cups and augments, indicating successful biological fixation in all cases. Clinically, there was a significant improvement in the WOMAC score from an average of 39.1±14.7 preoperatively to 5.1±6.4 postoperatively. These results suggest that the use of cementless cups and porous titanium acetabular augments in primary THA for DDH and RDC can lead to high levels of clinical improvement and reliable biological fixation, indicating their potential as a viable solution for managing challenging acetabular defects in these conditions

The best treatment method of large acetabular bone defects at revision THR remains controversial. Some of the factors that need consideration are the amount of residual pelvic bone removed during revision; the contact area between the residual pelvic bone and the new implant; and the influence of the new acetabular construct on the centre of rotation of the hip. The purpose of this study was to compare these variables in two of the most used surgical techniques used to reconstruct severe acetabular defects: the trabecular metal acetabular revision system (TMARS) and a custom triflanged acetabular component (CTAC). Pre- and post-operative CT-scans were acquired from 11 patients who underwent revision THR with a TMARS construct for a Paprosky IIIB defect, 10 with pelvic discontinuity, at Royal Adelaide Hospital. The CT scans were used to generate computer models to virtually compare the TMARS and CTAC constructs using a semi-automated method. The TMARS construct model was calculated using postoperative CT scans while the CTAC constructs using the preoperative CT scans. The bone contact, centre of rotation, inclination, anteversion and reamed bone differences were calculated for both models. There was a significant difference in the mean amount of bone reamed for the TMARS reconstructions (15,997 mm. 3. ) compared to the CTAC reconstructions (2292 mm. 3. , p>0.01). There was no significant difference between overall implant bone contact (TMARS 5760mm. 2. vs CTAC 5447mm. 2. , p=0.63). However, there was a significant difference for both cancellous (TMARS 4966mm. 2. vs CTAC 2887mm. 2. , p=0.008) and cortical bone contact (TMARS 795mm. 2. vs CTAC 2560mm. 2. , p=0.001). There was no difference in inclination and anteversion achieved. TMARS constructs resulted on average in a centre of rotations 7.4mm more lateral and 4.0mm more posterior. Modelling of two different reconstructions of Paprosky IIIB defects demonstrated potential important differences between all variables investigated

Aims. After failed acetabular fractures, total hip arthroplasty (THA) is a challenging procedure and considered the gold standard treatment. The complexity of the procedure depends on the fracture pattern and the initial fracture management. This study’s primary aim was to evaluate patient-reported outcome measures (PROMs) for patients who underwent delayed uncemented acetabular THA after acetabular fractures. The secondary aims were to assess the radiological outcome and the incidence of the associated complications in those patients. Methods. A total of 40 patients underwent cementless acetabular THA following failed treatment of acetabular fractures. The postoperative clinical and radiological outcomes were evaluated for all the cohort. Results. The median (interquartile range (IQR)) Oxford Hip Score (OHS) improved significantly from 9.5 (7 to 11.5), (95% confidence interval (CI) (8 to 10.6)) to 40 (39 to 44), (95% CI (40 to 43)) postoperatively at the latest follow-up (p < 0.001). It was worth noting that the initial acetabular fracture type (simple vs complex), previous acetabular treatment (ORIF vs conservative), fracture union, and restoration of anatomical centre of rotation (COR) did not affect the final OHS. The reconstructed centre of rotation (COR) was restored in 29 (72.5%) patients. The mean abduction angle in whom acetabular fractures were managed conservatively was statistically significantly higher than the surgically treated patients 42.6° (SD 7.4) vs 38° (SD 5.6)) (p = 0.032). We did not have any case of acetabular or femoral loosening at the time of the last follow-up. We had two patients with successful two-stage revision for infection with overall eight-year survival rate was 95.2% (95% CI 86.6% to 100%) with revision for any reason at a median (IQR) duration of follow-up 50 months (16 to 87) months following THA. Conclusion. Delayed cementless acetabular THA in patients with previous failed acetabular fracture treatments produces good clinical outcomes (PROMS) with excellent survivorship, despite the technically demanding nature of the procedure. The initial fracture treatment does not influence the outcome of delayed THA. In selected cases of acetabular fractures (either nondisplaced or with secondary congruency), the initial nonoperative treatment neither resulted in large acetabular defects nor required additional acetabular reconstruction at the time of THA. Cite this article: Bone Jt Open 2021;2(12):1067–1074

The management of severe acetabular bone defects poses a complex challenge in revision hip arthroplasty. Although biological fixation materials are currently dominant, cage has played an important role in complex acetabular revision in the past decades, especially when a biological prosthesis is not available. The purpose of this study is to report the long-term clinical and radiographic results of Paprosky type Ⅲ acetabular bone defects revised with cage and morselized allografts. We retrospectively analyzed 45 patients who underwent revision hip arthroplasty with cage and morselized allografts between January 2007 and January 2019. Forty-three patients were followed up. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients and 7 patients of the 24 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included cage stability, allografts incorporation, and center of rotation. All patients were followed up with a mean follow-up of 10.6 years, HHS and SF-12 improved significantly at last follow-up in comparison to the preoperative. There were 2 re-revisions, one at 5 years after surgery, another at 13.6 years after surgery. Two patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface. Allografts of 40 (93%) cases incorporated fully. The combination of cage and morselized allograft is an alternative option for acetabular revision with Paprosky type III bone defects with satisfactory long-term follow-up results

Femoroacetabular impingement is a prearthritic deformity frequently associated with early chondral damage. Several techniques exist for restoring larger cartilage defects. While AMIC proved to be an effective treatment in knee and ankle, there are only short-term data available in hip. This study aimed to investigate the mid-term clinical outcome of patients with chondral lesions treated by AMIC and evaluate the quality of repair tissue via MRI. This retrospective, single center study includes 18 patients undergoing surgical hip dislocation for FAI between 2013 and 2016. Inclusion criteria were: cam or pincer-type FAI, femoral or acetabular chondral lesions > 1 cm. 2. , (IRCS III-IV). Due to exclusion criteria and loss-to-follow-up 9 patients (10 hips) could be included. Patient reported outcome measures included Oxford Hip Score (OHS) & Core Outcome Measure Index (COMI)). MRIs were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. None of the patients underwent revision surgery except screw removals from the greater trochanter. Followup data indicate a satisfactory to good hip function at 5 years: PROMS improved from pre- to postop at 5 years: OHS from 38.1 to 43.4, COMI from to 1.8 and UCLA from 4 to 8.1 respectively. MOCART score was 67.5 postoperatively. Subgrouping showed slightly better results for acetabular defects (Ø 69.4) compared femoral defects (Ø 60). Based on the reported mid-term results, we consider AMIC as a valuable treatment option for larger chondral defects of the hip

Cup-cage constructs are one of several methods commonly used to treat severe acetabular bone loss during contemporary revision total hip arthroplasty. The purpose of this study was to provide a long-term results of the technique with emphasis on implant survivorship, radiographic results, and clinical outcomes for both full and half cup-cage reconstructions. We identified 57 patients treated with a cup-cage reconstruction for major acetabular bone loss between 2002–2012. All patients had Paprosky Type 2B through 3B bone loss, with 60% having an associated pelvic discontinuity. Thirty-one patients received a full cup-cage construct, and 26 a half cup-cage. Mean age at reconstruction was 66 years, 75% were female, and the mean BMI was 27 kg/m. 2. Mean follow-up was 10 years. The 10-year cumulative incidences of any revision were 14% and 12% for the full and half cup-cage construct groups, respectively. Of the 9 revisions, 3 were for dislocation, 2 for aseptic loosening and construct failure (both were pelvic discontinuities), 1 for adverse local tissue reaction, and 1 for infection with persistent pelvic discontinuity. The 10-year cumulative incidences of revision for aseptic loosening were 4.5% and 5% for the full and half cup-cage constructs, respectively. Of the unrevised cases, incomplete and non-progressive zone 3 radiolucent lines were observed in 10% of patients in each group. Three patients experienced partial motor and sensory sciatic nerve palsies (2 in the full and 1 in the half cup-cage group). Both the full and half cup-cage cohorts demonstrated significantly improved Harris hip scores. Full and half cup-cage reconstructions for major acetabular defects were successful at 10 years in regards to acetabular fixation without appreciable differences between the two techniques. However, zone 3 radiolucent lines were not uncommon in association with discontinuities, and dislocation continues to be a problem

THA in patients with acetabular bone defects is associated with a high risk of dislocation. Dual mobility (DM) cups are known to prevent and treat chronic instability. The aim of this study was to evaluate the dislocation rate and survival of jumbo DM cups. This was a retrospective, continuous, multicenter study of all the cases of jumbo DM cup implantation between 2010 and 2017 in patients with acetabular bone loss (Paprosky 2A: 46%, 2B: 32%, 2C: 15% and 3A: 6%). The indications for implantation were revisions for aseptic loosening of the cup (n=45), aseptic loosening of the femoral stem (n=3), bipolar loosening (n=11), septic loosening (n=10), periprosthetic fracture (n=5), chronic dislocation (n=4), intraprosthetic dislocation (n=2), cup impingement (n=1), primary posttraumatic arthroplasty (n=8), and acetabular dysplasia (n=4). The jumbo cups used were COPTOS TH (SERF), which combines press-fit fixation with supplemental fixation (acetabular hook, two superior flanges with one to four screws, two acetabular pegs). A bone graft was added in 74 cases (80%). The clinical assessment consisted of the Harris hip score. The primary endpoint was surgical revision for aseptic acetabular loosening or the occurrence of a dislocation episode. In all, 93 patients were reviewed at a mean follow-up of 5.3 ± 2.3 years [0, 10]. As of the last follow-up, the acetabular cup had been changed in five cases: three due to aseptic loosening (3.2%) and two due to infection (2.1%). The survivorship free of aseptic loosening was 96.8%. Three patients (3%) suffered a dislocation. At the last follow-up visit, the mean HSS scores were 72.15, (p < 0.05). Use of a jumbo DM cup in cases of acetabular bone defects leads to satisfactory medium-term results with low dislocation and loosening rates

Introduction. Revision total hip arthroplasty is often associated with acetabular bone defects. In most cases, assessment of such defects is still qualitative and biased by subjective interpretations. Three-dimensional imaging techniques and novel anatomical reconstructions using statistical shape models (SSM) allow a more impartial and quantitative assessment of acetabular bone defects [1]. The objectives of this study are to define five clinically relevant parameters and to assess 50 acetabular bone defects in a quantitative way. Methods. Anonymized CT-data of 50 hemi-pelvises with acetabular bone defects were included in the study. The assessment was based on solid models of the defect pelvis (i.e. pelvis with bone defect) and its anatomical reconstruction (i.e. native pelvis without bone defect) (Fig.1A). Five clinically relevant parameters were defined: (1) Bone loss, defined by subtracting defect pelvis from native pelvis. (2) Bone formation, defined by subtracting native pelvis from defect pelvis. Bone formation represents bone structures, which were not present in the native pelvis (e.g. caused by remodeling processes around a migrated implant). (3) Ovality, defined by the length to width ratio of an ellipse fitted in the defect acetabulum. A ratio of 1.0 would represent a circular acetabulum. (4) Lateral center-edge angle (LCE angle), defined by the angle between the most lateral edge of the cranial roof and the body Z-axis, and (5) implant migration, defined by the distance between center of rotation (CoR) of the existing implant and CoR of native pelvis (Fig. 1B). Results. All data are presented as single values as well as median and [25. th. , 75. th. ]- percentile (Fig.2). Bone loss was 53.6 [41.5, 76.7] ml with a minimum of 19.0 ml and maximum of 103.9 ml. Bone formation was 15.7 [10.5, 21.2] ml with a minimum of 3.5 ml and a maximum of 41.6 ml. Ovality was 1.3 [1.1, 1.4] with a minimum of 1.0 and a maximum of 2.0. LCE angle was 30.4° [21.5°, 40.1°] with a minimum of 11.6° and a maximum of 63.0°. Implant migration was 25.3 [15.1, 32.6] mm with a minimum of 5.4 mm and a maximum of 53.5 mm. Discussion. Within this study, 50 hemi-pelvises with acetabular bone defects were successfully quantified using five clinically relevant parameters. Application of this method provides impartial and quantitative data of acetabular bone defects, which could be beneficial in clinical practice for pre-operative planning or comparison of surgical outcomes. Including a larger number of cases, this method could even serve as a basis for a novel classification system for acetabular bone defects. For any figures or tables, please contact the authors directly