Aims. Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components. Methods. Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels. Results. In ten at-risk patients undergoing revision hip arthroplasty and submitted to our algorithm, six were recognized as being high risk to vascular injury during surgery. In those six high-risk patients, a preventive preoperative stent was implanted before the orthopaedic procedure. Four patients needed a second reinforcing stent to protect and to maintain the vessel anatomy deformed by the intrapelvic implants. Conclusion. The evaluation algorithm was useful to avoid blood vessels injury during revision total hip arthroplasty in high-risk patients. Cite this article: Bone Jt Open 2022;3(11):859–866

Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

There have been multiple approaches described for internal fixation of acetabular fractures. We discuss the results of acetabular fractures treated in our institution via a Stoppa intrapelvic approach. Between July 1997 to October 2002, the senior author surgically treated 14 acetabular fractures using this approach. Indications for utilizing this approach include displaced anterior column fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemi transverse component. The fractures were classified according to Letournel and Judet. There were 10 males, 4 females with a mean age of 34 years (20–57 years). Patients were followed up for an average of 26 months (8–60 months). All fractures went on to union at an average of 12 weeks. There was one superficial wound infection, which was successfully treated with antibiotics. No patients suffered loss of fixation. There were no nerve or visceral injury in our series. Clinical results evaluated were based on the Harris Hip Score (out of 100). Our results show 13 patients had good to excellent results (Score 80–100), whereas one patient had a fair result. The Stoppa intrapelvic approach offers improved reduction and fixation techniques with a decrease in complications associated with extensile approaches

Background: Unstable pelvic ring fractures are frequently associated with severe hemodynamic instability and mortality. Hemorrhage control of these disrupted pelvic fractures requires an urgent reduction of the intrapelvic volume and immediate mechanical stabilization. The aim of this study was to investigate the control of the intrapelvic volume and pelvic stability by different modes of external stabilization in a cadaver model. Methods: Various degrees of pelvic ring instability were induced in unembalmed human torsos. Haemorrhage induced volume displacement into the presacral and retroperitoneal space (RPP) was assessed by positioning two infusion lines right in front of the sacroiliac joint. The abdominal pressure measurement (IAP) was obtained by a percutaneous catheter in the abdominal cavity. Baseline pressure measurements of the intra pelvic volume were documented before and after dissection for uni-as bilateral instability. Reduction of pelvic instability was performed by non invasive T-POD. ®. Pelvic Stabilizer, a supraacetabular, iliac crest fixator, application of the pelvic C-Clamp without and with pelvic packing. Results: Baseline measurements (RPP) of the intact pelvis showed an average increase of 8,03 cmH2O per 1000 cc of infused fluid. In case of uni- and bilateral instability the pressure decreased to a rate of 2,88 and 1,48 cmH2O per 1000 cc. Following the application of each device an increase of RPP of 3,5 cmH2O (pelvic binder), 3,2 cmH2O (anterior frames), 5,4 cmH2O (C-Clamp) and 8,4 cmH2O (C-Clamp + packing) per 1000 cc was obtained in case of unilateral instability. In bilateral disruptions a significantly lower increase of pressure up to 4,0 cmH2O was seen. Conclusions: We investigated the efficacy of various external stabilization Methods: on potential hemorrhage on experimentally induced uni- and bilateral pelvic ring fractures. In case of intact pelvis the retroperitoneal space responds to fluid application with rapidly rising pressures. The application of external devices enable the reduction of the pelvic volume and thereby the retroper-itoneal pressure increase. The C-clamp combined with pelvic packing resulted to be superior

We present two patients with swelling of the groin following metal-on-metal total hip replacement without radiological signs of component loosening. MRI in both patients showed a round shaped intrapelvic lesion ventral to the femoral head. During surgery we found cystic structures filled with fluid and necrotic masses. After resection the metal head and insert were changed to a ceramic head and a polyethylene insert. Although two different kinds of CoCrMo alloy were used in the metal-on-metal THR (Sikomet: low carbon content-Metasul: high carbon content) histopathological analysis in both cases showed typical morphological signs of hypersensetively determined inflammation. Despite the distinct soft tissue reaction bony component integration was unaffected. In our opinion open resecion of the cystic lesion and changing of the metal-on-metal articulation is the treatment of choice. As we do not have any reliable testing for clinical use to predict a hypersensitive reaction to metal wear after implantation of metal-on-metal THR this articulation surface should not be used in cases where allergy to metal is suspected

Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws.

Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear.

Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant.

Background: Pelvic fractures are frecuently associated with massive intrapelvic bleeding from venous or arterial sources. Different treatment algorithms has been proposed in order to stablish early control of haemorragic sites, mostly based on external fixation/angiography. The aim of present study was to evaluate the clinical evolution of 70 pelvic fractures with uncontrolled hypotension treated with combined ex fix/angio based on fracture pattern. Materials and methods: Case serie . We analyzed a serie of patients admitted at our center between 1994 and 2004 with pelvic fracture and haemodinamic instability , treated by the same algorithm. Decision-making for the first treatment(angio vs external fixation) were based on the type of pelvic fracture. Patients was considered unstable if PAS was less than 90mmHg or the patients needs more than two blood products replacement in first 24 hours. Results: External fixation was used in 45 patients(64%) and 37 patients were treated by angio. We found active arterial bleeding in 31 cases (44%). The combination of both treatment was used in 20 patients. Laparotomy was performed in 21 patients. Incidence of sistemic complications were high . Mortality was 26% . Mortality were higher in two groups: patients with TBI and those treated by laparotomy. Conclusions: Arterial lesions demostrated by angio were high in our study(44%). In our experience a combined algorithm using both external fixation or angio based on type fracture control intrapelvic bleeding in most cases , although mortality in patients with pelvic fractre and haemodinamic instabilty remains high

Background: Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different approaches and treatments have been suggested in the literature with weakness of hip flexion, recurrence of symptoms and nerve injury following surgery. We describe a modified surgical approach for internal snapping of hip in adults with good results. Methods: Patients who failed conservative treatment for internal snapping between September 02 to February 04 were included. All patients had x-rays of relevant hips; ultrasound and MRI were done when required to exclude other causes. Patients were operated in supine position. A skin crease incision was made just lateral to the ASIS. The psoas tendon was reached sub-periosteally along the internal iliac surface hooked into the wound and divided releasing its musculo-tendonous junction. The patients were allowed to mobilise as able in the postoperative period. Results: There were 8 snapping hips (3 right, 3 left, 1 bilateral) in 7 patients (6 females, 1 male) with average age of 30 years (17–51 yrs). The mean follow was 11 months. The average duration of symptoms before operation was 4.5 years (range 2–10 years). Clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh. Discussion: The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extra pelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and sub-periosteal approach through oblique inguinal incision in adults, psoas muscle release at musculo-tendonous junction seems safe and effective (all clicking resolved) method. This method could be used as an alternative surgical approach for treatment of internal snapping of hip in adults

“Like other craftsmen, we have often two ways at least of doing the same job, the success of which is dependent upon the character and the integrity of the man. “Approaches” are for us both physical and psychological: in the case of the hip joint it seems clear that there is more than one good method and that, for the sake of those we train, we should keep an open mind.”. Norman A. Capener, 1950. Orientation relative to the abductor musculature and ease of access to the pathology in question should provide the compelling basis for selection of operative approaches to the hip, rather than being based solely on surgeon habit. Approaches to primary total hip arthroplasty remain the surgeon's choice; posterior approaches provide challenges to cup orientation and anterior approaches offer more difficult access to the proximal femur. Imperatives for a decubitus position posterior approach include pelvic dissociation with need for posterior column plating, removal of retained posterior hardware, and sciatic neurolysis after prior injury. Conversely, indications for a supine anterolateral approach include an isolated acetabular revision with a well-fixed femoral stem and the need for retroperitoneal removal of an intrapelvic acetabular component. Transgluteal approaches inflict potentially the greatest damage to the abductor musculature and are best reserved for primary operative settings; stability of a femoral endoprosthesis is optimised through this approach by preserving the posterior capsular structures. The transtrochanteric approach provides unrivaled exposure to both pelvis and acetabulum from either a supine or decubitus position, and is most helpful for removal of long well-fixed femoral stems whether cemented or cementless

Clear cell meningioma is a rare subtype of meningiomas graded II according to the World Health Organisation classification. In spite of its benign appearance, clear cell meningioma has an aggressive behaviour and it is characterized by its inordinately tendency to metastasize. The purpose of this study is to discuss the clinico-pathological features of this subtype of meningiomas as well as the metastatic pathways. We wish to report a rare case of a clear cell meningioma metastasizing to the sacrum 17 years after the removal of the primary tumour. A 26 year-old man was referred to our centre for low back pain related to a lytic lesion of the sacrum. He had a history of a tumour of the forth cervical vertebra that was removed when he was 9 year-old. CT scan revealed an osteolysis of the entire sacrum invading the intrapelvic organs and the sacro-iliac joints. Open biopsy revealed a clear cell meningioma. That was the same pattern of the tumour removed 17 years earlier. Chest CT showed lung metastases. The patient was managed conservatively by palliative radiation therapy. One year later, he experienced improvement of pain and walk. The mass was stable. Clear ell meningioma is an aggressive tumour with a potential to spread via cerebro-spinal fluid and haematologically. Patients with such a tumour should be closely followed for a long time

144 total hip replacements were performed by Swedish Orthopaedic Surgeons at Weston NHS Treatment Centre between 2004–2006, in an attempt to reduce the waiting list in Cardiff. Following concerns regarding the outcome of knee arthroplasty patients, the Welsh Assembly funded a clinical and radiographic review of all hip arthroplasty patients from the same unit. 100 hips were reviewed at a mean follow-up of 24 months. The mean Oxford Hip Score was 30 (range 12–60). Radiolucencies were seen in acetabular zone 1 in 34, and all 3 zones in 28 hips. Femoral component position was > 4 degrees varus in 41 cases. Medial floor breach with intrapelvic cement was seen in 12 cases. 10 cases had > 1cm leg length discrepancy. There were 3 early dislocations, 1 intraoperative distal femoral fracture, 1 Pulmonary Embolus and 2 superficial infections. 4 patients have received further treatment so far, and 12 have been listed for acetabular component revision for loosening. 1 has been listed for stem revision for symptomatic leg length discrepancy of 2.5cm. There is an unacceptably high early failure rate in this group of patients. The cost of further investigation and revision surgery far outweighs cost-savings achieved by outsourcing treatment to a distant centre

Two Air Assault Surgical Groups (AASGs) from 16 Close Support Medical Regiment deployed to Kuwait on Operation Telic in February 2003. Each AASG was comprised of a four-table resuscitation facility, a two table FST and a twin-bedded ITU facility. An A+E Consultant and nurse, an experienced radiographer and laboratory technician with two further RGNs and CMTs provided resuscitation support. Each FST had an orthopaedic and a general surgeon, two anaesthetists and eight operating department practitioners. Further equipment consisted of a Polymobil 111 x-ray unit, a Sonosite 180 ultrasound scanner and an ISTAT gas, haematocrit and electrolyte analyser. 100 units of mixed blood were carried by each AASG. Fifty-one surgical procedures were performed on thirty-one patients. Twenty-one of these patients were Iraqi prisoners of war or civilians. Seventeen wound debridements, five amputations, five laparotomies, four insertions of Denham pins with Thomas splintage for femoral fracture, three external fiations and one axillary artery repair formed the basis of the major cases undertaken. The first field use of activated factor 7 by the British Army was successful in the resuscitation of a patient with exsanguinating haemorrhage after an open-book (APC-III) pelvic fracture and a ruptured intrapelvic haematoma. The other cases included eleven manipulations under anaesthetic/application of plaster and four finger terminalisations. Forward military surgery has a continued role to play on the modern fast moving battlefield. 16 Close Support Medical Regiment normally supports 16 Air Assault Brigade with its remit for out-of-area operations and SF support. Its experience on Op Telic should influence planning for future deployments

One cementless cup which had porous outer surface with Apatite-Wollastonite glass ceramic (AWGC) coating, was revised 13 years after primary THA because of massive osteolysis expanded to medial iliac wall along the screws. While many retrieved studies of hydroxyapatite-coated cup have been reported, there has been no report on the retrieved cup with AWGC coating. The purpose of this study was to describe this rare case in detail, confirm the bone ingrowth to the porous cup, and discuss on the effectiveness of porous surface with AWGC coating. Case. The patient was a 64 old woman and complained of chronic mild pain around her left groin region. X-ray examination revealed that osteolysis had been expanding around the screws and extended proximally. The revision surgery was performed for the massive osteolysis through Hardinge antero-lateral approach. The retrieved implants included a cementless cup made of titanium alloy (QPOC cup, Japan Medical Materirals Inc.(JMM) Osaka, Japan), the outer surface of which was plasma-sprayed with titanium for porous formation and coated with AWGC in the deep layer. It was found that the polyethylene liner was destructed partially in the supero-lateral portion, but the cup was well fixed to the bone. The bone-attached area was found to be dispersed over the porous surface of the hemispherical cup. Histological examination revealed that matured bony tissue intruded into the porous surface of the cup, and contacted to bone directly, which was also demonstrated in the back-scattered electron image. It was also demonstrated that there were residual silicon (Si) rich regions on the porous surface by the SEM-EDX analysis, which indicated that constituents of AWGC still remained on the surface. On the other hand, the results of elementary analyses in the Si rich regions varied among the sections, which probably indicated that the extent of degradation and absorption of AWGC varied among the sections. AWGC was one of the bioactive ceramics and reported to have an ability to bond to bone earlier than hydroxyapatite (HA). In the present case, though massive osteolysis occurred with aggressive wear, it did not expand on the porous surface, and rather progressed along the smooth surface of the screws. Considering that there are many clinical studies reporting poor clinical results of HA-coated smooth cups, bioactive ceramic coating may function well and bring superior clinical results when combined with porous coated substrate. In our study, though the cause of massive polyethylene wear and intrapelvic giant osteolysis could not be revealed, the porous cup with AW-GC bottom coating was well fixed and gained bone-ingrowth at the porous surface under osteolytic conditions, which may demonstrate the long-term durability of this surface treatment

Aims: To describe the clinical characteristics, radiological classiþcation and management of 30 patients with severe pelvic injuries necessitating arterial embolization due to uncontrollable haemorrhage. Patients and methods: A prospective registration of patients admitted to our Level I- trauma hospital with pelvic fractures during a six year- period (1996-2002). Annually 168 patients had pelvic and acetabular fractures. The study group constituted of thirty of these patients where uncontrollable haemorrhage necessitated angiographic embolization of intrapelvic arteries. Results: 21 of the patients were male, on average 36 years old. All patients were subjected to high-energy traumas. Four had open pelvic fractures. One patient died in the initial phase due to multiple injuries. Average ISS score was 43,7. All patients had additional injuries, 50% were multitraumatized. Isolated sacral and acetabular fractures occurred in 5, the rest had pelvic ring injuries, 14 type B- and 11 type C-fractures. Deþnitive orthopaedic treatment was performed in 20 patients. There was a delay of 9 hours from admittance to embolization. Patients received 6,8 units prior to arrival at our unit, 15,4 units prior to embolization, 2 units 24-hours after embolization and 17,0 units from embolization to discharge. A total of 33, 9 units of erytrocytes was transfused at our unit. Time in angiography laboratory was 138 minutes. Branches of the internal iliac artery were affected in 28 patients, the superior gluteal artery being most frequently injured. Embolization was not effective in achieving haemostasis in 3. Conclusions: Pelvic fractures necessitating embolization due to uncontrollable haemorrhage are a result of high energy injuries and associated injuries are common. Arterial injuries associated with unstable pelvic haemorrhage are often due to injuries to branches of the internal iliac artery and early percutaneous embolization of these branches seems to control bleeding effectively

Purpose of the study: Acetabular dysplasia is a recognized cause of premature hip degeneration. With increasing use of arthroplasty, the role of conservative treatment can be debated. The purpose of this work was to describe technical advances achieved with Ganz triple periacetabular osteotomy and evaluate long-term results. Material and methods: This study included 32 dysplastic hips in 28 patients treated by Ganz triple osteotomy and assessed a mean 12 years follow-up (range 2 – 20 years). Mean age was 32 years (range 18–47). There were 24 women and four men. Hip joint measurements were made on preoperaive standard x-rays with complementary recentered views if needed as well as computed tomography (CT) to better distinguish progressive degeneration. For early patients, the iniail osteotomy involved three cuts (ilioischial, iliopubic, ilial) starting close to the acetabulum and performed via three approaches: sub coxofemoral, intrapelvic, extrapelvic. The first technical change involved osteotomy of the anterosuperior iliac spine and an oblique iliac cut farther from the acetabulum. Results: Mean preoperative angles were: 135° (121 to 150°) for CC’D, 23.2° (3 to 40°) for HTE, 8.4° (−14 to 22°) VCE, 11.3° (−26 to 32°) for VCA. The postoperative values were: 134.5° (121 to 150°) for CC’D, 9.5° (−9 to 20°) for HTE, 31.7° (14 to 60°) for VCE, 31.7° (10 to 48°) for VCA. Six patients required total hip arthroplasty on average four years later (range 2 – 9 years), including one patient with aseptic necrosis of the acetabulum. Discussion and Conclusion: This study confirms the usefulness of triple periacetabular osteotomy for conservative treatment of acetabular dysplasia. In light of our results, the following changes have been instituted:. all three cuts are performed via a single intra-pelvic approach;. For severe extreme dysplasia (Hip Study Group classification), a two-thirds triple osteotomy is performed (original technique). Currently the best indication appears to be a young patient (less than 30 years) with moderate to severe dysplasia, without intra-articular suffering and without any sign of early stage joint degradation

Introduction: Bilateral and transverse fractures of the first two sacral vertebrae with intrapelvic intrusion of the lumbo-sacral spine are very rare injuries. In most cases the lesion occurs after a fall from great height in a kyphotic position when landing. Today’s CT-scans in these mostly polytraumatized patients enable a clear diagnosis. In contrast conventional radiographs have a high risk to ignore these fractures. Operative treatment requires proper reduction and secure fixation which so far is not unrestricted possible using recommended techniques. For reduction lumbo-sacral distraction followed by lordotic extension is essential but difficult to obtain. Therefore we modified the lumbo-pelvic instrumentation to facilitate these requirements. Methods: In the last four years we treated three female patients (aged 27–68 years) as follows: Variable axis screws (VAS – Synthes®) were inserted in the L4 and L5 pedicles and connected with two connecting rods. An additional variable axis screw was inserted in each posterior iliac spine. These both screws were connected with a transverse connecting rod situated over the transverse fracture line. This rod was connected with the two upright rods using a rod-to-rod connector and forming a hinged joint. Due to the not tightened nut of the pedicle screws at that time it was possible to spread the lumbo-sacral fracture line. After tightening of the lumbar screws the upper part of the body was slightly elevated resulting in a lordotic extension in the hinged joint. Subsequently the hinged joint was locked (Video). Results: Postoperative CT scans revealed anatomic reduction and properly inserted implants in all cases. Follow-up was uneventful but a heparin related thrombopenia in one patient. Two patients were mobilized under full weight bearing within 4 and 10 days, respectively. In one cases this was not possible because of relevant foot fractures. Neurological deficits completely resolved in one patient within fourteen days and markedly diminished in another patient within months (persistent neuralgia). In one patient no neurological deficit existed. In all cases a complete hardware removal was done in 8 to 11 months. Conclusions: The presented procedure is suitable for the so-called jumper’s fractures and results in anatomic reduction of the displaced fractures and a secure stabilization. The described hinged joint offers effective lordotic extension which is the key point for reduction. Thus this configuration is a reduction as well a fixation device. Full weight bearing in an erect posture is immediately possible and clearly shorten the rehabilitation period

Objectives

The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.

This report reviews the long-term results of treating acetabula with unusually severe problems, such as pelvic discontinuity or major column loss after failed total hip arthroplasty (THA) and reconstruction problems. Loss of acetabular bone stock results from removal of bone during the original procedure, prosthetic failure, and osteolysis. In massive structural failure, the acetabular rim, quadrilateral plate, and associated columns become deficient. At worst, this may be combined with pelvic discontinuity and disruption of the ilium and ischium. Prosthetic protrusio may result from fixation loss and be associated with scarring of the femoral vessels, femoral nerve, ureter and bowel. A variety of implants has been used to in ace-tabular reconstruction. The results are often poor because of insufficient bone stock to support the implant. In a consecutive series of 251 THA revisions done between 1988 and 1996, 17 patients were treated for major pelvic column loss, pelvic discontinuity or both. In five patients, a posterolateral approach without trochanteric osteotomy was used. The extensile triradiate approach with ilioinguinal extension was used in 12 patients in whom severe prosthetic protrusio increased the risk of intrapelvic iatrogenic injury. A long anterior column pelvic plate was applied. A posteriorly placed AO 4.5-mm pelvic reconstruction plate with 10 to 12 holes was used in nine cases of pelvic discontinuity and in five cases of posterior column bone loss. This plate extended from the most inferior extent of the ischium across the wall of the posterior column to a point high on the ilium. Anterior column fixation was done in eight of nine cases of pelvic discontinuity and all three cases of anterior column deficiency. This called for an 8 to 12-hole 3.5-mm AO pelvic reconstruction plate that extended from the pubic symphysis across the pelvic rim. This spanned the anterior column defect, ranging from 4 cm to 8 cm, to the medial wall of the ilium. Bulk allograft was used in 16 of the 17 patients. The patient in whom allograft was not used had pelvic discontinuity following pelvic irradiation. Whole pelvic acetabular transplants were used in seven with severe bone loss or following resection for chondrosarcoma and the other for pigmented or villonodular synovitis. Posterior segmental acetabular allograft was used in two cases of posterior column absence. Femoral heads were used in two posterior column defects, three pelvic discontinuities with anterior column defect, and two anterior column defects. Acetabular components were cemented in six of seven whole bulk ace-tabular transplants, six of nine pelvic discontinuities and two anterior column defects. Cemented implants were classified as loose if there was a complete radiolucent line at the bone cement interface, measurable component migration or measurable change in position. Uncemented acetabular components were considered loose if component migration had occurred or screws had broken. Pelvic plates were considered loose if there was measurable migration or change in plate position or if fixation screws had backed out or broken. Radiographic union was considered present when bridging callus or trabecular bone was visible across the discontinuity site. Junctional healing was considered probable when radiographs did not show obvious signs of failure. Grafts were considered unhealed if there was obvious displacement, bone gaps or hardware breakage. Seven of the nine patients with pelvic discontinuity had late evidence of healing of the fracture and allograft consolidation. One underwent removal of the graft at three weeks after developing acute postoperative infection: early junctional healing of a whole bulk acetabular allograft required an osteotomy to break up the interface. Another patient, who underwent removal of the graft and implant at three months for chronic infection, had consolidation of a whole bulk ace-tabular allograft. One patient underwent revision of a pressfitted acetabular component at 60 months, and the pelvic discontinuity was solidly united. In a fourth patient, explored at 124 months for loosening of a cemented cup, there was near complete dissolution of the graft posterior acetabular wall and a loose posterior pelvic plate. In a patient with pelvic discontinuity after radiation therapy for uterine carcinoma, satisfactory healing of the pelvic discontinuity was confirmed at 32 months, when excisional arthroplasty for late chronic infection followed urinary sepsis. Seven patients had major column loss with severe cavitary defects. Consolidation of the allograft was noted in all seven within the first 12 months of follow-up. Revision (47%) was required for infection in three patients, implant loosening in four, and recurrent implant dislocation in one. The four loose cups were revised to a cemented all-polyethylene component. All four implants had been placed on less than 50% host bone. None of the four has required subsequent revision. Dislocation postoperatively occurred in eight patients. In six, the extensile triradiate approach had been used. This approach led to dislocation in 50%. The main reasons for using the extensile triradiate approach were to avoid catastrophic injuries by direct exposure of vital structures and to allow stable anterior column plate fixation. In that no neurovascular injuries occurred and stable durable allograft consolidation and healing of pelvic discontinuity took place, these goals were largely met. Three patients developed late sciatic palsy. In one, plaster immobilisation had possibly caused direct pressure over the fibular head and led to chronic peroneal palsy. The other two underwent additional exploration of the sciatic nerve for late entrapment caused by migration of screws from the posterior column plate. Two patients developed bladder infections postoperatively. Another developed superficial phlebitis of the lower leg. Acetabular revision for loosening was necessary in three of seven cementless implants, while only two of 10 cemented implants failed. The acetabular component should be cemented into the allograft when more than 50% of the prosthetic interface is non-viable. Virtually all graft material, including dense cortical grafts, may ultimately fail if used for implant fixation. Patients should be told about the inevitable risks. However, techniques used led to stable healing of the pelvic discontinuity in most cases. Long pelvic plates that securely stabilise the pelvis and allografts carefully opposed to host bone may explain the relative success in this series