Purpose. The effects of Acetabular Rim Osteophytes (ARO) in Total Hip Arthroplasty (THA), has not been quantified. During THA their presence and location is variable, and the effect on post-operative Range of Motion (ROM) is unknown. The purpose of this study was to evaluate the ROM of a modern hip implant in five cadaver models utilizing computerized virtual surgery, and to analyze the effect of AROs given their location on the acetabulum, and position of the prosthesis during motion. Method. CT scans of five cadaveric pelvises and femurs were used to create 3-D Models. Surgery, using virtual Stryker components was then performed to restore the natural anatomic offset and leg length. ROM to impingement was evaluated for each model in eight vectors: flexion/extension, internal/external rotation, abduction/adduction, and 90 degrees of flexion with internal/external rotation. An Osteophyte Impingement Model was then created by elevating the natural acetabular rim by 10 millimeters circumferentially in each virtual cadaver pelvis. Using the same THA components, ROM was then evaluated in this pelvic model and compared to the cadaveric models. Results. ROM in the Osteophyte Impingement Model yielded a statistically significant decrease in five of the eight vectors tested, when compared to the Cadaveric Model: Flexion, Extension, External Rotation, Flexion to 90 degrees with Internal Rotation, and Flexion to 90 degrees with External Rotation. Only 3 of these 5 vectors were within normal human physiological ROM: Flexion, External Rotation, and Flexion to 90 degrees with Internal Rotation. The osteophyte model yielded a decrease in absolute ROM in the following: Flexion to 101 vs 113 degrees (p= 0.03), External Rotation to 30.4 vs 49.5 degrees (p= 0.01), and Flexion to 90 degrees with Internal Rotation 16.7 vs 31.6 degrees (p=0.01). When mapped on the acetabulum of right-sided hip, with the 12 o'clock position as the superior pole of the acetabulum, impingement on the osteophyte was noted at the following locations: with Flexion, and Flexion to 90 degrees with Internal Rotation, impinged was noted between 1 and 2 o'clock on the acetabulum. In External Rotation impinged occurred between 7 and 8 o'clock on the acetabulum. Conclusion. This study showed that a 10 millimeter osteophyte can potentially decrease range of motion and lead to impingement in THA in certain planes of motions: Flexion, External Rotation and Flexion to 90 degrees with Internal Rotation. The location of this impingement is between the 1 and 2 o'clock in Flexion, and Flexion to 90 degrees with Internal Rotation. In External Rotation, the impingement will occur between the 7 and 8 o'clock. The above applies to a right-sided acetabulum, the left side will demonstrate the mirror image of this impingement: Between the 10 to 11 o'clock, and 4 to 5 o'clock positions respectively. Osteophytes 10 millimeters or more in height at these positions should be carefully evaluated intra-operatively and removed safely if possible

Introduction

Retrieval investigations have shown that cracking or rim failure of polyethylene hip liners may occur at the superior aspect of the liner, in the area that engages the locking ring of the shell¹. Failure could occur due to acetabular liner/stem impingement and/or improper cup position. Other contributing factors may include high body mass index, patient activity and design characteristics such as polyethylene material properties, thin liner rim geometry and cup rim design. Currently no standard multi-axis simulator methodology exists for high angle rim fatigue testing, although tests have been developed using static uniaxial load frames². The purpose of this study was to develop a technique to create a clinically relevant rim crack/fracture event on a 4-axis hip simulator, and to understand the contribution of component design and loading and motion parameters.

INTRODUCTION

Within total hip replacement, articulation of the femoral head near the rim of the acetabular liner creates undesirable conditions leading to a propensity for dislocation[1], increased contact stresses[2], increased load and torque imparted on the acetabular component[3], and increased wear[4]. Propensity for rim loading is affected by prosthesis placement, as well as the kinematics and loading of the patient. The present study investigates these effects.

Femoroacetabular impingement (FAI) deformities are a potential precursor to hip osteoarthritis and an important contributor to non-arthritic hip pain. Some hips with FAI deformities develop symptoms of pain in the hip and groin that are primarily position related. The reason for pain generation in these hips is unclear. Understanding potential impingement mechanisms in FAI hips will help us understand pain generation. Impingement between the femoral head-neck contour and acetabular rim has been proposed as a pathomechanism in FAI hips. This proposed pathomechanism has not been quantified with direct measurements in physiological postures. Research question: Is femoroacetabular clearance different in symptomatic FAI hips compared to asymptomatic FAI and control hips in sitting flexion, adduction, and internal rotation (FADIR) and squatting postures?. We recruited 33 participants: 9 with symptomatic FAI, 13 with asymptomatic FAI, and 11 controls from the Investigation of Mobility, Physical Activity, and Knowledge Translation in Hip Pain (IMAKT-HIP) cohort. We scanned each participant's study hip in sitting FADIR and squatting postures using an upright open MRI scanner (MROpen, Paramed, Genoa, Italy). We quantified femoroacetabular clearance in sitting FADIR and squatting using beta angle measurements which have been shown to be a reliable surrogate for acetabular rim pressures. We chose sitting FADIR and squatting because they represent, respectively, passive and active maneuvers that involve high flexion combined with internal/external rotation and adduction/abduction, which are thought to provoke impingement. In the squatting posture, the symptomatic FAI group had a significantly smaller minimum beta angle (−4.6º±15.2º) than the asymptomatic FAI (12.5º ±13.2º) (P= 0.018) and control groups (19.8º ±8.6º) (P=0.001). In the sitting FADIR posture, both symptomatic and asymptomatic FAI groups had significantly smaller beta angles (−9.3º ±14º [P=0.010] and −3.9º ±9.7º [P=0.028], respectively) than the control group (5.7º ±5.7º). Our results show loss of clearance between the femoral head-neck contour and acetabular rim (negative beta angle) occurred in symptomatic FAI hips in sitting FADIR and squatting. We did not observe loss of clearance in the asymptomatic FAI group for squatting, while we did observe loss of clearance for this group in sitting FADIR. These differences may be due to accommodation mechanisms in the active, squatting posture that are not present in the passive, sitting FADIR posture. Our results support the hypothesis that impingement between the femoral head-neck contour and acetabular rim is a pathomechanism in FAI hips leading to pain generation

Introduction. Malalignment of cup in total hip replacement (THR) increases rates of dislocation, impingement, acetabular migration, pelvic osteolysis, leg length discrepancy and polyethylene wear. Many surgeons orientate the cup in the same anteversion and inclination as the inherent anatomy of the acetabulum. The transverse acetabular ligament (TAL) and acetabular rim can be used as a reference. No study has yet defined the exact orientation of the TAL. The aim of this study was to describe the orientation of acetabular margin and compare it with TAL orientation. Materials and Methods. Sixty eight hips with osteoarthritis undergoing THR with computer navigation were investigated. Anterior pelvic plane was registered using anterior superior iliac spines and pubic symphysis. Orientation of the natural acetabulum as defined by the acetabular rim with any osteophytes excised was measured. Since TAL is a rectangular band like structure, three recordings were done for each corresponding to the outer middle and inner margin of the band. All the readings were given by software as radiological anteversion and inclination. Results. All patients were Caucasian, 30 males and 38 females with mean age 67.4 years (SD 9.6) and BMI 30 (SD 5). Inclination was 54.7(SD7.9), 53(SD6.9), 47.5(SD6.8), 42.1(6.7) and anteversion 5.7(SD8.7), 5.4(SD9.9), 9.7(SD9.6), 13.5(SD9.4) for acetabular rim, outer, middle and inner borders of the TAL respectively. For inclination TAL outer border was not significantly different to acetabular rim (mean difference 1.7°, 95%CIs −0.2° to 3.6°, p=0.082) but the middle (mean difference 7.3°, 95%CIs 5.6° to 8.9°) and inner (mean difference 12.6°, 95%CIs 11.0° to 14.2°) borders were (both p<0.001). For anteversion TAL outer border was not significantly different to acetabular rim (mean difference 0.2°, 95%CIs −1.3° to 1.8°, p=0.758) but the middle and inner borders were (mean difference −4.0° 95%CIs −5.5° to −2.5° and −7.9°, 95%CIs −9.6° to −6.1° respectively, both p<0.001). Anteversion for males was significantly lower than females with a mean difference of 4 for the rim and 5.7, 4.8 and 5.1 for the TAL outer, middle and inner margins respectively. Overall 57,53,40&26 of 68 patients had a combined inclination and anteversion of the native acetabulum that fell outside the “safe zone” of Lewinnek with acetabular rim, outer, middle and inner margins of TAL respectively. Compared to Lewinnek safe zones for inclination TAL inner margin performed best with 14.7% outliers and acetabular rim performed worst with 72% outliers. For anteversion TAL inner margin performed best with 25% outliers while outer margin of TAL performed worst with 39.7% outliers. Conclusion. Orientation of the acetabulum differs a lot between individuals. The TAL middle and inner margins differ in orientation as compared to acetabular rim and TAL outer border. TAL inner border provides the best bet for placing the cup in Lewinnek's safe zone. When using the natural acetabular orientation or TAL as a guide, it should not be assumed this will orientate the cup in Lewinnek safe zone although the validity of safe zones itself is questionable. Variation between patients must be taken into account and the difference between males and females, particularly in terms of anteversion, should be considered

INTRODUCTION. Mal-positioning of the acetabular component in total hip replacement (THR) could lead to edge loading, accelerated component wear, impingement and dislocation [1,2]. In order to achieve a successful position for the acetabular component, the assessment of the acetabular orientation with reference to different coordinate systems is important [3]. The aims of the present study were to establish a pelvic coordinate system and a global body coordinate system, and to assess the acetabular orientations of natural hips with reference to the two coordinate systems. METHODS. Three-dimensional (3D) computed tomographic (CT) images of 56 subjects (28 males and 28 females) lying supine were obtained from a public image archive (Cancer Image Archive, website: . www.cancerimagingarchive.net. ). 3D solid models of pelvis and spine were generated from the CT images. Two coordinate systems, pelvic and global body coordinate systems, were established. The pelvic coordinate system was established based on four bony landmarks on the pelvis: the bilateral anterior superior iliac spines (RASIS and LASIS) and the bilateral pubic tubercles (RPT and LPT). The global body coordinate system was generated based on the bony landmarks on the spine: the geometric centers of five lumbar vertebrae bodies and the most dorsal points of five corresponding spinous processes, as well as the anterior sacral promontory (Fig 1a and 1b). The acetabular rim plane was obtained by fitting a set of point along the acetabular rim to a plane using least squares method. The acetabular orientation was defined as the three coordinate components (x-, y- and z- components) of the unit normal vector of the acetabular rim plane in the two coordinate systems (Fig. 1c). RESULTS. Statistically significant differences of y- and z- components of the unit normal vector of the acetabular rim plane were calculated in the two coordinate systems (p<0.05). However, no significant difference of x- components was found (p=0.22) (Fig. 2). The differences of y- and z- components of the unit normal vector between the two coordinate system measurements were positive for most subjects. In addition, the differences and their standard deviations were larger for females compared to those for males (Fig. 3). DISCUSSION. Significantly different acetabular orientations were measured in the two coordinate systems, with larger variations in the global body coordinate system. The statistical analysis indicates that the different orientations measured in the two coordinate systems are primarily attributed to the pelvic tilt in the sagittal plane. The results also indicates that there was a trend of forward inclination of pelvis for most subjects considered in the present study and that the females generally have larger forward inclination and greater variation of pelvic tilt compared to males. SIGNIFICANCE. The study suggested that the consideration of pelvic tilt in THR placement is necessarily required in order to achieve a successful positioning of THR component with respect to the biomechanical axis of the body

Introduction. Optimal orientation of the acetabular cup is vital issue not only for primary but revision total hip arthroplasty (THA). Especially in revision THA, malorientation of the cup is likely to occur because anatomical landmark around acetabular rim often disappeared by the osteolytic bony destruction or the process of cup removal. As a consequence, higher dislocation rate and accelerated wear of bearing surface compared with primary THA, which affect the outcome of revision THA, are concerned. On the other hand, computer aided navigation system has been developed in recent years because of substantial errors of manual technique in cup placement even with experienced surgeon. The purpose of this study was to evaluate the accuracy of the cup orientation in revision cementless THA using CT based navigation system. Materials and Methods. Thirteen patients who underwent revision cementless THA with CT based navigation system (Stryker Japan) were employed for this study. The average age at surgery was 64 years (range, 45–78 years, 3 men and 11 women). Primary surgery was cementless THA in 4 and BHA in 9 hips. Disorder which led to revision THA was loosening of the cup, massive retroacetabular osteolysis, and severe proximal migration of bipolar outer head. In most cases, acetabular rim was not conserved. After removal of the cup or outer head, we revised acetabular components with cementless hemispherical TriAD cups (Stryker Japan) using direct lateral approach in lateral decubitus position. For all the patients, post-operative CT scans were performed and the cup inclination and anteversion angle were measured using 3D image-processing software (Stryker, Japan). The difference between the intra-operative target angle and the angle measured from the post-operative CT image were calculated. Results. The average cup orientation measured by postoperative CT was 39.6±3.8° (range, 34–46°) in inclination and 20.5±5.0° (range, 17–29°) in anteversion. The accuracy (calculated as a mean of the absolute difference between intra-operative target angle and post-operative CT angle) of inclination and anteversion angle were 2.0 ± 1.8° (range, 0–5°) and 2.3±2.2° (range, 0–5°), respectively. The accuracy was within 5° in all cases and there was no postoperative dislocation. Discussion. Our study showed that CT based navigation system provided accurate orientation of the acetabular component even in revision cementless THA as well as in primary THA. Although the basic process of the navigation system in revision THA is same as primary THA, several pitfalls exist. Metal artifact from preexisting hardware such as screws, cup, and head-neck of the stem makes it difficult to do preoperative planning, intraoperative point matching, and surface registration. We have to pay maximum attention to avoid including metal artifact especially around acetabular rim when editing surface of the pelvis at preoperative planning, and also avoid pointing the area around acetabular rim when doing surface registration intraoperatively

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Three separate patterns of augment placement have been utilised in our practice since the development of these implants a decade ago: Type 1 - augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely, but the need for structural bone is avoided. From 2000 through 2007, porous tantalum acetabular augments were used very selectively in 85 revision THA procedures out of total of the 1,789 revision hip cases performed at our institution. All cases had associated massive acetabular deficiency precluding stable mechanical support for a cup alone. Fifty-eight hips had complete radiographic and clinical follow at minimum 5 years. The majority of patients had either Paprosky type 3A defects (28/58, 48%) or 3B defects (22/58, 38%). Ten out of 58 had pre-operative pelvic discontinuities. Three separate patterns of augment placement were utilised: Type 1 - augment screwed onto the superolateral acetabular rim (21%), Type 2 – augment fixed to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect (34%), and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial medial wall (45%). At 5 years, 2/58 (3%) were revised for aseptic loosening and another 6/58 demonstrated incomplete radiolucencies between the acetabular shell and zone 3. One of the revised cups and 5 of 6 of the cups with radiolucencies had an associated pelvic discontinuity. Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Smaller patients are more likely to require this approach as reaming away defects to allow insertion of a jumbo cup is more difficult with a smaller AP dimension to the acetabular columns and less local bone for implant support. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

Introduction. In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions. Methods. In our classification system, the acetabulum is first divided into 6 zones as described by Ilizalithurri VM et al [Arthroscopy 24(5) 534-539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 – normal articular cartilage lesions; Grade 1 softening or wave sign; Grade 2 - cleavage lesion; Grade 3 - delamination and Grade 4 –exposed bone. The site of the lesion is further typed as A, B or C based on whether the lesion is 1/3 distance from acetabular rim to cotyloid fossa, 1/3 to 2/3 distance from acetabular rim to cotyloid fossa and > 2/3 distance from acetabular rim to cotyloid fossa. For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics. Results. We observed a high inter-observer reliability of the classification system with a kappa coefficient of 0.89 (range 0.78 to 0.91) and high intra-observer reliability with a kappa coefficient of 0.91 (range 0.89 to 0.96). In conclusion we have developed a simple reproducible classification system for acetabular cartilage lesions seen at hip arthroscopy

Background. Femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in sportspersons. In femoro-acetabular impingement abnormal contact occurs between the proximal femur and the acetabular rim during terminal motion of the hip as a result of abnormal morphologic features involving the proximal femur (CAM) or the acetabulum (Pincer) or both (Mixed) leading to lesions of acetabular labrum and the adjacent acetabular cartilage. It is likely that it is a cause of early hip degeneration. Ganz developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic technique to reshape the proximal femur and remove prominent antero-superior acetabular rim thereby relieving impingement. Methods. Twelve patients presented with mechanical hip symptoms and had demonstrable cam-type (eight patients) or mixed (four patients) FAI on radially-reconstructed MR arthrography, were treated by arthroscopic femoral osteochondroplasty and acetabular rim resection if indicated. All patients were competing at the highest level in their respective sport (football, rugby and athletics). All patients were followed up and post-operative Non-Arthritic Hip Scores (NAHS, maximum possible score 100) compared with pre-operative NAHS. Results. There were no complications. All patients were asked to be partially weight-bearing with crutches for four weeks and most returned to training within six weeks. All of them returned to competitive sports by 14 weeks. Symptoms improved in all patients, with mean NAHS improving from 72 pre-operatively to 97 at 3 months. Conclusion. Arthroscopic reshaping to relieve FAI is feasible, safe and reliable. However it is technically difficult and time-consuming. The results are comparable to open dislocation and debridement, but avoid the prolonged disability and the complications associated with trochanteric flip osteotomy. This is important in elite athletes as they can return to training and competitive sports much quicker with less morbidity

Introduction. Geometric variations of the hip joint can give rise to repeated abnormal contact between the femur and acetabular rim, resulting in cartilage and labrum damage. Population-based geometric parameterisation can facilitate the flexible and automated in silico generation of a range of clinically relevant hip geometries, allowing the position and size of cams to be defined precisely in three dimensions. This is advantageous compared to alpha angles, which are unreliable for stratifying populations by cam type. Alpha angles provide an indication of cam size in a single two-dimensional view, and high alpha angles have been observed in asymptomatic individuals. Parametric geometries can be developed into finite element models to assess the potential effects of morphological variations in bone on soft tissue strains. The aim of this study was to demonstrate the capabilities of our parameterisation research tool by assessing impingement severity resulting from a range of parametrically varied femoral and acetabular geometries. Methods. Custom made MATLAB (MathWorks) and Python codes. [1]. were used to generate bone surfaces, which were developed into finite element models in Abaqus (SIMULIA). Parametric femoral surfaces were defined by a spherical proximal head and ellipse sections through the neck/cam region. This method produced surfaces that were well fitted to bone geometry segmented from CT scans of cam patients and capable of producing trends in results similar to those found using segmented models. A simplified spherical geometry, including the labrum and acetabular cartilage, represented the acetabulum. Femoral parameters were adjusted to define relevant variations in cam size and position. Two radii (small and large cams) and two positions (anterior and superior cams) were defined resulting in four models. Alpha angles of these parametric femurs were measured in an anterior-posterior view and a cross-table lateral view using ImageJ (NIH). A further model was developed using a femur with a medium cam size and position, and the level of acetabular coverage and labrum length were varied. Bones were modelled as rigid bodies and soft tissues were modelled as transversely isotropic linearly elastic materials. With the acetabulum fully constrained in all cases, the femurs were constrained in translation and rotated to simulate flexion followed by internal rotation to cause impingement against the labrum. Results and Discussion. Models generated using the parametric approach showed that potential for tissue damage, indicated through local strain, was not predicted by measured alpha angle, but resulted from cam extent and position as defined by the ellipses. When variations were made to the acetabular rim, an increase in bone coverage had the greatest effect on impingement severity, indicated by strain in the cartilage labral-junction. An increase in labral length increased labral displacement, but had less effect on cartilage-labral strain. Patient specific models currently require full image segmentation, but there is potential to further develop these parametric methods to assess likely impingement severity based on a series of measures of the neck and acetabulum when three-dimensional imaging of patients is available

Standard evaluation and diagnosis of pincer-type femoroacetabular impingment (FAI) relies on anteroposterior (AP) radiographs, clinical evaluation, and/or magnetic resonance imaging (MRI). However, the current evaluation techniques do not offer a method for accurately defining the amount of acetabular rim overcoverage in pincer-type FAI. Several studies have remarked on the particular problems with radiographic evaluation, including beam divergence, difficulty with defining the acetabular rim, and pelvic tilt. Some studies have proposed methods to mitigate these issues; however, radiographic analysis still relies on projected and distorted images, making it difficult to acquire an accurate quantitative estimate of the amount of crossover. We propose a technique that utilises computed tomography (CT) data to accurately quantify the amount of acetabular crossover while accounting for known diagnostic problems, specifically pelvic tilt. This work describes a novel method that utilises CT data of a patient's afflicted hip joint region to assess the amount of acetabular overcoverage due to pincer deformity. The amount of overcoverage was assessed using a spline curve defined through the segmentation of the acetabular rim from CT data. To mitigate pelvic tilt, the user selected points to define both the pubic symphysis and the promontory in a lateral digitally reconstructed radiograph. The algorithm corrected the pelvic tilt by adjusting to a defined neutral position (in our case, a 60°), and the user adjusted for slight rotation differences ensuring there was a vertical line connecting the symphysis and the sacrococcygeal joint. After successfully repositioning the pelvis, the algorithm computed the amount of acetabular overcoverage. The algorithm identified the superolateral point of the acetabulum and the most inferior points of the anterior and posterior rim. A line, the mid-acetabular axis, was constructed between the superolateral point and the midpoint of the most inferior points on the anterior and posterior rims; the mid-acetabular axis was extended anterior and posterior to create a plane. Crossover occurred when the anterior rim of the acetabulum intersected this plane. If an intersection occurred, the algorithm measured the length of the mid-acetabular axis, and the length and width of the section representing overcoverage. These points were then projected onto anteroposterior DRRs and again measured to generate a basis of comparison. We tested our method on four cadaveric specimens to analyze the relationship between radiographic assessment and our technique. We simulated varying degrees of impingement in the cadavers by increasing the amount of pelvic tilt and defining that as the neutral position for a given trial. Moreover, we assessed interobserver variability in repositioning the pelvis as to the effect this would have on the final measurement of crossover length and width. The software achieved consistent, quantitative measurements of the amount of acetabular overcoverage due to pincer deformity. When compared with conventional radiographic measurements for crossover, there was a significant different between the two modalities. Specifically, both the ratios of crossover length to acetabular length and crossover width to crossover length were less using the CT-based approach (p < 0.001). Moreover, there were no significant differences between observers using our approach. The proposed technique can form the basis for a new way to diagnosis and measure acetabular overcoverage resulting in pincer impingement. This computational method can help clinicians to accurately correct for tilt and rotation, and subsequently provide consistent, quantitative measurement of acetabular overcoverage

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft, avoiding the potential for later graft resorption and the resulting loss of mechanical support that can follow. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Three separate patterns of augment placement have been utilised in our practice since the development of these implants a decade ago: Type 1 – augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed (with cement) to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible though in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely, but the need for structural bone is avoided. Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Smaller (often female) patients are more likely to require this approach as reaming away defects to allow insertion of a jumbo cup is more difficult in small patients with a smaller AP dimension to the acetabular columns and less local bone for implant support. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

To assess the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications. Three databases (PubMed, Ovid MEDLINE, EMBASE) were searched, and two reviewers independently screened the resulting literature. Methodological quality of all included papers was assessed using Methodological Index for Non-Randomized Studies criteria and the Cochrane Risk of Bias Assessment tool. Results are presented in a narrative summary fashion using descriptive statistics. Fourteen studies were included in this review. Four case series (491 patients, 56.6% female, mean age 33.9 years), nine controlled cadaveric/laboratory studies (111 cadaveric hips and 12 sawbones, 42.2% female, mean age 60.0 years), and one randomized controlled trial (37 hips, 55.6% female, mean age 34.2 years) were included. Anterior cortical perforation by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (three to four o'clock) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The mid-anterior (MA) and distal anterolateral (DALA) portals were used successfully, with some studies reporting difficulty placing anchors at anterior locations via the DALA portal. Small-diameter (< 1 .8-mm) suture anchors had a lower in vivo incidence of articular perforation with similar stability and pull-out strength in biomechanical studies. Suture anchors at anterior acetabular rim positions (3–4 o'clock) should be inserted with caution. Large-diameter (>2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (< 1 .8-mm) all-suture suture anchors (ASAs) from 10° to 20° using curved suture anchor drill guides, may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation

Major bone loss involving the acetabulum can be seen during revision THA due to component loosening, migration or osteolysis and can also occur as a sequela of infected THA. Uncemented porous ingrowth components can be used for reconstruction of the vast majority of revision cases, where smaller segmental or cavitary defects are typically present. But when stable structural support on host bone is lacking, highly porous metal acetabular augments have been described as an alternative to large structural allograft, avoiding the potential for later graft resorption and the resulting loss of mechanical support that can follow. The fundamental concept behind these acetabular augments is the provision of critical additional fixation, structural support and increased contact area against host bone over the weeks following surgery while the desired ingrowth into porous implant surfaces is occurring. Technique: Three separate patterns of augment placement have been utilised in our practice since the development of these implants: Type 1 - augment screwed onto the superolateral acetabular rim in a “flying buttress” configuration for treatment of a segmental rim defect, Type 2 – augment placed superiorly against host and then fixed (with cement) to the acetabular component adjacent to the cup to fill a mainly elliptical cavitary defect, and Type 3 – augment(s) placed medial to the cup to fill a protrusio type cavitary or combined cavitary segmental defect of the superomedial or medial wall, and allow peripheral cup placement against the still intact acetabular rim. In all cases the acetabular component and augment interface is fixed together with cement, with care to prevent any cement extrusion between any implant and the bone. When possible, we now prefer to place the acetabular component first and fix it provisionally with 2 or more screws, and then place the augments second as this is technically quicker and easier. This order of insertion is only possible though in type 1 and a few select type 2 cases. Type 3 cases always require placement of one or more augments first, before cup insertion. Supplemental cancellous bone graft is used routinely. Results: From 2000 through 2007, porous tantalum acetabular augments were used very selectively in 85 revision THA procedures out of total of 1,789 revision hip cases performed at our institution in that time frame. All cases had associated massive acetabular deficiency precluding stable mechanical support for a cup alone. Fifty-eight hips had complete radiographic as well as clinical follow at minimum 5 years. The majority of patients had either Paprosky type 3A defects (28/58, 48%) or 3B defects (22/58, 38%). Ten out of 58 had pre-operative pelvic discontinuities. At 5 years, 2/58 (3%) were revised for aseptic loosening and another 6/58 demonstrated incomplete radiolucencies between the acetabular shell and zone 3. One of the revised cups and 5 of 6 of the cups with radiolucencies had an associated pelvic discontinuity. Summary: Highly porous metal acetabular augments are an infrequently needed, but extremely valuable, versatile and reliable adjunctive fixation method for use with uncemented acetabular components during complex revision THA associated with major bone deficiency. Intermediate term durability and apparent radiographic incorporation has been very good despite the complex reconstructions originally required. This technique can allow the avoidance of structural bone grafting for even the most massive of bone defect problems, but additional followup is needed to see how durable these encouraging results are over the longer term

HXLPE acetabular liners were introduced to reduce wear-related complications in THA. However, post-irradiation thermal free radical stabilization can compromise mechanical properties, leave oxidation-prone residual free radicals, or both. Reports of mechanical failure of HXLPE acetabular liner rims raise concerns about thermal free radical stabilization and in vivo oxidization on implant properties. The purpose of this study is to explore the differences in the mechanical, physical and chemical properties of HXLPE acetabular liner rims after extended time in vivo between liners manufactured with different thermal free radical stabilization techniques. Remelted, single annealed and sequentially annealed retrieved HXLPE acetabular liners with in vivo times greater than 4.5 years were obtained from our implant retrieval laboratory. All retrieved liners underwent an identical sanitation and storage protocol. For mechanical testing, a total of 55 explants and 13 control liners were tested. Explant in vivo time ranged from 4.6 – 14 years and ex vivo time ranged from 0 – 11.6 years. Rim mechanical properties were tested by microindentation hardness testing using a Micromet II Vickers microhardness tester following ASTM standards. A subset of 16 explants with ex vivo time under one year along with five control liners were assessed for oxidation by FTIR, crystallinity by Raman spectroscopy, and evidence of microcracking by SEM. No significant difference in in vivo or ex vivo was found between thermal stabilization groups in either set of explants studied. In the mechanically tested explants, there was no significant correlation between in vivo time and Vickers hardness in any thermal stabilization group. A significant correlation was found between ex vivo time and hardness in remelted liners (r=.520, p = .011), but not in either annealed cohort. ANCOVA with ex vivo time as a covariate found a significant difference in hardness between the thermal free radical stabilization groups (p 0.1) was found in retrieved remelted (25%), single annealed (100%) and sequentially annealed (75%) liner rims. Crystallinity was increased in the subsurface region relative to control liners for both annealed, but not remelted, liner rims. Hardness was increased in oxidized rims for both annealed cohorts but not in the remelted cohort. Microcracking was only found along the surface of one unoxidized remelted liner rim. Mechanical properties were reduced at baseline and worsened after in vivo time for remelted HXLPE liner rims. Rim oxidation was detected in all groups. Oxidation was associated with increased crystallinity and hardness in annealed cohorts, but not remelted liners. Increased crystallinity and oxidation do not appear to be directly causing the worsened mechanical behavior of remelted HXLPE liner rims after extended in vivo time

Optimal alignment of the acetabular cup component is crucial for good outcome of total hip arthroplasty [THA]. Increased accuracy of implant positioning may improve clinical outcome. To achieve this, patient specific instrumentation was developed. A patient-specific guide manufactured by 3D printing was designed to aid in positioning of the cup component with a pre-operatively defined anteversion and inclination angle. The guide fits perfectly on the acetabular rim. An alignment K-wire in a pre-operatively planned orientation is used as visual reference during cup implantation. Accuracy of the device was tested on 6 cadaveric specimens. During the experiment, cadavers were positioned for a THA procedure using a posterolateral approach. A normal-sized incision was made and approach used as in the conventional surgical procedure. The PSI was subsequently fitted onto the acetabular rim and secured into its unique position due to its patient specific design. The metallic pin was placed in a drill hole of the PSI. Post-operative CT image data of each acetabulum with the placed pin were transferred to Mimics and the 3D model was registered to the pre-operative one. The anteversion and inclination of the placed pin was calculated and compared to the pre-operatively planned orientation. The absolute difference in degrees was evaluated. A secondary test was carried out to assess the error during impaction while observing the alignment K-wire as a visual reference. In a laboratory setting, error during impaction with a visual reference of the K-wire was measured. Deviation from planning showed to be on average 1.04° for anteversion and 2.19° for inclination. By visually aligning the impactor with this alignment K-wire, the surgeon may achieve cup placement as pre-operatively planned. The effect of the visual alignment itself was also evaluated in a separate test-rig showing minimal deviations in the same range. The alignment validation test resulted in an average deviation of 1.2° for inclination and 1.4° for anteversion between the metallic alignment K-wire used as visual reference and the metallic K-wire impacted by the test subjects. The inter-user variability was 0.9° and 0.8° for anteversion and inclination respectively. The intra-user variability was 1.6° and 1.0° for anteversion and inclination respectively. Tests per test subject were conducted in a consecutive manner. We investigated the accuracy of two factors affecting accuracy in the cup insertion with PSI, i.e. accuracies of the errors of bony fitting and cup impaction. Since the accuracy of the major contributing factors to the overall accuracy of PSI for cup insertion with linear visual reference of a metallic K-wire was within the acceptable range of 2 to 3 degrees, we state that the PSI we have designed assists to achieve the preoperatively planned orientation of the cup and as such leads to the reduction of outliers in cup orientation. This acetabular cup orientation guide can transfer the pre-operative plan to the operating room

Introduction. Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique. Methods. Functional outcome was measured in hips with over 12 month follow-up using the Oxford hip and McCarthy non-arthritic hip scores pre- and post-operatively. Results. From March 2003 to December 2005, 79 hips underwent surgical hip dislocation for treatment of FAI. Ten were skeletally immature and excluded. In 16 hips, grade 4 osteoarthritis was present in greater than 10 × 10mm regions after reshaping of the abnormal anatomy. In these cases, hip resurfacing was performed. Of the 53 hips preserved (average age 37(17-65)), 35 had the labrum detached, debrided and reattached using bone anchors, 32 underwent recession of the acetabular rim at the site of impingement, 21 had chondral ‘carpet’ flaps debrided, 5 had removal of medial osteophytes, 7 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. In 5 hips osteoarthritis progressed requiring hip resurfacing at an average of 8 months. Oxford Hip Score improved from an average 32 (range 13-59) to 23 (12-45) and McCarthy hip score from 50 (19-76) to 63 (28-79) in the preserved hips at an average 20 months following surgery (range 12-38 months). Conclusion. The early results of surgical hip dislocation are encouraging. The open procedure has distinct advantages compared to arthroscopy enabling a wider range of lesions to be treated. Careful patient selection is important in order to exclude patients with hip osteoarthritis. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

Introduction. Highly crosslinked, ultra-high molecular weight polyethylene (HXLPE) acetabular liners inherently have a risk of fatigue failure associated with femoral neck impingement. One of the potential reasons for liner failure was reported as crosslinking formulations of polyethylene, increasing the brittleness and structural rigidity. In addition, the acetabular component designs greatly affect the mechanical loading scenario, such as the offset (lateralized) liners with protruded rim above the metal shells, which commonly induce a weak resistance to rim impingement. The purpose of the present study was to compare the influence of the liner offset length on the impingement resistance in the annealed (first generation) and vitamin E-blended (second-generation) HXLPE liners with a commercial design. Materials and Methods. The materials tested were the 95-kGy irradiated annealed GUR1020, and the 300-kGy irradiated vitamin E-blended GUR1050 HXLPE offset liners, which were referred to as “20_95” and “50E_300”, respectively. These liners had 2, 3, 4-mm rim offset, 2.45-mm rim thickness, and 36-mm internal diameter. Their rims were protruded above the metal rim at 2, 3, 4mm. Rim impingement testing was performed using an electrodynamic axial-torsional machine. The cyclic impingement load of 25–250N was applied on the rims through the necks of the femoral stems at 1Hz. The rotational torque was simultaneously generated by swinging the stem necks on the rims at 1Hz and its rotational angle was set at the range of 0–10˚. The percent crystallinity was analyzed on the as-received (intact) and impinged HXLPE acetabular rims by confocal Raman microspectroscopy. Results. The number of cycles to failure was dependent on the offset length (2, 3, 4-mm) in 20_95 and 50E_300 liners. Our results showed that the shorter the rim offset, the shorter the number of cycles to failure. In both HXLPEs, accumulation of impingement damages significantly decreased crystallinity in their near-surfaces, indicating the occurrence of crystallographic breakdown. In each offset length tested, the fracture always occurred much earlier in 50E_300 than 20_95. However, the magnitudes of the microstructural changes at the time of failure were much less in 50E_300 than 20_95. Conclusions. Although it is known that vitamin E blend into HXLPE can improve the fatigue resistance of HXLPE, the impingement resistance of 50E_300 was lower than vitamin-E free 20_95, indicating a larger negative contribution of high-dose radiation (300kGy) over a positive contribution of the vitamin E blend in 50E_300. Our results implied that the reduction of the protruded rim length in the offset liners may increase the neck-rim contact stresses at the time of impingement, causing a decrease in the fatigue durability. Therefore, if HXLPE offset liner is used, surgeons should take special care in maximizing the volume of the protruded lip section

A well-fixed uncemented acetabular component is most commonly removed for chronic infection, malposition with recurrent dislocation, and osteolysis. However, other cups may have to be removed for a broken locking mechanism, a bad “track record”, and for metal-on-metal articulation problems. Modern uncemented acetabular components are hemispheres which have 3-dimensional ingrowth patterns. Coatings include titanium or cobalt-chromium alloy beads, mesh, and now the so-called “enhanced coatings”, such as tantalum trabecular metal, various highly porous titanium metals, and 3-D printed metal coatings. These usually pose a problem for safe removal without fracture of the pelvis or creation of notable bone deficiency. Preoperative planning is essential for safe and efficient removal of these well-fixed components. Strongly consider getting the operative report, component “stickers”, and contacting the implant manufacturer for information. There should a preoperative check list of the equipment and trial implants needed, including various screwdrivers, trial liners, and a chisel system. The first step in component removal is excellent 360-degree exposure of the acetabular rim, and this can be accomplished by several approaches. Then, the acetabular polyethylene liner is removed; a liner that is cemented into a porous shell can be “reamed out” using a specific device. Following this, any central or peripheral screws are removed; broken or stripped screw heads add an additional challenge. A trial acetabular liner is placed, and an acetabular curved chisel system is used. There are two manufacturers of this type of system. Both require the known outer acetabular diameter and the inner diameter of the trial liner. With the curved chisel system and patience, well-fixed components can be safely removed, and the size of the next acetabular component to be implanted is usually 4mm larger than the one removed. There are special inserts for removal of monobloc metal shells. Remember that removal of these well-fixed components is more difficult in patients compared to models, and is just the first step of a successful acetabular revision