We used a biodegradable mesh to convert an acetabular defect into a contained defect in six patients at total hip replacement. Their mean age was 61 years (46 to 69). The mean follow-up was 32 months (19 to 50). Before clinical use, the strength retention and hydrolytic in vitro degradation properties of the implants were studied in the laboratory over a two-year period. A successful clinical outcome was determined by the radiological findings and the Harris hip score. All the patients had a satisfactory outcome and no mechanical failures or other complications were observed. No protrusion of any of the impacted grafts was observed beyond the mesh. According to our preliminary laboratory and clinical results the biodegradable mesh is suitable for augmenting uncontained acetabular defects in which the primary stability of the implanted acetabular component is provided by the host bone. In the case of defects of the acetabular floor this new application provides a safe method of preventing graft material from protruding excessively into the pelvis and the mesh seems to tolerate bone-impaction grafting in selected patients with primary and revision total hip replacement

First-time revision acetabular components have a 36% re-revision rate at 10 years in Australia, with subsequent revisions known to have even worse results. Acetabular component migration >1mm at two years following revision THA is a surrogate for long term loosening. This study aimed to measure the migration of porous tantalum components used at revision surgery and investigate the effect of achieving press-fit and/or three-point fixation within acetabular bone. Between May 2011 and March 2018, 55 patients (56 hips; 30 female, 25 male) underwent acetabular revision THR with a porous tantalum component, with a post-operative CT scan to assess implant to host bone contact achieved and Radiostereometric Analysis (RSA) examinations on day 2, 3 months, 1 and 2 years. A porous tantalum component was used because the defects treated (Paprosky IIa:IIb:IIc:IIIa:IIIb; 2:6:8:22:18; 13 with pelvic discontinuity) were either deemed too large or in a position preventing screw fixation of an implant with low coefficient of friction. Press-fit and three-point fixation of the implant was assessed intra-operatively and on postoperative imaging. Three-point acetabular fixation was achieved in 51 hips (92%), 34 (62%) of which were press-fit. The mean implant to host bone contact achieved was 36% (range 9-71%). The majority (52/56, 93%) of components demonstrated acceptable early stability. Four components migrated >1mm proximally at two years (1.1, 3.2, 3.6 and 16.4mm). Three of these were in hips with Paprosky IIIB defects, including 2 with pelvic discontinuity. Neither press-fit nor three-point fixation was achieved for these three components and the cup to host bone contact achieved was low (30, 32 and 59%). The majority of porous tantalum components had acceptable stability at two years following revision surgery despite treating large acetabular defects and poor bone quality. Components without press-fit or three-point fixation were associated with unacceptable amounts of early migration

Introduction and Objective. The surgical strategy for acetabular component revision is determined by available host bone stock. Acetabular bone deficiencies vary from cavitary or segmental defects to complete discontinuity. For segmental acetabular defects with more than 50% of the graft supporting the cup it is recommended the application of reinforcement ring or ilioischial antiprotrusio devices. Acetabular reconstruction with the use of the antiprotrusion cage (APC) and allografts represents a reliable procedure to manage severe periprosthetic deficiencies with highly successful long-term outcomes in revision arthroplasty. Objective. We present our experience, results, critical issues and technical innovations aimed at improving survival rates of antiprotrusio cages. Materials and Methods. From 2004 to 2019 we performed 69 revisions of the acetabulum using defrosted morcellized bone graft and the Burch Schneider anti-protrusion cage. The approach was direct lateral in 25 cases, direct anterior in 44. Patients were re-evaluated with standard radiography and clinical examination. Results. Eight patients died from causes not related to surgery, and two patients were not available for follow up. Five patients were reviewed for, respectively, non-osseointegration of the ring, post-traumatic loosening with rupture of the screws preceded by the appearance of supero-medial radiolucency, post-traumatic rupture of the distal flange, post-traumatic rupture of the cemented polyethylene-ceramic insert, and dislocation treated with new dual-mobility insert. Among these cases, the first three did not show macroscopic signs of osseointegration of the ring, and the only areas of stability were represented by the bone-cement contact at the holes in the ring. Although radiographic studies have shown fast remodeling of the bone graft and the implant survival range from 70% to 100% in the 10-year follow up, the actual osseointegration of the ring has yet to be clarified. To improve osseointegration of the currently available APC whose metal surface in contact with the bone is sandblasted, we combined the main features of the APC design long validated by surgical experience with the 3D-Metal Technology for high porosity of the external surface already applied to and validated with the press fit cups. The new APC design is produced with the 3D-Metal technology using Titanium alloy (Ti6Al4V ELI) that Improves fatigue resistance, primary stability and favorable environment for bone graft ingrowth. We preview the results of the first cases with short-term follow up. Conclusions. Acetabular reconstruction with impacted morcellized bone graft and APC is a current and reliable surgical technique that allows the restoration of bone loss with a high survival rate of the implant in the medium to long term. The new 3D Metal Cage is designed to offer high friction for the initial stability. The high porosity of the 3D Metal structure creates a favorable environment for bone growth, thus providing valid secondary fixation reproducing the results achieved with the 3D metal press fit cup

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures. We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty. Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration. Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful. 3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock

Summary. This work proposes a novel, automatic method to obtain an anatomical reconstruction for 3D segmented bones with large acetabular defects. The method works through the fitting of a Statistical Shape Model to the non-defect parts of the bone. Introduction. Patient-specific implants can be used to treat patients with large acetabular bone defects (IIa-c, IIIb, Paprosky 1994). These implants require a full 3D preoperative planning that includes segmentation of volumetric images (CT or MRI), extraction of the 3D shape, reconstruction of the bone defect into its anatomic (non-defect) state, design of an implant with a perfect fit and optimal placement of the screws. The anatomic reconstruction of the bone defect will play a key role in diagnosing the amount of bone loss and in the design of the implant. Previous reconstruction methods rely on a healthy contralateral (Gelaude 2007); however this is not always available (e.g. partial scan or implant present). Statistical shape models (SSM) of healthy bones can help to increase the accuracy and usability of the reconstruction and will decrease the manual labor and user dependency. Skadlubowicz (2009) illustrated the use of an SSM to reconstruct pelvic bones with tumor defects; however tumors generally affect a smaller region of the bone so that the reconstruction will be easier than in large acetabular bone defects. Also, the tumor reconstruction method uses 80 manually indicated landmarks, while the proposed method only uses 14. Patients & Methods. CT-scans from subjects with a healthy hemi-pelvis (15 male, 33 female, mean age: 69±20) were used to generate an SSM. The CT-scans were segmented using Mimics (Materialise NV, Belgium) to create a triangulated mesh. Preprocessing of the meshes ensured that the triangulation was smooth and uniform to help solve the corresponding point problem. An algorithm based on Redert (1999) was used to morph the template hemi-pelvis onto each dataset entity, creating a dataset with corresponding points. From this dataset the SSM was calculated using principal component analysis, so that the principal components serve as parameters for the mathematical model of the hemi-pelvis. To fit the SSM to a new defect hemi-pelvis, a matching algorithm was used. The algorithm varies the Principal Components independently optimizing the distance of the non-defect parts of the defect hemi-pelvis to the SSM sample. To validate the reconstruction method, 6 healthy bone meshes were used to generate a synthetic defect in the acetabular region. The original mesh was used as ‘golden standard’ to measure the reconstruction error. To illustrate the clinical use of the reconstruction method, one hemi-pelvis with a substantial defect was reconstructed. Results. The correspondence error for the morphing algorithm was 4.68±0.78 mm. The leave-one-out error for the SSM was 1.30±0.96 mm. The reconstruction error for the non-defect part was 1.44±1.13mm and for the reconstructed part 2.15±1.53mm. Discussion/Conclusion. The proposed method performs comparable to the contralateral method and the tumor reconstruction method, without the need of a healthy contralateral geometry. Consequently, the validation and the clinical illustration show that the proposed method is promising for automatic reconstruction of large acetabular defects

Objectives

Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves.

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery.

A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.

Impacted bone allograft is often used in revision joint replacement. Hydroxyapatite granules have been suggested as a substitute or to enhance morcellised bone allograft. We hypothesised that adding osteogenic protein-1 to a composite of bone allograft and non-resorbable hydroxyapatite granules (ProOsteon) would improve the incorporation of bone and implant fixation. We also compared the response to using ProOsteon alone against bone allograft used in isolation. We implanted two non-weight-bearing hydroxyapatite-coated implants into each proximal humerus of six dogs, with each implant surrounded by a concentric 3 mm gap. These gaps were randomly allocated to four different procedures in each dog: 1) bone allograft used on its own; 2) ProOsteon used on its own; 3) allograft and ProOsteon used together; or 4) allograft and ProOsteon with the addition of osteogenic protein-1.

After three weeks osteogenic protein-1 increased bone formation and the energy absorption of implants grafted with allograft and ProOsteon. A composite of allograft, ProOsteon and osteogenic protein-1 was comparable, but not superior to, allograft used on its own.

ProOsteon alone cannot be recommended as a substitute for allograft around non-cemented implants, but should be used to extend the volume of the graft, preferably with the addition of a growth factor.