The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Aims

Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed.

Purpose. The purpose of the present study is to assess 5–10 years' follow-up results after acetabular impaction bone grafting (IBG) in primary cemented total hip arthroplasty (THA) for cases with acetabular bone defect. Patients and methods. We performed 36 primary cemented THA with acetabular IBG in 33 patients between November 2004 and May 2009. As one patient died due to unrelated disease at 6 months after the surgery, 35 hips of 32 patients were included in this study. The average age at the surgery was 62.4 years, and the average follow-up period was 7.9 years (5–10 years). Diagnoses were osteoarthritis due to acetabular dysplasia in 28 hips (26 patients), Rheumatoid arthritis (RA) in 4 hips (3 patients), rapidly destructive coxopathy (RDC) in 1 hip (1 patient), idiopathic acetabular protrusion in 1 hip (1 patient), and acromegaly in 1 hip (1 patient). For clinical assessment, the Merle d'Aubigné and Postel hip score was assessed and degree of post-operative improvement was classified according to their method as very great improvement, great improvement, fair improvement, and failure. Perioperative complications were also recorded. Acetabular bone defects were assessed at the surgery and categorized using AAOS acetabular bone defect classification system. For radiological assessment, anteroposterior radiographs of the bilateral hip joints were analyzed preoperatively and post-operatively. Radiolucent lines (RLL) of more than 2 mm around the acetabular components were assessed using the DeLee and Charnley zone classification. Acetabular component loosening was assessed according to the Hodgkinson et al. classification system, and type 3 (complete demarcation line) and type 4 (migration) were classified as “loosening”. Results. The mean Merle d'Aubigné and Postel hip score improved from 9.8 points before the operation to 15.9 points at the final follow-up. Degree of post-operative improvement was assessed as “very great” in 11 hips, “great” in 23 hips and “fair” in 1 hip. Dislocation, DVT, and infection were recorded in 1 hip, 1 hip, and 1 hip, respectively. Re-operation was performed for the acute infection (without loosening) case at 5.3 years after the primary THA. Acetabular bone defects were classified as segmental defect (AAOS type I) in 29 hips, cavitary defect (AAOS type II) in 3 hips and combined segmental and cavitary defect (AAOS type III) in 3 hips. Metal meshes were used for segmental defects of 29 AAOS type I hips and 2 AAOS type III hips, and for medial wall defect of 1 AAOS III hip. On radiographic assessment, no metal device breakage was detected during the follow-up period. There were no clear lines around the cup and all cups were assessed as stable at the final follow-up. Conclusion. Acetabular impaction bone grafting in primary cemented THA is technically demanding procedure. However, postoperative functional improvement is remarkable and stable radiographic findings were achievable independent from original diagnoses. This procedure is one of useful options to restore acetabular bone deficiency in cemented primary THA for cases with acetabular bone defect

Total hip arthroplasty (THA) in patients under 30 years remains a challenge. The long-term survival data are often disappointing. In our institution, we have always used cemented components in all patients under 30 years, combined with acetabular impaction bone grafting (IBG), if necessary. We reviewed 139 consecutive patients (180 hips) treated between 1986 to 2014. Mean age at time of surgery was 24 (13–30.0) years. Acetabular IBG was applied in 127 (71%) cases. AAOS cavitary defect was seen in 26 (14%) cases, a AAOS segmental defect in 51 (28%) and a combination in 17 (9%). The mean preoperative HHS improved from 47 (20–81) to 87 (28–100) at review. During follow-up 26 hips have been revised (23 cups and 11 stems). Indications for revision were aseptic loosening (n=15), septic loosening (n=5), recurrent dislocation (n=3), wear (n=1), and stem fracture (n=1). The 10-year Kaplan-Meier survival of any component with endpoint revision for any reason was 87% (95% CI 79%–92%) and for aseptic loosening 92% (84%–96%). The 15-year survival of any component with revision for any reason as the endpoint was 77% (65%–86%) and for aseptic loosening 84% (71%–92%). Cemented THA and, if needed with impaction bone grafting, in patients under 30 years provides satisfying long-term results up to 15 years after surgery. Probably this biological approach with IBG may facilitate the inevitable revisions in the future in these young patients because of more bone stock

Introduction. Impaction bone grafting for reconstitution of acetabular bone stock in revision hip surgery has been used for nearly 30 years. We report results in a group of patients upon whom data has been collected prospectively with a minimum ten year follow-up. Material and Methods. Acetabular impaction grafting was performed in 305 hips in 293 patients revised for aseptic loosening between 1995 and 2001. In this series 33% of cases required stainless steel meshes to reconstruct medial wall or rim defects prior to graft impaction. These meshes were the the only implants used for this purpose in this series. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of 10 years following the index operation; mean follow-up was 12.4 years (SD 1.5; range 10.0–16.0). Results. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 86% (95% CI 81.1 to 90.9%). Clinical scores for pain relief and function remained satisfactory (mean OHS 33.3, Harris hip score for pain 36.7, Harris hip score for function 27.3). Of the 125 hips still available with at least 10 years of radiographic follow-up, 97 appeared stable and 28 were judged to be radiologically loose; however, there was no significant difference in the pain and function scores between the two groups. The overall complication rate was 11.5%, including 1% peri-operative death, 3.3% dislocation and 0.3% deep infection. Discussion. This is the largest series of medium- to long-term results of acetabular impaction bone grafting with a cemented cup for revision hip arthroplasty reported to date. The technique is particularly successful when used for Paprosky grade 1 and 2 deficiencies; grade 3 deficiencies may be better managed with a different method for reconstructing larger defects e.g. trabecular metal augments. Conclusion. This series shows good long-term results for impaction bone grafting of acetabular deficiencies in revision hip surgery, with survivorship of 86% for aseptic loosening at 13.5 years and satisfactory clinical outcomes

Background. Cup migration and bone graft resorption are some of the limitations after acetabular impaction bone grafting (IBG) technique in revision hip surgery when used for large segmental defects. We asked whether the use of a metallic mesh may decrease the appearance of this complication. We compared the appearance of loosening in patients with a bone defect 3A or 3B according to Paprosky. Materials and Methods. We assessed 204 hips operated with IBG and a cemented cup according to Slooff et al between 1997 and 2004. There were 100 hips with a preoperative bone defect of 3A and 104 with a 3B. We used 142 medial and/or rim metallic meshes for uncontained defects. The mean follow-up for unrevised cups was 10.4 years. We detemined postoperative radiological cup position and acetabular reconstruction of the hip center according to Ranawat in both groups. We assessed the appearance of radiological loosening and resorption of the graft. Results. Postoperative cup position improved in both groups (p<0.001 for all parametres). Distance to the approximate center of the hip decreased from 23.5 to 8.5 mm. 8 hips showed radiological loosening in group with a bone defect 3A and 16 in group 3B. The survival rate for loosening at 15 years was for 83.2 +12% for group 3A and 72.5 + 12% for group 3B (Mantel-Cox, p=0.04). The survival rate when using mesh or not at 15 years for loosening was: No Mesh 89.1 + 14%, Medial mesh 84.9 + 12%, Rim 79.6 + 12%, Medial and Rim 53.9 + 22 % (Mantel Cox, p=0.008). Patients with a bone defect 3B and a rim metallic mesh had a higher risk for loosening (p=0.047; Hazard Ratio: 2.36, Confidence Interval 95% (CI) 1.01–5.5, and, p=0.026; HR: 3.7, CI 95%: 1.13–12.4, respectively). Conclusions. IBG provides an improvement of the reconstruction of the rotation of the hip centre in acetabular revision surgery. Although results are good for contained or medial large defects, hips with a rim large segmental defect may need other options for reconstruction of these challenged surgeries

Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland. A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored. 33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy. Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship. Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression

Introduction: Extensive bone loss associated with revision hip surgery is a significant orthopaedic challenge. Acetabular reconstruction with the use of impaction bone grafting and a cemented polyethylene cup is a reliable and durable technique in revision situations with cavitatory acetabular bone defects. Slooff et al. (1996) reported the use of cancellous graft alone. Brewster et al. (1999) morselised the whole femoral head after removal of articular cartilage. This paper asks, is it really necessary to use pure cancellous graft?. Methods: 42 acetabular revisions using impacted morselised bone graft without removal of articular cartilage and a cemented cup were studied retrospectively. The mean follow up was 2.6 years (1–5yrs). Clinical and radiographic assessment was made using the Oxford Hip score, Hodgkinson’s criteria (1988) for socket loosening and Gie classification (1993) for evaluation of allograft consolidation and remodelling. Results: 40(95%) sockets were considered radiologically stable (Type 0, 1, 2 demarcations). 2(5%) sockets were radiologically loose (Type 3 demarcation). There was no socket migration in our series. 27(64%) cases showed good trabecular remodelling (grade 3). 12(29%) cases showed trabecular incorporation (grade 2). Only 3(7%) cases showed poor allograft incorporation (grade 1). Average pre operative Oxford hip score was 41 and postoperative hip score was 27. There have been no socket re-revisions (100% survival) at an average of 2.6 years. Conclusion: Early radiological and clinical survival results with retaining articular cartilage of femoral head allograft are similar and comparable to other major studies for acetabular impaction bone grafting in revisions. Minimal loss of allograft mass is 40% in obtaining pure cancellous graft. When there is a limited supply and demand of allograft, saving up to 40 % of the material is a valuable and cost effective use of scarce resources

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

Cite this article: Bone Joint J 2024;106-B(4):312–318.

Aims

The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution.

We present an update of the clinical and radiological results of 62 consecutive acetabular revisions using impacted morsellised cancellous bone grafts and a cemented acetabular component in 58 patients, at a mean follow-up of 22.2 years (20 to 25). The Kaplan-Meier survivorship for the acetabular component with revision for any reason as the endpoint was 75% at 20 years (95% confidence interval (CI) 62 to 88) when 16 hips were at risk. Excluding two revisions for septic loosening at three and six years, the survivorship at 20 years was 79% (95% CI 67 to 93). With further exclusions of one revision of a well-fixed acetabular component after 12 years during a femoral revision and two after 17 years for wear of the acetabular component, the survivorship for aseptic loosening was 87% at 20 years (95% CI 76 to 97). At the final review 14 of the 16 surviving hips had radiographs available. There was one additional case of radiological loosening and four acetabular reconstructions showed progressive radiolucent lines in one or two zones.

Acetabular revision using impacted large morsellised bone chips (0.5 cm to 1 cm in diameter) and a cemented acetabular component remains a reliable technique for reconstruction, even when assessed at more than 20 years after surgery.