MANAGEMENT OF

ACETABULAR DEFECTS –
TOTAL HIP REPLACEMENT
Prof.(Dr.) Ajay Bharti
(MCh, MS Orthopedics, PGD in Clinical Research, PGDD
Rheumatology)
Medical Superintendent,
Professor & Head Orthopedics
AIIMS Gorakhpur
 COMMON CAUSES OF THE
FAILURE
 Aseptic loosening 25.6%
 Instability
21.7%
 Periprosthetic Fracture Acetabular bone
19.5%
loss
 Infection
17.7%
 Pain
17.3 %
 PRE OPERATIVE EVALUATION

 Inflammatory serum markers- CRP, Procalcitonin, Alpha-defensin

 If elevated--- JOINT aspiration

 Prior to any revision for acetabular bone loss Prosthetic

Joint Infection must be ruled out
 PREOPERATIVE IMAGING
 Radiographs provide sufficient and accurate characterization of
the bone deficit : Judet Views, AP, Lat.
 Computed tomography (CT) scan - characterize severe
acetabular bone loss: medial wall defects, protrusion, and pelvic
discontinuity
 Magnetic resonance imaging (MRI) - useful to evaluate soft
tissue abnormalities
 Metallosis
 pseudotumor formation
 The quality of the abductor complex

 CT angiography
 External Iliac Vessels
 CLASSIFICATION SYSTEM
Four classification systems:
 the American Academy of Orthopaedic Surgeons (AAOS)
classification,
 Ghanem & Andreas classification ,
 the Gross classification , and
 the Paprosky classification
 AAOS
 Describes bone loss by pattern and location
 Does not specify the size of the defect

1. segmental (Type I),

2. cavitary (Type II),
3. combined (Type III) defects.
4. pelvic discontinuity (type iv), and
5. hip arthrodesis(type v)
---Does not quantify bone loss,--- application is limited for
treatment planning
 PAPROSKY CLASSIFICATION
 is widely accepted and provides a basis for implant selection.
 the location and extent of bone loss are predicted based on
preoperative radiographs,
 and reconstruction options can be determined according to the
classification.
 For example,
 Paprosky 3B defects (supporting bone loss is greater than 60%
with significant superior-medial migration of the hip COR) -----
Antiprotrusio ilioischial cage constructs
PAPROSKY CLASSIFICATION (BASED ON QUANTIFICATION AND
LOCATION OF ACETABULAR BONE LOSS]
ACETABULAR RECONSTRUCTION METHODS BASED ON PAPROSKY
CLASSIFICATION SYSTEM*
 SURGICAL MANAGEMENT
 Restoration of the COR of the hip joint by managing bone defects
to achieve a stable and durable construct is the mainstay
 Various surgical techniques are based on
 acetabular bone loss, whether defects are small/contained or
larger/non-contained
 the surgeon’s own comfort and experience
 A particular surgical approach for adequate exposure,
explantation, and subsequent reconstruction of acetabulum is
determined. However, due to the circumferential acetabular
access required for safe revision surgery, the posterolateral
approach is most often utilized
COMMON RECONSTRUCTION
TECHNIQUES
 HEMISPHERICAL POROUS COATED
ACETABULAR SHELLS
 Commonly utilized in Paprosky type I and II bony defects with
segmental, partial rim loss and intact columns
 provide immediate component stability and long-term biological
fixation through osseointegration
 Current literature supports excellent longevity and improvement
in outcome scores.
 HEMISPHERICAL, POROUS COATED
ACETABULAR SHELL WITH MULTIPLE DIFFERENT
BEARING COMBINATIONS
 JUMBO CUPS
 Using a cementless jumbo cup
 defined as ≥66 mm for men and ≥62 mm for women (10 mm
larger than the mean cup diameter usually used for primary
THR)----effective technique for treating extensive bone defects
during acetabular revision
 relatively simple
 maximum surface contact between the component and the
host bone
 associated with elevated hip COR
 Paprosky type II/III acetabular bone loss
MASSIVE BONE LOSS MANAGED WITH A JUMBO CUP
AND MORCELIZED BONE GRAFT
 BONE IMPACTION GRAFTING WITH
CEMENTED CUP
 Good results in contained, cavitary and some segmental
acetabular bony defects
 Bone cavities are filled and tightly packed with cancellous bone
 impaction grafting can be protected with metal mesh before
polyethylene liner is cemented.
 Long-term results ---good healing of bony defects.
 Major challenges ---adequate amount of bone graft and graft
resorption
 Large acetabular defects—Paprosky 2B, 3A and 3B
IMPACTION BONE GRAFTING FOR CONTAINED
ACETABULAR DEFECTS
 STRUCTURAL BULK ALLOGRAFT
 Provides immediate structural support and mechanical stability
for uncemented acetabular fixation
 Femoral head allograft is most frequently utilized for this purpose
 Major drawbacks-- bone resorption, infection and component
loosening
 Newer generation modular highly porous coated metal
augments---significant reduction in the use of structural allograft
TYPE 2B & 3A ACETABULAR DEFECTS WERE REPAIRED WITH A
PROXIMAL TIBIA OR DISTAL FEMUR ALLOGRAFT CUT INTO A
NUMBER
7 GRAFT
RING AND CAGE RECONSTRUCTION
 Acetabular dome reinforcement ring in combination with
antiprotrusio cages, mostly Bursch Schneider cages (spanning
from ilium to ischium)
 Severe acetabular bone deficits
 The polyethylene liner can be cemented in the cage for proper
inclination and retroversion
 Major setbacks--- premature breakage, fatigue fracture, flange
breakage, loosening and eventually failure of revision
 Ring and cage constructs rely on screw and cement fixation
rather than biological fixation--- influence long-term survivorship
IMPLANTATION OF A GANZ RING & BURCH-
SCHNEIDER CAGE
 CUP AND CAGE RECONSTRUCTION
 Consists of a highly porous metal cup secured with screws, an
ilioischial cage, and a cemented liner
 Severe acetabular bone defects, Paprosky Type IIIA and IIIB, and
chronic pelvic discontinuity
 The uncemented porous metal acetabular shell with or without
modular metal augments can be fixed with host bones with
multiple supplemental screws---An antiprotrusio cage is then
placed inside the uncemented shell spanning pelvic discontinuity
from ilium to ischium
 This technique improves on the limitations of non-biologic with
ring and cage constructs by incorporating uncemented porous
coated hemispherical shell into the construct
CHRONIC DISCONTINUITY WITH A FAILED JUMBO
CUP, TREATED WITH A CUP-CAGE, HALF-CAGE
CONSTRUCT
 OBLONG CUP RECONSTRUCTION

 Customized uncemented shell for matching acetabular bone loss

in Paprosky type IIB and IIIA
 Mainly indicated for superior rim defects reconstruction
 Overtaken by uncemented Shell with Modular metal augments
due to better flexibility of intraoperative acetabular
reconstruction in revision THR
 PELVIC DISTRACTION TECHNIQUE
 Pelvic discontinuity ---occur in cases of severe osteolysis
 Separation and motion between the superior and inferior
hemipelvis-- Stable fixation of the acetabular prosthesis becomes
difficult
 Pelvic distraction technique is utilized to bridge the discontinuity
and primary bone healing of the gap
 Extra acetabular distraction is used for peripheral or lateral
distraction and central or medial compression at the discontinuity
 Independent motion of the superior and inferior segments is
diagnosed as pelvis discontinuity
 Basis of acetabular distraction technique to offer stable
anterosuperior and posteroinferior column fit for a porous metal
shell
SUPEROMEDIAL CUP MIGRATION IN A PATIENT WITH PRIOR POSTERIOR COLUMN
FRACTURE AND ASSOCIATED PELVIC DISCONTINUITY AND MEDIAL WALL
DEFICIENCY MANAGED WITH HALF CUP-CAGE RECONSTRUCTION WITH
REPLATING OF THE POSTERIOR COLUMN WITH MEDIAL FEMORAL HEAD
ALLOGRAFT.
 UNCEMENTED ACETABULAR
COMPONENT WITH MODULAR POROUS
METAL AUGMENT
 utilized in severe structural bony loss.
 Modular porous coated metal augments have been proven as
more reliable long-term options than bulk allograft in acetabular
bone loss management in revision THR
 Augments provide excellent anterosuperior to posteroinferior
fixation that is crucial for stable socket fixation
 Optimize host bone-implant contact and can downgrade defects
from more severe to less severe while maintaining the optimal
hip center.
 ASEPTIC LOOSENING OF A CAGE CONSTRUCT,
MANAGED WITH HIGHLY POROUS REVISION CUP
WITH SCREWS COMBINED WITH 2 AUGMENTS,
 PATIENT SPECIFIC CUSTOM MADE
AUGMENTS
 Custom-made titanium augments have been developed by 3D
printing technology
 Advantages of the porous metal augment with added accuracy
 Benefits of patient specific custom-made augments are
 precise reaming of the acetabulum, preserving bone stock,
matching the bone defects, granting adequate initial
component stability
 Reconstruct the hip joint COR and restore the hip biomechanics
 Acetabular components supported with custom-made 3D-printed
augments is--useful method to bridge severe bone deficiencies
CUSTOM 3D-PRINTED IMPLANTS FOR
ACETABULAR RECONSTRUCTION
 CUSTOM MONOFLANGE ACETABULAR
COMPONENT (CMAC)
 Demonstrates similar clinical outcome parameters and survival
rates as Triflanged CMAC
 Superior biomechanical features, bone ingrowth, and restoration
of Anatomical COR
 In Monoflanged CMAC, large segmental iliac defect is filled by the
implant’s metallic Monoblock assembled socket.
 CMACs iliac fixation is less invasive compared to three-point
fixation for triflanged custom acetabular components because it
requires less preparation at the ischium
 CUSTOM TRIFLANGE ACETABULAR
COMPONENT (CTAC)
 Patient specific custom-made acetabular implant
 Has plans for rigid fixation to the ilium, ischium and superior
pubic ramus with screws in order to bridge across the bony
defect or pelvic discontinuity
 3D CT scan of the pelvis is obtained--- defect and structural host
bone is identified---- custom model is created to fill the
defect----Screw trajectories can be planned
 The total process takes 4–6 weeks of planning and manufacturing
 The proposed advantages of CTACs are the ability to customize
and individualize the implant to the defect restoring the
acetabular anatomy, choosing the optimal COR, and optimizing
host bone contact area and osseointegration
MASSIVE ACETABULAR BONE LOSS MANAGED WITH
CUSTOM TRIFLANGED ACETABULAR COMPONENT
 CASE 1
A 66 year male operated case of THR Right hip had trauma to the
right hip presented with pain right hip and inability to stand

Pre op
POST OP
ANTIPROTRUSIO CAGE
 CASE 2
A 60 year old male patient had history of RTA presented with pain
in the right hip and difficulty in standing

Pre op
POST OP
 CASE 3
A 24 Year male patient had history of RTA presented with pain
left hip and inability to stand

Pre op
POST OP
 CASE 4
A 32 year female had history of RTA presented with pain left hip
and difficulty in standing

Pre op
POST OP