ACETABULAR RECONSTRUCTION

On the AP X-ray
-Migration of the hip center indicates proximal bone loss
-Ischial osteolysis indicates inferoposterior loss
-Destruction of the teardrop indicates inferoanterior loss
-Destruction of Kohler’s line indicates medial loss

Acetabular bone deficiencies

This is classified by the AAOS as:

Type I Segmental (Involve the supporting cortical shell) = uncontained

Peripheral
-Superior, Anterior or posterior
Central (Medial wall absent)

Type II Cavitary = Contained with supporting bone intact.

Peripheral
-Superior, Anterior or posterior
Central (Medial wall intact)

Type III Combined deficiencies

Type IV Pelvic discontinuity

Type VI Arthrodesis

Paprosky has also classified these according to how well they can support a cementless
component. i.e. how good is the rim, dome, walls and columns, and wether there is >50%
suportive bone.

Bone grafts

Morselized = fragments 5-10mm, better than milled bone.

Simulated structural is bone from another region fit to the acetabulum
Anatomical structural = donor acetabular graft.

Structural grafts fail due to resorption or fragmentation, thus cannot rely on these for long
term support. These merely unite to host bone, do not remodel. It is better though to use a
structural graft beneath a cage to share the load, as morselized graft can only do this
when it remodels, by this time the cage may have failed.

For complete acetabular grafts, cut the host from AIIS to notch, form a tongue in groove
for the graft, hold with screws. Use a cemented cup.
Treatment principles

*Best option if possible is to use an uncemented prosthesis. Cemented acetabulum

revision prosthesis have been shown to have a failure rate of up to 50% at 8 years. This
contrasts with the survival of 87% of uncemented cups after 11 years.

*Need at least 50% supportive host bone to use an uncemented cup

*If < 50% then a cage is needed with a cemented cup

Minor cavitary defects, >50% contact

-Larger components are usually required to enable rim fit at revision.

-Usually need support with screw fixation.
-Contained small cavitary defects can be filled with morselized graft (Up to 25%)
-The cup may be medialized to enable good superolateral coverage, with breaching of the
medial wall not associated with a poor outcome. (Dorr).
-Excellent results at 5 and 10 years (87-90%)

Minor segmental/combined defects, > 50% contact

-Small segmental defects can be ignored if they are peripheral, use a larger cup.

-If combined, but still > 50% contact, then can use a simulated allograft. Here the femoral
head graft can be shaped and fixed (Plate or screws) to the pelvic rim- this is usually
performed for superior defects. It is shaped like a number 7 and reamed, then an
uncemented prosthesis used. At these areas ingrowth will occur, whereas the allograft
will unite onto the cup, but no ingrowth will occur. Initial results at 4 years showing good
results, but at 10 years, 47% were loose.

Larger defects, <50% contact

*Large cavitary defects, with < 50% host contact can be treated with a roof reinforcing
ring, morselized graft and cemented cup.

*Moderate combined defects can be treated with a spanning acetabular cage, supporting
morselized or femoral head graft, and an uncemented cup.

*Can used an oblong cup for superior deficiencies to increase cortical contact to > 50%
and maintain the hip center. Hemispherical cups can be placed high with good results, but
need a trochanteric advancement and a long neck calcar replacing femur to maintain leg
length. Oblong components can be custom made off CT or used off the shelf. Problem
with fit may occur. Must lateralize the cup.

*Massive defects can be treated with entire acetabulum allografts. These have a 60%
failure rate at 16 years, but may further revision easier.