Review Article

Acetabular Bone Loss in Revision

Total Hip Arthroplasty: Evaluation
and Management

Abstract
Downloaded from https://journals.lww.com/jaaos by 9Q5OnpGX69sCtAqytkZIqbm+zFTjFnJKcNlU+FKG9ugKqJnK8L+Aq/sgRjfZSqHDMIrFZyCpjiVtDaRt+klWz2PdBuQG7idlqu2gC+9LBv0JArXQWYPzfF3nL5U4Of4h7+HMgzhMt/fXMDvlLI5oqg== on 09/24/2019

Neil P. Sheth, MD
Charles L. Nelson, MD
Bryan D. Springer, MD
Thomas K. Fehring, MD
Wayne G. Paprosky, MD
As the number of primary total hip arthroplasty (THA) procedures
performed continues to rise, the burden of revision THA procedures
is also expected to increase. Proper evaluation and management
of acetabular bone loss at the time of revision surgery will be an
increasing challenge facing orthopaedic surgeons. Proper
preoperative patient assessment and detailed preoperative
planning are essential in obtaining a good clinical result.
Appropriate radiographs are critical in assessing acetabular bone
loss, and specific classification schemes can identify bone loss
patterns and guide available treatment options. Treatment options
include impaction grafting and cementation of the acetabulum,
noncemented hemispheric acetabular reconstruction, structural
allograft reconstruction, noncemented reconstruction with modular
porous metal augments, ring and cage reconstruction, oblong cup
reconstruction, cup-cage reconstruction, and triflange
reconstruction.

A pproximately 300,000 primary

From Penn Orthopaedics, Hospital
of the University of Pennsylvania,
Philadelphia, PA (Dr. Sheth and
Dr. Nelson), OrthoCarolina Hip &
Knee Center, Charlotte, NC
(Dr. Springer and Dr. Fehring), and
the Department of Orthopedic
Surgery, Rush University Medical
Center, Chicago, IL (Dr. Paprosky).
J Am Acad Orthop Surg 2013;21:
128-139
http://dx.doi.org/10.5435/
JAAOS-21-03-128
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
total hip arthroplasty (THA) pro-
cedures are performed annually in the
United States,1 and that number is ex-
pected to increase as the population
ages and as younger patients are con-
sidered for the procedure. Conse-
quently, the burden of revision THA is
projected to increase exponentially.
The major indications for revision of
the acetabular component include asep-
tic loosening, hip instability, peripros-
thetic osteolysis, and periprosthetic in-
fection, which typically is managed with
two-stage exchange. Acetabular revi-
sion surgery is challenging because of
the variation in remaining bone qual-
ity and bone stock. Typically, the degree
of bone loss at the time of revision dic-
tates the type of reconstruction used.
Each reconstruction option has inher-
ent advantages and disadvantages.
Preoperative Patient
Evaluation
Thorough preoperative patient as-
sessment is critical in cases requiring
acetabular component revision, and
patient history is a key component.
All prior procedures must be noted
and a detailed history of all perioper-
ative complications obtained. Pain is
the most common complaint requir-
ing revision, and the history must
document the location, type, charac-
ter, duration, temporal nature (eg,
pain at night only, pain on ambula-
tion), and exacerbating and remit-
ting factors (ie, activity-related symp-
toms) of the pain as well as previous
treatment attempts. The time from
surgery or the duration of symptoms
can also influence diagnosis and
management, as in the case of acute

128 Journal of the American Academy of Orthopaedic Surgeons

 Neil P. Sheth, MD, et al

Figure 1
Axial CT angiogram demonstrating the close proximity of the ureter (arrow)
to the acetabular component. This image was used in preoperative planning
for revision left total hip arthroplasty.
hematogenous infection, which is
managed with irrigation and dé-
bridement along with head and liner
exchange.
The lack of a pain-free interval fol-
lowing primary THA may prompt
questioning of the indication for sur-
gery, or it may indicate the presence
of low-grade sepsis. Deep infection
must be ruled out. Serum erythro-
cyte sedimentation rate (normal, <20
mg/dL) and C-reactive protein (nor-
mal, <10 mg/dL) should be obtained
in all revision patients. Elevated se-
rum inflammatory markers should
prompt a preoperative hip aspira-
tion. Synovial fluid analysis includes
anaerobic and aerobic cultures as
well as a cell count. A white blood
cell count of 2,500 to 3,000 and a
differential of >60% segmented neu-
trophils is considered suspicious for
infection.2,3
Physical examination includes assess-
ment of the patient’s general health,
lumbosacral spine, and contralateral
limb, followed by a detailed examina-
tion of the affected hip and lower
extremity with documentation of pre-
vious incisions. Detailed motor (ie,
side-lying abduction), sensory, and vas-
cular examinations must also be per-
formed. The patient’s gait must be eval-
uated for the presence of painful
ambulation (ie, antalgic gait) and the
presence of weakness resulting in a
compensatory gait pattern (ie, Trende-
lenburg gait secondary to poor abduc-
tor function). Limb-length discrepancy
should be evaluated, as well.
Radiographic Evaluation
Preoperative radiographic assessment
requires projections that include the en-
tire prosthesis. An AP pelvis and a lat-
eral hip view usually suffice. An AP
view of the hip may be necessary to vi-
sualize the entire femoral implant.4
For the AP pelvis view, the x-ray
should be centered over the symphy-
sis pubis and aligned with the coccyx
to allow assessment of leg length.
All plain radiographs are assessed for
component position, potential compo-
nent loosening, the presence of eccen-
tric polyethylene wear, and the location
and degree of osteolysis with associated
bone loss. Judet views (ie, iliac oblique,
obturator oblique) are helpful in eval-
uating remaining acetabular bone stock
and the implant-bone interface.5
CT is useful as an adjunct in fur-
ther defining osteolysis and pelvic
bone loss.6 In cases in which the ac-
etabular component is medial to the
Kohler line, retained cement is pres-
ent, and/or previous screws are pres-
ent, Judet views and/or a three-
dimensional CT reconstruction with
contrast are valuable to evaluate the
pelvic vessels, ureter, and bladder
and their proximity to the acetabular
component7 (Figure 1).
Preoperative Surgical
Planning
Surgical Exposure
The approach for revision surgery is
determined based on surgeon experi-

Dr. Sheth or an immediate family member serves as a paid consultant to or is an employee of Zimmer. Dr. Nelson or an immediate
family member serves as a paid consultant to or is an employee of Greatbatch Medical and Zimmer and serves as a board member,
owner, officer, or committee member of the J. Robert Gladden Orthopaedic Society. Dr. Springer or an immediate family member is a
member of a speakers’ bureau or has made paid presentations on behalf of DePuy and CeramTec and serves as a paid consultant
to or is an employee of Stryker and ConvaTec. Dr. Fehring or an immediate family member has received royalties from, is a member
of a speakers’ bureau or has made paid presentations on behalf of, serves as a paid consultant to or is an employee of, and has
received research or institutional support from DePuy and serves as a board member, owner, officer, or committee member of the
American Association of Hip and Knee Surgeons and The Knee Society. Dr. Paprosky or an immediate family member has received
royalties from Wright Medical Technology and Zimmer, is a member of a speakers’ bureau or has made paid presentations on behalf
of Zimmer, serves as a paid consultant to or is an employee of Biomet and Zimmer, and serves as a board member, owner, officer, or
committee member of The Hip Society.

March 2013, Vol 21, No 3 129

Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management
Figure 2
Illustration depicting the paths of
different osteotomies about the
greater trochanter for use in
revision total hip arthroplasty:
A, standard trochanteric;
B, trochanteric slide; C, extended
trochanteric. (Reproduced from
Archibeck MJ, Rosenberg AG,
Berger RA, Silverton CD:
Trochanteric osteotomy and fixation
during total hip arthroplasty. J Am
Acad Orthop Surg 2003;11[3]:
163-173.)
ence and utility for the planned re-
construction. In conjunction with
patient factors (eg, high risk for in-
stability), other factors that influence
the choice of surgical approach in-
clude the need for additional expo-
sure (ie, osteotomy), the degree and
location of femoral and acetabular
bone defects, and the presence of dis-
torted anatomy. The posterolateral
approach is the most utilitarian and
affords excellent circumferential ex-
posure of the acetabulum and iliac
wing. Most reconstructions can be
managed with this approach; how-
ever, if mobilization of the femur is
difficult or if it is necessary to gain
access high on the iliac wing, a femo-
ral osteotomy can enhance exposure.
Various locations and configura-
tions of femoral osteotomy are avail-
130
able. Osteotomies about the greater
trochanter can be categorized as
standard single plane, trochanteric
slide, extended trochanteric, and
Wagner8 (Figure 2).
The standard single plane osteot-
omy is indicated in cases of previous
trochanteric escape or in which en-
hanced acetabular exposure is re-
quired.8 Fixation methods with this
technique have demonstrated union
rates ranging from 62% to 99%.8
The trochanteric slide osteotomy
capitalizes on the attachment of the
vastus lateralis soft-tissue sleeve to
minimize the risk of proximal tro-
chanteric fragment migration. The
remaining abductor and vastus at-
tachments generate a resultant me-
dial compression force vector that
confers enhanced fragment healing.
Extended trochanteric osteotomy
enhances exposure and facilitates
femoral component removal. The
original Wagner osteotomy used an
extended anterior trochanteric os-
teotomy that reflected the anterior
one half of the abductor complex in
continuity with the anterior one
third of the proximal femur. In 1995,
the Wagner osteotomy was modified
to include an extended lateral tro-
chanteric osteotomy, in which the
abductor complex is reflected in con-
tinuity with the lateral one third of
the proximal femur.9 The length of
the extended trochanteric osteotomy
is planned preoperatively, allowing
for at least 4 to 6 cm of diaphyseal
stem engagement. Typically, this os-
teotomy is performed through an ex-
tensile posterolateral approach.
Acetabular Bone Loss
Classifications
Following removal of the acetabular
component, the degree of bone loss
is correlated to the preoperative ra-
diographic assessment. Bone loss
classifications are helpful in assessing
the location and degree of bone loss
Journal of the American Academy of Orthopaedic Surgeons
as well as the type of reconstruction
that is needed to obtain stable fixa-
tion of the acetabular implant.
The American Academy of Ortho-
paedic Surgeons (AAOS) introduced
an acetabular bone loss classification
based on the presence of segmental,
cavitary, or combined defects10 (Ta-
ble 1). This classification is simple in
its organization; however, it is not
quantitative, and its practical appli-
cation is limited.
Several other classifications have
been described, but the most widely
used is the Paprosky classification of
acetabular bone loss.11 This classifi-
cation is comprehensive and pro-
vides treatment recommendations
based on the location and degree of
bone loss. Studies have demonstrated
adequate reliability and validity.12,13
The Paprosky classification is based
on four variables: location or migration
of the hip center of rotation in refer-
ence to the superior obturator line, de-
gree of teardrop destruction, amount of
ischial osteolysis, and integrity of the
Kohler line (ie, ilioischial line) (Table
2). Use of these four variables facilitates
objective assessment of bone loss in-
volving the superior dome, medial ac-
etabular wall, and posterior column.
In type I defects, the hemispheric
shape of the acetabulum is main-
tained (Figure 3, A). There is no hip
center migration, nor is there de-
struction of the teardrop or ischial
osteolysis, and the Kohler line re-
mains intact. The anterior and the
posterior columns are intact, allow-
ing for component stability, and
>70% of the prosthesis can be sup-
ported by host bone. Type I defects
can be managed with a nonce-
mented, porous-coated hemispheric
implant with the use of adjunctive
screw fixation for initial mechanical
stability.11
Type II defects are subdivided into
types A, B, and C. Type IIA defects
result in bone loss in the superior ac-
etabular dome with <3 cm of supe-
 Neil P. Sheth, MD, et al

rior hip center migration (Figure 3,
B). There is neither ischial osteolysis
nor minimal teardrop osteolysis, and
the Kohler line is intact. The anterior
and posterior columns are intact, al-
lowing for component stability, and
particulate bone graft is used to ad-
dress bone loss. Type IIA defects can
be managed with a noncemented,
porous-coated hemispheric implant
with the use of adjunctive screw fixa-
tion to achieve initial mechanical sta-
bility.11
Type IIB defects involve <3 cm of su-
perior and lateral hip center migration,
resulting in a superior dome defect (Fig-
ure 3, C). There may be minimal tear-
drop and ischial osteolysis, but the
Kohler line is intact. The anterior and
posterior columns are intact, allowing
for component stability, and >50% of
the prosthesis is in contact with host
bone. Type IIB defects are managed
with a noncemented, porous hemi-
spheric implant with the use of adjunc-
tive screw fixation to achieve initial me-
chanical stability. Biologic fixation is
possible even when up to 30% of the
cup is uncovered.11
Type IIC defects are medial wall
defects (Figure 3, D). Superior hip
center migration is minimal, but
there is medial migration with mod-
erate teardrop osteolysis and viola-
tion of the Kohler line. The anterior
and posterior columns are intact, al-
lowing for component stability;
however, the hemispheric rim may be
distorted. Type IIC defects can be
managed with a noncemented, po-
rous hemispheric implant with bone
grafting of the medial defect and the
use of adjunctive screw fixation for
initial mechanical stability. Compo-
nent stability is achieved through the
existing rim.11
The most complex bone loss pat-
terns are encountered in type III de-
fects. These defects may be associ-
ated with pelvic discontinuity. Type
IIIA defects are referred to as “up
and out” and type IIIB defects as “up
and in.” In type IIIA defects, 30% to
60% of the acetabular rim is miss-
ing, and the columns are nonsup-
portive (Figure 3, E). Superolateral
migration of the hip center is >3 cm,
and there is moderate teardrop and
ischial osteolysis. The Kohler line re-
mains intact. The use of a nonce-
mented, porous hemispheric implant,
along with supplemental porous
metal augments or structural graft, is
recommended. Adjunctive screw fix-
ation through the acetabular shell is
required, as is screw fixation through
the graft or augment. The augment
should be cemented or attached to
the acetabular shell to increase the
stability of the overall construct.11
Type IIIB defects are the most se-
vere defects encountered in revision
THA (Figure 3, F). These defects ex-
hibit >60% deficiency of the acetab-
ular host bone stock. The acetabular
rim and columns are completely non-
supportive. Superomedial hip center
migration is >3 cm, and there is se-
vere teardrop and ischial osteolysis,
with complete disruption of the
Kohler line.11 Type IIIB defects may
be associated with pelvic discontinu-
ity. Biologic fixation is unlikely with
use of a noncemented acetabular de-
vice alone. Instead, a noncemented
acetabular device must be used in
conjunction with structural allograft,
a reconstruction cage, modular po-
rous metal augments, or a combina-
tion of these options.
Acetabular Component
Removal
During preoperative planning, the
surgeon must identify implants that
Table 1
American Academy of
Orthopaedic Surgeons
Classification of Acetabular
Deficiencies10
Type Description
I Segmental defect
II Cavitary defect
III Combined segmental and
cavitary defect
IV Pelvic discontinuity
A Discontinuity with mild
segmental or cavitary
loss
B Discontinuity with moder-
ate to severe segmental
or cavitary loss
C Discontinuity with prior
pelvic irradiation
V Hip arthrodesis

Table 2
Paprosky Classification of Acetabular Bone Loss11
Femoral Head
Type Center Migration Ischial Osteolysis Kohler Line Teardrop

I None None Intact Intact

IIA Mild (<3 cm) None Intact Intact
IIB Moderate (<3 cm) Mild Intact Intact
IIC Mild (<3 cm) Mild Disrupted Moderate lysis
IIIA Severe (>3 cm) Moderate Intact Moderate lysis
IIIB Severe (>3 cm) Severe Disrupted Severe lysis

March 2013, Vol 21, No 3 131

Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management

Figure 3

Illustrations of the Paprosky classification of acetabular bone loss. A, Type I. B, Type IIA. C, Type IIB. D, Type IIC.
E, Type IIIA. F, Type IIIB. (Adapted with permission from Paprosky WG, Perona PG, Lawrence JM: Acetabular defect
classification and surgical reconstruction in revision arthroplasty: A 6-year follow-up evaluation. J Arthroplasty
1994;9[1]:33-44.)

are already in place. Surgical reports
on prior procedures performed else-
where are an essential part of the
planning process. In cases in which
acetabular component revision is re-
quired, component removal with the
least amount of additional bone loss
and preservation of key bone stock is
paramount. Complete circumferen-
tial exposure of the acetabular rim is
important for safe component re-
moval. A bone tamp placed at the
edge of the acetabular shell can be
used to determine the stability of the
component. Even well-fixed compo-
nents may require removal as a result
of component malposition. This may
require the use of special tools or in-
struments such as explants, trial lin-
ers, and screwdrivers. However, the
decision to remove a well-fixed im-
plant must be made carefully to
avoid excessive bone loss during re-
moval.14 The use of an explant de-
vice that has blades to cut through
the bone-prosthesis interface facili-
tates safe and expeditious removal of
most acetabular components.
Clinical Results by
Reconstruction Method
Impaction Grafting and
Cementation of the
Acetabulum
Acetabular impaction grafting re-
stores bone stock with tightly im-
pacted, well-contained cancellous
graft along with a cemented polyeth-
ylene cup. This technique is suitable
for simple cavitary defects. It also
can be used for segmental or com-
bined structural bone defects in
which metal mesh is used to create a
contained defect. Pelvic discontinuity
must be stabilized with a plate prior
to impaction grafting. Bridging with
metal mesh alone is inadequate.
Busch et al15 recently reported long-
term results (20- to 28-year follow-up)
following acetabular impaction graft-
ing. In their original study, a cohort of
patients with either cavitary or com-
bined segmental and cavitary bone de-
fects was treated with acetabular im-
paction grafting and cementation of a

132 Journal of the American Academy of Orthopaedic Surgeons


Figure 4
A, Preoperative AP pelvic radiograph of a patient with a type IIC acetabular defect of a prior hip implant.
B, Postoperative AP pelvic radiograph of the same patient following revision to a noncemented acetabular shell with
adjuvant screw fixation.
polyethylene liner.16 Of the original
cohort of 42 patients younger than
age 50 years, 37 patients were avail-
able for follow-up beyond 15 years.15
Using aseptic loosening as the end
point, this cohort demonstrated sur-
vivorship of 85% at 20 years and
77% at 25 years.15 Long-term
follow-up of impaction grafting has
demonstrated effective restoration of
bone stock and adequate cemented
fixation of polyethylene liners in the
setting of bone loss.
Noncemented Hemispheric
Acetabular Reconstruction
Noncemented reconstruction is the pre-
ferred method of acetabular recon-
struction in revision THA, specifically
for Paprosky types I and II defects.17
Several studies have demonstrated
favorable midterm (minimum, 5- to
10-year) results using noncemented
acetabular sockets with a rate of
aseptic loosening ranging from zero
to 11% and >90% survivorship with
aseptic loosening as the end
point.18-21 Della Valle et al22 reported
March 2013, Vol 21, No 3
the longest clinical follow-up (mean,
15 years; maximum, 19 years) of
noncemented acetabular cup use in
revision THA. In a cohort of 138
hips (131 patients), only 1 cup
(0.7%) was revised for aseptic loos-
ening. Cup survivorship was 96%
using revision for aseptic loosening
as an end point. A total of 19 cups
were revised for recurrent instability,
infection, or femoral component
complications. These results are con-
sistent with other revision series,
which demonstrate worse clinical
outcomes following revision THA
than following primary THA be-
cause of soft-tissue compromise,
bone deficit, and an inability to per-
fectly restore hip biomechanics.
Noncemented acetabular recon-
struction requires column and partial
rim support as well as the use of sup-
plemental fixation (Figure 4). Many
manufacturers now market porous
metal options to enhance initial sta-
bility and promote biologic fixation
in deficient bone beds. Structural al-
lografts also can be used in these
Neil P. Sheth, MD, et al
cases (Figure 5). Early results have
demonstrated enhanced biologic fix-
ation and decreased stress shielding
surrounding porous metal surfaces.23
Structural Allograft
Reconstruction
Bulk structural allograft is an option
in cases in which there is inadequate
host acetabular bone for component
fixation and stability. The purpose of
the allograft is to provide structural
stability for the noncemented com-
ponent until host bone ingrowth into
the acetabular component occurs. In
general, allograft is preferred in
young patients because it may result
in the availability of increased bone
stock that can be used in future re-
construction. However, concerns ex-
ist regarding the potential for al-
lograft resorption, infection, and
potential loosening of the construct.
Several studies have evaluated the
midterm results of structural al-
lograft in revision THA. Graft type
(ie, femoral head, distal femur, total
acetabulum) and surgical technique
133
Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management

Figure 5

A, Photograph of a modular porous metal augment placed adjacent to a revision porous metal noncemented
acetabular shell. B, Preoperative AP radiograph demonstrating a severe type IIIA defect of the right hip necessitating
reconstruction using porous metal augments in conjunction with a noncemented hemispheric shell. C, Intraoperative
photograph of a noncemented hemispheric acetabular shell cemented to a modular porous metal augment. D, AP
pelvic radiograph following noncemented hemispheric acetabular reconstruction with the modular porous metal
augment.

are the most important factors in de-
termining clinical success. An early
study by Paprosky et al11 demon-
strated component loosening in 4%
of cases (all type IIIB defects) at a
mean follow-up of 5.7 years after re-
vision to noncemented acetabular
shells with either femoral head or
distal femoral allograft. DeWal et al24
reported component loosening in
15% of revision cases performed
with femoral head or distal femoral
allograft and a noncemented device
(mean follow-up, 6.8 years).
More recently, Lee et al25 retro-
spectively reviewed 74 patients
treated with minor column shelf
structural allograft for uncontained
host acetabular bone deficits measur-
ing 30% to 50%. Minimum clinical
follow-up was 5 years (mean, 16
years). With re-revision for aseptic
loosening as an end point, cup survi-
vorship at 15 and 20 years was 67%
and 61%, respectively, and graft sur-
vivorship was 81%. Satisfactory
mid- and long-term results have been
achieved with the use of structural
allograft in revision THA; however,
the availability of porous metal aug-

134 Journal of the American Academy of Orthopaedic Surgeons


ments has led to a reduction in the
use of allograft.
Noncemented
Reconstruction With
Modular Porous Metal
Augments
A relatively new concept in the man-
agement of severe acetabular bone
loss involves the use of noncemented
hemispheric or elliptical components
in combination with modular aug-
ments.26 Unlike oblong or triflange
constructs, independent use of an ac-
etabular shell and one or more mod-
ular augments optimizes bone con-
tact and positioning of the shell and
the metal augment. Although both
the shell and augment can be inde-
pendently fixed to the pelvis, typi-
cally, the augment and noncemented
shell are “unitized” with cement.
The purpose of the augment is to
provide structural support for the ac-
etabular component until bone in-
growth occurs.
All augments are secured first to
the host bone with screws, then to
the noncemented acetabular shell
with cement. Morcellized bone graft
is placed into any remaining cavities
before the shell is impacted into posi-
tion. Additional screws are placed
through the cup into the ilium.
Noncemented porous sockets used
in conjunction with modular porous
metal augments have demonstrated
acceptable clinical results in the set-
ting of Paprosky type IIIA defects.
Sporer and Paprosky27 reviewed the
outcomes of 28 patients treated with
this type of reconstruction for Pa-
prosky type IIIA defects. At a mean
follow-up of 3.1 years, only one pa-
tient required re-revision for recur-
rent instability, and all other patients
had radiographically stable con-
structs. Van Kleunen et al28 evaluated
97 hips (90 patients) with Paprosky
types II, IIIA, and IIIB defects that
were managed with noncemented ac-
March 2013, Vol 21, No 3
etabular shells with porous metal
augments. There were no cases of
aseptic loosening at a mean
follow-up of 45 months.
For patients with pelvic discontinu-
ity and severe bone loss, treatment
options include custom triflange
cups with plate fixation, cup-cage
constructs, a hemispheric shell, or
acetabular impaction grafting. Re-
cently, a distraction technique that
combines a hemispheric shell and po-
rous metal augments has been used
to manage pelvic discontinuity. Re-
gardless of the reconstruction option
selected, healing of pelvic discontinu-
ity is difficult.
In the setting of pelvic discontinu-
ity, the distraction technique involves
the use of noncemented, hemispheric
components and augments. A reamer
is used until two points of contact
are made, typically posteroinferior to
anterosuperior. Once contact is
made, the size of the uncemented ac-
etabular shell is estimated. A series
of augments is used to decrease the
volume of the acetabulum. The aug-
ments may provide primary stability
(ie, contact between host bone and
augment to achieve initial mechani-
cal stability of the shell) or primary
fixation (ie, the initial mechanical
stability of the shell lies between two
points of host bone, but the aug-
ments provide additional surface
area for fixation of the construct).17
The use of augment distraction for
the management of pelvic disconti-
nuity is technically difficult, and only
short-term follow-up data are cur-
rently available.
The use of modular porous metal
augments with a noncemented socket
using distraction has been shown to
be effective in managing Paprosky
type IIIB defects with pelvic disconti-
nuity. In one study, 13 patients were
retrospectively reviewed at a mean
follow-up of 2.6 years.29 At final
follow-up, only 1 hip had possible
radiographic loosening secondary to
Neil P. Sheth, MD, et al
screw breakage, and the other 12
were radiographically stable. No pa-
tient required repeat surgical inter-
vention. The early results with po-
rous metal augments appear to be
promising. However, long-term
follow-up data are necessary because
of concerns regarding the manage-
ment of these augments should infec-
tion develop after ingrowth has oc-
curred.
Ring and Cage
Reconstruction
Rings and cages are indicated for use
in revision THA when remaining
bone stock is deficient and the device
can act as a scaffold while protecting
morcellized or structural allograft
during the bone remodeling phase.
The two types of ring used are the
roof reinforcement ring and the anti-
protrusio cage. The roof ring pro-
tects the superior acetabular dome,
whereas the antiprotrusio ring ex-
tends from the superior ilium inferi-
orly to the ischium and protects the
entire acetabulum. The major advan-
tages of rings and cages are the abil-
ity to cement a liner in any position
independent of the ring position and
the elution of local antibiotics from
the cement. The major disadvantage
is the risk of cage fracture or loosen-
ing resulting from lack of biologic
fixation. However, if the graft re-
models by the time of ring fracture, a
subsequent standard noncemented
acetabular revision is often possible.
The use of cages has decreased be-
cause of cage breakage over time and
because of increased enthusiasm for
the use of porous metal components
and augments.
Midterm results with the use of a
ring or cage have been satisfactory.
Zehntner and Ganz30 followed 27
patients for a mean of 7.2 years
(range, 5.5 to 10 years) and reported
80% survivorship of a roof ring con-
struct at 10 years. Goodman et al31
135
Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management
evaluated 42 hips at a mean follow-up
of 4.6 years after implantation of
Burch-Schneider cages and reported
76% survivorship with revision due to
construct fracture or loosening as an
end point. A recent evaluation of the
Burch-Schneider antiprotrusio cage in
60 elderly patients undergoing revision
THA for AAOS types III and IV ac-
etabular bone loss indicated that, at fi-
nal follow-up, only one revision was
performed, for recurrent instability.32
Radiographic evidence of component
loosening was absent in all cases.
Currently, this treatment option may
be optimally used in elderly patients
with extensive bone loss that pre-
cludes the implementation of a hemi-
spheric shell and for whom long-
term fixation is not mandatory.
Oblong Cup Reconstruction
The use of oblong cups is one tech-
nique of defect matching in revision
THA. These cups are designed to
achieve mechanical stability on host
bone, not on structural allograft.
Oblong cups are most commonly in-
dicated for superior rim defects (ie,
Paprosky types IIB and IIIA), and
less bone removal is required to
match the defect. Few long-term data
are available on this technique.
Landor et al33 recently reported mid-
term results in a comparison of two dif-
ferent oblong cups used to treat pa-
tients with Paprosky type IIB and IIIA
defects (mean follow-up, 7.3 years in
group 1 and 9.7 years in group 2). At
final follow-up, aseptic loosening rates
of 5.3% to 13.5% were seen in each
patient cohort. Oblong cups may have
a limited role in revision THA for the
management of specific bone loss pat-
terns; however, their use has largely
been supplanted by modular porous
metal augments.
Cup-cage Reconstruction
Cup-cage reconstruction is another
relatively new technique. A porous
136
metal acetabular shell is used in con-
junction with a spanning ilioischial
cage to allow for mechanical con-
struct stability while trying to
achieve biologic fixation of the
acetabular shell. Kosashvili et al34 re-
viewed a consecutive series of 26 ac-
etabular reconstructions with a cup-
cage construct in 24 patients with
pelvic discontinuity. The mean
follow-up was 44.6 months (range,
24 to 68 months). Failure was de-
fined as component migration of >5
mm. Twenty-three hips demon-
strated no clinical or radiographic
evidence of loosening at final
follow-up (88.5%). The mean Harris
hip score improved from 46.6 points
(range, 29.5 to 68.5 points) to 76.6
points (range, 55.5 to 92.0 points) at
2 years (P < 0.001). The authors
concluded that cup-cage constructs
were a reliable option for the man-
agement of pelvic discontinuity (Fig-
ure 6).
The cup-cage construct can be used
to manage not only Paprosky types
IIIA and IIIB bone loss but also pel-
vic discontinuity. In this technique, a
noncemented acetabular shell with
or without a porous metal augment
is fixed to host bone. An antiprotru-
sio cage is then placed in the nonce-
mented shell to stabilize the disconti-
nuity. Proponents of this technique
believe that the cage provides initial
stabilization of the discontinuity,
thereby allowing time for biologic
fixation of the porous noncemented
shell and augment to host bone.
Ballester Alfaro and Sueiro Fernán-
dez35 evaluated 13 patients with Pa-
prosky type IIIA bone loss and 6 pa-
tients with Paprosky type IIIB bone
loss that was managed with porous
metal shells and modular buttress
augments. Five of the 19 patients
had pelvic discontinuity, identified
either preoperatively or intraopera-
tively, and underwent a cup-cage re-
construction with a porous shell,
modular buttress augment, and anti-
Journal of the American Academy of Orthopaedic Surgeons
protrusio cage. At a mean follow-up
of 26 months (range, 18 to 43
months), there were no failures for
aseptic loosening. Although early re-
sults following reconstruction with a
porous metal shell in conjunction
with modular porous augments and
an antiprotrusio cage seem promis-
ing, long-term follow-up studies are
needed.
Triflange Reconstruction
In some cases, defect bridging tech-
niques are required instead of defect
matching techniques. Paprosky type
IIIA and IIIB defects typically require
management with a defect bridging
technique; major structural allografts
or antiprotrusio cages may be con-
sidered as salvage options for these
defects.
To generate a custom triflange con-
struct, a plastic hemipelvic model is de-
veloped based on a three-dimensional
CT scan of the patient’s pelvis. This
model is used to create a custom po-
rous or hydroxyapatite-coated flanged
titanium device (Figure 7). Model gen-
eration preoperatively can be very help-
ful for understanding bone defects and
for teaching purposes before surgery.
These individualized constructs allow
for potential biologic fixation of the
construct to the ilium, ischium, and pu-
bis. In cases of pelvic discontinuity, a
triflange component allows for rigid
fixation that spans the discontinuity; in
contrast, rings and antiprotrusio cages
are flexible. Rigid fixation may lead to
subsequent healing of the discontinu-
ity.
Excellent midterm clinical results
have been reported following place-
ment of triflange constructs in revi-
sion THA. Dennis36 retrospectively
reviewed 24 hips at a mean of 4
years following triflange cup inser-
tion. One cup required revision for
loosening, and two additional cups
demonstrated radiographic loosen-
ing, but the patient refused subse-
 Neil P. Sheth, MD, et al

Figure 6

A, Preoperative AP pelvic radiograph demonstrating severe bone loss and vertical displacement of the left acetabular
component. B, AP pelvic radiograph obtained following placement of a cup-cage construct to address severe
acetabular bone loss.

Figure 7

A, Preoperative AP pelvic radiograph of a patient who underwent previous primary total hip arthroplasty following
pelvic irradiation. There is evidence of superior migration and possible pelvic discontinuity secondary to underlying
radiation necrosis. B, Photograph of a custom triflange component that was created based on a hemipelvic plastic
model. The device was designed to span the bone defect and obtain screw fixation along the ilium and ischium. C, AP
pelvic radiograph demonstrating a well-fixed triflange construct at 9-year follow-up and healing of the underlying pelvic
discontinuity.

quent surgical intervention. DeBoer
et al37 performed triflange compo-
nent insertion in 18 patients (20
hips) with massive acetabular bone
loss and pelvic discontinuity. At a
mean follow-up of 10 years, none of
the components had been revised for
aseptic loosening, and healing of the
discontinuity was radiographically
evident in 18 of the 20 hips (90%).
Triflange constructs in the setting of
severe acetabular bone loss with or
without pelvic discontinuity have dem-
onstrated excellent midterm results,
with low rates of component loosening
and with healing of the discontinuity.
Concerns regarding the triflange con-
struct include the overall cost, the fea-
sibility of biologic ingrowth, and the
long-term effect of the stiff metal con-
struct on host bone.

March 2013, Vol 21, No 3 137

Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management
Summary
Successful acetabular revision surgery
requires thoughtful evaluation, metic-
ulous preoperative planning, and skill-
ful execution. It is essential to evaluate
the extent of bone loss present. In most
cases, the key is obtaining rigid fixation
of the hemispheric shell with adjuvant
screw fixation. Bone loss may be ad-
dressed with structural or particulate
bone graft, modular porous metal aug-
ments, structural allograft, a cup-cage
construct, or custom triflange cups.
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