The Journal of Arthroplasty Vol. 23 No.

7 2008

Technical Note

A Novel Technique for the Removal of

Well-Fixed Cementless, Large-Diameter
Metal-on-Metal Acetabular Components

Christophe Olyslaegers, MD, Tom Wainwright, BSc (Hons) MCSP, and

Robert G. Middleton, MA FRCS (Tr &Orth)

Abstract: Removing well-fixed cementless acetabular components can be a

challenge for every orthopedic surgeon involved in revision hip arthroplasty.
Forceful removal of such components often leads to acetabular bone loss and
compromises reimplantation of a new socket. Instruments like the Explant
Acetabular Cup Removal System (Zimmer, Warsaw, Ind) are developed to avoid
such issues. We report a novel technique, cementing a polyethylene liner inside the
uncemented metal-on-metal shell and using systems such as the Explant to safely
extract it without the need for matching large-diameter heads. We successfully used
this technique on 3 occasions and recommend its use. Key words: hip resurfacing,
acetabular revision, removal of cementless component.
© 2008 Elsevier Inc. All rights reserved.

Removing well-fixed cementless acetabular compo-
nents can be a challenge for every orthopedic
surgeon involved in revision hip arthroplasty. For-
ceful removal of such components using curved
gouges and osteotomes often leads to extended
acetabular bone loss and compromises reimplanta-
tion of a new socket whether it is cemented or
uncemented. The importance of using a more bone-
conservative technique has been emphasized in the
literature [1-4,10], and several techniques have
been described to address the difficulty of this task
[5-7]. Fortunately, indications for implant removal
are scarce, and most of the contemporary cementless
components perform very well through improved
From the Orthopaedic Department, The Royal Bournemouth and
Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK.
Submitted July 20, 2007; accepted April 8, 2008.
No benefits or funds were received in support of the study.
Reprint requests: Christophe Olyslaegers, MD, Orthopaedic
Department, Royal Bournemouth Hospital, Castle Lane East,
Bournemouth, BH7 7DW Dorset, UK.
© 2008 Elsevier Inc. All rights reserved.
0883-5403/08/2307-0020$34.00/0
doi:10.1016/j.arth.2008.04.006
bony ingrowth. Possible indications for application of
this technique would include proven deep infection,
which requires removal of all components, severe
backside osteolysis, and a malpositioned socket with
implant or bony impingement and subsequent
hip pain.
The implant industry has responded accurately to
the needs of the revision surgeon and developed
instruments such as the Explant Acetabular Cup
Removal System (Zimmer, Warsaw, Ind) to over-
come such issues with less effort. It was designed to
minimize acetabular bone loss at the bone-cup
interface and uses 2 blade styles for each cup size to
facilitate progressive removal of the cup. The blades
closely match the acetabular cup's outer diameter,
and centering heads, which match the acetabular
cup inner diameter, are used to stabilize and guide
the blades during cutting. Well-fixed, medialized
sockets should be approached very cautiously so as
to avoid damage to the medial wall. However, with
large-diameter metal-on-metal (MoM) articulations
becoming more popular, removing a well-fixed
cementless acetabular component remains a chal-
lenge. Matching large-diameter centering heads for

1071
1072 The Journal of Arthroplasty Vol. 23 No. 7 October 2008
Fig. 1. Dissociated Birmingham shell and Palacos cemen-
ted Zimmer cemented acetabulum liner.
these components are not as widely available as the
more common head sizes. A trial liner could be used,
but it would lack stability and spin or move when it is
introduced in the polished surface of the MoM
articulation. We report a novel technique using a
cemented polyethylene liner inside the uncemented
shell that facilitates component removal, is quick and
easy to use, and reduces acetabular bone loss (Fig. 1).
Surgical Technique
A default technique is used to dissect the hip joint,
and the acetabular component is exposed circum-
Fig. 2. Polyethylene liner cemented into a resurfacing
shell.
Fig. 3. Precise fit of the Explant blades around a
resurfacing shell.
ferentially. When implant details are available, the
matching-size Explant blades and centering head
can be mounted. With this system, sizes ranging
from 42 mm up to 72 mm outer diameter can be
addressed. All sizes of common heads (22, 26, 28,
and 32 mm) can be used, but we recommend using a
32-mm-diameter head. It provides better stability
and a bigger pivoting surface. Bone cement is mixed
and manually pressurized in its late phase, followed
by insertion of a polyethylene liner closely matching
the inner diameter of the exposed MoM shell. The
Fig. 4. The acetabulum after removal of a resurfacing
shell. Well-preserved bone stock and footprint of the shell
are clearly visible.
 Removal of Well-Fixed Cementless Acetabular Components  Olyslaegers et al
liner is oriented in the same plane as the receiving
socket (Fig. 2). Avoid cement leaking around the
circumference of the cementless shell as this will
block the Explant blades. We recommend down-
sizing the polyethylene liner one size because this
will facilitate the centering process and it avoids a
too big cement mantle. A smaller implant will create
an unnecessary thick cement mantle and the central
position of the liner is more difficult to control.
Positioning a liner eccentrically may cause oversized
blades to be used and will potentially remove more
bone than necessary. It is therefore important to
have a clear view on the entire socket to optimize
liner positioning to be able to use blades that will
closely match the shells' outer diameter (Fig. 3). For
improved stability of the socket-cement interface,
the inner surface of the socket can be roughened
with a high-speed carbide burr. After cement has
set, the liner can then be used as it was the case with
a contemporary cementless acetabular component.
Discussion
The concept of cementing a polyethylene liner
into a metal shell is not a new concept because it has
been used as a treatment method in revision hip
arthroplasty. Beaule et al [8] used this double-socket
technique as an alternative technique when con-
fronted with a deficient locking mechanism or the
unavailability of matching liners for a well-fixed
uncemented shell. In their article, they reported a
5-year survival rate of 78% with revision as an end
point, but they emphasize that this technique should
not be used when there is a history of instability.
More important, retaining the socket preserves
acetabular bone stock and still permits conversion
to alternate bearing surfaces [8]. Springer et al [9]
reviewed their series and published early results
using this technique. They did not see polyethylene
dissociation or acetabular loosening and found it to
be a successful technique at providing secure
fixation while preventing bone loss. We used this
technique to remove rather than preserve a well-
fixed acetabular component.
Removing a well-fixed acetabular component
may lead to significant bone loss and subsequently
result in a higher incidence of component loosen-
ing [10]. Furthermore, MoM arthroplasties are
frequently used in the younger patient where
preservation of bone stock is of particular impor-
tance. In our experience of 3 cases (2 infected and
1 malpositioned resurfacing arthroplasty), with
blades closely matching the shell's outer diameter,
the implant at time of revision averaged 4 mm
1073
more than the extracted cup's diameter with a
2-mm press fit (Fig. 4). These results are compar-
able with the results of articles using the same
technique [1] and less than results obtained by
conventional methods [11].
Several companies have already developed mod-
ular big heads to fit on Explant-like systems, but
availability and cost of hiring one of these sets of
instruments can be a concern. We found the combi-
nation of the Explant Acetabular Cup Removal
System and a polyethylene liner cemented inside a
large-diameter MoM socket to be technically repro-
ducible, quick, and efficient in preserving host bone.
The Explant system is a reliable and safe tool on its
own, and we would recommend its use in the
revision of well-fixed acetabular components.
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