Copyright 986 by The Journal of Bone and Joint Surgery.

Incorporated

Femoral Head Autografting to Augment Acetabular Deficiency

in Patients Requiring Total Hip Replacement
A MINIMUM FiVE-YEAR AND AN AVERAGE SEVEN-YEAR FOLLOW-UP STUDY*

BY SAMUEL D. GERBER, M.D.t, AND WILLIAM H. HARRIS, M.D.t, BOSTON, MASSACHUSETTS

From the Massachusetts General Hospital, Boston

ABSTRACT: Adults who have osteoarthritis that is on the hip. Charnley and Feagin thought, as did Coventry,
secondary to mild congenital dysplasia can be treated that total hip replacement is contraindicated when the ace-
with total hip replacement using customary techniques. tabular bone stock is inadequate. Because ofthese warnings,
Those who have severe acetabular dysplasia or total con- modifications of total hip arthroplasty have been sought that
genital dislocation usually require augmentation of ace- would avoid the complications that may arise because of
tabular bone stock in order to carry out the total hip inadequate acetabular bone stock. Proposals have included:
replacement. We reviewed the results offorty-seven total using a small acetabular component, inserting a graft be-
hip replacements in thirty-eight patients (age range, six- tween the split inner and outer tables of the ilium above the
teen to sixty-eight years; average age, forty-seven years) acetabulum, or doing a shelf or Chiari procedure. Harris et
who required autogenous grafting with bone from the 6
described the use of an autogenous bone graft from the
femoral head for severe acetabular deficiency. The av- femoral head in the reconstruction procedure.
erage length of follow-up was 7. 1 years (minimum, five The present report is a review of the results of forty-
years). All grafts united. The average preoperative Har- seven consecutive total hip-replacement procedures (in
ris hip rating was 46 points and the average postoper- thirty-eight patients) in which we used bone from the fem-
ative rating was 74 points. Five hips (approximately 10 oral head as an autogenous graft for correction of severe
per cent) had a failure that required reoperation; four acetabular deficiency. Follow-up data after a minimum of
hips had aseptic loosening of the acetabular component five years were available for all forty-seven hips, for which
and in the fifth sepsis developed after a reoperation to the average follow-up was 7. 1 years and the maximum was
reattach the greater trochanter. For the remaining forty- 1 1 .3 years. A forty-eighth hip was operated on, but was
two hips, the average postoperative Harris hip rating excluded from follow-up because the patient died of unre-
was 78 points. Six additional sockets (approximately 15 lated causes two years after the operation. The preoperative
per cent) were definitely loose by radiographic criteria, and perioperative data on the remaining hips were analyzed
making a total of ten hips (approximately 20 per cent) along with a review of all pertinent radiographs. Clinical
with definite aseptic loosening of the acetabular com- data were obtained from a written questionnaire for thirty-
ponent. The major factors that contributed to this asep- three patients, from a telephone interview for one, and from
tic loosening were complexity of the surgical procedure, a personal examination for four.
necessity for a graft, lack of a small-sized metal-backed
acetabular component, young age, obesity, lack of pos- Methods and Materials
tenor support, and resorption of the graft. Dislocation Between October 1973 and July 1979, one of us (W.
was common, occurring in five (approximately 10 per H. H .) performed forty-eight total hip replacements in thirty-
cent) of the hips. Despite the high rate of complications, nine patients, all of whom had severe acetabular deficiency.
the procedure is rewarding for patients who are severely Of the thirty-eight patients who were followed for a mini-
disabled by osteoarthritis that is secondary to severe mum of five years, thirty-four were female and four were
dysplasia or dislocation. male. The average age was forty-seven years (range, sixteen
to sixty-eight years). Eleven unilateral operations were done
Severe acetabular deficiency represents a major chal- on the right hip and eighteen, on the left. Both hips were
lenge to surgeons who perform reconstructive procedures operated on in nine patients.
The need for bone-grafting of the acetabulum is a din-
ical judgment that is made at the time of operation. Our
* One or more of the authors have received or will receive benefits
for personal or professional use from a commercial party related directly
preference is to have 80 per cent of the cup covered by iliac
or indirectly to the subject of this article. In addition, benefits have been bone after full preparation of the acetabulum. This deter-
or will be directed to a research fund or foundation, educational institution,
or other non-profit organization with which one or more of the authors are
mination is made after reaming the acetabulum down to,
associated. Funds were received in total or partial support of the research but not including, the wall and fitting the smallest acetabular
or clinical study presented in this article. The funding source was The
William Harris Foundation.
component available. Inability to obtain 70 to 80 per cent
t Massachusetts General Hospital, Boston, Massachusetts 021 14. coverage of the acetabular component by the remaining iliac

VOL. 68-A, NO. 8, OCTOBER 1986 1241

1242 S. D. GERBER AND W. H. HARRIS

bone was the indication for the use of a bone graft. The acetabular bone-cement interface was assessed as
The diagnosis in most patients was congenital dislo- described by DeLee and Charnley, with specific reference
cation (twenty-five hips) or severe congenital dysplasia to migration of the component, fracture of the cement, and
without dislocation (sixteen hips). The less frequent diag- radiolucency at the cement-bone interface. Although the use
noses were dislocation or severe acetabular deficiency sec- of plain radiographs results in an underestimation of the
ondary to arthrogryposis (two hips) or to Ollier’s disease, frequency of loosening of the acetabular component2 , only

rheumatoid arthritis, fracture-dislocation of the hip, or coxa plain radiographs were evaluated in this study because ar-
vara after a prior Milch resection arthroplasty (one hip each). thrograms were not available.
Twenty-three of the thirty-eight patients had involvement Definite loosening was defined as migration of the ace-
of both hips, and twenty-four prior operations had been tabular component - that is, a discernible shift in the po-
performed on nineteen of the forty-seven hips. These pro- sition of the acetabular graft, the acetabular component, or
cedures included eleven shelf arthroplasties, four subtro- the cement mantle - or a fracture of the cement or the
chanteric osteotomies, three cup arthroplasties, two Milch acetabular component, or both. Impending failure meant
osteotomies, two open reductions, one plating of a proximal that there was a radiolucent line at the cement-bone interface
femoral fracture, and one open reduction and internal fix- that both was continuous throughout the interface and was
ation of a fracture-dislocation. None of the patients had had at least two millimeters thick at every point’#{176}.Possible los-
sepsis in the hip that had the total replacement. The pre- ening was defined as any continuous radiolucency around
operative data as to physical and functional findings will be an acetabular component, any radiolucent zone of more than
presented in the section on Observations. The patients two millimeters, or failure of the fixation that had been used
ranged in height from 1 .47 to 1 .83 meters and in weight to hold the graft to the pelvis.
from 37.7 to 81 .7 kilograms (average, 58. 1 kilograms). The femoral components were evaluated in accordance
We used a modified Kocher incision with release of with the categories of loosening described by Harris et al.’7
the short external rotators, the posterior part of the capsule, In order for a component to be considered definitely lose,
and the gluteus maximus tendon’214’6. In forty-six hips bone there had to be evidence of migration; for it to be considered
from the ipsilateral femoral head was used for the autograft probably loose, there had to be a complete radiolucent zone
and in the forty-seventh bone from the contralateral femoral around the cement mantle; and for it to be considered pos-
head was used (the graft had been obtained fifteen days sibly lose, there had to be a radiolucent zone occupying
earlier, at the time of a contralateral total hip replacement, between 50 and 99 per cent of the cement-bone interface.
and had been stored sterile and frozen at 70 degrees
- Cel-
sius in the interval). The forty-seventh hip was in a patient Observations
who had had bilateral coxa vara and had undergone a Milch The duration of the operative procedures averaged 355
osteotomy on the ipsilateral side. minutes (range, 265 to 465 minutes), and the average mea-
Because of the small size of the acetabulum, a pros- sured intraoperative blood loss was 1 .488 milliliters (range,
thesis with a small acetabular component was used in thirty- 610 to 4, 100 milliliters). The average total blood loss during
seven of the forty-seven hips. The outer diameter of the hospitalization was 1 ,99l milliliters (range, 825 to 5,035
component was fifty millimeters in one hip, forty-nine mil- milliliters).
limeters in one hip, forty-four millimeters in eight hips, The greater trochanter was osteotomized in all hips. In
forty millimeters in nineteen, thirty-six millimeters in thir- forty-three hips it was advanced its entire length onto a
teen, and thirty-four millimeters in five hips, and the inner cortical bed, in one it was advanced halfway, and in three
diameter was twenty-six millimeters in twelve and twenty- it was reattached without advancement. In forty-two hips
two millimeters in thirty-five hips. No metal-backed ace- the site of the trochanteric osteotomy united within six
tabular components were used, and acetabular mesh was months, and in two it did not unite until more than six
used in only three hips. months elapsed. Three trochanters did not unite, and all
The results of fifteen of the forty-seven hips were in- three required reoperation, one revealing a fibrous union.
cluded in a previous report26, and for them we are now All of the trochanters that showed delayed union or non-
reporting a longer follow-up. union had been placed onto a cortical bed.
We analyzed all follow-up radiographs. Union of the To facilitate the operative exposure, the iliopsoas ten-
graft was evaluated by assessing radiographic evidence of don was released in all but one hip and was transferred
osseous bridging of the interface between the graft and the anteriorly into the leading edge of the gluteus medius as it
ilium. Resorption of the graft and coverage of the acetabular inserts onto the greater trochanter in forty-two hips. It was
component were assessed on anteroposterior radiographs. not reattached in four hips.
Resorption of less than one-third of the graft was considered Femoral shortening was required in forty-four hips.
minor; of between one-third and one-half of the graft, mod- The femoral osteotomy was done proximal to the level of
erate; and of more than one-half of the graft, major. The the lesser trochanter in one hip, at the level of the lesser
percentage of each acetabular component that was covered trochanter in six, and distal to the level of the lesser tro-
by intact acetabular bone, covered by autograft, and not chanter in thirty-seven.
covered by bone was recorded. The autograft was placed against the lateral aspect of

THE JOURNAL OF BONE AND JOINT SURGERY

 FEMORAL HEAD AUTOGRAFTING TO AUGMENT ACETABULAR DEFICIENCY 1243

the ilium in forty-four hips and into the acetabulum in three. eration. All dislocations were reduced closed, and none
Fixation was accomplished with two bolts in thirty hips, recurred.
three bolts in thirteen, four bolts in one, two bolts and one There were two large wound hematomas, neither of
screw in two, and one bolt and one screw in one. Small which required drainage. Two patients had a partial sciatic-
plates were used as washers to enhance the fixation in five nerve palsy and two, a lateral femoral cutaneous-nerve
hips. To gain exposure for the seating of the nut on the bolt, palsy. All four palsies resolved spontaneously. Two patients
a counter incision’3 was used to provide access to the inner had a cardiac complication: one, ischemia of the anterior
wall of the ilium in twenty hips. In the other hips the nuts aspect of the cardiac wall and the other, a left bundle branch
could be placed on the bolts blindly using a finger-tip nut- block. Both of these lesions resolved without long-term
carrier’ 2.4 sequelae. One patient had urinary retention with infection
All of the acetabular components were anteverted. of the urinary tract, viral labyrinthitis, and contact derma-
Their degree of abduction averaged 32 degrees (range, 52 titis.
to 21 degrees). Forty-four acetabular components were in- Heterotopic ossification developed in seventeen hips:
serted without pressurization of the cement and three, with Class I in seven, Class II in four, Class III in five, and Class
pressurization. IV in one2.
The microminiature Harris CDH femoral component Sepsis developed in one patient after a reoperation to
was used in twenty-seven hips, but in three it was ground reattach the greater trochanter and subsequently necessitated
down to a smaller size in the hospital machine shop. Three a resection arthroplasty.
CAD miniature, two CAD small standard, one CAD stan- Four patients underwent reoperation for symptomatic
dard, ten HD2 small-stem, two HD2 regular-stem, one me- aseptic loosening of the acetabular component. The mean
dium Charnley, and one miniature Charnley femoral time between the index operation and reoperation was sixty-
component were used in the remainder of the hips. The two months (range, thirty-five to ninety-two months). Be-
femoral canal was plugged with cement in twenty-one hips, fore reoperation, the average hip score” was 3 1 points
the others being too small to accept the syringe. The femoral (range, 15 to 47 points) and at follow-up, it was 80 points
cement was pressurized in only four hips. (range, 67 to 92 points). Two of the patients had loosening
Postoperatively, the patients remained in bed for three of both the femoral and the acetabular component at op-
to twenty-eight days (average, seven days). In the six pa- eration, and both underwent resection arthroplasty. One of
tients who remained in bed for eighteen to twenty-eight them had a large lytic area in the distal portion of the in-
days, reattachment of the greater trochanter had been dif- tramedullary canal that was attributed to a reaction to the
ficult. Two patients required a spica cast postoperatively. cement and therefore required an onlay allograft from the
One of them had an abductor slide, and the other had trau- femoral shaft as a cortical femoral strut into the medullary
matic cerebral dysfunction and was unable to cooperate with cavity. The remaining two patients who underwent reoper-
the partial weight-bearing. ation for aseptic loosening had loosening of only the ace-
All of the patients were instructed to use two crutches tabular component, and a revision total hip replacement was
for at least six months. One non-compliant patient who used done. Neither patient required any additional bone-grafting
two crutches for only two months was found to have a of the acetabulum.
broken trochanteric wire and a fracture of the acetabular In all four of the patients who underwent reoperation
cement at six months. The patient subsequently had tro- for aseptic loosening, it was revealed grossly that the au-
chanteric non-union and break-out of the prosthetic socket. tografts had united, and histological examination of biopsy
One patient used crutches for fifteen months because of specimens of the autografts showed evidence of osteone-
delayed union of the greater trochanter. The remaining pa- crosis with new-bone formation and revascularization (Fig.
tients used crutches for six to twelve months (average, nine 1).
months). In the total series, the preoperative and postoperative
Intraoperative complications included perforation of Harris scores averaged 46 and 74 points (ranges, 19 to 84
the distal part of the medial aspect of the femoral cortex by points and 15 to 100 points), respectively (Fig. 2). Preop-
the femoral stem in two hips. Autologous iliac-crest bone eratively, five hips in four patients had no or only slight
grafts were placed over the perforation. Two fractures of pain. Two of these patients had severe pain in the back and
the proximal end of the femur occurred. One was treated knee preoperatively, and the other two patients had little or
with cerclage wires and the other was grafted with autolo- no pain because they used two crutches for all walking.
gous iliac-crest bone. The graft fragmented intraoperatively Nineteen hips had mild or moderate pain and twenty-three
in one hip and required the use of a short
plate as a washer. had marked or disabling pain.
Postoperatively, there were eight venographically doc- Preoperatively, nineteen patients (with twenty-three in-
umented venous thromboses, six of which were treated with volved hips) required no support when walking. Ten patients
heparin and Coumadin (warfarin). Five total hip prostheses (with thirteen involved hips) required one cane or crutch.
dislocated: three anteriorly and two posteriorly. Three dis- Eight patients (with ten involved hips) used two canes or
locations occurred within one month after operation; one, crutches. One patient was bedridden with severe bilateral
at one and one-half years; and one, at five years after op- coxa vara.

VOL. 68-A, NO. 8. OCTOBER 1986

1244 S. D. GERBER AND W. H. HARRIS

FIG. I
Biopsy specimen of an autograft taken from a forty-year-old woman who underwent reoperation for aseptic loosening of the acetabular component
fifty-four months after total hip replacement.

Compared with the preoperative scores, the postop- component was seen to be completely covered in thirty-nine
erative hip ratings showed a significant over-all improve- hips. In the remaining eight the lack of coverage averaged
ment (p < 0.001). Postoperatively, the pain was 8 per cent (range, 5 to 15 per cent). An average of 42 per
significantly (p < 0.001)
less and function had significantly cent of the acetabular component was covered by graft
improved (p 0.01).
< However, there was no significant (range, 15 to 65 per cent). In five of the ten hips that had
difference in the patients’ preoperative and postoperative a loose acetabular component, the socket broke out. In ad-
use of supports. On follow-up evaluation, twenty (43 per dition to the five hips that required reoperation, six acetab-
cent) of the forty-seven hips required the patient to use at ular components showed definite loosening by radiographic
least a cane full-time for support. The patient who was criteria, and all six showed fracture of the cement. Five of
bedridden preoperatively used a cane full-time at follow- the six hips showed migration, and two of the five showed
up.
Excluding the five hips that were reoperated on, the
100- t,. .
average postoperative Harris hip rating was 78 points, but ..a$
for five of these hips the postoperative score was less than - z#{149} #{149}#{149}
.
the preoperative score. The remaining thirty-seven hips #{149}A A.
(Fig. 2) had an average improvement in the Harris hip rating 80- 21 #{149}#{149}#{149}#{149}#{149}S
of 46 points (range, 16 to 66 points). . ,
- ...
Union of the graft was difficult to assess in some hips, .. #‘#{149}

but it seemed to be solid in all. There was no evidence of 60- #{149}

resorption of the graft in seven hips, and there was minor
- oA#{149}
resorption in twenty-six, moderate resorption in eight, and
40- ,/‘ 0
major resorption in six hips. Resorption of the graft was
lateral in twenty-three hips, superior and lateral in seven,
superior in four, posterior and lateral
in three, inferior and
lateral in two, and posterior in one hip. 20- 7
None of the femoral head autografts migrated. Five
showed minor fragmentation, affecting less than one-third / 0
of the graft. Five grafts had cement in some part of the C I I I. I I I I I .I
bone-bone interface, but all of them united in the other parts.
0 20 40 60 80 100
In five hips, late fatigue failure of a bolt occurred. In two
of them there was major resorption of the graft, while in PREOPERATIVE H/P SCORE
FIG. 2
the other three it was only minor. In all five, the graft had
A comparison of preoperative and postoperative Harris hip scores. The
united and the bolt had failed afterward.
hollow circles represent hips that had a reoperation. The triangles represent
On the initial postoperative radiographs, the acetabular hips that had radiographic evidence of definite loosening.

THE JOURNAL OF BONE AND JOINT SURGERY

 FEMORAL HEAD AUTOGRAFTING TO AUGMENT ACETABULAR DEFICIENCY I 245

impending failure. None showed fracture of the acetabular apparently intact; at 4.5 years, approximately 94 per cent;
component. and at 5.5 years, approximately 92 per cent. Figure 3 is a
Four hips
showed possible loosening of the acetabular graphic representation of the percentage of acetabular com-
component that is, a progressive
- radiolucency of more ponents that became definitely loose over time.
than two millimeters in only one zone9 (Zone III in three Hips that were definitely loose by radiographic criteria
hips and Zone I in one). One of these four hips also showed had significantly lower scores (p < 0.02) than did hips that
failure of the bolt. None showed a continuous line of ra- were apparently intact. However, there was no significant
diolucency. difference between the ratings of the hips that were definitely
Two of the five hips that required reoperation showed loose and those that were possibly loose. There was also
loosening of the femoral component at operation, and two no significant difference between the ratings of the hips that
hips that did not require reoperation showed radiographic were apparently intact and those that were possibly lose.
evidence of possible loosening of the femoral component. Moreover, the clinical rating of the hip did not correlate
No hip that did not require reoperation showed definite or with its radiographic appearance. A history of prior surgery
probable loosening of the femoral component. had no prognostic significance in terms of the eventual de-
Of the ten hips that showed definite aseptic loosening velopment of definite loosening. There was no significant
of the acetabular component, the average time from the difference in outcome between the hips that had a primary
index operation to revision or to radiographic evidence of diagnosis of congenital total dislocation and those that had
definite loosening was 70.2 months (range, thirty-five to severe acetabular dysplasia.
105 months). At the time of the index operation, the average age of
So-called life-table survival analysis (Table I) showed the patients in whom the acetabular component showed def-
that there is approximately 85 per cent probability (standard mite radiographic loosening or who required revision for
error, 5 per cent) of an acetabular reconstruction performed aseptic loosening was thirty-five years (range, sixteen to
with the insertion of a femoral head autograft lasting six fifty years). in comparison, the average age of patients who
years. The risk of failure during the first two years after did not have definite radiographic loosening was fifty years
operation is zero, but after that the risk increases with time (range, nineteen to sixty-eight years) (p < 0.01).
(the risk between the third and fourth postoperative years Although there was no significant difference in the
is 0.0225, compared with 0.0230 between the fourth and average weight of the patients who had definite radiographic
fifth years and 0.057 1 between the fifth and sixth years). loosening compared with those who did not have such loos-
Although an assessment of the cumulative hazard function ening, patients who had symptomatic aseptic loosening that
shows that none of the acetabular components were defi- required reoperation were significantly heavier (an average
nitely loose at 2.5 years, the percentage of definitely lose of 25 per cent overweight25) than those who did not require
components increased over the next three years. At 3.5 reoperation for symptomatic loosening (an average of 8 per
years, approximately 95 per cent of the components were cent overweight) (p < 0.05).

1000

8.75

7.50

6.25

500

3.75

2.50

I .25

0
L I 1 1 1 1 1 1 1 1

0 0.7 1.4 21 2.8 3.5 42 4.9 5.6 6.3

TIME (years)
FIG. 3
The percentage of acetabular components that showed definite loosening, plotted against time.

VOL. 68-A, NO. 8, OCTOBER 1986

1246 S. D. GERBER AND W. H. HARRIS

FIG. 4-A FIG. 4-B

Figs. 4-A through 4-D: This forty-nine-year-old woman had congenital dislocation of the left hip.
Fig. 4-A: Preoperative radiograph.
Fig. 4-B: Radiograph made immediately after total hip replacement employing an autograft of bone from the femoral head.

All ten hips that had definite aseptic acetabular loos- resorption and three had major resorption of the graft. All
ening had some resorption of the graft. Five had minor, two of the hips that had major resorption of the graft showed
had moderate, and three had major resorption. Of the four either definite or possible acetabular loosening. Radio-
hips that had possible acetabular loosening, one had minor graphic evidence of definite or possible acetabular loosening

No Posterior Support
\.

FIG. 4-C
Fig. 4-C: The lack of posterior support of the acetabular component is illustrated.
Fig. 4-D: Radiograph made eighty-two months after total hip replacement, showing a definitely loose acetabular component with a fracture of the
acetabular cement. Minor superior resorption of the graft is also apparent.

ThE JOURNAL OF BONE AND JOINT SURGERY

 FEMORAL HEAD AUTOGRAFTING TO AUGMENT ACETABULAR DEFICIENCY 1247

TABLE I

LIFE-TABLE SURVIVAL ANALYSIS

No. of
No. of Hips Lost No. of Cumulative
Hips at to Follow-up No. of Hips Proportion
Time Beginning during Hips with Exposed to of Intact
Interval of Interval Interval Failure* Failure Componentstt Hazardtl
(Yrs.)

0.0-1.0 48 0 0 48.0 1.0000 0.0000

(0.0000) (0.0000)
1.0-2.0 48 0 0 48.0 1.0000 0.0000
(0.0000) (0.0000)
2.0-3.0 48 1 2 47.5 1.0000 0.0430
(0.0000) (0.0304)
3.0-4.0 45 0 1 45.0 0.9579 0.0225
(0.0291) (0.0225)
4.0-5.0 44 0 1 44.0 0.9366 0.0230
(0.0354) (0.0230)
5.0-6.0 43 14 2 36.0 0.9153 0.0571
(0.0405) (0.0404)
6.0- 27 8 2 23.0 0.8645 0.0000
(0.0518) (0.0000)

* Failure is defined as definite loosening of the acetabular component.

t Until the beginning of the interval.
1: Standard errors are in parentheses.
§ Rate of instantaneous failure at the mid-point of the interval.

was associated with resorption of the graft (p < 0.001). improve posterior support for the acetabular component.
Although it is difficult to quantify the amount of pos- Evidence from finite-element analyses324 of acetabular
tenor acetabular support, the radiographic appearance sug- composite stress has indicated that an increase in the stiff-
gested a lack of posterior support in fifteen hips. Ten of ness of the acetabular component will improve the stress
them showed radiographic evidence of definite loosening
and three showed possible loosening. Figures 4-A through
4-D show a hip in which the lack of posterior support for
the acetabular component progressed to definite loosening.

Discussion
In a patient who has osteoarthritis and a severe defi-
ciency of acetabular bone stock, use of an autologous graft
of bone from the femoral head has made prosthetic total hip
arthroplasty a practical procedure. However, the distorted
anatomy that results from congenital dislocation of the hip
or dysplasia and, in addition, from prior surgical procedures
makes the operation in these patients difficult technically.
In previous studies of this type of grafting in total hip
replacement67”2223, the rates of aseptic loosening of the
acetabular component have varied widely. Authors who re-
ported no evidence of aseptic loosening of the component2223
evaluated fewer arthroplasties of the hip than we did, and
their patients were followed for a shorter period of time.
Other investigators67” have found rates ofaseptic loosening
of the acetabular component comparable with ours.
In this study, important associations were found be-
tween aseptic loosening and young age and obesity. These
findings are in agreement with those of studies of total hip
replacements that were done without the use of bone
grafts4’#{176}.We found a similar association between resorption
of the graft and a lack of posterior osseous support of the FIG. 5
Placement of an autograft from the femoral neck along the posterior
acetabular cement. Figure 5 shows how placement of the
acetabular rim may be used to improve posterior support for the acetabular
femoral neck along the posterior rim of the acetabulum can component.

VOL. 68-A, NO. 8, OCTOBER 1986

1248 S. D. GERBER AND W. H. HARRIS

relationships. Practical experience has supported the con- osseous support to the acetabular component had been
clusion that the rate of aseptic loosening is reduced by the achieved. The adequacy of the acetabular bone stock in the
use of metal-backed acetabular components’5’9. The use of hips that required revision also suggested that autografting
metal-backed acetabular components in association with au- with bone from the femoral head has a useful role. It is
tografting of the acetabulum may be expected to decrease clear that the treatment of these hips involves marked com-
the rate of aseptic loosening in these patients. plexity, a high rate of complications, and a lower over-all
There are two definite advantages to using an adjunc- average clinical rating’#{176}’5. Nevertheless, the procedure is
tive autograft in patients who have deficient acetabular bone of great benefit for patients with these severe problems,
stock. Union of all of the grafts in our series showed that particularly in terms of their major aim of relief of pain.

References
I. BECKENBAUGH, R. D. , and ILSTRUP, D. M.: Total Hip Arthroplasty. A Review of Three Hundred and Thirty-three Cases with Long Follow-up.
J. Bone and Joint Surg. , 60-A: 306-313, April 1978.
2. BROKER, A. F.; BOWERMAN, J. W. ; ROBINSON, R. A.; and RILEY, L. H. , JR.: Ectopic Ossification following Total Hip Replacement. Incidence
and a Method of Classification. J. Bone and Joint Surg. , 55-A: 1629-1632. Dec. 1973.
3. CARTER, D. R. ; VASU, R. ; and HARRIS, W. H. : Stress Distributions in the Acetabular Region - II. Effects of Cement Thickness and Metal
Backing of the Total Hip Acetabular Component. J. Biomech., 15: 165-170, 1982.
4. CHANDLER, H. P. ; REINECK, F. T. ; WIXSON, R. L. ; and MCCARTHY, J. C. : Total Hip Replacement in Patients Younger than Thirty Years Old.
A Five-Year Follow-up Study. J. Bone and Joint Surg., 63-A: 1426-1434, Dec. 1981.
5. CHARNLEY, JOHN, and FEAGIN, J. A.: Low-Friction Arthroplasty in Congenital Subluxation of the Hip. Clin. Orthop., 91: 98-113, 1973.
6. CHRISTIE, M. J. ; EWALD, F. C. ; THOMAS, W. H.; KELLEY, K. M. ; SLEDGE, C. B. ; LOWELL, J. D. ; Poss, R. ; THORNHILL, T. ; and REILLY, D.:
Total Hip Arthroplasty in Congenital Dislocation of the Hip. Orthop. Trans. , 9: 449, 1985.
7. CONN, R. A. ; PETERSON, L. F. A. ; STAUFFER, R. N. ; and ILSTRUP, DUANE: Management of Acetabular Deficiency. Long Term Results of Bone
Grafting in Total Hip Arthroplasty. Orthop. Trans., 9: 451-452, 1985.
8. COVENTRY, M. B. : Selection of Patients for Total Hip Arthroplasty. In Instructional Course Lectures. The American Academy of Orthopaedic
Surgeons. Vol. 23, pp. 136-142. St. Louis, C. V. Mosby. 1974.
9. DELEE, J. 0., and CHARNLEY, JOHN: Radiological Demarcation of Cemented Sockets in Total Hip Replacement. Clin. Orthop. , 121: 20-32, 1976.
10. D0RR, L. D. ; TAKEI, G. K.; and CONATY, J. P.: Total Hip Arthroplasties in Patients Less than Forty-five Years Old. J. Bone and Joint Surg.,
65-A: 474-479. April 1983.
I I . HARRIS, W. H. : Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures: Treatment by Mold Arthroplasty. An End-Result Study
Using a New Method of Result Evaluation. J. Bone and Joint Surg. , 51-A: 737-755, June 1969.
12. HARRIS, W. H.: Total Hip Replacement for Congenital Dysplasia of the Hip: Technique. In The Hip: Proceedings of the Second Open Scientific
Meeting of The Hip Society, pp. 251-265. St. Louis, C. V. Mosby, 1974.
13. HARRIS, W. H.: Total Hip Replacement for Osteoarthritis Secondary to Congenital Dysplasia or Congenital Dislocation of the Hip. Internat.
Orthop., 2: 127-138. 1978.
14. HARRIS, W. H. , and CROTHERS, 0. D. : Autogenous Bone Grafting Using the Femoral Head to Correct Severe Acetabular Deficiency for Total
Hip Replacement. In The Hip: Proceedings of the Fourth Open Scientific Meeting of The Hip Society, pp. 161-185. St. Louis, C. V. Mosby,
1985.
15. HARRIS, W. H. , and WHITE, R. E. , JR. : Socket Fixation Using a Metal-Backed Acetabular Component for Total Hip Replacement. A Minimum
Five-Year Follow-up. J. Bone and Joint Surg. , 64-A: 745-748, June 1982.
16. HARRIS, W. H. ; CROTHERS, OMAR; and OH, INDONG: Total Hip Replacement and Femoral-Head Bone-Grafting for Severe Acetabular Deficiency
in Adults. J. Bone and Joint Surg. , 59-A: 752-759, Sept. 1977.
17. HARRIS, W. H. ; MCCARTHY, J. C. , JR. ; and O’NEILL, D. A. : Femoral Component Loosening Using Contemporary Techniques of Femoral Cement
Fixation. J. Bone and Joint Surg. , 64-A: 1063-1067, Sept. 1982.
18. JASTY, M. , and HARRIS, W. H. : Total Hip Reconstruction Using Frozen Femoral Head Allografts in Patients with Major Acetabular Bone Loss.
Unpublished data.
19. MATTINGLY, D. A. ; HopsoN, C. N. ; KAHN, ALFRED, III; and GIANNESTRAS, N. J. : Aseptic Loosening in Metal-Backed Acetabular Components
for Total Hip Replacement. A Minimum Five-Year Follow-up. J. Bone and Joint Surg. . 67-A: 387-391 , March 1985.
20. MILCH, HENRY: The Resection-Angulation Operation for Hip-Joint Disabilities. J. Bone and Joint Surg.. 37-A: 699-717. July 1955.
21 . O’NEILL, D. A. , and HARRIS, W. H.: Failed Total Hip Replacement: Assessment by Plain Radiographs, Arthrograms, and Aspiration of the Hip
Joint. J. Bone and Joint Surg. , 66-A: 540-546, April 1984.
22. PENNENBERG, B. , and CHANDLER, H. P.: Personal communication.
23. RITTER, M. A. , and TRANCIK, T. M.: Lateral Acetabular Bone Graft in Total Hip Arthroplasty. A Three- to Eight-Year Follow-up Study without
Internal Fixation. Clin. Orthop. , 193: 156-159, 1985.
24. VASU, R. ; CARTER, D. R. ; and HARRIS, W. H. : Stress Distributions in the Acetabular Region - I. Before and after Total Joint Replacement. J.
Biomech. , 15: 155-164, 1982.
25. WILLIAMS, S. R.: Height and Weight Tables for Adults. In Nutrition and Diet Therapy. Ed. 2, p. 655. St. Louis, C. V. Mosby, 1973.
26. WOOLSON, S. T. , and HARRIS, W. H.: Complex Total Hip Replacement for Dysplastic or Hypoplastic Hips Using Miniature or Microminiature
Components. J. Bone and Joint Surg. , 65-A: 1099-1108, Oct. 1983.

ThE JOURNAL OF BONE AND JOINT SURGERY