How to Do a Revision Total Hip Arthroplasty: Revision of ... · Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be

Selected

InstructionalCourse LecturesThe American Academy of Orthopaedic SurgeonsPAUL TORNETTA IIIEDITOR, VOL. 61

COMMITTEEPAUL TORNETTA IIICHAIR

KENNETH A. EGOLMARY I. O’CONNORMARK PAGNANOROBERT A. HART

EX-OFFICIO

DEMPSEY S. SPRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERYFOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy ofOrthopaedic Surgeons. This article, as well as other lecturespresented at the Academy’s Annual Meeting, will be availablein February 2012 in Instructional Course Lectures, Volume 61.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

1358

How to Do a Revision Total Hip Arthroplasty:Revision of the Acetabulum

Scott M. Sporer, MD, MS

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The most common indications for ace-tabular revision include instability, in-fection, polyethylene wear, and asepticloosening1. The prevalence of theseconditions remains essentially un-changed despite improved prostheticcomponent designs and enhanced sur-gical techniques. A successful acetabularrevision must provide intimate contactbetween the acetabular implant and thehost bone, a stable mechanical constructminimizing micromotion to allow boneingrowth into a cementless acetabularcomponent, and a mechanical constructthat distributes the physiologic stressesto the surrounding acetabular bone.Additionally, the acetabular reconstruc-tion must allow appropriate component

orientation to minimize the risk ofdislocation and reestablish the anatomichip center to improve the overall jointkinematics. Biologic methods of ace-tabular reconstruction are advised ex-cept in cases of severe bone loss or priorradiation treatment in the hip region,since nonbiologic revisions eventuallyfail2. Periacetabular bone loss can com-promise component fixation, resultingin early loosening of the revised ace-tabulum. The amount of bone lossundoubtedly influences the ability toobtain initial optimal fixation. Thelocation of remaining supportive bone,however, has a more important role inproviding durable fixation than doesthe quantity of bone loss.

Defect Classification SystemsAcetabular defect classification systemscan be used to predict the extent of boneloss seen intraoperatively and guidesubsequent reconstructive options. Thethree most common classification sys-tems for acetabular defects are theAmerican Academy of OrthopaedicSurgeons (AAOS) classification systemdescribed by D’Antonio et al.3 (Table I),the Gross classification system describedby Saleh et al.4 (Table II), and thePaprosky classification system5 (TableIII). The AAOS classification systemidentifies the pattern of acetabular boneloss, but does not quantify the size orlocation of the defect. Despite being themost commonly cited, the AAOS defectclassification system does not guide theidentification of reconstructive options.The system described by Saleh et al. isbased on the degree of bone loss seen onpreoperative standard anteroposteriorand lateral radiographs of the hip. Abone defect is considered uncontainedif morselized bone graft cannot be usedto fill the defect. The Paprosky classi-fication system is based on four

Look for this and other related articles in Instructional Course Lectures,Volume 61, which will be published by the American Academy of

Orthopaedic Surgeons in February 2012:

d ‘‘Femoral Fixation in Revision Total Hip Arthroplasty,’’ by

Curtis W. Hartman, MD, and Kevin L. Garvin, MD

Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of anyaspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in thebiomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any otherrelationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. Thecomplete Disclosures of Potential Conflicts of Interest submitted by the author of this work are available with the online version of this article atjbjs.org.

J Bone Joint Surg Am. 2011;93:1359-66

1359

THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORG

VOLUME 93-A d NUMBER 14 d JULY 20, 2011HOW TO DO A REVI S ION TOTAL HIP ARTHROPLASTY:REV I S ION OF THE ACETABULUM

radiographic criteria from an antero-posterior pelvic radiograph: (1) supe-rior migration of the hip center, (2)ischial osteolysis, (3) acetabular tear-drop osteolysis, and (4) position of theimplant relative to the Kohler line5

(Fig. 1). Superior migration of the hipcenter represents bone loss of theacetabular dome involving the anteriorand posterior columns. Ischial osteol-ysis indicates bone loss from the pos-terior column including the posteriorwall, while teardrop osteolysis andmigration beyond the Kohler linerepresent medial acetabular bone loss.

Type-III defects require structuralsupport from bulk allograft, metallicaugmentation, an acetabular cage, or acustom acetabular component. ThePaprosky classification system is oftenused clinically, as it not only predictsbone loss encountered intraopera-tively but also assists in determiningreconstructive options.

Component RemovalSuccessful acetabular reconstructionbegins with a meticulous surgical tech-nique to remove a well-fixed acetabularcomponent. The use of acetabular ‘‘ex-

plant osteotomes’’ (Fig. 2) facilitates thesafe removal of well-fixed components.An osteotome blade, which is the outerdiameter of the acetabular component,is used with a so-called femoral headthat matches the diameter of the bear-ing surface. The osteotome is rotatedaround the periphery of the socket,disrupting the interface between theimplant and the host bone. Areas of thepelvis that are crucial for subsequentreconstruction are the anterosuperiorand posteroinferior aspects of the ace-tabulum. Monoblock acetabular com-ponents are removed with use of aso-called bipolar articulation with acurved osteotome blade matchingthe outer diameter of the acetabularcomponent. Alternatively, manual in-struments such as curved chisels andmotorized burrs can be used to disruptthe prosthesis-bone interface or sectionthe cup. One should avoid the tempta-tion to forcefully manipulate the com-ponent during removal as severe boneloss and associated pelvic discontinuitymay occur. A preoperative angiogramand/or vascular surgery consultationshould be obtained if the acetabularcomponent has migrated medially pastthe Kohler line (Fig. 3).

Treatment AlgorithmThe treatment of acetabular defectsdepends on the degree and location ofbone loss in addition to the potentialfor biologic fixation. Prior irradiationof the pelvis can result in periacetab-ular osteonecrosis with limited in-growth potential2. In these situations,nonbiologic fixation options, such asacetabular cages, custom implants,and fixed-angled devices, which off-load the host bone, should be consid-ered. Fortunately, the majority ofacetabular revisions can be managedsuccessfully with a hemisphericalcomponent alone6-9. The goals of re-vision surgery are to obtain stablefixation on the remaining host boneand to restore the hip center with theacetabular component near the Kohlerline and the inferomedial aspect ofthe acetabular component near theinferior portion of the acetabularteardrop. An algorithmic approach to

TABLE I AAOS Classification System for Acetabular Defects3*

Type Description

I Segmental defectII Cavitary defectIII Combined segmental and cavitary defectIV Pelvic discontinuity

IVa Discontinuity with mild segmental or cavitary bone lossIVb Discontinuity with moderate-to-severe segmental or cavitary bone lossIVc Discontinuity with prior pelvic irradiation

V Hip arthrodesis

*AAOS = American Academy of Orthopaedic Surgeons.

TABLE II Gross Classification System for Acetabular Defects Described by Saleh et al.4

Type Description

I No substantial loss of bone stockII Contained loss of bone stock (columns and/or rim intact)III Uncontained loss of bone stock (<50% acetabulum)IV Uncontained loss of bone stock (>50% acetabulum)V Contained loss of bone stock with pelvic discontinuity

TABLE III Paprosky Classification System for Acetabular Defects5

Description

TypeFemoral Head

Center MigrationIschial

OsteolysisKohlerLine Teardrop

I Minimal (<3 cm) None Intact IntactIIA Mild (<3 cm) Mild Intact IntactIIB Moderate (<3 cm) Mild Intact IntactIIC Mild (<3 cm) Mild Disrupted Moderate lysisIIIA Severe (>3 cm) Moderate Intact Moderate lysisIIIB Severe (>3 cm) Severe Disrupted Severe lysis

1360



acetabular defects helps both preopera-tive planning as well as surgical decision-making (Fig. 4).

Acetabular ReconstructionHemispherical or Elliptical ComponentAn acetabular component with a hemi-spherical or elliptical design can beused in patients when the hip centerof rotation has not migrated >3 cmproximally (Paprosky Types I, IIA, IIB,and IIC)10,11. After acetabular compo-nent removal, the remaining host boneshould be exposed and all granulationtissue thoroughly debrided. Pelvic dis-continuity is assessed by looking formotion between the superior and theinferior hemipelvis when applying acaudal stress to the ischium with aCobb elevator.

A retractor is placed in the obtu-rator foramen to determine the level ofthe true acetabulum, which is the level ofthe inferior border of the acetabulum.Sequentially larger hemispherical ace-tabular reamers are used to determinethe size of the acetabulum until theanterior and posterior columns areengaged by the reamer. To minimize the

likelihood of creating pelvic disconti-nuity while reaming, in general, anterioracetabular bone should be sacrificedbefore posterior column bone. Trialacetabular components are used toassess the stability of the acetabularsocket along with the degree of com-ponent coverage. Most acetabular de-fects have 5% to 20% of the acetabularcomponent uncovered posterosuperi-orly if the trial cup is placed in 40!of vertical inclination and 15! ofanteversion. One should avoid thetemptation to place the componentmore vertically to improve coverage asthis can increase the risk of dislocationand wear. Cavitary bone defects arepacked with either local autograft orallograft with use of a reamer 2 mmsmaller than the last reaming in re-verse. An acetabular component thatis 2 mm larger at the periphery thanthe last reamer is used in most patientsto obtain a so-called press-fit andinitial fixation. Supplemental fixationwith multiple screws is advised in allrevisions to minimize micromotionand promote bone ingrowth. Screwsshould be placed not only postero-

superiorly into the dome of the ace-tabulum but also inferiorly into theischium.

Surgical Treatment ofType-IIIA DefectsProximal and lateral migration of theacetabular component of >3 cm resultsin an acetabular dome deficiency thatdoes not provide enough stability for ahemispherical acetabular componentalone. Treatment options for patientswith superior segmental bone loss in-clude the use of structural bulk allograft,dual-geometry monoblock compo-nents, hemispherical components withmetallic superior augmentation, orplacement of an implant with a high hipcenter. A high hip center places thehip abductor muscles at a mechanicaldisadvantage and necessitates the useof a small acetabular component. It canbe challenging to obtain stable fixationand appropriate component orienta-tion with use of a monoblock dual-geometry acetabular component12,13. Iprefer to use a hemispherical acetabularcomponent placed at the level of thetrue acetabulum and to create superiorcup coverage with the use of metallicaugmentation.

Fig. 1

Components of the radiographic criteria in the Paprosky classification system for acetabulardefects.

Fig. 2

Acetabular component extraction tool. A bipolarfemoral head may be used to remove a mono-block cobalt-chromium acetabular component.(Reprinted, with permission, from Taylor PR,Stoffel KK, Dunlop DG, Yates PJ. Removal ofthe well-fixed hip resurfacing acetabular com-ponent: a simple, bone preserving technique.J Arthroplasty. 2009;24:484-6.)

1361



Hemispherical Component withMetallic AugmentationThe surgical treatment of a superiorsegmental bone defect with a hemi-spherical shell and augment begins byidentifying the location of the trueacetabulum with a retractor placed intothe obturator foramen. Hemisphericalreamers are then used to ream in theanatomic position until the anterior andposterior columns are engaged, whichresults in partial stability of a trialacetabular component. A superior aug-ment is used either as a buttress inpatients with primarily segmental boneloss or as a superior graft in patientswith primarily oblong cavitary bone loss(Figs. 5-A, 5-B, and 5-C). It is crucialthat the position of the augment notinfluence the ultimate position of theacetabular component. With the trialcomponent in place, the augment issecured to the host bone with screws.The augment is then packed with bonegraft, leaving the portion facing the cupexposed. Polymethylmethacrylate ce-

ment is placed directly on the porousrevision cup only in the areas matingwith the augment. The acetabular com-ponent is firmly impacted to achieve apress-fit against the host bone. In severebone loss, the polyethylene liner canbe cemented into the acetabular shellin order to place screws at a fixed angle.Multiple screws are used in differentplanes to maximize stability and min-imize the likelihood of componentloosening14.

Hemispherical Component withDistal Femoral AllograftThe use of bulk allograft has been largelyabandoned except in young patientsbecause of the increased surgical time,need for more soft-tissue exposure, andconcern for graft resorption15. Similar tometallic augmentation, the first step inthe acetabular reconstruction with bulkallograft is to identify the location ofthe desired hip center and to utilize ac-etabular reamers to size and shape theanteroposterior dimensions of the ac-

etabulum to accept a hemisphericalcementless implant. The distal femoralallograft is prepared to accommodatethe segmental dome defect once it hasbeen determined that there is inade-quate coverage of a hemispherical com-ponent. The cortex of the distal femoralallograft shaft in the coronal plane rel-ative to the condyles is removed. Theposterior aspect of the condyles is thenshaped to correspond with the superioracetabular defect with use of a femalereamer measuring 2 mm larger than thelast reamer used to size the defect. Theanterior-to-posterior aspect of the distalfemoral allograft should correspond tothe medial-to-lateral depth of the defect.The superior cortical limb of the graftshould be approximately 4 to 5 cm toallow adequate fixation to the lateralaspect of the ilium. The contoured graftis impacted into the superior defect,obtaining a press-fit. The allograft is se-cured with three or four parallel 6.5-mmcancellous screws with washers. Thescrews are oriented obliquely into theilium in the direction of loading to pro-vide compression of the graft against theremaining ilium. The acetabular cavityis reamed to contour the portion of thegraft that will contact the hemisphericalcomponent16 (Fig. 6).

Surgical Treatment ofType-IIIB DefectsProximal and medial migration of theacetabular component of >3 cm resultsin an acetabular dome deficiency as wellas a medial wall deficiency that does notprovide enough intrinsic stability for ahemispherical acetabular componentalone. Treatment options for patients withsuperomedial segmental bone loss includestructural bulk allograft, custom implantsspanning the iliac wing to the ischium,hemispherical components with multiplemetal augments, or an acetabular cage.Pelvic discontinuity frequently occurs inpatients with severe proximal medial mi-gration of the acetabular component.

Acetabular Transplant with CageAcetabular reamers are used to size theacetabular cavity and identify the loca-tion of remaining bone along the supe-rior aspect of the ilium that will abut

Fig. 3

Intrapelvic migration of the acetabular component—a Paprosky Type-IIIB defect. A preoperativeangiogram or vascular surgery consultation should be considered to minimize the risk of injury to theiliac vessel during revision arthroplasty.

1362



the allograft. The acetabulum of thehemipelvic allograft is reamed on theback table to accept the cage. A curvi-linear osteotomy is made in the allograftfrom the greater sciatic notch to theanterior superior iliac spine. The pubicand ischial portions of the allograft areremoved distal to the confluence of theacetabulum with enough length to ac-commodate any inferior defects. Oneshould avoid leaving excessive inferiorbone on the allograft that may preventoptimal medialization of the graft,which leads to subsequent vertical cupplacement and lateralization of the hipcenter. A female reamer, 1 to 2 mmlarger than the acetabular reamer usedto size the acetabulum, should be usedto mark and shape the medial aspect of

the graft to fit the defect. A groove ismade in the superior aspect of the iliumof the allograft to correspond to theledge of bone along the superior aspectof the native acetabulum. This tongue-and-groove junction provides a stablebuttress between the host and the allo-graft. A burr is used to debulk the in-ner table of the allograft ilium, whilea shelf that will fill the defect of theacetabulum is maintained distally.The graft is secured with Steinmannpins provisionally until four 6.5-mmpartially threaded screws are placedobliquely into the ilium from both theintra-articular and lateral aspects ofthe ilium of the graft. A pelvic recon-struction plate contoured to the pos-terior column with three screws in the

native ilium and ischium is used forfixation. A cage is recommended toprotect all transplants, and if possible,the inferior flange of a cage is insertedinto a slot in the ischium for fixation.A metal shell or a polyethylene lineris cemented into the cage-allograftcomposite, with care taken to avoid thetendency to place the acetabular com-ponent in a vertical and retrovertedposition.

Type-IIIB Defect: ModularMetal AugmentationThe acetabulum is reamed in the ana-tomical location and direction (anteriorto posterior, anterior-inferior to posterior-inferior, or posterior-superior to anterior-inferior) for the eventual reconstructionuntil two points of fixation are achieved,as this determines the size of the ace-tabular defect. Acetabular augments areused to decrease the acetabular volumeand restore a rim to support a revisioncup. The location and orientation ofaugments depends on the pattern of boneloss. Augments are frequently placedalong the medial aspect of the ilium orare stacked together to reconstruct thesuperomedial defect. It is more commonto use augments with the wide baseplaced laterally and the apex medially,which is the opposite of how the aug-ments are often used in the Type-IIIAdefect. The revision acetabular cupdirectly contacts the augments, and theaugments are necessary to achieve apress-fit of the acetabular component.Similar to the treatment of a Type-IIIAdefect, augments for a Type-IIIB defectare initially secured to the host bonewith the use of multiple screws. Por-tions of the augments are removedwith a burr or a reamer as needed tooptimize the surface area contact be-tween the revision shell and the aug-ments. Particulate bone graft is placedinto any remaining cavities before thehemispherical revision shell is impactedin place. Similar to the treatment of aType-IIIA defect, the interface betweenthe revision shell and the augment iscemented to minimize micromotionand subsequent fretting. Multiple screwsinto both the ilium and ischium are usedfor fixation.

Fig. 4

Treatment algorithm for acetabular revision surgery. (Reprinted, with permission, from: PaproskyWG.Acetabular revision. New York: Springer; 2005.)

1363



Pelvic DiscontinuityA hemispherical acetabular componentalone does not provide adequate im-plant stability in patients with a pelvicdiscontinuity. Treatment options for apelvic discontinuity include compres-sion plating of the posterior columnwith use of a hemispherical component,placement of an acetabular cage, use of acustom implant that spans the discon-tinuity, or use of metal acetabular aug-

ments to ‘‘distract’’ across the pelvicdiscontinuity17. In patients with a chronicpelvic discontinuity, the amount of boneloss along the posterior column is oftentoo severe to provide direct bone appo-sition during compression plating.

Modular Metal Augmentation withDistraction for Pelvic DiscontinuityThe goal of the distraction techniquefor a pelvic discontinuity is to use

ligamentotaxis secondary to thelengthening across the discontinuityto provide initial component stability.The location and severity of bone lossdetermine the type and position of theacetabular augments used to enhanceinitial component stability. Acetabularaugments are frequently used to re-construct portions of the anterosupe-rior aspect of the acetabulum as well asthe posteroinferior aspect of the ace-tabulum to provide two secure pointsof fixation for the acetabular compo-nent both cephalad and caudal to thediscontinuity. A porous acetabularcomponent, which is 6 to 8 mm largerthan the hemispherical reamer thatengaged the anterior and posteriorcolumns, is used to distract the supe-rior hemipelvis from the inferiorhemipelvis. Multiple screws are placedinto the remaining ilium and ischiumthrough the acetabular shell, and theaugments are secured to the cup withpolymethylmethacrylate. A polyethyl-ene liner is cemented into the acetab-ular component, allowing screws to beplaced at a fixed angle. A successfulreconstruction of a pelvic discontinu-ity requires ingrowth of the host boneinto both the superior and inferiorportions of the acetabular component tobridge the discontinuity. Consequently,one must obtain as much contact be-tween the host bone and the porousaugments and acetabular component aspossible.

Tips and Pearls forAcetabular RevisionPaprosky Type-IIB Defects

! Ream until the anterior andposterior columns are engaged, toallow intrinsic stability of the trialcomponent.

! Ream slightly superiorly to im-prove coverage.

! Avoid attempts to provide cov-erage of the superior dome—the supe-rior portion of the acetabularcomponent may remain uncovered.

! Reverse reamwith a reamer thatis 1 to 2 mm undersized to pack cavitarydefects.

! Use a cup with multiple holes.! Avoid a spiked cup.

Fig. 5-A

Fig. 5-B

Fig. 5-AType-IIIA acetabular defectwith superior andposterior bone loss.Fig. 5-BAcetabular augmentused as a buttress to provide additional superior coverage.

1364



Paprosky Type-IIC Defects! Ream until the anterior and

posterior columns are engaged, to allowintrinsic stability of trial cup along theacetabular rim.

! Medial bone graft is added untilthe reverse reamer, which is 1 to 2 mm

undersized, disengages from the driveshaft.

! Use an acetabular componentthat is 2 mm larger than the last reamerto achieve press-fit fixation.

! Use a cup with multipleholes.

Paprosky Type-IIIA Defects—DistalFemoral Allograft

! Verify that the surgical site isfree of infection before opening thedistal femoral allograft.

! Culture the femoral allograft.! Avoid the use of femoral head

allograft.! Elevate abductor musculature

with use of a Taylor retractor to al-low adequate visualization of the iliacwing.

! Cut a figure-7-shaped portionof allograft at slightly less than 90! toallow intrinsic stability.

! Use 6.5-mm cancellous screwsand always use with a washer.

! Tap screws in the allograft toavoid fracture.

! Avoid the tendency to place thecomponent in excessive abduction andretroversion, i.e., the cup may remainuncovered.

! Place screws through cup-allograft-host bone if possible.

Paprosky Type-IIIADefects—Hemispherical Componentwith Metal Augment

! Progressively ream in the ana-tomic position to engage the anteriorand posterior columns to allow intrinsicstability to the acetabular trial.

! Place the superior augment withthe trial component in place (withappropriate version and abduction). Theaugment can be placed in any position ororientation to allow improved initialstability. Leave 1 to 2 mm between thecup and the augment for the placementof cement.

! Use a motorized burr along thesuperior dome to fit the host bone to theaugment to improve intrinsic stabilityand maximize bone contact.

! Pack the augment with bonegraft, leaving the metal of the augmentthat faces the cup exposed.

! Place cement directly onto theporous revision cup only in areas matingwith the augment.

! Insert the cup with cement inthe doughy phase to improve interdigi-tation between the cup and the augment.

! Consider the use of cement withantibiotics.

Fig. 5-C

Augment used as a cavitary graft to fill cavitary bone defect and lower hip center.

Fig. 6

Distal femoral structural allograft used to reconstruct the superior dome of the acetabulum. (Reprintedfrom: Sporer SM, O’RourkeM, Chong P, PaproskyWG. The use of structural distal femoral allografts foracetabular reconstruction. Average ten-year follow-up. J Bone Joint Surg Am. 2005;87:760-5.)

1365



! Before the cement hardens, at-tempt to place a screw in the revisioncup to eliminate motion during the finalseating of the screws.

! Place bone wax in the end of thescrews to facilitate cup removal.

Paprosky Type-IIIBDefects—Hemispherical Component withMetal Augment and No Discontinuity

! Use augments to reconstructthe pelvis with nonbiologic material.

! Expose all margins of the ace-tabular defect.

! Progressively ream (anterior-posterior, anterior-inferior, and posterior-inferior) until two points of fixation areachieved.

! Loss of inferior bone stock(ischium) is often involved.

! Intrinsic stability will not beobtained with the trial component.

! Use augments to decrease ace-tabular volume and facilitate press-fitbetween the cup and the augment, i.e.,attempt to place the augment in directcontact with the revision cup.

! Secure the augment first.! Reverse ream with the augment

in place to pack the bone graft.

! Clear bone graft from the ex-posed host bone, i.e., maximize thecontact area between the host bone andthe revision porous cup.

! Attempt to place screws infe-riorly into the ischium to avoid cuppullout.

Paprosky Type-IIIB Defects—PelvicDiscontinuity Distraction

! Use a porous acetabular com-ponent to reconstruct the pelvis withbiologic material as an internal fixationdevice.

! Expose all margins of the ace-tabular defect and discontinuitythoroughly.

! Progressively ream (anterior toposterior, anterior-inferior to posterior-inferior, or posterior-superior to anterior-inferior) until two points of fixation areachieved.

! Intrinsic stability will not beobtained.

! Use augments to decreaseacetabular volume and facilitatepress-fit between the cup and theaugment, i.e., attempt to place the aug-ment in direct contact with the revisioncup.

! Bridge the discontinuity withthe augment and place screws cephaladand caudal to the discontinuity.

! Remove fibrous tissue in thediscontinuity and place the bonegraft.

! Reverse ream with the augmentin place to pack the bone graft.

! Clear bone graft from exposedhost bone, i.e., maximize contact areabetween the host bone and the revisioncup.

Scott M. Sporer, MD, MSDepartment of Orthopaedic Surgery,Rush University Medical Center,25 North Winfield Road, Suite 505,Winfield, IL 60190.

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. This article,as well as other lectures presented at theAcademy’s Annual Meeting, will be availablein February 2012 in Instructional CourseLectures, Volume 61. The complete volumecan be ordered online at www.aaos.org, or bycalling 800-626-6726 (8 a.m.-5 p.m., Centraltime).

References

1. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ.The epidemiology of revision total hip arthroplasty inthe United States. J Bone Joint Surg Am. 2009;91:128-33.2. Jacobs JJ, Kull LR, Frey GA, Gitelis S, SheinkopMB, Kramer TS, Rosenberg AG. Early failure ofacetabular components inserted without cement afterprevious pelvic irradiation. J Bone Joint Surg Am.1995;77:1829-35.3. D’Antonio JA, Capello WN, Borden LS, Bargar WL,Bierbaum BF, Boettcher WG, Steinberg ME, StulbergSD, Wedge JH. Classification and management ofacetabular abnormalities in total hip arthroplasty. ClinOrthop Relat Res. 1989;243:126-37.4. Saleh KJ, Holtzman J, Gafni ASaleh L, JaroszynskiG, Wong P, Woodgate I, Davis A, Gross AE. Develop-ment, test reliability and validation of a classificationfor revision hip arthroplasty. J Orthop Res. 2001;19:50-6.5. Paprosky WG, Perona PG, Lawrence JM. Acetabu-lar defect classification and surgical reconstruction inrevision arthroplasty. A 6-year follow-up evaluation.J Arthroplasty. 1994;9:33-44.6. Della Valle CJ, Berger RA, Rosenberg AG, GalanteJO. Cementless acetabular reconstruction in revision

total hip arthroplasty. Clin Orthop Relat Res. 2004;420:96-100.7. Gaffey JL, Callaghan JJ, Pedersen DR, Goetz DD,Sullivan PM, Johnston RC. Cementless acetabularfixation at fifteen years. A comparison with the samesurgeon’s results following acetabular fixation withcement. J Bone Joint Surg Am. 2004;86:257-61.8. Hallstrom BR, Golladay GJ, Vittetoe DA, Harris WH.Cementless acetabular revision with the Harris-Galante porous prosthesis. Results after a minimumof ten years of follow-up. J Bone Joint Surg Am.2004;86:1007-11.9. Templeton JE, Callaghan JJ, Goetz DD, SullivanPM, Johnston RC. Revision of a cemented acetabularcomponent to a cementless acetabular component. Aten to fourteen-year follow-up study. J Bone Joint SurgAm. 2001;83:1706-11.10. Leopold SS, Rosenberg AG, Bhatt RD, SheinkopMB, Quigley LR, Galante JO. Cementless acetabularrevision. Evaluation at an average of 10.5 years. ClinOrthop Relat Res. 1999;369:179-86.11. Silverton CD, Rosenberg AG, Sheinkop MB, KullLR, Galante JO. Revision total hip arthroplasty using acementless acetabular component. Technique andresults. Clin Orthop Relat Res. 1995;319:201-8.

12. Chen WM, Engh CA Jr, Hopper RH Jr, McAuley JP,Engh CA. Acetabular revision with use of a bilobedcomponent inserted without cement in patients whohave acetabular bone-stock deficiency. J Bone JointSurg Am. 2000;82:197-206.13. Schutzer SF, Harris WH. High placement ofporous-coated acetabular components in complextotal hip arthroplasty. J Arthroplasty. 1994;9:359-67.14. Sporer SM, Paprosky WG. The use of a trabecularmetal acetabular component and trabecular metalaugment for severe acetabular defects. J Arthroplasty.2006;21(6 Suppl 2):83-6.15. Sporer SM, O’Rourke M, Chong P, Paprosky WG.The use of structural distal femoral allografts foracetabular reconstruction. Average ten-year follow-up.J Bone Joint Surg Am. 2005;87:760-5.16. Sporer SM, O’Rourke M, Chong P, Paprosky WG.The use of structural distal femoral allografts foracetabular reconstruction. Surgical technique. J BoneJoint Surg Am. 2006;88 Suppl 1 Pt 1:92–9.17. Paprosky WG, O’Rourke M, Sporer SM. Thetreatment of acetabular bone defects with an associ-ated pelvic discontinuity. Clin Orthop Relat Res. 2005;441:216-20.

1366



Documents

How to Do a Revision Total Hip Arthroplasty: Revision of ... · Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be