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Teh HL, Selvaratnam V, Low WJ, Kassim AF, Ganapathy SS, Chopra S. Outcomes of Impaction Bone Grafting in the Management of Acetabular Defects with the Use of Uncemented Acetabular Cups: Do Autografts and Irradiated Femoral Head Allografts Integrate? Indian J Orthop 2023; 57:1842-1849. [PMID: 37881276 PMCID: PMC10593662 DOI: 10.1007/s43465-023-00983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/18/2023] [Indexed: 10/27/2023]
Abstract
Introduction Acetabular impaction bone grafting (AIBG) has been used widely to reconstruct acetabular defects in complex primary and revision cases. The aim of this study was to look at the outcomes AIBG using either frozen irradiated femoral head allografts or autografts with uncemented acetabular cups. Method We retrospectively reviewed 38 patients who had AIBG and uncemented cup reconstruction of the acetabulum performed between 2008 and 2021 for complex primary and revision surgery. Graft incorporation, radiological loosening and cup migration were evaluated in follow-up X-rays. Result There were 24 complex primary and 14 revision total hip arthroplasty. Autografts were used in 10 hips with smaller defects, while 28 hips with larger defects required frozen irradiated femoral head allografts. Using Paprosky classification to evaluate acetabular defects; 8 patients were classified as 2A, 12 as 2B, 7 as 2C, 8 as 3A and 3 as 3B. The Kaplan-Meier survival rate for AIBG with uncemented cups in our series is 89.70% in 10 years. Acetabular cup position was anatomically restored in all autograft AIBG cases and in 25 out of 28 in the allograft group. The mean pre-operative Oxford Hip Score (OHS) was 19 (range 10-24) and post-operative OHS was 39 (range 21-48) (p < 0.001). Conclusions The mid- to long-term results for AIBG and uncemented acetabular cups is good. With newer and more porous uncemented cups especially revision cups, it may serve as an extended indication to achieve solid fixation together with AIBG technique in managing acetabular defects of ≤ 3A.
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Affiliation(s)
- Hak Lian Teh
- Arthroplasty Unit, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Malaysia
| | - Veenesh Selvaratnam
- Arthroplasty Unit, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Malaysia
- Joint Reconstruction Unit, National Orthopedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Wei Jian Low
- Arthroplasty Unit, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Malaysia
- Joint Reconstruction Unit, National Orthopedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ahmad Fauzey Kassim
- Arthroplasty Unit, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Malaysia
| | - Shubash Shander Ganapathy
- Institute for Public Health, National Institute of Health, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Suresh Chopra
- Arthroplasty Unit, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Malaysia
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Yang C, Zhu K, Dai H, Zhang X, Wang Q, Wang Q. Mid- to Long-term Follow-up of Severe Acetabular Bone Defect after Revision Total Hip Arthroplasty Using Impaction Bone Grafting and Metal Mesh. Orthop Surg 2023; 15:750-757. [PMID: 36644857 PMCID: PMC9977582 DOI: 10.1111/os.13651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In revision total hip arthroplasty (THA), reconstruction of severe acetabular bone defect continues to be problematic for orthopedic surgeons. This study reports the mid- to long-term survivorship, radiological outcomes, and complications of impaction bone grafting (IBG) and metal mesh with a cemented acetabular component in the reconstruction of severe acetabular bone defects in revision THA. METHODS This retrospective consecutive study included 26 patients (29 hips: type II B, four; type II C, three; type III A, 10; and type III B, 12) who underwent revision THA, which was performed using IBG and metal mesh, between 2007 and 2014 in our institution. All patients were followed up regularly for clinical and radiographical assessments. Migration and loosening of prosthesis graft integration and complications were observed and analyzed. Survival analysis was performed using a Kaplan-Meier survival analysis. RESULTS At the time of revision, 75.9% of the hips (22 hips) were classified as type III bone defects. The average follow-up period was 9.4 ± 2.8 (range, 2.4-14.0) years. Of the 29 hips, four hips (13.8%) were assessed as clinical failures; at the last follow-up, two had undergone re-revision THA, and two had not been scheduled for re-revision THA despite radiological failure of the acetabular component. Among them, three clinical failures (10.3%) were due to aseptic loosening, and one (3.4%) was due to infection. Radiographic evaluation showed bone graft integration in all hips during the follow-up. The Kaplan-Meier survivorship analysis revealed an acetabular reconstruction survival rate of 86.5% (95% confidence interval, 61.4%-95.7%) at 10 years. CONCLUSION IBG and metal mesh with a cemented acetabular component for revision THA is an effective technique for treating severe acetabular bone defects, with effective mid- to long-term outcomes due to the solid reconstruction of the acetabular bone defect and restoration of the hip rotation center.
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Affiliation(s)
- Chao Yang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Kechao Zhu
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Huiyong Dai
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Xianlong Zhang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Qiaojie Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Qi Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
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Rohe S, Dörr N, Böhle S, Matziolis G, Brodt S, Röhner E. Mid-term results in revision hip arthroplasty with impaction bone grafted cup reconstruction for acetabular defects. Sci Rep 2022; 12:13322. [PMID: 35922465 PMCID: PMC9349309 DOI: 10.1038/s41598-022-17526-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Acetabular defects are a challenging condition for surgeons in revision THA. A crucial aim is an anatomical restoration of the centre of rotation (COR) through grafts. The aim of this study was to determine the cup survival after biological restoration of acetabular defects in THA and the effect of Paprosky classification, age, BMI, and number of previous operations on cup survival. Retrospectively patients with a cup exchange and an impaction of cortico-cancellous or bulk grafts between 2009 and 2012 were included with a follow up with a minimum of 5 year. Implant failure was defined as radiographic loosening or explantation of the cup. The acetabular defect situation was classified to Paprosky. 82 patients (58 female 70.7%) were included. 26 patients were not available to contact. 56 patients (40 female 71.4%) remained for survival analysis with mean age of 75.6 ± 8 years. Survival of the cup after 5 years was 90% and after 7.8 years 88%. There was no difference in survival concerning defect classification, type of implant or graft, age, BMI, and number of previous operations. Patients on the follow up reached an HHS of 67.4 ± 19, a WOMAC Score of 33.4 ± 25.4 points and an unsatisfactory result in the SF-36. Impaction bone grafting of acetabular defects is a good option with satisfactory biomechanical results and survival for small defects. Predictive factors for cup survival could not be clarified in our study. So, the correct indication, knowing the limits of the methods and the correct choice of implant allow a defect-oriented approach and are decisive for the success of the operation.
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Affiliation(s)
- Sebastian Rohe
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | - Nicoletta Dörr
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Sabrina Böhle
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Georg Matziolis
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Steffen Brodt
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Eric Röhner
- Orthopaedic Department of the Heinrich-Braun-Hospital Zwickau, 08060, Zwickau, Germany
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D’Apolito R, Zagra L. Uncemented Cups and Impaction Bone Grafting for Acetabular Bone Loss in Revision Hip Arthroplasty: A Review of Rationale, Indications, and Outcomes. MATERIALS 2022; 15:ma15103728. [PMID: 35629756 PMCID: PMC9145197 DOI: 10.3390/ma15103728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/20/2022]
Abstract
Total hip arthroplasty (THA) is increasingly performed in young patients and the number of revisions is estimated to rise over time. Acetabular osteolysis and bone loss are frequently encountered during revision and may be classified and treated in different ways. Impaction bone grafting (IBG) with morselized allograft offers a viable option. IBG was introduced over 40 years ago in combination with cemented cups, and is also used with uncemented cups. The impacted bone chips act as a void filler to restore bone stock; once incorporated they are substituted by host bone. Surgery entails assessment of the defect, acetabular preparation, preparation of the morselized graft, impaction of the graft, and cup implantation. Satisfactory medium- and long-term results have now been reported in most studies. With the advent of high-porosity cups, indications have been extended, enhancing the potential of IBG, in which primary stability of the cup to the host bone is essential for a successful procedure. Synthetic bone substitutes have also been used in combination with allogenic grafts and may extend the original technique for which long-term studies are warranted.
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Perlbach R, Palm L, Mohaddes M, Ivarsson I, Schilcher J. Good implant survival after acetabular revision with extensive impaction bone grafting and uncemented components. Bone Joint J 2020; 102-B:198-204. [DOI: 10.1302/0301-620x.102b2.bjj-2019-0584.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims This single-centre observational study aimed to describe the results of extensive bone impaction grafting of the whole acetabular cavity in combination with an uncemented component in acetabular revisions performed in a standardized manner since 1993. Methods Between 1993 and 2013, 370 patients with a median age of 72 years (interquartile range (IQR) 63 to 79 years) underwent acetabular revision surgery. Of these, 229 were more than ten years following surgery and 137 were more than 15 years. All revisions were performed with extensive use of morcellized allograft firmly impacted into the entire acetabular cavity, followed by insertion of an uncemented component with supplementary screw fixation. All types of reoperation were captured using review of radiographs and medical charts, combined with data from the local surgical register and the Swedish Hip Arthroplasty Register. Results Among patients with possible follow-up of ten and 15 years, 152 and 72 patients remained alive without revision of the acetabular component. The number of deaths was 61 and 50, respectively. Of those who died, six patients in each group had a reoperation performed before death. The number of patients with a reoperation was 22 for those with ten-year follow-up and 21 for those with 15 years of follow-up. The Kaplan-Meier implant survival rate for aseptic loosening among all 370 patients in the cohort was 96.3% (95% confidence interval (CI) 94.1 to 98.5) after ten years and 92.8% (95% CI 89.2 to 96.6) after 15 years. Conclusion Extensive bone impaction grafting combined with uncemented revision components appears to be a reliable method with favourable long-term survival. This technique offers the advantage of bone stock restoration and disputes the long-standing perception that uncemented components require > 50% of host bone contact for successful implant survival. Cite this article: Bone Joint J 2020;102-B(2):198–204.
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Affiliation(s)
- Rico Perlbach
- Department of Orthopedic Surgery and Department of Clinical and Experimental Medicine, University Hospital Linköping, Linköping University, Linköping, Sweden
| | - Lars Palm
- Department of Orthopedic Surgery and Department of Clinical and Experimental Medicine, University Hospital Linköping, Linköping University, Linköping, Sweden
| | - Maziar Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy
- University of Gothenburg, Swedish Hip Arthroplasty Register, Registercentrum VGR, Gothenburg, Sweden
| | - Ingemar Ivarsson
- Department of Orthopedic Surgery and Department of Clinical and Experimental Medicine, University Hospital Linköping, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Department of Orthopedic Surgery and Department of Clinical and Experimental Medicine, University Hospital Linköping, Linköping University, Linköping, Sweden
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Pierannunzii L, Zagra L. Bone grafts, bone graft extenders, substitutes and enhancers for acetabular reconstruction in revision total hip arthroplasty. EFORT Open Rev 2017; 1:431-439. [PMID: 28461922 PMCID: PMC5367522 DOI: 10.1302/2058-5241.160025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty. Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips. Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases. Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting. Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.
Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025
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Affiliation(s)
| | - Luigi Zagra
- IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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Shon WY, Santhanam SS, Choi JW. Acetabular Reconstruction in Total Hip Arthroplasty. Hip Pelvis 2016; 28:1-14. [PMID: 27536638 PMCID: PMC4972873 DOI: 10.5371/hp.2016.28.1.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 01/23/2016] [Accepted: 02/01/2016] [Indexed: 11/24/2022] Open
Abstract
The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. Acetabular reconstruction in revision total hip arthroplasty can successfully be achieved with hemispherical components featuring a porous or roughened ingrowth surface and options for placement of multiple screws for minor acetabular defect. Acetabular component selection is mostly based on the amount of bone loss present. In the presence of combined cavitary and segmental defects without superior acetabular coverage, reconstructions with a structural acetabular allograft protected by a cage or a custom-made triflange cage have been one of preferred surgical options. The use of a cage or ring over structural allograft bone for massive uncontained defects in acetabular revision can restore host bone stock and facilitate subsequent rerevision surgery to a certain extent. But high complication rates have been reported including aseptic loosening, infection, dislocation and metal failure. On the other hand, recent literature is reporting satisfactory outcomes with the use of modular augments combined with a hemispherical shell for major acetabular defect. Highly porous metals have been introduced for clinical use in arthroplasty surgery over the last decade. Their higher porosity and surface friction are ideal for acetabular revision, optimizing biological fixation. The use of trabecular metal cups in acetabular revision has yielded excellent clinical results. This article summarizes author's experience regarding revision acetabular reconstruction options following failed hip surgery including arthroplasty.
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Affiliation(s)
- Won Yong Shon
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | | | - Jung Woo Choi
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
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Kokubo Y, Oki H, Sugita D, Negoro K, Takeno K, Miyazaki T, Nakajima H. Long-term clinical outcome of acetabular cup revision surgery: comparison of cemented cups, cementless cups, and cemented cups with reinforcement devices. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:407-13. [DOI: 10.1007/s00590-016-1763-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/11/2016] [Indexed: 11/24/2022]
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Solomon LB, Studer P, Abrahams JM, Callary SA, Moran CR, Stamenkov RB, Howie DW. Does cup-cage reconstruction with oversized cups provide initial stability in THA for osteoporotic acetabular fractures? Clin Orthop Relat Res 2015; 473:3811-9. [PMID: 26194560 PMCID: PMC4626507 DOI: 10.1007/s11999-015-4460-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of acetabular fractures in osteoporotic patients is increasing. Immediate total hip arthroplasty (THA) has potential advantages, but achieving acetabular component stability is challenging and, at early followup, reported revision rates for loosening are high. QUESTIONS/PURPOSES This study measured acetabular component stability and the initial surface contact achieved between the acetabular component and unfractured region of the pelvis after THA using an oversized acetabular component and cup-cage reconstruction. METHODS Between November 2011 and November 2013, we treated 40 acute acetabular fractures in patients older than 70 years of age. Of these, 12 (30%) underwent immediate THA using an oversized acetabular component with screws inserted only into the ilium and a cup-cage construct. Postoperatively all patients were mobilized without weightbearing restrictions. Indications for immediate THA after acetabular fractures were displaced articular comminution deemed unreducible. Eleven of the 12 were prospectively studied to evaluate the initial stability of the reconstructions using radiostereometric analysis. One of the patients died of a pulmonary embolism after surgery, and the remaining 10 (median age, 81 years; range, 72-86 years) were studied. Of these, five were analyzed at 1 year and five were analyzed at 2 years. Acetabular component migration was defined as acceptable if less than the limits for primary THA that predict later loosening (1.76 mm of proximal migration and 2.53° of sagittal rotation). The contact surface between the acetabular component and ilium in direct continuity with the sacroiliac joint, and the ischium and pubis in direct continuity with the symphysis pubis, was measured on postoperative CT scans. RESULTS At 1 year the median proximal migration was 0.83 mm (range, 0.09-5.13 mm) and sagittal rotation was 1.3° (range, 0.1°-7.4°). Three of the 10 components had migration above the suggested limits for primary THA at 1 year postoperatively. The contact surface achieved at surgery between the acetabular component and pelvis ranged from 11 to 17 cm(2) (15%-27% of each component). CONCLUSIONS The majority of acetabular components in this cohort were stable despite the small contact surface achieved between the component and pelvic bone. Three of 10 migrated in excess of the limits that predict later loosening in primary THA but it remains to be seen whether these limits apply to this selected group of frail osteoporotic patients. We continue to use this technique routinely to treat patients with the same indications, but since the analysis of these data we have added screw fixation of the acetabular component to the ischial tuberosity and the superior pubic ramus. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Lucian B. Solomon
- />Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000 Australia , />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
| | - Patrick Studer
- />Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000 Australia
| | - John M. Abrahams
- />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
| | - Stuart A. Callary
- />Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000 Australia , />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
| | - Caroline R. Moran
- />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
| | - Roumen B. Stamenkov
- />Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000 Australia , />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
| | - Donald W. Howie
- />Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000 Australia , />Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000 Australia
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Abstract
The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR. Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.
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Affiliation(s)
- M. S. Ibrahim
- University College London Hospitals, University
College Hospital, 235 Euston Rd, London, NW1
2BU, UK
| | - S. Raja
- University College London Hospitals, University
College Hospital, 235 Euston Rd, London, NW1
2BU, UK
| | - F. S. Haddad
- University College London Hospitals, University
College Hospital, 235 Euston Rd, London, NW1
2BU, UK
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