Review ArticleClinical evaluation and surgical options in acetabular reconstruction: A literature review
Introduction
Total hip arthroplasty (THA) is perhaps the most recognized operation in the field of orthopedic surgery and regarded as a benchmark treatment of end-stage hip joint disease. The aging population and growing incidence in obesity will continue to increase the number of hip replacements. Despite excellent clinical results, many patients outlive the typical lifespan of implants with approximately 17% of all primary hips eventually failing and requiring revision.1 Acetabular revision in the context of poor bone stock is a technically challenging procedure; therefore, it is imperative for the arthroplasty surgeon to understand the advantages and disadvantages of the available acetabular component systems. In this paper, we review clinical indications for acetabular revision, radiographic classification systems, and pre-operative planning. We also include a summary of available acetabular component systems and highlight unique features.
Section snippets
Clinical evaluation
Clinical presentation depends on the fundamental etiology for acetabular implant failure, which include aseptic loosening, infection, instability, wear, trauma, and osteolysis.2 Groin or buttock pain is a characteristic patient complaint associated with acetabular implant failure while thigh pain is often associated with femoral implant failure.2, 3 A comprehensive medical history and focused physical exam should be performed on all patients regardless of clinical presentation. Laboratory
Classification of acetabular defects
An ideal radiological classification system provides accurate and standardized algorithm to evaluate the extent of bone loss, assist in pre-operative planning and clinical management. Acetabular defects are routinely described using the American Academy of Orthopaedic Surgeons (AAOS) and Paprosky classification system.
The AAOS classification system categorizes lesions into cavitary, segmental, combined cavitary and segmental, pelvic discontinuities, and arthrodesis.9 Cavitary defects are
Cavitary defects
Cementless hemispheric acetabular components are generally used for patients with cavitary defects. Small cavitary defects can be reamed with a larger size reamer to increase contact area between native bone and implant. The acetabular shell is then impacted into the socket and transacetabular screws are placed in the posterior quadrants to provide ancillary fixation to the ileum and ischium. Anterosuperior and anteroinferior placements of screws increase the risk of injury to external iliac
Segmental defects
Under circumstances of substantial superior segmental defects, the arthroplasty surgeon may consider placing the joint in a superiorly elevated position using a cementless hemispherical cup as described previously or restore hip center with supplementation of bulk allograft or using a larger size cup.
Custom triflange implants
Triflange implants are custom-made, porous coated titanium alloy components considered a final therapeutic salvage option in patients with pelvic discontinuity and/or prior radiation to pelvis. A triflange construct is designed from pelvis CT scans with metal subtraction software converted into a three-dimensional (3D) representation of the patient's hemipelvis. The implant manufacture generates individualized implants from the respective imaging (Fig. 4). Some authors have reported variable
Conclusion
In summary, many constructs are available to achieve sufficient acetabular bony contact and return hip center to normal anatomic position; including the use of bone cages, allografts, jumbo and oblong cups, triflange implants, and porous acetabular metal augments. It is important to understand the advantages and disadvantages of the available acetabular component systems to deal with poor bone stock.
Conflicts of interest
The authors have none to declare.
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