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Aims: Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction. Methods: Between 2014 and 2023, 79 patients with a mean follow-up of 33 months (SD 22; 9 to 103) were included. Functional outcome was measured using the Harris Hip Score and EuroQol five-dimension questionnaire (EQ-5D). PPR revisions were defined as an endpoint, and subgroups were analyzed to determine risk factors. Results: Implantation was possible in all cases with a 2D centre of rotation deviation of 10 mm (SD 5.8; 1 to 29). PPR revision was necessary in eight (10%) patients. HHS increased significantly from 33 to 72 postoperatively, with a mean increase of 39 points (p < 0.001). Postoperative EQ-5D score was 0.7 (SD 0.3; -0.3 to 1). Risk factor analysis showed significant revision rates for septic indications (p ≤ 0.001) as well as femoral defect size (p = 0.001). Conclusion: Since large acetabular defects are being treated surgically more often, custom-made PPR should be integrated as an option in treatment algorithms. Monoflange PPR, with primary iliac fixation, offers a viable treatment option for Paprosky III defects with promising functional results, while requiring less soft-tissue exposure and allowing immediate full weightbearing. Cite this article: Bone Jt Open 2024;5(8):688–696.

Purpose : Supra-acetabular bone loss close beyond the sciatic notch is one of the most challenging defect types for stable anatomical reconstruction in revision arthroplasty. Using reconstruction strategies from tumour orthopaedic surgery, we adapted tricortical trans-iliosacral fixation options for custom-made implants in revision arthroplasty. The aim of the present study was to present the clinical and radiological results of this extraordinary pelvic defect reconstruction. Methods: Between 2016 and 2021, 10 patients with a custom-made pelvic construct using tricortical iliosacral fixation (see Fig. 1) were included in the study. Follow-up was 34 (SD 10; range 15–49) months. Postoperatively CT scans evaluating the implant position were performed. Functional outcome and the clinical results were recorded. Results: Implantation was possible as planned in all cases in 236 (SD 64: range 170–378) min. Correct centre of rotation (COR) reconstruction was possible in nine cases. One sacrum screw crossed a neuroforamen in one case without clinical symptoms. During the follow-up period, four further operations were required in two patients. There were no individual implant revisions or aseptic loosening recorded. The Harris Hip Score increased significantly from 27 Pts. to 67 Pts. with a mean improvement of 37 (p < 0.005). EQ-5D developed from 0.562 to 0.725 (p = 0.038) as a clear improvement in quality of life. Conclusion: Custom-made partial pelvis replacement with iliosacral fixation offers a safe solution in "beyond Paprosky type III defects" for hip revision arthroplasty. Due to meticulous planning, precise implantation with good clinical outcome can be achieved. Furthermore, the functional outcome and patient satisfaction increased significantly showing promising early results with a relatively low complication rate. [ABSTRACT FROM AUTHOR]

Abstract Introduction Extensive acetabular bone loss and poor bone quality are two key challenges often encountered in revision total hip arthroplasty. A new 3D-printed porous acetabular shell has been made available with the option to insert multiple variable-angle locking screws. We sought to evaluate the early clinical and radiological outcomes of this construct. Methods A retrospective review of patients operated by two surgeons was performed in a single institution. Fifty-nine revision hip arthroplasties were performed in 55 patients (34 female; mean age 68.8 ± 12.3 years) for Paprosky defects I (n = 21), IIA/B (n = 22), IIC (n = 9), III (n = 7) between February 2018 and January 2022 using the novel porous titanium acetabular shell and multiple variable angle locking screws. Postoperative clinical and radiographic outcomes were locally maintained. Patient-reported outcome measures collected included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Hip Score, and the 12-item Short Form Survey. Results After a mean follow-up of 25.7 ± 13.9 months, two cases of shell migration were noted. One patient had a failed constrained mechanism and received revision to a cemented dual mobility liner. No other acetabular shells showed any evidence of radiographic loosening at the final follow-up. Preoperatively, 21 defects were classified as Paprosky grade I, 19 grade IIA, 3 grade IIB, 9 IIC, 4 grade IIIA, and 3 IIIB. The mean postoperative WOMAC function score was 84 (SD 17), WOMAC (stiffness) 83 (SD 15), WOMAC (pain) 85 (SD 15), and WOMAC (global) 85 (SD 17). The mean postoperative OHS was 83 (SD 15), and mean SF-12 physical score was 44 (SD 11). Conclusion The additional augmentation of porous metal acetabular shells with multiple variable-angle locking screws provides reliable initial fixation with good clinical and radiological outcomes in the short term. Further studies are needed to establish the medium- and long-term outcomes. Level of evidence IV.

Extensively porous-coated cylindrical stems have demonstrated excellent results in revision total hip arthroplasties (THAs). However, most studies are midterm follow-ups and of modest cohort size. This study aimed to evaluate long-term outcomes of a large series of extensively porous-coated stems. From 1992 to 2003, 925 extensively porous-coated stems were utilized in revision THAs at a single institution. The mean age was 65 years, and 57% of patients were males. Harris hip scores were calculated, and clinical outcomes were assessed. Radiographic assessment for stem fixation was categorized as either in-grown, fibrous stable, or loose according to Engh criteria. Risk analysis used Cox proportional hazard method. The mean follow-up was 13 years. Mean Harris hip scores improved from 56 to 80 at the last follow-up (P <.001). Fifty-three femoral stems (5%) were rerevised: 26 for aseptic loosening, 11 for stem fractures, 8 for infection, 5 for periprosthetic femoral fractures, and 3 for dislocation. Cumulative incidence of aseptic femoral loosening and femoral rerevision for any reason were 3% and 6.4% at 20 years, respectively. Nine of eleven stem fractures occurred with 10.5-13.5 mm diameters (mean 6 years). Radiographic review of unrevized stems demonstrated 94% bone-ingrown. Demographics, femoral bone loss, stem diameter, and length were not predictors of femoral rerevision. In this large series of revision THAs using a single extensively porous-coated stem design, the cumulative incidence of rerevision for aseptic femoral loosening was 3% at 20 years. These data confirm the durability of this stem in femoral revision, providing a long-term benchmark for newer uncemented revision stems. Level IV, retrospective study. [ABSTRACT FROM AUTHOR]

Abstract Introduction A novel fully porous acetabular titanium shell has been designed to reduce stiffness mismatch between bone and implant and promote osseointegration in complex (cTHA) and revision total hip arthroplasty (rTHA). A highly cross-linked polyethylene (XLPE) liner is cemented within the cup to reduce wear rates and increase survivorship. This study reported the outcomes of an XLPE liner cemented into a novel 3D-printed fully porous cup in cTHA and rTHA. Methods Presented was a multicenter retrospective review of 40 patients (6 cTHA and 34 rTHA) who underwent THA with a fully porous titanium acetabular cup and cemented XLPE liner. Data were collected on demographics, surgical information, outcomes, including osseointegration and migration and implant survivorship. Results On average, patients were 71.42 ± 9.97 years old and obese (BMI: 30.36 ± 6.88 kg/m2) and were followed up for a mean time of 2.21 ± 0.77 years. Six patients underwent cTHA and 34 patients underwent rTHA. The mean hospital length of stay was 5.34 ± 3.34 days. Three (7.5%) 90-day readmissions were noted. Harris Hip Scores improved, on average, from 53.87 ± 12.58 preoperatively to 83.53 ± 12.15 postoperatively (P

Introduction: Extensive acetabular bone loss and poor bone quality are two key challenges often encountered in revision total hip arthroplasty. A new 3D-printed porous acetabular shell has been made available with the option to insert multiple variable-angle locking screws. We sought to evaluate the early clinical and radiological outcomes of this construct. Methods: A retrospective review of patients operated by two surgeons was performed in a single institution. Fifty-nine revision hip arthroplasties were performed in 55 patients (34 female; mean age 68.8 ± 12.3 years) for Paprosky defects I (n = 21), IIA/B (n = 22), IIC (n = 9), III (n = 7) between February 2018 and January 2022 using the novel porous titanium acetabular shell and multiple variable angle locking screws. Postoperative clinical and radiographic outcomes were locally maintained. Patient-reported outcome measures collected included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Hip Score, and the 12-item Short Form Survey. Results: After a mean follow-up of 25.7 ± 13.9 months, two cases of shell migration were noted. One patient had a failed constrained mechanism and received revision to a cemented dual mobility liner. No other acetabular shells showed any evidence of radiographic loosening at the final follow-up. Preoperatively, 21 defects were classified as Paprosky grade I, 19 grade IIA, 3 grade IIB, 9 IIC, 4 grade IIIA, and 3 IIIB. The mean postoperative WOMAC function score was 84 (SD 17), WOMAC (stiffness) 83 (SD 15), WOMAC (pain) 85 (SD 15), and WOMAC (global) 85 (SD 17). The mean postoperative OHS was 83 (SD 15), and mean SF-12 physical score was 44 (SD 11). Conclusion: The additional augmentation of porous metal acetabular shells with multiple variable-angle locking screws provides reliable initial fixation with good clinical and radiological outcomes in the short term. Further studies are needed to establish the medium- and long-term outcomes. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Introduction: A novel fully porous acetabular titanium shell has been designed to reduce stiffness mismatch between bone and implant and promote osseointegration in complex (cTHA) and revision total hip arthroplasty (rTHA). A highly cross-linked polyethylene (XLPE) liner is cemented within the cup to reduce wear rates and increase survivorship. This study reported the outcomes of an XLPE liner cemented into a novel 3D-printed fully porous cup in cTHA and rTHA. Methods: Presented was a multicenter retrospective review of 40 patients (6 cTHA and 34 rTHA) who underwent THA with a fully porous titanium acetabular cup and cemented XLPE liner. Data were collected on demographics, surgical information, outcomes, including osseointegration and migration and implant survivorship. Results: On average, patients were 71.42 ± 9.97 years old and obese (BMI: 30.36 ± 6.88 kg/m2) and were followed up for a mean time of 2.21 ± 0.77 years. Six patients underwent cTHA and 34 patients underwent rTHA. The mean hospital length of stay was 5.34 ± 3.34 days. Three (7.5%) 90-day readmissions were noted. Harris Hip Scores improved, on average, from 53.87 ± 12.58 preoperatively to 83.53 ± 12.15 postoperatively (P<0.001). One case of acetabular shell aspetic loosening with migration was noted. Thirty-nine of the 40 acetabular components were fully osseointegrated without migration. Two patients underwent re-revision surgery for PJI and one patient received acetabular shell+liner re-revision due to aseptic loosening. Kaplan-Meier analysis showed an all-cause revision-free survival rate of 95.0% at 6 months and 1 year, and 92.0% at 4-years. Aseptic acetabular cup, liner dislocation/loosening, and fracture-free survival was 100% at 6 months and 1-year, and 97.1% at 2 years. Conclusion: The combined use of a novel 3D-printed fully porous titanium acetabular shell and cemented XLPE acetabular liner yielded excellent rates of osseointegration, and all-cause and acetabular aseptic loosening survivorship at a minimum 1-year follow-up. Further long-term studies are needed to assess the longevity of this construct. [ABSTRACT FROM AUTHOR]

Introduction: There is no distinct classification system to evaluate the bone defect in previously managed acetabular fractures. We propose a new classification system for bone defect evaluation in a previously managed acetabular fracture that will be helpful for total hip arthroplasty (THA). Materials and Methods: The preoperative pelvis radiographs of 99 THA patients with previous acetabular fractures with at least 2 years of follow-up were evaluated by 10 experienced surgeons (Paprosky and new classification systems). As per the new classification system, the five types of bone defects are circumferential, posterior wall, posterior column, both column defect, and anterior column. The interobserver and intraobserver reliability was calculated, and a consensus management plan based on the recommendation of the observers was formulated. Results: There was fair interobserver reliability for Paprosky classification (alpha coefficient 0.39) and substantial interobserver reliability for the new classification (alpha co-efficient 0.71). There was a substantial intraobserver agreement for the new classification (kappa value 0.80) and moderate intraobserver agreement for Paprosky classification (kappa value 0.55). Sixty-nine patients who were treated as per the management plan of the observers reported significant improvement in modified Harris hip score (improved from 25 to 85.88, p < 0.001). 89.7% of patients reported good to excellent outcomes. Overall best health as per EQ-5D VAS was obtained in THA following anterior column fracture (EQ-5D VAS 97.5), and relatively poor health was obtained after THA of posterior column nonunion (EQ-FD VAS 80). Conclusions: The new classification system for bone defect evaluation in previously treated acetabular fractures is valid and reliable. The proposed surgical plan for the management of bone defects in THA provided good to excellent outcomes. [ABSTRACT FROM AUTHOR]

Background: The paradigm of revision surgery has been evolving constantly. There is a wide range of surgical options for successful reconstruction. Objective: This study aimed to evaluate the results of reconstruction techniques in acetabular deficiency. Patients and methods: A prospective interventional design included patients with acetabular deficiency who were admitted to Orthopedic Department at Zagazig University Hospitals. We had 10 patients with acetabular deficiency (Three were classified as Paprosky IIIA; one of them was AAOS IIB and two were AAOS III, Two were classified as Paprosky IIIB and AAOS III, Two were classified as Paprosky IIA and AAOS IIA; one was Paprosoky IIB and AAOS IIB and Two patients were classified as Paprosky IIC; one of them was AAOS IIB and the other was AAOS III). The evaluation and follow up of patients depended mainly on the Harris hip score, which evaluates the patient clinically preoperatively and postoperatively. Results: All the patients reached full weight bearing between 7 and 9 weeks after surgery. Revision total hip replacement (THR) was the treatment of choice for patients with severe groin pain and apparent acetabular deficiency. Restoration of the normal center of rotation was essential for the joint biomechanics and survival of the prosthesis. Conclusion: There was no method of reconstruction of acetabulum superior to another method; each method had specific indication, which differs according to the percentage of acetabular coverage and bone stock. Patients with mild to moderate acetabular deficiency (Paprosky I, IIA and IIB) were managed by using acetabular augmentation graft or small acetabular component with medialization. [ABSTRACT FROM AUTHOR]

Introduction: The evaluation and management of acetabular bone loss in total hip arthroplasty is a challenge for orthopedic surgeons, we wish in this study to determine the inter-observer concordance in the Paprosky classification for acetabular defects. Material and methods: Observational, descriptive, longitudinal, prospective study. It was performed using anteroposterior hip radiographs of patients scheduled for primary total hip arthroplasty or revision with acetabular bone defect, Sinapse local X-ray system, 20 X-rays were assessed per observer taken randomly (doctors assigned to the joint replacement service with minimum experience of five years) using the Paprosky classification spontaneously, (without previous classes) for acetabular defects, inter-observer concordance was assessed using Cohen's Kappa coefficient. Results: An interobserver agreement was obtained on average for the Paprosky classification of acetabular defects using the Cohen's Kappa coefficient, the concordance analysis was done using the statistical program statistical package for the social sciences of 0.237. Conclusions: Both the null hypothesis (Kappa greater than 0.80 value considered optimal) and the alternative hypothesis (Kappa from 0.41 to 0.80 value equal to moderate to good) did not agree with our study (Kappa equal to 0.237) value equal to mild, in addition, it was shown that the greater the acetabular defect, the lower the interobserver agreement in surgeons in our institution. [ABSTRACT FROM AUTHOR]

Introduction: The treatment of severe acetabular bone loss remains a difficult challenge. No classification system is available that combines intuitive use, structured design and offers a therapeutic recommendation according to the current literature and modern state of the art treatment options. The goal of this study is to introduce an intuitive, reproducible and reliable guideline for the evaluation and treatment of acetabular defects.Methods: The proposed Acetabular Defect Classification (ADC) is based on the integrity of the acetabular rim and supporting structures. It consists of 4 main types of defects ascending in severity and subdivisions narrowing down-defect location. Type 1 presents an intact acetabular rim, type 2 includes a noncontained defect of the acetabular rim ≤ 10 mm, in type 3 the rim defect exceeds 10 mm and type 4 includes different kinds of pelvic discontinuity. A collective of 207 preoperative radiographs were graded according to ADC and correlated with intraoperative findings. Additionally, a randomized sample of 80 patients was graded according to ADC by 5 observers to account for inter- and intra-rater reliability.Results: We evaluated the agreement of preoperative, radiographic grading and intraoperative findings presenting with a k value of 0.74. Interobserver agreement presented with a k value of 0.62 and intraobserver at a k value of 0.78.Conclusion: The ADC offers an intuitive, reliable and reproducible classification system. It guides the surgeon pre- and intraoperatively through a complex field of practice. [ABSTRACT FROM AUTHOR]

Purpose: Our study aims at the evaluation of the recently introduced Lima Promade custom-made acetabular device for the treatment of complex acetabular Paprosky 3B defects.Methods: Between 2016 and 2018, eight patients with major acetabular osteolysis and multiple revisions history were treated with a custom-made implant in a single centre and by a single surgeon. We assessed patients' demographics, peri-operative data, and complications and a specific questionnaire was submitted to the surgeon after each procedure.Results: All the devices were correctly positioned. In two over eight cases, a post-operative dislocation occurred, where extensive soft tissue impairment was present. The questionnaire showed a good pre-operative and intra-operative experience of the surgeon.Conclusions: The Promade custom-made acetabular system showed encouraging results for complex defects and the entire procedure was positively rated. Further analysis with a higher number of cases and a longer follow-up should be performed for a complete clinical and cost-effective evaluation. [ABSTRACT FROM AUTHOR]

Introduction: The evaluation and management of acetabular bone loss in total hip arthroplasty is a challenge for orthopedic surgeons, we wish in this study to determine the inter-observer concordance in the Paprosky classification for acetabular defects., Material and Methods: Observational, descriptive, longitudinal, prospective study. It was performed using anteroposterior hip radiographs of patients scheduled for primary total hip arthroplasty or revision with acetabular bone defect, Sinapse local X-ray system, 20 X-rays were assessed per observer taken randomly (doctors assigned to the joint replacement service with minimum experience of five years) using the Paprosky classification spontaneously, (without previous classes) for acetabular defects, inter-observer concordance was assessed using Cohen's Kappa coefficient., Results: An interobserver agreement was obtained on average for the Paprosky classification of acetabular defects using the Cohen's Kappa coefficient, the concordance analysis was done using the statistical program statistical package for the social sciences of 0.237., Conclusions: Both the null hypothesis (Kappa greater than 0.80 value considered optimal) and the alternative hypothesis (Kappa from 0.41 to 0.80 value equal to moderate to good) did not agree with our study (Kappa equal to 0.237) value equal to mild, in addition , it was shown that the greater the acetabular defect, the lower the interobserver agreement in surgeons in our institution.

Purpose: Patient-specific, flanged acetabular components are used for the treatment of Paprosky type III defects during revision total hip arthroplasty (THA). This monocentric retrospective cohort study analyzes the outcome of patients treated with custom made monoflanged acetabular components (CMACs) with intra- and extramedullary iliac fixation., Methods: 14 patients were included who underwent revision THA with CMACs for the treatment of Paprosky type III defects. Mechanism of THA failure was infection in 4 and aseptic loosening in 10 patients. Seven patients underwent no previous revision, the other seven patients underwent three or more previous revisions., Results: At a mean follow-up of 35.4 months (14-94), the revision rate of the implant was 28.3%. Additionally, one perioperative dislocation and one superficial wound infection occurred. At one year postoperatively, we found a significant improvement of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score ( p = 0.015). Postoperative radiographic analysis revealed good hip joint reconstruction with a mean leg length discrepancy of 3 mm (-8-20), a mean lateralization of the horizontal hip center of rotation of 8 mm (-8-35), and a mean proximalization of the vertical hip center of rotation of 6 mm (13-26). Radiolucency lines were present in 30%., Conclusion: CMACs can be considered an option for the treatment of acetabular bone loss in revision THA. Iliac intra- and extramedullary fixation allows soft tissue-adjusted hip joint reconstruction and improves hip function. However, failure rates are high, with periprosthetic infection being the main threat to successful outcome.