A Review and Description of Acetabular Impaction Bone Grafting: Updating the Traditional Technique

Abstract

Restoring acetabular bone loss in revision hip arthroplasty is a major challenge for the orthopaedic surgeon. This paper discusses the traditional cemented technique of impaction bone grafting as applied to the acetabulum, as well as the evolution of the technique to employ uncemented implants. Some of the recent published literature regarding these techniques is reviewed and the personal experiences of the senior author with these techniques are also reported.

Keywords: Acetabulum; Bone cement; Bone grafting; Reoperation; Total hip arthroplasty.

Fig. 1. Ideal bone chip sizes, hand produced by rongeur, range between 8 mm and 10 mm.

Fig. 2. Range of bone chip sizes, cancellous bone in the left dish and larger cortico-cancellous in the right.

Fig. 3. In cases where the autograft bone quality is poor, cancellous bone is harvested, which may be augmented by cortico-cancellous allograft.

Fig. 4. (A, B) The use of impaction bone grafting in protrusio acetabulae, and the performance of a complex primary total hip replacement to restore hip biomechanics.

Fig. 5. Radiographs of a 77-year-old female undergoing revision of a loose cemented acetabular component. Preoperative radiograph (A) and 5-year follow-up radiograph (B) after impaction bone grafting and cemented cup on right. Restoration of bone stock, leg length, and femoral offset as well as incorporation of graft is shown.

Fig. 6. Radiograph showing appearances after eight years. Note screw breakage, protrusio acetabulae deformity, and superior migration of acetabular component which demonstrates significant polyethylene wear.

Fig. 7. The same patient shown in Fig. 6, three years after acetabular impaction grafting. Note that the medial bone stock is restored and appears to have incorporated. Some features suggest that this implant may migrate as well.

Fig. 8. (A) Radiograph of early failure of a cemented total hip replacement (THR) at four years postoperative in a 45-year-old amputee. Core biopsy result suggested low-grade infection. (B) Radiograph at 12 months post impaction bone grafting and good incorporation of graft with a Cup-Cage system.

Fig. 9. Preoperative radiograph 2009 (A) and 10-year postoperative (B) radiographs 2019 of an 83-year-old patient undergoing revision of cemented total hip replacement.

Fig. 10. Preoperative (A) and postoperative (B) radiographs showing central and superior migration of the cemented acetabular component. The cup-cage construct is useful to stabilise and prevent proximal migration, hence affording the construct increased stability.