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Ice cream cone (pedestal) prosthesis for chronic pelvic discontinuity

Background Chronic pelvic discontinuity (CPD) is among the most challenging situations in revision total hip arthroplasty (THA) and is estimated to cause 1% to 5% of all acetabular revisions. , It is a distinct form of bone loss and is defined as a separation of the superior pelvis from the inferior pelvis by a fracture, osteolysis, or non-union. Risk factors for CPD are female sex, severe…

Cup-cage/half cage for chronic pelvic discontinuity

Introduction Chronic pelvic discontinuity and major acetabular bone loss cause difficulty achieving a stable motionless interface with a hemispherical uncemented acetabular component, the key to obtaining bone ingrowth. If biologic fixation is not achieved, implant failure and migration will likely occur. Chronic pelvic discontinuity has a clear association with acetabular component loosening when a standard hemispherical cup with screws is utilized. Adjunctive posterior column plating or…

Acetabular bone loss with chronic pelvic discontinuity: Acetabular cup-cage vs cage-augment reconstruction

Background Pelvic discontinuity is defined as a dissociation of the proximal and distal halves of the acetabulum associated with variable amounts of bone loss. This dissociation results in multiple challenges for revision total hip arthroplasty. Pelvic discontinuity can be acute or chronic. Often it can occur intraoperatively, and in these circumstances, it is usually treated with open reduction internal fixation using plate fixation followed by conventional…

Acetabular impaction bone grafting for chronic pelvic discontinuity

Background Acetabular impaction bone grafting is an attractive technique in hip revision surgery. There are over 40 years of clinical experience with this technique combined with a cemented cup. , Recent studies have also published results regarding the successful application of this method with uncemented cups. , Impaction bone grafting is the only technique that really restores bone stock deficiencies. Several studies have proven the incorporation…

Kerboull acetabular ring device with allograft for chronic pelvic discontinuity

Background The demand for total hip and knee replacement is increasing at a frenetic rate. Data from prior studies , and projection investigations demonstrate that the number of revision total hip arthroplasty (THA) will rise 137% over the next 25 years in the United States, and similar trends have been observed in the United Kingdom and Australia. , Among revision THA, Bozic et al. have shown…

Cages/ reconstruction rings (Burch-Schneider/ Ganz) for reconstruction of chronic pelvic discontinuity

Background Chronic pelvic discontinuity is an uncommon and difficult problem in the setting of revision total hip arthroplasty. It is usually seen in conjunction with Paprosky III-A, III-B, and II-C defects and is more common in females and rheumatoid patients. The treatment goals include achieving union across the discontinuity, restoration of bone stock, and implantation of a stable mechanical construct with potential for long-term biologic fixation.…

Intraoperative identification and bone grafting of a chronic pelvic discontinuity

Background Pelvic discontinuity presents unique treatment dilemmas and is one of the most difficult problems encountered during revision total hip arthroplasty (THA). This clinical entity is often chronic secondary to osteolysis, resulting in significant acetabular bone loss, but can also be seen in acute acetabular fractures, most notably in the elderly population, and following iatrogenic fracture during THA. Pelvic discontinuity involves separation of the ilium superiorly…

Plating of an acute pelvic discontinuity

Background Periprosthetic pelvic discontinuity is the loss of continuity between the superior and inferior hemipelvis involving the floor and both columns of the acetabulum because of either fracture or bone loss. The prevalence of pelvic discontinuity is challenging to assess; however, most series report the incidence at between 1% to 5% in revision total hip arthroplasty (THA). It is usually chronic in nature, associated with pathologic…

Acetabular revision with impaction grafting for severe acetabular bone loss without pelvic discontinuity

Background Acetabular reconstruction in the presence of significant or severe acetabular bone loss can be achieved in different ways. Classification of the expected bone loss is important. Similarly, patient characteristics and clinical experience should be considered when determining how best to manage each individual patient. Numerous techniques exist in acetabular revision. With regard to the use of cemented components in acetabular revision, results have been varied…

Cementless acetabular revision for severe acetabular bone loss without pelvic discontinuity (type IIIA and B defects)

Introduction Severe acetabular bone loss poses a challenging reconstructive problem in revision total hip arthroplasty (THA), with some of the most complex patterns seen in Paprosky type IIIA and IIIB defects. Even in the absence of chronic pelvic discontinuity, the treatment of IIIA and IIIB remains a significant operative challenge. In acetabular revisions, fully cementless constructs offer several advantages over cemented or hybrid components. First, there…

Cemented acetabular revision for the distorted acetabulum with intact columns (type IIA, B, and C defects)

Background Distortion of the acetabulum is a common finding after the removal of failed acetabular components. Reconstruction of such defects is a necessity for any orthopaedic surgeon performing revision total hip arthroplasty (THA) procedures, as the creation of a type II defect during implant removal must always be ruled out. Various techniques exist for reconstructing these defects, and cement in conjunction with donor bone is widely…

Cementless acetabular revision for the distorted acetabulum with intact columns (type IIA, B, and C defects)

Background The Paprosky classification of acetabular bone loss was established in 1994 to define the severity of bone loss and to suggest a revision algorithm to obtain a stable acetabular reconstruction. , The treatment is based on the location and degree of bone loss. Four variables need to be considered: (1) the location and migration of the hip center of rotation, (2) the degree of teardrop…

Cemented revision in type I defects

Background Acetabular bone loss is a technical challenge encountered at the time of revision total hip arthroplasty (THA). The severity of bone loss can be diverse, ranging from minimal deformities with intact columns (Paprosky type I) to complete loss of bony contact between the superior and inferior halves of the acetabulum, with superomedial cup migration (pelvic discontinuity, Paprosky type IIIB). Paprosky type I acetabular defects can…

Cementless acetabular revision (type I defects)

Background As the popularity of total hip arthroplasty (THA) continues to rise, there is expected to be a concomitant increase in the number of revision procedures. Revision of the acetabular component is regarded as one of the most challenging aspects of reconstructive surgery. To aid in clinical decision-making and preoperative planning, Paprosky and colleagues created a widely used classification system for acetabular bone loss. The Paprosky…

Radiographic evaluation of severe acetabular bone loss +/– chronic pelvic discontinuity

Background Pelvic discontinuity is a complex reconstructive challenge characterized by a dissociation of the superior and inferior hemipelvis secondary to fracture or substantial bone loss in the setting of total hip arthroplasty. Potential massive bone loss and motion through the fracture site have led to poor results following revision surgery. , The ability to describe the location and the amount of bone loss is important when…

Acetabular bone loss classification

Introduction As with many clinical scenarios encountered in orthopaedics, classification systems have been developed to concisely communicate radiographic and/or intraoperative findings among providers and researchers and, perhaps most importantly, provide guidelines for clinical management. Acetabular bone loss in the setting of primary or revision total hip arthroplasty (THA) can result from osteolysis, component migration, infection, iatrogenic bone removal during component extraction, and many other causes. With…

Unicompartmental Knee Arthroplasty Technique

Before proceeding with unicompartmental knee arthroplasty (UKA), the surgeon must decide at arthrotomy whether the patient is an appropriate candidate. Both cruciate ligaments should be intact, although a deficient anterior cruciate ligament (ACL) occasionally is acceptable if certain criteria are fulfilled. These criteria include a tibial wear pattern that remains in the anterior two thirds of the tibial plateau. A posterior wear pattern represents unacceptable ACL…

Unicompartmental Knee Arthroplasty

In theory, unicompartmental knee arthroplasty (UKA) is an attractive alternative to osteotomy and total knee arthroplasty (TKA) in selected osteoarthritic patients. Advantages of UKA over osteotomy include higher initial success, fewer early complications, greater longevity, better cosmetic limb alignment, easier conversion to TKA, and the potential to perform bilateral procedures on the same day. Later conversion of osteotomy to TKA is potentially complicated by many factors…

Mobile Versus Fixed Bearings in Total Knee Arthroplasty

Mobile-bearing articulations for knee arthroplasty have been available since the 1970s. Nevertheless, for decades, they never gained great popularity and remained an alternative technique embraced by a small group of surgeons. In the early 2000s, interest in these articulations was renewed as an option to address both top-side and back-side wear and osteolysis occurring in modular fixed-bearing knees. Why Consider a Mobile-Bearing Alternative? Fixed-bearing knees, whether…