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https://upload.orthobullets.com/topic/5009/images/13a_moved.jpg
https://upload.orthobullets.com/topic/5009/images/aaos acetabulum.jpg
https://upload.orthobullets.com/topic/5009/images/aaos type 2 acetabular.jpg
https://upload.orthobullets.com/topic/5009/images/aaos type iii acetabular..jpg
https://upload.orthobullets.com/topic/5009/images/aaos pelvic discontinuity.jpg
https://upload.orthobullets.com/topic/5009/images/paprosky acetabulum.jpg
 Introduction
  • Overview
    • revision total hip arthroplasty is most commonly caused by aseptic loosening, fracture, instability, or infection
  • Epidemiology
    • incidence 
      • in the United States is projected to increase >100% by 2030
    • demographics
      • roughly equal male to female
      • average age of roughly 65-70 in most studies
  • Pathophysiology
    • femoral component failure
    • acetabular component failure
    • both component failure
    • neither
  • Indications
    • wound healing complications
    • periprosthetic fracture
    • implant fracture
    • hip instability  
    • periprosethic joint infection (PJI)
    • adverse local soft tissue reaction (MoM) 
    • trunnionosis
    • osteolysis  
    • aseptic loosening
    • limb length discrepancy (LLD)
  • Broad categories
    • revision surgery without affecting modular OR nonmodular components
      • revision wound closure
      • psoas release
      • heterotopic bone excision
      • ORIF of periprosthetic fracture
    • revision surgery affecting modular components only
      • femoral head and or polyethyelene exchange
      • titanium sleeve 
    • revision surgery nonmodular components
      • acetabular component exchange
        • most common reason for revision in the Charnley "low-friction" total hip arthroplasty 
      • femoral component exchange
      • removal of both components
        • replaced with new components
        • replaced with antibiotic spacer
        • girdlestone
  • Prognosis
    • lower mid-term and long term survival compared to primary THA with higher rates of complications
      • dislocation (even in simple procedures) 
      • infection
      • nerve palsy
      • fractures
      • abductor deficiency 
      • DVT
      • limb length discrepancy
Classification of Bone Loss
  • Acetabulum
AAOS Classification of Acetabular Bone Loss
Type I (segmental) Loss of part of the acetabular rim or medial wall
Type II (cavitary) Volumetric loss in the bony substance of the acetabular cavity  
Type III (combined deficiency) Combination of segmental bone loss and cavitary deficiency  
Type IV (pelvic discontinuity)     Complete separation between the superior and inferior acetabulum  
Type V (arthrodesis) Arthrodesis
 
Paprosky Classification of Acetabular Bone Loss
Type I

Minimal deformity, intact rim

Type IIA Superior bone lysis with intact superior rim  
Type IIB  Absent superior rim, superolateral migration  
Type IIC Localized destruction of medial wall  
Type IIIA  Bone loss from 10am-2pm around rim, superolateral cup migration  
Type IIIB

Bone loss from 9am-5pm around rim, superomedial cup migration

 
  • Femur
AAOS Classification of Femoral Bone Loss
Type I (segmental) Loss of bone of the supporting shell of femur
Type II (cavitary) Loss of endosteal bone with intact cortical shell  
Type III (combined) Combination of segmental bone loss and cavitary deficiency  
Type IV (malalignment) Loss of normal femoral geometry due to prior surgery, trauma, or disease
Type V (stenosis) Obliteration of the canal due to trauma, fixation devices, or bony hypertrophy
Type VI (femoral discontinuity) Loss of femoral integrity from fracture or nonunion
 
Paprosky Classification of Femoral Bone Loss
Type I Minimal metaphyseal bone loss
Type II Extensive metaphyseal bone loss with intact diaphysis  
Type IIIa Extensive metadiaphyseal bone loss, minimum of 4 cm of intact cortical bone in the diaphysis  
Type IIIb Extensive metadiaphyseal bone loss, less than 4 cm of intact cortical bone in the diaphysis  
Type IV Extensive metadiaphyseal bone loss and a nonsupportive diaphysis  
 
Presentation
  • Symptoms
    • groin pain --> acetabulum
    • thigh pain --> femoral stem 
    • start-up pain --> component loosening
    • night pain --> infection
    • no improvement in pain after surgery --> incorrect diagnosis
  • Physical exam
    • inspection
      • assess wound for infection
      • gait
    • range of motion
      • in flexion, extension, abduction looking for restriction of motion or pain
        • avoid positions of dislocation based on THA approach
    • provocative test
      • pain with resisted hip flexion suggests psoas impingement
Imaging
  • Radiographs
    • recommended views
      • AP pelvis 
      • orthogonal views of involved hip
      • full-length femur radiographs
    • opitional views
      • pre-operative radiographs
      • immediate post-operative radiographs
      • Judet views
        • useful for assessment of columns  
  • CT scan
    • indications
      • useful for determining extent of osteolysis
        • radiographs frequently underestimate extent of osteolysis 
      • assessment of component position
Studies
  • Serum labs
    • infectious laboratories 
      • ESR
      • CRP 
      • CBC
    • metal levels
      • cobalt and chromium levels
        • trunnionosis 
        • THA pseudotumor 
  • Aspiration
    • recommended if infectious laboratories are suggestive of infection
Treatment
  • Nonoperative
    • indications
      • differing etiology of pain (i.e. back pain, greater trochanteric bursitis, etc.)
      • no identifiable etiology of pain
  • Femoral revision
    • primary total hip arthroplasty components 
      • indications
        • minimal metaphyseal bone loss, Paprosky I
    • uncemented extensively porous-coated long-stem prosthesis (or porous-coated/grit blasted combination) or modular tapered stems    
      • indications
        • most Paprosky II and IIIa defects; Paprosky IIIb (modular fluted tapered stem)
      • outcomes
        • 95% survival rate at 10-years
    • femoral impaction bone grafting 
      • indications
        • large ectactic canal and thin cortices 
        • Paprosky IIIb and IV defects
      • outcomes
        • most common complication is stem subsidence
    • allograft prosthetic composite (APC) 
      • indications
        • Paprosky IIIb and IV defects
    • endoprosthetic replacement (EPR) 
      • indications
        • massive bone loss with a non-supportive diaphysis
        • Paprosky IIIB and IV defects
    • cemented stems
      • indications
        • irradiated bone
        • elderly
        • low-demand patients
      • outcomes
        • high failure rate
  • Acetabular revision
    • porous-coated hemisphere cup or jumbo secured with screws   
      • indications
        • at least 50% of bone stock present to support cup
      • disadvantage
        • jumbo cup may disrupt posterior column with additional bone reamed
        • dislocation
    • porous-coated hemispherical cup with acetabular augments
      • indications
        • bone loss (Paprosky defects Type IIB-C and IIIA-B)
      • outcomes
        • 2 year survivorship 94%-100%
        • 5 year survivorship 92%-100%
        • 10 year survivorship 92%
    • reconstruction cage with structural bone allograft   
      • indications
        • rim is incompetent (<2/3 of rim remaining), <50% of bone stock present
      • outcomes
        • allograft failure is the most common complication 
        • high failure rate (40-60%) without reconstruction cage due to component migration after graft resorption
    • custom triflange cup  
      • indications
        • pelvic discontinuity
    • cemented acetabular components
      • can cement a liner by itself or into a well fixed cup
    • liner options
      • e.g. face changing, oblique, lipped, offset, contrained, dual mobility, etc.
  • Combined revision
    • femoral head and polyethylene exchange
      • indications
        • eccentric wear of the polyethylene with stable acetabular and femoral components 
        • acute infectiontrunnionosis
        • outcomes
        • hip instability is the most common complication of isolated liner exchange  
    • conversion from a hip arthrodesis 
      • indications
        • low back and knee pain as a result of arthrodesis
      • outcomes
        • implant survival greater than 95% at 10 years
        • competence of abductor and gluteal musculature is predictive of ambulatory success
        • improved ipsilateral knee and back pain
  • Revision without changed modular or nonmodular components
    • ORIF periprosthetic fracture
      • indications
        • fracture with stable components
    • psoas release
      • indications
        • painful psoas with clinical signs of impingement and improvement with lidocaine injection
        • can be completed arthroscopically
    • heterotopic bone excisions
      • indications
        • mature heterotopic bone formation causing pain and restricted range of motion
Surgical Techniques
  • Femoral revision
    • primary total hip arthroplasty components
      • technique
        • must be sure there is no unexpected bone loss
    • uncemented extensively porous-coated long-stem prosthesis or modular tapered stems
      • technique
        • removal of stem may require extended trochanteric osteotomy (ETO)
          • ETO decreases load to failure (fracture) 
        • femoral stem must bypass most distal defect by 2 cortical diameters
          • prevents bending moment through cortical hole
        • cavitary lesions are grafted with particulate graft
        • allograft cortical struts or plates may be used to reinforce cortical defects 
    • femoral impaction bone grafting
      • technique 
        • morselized fresh-frozen allograft packed into canal
        • smooth tapered stem cemented into allograft
    • allograft prosthetic composite (APC)
      • technique
        • measure host canal size, allograft canal size should be slightly larger than distal host canal
        • mark rotation and make femoral osteotomy (transverse or step) cut on host bone
        • allograft is prepared (usual neck cut and canal reamining) for cementing of fully porous-coated stem
        • host femur is prepared with straight reamers with goal of 4-6cm of good scratch fit distal to osteotomy
        • component is cemented into allograft and press fit into host bone
    • endoprosthetic reconstruction (EPR)
      • technique
        • a sample of bone from distal femoral osteotomy should be sent for frozen section to confirm no tumor cells are present prior to instrumenting
        • option for distal fixation include a cemented stemmed endoprosthesis, compressive osseointegration, or a press-fit fully porous-coated cylindrical stem
    • cemented stems
      • technique
        • bone grafting of any femoral defects prior to cementing
        • ensure canal preparation has removed old cement, neocortex (greater and less troch), and sclerotic bone for cement interdigitation
  • Acetabular revision
    • porous-coated hemisphere cup or jumbo secured with screws 
      • technique
        • cavitary lesions are filled with particulate graft
        • cup placement should be inferior and medial
          • lowers joint reactive forces
        • metallic wedge augmentation may be used if cup in good position and rigid internal fixation is achieved
        • jumbo cups may be used when larger reamer is needed to make cortical contact
        • structural allografts may be used to provide stability while bone grows into cementless cup
    • porous-coated hemispherical cup with acetabular augments
      • technique
        • gentle reaming to smooth the acetabulum and minimizing the removal of good supportive bone
        • assess cup size with trials and location for augments
        • fix the augment with screws
        • place small amount of cement on the augment and place real cup to unite the augment to the cup
        • place screws in the cup, goal is to have a screw go through the cup and augment
    • reconstruction cage and structural bone allograft
      • technique
        • polyethylene cup is cemented into reconstruction cage
        • bone graft placed behind cage
    • custom triflange
      • technique
        • sterilize custom triflanged acetabular component (CTAC) model for intraopeative reference
        • removal of prior implant and assess needed excess bone removal
        • place iliac flange first followed by pubic and ischial flange
        • secure with screw fixation
        • consider placement of posterior column plate
    • cemented cup
      • technique
        • cement polyethylene into stable cup
  • Combined revision
    • Femoral head and polyethylene exchange
      • technique
        • exchange both head and liner
        • osteolytic defects may be bone grafted through screw holes to fill bony defects    
    • Conversion from hip arthrodesis
      • technique
        • osteotomy of remaining greater trochanter
        • femoral neck ostoetomy and acetabular reaming can be done under radiographic guidance given limitations in bony landmarks
        • consideration for revision cup and femoral stem as well as dual mobility or constrained liner given high dislocation rate
        • if abductor deficiency can perform glut max transfer 
          • along with the tensor fascia lata, the anterior aspect of the gluteus maximus is freed and transferred to the greater trochanter so that the fibers are similarly oriented to the native abductor musculature
  • Revision without changed modular or nonmodular components
    • ORIF periprosthetic fracture
      • technique
        • assess stability of components, if stable treat fracture and if unable revise
        • see topic page  
    • psoas release
      • technique
        • see topic page  
    • heterotopic bone (HO) excision
      • technique
        • await maturation of bone 
        • excision of bone should be followed by HO prophylaxis of either NSAIDs, radiation, or both.

 

 

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Questions (37)
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(OBQ13.272) A 72-year-old patient is scheduled to undergo revision total hip arthroplasty. A 3D-model of the patient's hemipelvis is constructed for pre-operative planning and is shown in Figure A. A custom-designed implant shown in Figure B is created. Which of the following is TRUE of the planned reconstruction? Tested Concept

QID: 4907
FIGURES:
1

The implant is a bilobed cup.

4%

(173/4313)

2

The most common complication is dislocation.

54%

(2325/4313)

3

The acetabular defect can be classified as AAOS Type V.

25%

(1071/4313)

4

Radiation-compromised bone stock is a contraindication.

10%

(415/4313)

5

The winged profile of the implant facilitates insertion through both anterior and anterolateral approaches.

7%

(307/4313)

L 4 B

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(OBQ12.17) A 71 year old gentleman underwent left total hip arthroplasty 10 years ago. Eighteen months ago he began having hip and thigh pain. Over the past 6 weeks, the pain has become excruciating and he has been unable to ambulate, even with the aid of a walker. He has mild pain with passive internal and external rotation of the hip. He is unable to ambulate in the office. Laboratory values are notable for a WBC of 10,300, CRP of 0.2, and ESR of 13. A radiograph is provided in figure A. Which of the following is the best treatment option? Tested Concept

QID: 4377
FIGURES:
1

Radionuclide bone scan and MRI

3%

(176/5968)

2

Open reduction internal fixation with a cable plate and allograft strut

5%

(284/5968)

3

Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft

61%

(3655/5968)

4

Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation

23%

(1367/5968)

5

Revision arthroplasty with a total femur prosthesis

8%

(448/5968)

L 3 B

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(OBQ12.16) Which of the following statements is true regarding the thirty-year follow-up data obtained from the Charnley "low-friction" total hip arthroplasty? Tested Concept

QID: 4376
1

Acetabular component failure was the least common reason for revision surgery

5%

(272/5266)

2

The number of revisions required for periprosthetic fractures was higher than that for deep infections

5%

(271/5266)

3

Acetabular component failure was a more common reason for revision than deep infection

62%

(3270/5266)

4

Femoral component failure was a more common reason for revision than acetabular component failure

17%

(873/5266)

5

Deep infection was the most common reason for revision

10%

(522/5266)

L 3 B

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(OBQ12.149) A 91-year-old male with a history of chronic leukemia and dementia falls and sustains the hip fracture shown in Figure A. He undergoes a hemiarthroplasty through a posterior approach. A post-operative radiograph is shown in Figure B. Three weeks later he dislocates the hip arising from the toilet seat. A radiograph is shown in Figure C. The patient undergoes a closed reduction and is placed in a hip abduction brace. Post reduction radiograph is shown in Figure D. One month later he returns to clinic complaining of pain and inability to bear weight through the leg. A radiograph of the hip is included in Figure E. Which of the following factors has MOST likely contributed to the instability of the hip hemiarthroplasty? Tested Concept

QID: 4509
FIGURES:
1

Femoral stem subsidence

1%

(66/4411)

2

Increased offset

12%

(546/4411)

3

Inadequate femoral stem neck length

13%

(578/4411)

4

Patient's dementia status

71%

(3149/4411)

5

Patient's gender

1%

(35/4411)

L 4 B

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(OBQ12.67) A 72-year old female who underwent an uncemented right total hip arthroplasty 2 years ago complains of right hip pain after a fall. Figure A shows her current radiograph. Which acetabular bone defect classification and treatment option best describes this scenario? Tested Concept

QID: 4427
FIGURES:
1

AAOS Type III - anti-protrusio cage with augmentation and a posterior column plate

24%

(1059/4391)

2

AAOS Type IV - anti-protrusio cage with screw fixation and a posterior column plate

62%

(2703/4391)

3

AAOS Type II - jumbo cup with augmentation and a posterior column plate

8%

(341/4391)

4

AAOS Type I - total acetabular allograft with a cemented cup

1%

(53/4391)

5

AAOS Type II - custom triflange acetabular component

4%

(194/4391)

L 4 B

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(OBQ12.50) A 74-year-old man presents with start-up thigh pain following a total hip replacement 10 years ago. Immediate post-operative radiograph is shown in Figure A. A current radiograph is shown in Figure B. Aspiration of the hip yields 1,005 white blood cells/ml. ESR is 12 (normal <40) and CRP is 0.4 (normal <1.2). Which of the following is the most appropriate management at this time? Tested Concept

QID: 4410
FIGURES:
1

Revision of the femoral component to an uncemented, long, fully porous-coated stem

78%

(3774/4838)

2

Revision of the femoral component to a cemented stem

16%

(796/4838)

3

Revision of the femoral component to an allograft prosthetic composite

2%

(82/4838)

4

Revision of the femoral component to a proximal femoral replacement

1%

(68/4838)

5

Removal of prosthesis with insertion of antibiotic spacer

2%

(78/4838)

L 2 A

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(SAE10HK.15) A 71-year-old woman with coronary artery disease underwent an uncomplicated right total hip arthroplasty for osteoarthritis 12 years ago. Her hip has functioned well until approximately 18 months ago when she noted the spontaneous onset of groin, buttock, and proximal thigh pain that is present at rest and made worse with activity. A radiograph is shown in Figure 15. What is the recommended management at this point? Tested Concept

QID: 7003
FIGURES:
1

Immediate admission to the hospital and emergent revision hip arthroplasty

3%

(8/286)

2

Reassurance and follow-up if symptoms worsen

1%

(3/286)

3

Repeat radiographs in 1 month

2%

(7/286)

4

Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared

91%

(260/286)

5

A prescription for alendronate and reevaluation in 1 year

2%

(6/286)

L 1 E

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(OBQ10.187) Which of the following is true regarding the conversion of hip arthrodesis to total hip arthroplasty? Tested Concept

QID: 3280
1

Implant survivorship is greater than 95% at 20 years following conversion to arthroplasty

5%

(169/3449)

2

Conversion to arthroplasty should not be performed if arthrodesis is more than 15 years old

7%

(226/3449)

3

Function of gluteus medius is predictive of ambulatory status

85%

(2924/3449)

4

Rate of complication is equivalent to primary total hip arthroplasty

2%

(62/3449)

5

Incidence of nerve palsy is comparable to primary total hip arthroplasty

1%

(47/3449)

L 2 C

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(OBQ10.7) A 72-year-old female returns to clinic for 15 year follow up of left total hip arthroplasty. She ambulates without any assistive devices, has no pain, and denies any recent fevers or systemic illness. A radiograph is provided in figure A. Which of the following is the best treatment option? Tested Concept

QID: 3095
FIGURES:
1

Follow up radiographs in 3 years

21%

(831/3924)

2

Follow up radiographs in 5 years

2%

(80/3924)

3

Revision surgery with femoral head and polyethylene exchange and retroacetabular bone grafting

63%

(2469/3924)

4

Revision of acetabular component with jumbo cup and femoral head exchange

11%

(419/3924)

5

Revision of acetabular component with jumbo cup and femoral stem revision

3%

(116/3924)

L 3 C

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(OBQ08.217) A 67-year-old female with history rheumatoid arthritis presents with acute onset severe left hip pain eight years status-post total hip arthroplasty. She is unable to weight bear on the left leg, but denies any other pain or systemic symptoms. A current radiograph of the pelvis is shown in Figure A. What is the most likely cause of the patient's current hip pain symptoms? Tested Concept

QID: 603
FIGURES:
1

Poor surgical technique

1%

(41/3127)

2

Rheumatoid arthritis flare

2%

(49/3127)

3

Catastrophic implant failure

16%

(504/3127)

4

Development of pelvic discontinuity

80%

(2498/3127)

5

Acute sepsis

1%

(25/3127)

L 2 C

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(OBQ08.148) A 85-year-old man who underwent hemiarthroplasty 5 years ago now complains of thigh pain for the past four months. Laboratory studies show a normal white blood cell count (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An aspiration of the hip is performed and is negative for infection. A radiograph is shown in Figure A. Which of the following is the best management option for the femoral implant? Tested Concept

QID: 534
FIGURES:
1

Bone scan to look for loosening

12%

(240/1976)

2

Touch down weight bearing and physical therapy

1%

(21/1976)

3

Revision with a tumor prosthesis

3%

(55/1976)

4

Revision of femoral component with metaphyseal cement fixation of the stem

14%

(275/1976)

5

Revision to a cementless femoral component with diaphyseal press-fit fixation of the stem

70%

(1376/1976)

L 3 C

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(SAE07HK.74) Figure 44 shows the radiograph of a 65-year-old man who underwent a revision arthroplasty to remove a loose, cemented femoral stem. When planning the postoperative restrictions, the surgeon should be aware that Tested Concept

QID: 6034
FIGURES:
1

the approach used reduces the torque-to-failure (fracture) of the construct to less than 50% of the intact femur.

26%

(91/356)

2

the technique of repair can return the reconstructed prosthesis/bone composite to nearly the strength of the intact femur.

26%

(93/356)

3

there is no relationship between the density of the native bone and the strength of the prosthesis/bone composite.

3%

(12/356)

4

the addition of bone graft substitute or autograft has been shown to lessen the time to complete healing.

14%

(49/356)

5

there is a one in five chance of fracture with this technique; therefore, the surgeon must carefully weigh the potential benefits versus this risk.

30%

(107/356)

N/A E

Select Answer to see Preferred Response

(SAE07HK.67) What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39? Tested Concept

QID: 6027
FIGURES:
1

Nonmodular implant

1%

(5/378)

2

Instability

2%

(6/378)

3

Well-designed, well-fixed modular implant

94%

(355/378)

4

Complete radiolucency of the acetabular component

2%

(6/378)

5

Migration of the acetabular component

2%

(6/378)

L 1 E

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(SAE07HK.21) A 72-year-old woman who underwent right total hip arthroplasty 7 years ago now reports right hip pain and limb shortening. Studies for infection are negative. AP and lateral radiographs are shown in Figures 13a and 13b. What is the most appropriate management? Tested Concept

QID: 5981
FIGURES:
1

Observation only

0%

(0/302)

2

Nonsteroidal anti-inflammatory drugs and protected weight bearing

1%

(2/302)

3

Revision of the acetabular component with a jumbo cup with screws

14%

(42/302)

4

Revision of the acetabular component with a reinforcement cage and bone grafting

85%

(258/302)

5

Resection arthroplasty

0%

(0/302)

L 1 D

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(OBQ06.174) Figure A shows an AP hip radiograph of a 72-year-old woman who had had a right total hip arthroplasty fifteen years previously. CT imaging of the affected hip shows non-contained defects in both the anterior and posterior columns of the peri-acetabular region affecting greater than 50% of the weight bearing surface. Which of the following revision procedures would restore the most acetabular bone stock and be most appropriate for this patient? Tested Concept

QID: 360
FIGURES:
1

Morselized allograft and/or autograft bone, combined with a cemented acetabular component

4%

(135/3561)

2

Acetabular revision with use of a bilobed cementless component and morselized allograft

7%

(255/3561)

3

Morselized allograft and/or autograft bone, combined with a cementless acetabular component

7%

(237/3561)

4

Revision using an ilioischial reconstruction ring acetabular component and structural corticocancellous graft

70%

(2488/3561)

5

Revision using a roof ring acetabular component and structural corticocancellous graft

12%

(429/3561)

L 3 C

Select Answer to see Preferred Response

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