ACETABULAR DEFECTS

Pratik Prasher
 Acetabular deficiency
• Acetabulum is an cup-shaped socket on the lateral aspect of the pelvis, which
articulates with the head of the femur to form the hip joint

Types of deficiency/ Defects

• Dysplasia
• (hip socket doesn't fully cover the ball portion of the upper thighbone)
• Protrusio acetabuli
• (uncommon defect of the acetabulum).
• Post-traumatic degenerative disease
• (acute joint trauma that can lead to osteoarthritis)
• Pelvic discontinuity

Treatment options

• Hemispherical cementless cups, jumbo cups, bilobed cups, high hip center,
impaction grafting of the acetabulum, bulk structural allograft, antiprotrusio cages,
and highly porous acetabular cups
Acetabular
Protusion
Post-traumatic degenerative disease
 Goals of reconstruction
• Restore hip mechanics

• Re-establish osseous
coverage of new
acetabular component

• Rigid fixation
– Acetabular component
– Graft
 Preoperative Planning
• X-Ray
• 3-d(CT) scans
• Magnetic Resonance imaging
Important Landmarks
 Important Landmarks
• Kohler line:
• The ilioischial line, also known as the Köhler line, is a radiologic feature seen in
the AP pelvis view and serves to assess the posterior acetabular column

• Teardrop:
• Also known as U-figure or Köhler​teardrop, is a radiographic feature seen on
pelvic x-rays and results from the end-on projection of a bony ridge running along
the floor of the acetabular fossa
 Migration and its impact
• Medial migration  anterior
column.
– Grade 1 migration- Lateral to line and

– Grade 3 migration. - medial to the line

– Grade 2 migration to Kohler’s line or slight

remodeling of iliopubic & ilioischial lines
without a break in continuity.
• Superior migration

– Bone loss in acetabular dome involving

anterior & posterior columns

• Superior & medial anterior column.

• Superior & lateral  posterior
column.
 Osteolysis
• Ischial osteolysis - inferior aspect
of the posterior column, including
the posterior wall.

• Mild < 7 mm, & severe >15 mm.

• Teardrop osteolysis - inferior &

medial aspects of the acetabulum

• Moderate osteolysis - partial

destruction of the teardrop with
maintenance of the medial
limb

• Severe - complete obliteration of the

teardrop.
Paprosky classification:
Based on the presence or absence of an intact acetabular rim and its ability to provide
rigid support for an implanted acetabular component

Classify defects on the basis of

• Amount of acetabular component migration

• Status of the acetabular supporting structures including the anterior and posterior
columns
• Superior weightbearing dome
• Medial wall

Benefit

• Offered recommendations regarding the type and amount of supplemental allograft

needed for reconstruction, methods of graft fixation, and implant selection
Paprosky classification
 Type – I
• Acetabular rim and walls are intact and
supportive without distortion

• Anterior and posterior coloumns intact

• Acetabulum hemispherical

• No migration

• No osteolysis

• Full inherent stability is achieved,

and particulate grafting can be
used to fill the minor areas of bone
loss
• Hemispherical Cup +/- graft
 TYPE 2A
• Oval enlargementssuperior bone
lysis

• Superior rim of the acetabulum is

intact

• Migration - cavitary defect is evident

medial to a thinned superior rim and
is directed superior or superior
medial.

• This migration is less than 2 cm.

• Rx- particulate allograft 

remaining superior rim provides a
buttress for containment of the
• The superior acetabular rim is Pap-2B
missing.
• <1/3rdcircumference of superior
rim
deficient.

• Defect is not contained.

• Remaining anterior and posterior rims

and columns are supportive of
implant.

• Most reconstructions are done

without grafting of the segmental
defect.

• Occasionally, an allograft  it is not

supportive of the implant.
 Type - 2C
• Medial wall defect and migration of
the acetabular component medial to
the Kohler line.

• The teardrop may be obliterated

• The rim intact and will support a

hemispherical component.

• Particulate bone graft can be

placed medially to lateralize the hip
center of rotation back to its
anatomic position
 Type 2 defect management
• Identifying true
acetabulum • Uncemented
 Obturator
foramen/ Pubis/ hemispherical cup with
Ischium screws
 Greatest bone
volume
• Graft cavitatory defects

• +/- structural allograft to

restore bone graft
 Medialisation of inner table

• Expansion Ream at true

acetabulum until ant& Post
column contact

• Hemispherical shape

• Insert trial

• Assess bone loss

– Structural allograft
– Porous metal augument
Structural Allograft
technique
Supero-Lateral Defects
Supero- lateral defects
 Type 3A

• >1/3rd-<2/5th acetabular rim. (10 o clock and 2 o clock )

• Ischial lysis is mild to moderate, < 15 mm inferior to the obturator line.

• Trial components - partially stable,  structural augment or allograft

Type 3 A
Acetabular Cages
• Consider in Large Posterior
Segmental or combined
defects

• The principle - bridging an

acetabular defect by anchoring
ilium and ischium.

• 5to 7 cm of the defect by

means of a proximal flange
to the ilium and a distal nose
to the ischium.
“The Cage must be adapted to the bone, and the bone must be adapted to the
implant” – Gross JORR; 2004
 Pelvic Discontinuity
• Disruption of Anterior &
Posterior columns.

• No bony continuity between

illium and ischium/pubis

• Non-Supportive Superior
dome with >3cm migration
Pelvic Discontinuity
<2 cm

Press Fit
 AAOS – D’
• Antonio
83 AP and lateral xray
vs intraoperatively,

• 2categories:

– A segmental defect -
complete loss of bone in the
hemisphere of the acetabulum,
peripherally or centrally.

– A central - medial wall of the

acetabulum.

• A cavitary deficiency (type II)

- volumetric bony loss of the
acetabulum with an intact rim.
 • Combined segmental and cavitary-
Aaos .. – Failed, Migrated endoprosthesis and
III
– Developmental dysplasia

• Pelvic discontinuity (type IV)

– Superior pelvis and the inferior pelvis are

separated.

– Visible fracture line through the anterior and

posterior columns, a break in Kohler’s line 
superior & inferior pelvis are offset

– Rotation of inferior aspect hemipelvis : superior

which is often seen as asymmetry of the
obturator rings.

• Arthrodesis (type V).

• Flaw
– Identifies pattern & location ; not quantify

– management of these defects.

ACETABULAR DEFECTS IN BONE
TUMOURS
When in doubt!!!!!!!