Acetabuloplasty technique in primary total hip arthroplasty for the dysplastic hip

Wong HC*, Ho ST**

*Resident specialist, **Consultant Department of Orthopaedics and
Traumatology, Caritas Medical Centre, Hong Kong
ABSTRACT
Dysplastic hip is one of the commonest causes of secondary osteoarthritis of the
hip. Reconstruction of a dysplastic acetabulum during total hip arthroplasty is
often technically challenging. Various techniques have been used with total hip
arthroplasty to reconstruct the dysplastic acetabulum. We report a case of a 55year-old female patient receiving cementless total hip replacement combined
with acetabuloplasty performed to achieve satisfactory acetabular cup coverage.
The patient was successfully operated with satisfactory clinical outcome.
Keywords: dysplasia, hip, arthroplasty, total, acetabuloplasty
Corresponding Author :
Dr HC Wong Department of Orthopaedics & Traumatology, Kwong Wah Hospital,
25 Waterloo Road, Kowloon, Hong Kong. Email: drkenwong2000@yahoo.com
INTRODUCTION
Dysplastic hip is one of the commonest causes of secondary osteoarthritis of the
hip. Patients who have painful hip dysplasia with secondary osteoarthritis are
often young and active. Total hip arthroplasty can offer good pain relief and
improve function of these patients.
However, dysplastic hip presents with wide range of anatomical abnormalities.
Acetabular reconstruction of the dysplastic hip is one of the most difficult
challenges in primary total hip arthroplasty. Various techniques have been used
to reconstruct the dysplastic acetabulum with success. However, acetabular
reconstruction in the dysplastic hip still generates a great deal of controversy.
The acetabuloplasty technique was described in 1978 by Stamos.1 Although the
technique has been of great popularity and is practiced worldwide, it is relatively
rare technique in Hong Kong, in which the medial wall of a dysplastic acetabulum
is perforated purposefully to permit coverage of acetabular component without
superolateral bone-graft support.

CASE REPORT
A 55-year-old lady presented with right hip pain for many years. She complained
of increase in right hip pain on standing and had difficulty in walking staircase.
She walked unaided for 2 blocks only. Examination showed Trendelenburg gait
and positive Trendelenburg sign. There was right femoral shortening by 2cm
clinically. The range of motion of right hip was full. Harris hip score was 52. X-ray
showed Crowe II dysplastic right hip with secondary osteoarthritis, deficient
acetabular roof and fossa covering osteophyte obscuring the true acetabulum.
(Figure 1)

n February, 2009, right cementless total hip arthroplasty was performed via
posterolateral approach under general anaesthesia. Superior and posterior
capulostomy were performed. Acetabulum was reamed with medial protrusio
technique. Firstly, the true acetabulum was exposed after the fossa covering
osteophyte lateral to the medial wall was osteotomized and removed. The
acetabular reaming was directed medially with the smallest reamer and then
progressively reaming was performed in posterosuperior direction. Cotyloplasty
was performed in view of superolateral acetabular uncoverage with a trial cup.
Controlled circular medial wall fracture on the cotyloid notch was created with
osteotome. The medial wall fracture was completed and impacted medially with
a liner punch. Reamed bone as graft was packed and impacted into the medial
wall defect by reversed reaming. The 50mm acetabular cup was impacted in the
true acetabulum at 20 degrees anteversion and 45 degrees inclination. Size 3
tapered femoral stem were implanted in the usual manner. A ceramic insert and
a 28 mm ceramic femoral head were coupled accordingly. The right hip was
stable at 90 degrees flexion and 30 degrees internal rotation & 20 degree
hyperextension and 25 degree external rotation.
She was allowed partial weight bearing walking. At followup, she had no right hip
pain. Harris hip score was increased from 52 to 93 at one year. The limb length
was equalized. The true acetabular region and the approximate femoral head
centre were defined by comparing with contralateral normal hip in radiograph. It
showed the hip centre was 9 mm superior to the approximate femoral head
centre with 6 mm medialization. The medially displaced acetabular medial wall
was reconstituted and united. Bone ingrowth onto the acetabular shell was
evident at three months. Although there was slightly superior
hip centre, limb length discrepancy was corrected by increased femoral neck
length. There was no progressive protrusio at one year.
DISCUSSION
Acetabular reconstruction of a dysplastic hip is one of the most difficult
challenges in primary total hip arthroplasty. Obtaining satisfactory acetabular
coverage is the key step. The main predictors that lead to loosening include lack
of lateral osseous support, degree of preoperative dislocation and lateralization &
height of the acetabular component relative to the true acetabulum. Several
techniques have been described to overcome the problem of acetabular
deficiency in total hip arthroplasty when cover of the acetabular component with
host bone is deficient. The use and the results of cemented acetabular
component are well documented2-4. It necessitates only deeper reaming, use of
small or extra-small acetabular cup (nonstandard custom components) to
accomplish osseous coverage or use of cement to fill defects. The best results
are reported when the medial acetabular wall has been maintained and without
more than five millimeters of the cup uncovered by bone2, 5, 6. It is shown that
when the superolateral aspect of the acetabular rim is lacking, the load shifts to
the posterosuperior rim and stresses at the bone-cement interface increase.
Another technique involves roof reconstruction by augmentation of the
superolateral defect with a structural bulk bone graft with cemented cup.6 Shortterm results of bone graft generally have been favourable, but long-term results
have been less impressive. It was reported the increased failure rates when

increase in bone graft used to provide superolateral coverage of the cemented

cup4. Some authors recommended that no more than 30% of the cup should be
covered with the graft4, 7, 8. For cementless cup, the structural bone graft is
aimed only for bone reconstruction, but not cup fixation. The key point is that the
load must not be placed on the graft. Otherwise mechanical failure will ensue.
Other method without using a structural bone graft is the placement of
acetabular cup in non-anatomical position, creating high hip centre9. However,
less favorable results of high or lateral placement have been reported10. It has
mechanical disadvantage on abductor function as the lever arm for body weight
is much longer than that of abductors in high hip centre. It results in excessive
loading on the hip joint. The shearing force acting on the cup may lead to early
loosening11. The limb length discrepancy more commonly perpetuates in high
hip centre. The next method, the use of an acetabular reinforcement ring in the
dysplastic hip is reported promising results and is deemed to be able to restore
the anatomical hip centre with less technical difficulties12. It is recommended to
use autogenous graft medially and superiorly to fill osseous defects under the
ring instead of cement.
Currently, the consensus aims to insert the acetabular component in the true
acetabulum better without cement. The other crucial point in acetabular
reconstruction of the dysplastic hip is to achieve satisfactory superolateral
support of the component with host bone. Acetabuloplasty technique makes it
possible to achieve these two targets. It involves reaming into or through the
medial acetabular wall so that cemented cup can be inserted into the true
acetabulum with good bone coverage. In some studies, this technique is also
applied to provide a stable press-fit of the cementless component even in severe
dysplastic hips provided at least 80% cover of the implant with host bone can be
obtained in the true acetabulum11, 13, 14. The result of acetabuloplasty in
combination with primary total hip arthroplasty for the dysplastic hip has showed
durable cementless acetabular survival and fixation14. The biologic fixation with
bone ingrowth can lead to longer-lasting fixation. The cotyloplasty is adopted to
deepen the acetabulum when the depth of the osseous cavity after deeper
medial reaming is not sufficient to permit satisfactory cup coverage and socalled press-fit fixation. It involves medialisation of the acetabular floor by
creating a controlled comminuted fracture of the medial wall and impaction of
autogenous morcellised bone graft so as to reconstitute the medial acetabular
wall should there is revision in future. This technique results in placement of the
medial aspect of the dome of the acetabular component medial to the Kohler
line, as seen radiographically. Perforation of the medial acetabular wall requires
breaking through the cortical bone of the cotyloid notch. Whereas Dunn and Hess
recommended controlled fracture of the medial acetabular wall with an
osteotome15, Hartofilakidis et al. perforated the wall with a reamer1. The
intentional violation of the medial wall, of course, may compromise later
revisions if the medial wall is destroyed without reconstitution. An intraacetabular corkshaped spherical osteotomy is recently described by Hong et
al.16 It advantageously reserves the medial wall fragment instead of reaming
through it.
In our case, the hip centre was slightly higher than that from pre-operative
templating. This was partly attributed by the fact that the acetabular cup size

was undersize compared with the intended size 54 mm. Acetabular

anteroposterior diameter actually limited further reaming and the use of bigger
cup without risk of compromise of acetabular wall for press-fit fixation. Moreover,
excessive medialization should be avoided to prevent dislocation due to
impingement. Other complications such as protrusio acetabuli, fracture of
acetabular column and unstable fixation are possible with this technique if
excessive (more than 25 percent) destruction of the medial wall weakens the
hemispherical osseous acetabular cavity. Therefore, the caution that no more
than 25 percent of the area of the acetabulum should be perforated as
recommended by Dorr et al.14 should be strictly followed.
Despite the encouraging immediate result, the follow-up of our case is short.
Long-term result and more cases will definitely enrich our experience. In
conclusion, acetabular reconstruction for the dysplastic hip is complicated and
always challenging. Acetabuloplasty technique, although an old technique, if
used properly, is still one of good surgical alternatives to yield promising result