Severe Acetabular Deficiency Research Articles

Bispherical metal augment improved biomechanical stability in severe acetabular deficiency reconstruction: a comparative finite element analysis

BackgroundThis study used finite element analysis (FEA) to compare the biomechanical stability of bispherical metal augment (BA) and wedge-shaped trabecular-metal augment (TA) in different acetabular defect reconstruction models, thereby explaining the application value of this novel bispherical augment in complex hip revision.MethodsThree different acetabular defect pelvis models originating from three representative patients with different types of severe acetabular defects (Paprosky IIC, IIIA, and IIIB) were constructed and reconstruction with BA and TA technique was simulated. Based on the FEA models, the displacement of reconstruction implants, relative displacement of bone implants, and hemi-pelvic von Mises stress were investigated under static loads.ResultsBA acquired smaller reconstruction system displacement, less relative displacement of bone implants, and lower pelvic von Mises stress than TA in all Paprosky IIC, IIIA, and IIIB defect reconstructions.ConclusionThe FEA results show that BA could acquire favourable biomechanical stability in severe acetabular defect reconstruction. This technique is a reliable method in complex hip revision.

Modular revision strategy with bispherical augments in severe acetabular deficiency reconstruction.

Reconstruction of severe acetabular deficiency is extremely challenging in total hip arthroplasty (THA) revisions. Novel bispherical augments were designed to fill acetabular bone loss and facilitate restoration of hip center of rotation (HCOR). Current study aims to compare the outcomes of bispherical augments and tantalum augments. Between July 2017 and December 2018, bispherical augments (BA group) were implanted in 25 patients (25 hips) and 22 patients (22 hips) underwent porous tantalum augments (TA group) reconstruction in revision THA. Clinical and radiographic results were evaluated for 25 hips in BA group and 20 hips in TA group at the final follow-up. The mean duration of follow-up was 2.9years (range, 2.2 ~ 3.7) in BA group and 2.9years (range, 2.3 ~ 3.8) in TA group. Harris hip scores, HCOR, and leg length discrepancy (LLD) correction did not differ between the treatment groups. The bispherical augments were located more closer to the medial-superior part (zone II) of acetabular shell while the majority of tantalum augments were located at the lateral-superior part (zone I) (P = 0.010). More screws were used in the BA group for augment fixation (mean 2.1 vs. 1.3) (P = 0.000). There was no evidence of loosening or migration in all hips. Only one dislocation occurred in BA group and treated with closed reduction, no recurrence of instability up to the final follow-up. The clinical and radiological outcomes of bispherical augments were comparable with tantalum augments; this technique was a reliable alternative method in severe acetabular deficiency reconstruction.

Periacetabular triple osteotomy by single anterior approach for children under 6-years-old with severe acetabular deficiency: prevention of retroversion and anterior impingement.

The aim of this study was to perform periacetabular triple osteotomy (PATO) in children under 6-years-old with severe acetabular deficiency aiming to obtain important correction and avoid excessive pressure on epiphysis, anterior overcorrection and acetabular retroversion. This is a retrospective study of 29 PATO using single anterior approach in 24 patients under 6-years-old with dysplasia of the hip. Clinical examination and radiographic evaluation were done pre-op, post-op and at last follow-up. Computed tomography (CT) scan was obtained, comparing operated hip to contro-lateral normal hip. Clinical examination of the operated hip, at the last follow-up, showed a normal range of motion with nonsignificant difference when compared to normal hip. All hips were classified as Wicart A, and all activities were allowed. Radiographically, X-ray revealed improvement of all parameters postoperatively, with nonsignificant change compared to the last follow-up. CT-2D axial analysis demonstrated the absence of acetabular retroversion with good anterior and posterior coverage. CT-3D imaging comparing the anterior acetabular inclination, anterolateral and posterolateral inclination angles of operated hip and normal hip showed comparable results. Patients less than 6 years with severe acetabular deficiency could benefit from PATO. Performing osteotomies close to joint gave important acetabular fragment freedom, allowing an important correction. Appropriate manoeuver of reorientation avoided anterior overcorrection and acetabular retroversion, responsible for early pain and osteoarthritis. Age should not be the only criteria to choose the type of osteotomy. Level of evidence: level IV.

Triple osteotomy of pelvis (TOP) in children under six years with single approach: Prevention of retroversion and anterior impingement

For children under 6 years old requiring high degree correction for acetabular deficiency, we carried out periacetabular triple osteotomy of pelvis (TOP) avoiding hyper-pressure on epiphysis, anterior overcorrection and retroversion of acetabulum. TOP achieved in 11 patients (2 to 5.5 years old), 12 hips: 8 hips of DDH with important dysplasia (CEA: −14° to 15°) and 4 hips of Legg-Calvé-Perthes (Stulberg IV). Clinical examination and CT scan performed and compared the operated hip (OH) to the non-operated hip (NOH). Radiographic exams evaluated pre and post-op angles at the OH. Clinical assessment postoperatively: flexion decreased 14°, extension increased 7°, external rotation increased 5°, internal rotation decreased 5°. Radiographic assessment: acetabular sharp angle: (preop: 45.3°, postop: 37.1°), the CEA: (preop: 5.7°, postop: 38.7°) and the sourcil-slope: (preop: 22.6°, postop: 7.3°). CT-2D axial analysis: acetabular anteversion (OH: 1°, NOH: 2°), anterior coverage (OH: 37.5°, NOH: 34.7°), posterior coverage 21° (OH and NOH). CT-3D analysis: anterolateral inclination of the lip (OH: 32.7°, NOH: 52°), posterolateral inclination (OH: 48°, NOH: 66°), anterior acetabular inclination (OH: 5.5°, NOH: 15°). In children less than 6 years old, TOP performed by moving the acetabulum anteriorly (extension) and mainly laterally (adduction) as steering wheel, permitted the correction of severe acetabular deficiency, avoiding anterior overcorrection and retroversion of acetabulum, all responsible of early pain and osteoarthritis. Age should not be the only criteria to choose between Salter's osteotomy and TOP. Patients less than 6 years with severe acetabular deficiency could benefit from TOP.

Midterm Survivorship After Revision Total Hip Arthroplasty With a Custom Triflange Acetabular Component

BackgroundCustom triflange acetabular components are being increasingly used for the reconstruction of Paprosky type IIIB acetabular defects. However, midterm survivorship data are lacking. MethodsWe queried the prospective registries at 2 high-volume revision centers for patients who had undergone revision total hip arthroplasty using a custom triflange component between 2000 and 2011. We identified 73 patients with minimum 5-year follow-up. These patients' records were reviewed to determine incidence of revision or reoperation, clinical performance, and radiographic stability. The mean follow-up was 7.5 years (range 5-12 years). ResultsFifteen of 73 triflange components (20.5%) were indicated for revision during the follow-up period, including 6 for instability (8%) and 8 for infection (11%). Twelve of 73 patients (16%) underwent reoperation for reasons other than failure of the triflange component. The median hip disability and osteoarthritis outcome score for joint replacement score at midterm follow-up was 85 (interquartile range 73-100). Only 1 of 73 implants was determined to be radiographically loose at midterm follow-up. ConclusionCustom triflange reconstruction for severe acetabular deficiency is a viable option; however, complications are common and significant challenges remain for those that fail.

Short-term outcomes of using cup-cage for revision hip arthroplasty in severe acetabular bone deficiency

Objective To investigate the short-term outcomes after revision hip arthroplasty for severe acetabular bone deficiency by cup-cage. Methods We retrospectively analyzed 16 patients (16 hips) with Paprosky type ⅢB acetabular bone deficiency, who received cup-cage from October 2013 to May 2016. There were 6 males and 10 females, with an average age of 62.6 years (range 40-84 years). All but one patient were with pelvic discontinuity. The reason for revision was aseptic loosening for 14 patients and periprosthetic joint infection for 2. Eleven patients underwent surgery via Trabecular Metal Acetabular Revision System (cup+cage), 2 via Trabecular Metal cup and AR cage, and 3 via R3 cup and AR cage. During the follow-up, Harris hip score was recorded to evaluate the clinical efficacy, and X-rays were performed to identify the signs of loosening and changes in rotation center position. Results The mean follow-up was 18.7 months (range 6-36 months). The height of rotation center was decreased from 42.00±12.18 mm preoperatively to 22.75±8.44 mm postoperatively, whereas the horizontal distance of the rotation center was 26.81±7.61 mm preoperatively and 32.50±6.51 mm postoperatively (t=8.249, P<0.001; t=-4.786, P<0.001). The height of the rotation center was slightly higher than that of the contralateral side postoperatively (t=-3.478, P=0.003), whereas the difference in the horizontal distance of the rotation center between the two groups was not statistically significant (t=1.235, P=0.236). The Harris hip score was improved from 45.63±11.68 preoperatively to 75.78±9.12 postoperatively (t=-12.157, P<0.001). During the follow-up, one dislocation occurred at 5 days postoperatively and closed reduction was conducted under anesthesia. There was no blood vessel injury, nerve injury, wound complication and periprosthetic joint infection. No recurrence of infection occurred in 2 patients who received revision hip arthroplasty for periprosthetic joint infection. Conclusion Revision hip arthroplasty for PaproskyⅢB acetabular bone deficiency by cup-cage can achieve good primary stability and reconstruct the rotation center, especially for patient with pelvic discontinuity. Key words: Arthroplasty, replacement, hip; Reoperation; Acetabulum

The clinical application of custom 3D-printed acetabular filling technology in complicated hip arthroplasty

Objective To observe and summarize the clinical efficacy and surgical experience of 3D printing technology in hip arthroplasty for severe acetabular bone deficiency. Methods 3D printing was applied to 11 complicated hip surgeries for Paprosky Ⅳ acetabular bone deficiency. The imaging data of the patients were captured and utilized to build CAD models. These data were converted and input to 3D printer to print the model of defected acetabular bone. Meanwhile, defected acetabulum was repaired with active titanium filling through hip arthroplasty, to reconstruct the rotation center of the hips and implant hip joint prosthesis. Imaging data and Harris hip score were monitored after the surgeries. Results The Harris hip scores of the 11 patients were 46.6±10.7 before surgeries, and imaging data indicated severe acetabular bone deficiency. After surgeries, imaging data presented that the acetabular bone deficiency was repaired by printed filling. Moreover, rotation center was reconstructed successfully. The Harris hip score became 85.2±4.5 at 6th month after the surgeries, which showed satisfactory clinical efficacy. Conclusion 3D-printing technology implemented in hip surgeries for Paprosky Ⅳ acetabular bone deficiency can be successfully utilized to mock surgery, print acetabular filling and improve the efficacy and success rate of the surgery. Key words: 3D-printing technology; Hip arthroplasty; Acetabular bone deficiency

CORR Insights(®): Custom Acetabular Cages Offer Stable Fixation and Improved Hip Scores for Revision THA With Severe Bone Defects.

T he ideal reconstructive method for the severely deficient acetabulum in revision THA remains unsolved. Severe acetabular deficiencies may be evaluated by the Paprosky et al. [7] grading system from which both the anticipated bony defects and the reconstruction needs may be identified. Fortunately, the incidence of severe acetabular deficiency is low, with a report from the Mayo Clinic finding that Paprosky IIIB defects occurred in only 0.9% of hips (31/3505) undergoing revision acetabular surgery at that tertiary care center between 1969–1995 [1]. Most acetabular reconstructions are performed with a large hemispherical shell with a survivorship range of 94% to 100% at midto long-term followup [2]. For acetabuli with greater bony loss, porous metal augments may be added, allowing the creation of a bony and metal concavity supportive of a hemispherical shell. As the defect worsens, more-elaborate options come into the picture, perhaps including custom acetabular cages (or triflange cups), reconstruction cages, cup-cage constructs, or cup-cup constructs. Surgeons must recognize the high surgical complexity when contemplating using one of these approaches, as complications can be severe, and unrecognized or untreated pelvic discontinuities can result in a high risk of failure. During more than a 10-year period, the authors of the current study reported the surgical treatment of 26 patients (all with Type IIIB defects, four with a pelvic discontinuity) who underwent acetabular reconstruction using a gritblasted titanium custom cage. At a mean followup of 67 months (range, 24 months to 120 months) in 24 patients only one cage was felt to be possibly loose, and the authors reported the appearance of particulate allograft incorporation in 23 of 24 patients. One important caveat of this study is that this was the first revision surgery for all but one patient. We can compare the results in this series to other reports about severe acetabular defects, which used other approaches, namely reconstruction cages, or custom triflange cups. In a single-surgeon series, reconstruction cages failed in 24% of reconstructions at mean 4.6-year followup, with the highest failure rates occurring in 10 hips with American Academy of Orthopaedic Surgeons (AAOS) Type This CORR Insights is a commentary on the article ‘‘Custom Acetabular Cages Offer Stable Fixation and Improved Hip Scores for Revision THA With Severe Bone Defects’’ by Li and colleagues available at: DOI: 10.1007/s11999-015-4587-0. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999015-4587-0.

Radiography versus multidetector computed tomography in assessing graft integration after acetabular reconstruction.

To compare radiography with multidetector computed tomography (MDCT) in the evaluation of graft integration following acetabular reconstruction for failed total hip arthroplasty (THA). Records of 5 men and 6 women aged 60 to 78 (mean, 71.8) years who underwent acetabular reconstruction using structural allografts for severe acetabular deficiency secondary to aseptic loosening (n=9) or septic loosening (n=2) were reviewed. The mean survival time of the THA was 136.4 (range, 12-360) months. Acetabular defects were classified as IIC (n=2), IIIA (n=3), or IIIB (n=6). Structural allografts were fixed with impaction followed by a reinforcement ring (n=10), an antiprotrusio cage (n=2), and/or an oblong cup (n=1) with gentamicineloaded cement. Cup loosening, graft integration, and graft resorption were evaluated using radiography. In addition, graft integration was evaluated using MDCT. At a mean follow-up of 4.2 (range, 2-11) years, the survival of the acetabular reconstruction was 90.9%. No patient had any signs of infection. One patient underwent reoperation 22 months later for dislocation secondary to abductor deficiency caused by nonunion of the trochanteric fracture. According to radiography, all patients had graft integration. One patient had definitive and another had possible cup loosening. Four patients had minor graft resorption. According to MDCT, graft integration was complete in only one patient, partial >50% in 3, partial <50% in 4, and absent in 2. MDCT is more accurate than radiography in evaluating graft integration following acetabular reconstruction.

Revision of Type III and Type IVB Acetabular Defects With Burch–Schneider Anti-Protrusio Cages

Extensive bone loss in severe acetabular deficiencies can make repair with acetabular shells impossible. We retrospectively analyzed mid-term to long-term results of acetabular revision with Burch–Schneider reinforcement cages in 33 hips in patients with a mean age of 59.03years after a mean follow-up period of 6.19years. Under the American Academy of Orthopaedic Surgeons classification, 9 patients had type III acetabular bone defects and 24 had type IVB. Merle D’Aubigné scores improved by a mean of 9.3 points. The prosthesis failure rate was 15.1%, the series complication rate was 21.2%, and the mean survivorship was 11.57years. The Burch–Schneider cage is useful for reconstruction in massive acetabular deficiency, but complication rates are high and long-term mechanical failure is a concern.

High Complication Rate in Revision Total Hip Arthroplasty in Juvenile Idiopathic Arthritis

Revision total hip arthroplasty (THA) in patients with juvenile idiopathic arthritis (JIA) is challenging as a result of the patient's young age, systemic disease, multiple affected joints, small proportions, and bone loss. The intermediate- to long-term results of these surgeries remain unknown. The purpose of this study is to determine the (1) functional outcomes; (2) surgical complications; and (3) frequency of reoperation or revision after revision THA for JIA. We reviewed the records of all patients from one center who underwent revision THA for JIA who had a minimum of 5 years of followup (mean, 9 years; range, 5-19 years). This resulted in a series of 24 revision THAs in 15 patients. All patients were Charnley Class C. Age at revision averaged 35 years (range, 21-53 years). The 20 acetabular and 12 femoral revision components included 15 cementless cups, five reconstruction/roof rings with a cemented cup, and four cemented and eight cementless femoral stems. The Harris hip scores improved from 54 (range, 34-85) to 77 (range, 37-100) (p < 0.001). Complications included two proximal femoral fractures associated with severe osteolysis and one sciatic nerve palsy in a patient with severe acetabular deficiency. A total of seven hips (29%) required reoperation or revision surgery, including three for infection (one early and two late) and four for mechanical loosening. Revision THA in JIA is very challenging owing to patients' small proportions and compromised bone stock. The intraoperative and early complication rates are relatively high. Prognosis for long-term survivorship is guarded; limiting factors include periprosthetic osteolysis associated with older implants that used conventional polyethylene and cemented stems.

Orthopaedic Reconstruction of Complex Pelvic Bone Defects. Evaluation of Various Treatment Methods

Despite major developments in the field of revision surgery in recent decades, the management of severe acetabular deficiency at revision arthroplasty, complex primary total hip replacement or after pelvic tumour resection remains a complex problem. The options available for the management of severe bone loss include the use of uncemented press-fit cups with or without metal augments, impaction allografts, allograft-prosthesis composites, custom-made triflange cups, hip transposition, reconstruction prostheses or various combinations of these. This paper describes defect classification, various treatment options, clinical outcomes, survival of reconstruction, and typical complications in relation to treatment.

The Burch-Schneider Cage: 9-Year Survival in Paprosky Type 3 Acetabular Defects. Clinical and Radiological Follow-Up

Revision hip arthroplasty in cases with severe acetabular deficiency represents a technical challenge. The aim of this study was to determine: 1. The 9-year survival of the Burch Schneider anti-protrusio cage (BS-APC) in severe acetabular defects. 2. The migration of the cage and correlation of this with functional outcome. 3. The anticipated functional outcome users can expect in a district general hospital setting in the management of severe acetabular defects. A single-surgeon consecutive series of 30 complex acetabular reconstructions using the BS-APC was retrospectively reviewed. Clinical and radiological follow up at 5-9 years was obtained. Survival was established with revisions and further surgery as different end-points. A radiological analysis using ein bilt roentgen analyse (EBRA) was performed. At a mean follow-up of 85 months (range: 64-118) 26 patients (87%) were alive. Nine-year survival was 95% for revision of BS-APC as an end-point and 92% with any cause of further surgery as an end-point. The mean Oxford Hip Score was 34.5 and UCLA activity score was 4.4. All cases demonstrated evidence of significant migration, but no screws were found to be broken. There was no correlation between cup migration and Oxford hip score (p=0.07). Our non-specialist centre experience suggests the BS-APC should not be dismissed as a reconstruction option in the most severe acetabular defects.

Cementless acetabular revision: past, present, and future

Acetabular revision is probably the most difficult aspect of hip reconstructive surgery. Although the majority of acetabular revisions can be performed using an uncemented hemispherical acetabular device with ancillary fixation, patients with severe acetabular deficiencies and poor bone quality require more complex alternatives for revision. The limitations of traditional cementless acetabular implants has promoted the development of improved methods of fixation and revision techniques. Highly porous metals have been introduced for clinical use in arthroplasty surgery over the last decade. Their higher porosity and surface friction are ideal for acetabular revision, optimising biological fixation. The use of trabecular metal cups in acetabular revision has yielded excellent clinical results. This review focuses on the use of cementless implants for acetabular revision. The use of trabecular metal cups, augments, jumbo cups, oblong cups, cages, and structural grafting are also discussed.

Reconstruction of the acetabulum in THA using femoral head autografts in developmental dysplasia of the hip

BackgroundSevere acetabular deficiencies in cases of developmental dysplasia of the hip (DDH) often require complex reconstructive procedures in total hip arthroplasty (THA). The use of autologous femoral head grafts for acetabular reconstruction has been described, but few data is available about clinical results, the rates of non-union or aseptic loosening of acetabular components.MethodsIn a retrospective approach, 101 patients with 118 THA requiring autologous femoral head grafts to the acetabulum because of DDH were included. Six patients had died, another 6 were lost to follow-up, and 104 hips were available for clinical and radiological evaluation at a mean of 68 ± 15 (13 to 159) months.ResultsThe average Merle d'Aubigné hip score improved from 9 to 16 points. Seven implants had to be revised due to aseptic loosening (6.7%). The revisions were performed 90 ± 34 (56 to 159) months after implantation. The other hips showed a stable position of the sockets without any signs of bony non-union, severe radiolucencies at the implant-graft interface or significant resorption of the graft.ConclusionThe use of autologous femoral head grafts with cementless cups in primary THA can achieve promising short- to midterm results in patients with dysplastic hips.

Morsellized Allograft and Acetabular Reconstruction Cage: Follow-up of 2 to 9 years

We report the outcome of 32 patients who underwent total hip replacement (THR) augmented with morsellized fresh frozen femoral head allografts and acetabular reconstruction cages. Nine patients underwent primary THR and 23 patients underwent revision THR. Follow-up ranged from two to 9 years. Two most common indications for the procedures as reported in literature were rheumatoid arthritis and aseptic loosening of the hip. All but one patient achieved good outcome with radiographs showing full incorporation of bone grafts and no evidence of loosening of the implants. Morsellized bone grafting used with acetabular reinforcement devices is valuable for addressing severe acetabular deficiencies.

A stemmed acetabular component in the management of severe acetabular deficiency

We evaluated the use of a stemmed acetabular component in the treatment of severe acetabular deficiency during revision and complex primary total hip arthroplasty. There were 31 hips of which 24 were revisions (20 for aseptic loosening, four for infection) and the remainder were complex primary arthroplasties. At a mean follow-up of 10.7 years (6 to 12.8), no component had been revised for aseptic loosening; one patient had undergone a revision of the polyethylene liner for wear. There was one failure because of infection. At the latest follow-up, the cumulative survival rate for aseptic loosening, with revision being the end-point, was 100%; for radiographic loosening it was 92% and for infection and radiographic loosening it was 88%. These results justify the continued use of this stemmed component for the reconstruction of severe acetabular deficiency.

Structural allograft and primary press-fit cup for severe acetabular deficiency

Between October 1992 and December 1996, 23 patients with pelvic bone stock deficiency involving major columns underwent revision surgery with a cementless press-fit cup and a structural bone graft. Twenty cases were followed up for a minimum of 6 (average 7.6, range 6-11) years. Three cups were revised: one for aseptic loosening, one for septic loosening, and one for recurrent dislocation. At latest follow-up, the average Merle d'Aubigne hip score improved from 10.9 to 16.2; four hips were rated excellent, seven very good, three good, two fair, and one poor. All cups were stable; the grafts were integrated and anatomy was restored. The Kaplan-Meier cumulative probability of not having revision for loosening at 11 years, predicted a survival rate of 84.4%. We are confident that these results are satisfactory for a very demanding procedure.

Clinical and radiological results of impaction bone allograft technique in acetabular revisions associated with massive bone stock deficiencies: Four to seven years follow-up study

We conducted this retrospective study to evaluate the medium- term results of impaction bone allograft technique when used on its own with cemented cups in acetabular revisions associated with massive bone loss. This study involved 28 hips in 27 patients classified as severe acetabular deficiencies (Paprosky type 3) secondary to aseptic loosening. All were revised with impacted morsellised bone allograft using fresh-frozen and freeze-dried bone together with cemented rim bearing UHMWP (28 mm I.D.) cups and followed for an average of 72 months (range 48 to 91 m). Clinical assessment was based on the Harris Hip Score (HHS). Radiological assessment included measurement of cup migration using image analysis computer software as well as assessment of graft incorporation. Clinically, HHS improved from pre-operative average of 24.9 to average of 78 at the last follow-up. One hip was revised at 12 months postoperatively due to aseptic loosening. Survivorship for the cup with endpoint revision for any reason was 96.4%. Radio-logically, the average of superior migration was 1.53 mm; average of medial migration was 0.59 mm. 92.8% of hips showed radiographic evidence of graft incorporation. Cup survival rate with aseptic loosening as endpoint was 92.85%. The technique of impaction bone grafting using morsellised fresh frozen bone allograft appears to be a valuable biological option in such patients, with encouraging results, but further follow-up is required to establish the longer term outcome of these reconstructions. (Hip International 2005; 15: 46-51).

Clinical and radiological results of impaction bone allograft technique in acetabular revisions associated with massive bone stock deficiencies: Four to seven years follow-up study

We conducted this retrospective study to evaluate the medium- term results of impaction bone allograft technique when used on its own with cemented cups in acetabular revisions associated with massive bone loss. This study involved 28 hips in 27 patients classified as severe acetabular deficiencies (Paprosky type 3) secondary to aseptic loosening. All were revised with impacted morsellised bone allograft using fresh-frozen and freeze-dried bone together with cemented rim bearing UHMWP (28 mm I.D.) cups and followed for an average of 72 months (range 48 to 91 m). Clinical assessment was based on the Harris Hip Score (HHS). Radiological assessment included measurement of cup migration using image analysis computer software as well as assessment of graft incorporation. Clinically, HHS improved from pre-operative average of 24.9 to average of 78 at the last follow-up. One hip was revised at 12 months postoperatively due to aseptic loosening. Survivorship for the cup with endpoint revision for any reason was 96.4%. Radio-logically, the average of superior migration was 1.53 mm; average of medial migration was 0.59 mm. 92.8% of hips showed radiographic evidence of graft incorporation. Cup survival rate with aseptic loosening as endpoint was 92.85%. The technique of impaction bone grafting using morsellised fresh frozen bone allograft appears to be a valuable biological option in such patients, with encouraging results, but further follow-up is required to establish the longer term outcome of these reconstructions. (Hip International 2005; 15: 46-51).