Uncemented Hemispherical Cups

Joshua S. Bingham

Robert T. Trousdale

Key Concepts

Several options are available for acetabular reconstruction in the revision setting, including cementless hemispherical components, impaction grafting, reconstruction cages or rings, hemispherical cups with augments, cemented all-polyethylene components, and custom implants.
Although multiple options are available, the great majority of acetabular reconstructions can be successfully performed using an uncemented hemispherical component with screw supplemental augmentation.
This surgical technique is straightforward and should be familiar to most arthroplasty surgeons. The mid- and long-term results have been good.
Excellent long-term results have been reported with uncemented hemispherical cups in the revision setting (Table 25.1).
Highly porous metal implants with enhanced frictional coefficient against bone and high bone-ingrowth potential have expanded the indications for this form of reconstruction.
Alternative forms of acetabular reconstruction should be considered in cases with severe segmental bone loss, in cases with a pelvic discontinuity, and in situations in which obtaining bone ingrowth is challenging.

Sterile Instruments and Implants

Implants

Either a fully porous coated hemispherical multihole revision acetabular component (with instrumentation) or a highly porous titanium or tantalum cup. For complex revisions consider using a tantalum cup that allows the surgeon to bore supplement screw holes.
Appropriately sized acetabular screws with a tap and instrumentation.
Full array of bearing options including highly cross-linked polyethylene inserts of different inside diameters with different lateralized or elevated rim options. When instability is a concern, modular dual-mobility implants may be considered.

Table 25.1

Results of Cementless Acetabular Reconstruction in Revision Total Hip Arthroplasty

Author (y)	No. of Hips	Follow-up in Years (Range)	Results
Della Valle et al. (2005)	138	17 (15-19)	2.2% of aseptic loosening, 96% survivorship at 15 y
Templeton et al. (2001)	61	12.9 (11.5-14.3)	3.5% were radiographically loose at last follow-up
Paprosky et al. (1994)	147	5.7 (3-9)	4.1% rate of failure, all failures in 3B acetabulums
Jamali et al. (2004)	63	11 (5-17)	5% rate of aseptic loosening
Hallstrom et al. (2004)	188	12 (10-17)	11% aseptic loosening, 96% survivorship at 12 y
Leopold et al. (1999)	138	10.5 (7-14)	1.8% radiographically loose at last follow-up
Silverton et al. (1996)	138	8.3 (7-11)	0.7% failure rate at last follow-up

Positioning

The patient is placed in a lateral decubitus position, which allows for a more extensile exposure if needed.
Draping should allow for adequate access to the proximal pelvis and entire femur.

Surgical Approaches

The preferred approach of the authors in the majority of revision total hip arthroplasties (THAs) is a posterior approach. The posterior approach allows access to the posterior column and the ability to perform an extended femoral osteotomy if needed. However, anterolateral approaches also are compatible with this technique (as are direct anterior approaches for surgeons expert at the approach in very selected cases).
The skin incision is partly dictated by the previous incisions, but ideally, a lateral incision is used, centered over the posterior trochanter and curving posteriorly proximally.

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