Revision of Total Hip Arthroplasty with Acetabular Bone Defects: Are Biological Grafts Really Better than Synthetic Bone Graft Substitutes?

Document Type : RESEARCH PAPER


1 University of Turin, Italy

2 San Luigi Gonzaga Hospital, University of Turin Medical School, Orbassano, Turin, Italy

3 Degli Infermi Hospital, Rivoli, Turin, Italy


Background: Acetabular aseptic loosening due to bone defect in total hip arthroplasty revisions is a great challenge
and several solutions have been proposed, but a broadly accepted consensus in the literature has not been reached
yet. The aim of this study is to compare the clinical and radiographic results of acetabular bone defects treatment with
biological-only graft or with a mixture of bone graft substitute and biological graft.
Methods: 33 patients had revision hip arthroplasty using impaction grafting with biological-only graft (21 patients,
Group A) or a 1/3 mixture of allograft and tricalcium phosphate bone graft substitute (12 patients, Group B). Patients
were reassessed at a minimum of one year after surgery with new x-rays and the Harris Hip Score (HHS).
Results: Survivorship of bone graft was 86% in Group A and 100% in Group B at a mean follow-up of 35 months. No
statistical difference between the two groups was found in terms of implants survivorship (P=0.28), clinical (P=0.08) or
radiographic (P=0.27) outcomes.
Conclusion: In our experience the use of tricalcium phosphate bone graft substitutes in combination with allo and
autograft provides good outcomes, low risk of failure and great clinical and radiographic results. Further investigations
on larger samples are needed to impact clinical practice.
Level of evidence: III


  1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007; 370(9597):1508-19.
  2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Jbjs. 2007;89(4):780-5.
  3. Kurcz B, Lyons J, Sayeed Z, Anoushiravani AA, Iorio R. Osteolysis as it pertains to total hip arthroplasty. Orthopedic Clinics. 2018;49(4):419-35
  4. Haynes JA, Stambough JB, Sassoon AA, Johnson SR, Clohisy JC, Nunley RM. Contemporary surgical indications and referral trends in revision total hip arthroplasty: a 10-year review. The journal of arthroplasty. 2016;31(3):622-5.
  5. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. JBJS. 2009;91(1):128-33.
  6. Bozic KJ, Durbhakula S, Berry DJ, Naessens JM, Rappaport K, Cisternas M, et al. Differences in patient and procedure characteristics and hospital resource use in primary and revision total joint arthroplasty: a multicenter study. The Journal of arthroplasty. 2005;20:17-25.
  7. Borland WS, Bhattacharya R, Holland JP, Brewster NT. Use of porous trabecular metal augments with impaction bone of porous trabecular metal augments with impaction bone. Acta Orthop. 2012; 83:347-52.
  8. Hendrich C, Mehling I, Sauer U, Kirschner S, Martell JM. Cementless acetabular reconstruction and structural bone-grafting in dysplastic hips. J Bone Joint Surg. 2006; 88:387-94.
  9. Joong-Myung Lee, Tae-ho Kim. Acetabular Cup Revision Arthroplasty Using Morselized Impaction Allograft. Hip Pelvis. 2018; 30(2): 65-77.
  10. Brydone AS, Meek D, Maclaine S. Bone grafting, orthopaedic biomaterials, and the clinical need for bone engineering. Proc Inst Mech Eng. 2010;224:1329–43.
  11. Holt G, Arthur A, Frame D, Muirhead A. Human skeletal allograft collection – room for improvement? Scott Med J. 2004; 49:146–8.
  12. Friedlaender GE, Strong DM, Tomford WW, Mankin HJ. Long-term follow-up of patients with osteochondral allografts. A correlation between immunologic responses and clinical outcome. Orthop Clin North. 1999;30:583–8.
  13. Stepanović ŽLj, Ristić BM. Bacterial infections associated with allogenic bone transplantation. Vojnosanit Pregl. 2015;72(5):427-30.
  14. Graham SM, Leonidou A, Aslam-Pervez N, Hamza A, Panteliadis P, Heliotis M, et al. Biological therapy of bone defects: the immunology of bone allo-transplantation. Expert Opinion on Biological Therapy. 2010;10(6):885-901.
  15. Campana V, Milano GI, Pagano E, Barba M, Cicione C, Salonna G, et al. Bone substitutes in orthopaedic surgery: from basic science to clinical practice. Journal of Materials Science: Materials in Medicine. 2014;25(10):2445-61.
  16. McNamara IR. Impaction bone grafting in revision hip surgery: past, present and future. Cell Tissue Bank. 2010;11:57–73.
  17. Beswick A, Blom AW. Bone graft substitutes in hip revision surgery: A comprehensive overview. Injury, Int. J. Care Injured. 2011; 42, S40–S46.
  18. Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. J Arthroplasty. 1994;9:33–44.
  19. Nilsdotter A, Bremander A. Measures of hip function and symptoms: Harris hip score (HHS), hip disability and osteoarthritis outcome score (HOOS), Oxford hip score (OHS), Lequesne index of severity for osteoarthritis of the hip (LISOH), and American Academy of orthopedic surgeons (AAOS) hip and knee questionnaire. Arthritis care & research. 2011;63(S11):S200-7.
  20. WH, Harris. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-resultstudy using a new method of result evaluation. J Bone Joint Surg Am. 1969; 51:737–755.
  21. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop. 1976; 21:20–32.
  22. Hodgkinson J P, Shelley P, Wroblewski B M. The correlation between the roentgenographic appearance and operative findings at the bone-cement junction of the socket in Chamley low friction arthroplasties. Clin Orthop. 1988; 228: 105-9.
  23. Calori GM, Mazza E, Colombo M, Ripamonti C. The use of bone-graft substitutes in large bone defects: Any specific needs? Injury, Int. J. Care Injured. 2011; 42; S56–S63.
  24. Coetzee AS. Regeneration of bone in the presence of calcium sulfate. Arch Otolaryngol. 1980;106:405–9.
  25. Board TN, Brunskill S, Doree C, Hyde C, Kay PR, Meek RD, et al. Processed versus fresh frozen bone for impaction bone grafting in revision hip arthroplasty. Cochrane Database of Systematic Reviews. 2009(4).
  26. Harris WH, Crothers O, Oh I. Total hip replacement and femoral-head bone-grafting for severe acetabular deficiency in adults. J Bone Joint Surg Am. 1977;59:752-9.
  27. Oommen AT, Krishnamoorthy VP, Poonnoose PM, Korula RJ. Fate of bone grafting for acetabular defects in total hip replacement. Indian J Orthop. 2015;49:181-6.
  28. Haddad FS. The role of impaction grafting: the when and how. Orthopedics (Online). 2009;32(9):675.
  29. Lee JM, Nam HT. Acetabular Revision Total Hip Arthroplasty Using an Impacted Morselized Allograftand a Cementless Cup: Minimum 10-Year Follow-Up. The Journal of Arthroplasty. 2011;26(7):1057-60.
  30. Huang C, Qin L, Yan W, Weng X, Huang X. Clinical evaluation following the use of mineralized collagen graft for bone defects in revision total hip arthroplasty. Regenerative Biomaterials. 2015; 245–249.
  31. Schwartz C, Bordei R. Biphasic phospho-calcium ceramics used as bone substitutes are efficient in the management of severe acetabular bone loss in revision total hip arthroplasties. . Eur J Orthop Surg Traumatol. 2005; 15:191–6.
  32. Schwartz, M. Vautrin. Phosphocalcium ceramics are efficient in the management of severe acetabular loss in revision hip arthroplasties. A 22 cases long-term follow-up study. Eur J Orthop Surg Traumatol. 2015; 25:227–232.
  33. Bohner M. Calcium orthophosphates in medicine: from ceramics to calcium phosphate cements. Injury. 2000; 31(Suppl. 4),S37-47.
  34. Hollinger JO, Brekke J. Role of bone substitutes. Clin Orthop Relat Res. 1996;324:55-65.
  35. Bernstein P, Bornhauser M, Gunther K, Stiehler M. Bone tissue engineering in clinical application. Assessment of the current situation. Orthopade 2009; 38:1029–37.
  36. Šponer P, Kučera T, Brtková J, Urban K, Kočí Z, Měřička P, et al. Comparative study on the application of mesenchymal stromal cells combined with tricalcium phosphate scaffold into femoral bone defects. Cell transplantation. 2018;27(10):1459-68.
  37. Abdullah KM, Hussain N, Parsons SJ, Porteous MJ, Atrey A. 11-Year Mean Follow-Up of Acetabular Impaction Grafting With a Mixture of Bone Graft and Hydroxyapatite Porous Synthetic Bone Substitute. The Journal of Arthroplasty. 2018 May 1;33(5):1481-6.
  38. Whitehouse MR, Dacombe PJ, Webb JCJ, Blom AW. Impaction grafting of the acetabulum with ceramic bone graft substitute mixed with femoral head allograft: High survivorship in 43 patients with a median follow-up of 7 years. Acta Orthopaedica. 2013; 84 (4): 365–370.
  39. Blom A W, Wylde V, Livesey C, Whitehouse M R, Eastaugh-Waring S, Bannister G C, et al. Impaction bone grafting of the acetabulum at hip revision using a mix of bone chips and a biphasic porous ceramic bone graft substitute. Acta Orthop. 2009; 80 (2): 150–4.
  40. McNamara I, Deshpande S, Porteous MJ. Impaction grafting of the acetabulum with a mixture of frozen, ground irradiated bone graft and porous synthetic bone substitute (Apapore 60). J Bone Joint Surg [Br]. 2010; 92-B:617-23.
  41. Blom AW, Cunningham JL, Hughes G, Lawes TJ, Smith N, Blunn G, et al. The compatibility of ceramic bone graft substitutes as allograft extenders for use in impaction grafting of the femur. J Bone Joint Surg Br. 2005;87(3):421–5.
  42. Jacofsky DJ, McCamley JD, Jaczynski AM, Shrader MW, Jacofsky MC. Improving initial acetabular component stability in revision total hip arthroplasty: Calcium phosphate cement vs reverse reamed cancellous allograft. The Journal of Arthroplasty. 2012;27(2):305-9.
  43. Kumar V, Ricks M, Sherif Abouel-Enin, Dunlop DG. Long term results of impaction Bone grafting using a synthetic graft (Apapore) in revision hip surgery. Journal of Orthopaedics. 2017; 14; 290–293.
  44. Aulakh TS, Jayasekera N, Kuiper JH, Richardson JB. Long-term clinical outcomes following the use of synthetic hydroxyapatite and bone graft in impaction in revision hip arthroplasty. Biomaterials. 2009; 30; 1732–1738.
  45. Van Egmond N, De Kam DC, Gardeniers JW, Schreurs BW. Revisions of extensive acetabular defects with impaction grafting and a cement cup. Clin Orthop Relat Res. 2011;469:562-73.
  46. Van Haaren EH, Heyligers IC, Alexander FG, Wuisman PI. High rate of failure of impaction grafting in large acetabular defects. J Bone Joint Surg. 2007;89:296-300.
  47. Leung HB, Fok MW, Chow LC, Yen CH. Cost comparison of femoral head banking versus bone substitutes. J Orthopaedic Surg. 2010;18:50–4.
  48. Welten ML, Schreurs BW, Buma P, Verdonschot N, Slooff TJ. Acetabular Reconstruction With Impacted Morcellized Cancellous Bone Autograft and Cemented Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2000; Vol. 15 No. 7.
  49. Ibrahim MS, Raja S, Haddad FS. Acetabular impaction bone grafting in total hip replacement. The Bone & Joint Journal. 2013;95(11_Supple_A):98-102.