Acetabular Revision Surgery in Birmingham
Complex reconstruction of the failed acetabular (socket) component of a hip replacement, using augments, cages, bone grafting, and custom triflange implants where required. Mr Hussain performs acetabular revision at the Royal Orthopaedic Hospital Birmingham.
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ENDO-Klinik Hamburg
Overview
What Is Acetabular Revision Surgery?
Acetabular revision surgery replaces or reconstructs the acetabular component (the cup or socket) of a failed hip replacement. It addresses problems arising on the pelvis side of the hip joint, including cup loosening, bone loss from osteolysis, recurrent instability due to cup malposition, and infection requiring full explant.
Acetabular revision can be performed as an isolated procedure (when the femoral stem remains well fixed and the problem is confined to the cup), or as part of a complete hip revision addressing both sides of the joint simultaneously.
The cup side is frequently the more technically challenging aspect of revision hip surgery. The amount and pattern of bone loss in the pelvis around a failed cup is highly variable and often unpredictable until the cup is removed intraoperatively. This requires the surgeon to have a range of reconstruction options available and the experience to choose and execute the most appropriate solution based on what is found at surgery.
Mr Hussain trained at ENDO-Klinik Hamburg, where acetabular reconstruction with complex bone defects is a routine part of the clinical programme. He has experience across the full spectrum of acetabular reconstruction options, from standard revision cups through to custom-designed triflange implants for the most challenging cases.
Causes of Failure
Why Does the Acetabular Cup Fail?
Aseptic Loosening
The most common cause of acetabular cup failure. The bond between the cup and the pelvic bone breaks down without infection, often accompanied by progressive osteolysis. Patients notice gradually worsening groin or hip pain, particularly with activity, and may develop a limp. X-rays and CT scanning reveal cup migration, tilt, or radiolucent lines indicating loss of bone-implant contact. Aseptic loosening is most common with older cemented cups but also occurs with cementless designs, particularly those with inadequate initial fixation or bearing surface wear over time.
Osteolysis and Bone Loss
Wear particles generated by the bearing surface trigger an inflammatory reaction in the pelvic bone around the cup, progressively destroying bone in a process called osteolysis. This creates cavitary defects (holes within the remaining bone shell) or segmental defects (loss of entire sections of the pelvic wall). Osteolysis may be clinically silent until extensive destruction has occurred, or may be detected on surveillance imaging. Early detection with a well-fixed cup and contained defects may allow isolated liner exchange and bone grafting; advanced osteolysis requires full cup revision with augmented reconstruction.
Instability and Chronic Dislocation
Recurrent hip dislocation related to cup malposition (incorrect inclination or version angle) may require revision of the cup component to restore optimal orientation. A cup that is too vertical (high abduction angle) or insufficiently anteverted is a common contributory cause of instability. Revision to correct cup position, often combined with insertion of a dual mobility bearing to further reduce dislocation risk, is effective in carefully selected patients where cup position is the primary cause.
Periprosthetic Joint Infection
Infection around the hip replacement necessitates removal of all implant components, including the acetabular cup, as part of the treatment strategy. Whether the cup is revised as part of DAIR (with the cup retained if well fixed and the procedure appropriate) or as part of two-stage revision (with full explant in all cases), the acetabular reconstruction at reimplantation must address any bone loss that has occurred as a result of the infection or the preceding period with an antibiotic spacer in situ.
Component Malposition
A cup placed at an incorrect angle at the time of primary surgery creates mechanical problems that may only become apparent over time: impingement (the neck of the femoral component striking the cup rim, generating wear and possible fracture), edge loading of the bearing surface (accelerating wear), or instability from inadequate coverage of the femoral head. When the malposition is severe enough to cause symptoms or accelerated wear, cup revision to restore correct orientation is required.
Surgical Options
Reconstruction Techniques
The choice of acetabular reconstruction technique is dictated by the size, location, and severity of bone loss, classified using the Paprosky system. The goal in all cases is to achieve a stable, well-fixed cup at the correct anatomical centre of rotation, with adequate bone support. Mr Hussain plans every case individually using CT-based 3D imaging and maintains intraoperative flexibility to adapt the plan based on actual bone loss found at surgery.
Standard Cementless Revision Cup
For cases with mild to moderate bone loss (Paprosky Type 1 and 2A), a large-diameter hemispheric cementless revision cup with multiple supplementary screws provides excellent fixation in the remaining host bone. The increased cup size fills minor defects and engages a larger surface area of viable bone. The cup is impacted into the reamed acetabulum and secured with multiple screws for immediate stability. A polyethylene or ceramic liner completes the bearing surface.
Cup and Augment Construct
For cases where bone defects cannot be adequately filled by a larger cup alone (Paprosky Type 2B, 2C, and some 3A defects), metal augments are used to supplement the cup. These highly porous titanium or tantalum blocks are shaped and positioned to fill the cavitary or uncontained defect, restoring the bone geometry and providing additional fixation points. The cup is then cemented into the augment construct, which is itself fixed with screws to the remaining host bone. This versatile technique accommodates a wide range of defect shapes and sizes.
Cage and Cup Construct
For severe defects involving significant column deficiency or pelvic discontinuity (Paprosky Type 3A and 3B), a trabecular metal or titanium cage is used. The cage spans the defect and distributes load across a wider area of the pelvis, with fixation points in the ilium above and ischium below the defect, bridging the zone of bone loss. A polyethylene cup is then cemented into the cage. This technique is particularly useful for superior dome defects and cases where a standard cup and augment cannot achieve adequate stability.
Custom Triflange Implant
For the most severe acetabular defects, including pelvic discontinuity (a complete break in the anterior and posterior columns of the acetabulum), a custom-designed triflange implant offers a highly effective solution. The implant is designed from the patient's CT scan using 3D planning software, creating a patient-specific construct with three flanges that engage the ilium, ischium, and pubis, bridging the discontinuity and achieving stable fixation even in the absence of structural acetabular bone. Manufacturing typically requires 6 to 8 weeks, so pre-operative planning and lead time must be factored into the surgical timeline.
Bone Grafting
Bone grafting is used in conjunction with most acetabular reconstruction techniques to restore biological bone stock. Morselised impaction grafting fills contained (cavitary) defects, providing a scaffold for bone ingrowth over time. Structural allograft (a block of donor bone) is used for uncontained segmental defects where a volume of bone must be replaced to support the cup construct. Bone grafting is particularly important in younger patients, where preserving bone stock for any future revisions is a clinical priority.
Dual Mobility Cup
The dual mobility cup uses a polyethylene liner that articulates both within the metal shell (creating a large effective femoral head) and around a smaller femoral head inside the liner (creating a second articulation). This design dramatically increases the effective head size and range of movement before dislocation occurs. Dual mobility cups are routinely used in acetabular revision surgery, where the risk of dislocation is substantially higher than after a primary hip replacement, regardless of the reason for revision.
Complexity and Expertise
Why Acetabular Revision Is Particularly Complex
Acetabular revision surgery carries a higher technical complexity than most other revision procedures, for several interconnected reasons:
Unpredictable bone loss. The extent and pattern of bone loss in the pelvis cannot be fully determined from pre-operative imaging alone. CT scanning gives the best pre-operative assessment, but the true degree of deficiency is only apparent when the failed cup is removed and the underlying bone is exposed. The surgeon must be prepared to escalate the reconstruction plan intraoperatively if the defects are more severe than anticipated.
Proximity of neurovascular structures. The major blood vessels to the lower limb (iliac artery and vein) and the sciatic nerve lie in close proximity to the acetabulum. Severe bone defects or migration of a failed cup can distort the normal anatomy and increase the risk of injury. Careful surgical technique, thorough knowledge of the anatomy, and pre-operative imaging are essential to safe dissection in this region.
Restoring the centre of rotation. Placing the acetabular cup at the correct anatomical centre of hip rotation is essential for optimal biomechanical function and longevity. In the context of severe bone loss, the correct position may not be achievable without augmentation, and compromise is sometimes necessary. An elevated hip centre can function well if leg length and offset are appropriately managed.
Need for intraoperative flexibility. Because the bone stock found at surgery may differ from pre-operative assessment, the surgeon must have access to the full range of reconstruction options at the time of the procedure, from simple revision cups through to augments, cages, and custom implants. The operating environment must support this, with access to the appropriate implant inventories and, where necessary, pre-ordered custom components.
- CT-based 3D planning for every complex acetabular revision case
- Full inventory of revision cups, augments, cages, and liners available intraoperatively
- Custom triflange implants planned and ordered in advance where indicated
- Dual mobility cup used routinely to address the elevated dislocation risk
- ENDO-Klinik Hamburg fellowship training in complex acetabular reconstruction
Revision Surgery in Birmingham
Why Choose Mr Hussain for Revision Surgery?
Mr Hussain holds a subspecialty fellowship from ENDO-Klinik Hamburg, one of the world's leading centres for revision arthroplasty, and has contributed 33 peer-reviewed publications to the orthopaedic literature. His practice at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, and Harborne Hospital is built on a foundation of 5,000+ procedures and a Doctify rating of 4.98 from 498 verified reviews.
Patient Questions
Frequently Asked Questions
Ready to Discuss Your Revision Surgery?
Book a private consultation with Mr Hussain at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, or Harborne Hospital.