Clinical Orthopaedics and Related Research®

, Volume 470, Issue 2, pp 435–441 | Cite as

Surgical Technique: A Cup-in-Cup Technique to Restore Offset in Severe Protrusio Acetabular Defects

Symposium: Papers Presented at the Annual Meetings of The Hip Society



Severe medial and/or superior defects encountered in revision THA are currently managed with jumbo (≥ 66 mm) acetabular components and modular augments, with reconstruction cages, or with the cup-cage technique. Preoperative planning can indicate when these techniques may not restore vertical and horizontal offset. Failure to restore offset can lead to impingement, leg length inequality, abductor weakness, and dislocation.

Surgical Technique

We developed a “cup-in-cup” technique in which a porous tantalum acetabular shell was impacted into supportive medial host bone. A second tantalum shell was then cemented in, and this shell’s diameter could be selected based on preoperative planning to achieve restoration of horizontal and vertical offset.

Patients and Methods

We implanted porous tantalum hemispheric shells in seven patients undergoing eight revision THAs. The average age was 73 years at the time of the procedure. Preoperative defects per the classification of Paprosky et al. were three IIC, four IIIA, and one IIIB. All patients were followed clinically and radiographically for a minimum of 12 months (average, 28 months; range, 12–50 months).


Abductor strength was either improved by one grade (four hips) or unchanged (four hips). Horizontal offset was increased an average of 10.5 mm (range, 8–16 mm), and vertical offset improved by an average of 18.4 mm (range, 10–29 mm). There was no evidence of loosening or migration at the time of final followup.


At short-term followup, the early experience cautiously supports the use of this construct. Long-term followup and a larger patient experience will be required to determine the durability of this novel technique.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Ballester Alfaro JJ, Sueiro Fernández J. Trabecular Metal buttress augment and the Trabecular Metal cup-cage construct in revision hip arthroplasty for severe acetabular bone loss and pelvic discontinuity. Hip Int. 2010;20(Suppl 7):S119–S127.Google Scholar
  2. 2.
    Beaule PE, Ebramzadeh E, LeDuff M, Prasad R, Amstutz HC. Cementing a liner into a stable cementless acetabular shell: the double socket technique. J Bone Joint Surg Am. 2004;86:929–934.PubMedGoogle Scholar
  3. 3.
    Berry DJ, Sutherland CJ, Trousdale RT, Colwell CW, Chandler HP, Ayres D, Yashar AA. Bilobed oblong porous coated acetabular components in revision total hip arthroplasty. Clin Orthop Relat Res. 2000;371:154–160.PubMedCrossRefGoogle Scholar
  4. 4.
    Christie MJ, Barrington SA, Brinson MF, Ruhling ME, DeBoer DK. Bridging massive acetabular defects with the Triflange Cup: 2- to 9-year results. Clin Orthop Relat Res. 2001;393:216–227.PubMedCrossRefGoogle Scholar
  5. 5.
    DeBoer DK, Christie MJ. Reconstruction of the deficient acetabulum with an oblong prosthesis: three-to-seven-year results. J Arthroplasty. 1998;13:674–680.PubMedCrossRefGoogle Scholar
  6. 6.
    DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20–32.PubMedGoogle Scholar
  7. 7.
    Ebramzadeh E, Beaule PE, Culwell JL, Amstutz HC. Fixation strength of an all-metal acetabular component cemented in to an acetabular shell: a biomechanical analysis. J Arthroplasty. 2004;19:45–49.PubMedGoogle Scholar
  8. 8.
    Fernandez-Fairen M, Murcia A, Blanco A, Merono A, Murcia A Jr, Ballester J. Revision of failed total hip arthroplasty acetabular cups to porous tantalum components: a 5-year follow-up study. J Arthroplasty. 2010;25:865–872.PubMedCrossRefGoogle Scholar
  9. 9.
    Flecher X, Sporer S, Paprosky W. Management of severe bone loss in acetabular revision using a Trabecular Metal shell. J Arthroplasty. 2008;23:949–955.PubMedCrossRefGoogle Scholar
  10. 10.
    Goodman S, Saastamoinen H, Nadav S, Gross A. Complications of ilioischial reconstruction rings in revision total hip arthroplasty. J Arthroplasty. 2004;19:436–446.PubMedCrossRefGoogle Scholar
  11. 11.
    Haft GF, Heiner AD, Dorr LD, Brown TD, Callaghan JJ. A biomechanical analysis of polyethylene liner cementation into a fixed acetabular shell. J Bone Joint Surg Am. 2003;85:1100–1110.PubMedCrossRefGoogle Scholar
  12. 12.
    Lucas DH, Scott RD. The Ranawat sign: a specific maneuver to assess component positioning in total hip arthroplasty. J Orthop Tech. 1994;2:59–61.Google Scholar
  13. 13.
    Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treatment of severe acetabular bone loss during revision hip arthroplasty. Clin Orthop Relat Res. 2004;429:201–208.PubMedCrossRefGoogle Scholar
  14. 14.
    Paprosky WG, Perona PG, Lawrence MJ. Acetabular defect classification and surgical reconstruction in revision arthroplasty: a 6-year follow-up evaluation. J Arthroplasty. 1994;9:33–44.PubMedCrossRefGoogle Scholar
  15. 15.
    Sporer SM, Paprosky WG. The use of a Trabecular Metal acetabular component and Trabecular Metal augment for severe acetabular defects. J Arthroplasty. 2006;21(Suppl 6):83–86.PubMedCrossRefGoogle Scholar
  16. 16.
    Wachtl SW, Jung M, Jakob RP, Gautier E. The Burch-Schneider antiprotrusio cage in acetabular revision surgery: a mean follow-up of 12 years. J Arthroplasty. 2000;15:959–963.PubMedCrossRefGoogle Scholar
  17. 17.
    Weeden SH, Schmidt RH. The use of tantalum porous metal implants for Paprosky 3A and 3B defects. J Arthroplasty. 2007;22(6 Suppl 2):151–155.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  1. 1.University of California at Davis and Sutter Medical CenterSacramentoUSA

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