Archives of Orthopaedic and Trauma Surgery

https://doi.org/10.1007/s00402-020-03379-6

HIP ARTHROPLASTY

Acetabular defects in revision hip arthroplasty: a therapy‑oriented

classification
Dieter Christian Wirtz1 · Max Jaenisch1   · Thiemo Antonius Osterhaus1 · Martin Gathen1 · Matthias Wimmer1 ·
Thomas Martin Randau1 · Frank Alexander Schildberg1 · Philip Peter Rössler1

Received: 12 November 2019

© The Author(s) 2020

Abstract
Introduction  The treatment of severe acetabular bone loss remains a difficult challenge. No classification system is available
that combines intuitive use, structured design and offers a therapeutic recommendation according to the current literature
and modern state of the art treatment options. The goal of this study is to introduce an intuitive, reproducible and reliable
guideline for the evaluation and treatment of acetabular defects.
Methods  The proposed Acetabular Defect Classification (ADC) is based on the integrity of the acetabular rim and support-
ing structures. It consists of 4 main types of defects ascending in severity and subdivisions narrowing down-defect location.
Type 1 presents an intact acetabular rim, type 2 includes a noncontained defect of the acetabular rim ≤ 10 mm, in type 3
the rim defect exceeds 10 mm and type 4 includes different kinds of pelvic discontinuity. A collective of 207 preoperative
radiographs were graded according to ADC and correlated with intraoperative findings. Additionally, a randomized sample
of 80 patients was graded according to ADC by 5 observers to account for inter- and intra-rater reliability.
Results  We evaluated the agreement of preoperative, radiographic grading and intraoperative findings presenting with a k
value of 0.74. Interobserver agreement presented with a k value of 0.62 and intraobserver at a k value of 0.78.
Conclusion  The ADC offers an intuitive, reliable and reproducible classification system. It guides the surgeon pre- and
intraoperatively through a complex field of practice.

Keywords  Hip · Acetabulum · Revision · Arthroplasty · Classification · Paprosky

Introduction million per year in Europe alone, there is an increased proba-

bility of component loosening associated with periprosthetic
The operative treatment of severe acetabular bone loss bone defects [1]. With the age of the general population
remains one of the greatest challenges facing the field of increasing revision rates of up to 12% will be common [2].
revision hip arthroplasty. Considering the rising number General principles in the treatment of severe periacetabu-
of primary total hip arthroplasties, which have reached 3.2 lar bone loss include the reconstruction of a physiological
joint geometry, including correct positioning of the anatomi-
cal hip center of rotation, as well as an appropriate femoral
Dieter Christian Wirtz, Max Jaenisch contributed equally.

* Max Jaenisch Thomas Martin Randau

max.jaenisch@ukb.uni‑bonn.de thomas.randau@ukb.uni‑bonn.de
Dieter Christian Wirtz Frank Alexander Schildberg
dieter.wirtz@ukb.uni‑bonn.de frank.schildberg@ukb.uni‑bonn.de
Thiemo Antonius Osterhaus Philip Peter Rössler
thiemo.osterhaus@gmail.com philip.roessler@ukb.uni‑bonn.de
Martin Gathen 1
Department of Orthopaedics and Traumatology, University
martin.gathen@ukb.uni‑bonn.de
Hospital Bonn, Germany, Sigmund‑Freud‑Straße 25,
Matthias Wimmer 53127 Bonn, Germany
matthias.wimmer@ukb.uni‑bonn.de

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 Archives of Orthopaedic and Trauma Surgery

offset [3]. A primary stable implantation with proper force acetabular component. Patients were excluded if the pre-
transmission to the remaining acetabular bone stock is essen- operative radiographs could not be retrieved or were of
tial to enable long-term stability. Noncontained acetabular insufficient quality, as well as if intraoperative recordings
defects should be transitioned to contained defects using were incomplete and did not allow for a reliable grading.
some form of augmentation. Another goal of hip revision In addition, patient characteristics including age, sex, date
arthroplasty is the downsizing of the bone defect to improve of revision and implant inserted were collected. During the
the outcome in following revision procedures [4]. selection process, 21 cases were excluded because no digi-
To achieve these goals, precise preoperative planning and tal copies of preoperative radiographs could be retrieved or
proper implant choice are essential. Because correct inter- because radiographs were of insufficient quality. Addition-
pretation of radiographic findings can be difficult an exact ally, 25 cases were excluded because intraoperative data did
definition of common patterns of defect morphology with a not match the defined requirements (see intraoperative eval-
resultant therapeutic recommendation is needed. uation). After exclusion 207 patients have been evaluated.
To address this purpose, a number of classification sys-
tems have been published, which can in general be divided Intraoperative evaluation
into 2 categories. Classifications such as proposed by the
AAOS or Engh and Gross follow a volumetric approach and Collection and conversion into ADC grading of intraopera-
offer a rather simplified, but reproducible evaluation, when tive data was carried out in a retrospective manner by one of
in contrast classifications, such as proposed by Paprosky, the originators of the ADC. Surgical reports were screened
Saleh or D’Antonio focus on detailed defect description and for information concerning the exhibited acetabular defect
preoperative planning [5–9]. Due to the simple nature of the location and size. Additional information, such as implants
first category, these classifications lack therapeutic guidance used and/or use of augmentation were taken into considera-
while the second category can be difficult to memorize and tion as well. Cases were excluded if the exact defect location
therefore impede intuitive use. was not specified and if no measurement of defect size had
To the authors knowledge, no classification system is been recorded.
available that combines intuitive use and structured design
while still producing a detailed defect description and offer- Radiographic evaluation
ing a therapeutic method according to the current literature
and modern state of the art treatment options. The radiographs were anonymized by numerical coding and
The goal of the present retrospective study is to introduce all identifying features have been removed. Subsequently,
an intuitive guideline for the evaluation and treatment of ace- the radiographs were graded according to ADC by one of
tabular defects in revision hip arthroplasty. To account for the originators of the ADC, without prior knowledge of the
reliability, we compared preoperative gradings with intraop- recorded intraoperative findings. As a next step, agreement
erative findings and in the evaluation of reproducibility we of radiographic and intraoperative grading using Cohens 𝜅
rated inter- and intra-rater agreement. has been performed.
We hypothesized that the ADC is a reliable and repro- After power analysis, 80 anonymized radiographs were
ducible classification system, which provides the surgeon chosen at random and distributed to 5 raters. All of these
preoperativley with a valid estimation of the defect sever- raters were experienced orthopaedic surgeons in the field of
ity and the needed preparations. Additionally, we devised a hip revision arthroplasty. Each rater received 1 teaching ses-
clear algorithm for intraoperative assistance while deciding sion consisting of thorough explanation of the classification
the definitive choice of implants and additions such as aug- system and supervised evaluation of 10 random cases. The
ments or bone grafting. teaching session did not include any of the 80 cases used for
later evaluation. A scoring sheet inspired by a publication
of Yu et al. and adapted for the ADC has been distributed to
Materials and methods observers [5]. None of the raters had any prior knowledge
of the ADC or were involved in the creation. The distrib-
Study design and patients uted radiographs have been analysed on 2 occasions with an
interval of at least 2 weeks in between as a washout period.
Study approval was obtained through our institution’s review Radiographs were relabelled and randomized prior to the
board. The presented single-centre, cohort study was based second evaluation.
on retrospectively collected data of 253 consecutive patients, The preoperative radiographs included pelvis a.p. stand-
which underwent acetabular revision surgery between 2011 ing and involved hip axial. The preoperative images were
and 2017 for any reason. Inclusion criteria were cases of graded according to ADC using IMPAX EE (Agfa Health-
THA revision for any reason with exchange of at least the Care GmbH, Bonn, Germany).

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Archives of Orthopaedic and Trauma Surgery

Classification system Type 2 defects

The ADC is based on the integrity of the acetabular rim Type 2 demonstrates a noncontained defect of the acetabu-
and the supporting structures. It consists of 4 main types of lar rim in addition to cancellous bone defects. The defect
defects ascending in severity, with an additional subdivision measures below or equal 10 mm in the vertical plane and is
into a, b and c narrowing down-defect location. considered as nonstructural. For 2A the rim defect affects
the superolateral portion while in 2B the posterior column
Type 1 defects is deficient (horizontal plane). A Type 2C defect is a com-
bination of A and B and displays a defect including the full
Type 1 defects are characterized as contained defects with weight bearing portion of the rim. Because of its measure-
the acetabular rim remaining intact and the acetabulum ment below 10 mm, it is also considered as nonstructural.
only showing cancellous bone defects in different locations Graphic illustrations are presented in Fig. 2.
according to subdivision. A 1A defect displays randomly
distributed cancellous defects, which respect the superome- Type 3 defects
dial aspect of the acetabulum and the medial wall. A 1B
defect exhibits a lysis of the superomedial aspect of the Type 3 defects possess noncontained, structural defects of
acetabulum in addition to defects already described for A. the acetabular rim over. The subdivision follows the same
A 1C defect displays a deficiency of the medial wall, which structure as for the type 2 defects with A including the supe-
does not affect the anterior or posterior column. Graphic rior aspect, B the posterior column and C being a combina-
illustrations are presented in Fig. 1. tion of both. Graphic illustrations are presented in Fig. 3.

Fig. 1   a–f Acetabular Defect

Classification (ADC) Type 1 a
lateral view of a Type 1a defect
b lateral view of a Type 1b
defect c lateral view of a Type
1c defect d 45° view of a Type
1a defect e 45° view of a Type
1b defect f 45° view of a Type
1c defect

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 Archives of Orthopaedic and Trauma Surgery

Fig. 2  a–f Acetabular Defect

Classification (ADC) Type 2 a
lateral view of a Type 2a defect
b lateral view of a Type 2b
defect c lateral view of a Type
2c defect d 45° view of a Type
2a defect e 45° view of a Type
2b defect f 45° view of a Type
2c defect

Type 4 defects producing the mean 𝜅 of all raters. The extend of agreement
was interpreted using the criteria described by Landis and
Type 4 defects exhibit a disruption of the bone stock between Koch [6]. Therefore, if the 𝜅 value exceeds 0.80 excellent
the ischium and the ilium. The anterior and posterior col- agreement is achieved, between 0.61 and 0.8 indicated good
umns are rendered nonsupportive. The subclassification in agreement, a score of 0.41–0.60 indicated moderate agree-
A, B and C account for the amount of remaining superior ment, a score between 0.21 and 0.4 indicates fair agree-
bone stock. For A the superior bone stock is considered ment and finally a score of 0.20 and below indicates poor
supportive, for B a nonstructural superior rim defect under/ agreement.
equal 10 mm in the vertical plane is described and for C a
structural superior rim defect over 10 mm accompanies the
pelvis discontinuity. Graphic illustrations are presented in Results
Fig. 4.
In this study, 207 preoperative radiographic gradings have
Statistical analysis been compared to intraoperative findings to account for
agreement of defect severity. A Cohens 𝜅 of 0.74 could be
All analyses were performed using IBM SPSS Statistics evaluated, accounting for good agreement between preop-
1.0.0.1131 (IBM Inc., Armonk, New York, USA). The level erative radiographs and intraoperative findings. The large
of significance was set at p < 0.05. The confidence interval sample of 207 proved well balanced, displaying 81 type 1
has been set at 95%. Fleiss 𝜅was used as a means to account defects (39%), 72 type 2 defects (35%), 37 type 3 defects
for inter-rater reliability in the process of comparing ordered (18%) and 17 type 4 defects (8%). Due to randomization, the
categorical data with more than 2 observers. Intra-rater reli- smaller sample to account for inter- and intra-rater reliability
ability was being accessed using Cohens 𝜅and in a next step displayed a different distribution (Fig. 5).

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Archives of Orthopaedic and Trauma Surgery

Fig. 3   a–f Acetabular Defect

Classification (ADC) Type 3 a
lateral view of a Type 3a defect
b lateral view of a Type 3b
defect c lateral view of a Type
3c defect d 45° view of a Type
3a defect e 45° view of a Type
3b defect f 45° view of a Type
3c defect

To account for inter-rater reliability, 80 patients have By creating the ADC, we aim to distribute a reliable,
been evaluated by 5 different observers. Testing for inter- reproducible and intuitive classification system to aid sur-
rater reliability, a Fleiss 𝜅 of 0.624 (low CI 0.6; high CI 0.65) geons in navigating a difficult field of practice by improv-
could be evaluated falling into the good agreement range as ing the diagnostic assessment and providing therapeutic
defined by Landis and Koch [6]. When testing for intra-rater guidance.
reliability, Cohens 𝜅 of each of the 5 raters has been analyzed In the creation of an ideal acetabular defect classifica-
and the mean was calculated (Fig. 6). Testing for intra-rater tion certain key points should be considered. First, it should
reliability revealed a mean 𝜅 of 0.79, which still remains to be applicable to the evaluation of native radiographs of the
be in the good agreement range almost accounting for per- pelvis. Patients with significant osteolytic lesions can remain
fect agreement. asymptomatic as long as the fixation is stable. During those
asymptomatic years, bone loss progresses and increases the
difficulty of revision options. To achieve an early diagnosis
of increasing acetabular osteolysis, regular, postoperative
Discussion follow-up assessments, including plain radiographs of the
pelvis are essential. Native radiographs, present a limited
Acetabular revision arthroplasty provoked by extensive amount of radiation exposure, are cheap, easy to produce
periprosthetic osteolysis presents a difficult challenge for and widely available.
orthopaedic surgeons. Depending on the defect size and The radiographic evaluation according to the ADC
location different approaches and implants, as well as addi- appears to provide a reliable estimation of the defect extend
tions like augments or bone grafting, need to be considered. compared to intraoperative findings with a k value of 0.74
In such a high stakes field of surgery, meticulous preopera- indicating good agreement. The authors contribute the good
tive planning is essential for achieving successful and lasting results to the analytical approach of the provided evaluation
fixation. spreadsheet, which focuses on standardized definitions of

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 Archives of Orthopaedic and Trauma Surgery

Fig. 4  a–f Acetabular Defect

Classification (ADC) Type 4 a
lateral view of a Type 4a defect
b lateral view of a Type 4b
defect c lateral view of a Type
4c defect d 45° view of a Type
4a defect e 45° view of a Type
4b defect f 45° view of a Type
4c defect

Fig. 5  Illustration of the distri-

bution of types of defect in the
randomized sample (y axis n
out of 80, x axis type of defect
form 1–4)

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Archives of Orthopaedic and Trauma Surgery

Fig. 6  Accounting for Intrarater

reliability Cohens 𝜅 (y axis) has
been evaluated and illustrated
matching each rater (x axis)

radiographic landmarks and a structured analysis. Each sup- acetabular rim and presence of pelvic discontinuity already
porting structure is being evaluated separately and added up sets the tone for possible therapeutic options. The subcat-
to provide a final grading. egories further narrow down-defect location and complete
The analysis of the discrepancies between preoperative the necessary evaluation to apply the therapeutic algorithm.
grading and intraoperative situation showed a limited accu- The practical application of a classification only finds its
racy regarding defects of the posterior column and wall, as way in daily practice and research if a sufficient reproduc-
well as the recognition of pelvic discontinuities. This prob- ibility and reliability can be established.
lem has been described before and in most cases, it is due Traditional classification systems, such as AAOS,
to radiopaque implants obscuring the visualization in plain Paprosky et al. or Gross et al. have yielded disappointing
radiographs [5]. A publication by Claus et al. evaluated 128 results in evaluations in literature and appear to mostly fall
radiographs, and was able to report a decent sensitivity for into the poor to moderate range for intra-rater and inter-
defects of the ilium (71.5%), but a poor sensitivity for lesions rater reliability when evaluating preoperative radiographs
of the posterior column (15%) [7]. Because the posterior [6, 8, 11]. As discussed above, correct interpretation of
column/wall is essential for proper implant choice, a com- radiographic signs can be challenging and presents a lim-
puter tomography should be performed preoperatively if the ited reliability in itself [5, 7]. In a study conducted by Yu
integrity of the dorsal structures is in question [8]. Some et al. a significant improvement of the agreement concern-
studies also show an increased sensitivity for the recognition ing the Paprosky classification could be observed when
of posterior wall/column defects and pelvic discontinuity utilizing teaching sessions and a structured scoring table
through the use of oblique radiographs [9, 10]. guiding evaluation [5]. The inter-rater and intra-rater reli-
Secondly in order for a classification to integrate itself in ability of the ADC presents with k values of 0,62 and 0,78
the daily use of a clinician, it needs to be intuitive. While as satisfactory falling into the good agreement category as
creating the ADC, the authors decided to use a detailed defined by Landis and Koch [6]. The authors contribute this
defect description in order to offer a clear therapeutic algo- to the overall structured and intuitive design, as well as to
rithm, but at the same time kept definitions and structure the utilization of teaching session and a structured scoring
consistent throughout the system to facilitate intuitive appli- table. Since this publication represents the introduction of
cation. The 4 main categories are easy to memorize and the ADC, more research into the reliability and reproduc-
already provide vital information of the defect morphology. ibility is needed, but these early results are promising and
Dividing defects due to integrity/extend of damage to/of the confirm this new classification as reliable.

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 Archives of Orthopaedic and Trauma Surgery

The final and most important criteria for a well-estab- long-term results and the observation of bone mineral den-
lished classification is a clear therapeutic algorithm, which sity changes, which can be interpreted as a progressive appo-
moves along the different gradings. Established classification sition of vital new host bone [4, 14, 15]. Impaction bone
systems, such as provided by Paproksy et al. focus on the grafting has proven itself to be a valid method of treatment
utilization of bulk allografts, which have been established as and should be used in contained defects or severe defects in
having a poor long-term stability as discussed below [12]. combination with other methods of reconstruction. If the
Since most established defect classifications have been intro- lesion of the medial wall in 1C defects is rather large caus-
duced in the 1990s, an update, which includes and addresses ing a protrusion medially, a cup-and-cage-design can be
the application of modern techniques is needed. used to bridge the defect and allow for proper grafting and
The following treatment choices are recommendations defect downsizing [16, 17]. However, there are publications
based on the algorithm the authors established and use in showing good short-term results when treating protrusion
their own clinical practice and a thorough review of the cur- acetabuli relying on rim pressfit even in large medial defect
rent literature. The full algorithm is provided in Table 1. situations [18]. Therefore a screw-in-cup is feasible as well. 
Type 1 defects are defined by an intact acetabular rim Once the defect level reaches 2 or above a noncontained
with cancellous bone defects in different locations. There- defect of the acetabular rim exists. In the authors opinion,
fore, a circumferential pressfit can be established [13]. Addi- a long-term stable fixations and anatomical reconstruction
tionally, screws can be added to the implant of choice, but of the center of rotation can only be achieved by converting
only if a primary stable fixation is achieved through pressfit. the uncontained defect into a contained defect through aug-
In the interest of defect downsizing, impaction bone grafting mentation. Different means of augmentation have been intro-
should be applied. Several publications report good mid- and duced and are discussed controversially. The superolateral

Table 1  Therapeutic Type of defect Implant choice

recommendation based on
defect type according to ADC 1 A/B Pressfit cup/Screw-in cup
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
1C Pressfit cup/Cup and Cage/Modular cage/Screw-in-cup
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
2 A/B/C Metal-Augmentation of defect through:
A: Augment-and-Cup/Augment-and-(modular)-Cage/
Oblong Cup/Cranial socket system; B/C: additional
flanges and/or iliac peg
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
3 A/B/C Metal-Augmentation of defect with additional flanges
through:
Augment-and-(modular)-Cage
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
4A Iliac–ischial plating in combination with:
Augment-and-(modular)-cage
–
Oblong cup/Cranial socket system with iliac peg and addi-
tional flanges
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
4B Augment-and-(modular)-cage, oblong cup with iliac peg
and additional flanges, Custom individualized monoblock
pelvic replacement with tripolar cup system (dual mobil-
ity)
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum
4C Custom individualized monoblock pelvic replacement with
tripolar cup system (dual mobility)
Impaction bone grafting of the medial and superomedial
aspect of the acetabulum

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Archives of Orthopaedic and Trauma Surgery

portion of the acetabulum takes up a special role for being defects, while in IV C defects due to the massive amount
the most taxed portion of the rim considering weight bear- of bone loss, stable fixation as well as anatomical recon-
ing and therefore often exhibits a pronounced sclerosis and struction of the center of rotation are unlikely.
limited vascularization. Therefore, structural bulk allografts If the pelvic osteolysis reaches a type IV C defect, the
do not present a promising option with limited integration, authors recommend the use of a custom-made acetabular
consecutive resorption and failure of fixation in the long component based on a CT scan. The continuous improve-
term [19]. Various publications were able to display a high ment in the recognition of pelvic osteolysis through
rate of failure in long-term follow-up in strong contrast to advanced CT hardware and progress in the development
promising short-term results [20, 21]. Even in radiographi- of promising software postprocessing implements a pre-
cally stable allografts, a fibrous encapsulation without sig- cise preoperative planning and visualization of the defect
nificant bone union and no evidence of implant ingrowth morphology [8]. This enables the surgeon to utilize the
could be evaluated postmortem [22]. remaining landmarks and apply different fixation tech-
Means of augmentation can include oblong cups, cranial niques, such as flanges, intramedullary pole screws and
socket systems, augment-and-cup and augment-and-cage integrated augments to properly address the specific defect
designs. Recently, promising early results for an augment- configuration. Even though the amount of literature report-
and-modular-cage-design have been published showing an ing on long-term outcome is still limited, and promising
improvement of clinical function and patient reported out- short-term results have been published [29–35]. Whenever
come as well as efficient reconstruction of the acetabular the risk of gluteal insufficiency becomes apparent tripolar
center of rotation [23]. In cases of severe bone loss to the cup systems (dual mobility) should be utilized.
dorsal column anatomic flanges and/or iliac pegs should be The main limitation of this study is the retrospective
added to the construct. assessment of intraoperative defects. Due to this method,
Once the defect size exceeds 10 mm and is therefore information is bound to be lost and validation is limited. In
defined as a type III defect additionally to the augmen- order to provide a more valid estimation of the reliability
tation an anatomic flange is necessary even for isolated of the ADC, further studies including prospective intraop-
superolateral defects (A) and should be added to the con- erative assessment in comparison to preoperative imaging
struct in order to bridge the defect and obtain contact to a are needed. Another factor accounting for a possible lack
sufficient amount of stable host bone for proper fixation. of reliability between preoperative grading and intraopera-
This can be applied through a conventional or modular tive findings is a limited reliability of radiographic land-
augment and cage system. Oblong cups or cranial socket marks and signs as discussed above. Along the foreseen
systems are no longer feasible because the extensive cran- future advancements of three-dimensional diagnostic solu-
iolateral defect leads to consecutive cranialization of the tions, the ADC can be applied as well.
hip center of rotation if not adequatly augmented. A limitation afflicting all classification systems with
Pelvic discontinuity presents the most severe defect a therapeutic recommendation is the anticipated further
situation portrayed in this classification. It poses a most advancement of treatment options and operative techniques.
difficult challenge to the surgent and implant and needs to For this reason, sooner or later, an updated therapeutic
be evaluated and planned carefully to allow for successful spread sheet will be necessary. The classification in itself,
reconstruction. Independently of the chosen method, the being based on biomechanical principles, will remain solid
goal is to achieve a stable fixation and anatomical recon- even once therapeutic possibilities evolve.
struction of the center of rotation as well as the healing of This publication focusses on the reliability and the repro-
the discontinuity [24]. ducibility of the ADC. Even though a therapeutic algorithm
Depending on the remaining bone stock, different oper- has been provided, it is based on the current literature and
ative approaches can be chosen. Even after careful prepa- expert opinion. Differences in the outcome were not being
ration, enough bone stock remains to allow for a stable explored, and further prospective randomized studies are
bridging and an extramedullary iliac–ischial plate can be needed to establish a benefit in improved outcome.
applied effectively downsizing the type IVa defect, which
then can be treated accordingly taking the remaining supe-
rior and dorsal bone stock into consideration [25, 26]. Conclusion
If plate fixation does not pose a feasible possibility
for defect downsizing, a primary stable fixation needs to With the Acetabular Defect Classification (ADC), the
be achieved through implant design. Different implant authors introduced an innovative, reliable and reproducible
designs offer a combination of an intramedullary iliac peg, classification system, which allows for detailed preoperative
an anatomic flange and different means of defect augmen- planning. It can be applied as a preoperative planning tool,
tation [27, 28]. Those systems are applicable up to IV B

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as well as a means for step-by-step intraoperative guidance. 12. Paprosky WG, Perona PG, Lawrence JM (1994) Acetabular defect
In addition, a therapeutic guidance according to the current classification and surgical reconstruction in revision arthroplasty
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