OVT Video Details Superior Pubic Ramus Screw Fixation in Revision Hip Arthroplasty with Acetabular Bone Loss

Editor’s note:  The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Obtaining fixation of the acetabular component in the setting of revision hip arthroplasty can be particularly challenging. In cases of major bone loss and ischial osteolysis, the superior pubic ramus may be the only inferior bone available for revision cup fixation. Inferior cup fixation in the setting of major bone loss may be necessary to prevent abduction failure of the cup. Placement of a screw through the superior pubic ramus is technically difficult because of the risk of neurovascular damage that can occur with cortical perforation. In the OVT video titled “Superior Pubic Ramus Screw Fixation in Revision Total Hip Arthroplasty for Acetabular Bone Loss,” narrated by Neil P. Sheth, MD, FAAOS, the authors present a clear step-by-step technique to place this screw.

This process adopts a commonly used technique in orthopaedic trauma of placing an anterior column screw from posterior to anterior across the acetabulum. This technique is also used to place a retrograde pubic ramus screw. The authors describe the lateral decubitus positioning and set up for the surgery. The C-arm is brought in from the opposite side to obtain the inlet view and the obturator outlet view. The instruments and scrub technician are behind the surgeon. The video provides a nice schematic of how the room should be set up.

The authors present a case example of an aseptic failed acetabular reconstruction. After exposure, they identify the location of the pubic root under direct vision by identifying it as the structure just proximal to the obturator foramen. The screw pathway is then drilled according to the obturator outlet view to visualize the superior and inferior border of the superior pubic ramus. The inlet view is used to visualize the medial and lateral border of the inferior pubic ramus. The authors recommend drilling on oscillate to avoid cortical perforation. Cortical perforation of the superior cortex is especially dangerous because of the proximity of the external iliac artery. A depth gauge is used to measure the length of the screw. A Kirschner wire (K-wire) is placed in the screw hole. The authors then place the acetabular component over the K-wire and replace the K-wire with the appropriate length acetabular screw. The authors then show the final radiographs with the position of the superior acetabular screw (Fig. 1). They also show additional case examples of failed acetabular components, one being a pelvic discontinuity treated with this superior pubic ramus screw technique. The authors then describe their closure technique and review the above technical tips.

The authors then present a radiostereometric analysis study of porous tantalum components in revision total hip arthroplasty in the setting of major bone loss. There was a remarkably high construct failure rate when inferior fixation (either ischial or superior pubic ramus screws) was not performed, especially in cases with pelvic discontinuity.

Following the nicely described technique in the video, arthroplasty surgeons will learn to reliably place an acetabular screw in this stable pelvic landmark.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania. He is also a former member of the AAOS Now Editorial Board.

Video details

Title: Superior Pubic Ramus Screw Fixation in Revision Total Hip Arthroplasty for Acetabular Bone Loss
Authors: Neil P. Sheth, MD, FAAOS; Yehuda E. Kerbel, MD; Christopher Michael Melnic, MD, FAAOS; Wayne Gregory Paprosky, MD, FAAOS
Published: Feb. 27, 2023
Time: 10:58
Tags: Adult Reconstruction Hip, Revision Hip Arthroplasty

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