The cup-on-cup technique for managing massive acetabular defects in revision total hip arthroplasty: a systematic review.
- 1Department of Aging, Orthopaedic and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy. [email protected].
- 2Department of Aging, Orthopaedic and Rheumatological Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
- 3Department of Orthopedics, Ospedale Isola Tiberina-Gemelli Isola, 00186, Rome, Italy.
Abstract
Background
Severe acetabular bone loss, particularly Paprosky types IIIA and IIIB, remains a major challenge in revision total hip arthroplasty (rTHA). The "cup-on-cup" or "double-cup" construct has been introduced as a salvage technique to improve fixation and restore hip biomechanics. The aim of this systematic review is to synthesise the available evidence regarding the indications, clinical outcomes, and complication rates of this technique.Methods
A comprehensive literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library up to April 2025, following PRISMA guidelines. Studies reporting clinical outcomes of cup-on-cup constructs for acetabular revision were included. Six studies met the inclusion criteria. The methodological quality was assessed using OCEBM criteria.Results
The study population comprised 111 patients (52 men, 59 women). Primary indications were aseptic loosening with massive bone loss: defects were classified as Paprosky type IIIA (n = 51, 46%) and type IIIB (n = 58, 52%), with only two cases of type IIC. At a mean follow-up of 2.4-4.6 years, the weighted mean Harris Hip Score (HHS) improved significantly from 33.6 points to 86.7 points. Radiographic assessment showed stable fixation, with only one study reporting a 6.3% rate of aseptic loosening. However, complications were relatively frequent, with dislocation rates varying widely (0% to 30%) and deep infection occurring in up to 20% of cases in specific cohorts.Conclusion
The cup-on-cup technique represents a promising solution for managing severe acetabular bone loss without pelvic discontinuity, combining the biological benefits of porous metal with the mechanical stability of a modular construct. Despite satisfactory functional outcomes, the procedure is associated with a non-negligible risk of instability. Current evidence is limited to low-quality studies; therefore, this technique should be used judiciously in carefully selected patients.Level of evidence
Level IV, Systematic Review of Level III and IV studies.
Related
- Comparing Short-Term Clinical Outcomes and Survivorship of Complex Revision Total Hip Arthroplasty: Custom Triflange Acetabular Implants Vs Standard Cage Reconstruction
- Burch-Schneider Ring Alone Vs Cup-Cage Construct in Massive Acetabular Bone Defect in Revision Total Hip Arthroplasty
- Patient-specific management in high-risk revision total hip arthroplasty: mid-term outcomes of a next-generation constrained acetabular liner.
- Revision of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty Using the CORITM Imageless System: A Step-By-Step Surgical Technique.
- Staged Revision Reverse Total Shoulder Arthroplasty to Functional Hemiarthroplasty With Retained Humeral Implant: A Salvage Technique
BibTeX
@article{bove2026cuponcup,
title = {{The cup-on-cup technique for managing massive acetabular defects in revision total hip arthroplasty: a systematic review.}},
author = {Antonio Bove and Giovan Giuseppe Mazzella and Davide Ghibaudo and Luca Magrini and Raffaele Vitiello and Antonio Ziranu},
journal = {Journal of orthopaedic surgery and research},
year = {2026},
month = aug,
doi = {10.1186/s13018-026-07120-8},
url = {https://europepmc.org/article/MED/42968177},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - The cup-on-cup technique for managing massive acetabular defects in revision total hip arthroplasty: a systematic review.
AU - Antonio Bove
AU - Giovan Giuseppe Mazzella
AU - Davide Ghibaudo
AU - Luca Magrini
AU - Raffaele Vitiello
AU - Antonio Ziranu
PY - 2026
DA - 2026/08/05
JO - Journal of orthopaedic surgery and research
DO - 10.1186/s13018-026-07120-8
UR - https://europepmc.org/article/MED/42968177
AB - Background Severe acetabular bone loss, particularly Paprosky types IIIA and IIIB, remains a major challenge in revision total hip arthroplasty (rTHA). The "cup-on-cup" or "double-cup" construct has been introduced as a salvage technique to improve fixation and restore hip biomechanics. The aim of this systematic review is to synthesise the available evidence regarding the indications, clinical outcomes, and complication rates of this technique.Methods A comprehensive literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library up to April 2025, following PRISMA guidelines. Studies reporting clinical outcomes of cup-on-cup constructs for acetabular revision were included. Six studies met the inclusion criteria. The methodological quality was assessed using OCEBM criteria.Results The study population comprised 111 patients (52 men, 59 women). Primary indications were aseptic loosening with massive bone loss: defects were classified as Paprosky type IIIA (n = 51, 46%) and type IIIB (n = 58, 52%), with only two cases of type IIC. At a mean follow-up of 2.4-4.6 years, the weighted mean Harris Hip Score (HHS) improved significantly from 33.6 points to 86.7 points. Radiographic assessment showed stable fixation, with only one study reporting a 6.3% rate of aseptic loosening. However, complications were relatively frequent, with dislocation rates varying widely (0% to 30%) and deep infection occurring in up to 20% of cases in specific cohorts.Conclusion The cup-on-cup technique represents a promising solution for managing severe acetabular bone loss without pelvic discontinuity, combining the biological benefits of porous metal with the mechanical stability of a modular construct. Despite satisfactory functional outcomes, the procedure is associated with a non-negligible risk of instability. Current evidence is limited to low-quality studies; therefore, this technique should be used judiciously in carefully selected patients.Level of evidence Level IV, Systematic Review of Level III and IV studies.
SN - 1749-799X
ER -