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. 2026 Mar 21;39:101998. doi: 10.1016/j.artd.2026.101998

Bone Morphogenetic Protein Augmentation of Large Acetabular Defects in Revision Total Hip Arthroplasty: A Viable Option for Massive Bone Loss

Nathanael D Heckmann a,∗, Douglass W Tucker b, Brian C Chung a, Thomas Steck a, Brandon S Gettleman c, Daniel A Oakes a
PMCID: PMC13020009  PMID: 41907178

Abstract

Background

Large acetabular defects in revision total hip arthroplasty (THA) are challenging surgical problems. While bone morphogenetic proteins (BMPs) have shown promise in enhancing bone growth, the long-term outcomes of revision THA with BMP-2 augmentation for large acetabular defects are unknown.

Methods

A single-surgeon retrospective cohort study of consecutive patients who received BMP-2 augmentation during revision THA was conducted. Acetabular defects were graded using the Paprosky classification, heterotopic ossification was quantified using the Brooker classification, and bone consolidation was assessed radiographically. Postoperative complications, subsequent reoperations, and Oxford Hip Scores were recorded. Kaplan-Meier survival estimates were generated with all-cause reoperation as the endpoint.

Results

Fifteen patients (18 hips) with an average age of 64.6 ± 16.1 years and a mean follow-up of 76.3 ± 43.1 months were included. Patients underwent an average of 1.9 ± 1.3 surgeries prior to revision. There were 10 hips with Paprosky 3B defects, 3 with 3A defects, 3 with 2C defects, and 2 with 2B defects. Eleven hips had pelvic discontinuity. Postoperatively, 15 hips (83.3%) showed radiographic evidence of >50% bone consolidation. With all-cause reoperation as the primary endpoint, 6- and 10-year survivorship was 90.0% (95% CI: 47.3%-100.0%) and 70.0% (95% CI: 32.9%-89.2%), respectively. Regarding acetabular loosening, both 6- and 10-year survivorship was 90.0% (95% CI: 47.3%-98.5%). Mean Oxford Hip Score was 34.8 ± 9.2 at final follow-up.

Discussion

BMP-2 augmentation is a viable treatment option in revision THA when massive bone loss is encountered. However, further research is necessary to elucidate the safety and efficacy of BMP-2 adjuvant therapy in the setting of revision THA.

Keywords: Acetabular Defects, Revision total hip arthroplasty, Bone Loss, Bone Morphogenetic Protein

Introduction

Large acetabular defects in the setting of revision total hip arthroplasty (THA) are a challenging surgical problem encountered by the arthroplasty surgeon. While many classification systems have been implemented to describe acetabular bone loss, the Paprosky classification provides a valid, reliable, and anatomically oriented system designed to classify acetabular defects and drive surgical management strategies [1,2]. Historical and contemporary treatment options for Paprosky 3A and 3B defects include bulk structural allograft, trabecular metal augments, cup-cage constructs, and custom triflange implants [[3], [4], [5], [6]]. Although trabecular metal augments and cup-cage constructs have the potential to enhance acetabular component fixation, these fixation strategies do not reconstitute acetabular bone stock [7]. Novel techniques to enhance bone growth, particularly among patients with large cavitary defects, may help improve implant longevity by facilitating osseointegration and aid in future surgeries if re-revision surgery is required.

One potential solution to address severe acetabular bone loss in the setting of revision THA involves the use of recombinant human bone morphogenetic proteins (BMPs). BMPs are osteoinductive and osteogenic molecules that have demonstrated utility in various orthopaedic applications. These include addressing critical bone loss in orthopaedic trauma, augmenting bony fixation during ligament reconstruction, and promoting bony fusion during spine surgery [[8], [9], [10], [11], [12], [13], [14], [15]]. A comprehensive analysis of all 14 subtypes of human BMPs revealed that BMP-2 possesses significant osteogenic activity due to its ability to induce differentiation of mesenchymal stem cells into osteoblasts and stimulate osteogenesis in mature osteoblasts [16]. However, within the arthroplasty literature, data have been limited to canine model studies, case reports, and small case series with marked study and patient variability [7,[17], [18], [19], [20], [21], [22], [23]].

While BMPs have shown promise in enhancing bone growth during spinal fusion surgery, the efficacy and long-term outcomes of BMP-2 augmentation in patients with large acetabular defects are unknown. The purpose of this study was to evaluate the mid-term clinical and radiographic outcomes associated with BMP-2 augmentation of acetabular bone loss in the setting of revision THA. We hypothesized that BMP-2 augmentation would lead to bony consolidation and improved host bone stock in patients undergoing revision THA with large acetabular defects secondary to its osteogenic and osteoinductive properties, with similar complication and reoperation rates compared to alternative contemporary strategies for managing acetabular bone loss.

Material and methods

A retrospective review was conducted for all patients who underwent BMP-2 Infuse (Medtronic, Dublin, Ireland) augmentation for an acetabular defect during revision THA between 2011 and 2019 at a single tertiary referral center. All procedures were performed by a single surgeon (D.A.O.). Exclusion criteria included patients with a follow-up of <2 years following revision surgery and patients with incomplete clinical or operative records.

During surgery, the acetabular component was removed in standard fashion via a posterior approach to the hip using curved osteotomes, with care taken to preserve host bone stock. After component removal, the acetabulum was meticulously debrided of all fibrous tissue and sclerotic bone until viable bleeding host bone was encountered. The bony defect was then provisionally sized with empty reamer baskets and augment trials when appropriate. Residual bone loss that was not reconstituted by highly porous metal augments or the acetabular component was then addressed utilizing allograft and BMP-2 in a layered “parfait-technique” (Fig. 1). Crushed cancellous allogenic bone chips were packed into the acetabular defect against a bed of bleeding host bone, followed by a layer of BMP-2 Infuse collagen sponge. This layering process was repeated until the defect was filled. The final layer of impacted allograft chips was reverse reamed with a reamer size 2 millimeters smaller than the intended cup size. Acetabular augments, the acetabular components, and other adjunct fixation (eg, cages) were then placed in standard fashion. Limited irrigation was performed after graft placement until seating of the final polyethylene liner.

Figure 1.

Figure 1

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Schematic of the layered “parfait-technique” for addressing acetabular bone loss with a combination of allograft bone chips, bone morphogenetic protein (BMP), and demineralized bone matrix.

The electronic medical record was reviewed for patient demographics, comorbidities, prior operations, surgical details, and postoperative course. Preoperative and postoperative imaging was reviewed by a single fellowship-trained orthopaedic arthroplasty surgeon (N.D.H.), and acetabular defects were classified using the Paprosky classification [24]. Heterotopic bone was quantified according to the Brooker classification and implant fixation was assessed at the most recent follow-up [25,26] (Fig. 2). Bony consolidation was assessed qualitatively with serial biplanar radiographs (Fig. 3).

Figure 2.

Figure 2

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Example case of a patient who underwent BMP-2 Infuse augmentation for an acetabular defect during revision THA. (a) Preoperative anteroposterior (AP) hip prior to BMP revision demonstrating a Paprosky 3B acetabular defect. (b) AP hip at 3 months postoperative for the left hip. (c) Postoperative AP hip at 5-year follow-up for BMP revision of the left hip, demonstrating Brooker 3 heterotopic ossification.

Figure 3.

Figure 3

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Example case of a patient with a failed right total hip arthroplasty with pelvic discontinuity who underwent BMP-2 Infuse augmentation during revision THA. (a) Preoperative anteroposterior (AP) hip prior to BMP revision demonstrating a Paprosky 3B acetabular defect. (b) AP hip at 3 months postoperative for the right hip. (c) Postoperative AP hip at 9-year follow-up for BMP revision right total hip arthroplasty, demonstrating radiographic evidence of >50% bony consolidation. (d) Preoperative frog lateral hip prior to BMP revision demonstrating a Paprosky 3B acetabular defect. (e) Frog lateral right hip at 3 months postoperative. (f) Postoperative frog lateral hip at 9-year follow-up for BMP revision right total hip arthroplasty, demonstrating radiographic evidence of >50% bony consolidation.

Each patient was contacted individually by phone and asked to complete a questionnaire to assess clinical outcomes. Of the 15 patients who met the inclusion criteria, 1 patient was deceased. Oxford Hip Scores were collected for 10 patients (13 hips) [27]. Postoperative complications including periprosthetic dislocation, periprosthetic infection, nerve palsy, and the need for subsequent reoperation were recorded for each patient.

Statistics and data analysis were performed using SPSS version 27 (IBM, Armonk, New York, USA) and Prism 8 (Graphpad, San Diego, CA, USA). Patient demographics, operative variables, and postoperative outcomes are presented as means or percentages with associated standard deviations or ranges where appropriate. Six- and 10-year survivorship was determined using the Kaplan-Meier method with all-cause reoperation as the endpoint with acetabular revision as the secondary endpoint.

This study was conducted in accordance with institutional review board approval (HS-22-00553).

Results

Patient demographics

Overall, 15 patients (18 hips) underwent BMP-2 augmentation for large acetabular defects during revision THA. The average age of the cohort was 64.6 ± 16.1 years (range: 24.0-87.0 years), the average BMI was 24.0 ± 3.1 kg/m2 (range: 19.9-30.0 kg/m2), and the mean follow-up was 76.3 ± 43.1 months (range: 24.0-140.0). Patients underwent an average of 1.9 ± 1.3 prior surgeries (range: 1-5 surgeries) on the affected hip before revision (Table 1). There were 10 hips (55.6%) with Paprosky 3B defects, 3 (16.7%) with 3A defects, 3 (16.7%) with 2C defects, and 2 (11.1%) with a 2B defect. There were 11 hips (61.1%) with a pelvic discontinuity before undergoing revision THA with BMP-2 augmentation (Table 2).

Table 1.

Mean descriptive analysis.

Mean descriptives
Minimum Maximum Average Standard deviation
Age (y) 24.0 87.0 64.6 16.1
BMI (kg/m2) 19.9 30.0 24.0 3.1
Follow-up (mo) 24.0 139.3 76.3 43.1
Number of prior surgeries 1.0 5.0 1.9 1.3
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Table 2.

Frequency descriptive analysis.

Frequency descriptives N %
Laterality
 Left 9 50.0
 Right 9 50.0
Sex
 Male 6 40.0
 Female 9 60.0
Paprosky classification
 3B 10 55.6
 3A 3 16.7
 2C 3 16.7
 2B 2 11.1
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Operative and hospital stay details

Based on the size of the bony defect, 5 patients (27.8%) received 5.6 cc of BMP-2 and 13 patients (72.2%) received 8.0cc of BMP-2. The mean inpatient length of stay following these operations was 4.9 ± 1.2 days (range: 3.0-7.0 days), with an average time to weight-bearing as tolerated of 18.1 ± 10.8 weeks (range: 7.6-42.0 weeks) (Table 3).

Table 3.

Operative and hospital details.

Operative and hospital details
Minimum Maximum Average Standard deviation
Amount of BMP (cc) 5.6 8.0 7.2 1.2
Time until WBAT (wk) 7.6 42.1 18.1 10.8
Hospital stay (d) 3.0 7.0 4.9 1.2
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Postoperative outcomes

All patients were non-ambulatory prior to undergoing revision THA with BMP-2 augmentation. In total, postoperative Oxford Hip scores were obtained for 13 hips (72.2%). The average postoperative Oxford Hip Score was 34.8 ± 9.2 (range: 18.0-48.0), assessed at a mean of 83.5 ± 36.5 months (range: 24.2-160.2) from surgery. At the final radiographic follow-up, 15 (83.3%) hips demonstrated radiographic evidence of >50% bone consolidation (Table 4). None of the patients demonstrated evidence of graft resorption.

Table 4.

Postoperative patient outcomes following BMP augmented THA.

Patient outcomes
Minimum Maximum Average Standard deviation (STD)
Time until Oxford Hip Score obtained (mo) 24.2 160.2 83.5 36.5
Oxford Hip Score 18.0 48.0 34.8 9.2
N % Average STD
Bony consolidation (>50%) 15 83.3 - -
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Complications

Three hips (16.7%) developed Brooker 2, and 2 hips (11.1%) developed Brooker 3 heterotopic bone. However, none of these 5 patients had pain or other symptoms associated with their heterotopic bone which led the patient to seek bony resection. In total, there were 5 (27.7%) postoperative complications observed during the follow-up period. Two patients developed postoperative infections (11.1%), one of which was in a patient with a history of prior periprosthetic joint infection of their operative hip. One hip (5.5%) was re-revised due to a periprosthetic joint infection at 84.0 months, while the second patient was treated with lifelong antibiotic suppression with oral doxycycline. Additionally, there were 2 dislocations (11.1%) and one sciatic nerve palsy (5.5%). Two (11.1%) hips underwent reoperation due to periprosthetic dislocation at 61.0 and 82.0 months. The hip that was revised at 61 months also showed signs of acetabular loosening, which was the primary indication for revision THA. The hip that was revised at 82 months was managed with conversion to a constrained articulation and retention of the prior acetabular component, which was found to be stable intraoperatively (Table 5).

Table 5.

Patient complications following BMP augmented THA.

Complications N %
Brooker classification
 Brooker 0 5 27.8
 Brooker 1 8 44.4
 Brooker 2 3 16.7
 Brooker 3 2 11.1
Reoperationa 2 11.1
 Dislocation 2 11.1
 Acetabular loosening 1 5.6
Revision 1 5.6
 Infection 1 5.6
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a

1 patient had recurrent dislocations and acetabular loosening warranting reoperation.e

Using all-cause reoperation as the primary endpoint, the estimated 6-year survival was 90.0% (95% confidence interval [95% CI]: 47.3%-98.5%) and 10-year survival was 70.0% (95% CI: 32.9%-89.2%) (Fig. 4). Using acetabular component revision as the primary endpoint, the estimated 6-year survival was 90.0% (95% CI: 47.3%-98.5%) and 10-year survival was 90.0% (95% CI: 47.3%-98.5%) (Fig. 5).

Figure 4.

Figure 4

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Kaplan-Meier analysis of BMP augmented THA with all-cause reoperation as the endpoint.

Figure 5.

Figure 5

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Kaplan-Meier analysis of BMP augmented THA with acetabular loosening as the endpoint.

Discussion

The present study is the first to describe the mid-term clinical and radiographic outcomes following the use of recombinant BMP to address large acetabular defects during revision THA. At a mean follow-up of 76.3 months, we found a modest rate of postoperative complications (27.7%) and reoperations (11.1%) following these complex revision procedures. Additionally, we found an estimated survivorship with respect to all-cause reoperation of 90% and 70% at 5 and 10 years, respectively. Additionally, despite all patients being nonambulatory prior to undergoing revision THA with BMP-2 augmentation, the majority of patients in the present study demonstrated Oxford Hip Scores at final follow-up with scores corresponding to a native joint with mild to no osteoarthritis, demonstrating results comparable to other studies for patients undergoing revision THA with severe acetabular defects [[28], [29], [30], [31], [32], [33], [34], [35]]. While there are many other reconstructive strategies for addressing large acetabular defects that have demonstrated significant efficacy [[36], [37], [38]], the use of BMP augmentation during revision THA is a novel technique that can be employed reliably when there are concerns for poor bone stock or limited biological capacity for healing.

While BMP augmentation has many described uses within orthopaedic surgery, including to address large defects in long bones [8,39,40] and inducing fusion in spinal surgery [[41], [42], [43]], there remain additional opportunities for the use of BMP in patients with overall poor bone scaffolding. These include the use of regional gene therapy, as well as the utilization of three dimensional (3D)-printed scaffolds for critical bone defects [44,45]. Although these techniques have not yet been proven to be effective in human models, the combination of BMP augmentation alongside 3D-printed scaffolds such as custom triflange implants in revision THA may further decrease reoperation rates in this challenging patient population.

Previous studies have demonstrated that recombinant human BMP-2 (rhBMP-2) results in equivalent or increased rates of fusion following posterior or interbody lumbar spine fusion [43,[46], [47], [48]]. Unfortunately, prior studies have indicated that the efficacy of rhBMP-2 may be limited by its rapid release from the collagen sponge carrier [49]. Therefore, large amounts of rhBMP-2 are required to induce clinically significant bone formation. This has been associated with complications such as ectopic bone formation, poor wound healing, and soft tissue swelling [50,51]. In the present study, there were no identified cases of rates of wound infection that required repeat operative intervention, similar to previously published studies [5,36,38,52,53]. While the present study lacked a comparative control group, we did not identify any postoperative wound complications in our cohort and demonstrated similar reoperation and overall complication rates compared to other studies in the literature investigating revision THA patients with severe acetabular defects [5,36,38,52,53]. Importantly, none of the patients in our cohort demonstrated evidence of graft resorption. Although our results must be interpreted in the context of a relatively small sample size and lack of a control group, we believe that the present study demonstrates the potential of BMP augmentation during revision THA to improve the biological capacity to heal and osseointegration for patients with poor bone stock or other biologic limitations.

Autologous bone grafting is currently the gold standard for providing structural support for large acetabular defects, as it provides osteogenic cells, osteoinductive stimulus, and an osteoconductive scaffold over which new bone can form [54,55]. This technique provides additional stability for uncemented components until bony ingrowth occurs [36,37]. Despite these benefits, harvesting of bone grafts predisposes patients to an increased risk for donor-site complications including pain, infection, and nerve injury. Of note, failure rates are directly correlated to the amount of autograft used [56]. Therefore, the use of BMP augmentation to induce bony ingrowth may assist with decreasing the risk of donor site complications. BMP augmentation may allow for enhanced, accelerated component fixation when used in combination with autologous bone graft, or even decrease the need for the use of autologous graft altogether depending on the patient's specific defect and reconstruction technique required. In our study, the average time to weight-bearing as tolerated (WBAT) was 18.1 weeks (median 13.3 weeks), though this result was skewed by 3 patients who took more than 6 months prior to achieving WBAT status. While there was no comparative control group, optimization of postoperative rehabilitation protocols with a focus on decreasing the time until the patient is able to WBAT may ultimately decrease morbidity and caretaker fatigue, while improving overall patient satisfaction.

Cup-cage constructs can be used in patients with Paprosky type IIIA and IIIB defects as well as patients with pelvic discontinuity, as these constructs utilize porous metal acetabular shells that allow for both biological fixation and mechanical stability. Kosashvili et al. reported on a series of 26 revision THA patients with severe acetabular bone loss associated with pelvic discontinuity, with 89% of patients demonstrating no radiographic signs of component loosening at a mean 45-month follow-up [38]. Similarly, in a review of 13 revision THAs with pelvic discontinuity managed with structural bone graft protected with an antiprotrusio cage construct, Berry et al. demonstrated a satisfactory result with a mechanically stable construct in 84.6% of cases (n = 11) [57]. Conversely, in a separate study of 10 pelvic discontinuity cases by Goodman et al., only 50% of patients reconstructed with antiprotrusio cages were stable after a mean follow-up of 41 months without the need for further revision [58]. Of note, 3 patients (16.7%) in our cohort received cup-cage constructs that were augmented with BMP. While this subgroup of patients was not the focus of the present study, we found similar levels of radiographic consolidation in 15 of 18 hips (83.3%). Similarly, Amenbar et al. reported on a series of 67 patients (41 of whom had pelvic discontinuity), demonstrating 5-year and 10-year survivorship of 93% and 85%, respectively [53]. These findings are similar to those of the present cohort, which demonstrated a 6-year and 10-year survivorship of 90.0% and 70.0%, respectively. Future studies comparing patients undergoing revision THA with large acetabular defects with BMP augmentation to those without BMP augmentation are necessary to further validate the efficacy of this intervention.

Finally, custom triflange components can provide rigid fixation individualized to each patient's specific defect. This customization is of particular importance in patients with Paprosky type IIIA defects, type IIIB defects, as well as for patients with pelvic discontinuity. BMP augmentation of these custom triflange components may serve to increase bony ingrowth, which is especially important in these components as they have demonstrated a higher risk of stress shielding and the long-term ingrowth of these rigid constructs is currently unknown [[59], [60], [61]]. Taunton et al. reported on 57 patients with discontinuity and custom triflange components with a mean follow-up of 65 months [52]. Within this cohort, 95% of patients did not undergo revision surgery, and 81% had a healed discontinuity. For these high-risk patients with severe defects, BMP augmentation may assist with their bony ingrowth and improve implant survivorship.

This study is not without limitations. First, this study is retrospective and is therefore subject to selection bias. Second, this study did not have a control group or the ability to compare different reconstruction techniques or acetabular components. Therefore, this analysis did not include a comparison of outcomes between patients with large acetabular defects undergoing revision THA with and without BMP. An additional limitation of the present study is the absence of a cost-effective analysis, as the costs associated with utilization of the BMP-2 are variable and dependent on institutional contracts. Although the broad utilization of BMP augmentation during revision THA may not be cost effective, the costs associated with contemporary alternative strategies for the management of massive acetabular bone loss such as trabecular metal augments, cup-cage constructs, and custom triflange components are significant. Third, the indication for BMP augmentation was determined either preoperatively or intraoperatively by the operating surgeon. Fourth, preoperative patient-reported outcomes measures were not collected, limiting our ability to quantify improvement postoperatively. However, with all patients being nonambulatory prior to undergoing revision THA with BMP augmentation and a mean postoperative Oxford Hip score of 34.8, many patients likely experienced a significant improvement in their overall functional status given the severity of preoperative acetabular bone loss observed. Fifth, all procedures were performed by a single surgeon at a tertiary referral center within the United States, limiting the generalizability of our results. Nevertheless, the present study provides important data for revision arthroplasty surgeons due to the novelty of the surgical technique described, as the present study is the first to our knowledge to report on the mid-term clinical, radiographic, and patient-reported outcomes in a cohort of patients undergoing revision THA with BMP augmentation to address large acetabular defects at a mean follow-up of greater than 6 years.

Conclusions: Here, we report a novel method for addressing large acetabular defects in revision THA with BMP-2 augmentation. Currently, such defects are often addressed with large components such as cup-cage and triflange constructs to compensate for poor bone stock. However, the long-term outcomes of these rigid constructs are currently unknown. Therefore, alternatives to increase bone stock and improve subsequent bone consolidation, component fixation, and bony ingrowth warrant further investigation. We propose a novel method involving the use of BMP-2 augmentation in revision THA, providing osteogenic activity to improve host bone stock and component support in the setting of large acetabular defects. The use of BMP-2 augmentation offers promise in improving overall component longevity, particularly in patients at high risk for subsequent revision procedures. Nevertheless, further research is necessary to elucidate the safety and efficacy of BMP-2 adjuvant therapy in the setting of revision THA.

CRediT authorship contribution statement

Nathanael D. Heckmann: Writing – review & editing, Writing – original draft, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Douglass W. Tucker: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Data curation, Conceptualization. Brian C. Chung: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Thomas Steck: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Data curation, Conceptualization. Brandon S. Gettleman: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis. Daniel A. Oakes: Writing – review & editing, Writing – original draft, Visualization, Supervision, Methodology, Data curation, Conceptualization.

Conflicts of interest

N.D. Heckmann receives royalties from Corin U.S.A; is a paid consultant for Intellijoint Surgical, MicroPort Orthopedics, Corin U.S.A., and Zimmer; has stock or stock options in Intellijoint Surgical; and is a board/committee member of AAOS, AJRR, AAHKS, Knee Society, and Hip Society. D.A. Oakes is a paid consultant for LimaCorporate; all other authors declare no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2026.101998.

Appendix A. Supplementary data

Conflict of Interest Statement for Chung
mmc1.docx (51.9KB, docx)
Conflict of Interest Statement for Oakes
mmc2.docx (24.6KB, docx)
Conflict of Interest Statement for Gettleman
mmc3.docx (29.1KB, docx)
Conflict of Interest Statement for Tucker
mmc4.pdf (272.8KB, pdf)
Conflict of Interest Statement for Heckmann
mmc5.docx (27.6KB, docx)
Conflict of Interest Statement for Steck
mmc6.pdf (257.9KB, pdf)

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Supplementary Materials

Conflict of Interest Statement for Chung
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Conflict of Interest Statement for Oakes
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Conflict of Interest Statement for Gettleman
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Conflict of Interest Statement for Tucker
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Conflict of Interest Statement for Heckmann
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Conflict of Interest Statement for Steck
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