Severe Proximal Femoral Bone Loss Research Articles

Megaprostheses for the revision of infected hip arthroplasties with severe bone loss

BackgroundPeriprosthetic hip infections with severe proximal femoral bone loss may require the use of limb salvage techniques, but no agreement exists in literature regarding the most effective treatment. Aim of this study is to analyze the infection eradication rate and implant survival at medium-term follow-up in patients treated with megaprostheses for periprosthetic hip infections with severe bone loss.MethodsTwenty-one consecutive patients were retrospectively reviewed at a mean 64-month follow-up (24–120). Functional and pain scores, microbiological, radiological and intraoperative findings were registered. Kaplan Meier survival analysis and log rank test were used for infection free survival and implant survival analyses.ResultsThe infection eradication rate was 90.5%, with an infection free survival of 95.2% at 2 years (95%CI 70.7–99.3) and 89.6%(95%CI 64.3–97.3) at 5 years. Only two patients required major implant revisions for aseptic implant loosening. The most frequent complication was dislocation (38.1%). The major revision-free survival of implants was 95.2% (95%CI 70.7–99.3) at 2 years and 89.6% (95%CI 64.3–97.3) at 5 years. The overall implant survival was 83.35% (CI95% 50.7–93.94) at 2 and 5 years. Subgroup analyses (cemented versus cementless MPs, coated versus uncoated MPs) revealed no significant differences at log rank test, but its reliability was limited by the small number of patients included.ConclusionsProximal femoral arthroplasty is useful to treat periprosthetic hip infections with severe bone loss, providing good functional results with high infection eradication rates and rare major revisions at medium-term follow-up. No conclusions can be drawn on the role of cement and coatings.

Clinical and radiological outcomes of combined modular prothesis and cortical strut for revision proximal femur in giant cell tumor of bone patients.

Femoral bone deficiency is a challenging problem in revision proximal femoral replacement. The purpose of this study is to evaluate the clinical and radiological outcomes of revision proximal femoral replacement as a salvage treatment for severe bone loss after oncologic proximal replacement surgery in patient with benign giant cell tumor of bone. 16 patients (6 men and 10 women) were included in this retrospective study, with a mean age of 46.6year at the time of revision surgery. All patients underwent revision proximal femoral replacement with the use of modular prosthesis and cortical strut allografts. The modified Harris Hip Score, Short Form 36, and musculoskeletal Tumor Society Score were used for patient evaluation. Regular follow-up was performed to evaluate the recurrence and metastases rate, limb function, and long-term complications of patients. The average follow-up was 46.3months (range, 26-75months), during which there was no local recurrence and metastases of patient. At the latest follow-up, the mean modified Harris Hip Score was 70.6 points, which was significantly improved compared with that of preoperative (p < 0.05). The final follow-up results of Short Form 36, Musculoskeletal Tumor Society Score, and limb-length discrepancy were also significantly improved compared to that of preoperative (p < 0.05). At the latest follow-up, the implanted femoral stems were all stable and all cortical strut allografts were also incorporated to their own bone. Using modular prosthesis and cortical strut allografts in revision, proximal femur replacement is an acceptable procedure for relatively young patient with severe proximal femoral bone loss after oncologic surgery with benign giant cell tumor of bone. More attentions should be paid to reduce the risk of complications in these complex reconstructions.

Impaction Bone Grafting for Severe Femoral Bone Loss: Surgical Technique in Revision Total Hip Arthroplasty.

The specific steps to perform this procedure include (1) preoperative planning; (2) positioning of the patient and surgical approach; (3) cautious removal of the previous components; (4) preparation of the bone graft; (5) implantation of the appropriate IBG revision system, restoring bone loss from distal to proximal and utilizing metal mesh as needed; (6) implantation of the new stem, bypassing the defect; and (7) aftercare with protected weight-bearing in order to avoid subsidence of the stem and periprosthetic fracture. There are several alternatives to the IBG technique in the setting of revision total hip arthroplasty with extensive femoral bone loss. These alternatives include distal cementless fixation (either modular or nonmodular), a megaprosthesis, or an allograft-prosthesis composite. The rationale for use of the IBG technique is restoration of bone stock. Although this issue may be irrelevant in low-demand elderly patients, we believe it is of the utmost importance among young (i.e., <60 years old) and active patients. This technique is versatile enough to be utilized in different scenarios such as periprosthetic fracture, periprosthetic joint infection (2-stage protocols), and aseptic loosening. We have reported favorable clinical and radiographic outcomes for the treatment of both aseptic and septic femoral component loosening. In all cases, we utilized vancomycin-supplemented impacted cancellous allograft without evidence of secondary effects with regard to bone incorporation, nephrotoxicity, or allergic reactions. Although it was initially contraindicated, we further extended the indication for this reconstruction alternative to cases of circumferential proximal bone loss with non-neoplastic bone defects of ≤15 cm, utilizing encompassing metal mesh and a bypassing long stem. Recently, we reported on poorer outcomes following IBG compared with the use of uncemented modular stems for the treatment of type B3 periprosthetic femoral fractures, with a significantly higher rate of infection and implant breakage for the former treatment. Nowadays, we advocate the use of this technique in young, active patients (i.e., <60 years old) with a femoral bone defect Paprosky grade IIIB or IV, in which reconstitution of bone stock is crucial to avoid an eventual implant failure in the long term. This technique requires an experienced team. This procedure should be avoided in the presence of active periprosthetic joint infection.The gluteus maximus tendon should be detached to avoid tensioning the sciatic nerve and to decrease the chance of periprosthetic femoral fracture.Massive bone loss can jeopardize correct implant orientation and restoration of biomechanics. In this scenario, surgeons might consider the intercondylar axis as a guide for femoral version.Try to avoid (if possible) trochanteric or extended trochanteric osteotomy because proximal bone stock is necessary to contain the bone grafts. In some cases, such as those in which the removal of the stem is difficult, especially with certain uncemented stem designs, an extended trochanteric osteotomy must be performed. Whether or not a cemented stem is removed, it is mandatory to remove all remaining cement in the femoral canal.Preoperative templating is a necessity to reconstruct leg length. Accurately determining the length of the mesh is the most important step to avoid shortening or overlengthening of the lower extremity.Approximately 10 cm of circumferential metal mesh should be fixed with 3 to 5 double cerclage metal wires to the remaining bone. The new femoral stem should bypass extend beyond the mesh for approximately 5 cm. If the stem does not bypass the mesh, there is an increased risk of postoperative fracture.In order to decrease the risk of intraoperative femoral fracture, the distal aspect of the femur should be secured with cerclage wires, and the proximal aspect of the femur should also be protected with cerclage wires over the mesh. As in any other complex femoral revision procedure, torsional forces in the supracondylar zone should be avoided, especially during trial or stem reduction maneuvers.Always utilize a bone graft mixed with antibiotic powder.Retrograde cementation must be done with cement that is in a more liquid state than in primary total hip arthroplasty. PO = postoperativePMMA = polymethyl methacrylateIV = intravenousLMWH = low molecular weight heparinDVT/EP = deep vein thrombosis and extended prophylaxis.

Survivorship and clinical outcomes of proximal femoral replacement in non-neoplastic primary and revision total hip arthroplasty: a systematic review

BackgroundSeveral studies have evaluated the survivorship and clinical outcomes of proximal femoral replacement (PFR) in complex primary and revision total hip arthroplasty with severe proximal femoral bone loss; however, there remains no consensus on the overall performance of this implant. We therefore performed a systematic review of the literature in order to examine survivorship and complication rates of PFR usage.MethodsA systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords.ResultsIn all, 18 articles met the inclusion criteria. A total of 578 PFR were implanted. The all-cause reoperation-free survivorship was 76.6%. The overall complication rate was 27.2%. Dislocation was the most common complication observed and the most frequent reason for reoperation with an incidence of 12.8 and 7.6%, respectively. Infection after PFR had an incidence of 7.6% and a reoperation rate of 6.4%. The reoperation rate for aseptic loosening of the implant was 5.9%. Overall, patients had improved outcomes as documented by postoperative hip scores.ConclusionPFR usage have a relatively high complication rate, however, it remains an efficacious treatment option in elderly patients with osteoporotic bone affected by severe proximal femoral bone loss. Modular designs have shown reduced dislocations rate and higher survivorship free from dislocation. However, PFR should only be used as salvage procedure when no other reconstruction options are available.

Proximal femoral reconstruction with modular megaprostheses in non-oncological patients

IntroductionMultiple revision hip arthroplasties and critical trauma might cause severe bone loss that requires proximal femoral replacement (PFR). The aim of this retrospective study was to analyse complication- and revision-free survivals of patients who received modular megaprostheses in an attempt to reconstruct massive non-neoplastic bone defects of the proximal femur.Questions/purposes(1) What were general complication rates and revision-free survivals following PFR? (2) What is the incidence of complication specific survivals? (3) What were risk factors leading to a diminished PFR survival?Materials and methodsTwenty-eight patients with sufficient follow-up after receiving a modular proximal femoral megaprosthesis were identified. The indications for PFR included prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, non-union and critical femoral fracture. Complications were grouped according to the ISOLS-classification of segmental endoprosthetic failure by Henderson et al.ResultsOverall, the complication-free survival was 64.3% at one year, 43.2% at five years and 38.4% at ten years, with 16 patients (57%) suffering at least one complication. Complications were dislocation in eight patients (29%), PJI in 6 patients (21%), periprosthetic fracture in five patients (18%), and aseptic loosening in six patients (21%). Prosthesis stem cementation showed a lower risk for revision in a cox proportional hazard model (95% CI 0.04–0.93, HR 0.2, p = 0.04).ConclusionPFR with modular megaprostheses represents a viable last resort treatment with high complication rates for patients with severe proximal femoral bone loss due to failed arthroplasty or critical fractures. In revision arthroplasty settings, PFR cementation should be advocated in cases of impaired bone quality.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

BackgroundThere is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.MethodsPatients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.ResultsTwenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).ConclusionsOur technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Single 3° tapered fluted femoral stems demonstrate low subsidence at mid-term follow-up in severe bony deficiency.

Tapered femoral stems have become popular in revision total hip arthroplasty (rTHA). Increasing the distal taper angle may mitigate subsidence. This study reports osseointegration of a new 3 degree distal taper revision stem at minimum 4 years post-operatively. Indication for surgery, pre-operative bony deficiency and latest clinical, tribological and radiological follow-up were analysed. Radiographs were assessed by two blinded observers for preoperative femoral bone stock according to Paprosky, postoperative subsidence according to Callaghan and restoration of femoral bone stock over time according to Kolstad. Stem integration was determined using the Rodriguez classification. Twenty-three cases were analyzed at 5.9±1.0 years. All patients presented with Paprosky III defects. All stems met the criteria for osseointegration. Spot welds occurred distal to the proximal modular junction and at the tip. Two femora with severe proximal femoral bone loss recovered bone stock by final follow-up but two demonstrated stress shielding. No intraoperative fractures occurred. One stem subsided early but remained stable and osseointegrated at final follow up. There were no stem failures due to taper corrosion or modular junctional failure. This study reports good osseointegration and low subsidence with a novel fluted, 3-degree tapered femoral stem demonstrates at medium-term follow-up in cases with severe femoral bone deficiency.

Proximal femoral replacement in non-oncologic patients undergoing revision total hip arthroplasty.

Proximal femoral replacements (PFRs) have been recently utilized in complex revision arthroplasties where proximal femoral bone is compromised. The purpose of this study is to evaluate the clinical outcomes, complications, and survivorship of PFRs as a salvage treatment for severe bone loss after non-oncologic revision total hip arthroplasty. This is a retrospective review of all patients who underwent femoral revision surgery using a single design PFR between 2004 and 2013 at our institution. Forty patients (41 hips) were included with a mean age of 64years (29-90). According to Paprosky classification, 15 femurs had type IIIB defect, and 26 had type IV defect. Patients were followed for a mean of five years (2-10). The average length of reconstruction was 150mm (81-261). A Kaplan-Meier analysis was used to determine the survival of the PFR. A total of nine patients (9 PFRs, 22%) were re-operated upon. Three re-operations were for infection, two for dislocation, two for aseptic loosening, and two for periprosthetic fracture. The survivorship at fiveyears was 95.1% for revision of the femoral stem for aseptic loosening. We did not find length of the segmental reconstruction or the indication for revision, to be a risk factor for implant failure or re-revision. Proximal femoral replacements have shown an acceptable survivorship in non-oncologic revision hip arthroplasties for severe proximal femoral bone loss. The frequent use of constrained liners may decrease the risk of dislocation due to the loss of the abductor mechanism encountered in these complex reconstructions.

Revision total hip arthroplasty in patients with extensive proximal femoral bone loss using a fluted tapered modular femoral component.

Revision total hip arthroplasty (THA) is challenging when there is severe loss of bone in the proximal femur. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with severe proximal femoral bone loss treated with a fluted, tapered, modular femoral component. Between January 1998 and December 2004, 92revision THAs were performed in 92 patients using a single fluted, tapered, modular femoral stem design. Pre-operative diagnoses included aseptic loosening, infection and peri-prosthetic fracture. Bone loss was categorised pre-operatively as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic fracture. The mean clinical follow-up was 6.4years (2 to 12). A total of 47 patients had peri-operative complications, 27 of whom required further surgery. However, most of these further operations involved retention of a well-fixed femoral stem, and 88/92 femoral components (97%) remained in situ. Of the four components requiring revision, three were revised for infection and were well fixed at the time of revision; only one (1%) was revised for aseptic loosening. The most common complications were post-operative instability (17 hips, 19%) and intra-operative femoral fracture during insertion of the stem (11 hips, 12%). Diaphyseal stress shielding was noted in 20 hips (22%). There were no fractures of the femoral component. At the final follow-up 78% of patients had minimal or no pain. Revision THA in patients with extensive proximal femoral bone loss using the Link MP fluted, tapered, modular stem led to a high rate of osseointegration of the stem at mid-term follow-up. Cite this article: Bone Joint J 2015; 97-B:312-17.

Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty

Bone loss represents one of the greatest challenges in revision joint surgery. A retrospective review was conducted of both radiographic and clinical outcomes of eleven patients who underwent revision arthroplasty using a long extensively porous coated cylindrical femoral component. All patients' femurs presented with severe proximal femoral bone loss (Paprosky class IIIB and IV). With a mean follow-up of 8years (2 to 14) we report no femoral revisions and one acetabular revision to a constrained cup secondary to instability. All patients were clinically and radiographically stable. We did not observe any issue with proximal stress shielding or component loosening. The article reports that in patients with severe proximal femoral bone loss, extensively porous-coated non-modular stems are a viable option offering stable and predictable outcomes.

Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC’s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156months). The 5 and 10year survival rates were 83.5% (95% CI, 79–100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.

The use of femoral struts and impacted cancellous bone allograft in patients with severe femoral bone loss who undergo revision total hip replacement

We determined the midterm survival, incidence of peri-prosthetic fracture and the enhancement of the width of the femur when combining struts and impacted bone allografts in 24 patients (25 hips) with severe femoral bone loss who underwent revision hip surgery. The pre-operative diagnosis was aseptic loosening in 16 hips, second-stage reconstruction in seven, peri-prosthetic fracture in one and stem fracture in one hip. A total of 14 hips presented with an Endoklinik grade 4 defect and 11 hips a grade 3 defect. The mean pre-operative Merle D'Aubigné and Postel score was 5.5 points (1 to 8). The survivorship was 96% (95% confidence interval 72 to 98) at a mean of 54.5 months (36to 109). The mean functional score was 17.3 points (16 to 18). One patient in which the strut did not completely bypass the femoral defect was further revised using a long cemented stem due to peri-prosthetic fracture at six months post-operatively. The mean subsidence of the stem was 1.6 mm (1 to 3). There was no evidence of osteolysis, resorption or radiolucencies during follow-up in any hip. Femoral width was enhanced by a mean of 41% (19% to 82%). A total of 24 hips had partial or complete bridging of the strut allografts. This combined biological method was associated with a favourable survivorship, a low incidence of peri-prosthetic fracture and enhancement of the width of the femur in revision total hip replacement in patients with severe proximal femoral bone loss.

Staged Custom, Intramedullary Antibiotic Spacers for Severe Segmental Bone Loss in Infected Total Hip Arthroplasty

Introduction. Total hip arthroplasty (THA) infections with severe bone loss pose significant reconstructive challenges. We present our experience with two-stage hip reimplantation using an intramedullary, antibiotic-impregnated nail. Methods. Three patients with infected THA with severe proximal femoral bone loss (Mallory type IIIB or greater) were treated using a custom antibiotic spacer. Clinical outcomes and any complications were recorded. Average followup was 49 months from final reimplantation. Results. Mean age at spacer placement (stage 1) was 53 years. The mean Harris Hip Score at final followup was 80. Two patients had asymptomatic heterotopic ossification, and one patient had a 2 cm leg-length discrepancy. Conclusions. A custom intramedullary nail antibiotic spacer is a reliable option in the staged management of the infected THA with severe proximal femoral bone loss. Benefits of this technique include limb salvage with maintenance of leg length, soft tissue tension, and functional status.

Massive Femoral Bone Loss: Solutions of Last Resort

Despite remarkable advances in the field of revision surgery during the last decades, the reconstruction in patients with massive femoral bone loss is still challenging. Proximal femoral replacement (megaprosthesis) and the use of an allograft-prosthesis composite are 2 valuable options for managing severe proximal femoral bone loss conditions. Although an allograft-prosthesis composite has several advantages, such as a potential restoration of proximal femoral bone mass and providing a site for soft-tissue attachment, a proximal femoral replacement has the benefit of being more readily available, technically less demanding, and more expeditious to implant than allograft-prosthesis composite. The outcome of megaprosthesis in non-neoplastic condition is dependent on several different issues, including patient selection, appropriate preoperative planning and templating, proper surgical techniques, and good postoperative care. We believe that proximal femoral replacement is a viable option for reconstruction of elderly and sedentary patients with severe femoral bone deficiency.

Proximal femoral allograft-prosthesis composites in revision hip replacement

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Use of an ‘internal proximal femoral replacement’ with distal fixation in revision arthroplasty of the hip

We have managed 27 patients (16 women and 11 men) with a mean age of 68.4 years (50 to 84), with failed total hip replacement and severe proximal femoral bone loss by revision using a distal fix/proximal wrap prosthesis. The mean follow-up was for 55.3 months (25 to 126). The mean number of previous operations was 2.2 (1 to 4). The mean Oxford hip score decreased from 46.2 (38 to 60) to 28.5 (17 to 42) (paired t-test, p < 0.001) and the mean Harris Hip score increased from 30.4 (3 to 57.7) to 71.7 (44 to 99.7) (paired t-test, p < 0.001). There were two dislocations, and in three patients we failed to eradicate previous infection. None required revision of the femoral stem. This technique allows instant distal fixation while promoting biological integration and restoration of bone stock. In the short term, the functional outcome is encouraging and the complication rates acceptable in this difficult group of patients.

Proximal Femoral Replacement in Patients with Non-Neoplastic Conditions

Numerous factors may give rise to the loss of femoral bone stock that can be encountered in revision hip arthroplasty. Proximal femoral replacement is an option for the treatment of severe proximal femoral bone loss. In this study, we sought to determine the outcome of reconstructive surgery with the use of a modular proximal femoral replacement (a so-called megaprosthesis) in patients with proximal femoral bone loss due to non-neoplastic conditions. A review of computerized databases from two institutions identified forty-eight patients with a mean age of 73.8 years who had undergone the placement of a modular megaprosthesis with or without bone-grafting. The indication for proximal femoral replacement was a periprosthetic fracture in twenty patients, reimplantation because of a deep infection in thirteen, a failed arthroplasty in thirteen, nonunion of an intertrochanteric fracture in one, and radiation-induced osteonecrosis with a subtrochanteric fracture in one. Three patients died before the minimum two-year follow-up interval had elapsed, and two additional patients were lost to follow-up. The mean duration of follow-up for the remaining study group of forty-three patients was 36.5 months. At the time of follow-up, there was a significant improvement in function as measured with the Harris hip score (p < 0.05). The proximal femoral replacement achieved an excellent or good functional outcome in twenty-two of the forty-three hips. The functional outcome was found to be fair in ten hips and poor in the remaining eleven. Ten patients required a reoperation or revision because of at least one complication. With revision used as the end point, the survivorship of the implant was 87% at one year and 73% at five years. Patients with severely compromised bone stock in whom the use of a conventional prosthesis is precluded because of an inability to achieve adequate fixation may be candidates for proximal femoral replacement. Our short-term results suggest that this is a viable salvage procedure for these patients.

Femoral Revision with the Wagner SL Revision Stem

Purpose : To evaluate the results of revision total hip arthroplasty using a Wagner SL revision stem. Materials and Methods : This study reviewed 56 revisions of the femoral component performed using a Wagner stem in 55 patients between 1992 and 2001. The mean age of the patients at the time of the revision was 50 years. The mean follow up duration was 8.4 years (range, 5 to 12.5 years). The indication for revision was aseptic loosening in fifty-two hips, septic loosening in two and periprosthetic fractures in two. The pre-revisional femoral defects were classified according to the Paprosky classification system. A clinical evaluation and radiological assessment were performed. Results : The mean Harris hip score improved from 47 points preoperatively to 87 points at the latest follow-up. There were 5, 20, 22 and 9 hips of type I, II, IIIA and IIIB according to the Paprosky classification system. Fifty two hips (93%) showed stable stems at the latest follow-up radiographs. The mean vertical subsidence of the stem was 6.2 mm (range, 0 to 21 mm). Severe progressive vertical subsidence in three hips and an infection in one occurred requiring repeat revision. Conclusion : For severe proximal femoral bone loss, the conical femoral revision stem with a fully grit-blasted surface produced satisfactory results with distal press-fit fixation. We can expect a decrease in the rate of mechanical failure rate of the stem by reducing the subsidence derived from the stem design itself.

Cementless Revision Total Hip Arthroplasty without Allograft in Severe Proximal Femoral Defects

This study evaluates the difficult reconstructive challenge of severe proximal femoral bone loss. We present intermediate-term results of 46 hips with extensive proximal femoral bone loss that underwent revision total hip arthroplasty using cementless distal fixation without supplemental allograft. All were evaluated with the Harris hip score at a minimum of 2 years. Radiographs were assessed using the Engh fixation scale. At a mean of 6.4 (range 2-12) years, 43 of the 46 prostheses were functioning well. Two patients required revision for symptomatic loosening, and 1 prosthesis remains radiographically loose with a fair clinical score. Mean Harris hip score was 77 at last follow-up. There were 6 intraoperative femur fractures, 9 dislocations, 10 cases of severe stress shielding, and no infections.

Major Femoral Bone Loss in Revision Total Hip Arthroplasty Treated with Tapered, Porous-Coated Stems

Clinical results of revision total hip arthroplasty using fully porous-coated tapered titanium stems to treat severe proximal femoral bone loss were evaluated in a retrospective review of 39 patients (45 hips). The bone was reinforced with cables in 39 hips, and in 14 hips strut allografts were added. Fixation was successful in 44 hips, and one hip required revision to treat undetected fracture and migration of the stem. All the others had radiographic evidence of bone attachment. Neither bone atrophy nor reconstitution was noted. Three patients (3 hips) had mild thigh pain, but the others had no pain related to the femoral component. Eight hips dislocated; one resolved and seven had recurrent dislocation that was treated with a constrained acetabular component, capsulorrhaphy, or liner reorientation. Ten patients (12 hips) used a walker and 10 patients (12 hips) used a cane at the last postoperative visit. Whereas fixation was successful with this surgical technique, complications related to deficiency of the soft tissue structures were common.