Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

In using the S-ROM proximally supported, modular stem for hip revision surgery, the hip is classified into three types after previous implant removal. Type I is an intact isthmus, i.e. the area below the subtrochanteric region. This can be handled with a primary stem. Type II is significant damage to the isthmus and requires a long stem. Type III is no proximal femur over a distance of greater than 70 mm. This requires a long stem with a proximal femoral allograft cemented to the sleeve. A long-term cohort prospective study has been carried out on these cases.

There were 99 in Group 1 (primary stems) with a mean age of 63. Five died at less than two years and four were lost to follow-up. No stems have been removed or revised. The Harris Hip Score is 61.1% excellent, 22.2% good, 10% fair and 6.7% poor. In Group 2 (long stems) there were 157 cases with a mean age of 70. Thirteen died at less than two years and four were lost to follow- up. Seven stems required removal or revision, five for sepsis (mainly in previously septic cases) and two for aseptic loosening. The Harris Score was 58.6% excellent, 18.8% good, 8.3% fair and 14.3% poor. In general, the Harris Hip Score reflects more the function of the glutei. Those with a severe limp can never score excellent. In Group 3 there were five cases, none of which have required stem revision or removal.

In long-term cases polyethylene wear has not been a major feature doubtless reflecting decreased activity level. Osteolysis was also not proved to be a significant problem. There are no cases of osteolysis distal to the sleeve.

Purpose: Shaft fractures are not uncommon in elderly subjects who have proximal osteosynthesis material. There are several options for the surgical technique and the fixation method, the choice depending on their aggressiveness.

Material and methods: Between January 1998 and January 2002, retrograde nailing with proximal locking using the fixation screws already in the femur was used for eight women aged 79–99 years (mean 92). The classical ascending nailing procedure was used to insert a Russell-Taylor nail in six patients and a supracondylar Stryker nail in two. The proximal locking was used by apposing the fixation screw, which implied coinciding the locking holes in the nail with the plate screws. This required using only one screw for locking in some cases because of the distances between the holes.

Results: There were no infectious complications. Fracture alignment was correct in all cases. Subjectively, total recovery of motion and independence was achieved. Likewise for pain relief although assessment was difficult. Bone healing was achieved in four months. Secondary varus displacement occurred due to insufficient hold of the proximal locking screw in the medial cortical.

Conclusion: Although not perfect, the retrograde nail locked in the proximal implant provides a satisfactory solution for these often debilitated elderly patients. This option enables a minimally aggressive operation allowing a composite osteosynthesis protecting the entire femur without imposing points of peak stress.

Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population.

The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded.

The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively.

We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture.

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF. This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed. The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups. Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate

The S-ROM stem is distally circular canal filling with thin sharp flutes which engage the endosteal cortex. The rotational stability produced by this is 37 Nm, which exceeds the service loads on the hip of 22 Nm. The distal canal fill prevents varus and valgus displacement. The porous-coated proximal sleeve provides resistance to vertical sink and also excludes the distal stem from the effective joint space.

The primary stem is straight and the long stem is bowed with a 15 degrees anteversion twist proximally. The neck comes in lengths from 30 to 46mm with varying offset. The sleeves come in variable size and geometry.

The stem choice in revision surgery is based on the Scoot Diamond Classification. Type 1 (this is going to be easy) is a primary stem. Type 2 (this is going to be difficult) implies diaphyseal bone loss and will require a long stem. Type 3 (Oh My God), implies more than 70mm of completely missing proximal femur and will require a structural allograft cemented to the sleeve.

A femoral stem using a double threaded cone locking mechanism has been developed down under. Over 400 prostheses have been implanted as primary, revision and replacement prostheses over the last 4 years. Stem insertion is achieved by a gentle screw home mechanism and does not use the “hammer and nail” insertion principle.

Design

The prosthesis has two components:

A cone shaped stem

The stem body externally is a slowly tapering hydroxyapatite coated cone, with a distal pilot and two differing speed external threads. The parallel threads strongly resist derotation of the prosthesis in the bone and impart rotatory stability. The cone shape imparts excellent vertical stability.

Full four-vector adjustability is available at the end of stem preparation:

Vertical height (leg length)

Design Advantages

The locking mechanism gains immediate and longterm vertical and torsional stability in the femur.

Immediate full weight bearing is possible, especially in primary total hip replacements.

The locking mechanism grips equally well in the metaphysis and proximal or distal diaphysis of the femur.

Bulk structural allograft may not be necessary even in the severely deficient proximal femur.

The prosthesis can be used in wide medullary canals.

The early clinical experience with this prosthesis will be presented.

Aims: To compare retrospectively the results of percutaneous þxation, open reduction and þxation and hemi-arthroplasty in displaced proximal humerus fractures. Methods: The initial study group lost 29.50% of patients to follow-up and registered 14.75% deaths. Finally, 98 patients came back for revision and were included in the study with an average follow-up of 41 months. The hemi-arthroplasty group (H) included 34 patients, the percutaneous group (P) 32 and the internal þxation (I) 32. The average age was 55 for P group, 58 for I and 72 for H. Females represented 62% of P, 50% of I and 79% of H. Low energy fractures accounted for 62%, 63% and 78% respectively. Comorbidity in H was present in 50% of cases and associated fractures in 28%. Three and four part fractures following Neer classiþcation were present in 55% P, 55% for I and 100% for H. Results: Average elevation was 130û for P, 106û for I and 80û for H patients. Selecting only three and four part fractures, elevation was 105û in P, 104û in I and 80û in H. Constant score reached in average 81 points in P, 68 in I and 57 in H. For three and four part patients mean Constant was 74, 68 and 57 respectively. VAS with daily activities was 0.6 for P, 2.3 for I and 3.8 for H. Good and average radiological reduction was achieved in 55% of P and I groups and 12.5% osteonecrosis developed in I but none in P. Conclusions: Percutaneous þxation represents a good surgical option comparable to open reduction and þxation. Hemiarthroplasty only achieves modest functional results but patients have quite different epidemiological data.

Purpose: The purpose of this study is to compare two fixation methods for surgical neck proximal humeral fractures with medial calcar comminution:

locking plate fixation alone and

Method: Eight embalmed pairs of cadaveric specimens were utilized in this study. Dual energy X-ray absorptiometry (DXA) scans were initially performed to determine the bone density of the specimens. Surgical neck proximal humerus fractures were simulated in these specimens by creating a 1-centimeter wedge-shaped osteotomy at the level of the surgical neck to simulate medial calcar fracture comminution. Each pair of specimens had one arm randomly repaired with locking plate fixation, and the other arm repaired with locking plate fixation augmented with an intramedullary fibular autograft bone peg. The constructs were tested in bending to determine the failure loads, and initial stiffness using Digital Imaging Correlation (DIC) technology. The moment created by the rotator cuff was replicated by fixating the humeral head, and applying a point load to the distal humerus. A load was applied with a displacement rate of 4 mm/min, and was stopped approximately every 5 lbs to take a picture and record the load. This process was continued until failure of the specimens was obtained.

Results: The intramedullary bone peg autograft increased the failure load of the constructs by 1.57±0.59 times (p = 0.026). Initial stiffness of the construct was also increased 3.13±2.10 times (p = 0.0079) with use of the bone peg.

Conclusion: The stronger and stiffer construct provided by the addition of an intramedullary fibular allograft bone peg to locking plate fixation may help maintain reduction, and reduce the risk of fixation failure in surgical neck proximal humerus fractures with medial comminution.

The goal of this study was to determine which of two techniques for the treatment of peri-prosthetic femoral shaft fractures has the greatest torsional integrity. The study designed was a laboratory study, using 13 matched pairs of embalmed femurs. The femurs were implanted with a cemented total hip prosthesis, with a transverse osteotomy distal to the stem. These fractures were fixed either with a metal plate with three proximal unicortical screws and three distal bicortical screws or with three proximal cables and three distal bicortical screws. The fracture fixation was tested to failure in torsion. The pattern of failure and torsional limits were recorded.

There was no significant difference to failure level between the two constructs. Failure with the proximal unicortical screws was usually catastrophic versus non-catastrophic with proximal cables. The femurs were significantly more likely to fracture in internal rotation.

Treatment with proximal cables has the same load to failure in torsion but significantly less complications than with unicortical screws, in agreement with the literature. The findings of the construct being weaker in internal rotation, appears to be a new finding and an area of possible new research.

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation

Periprosthetic femoral fractures are a challenging problem to manage. In the literature various constructs have been designed and tested, most requiring cables for proximal fixation. The Synthes Locking Attachment Plate (LAP) has been designed to achieve proximal fixation without the use of cables. The aim of this study was to biomechanically evaluate the LAP construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty (THA). Twelve synthetic femora were tested in axial compression, lateral bending and torsion to determine initial stiffness, and stiffness following fixation of a simulated midshaft fracture with and without a bone gap. Two different fracture fixation constructs (six per group) were assessed. Each construct incorporated a broad curved LCP with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bicortical locking screws. Axial, lateral bending and torsional stiffness were assessed using intact specimen values as a baseline. Axial load to failure was also measured. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (simulating a comminuted fracture) (p=0.01). There were no significant differences between the two constructs in any of the other modalities tested. Loading to failure resulted in no significant differences between constructs, in either initial stiffness or peak load. In conclusion the LAP construct enables bi-cortical screw fixation around a prosthesis. Compared to cables, this was stiffer when there was a bone gap and thus should offer improved proximal fixation of Vancouver B1 proximal femoral fractures in cemented THA

Debate surrounds the optimum operative treatment of periprosthetic distal femoral fractures (PDFFs) at the level of well fixed femoral components; lateral locking plate fixation (LLP-ORIF) or distal femoral replacement (DFR). To determine which attributed the least peri-operative morbidity and mortality we performed a retrospective cohort study of 60 consecutive unilateral PDFFs of Su types II (40/60) and III (20/60) in patients ≥60 years; 33 underwent LLP-ORIF and 27 underwent DFR. The primary outcome measure was reoperation. Secondary outcomes included perioperative complications and functional mobility status. Kaplan Meier survival analysis was performed. Cox multivariable regression analysis identified risk factors for reoperation after LLP-ORIF. Mean length of follow-up was 3.8 years (range 1.0–10.4). One-year mortality was 13% (8/60). Reoperation rate was significantly higher following LLP-ORIF: 7/33 vs 0/27, p=0.008. For the endpoint reoperation, five-year survival was better following DFR: 100% compared to 70.8% (51.8 to 89.8 95%CI) (p=0.006). For the endpoint mechanical failure (including radiographic loosening) there was no difference at 5 years: ORIF 74.5% (56.3 to 92.7); DFR 78.2% (52.3 to 100), p=0.182). Reoperation following LLP-ORIF was independently associated with medial comminution: HR 10.7 (1.45 to 79.5, p=0.020). Anatomic reduction was protective against reoperation: HR 0.11(0.013 to 0.96, p=0.046). When inadequately fixed fractures were excluded differences in survival were no longer significant: reoperation (p=0.156); mechanical failure (p=0.453). Reoperation rates are higher following LLP-ORIF of low PDFFs compared to DFR. Where adequate reduction, proximal fixation and augmentation of medial comminution is used there is no difference in survival between LLP-ORIF and DFR

Introduction. The purpose of this study was to evaluate the long term changes in bone mineral density (BMD) following implantation of a low-modulus composite femoral component designed to closely match the stiffness of the proximal femur and minimize stress shielding. Specifically, we asked: 1) How does BMD in the proximal femur change with time and with Gruen zone location; 2) Does BMD in the proximal femur stabilize after two years of implantation?. Methods. We retrospectively reviewed a subgroup of sixteen patients who had preoperative and postoperative DEXA scans in an FDA multi-center prospective trial of this composite stem. Five of these sixteen patients returned for long-term DEXA scans at a mean 22.0 years post-op (range 21.2–22.6 years). BMD in the 7 Gruen zones at final follow-up was compared to immediate post-operative and 2-year follow-up values. Percentage change was calculated and change in BMD was plotted against time from immediate post-operative measurements to each subsequent follow-up. Results. At the time of last follow-up, all stems were well fixed with signs of extensive osteointegration. There were no mechanical implant failures. In Gruen zone 1, patients underwent an overall decrease or little change in BMD, though one patient experienced a notable increase from initial post-op to the latest follow-up. The overall mean (+ SD) annual percent change in BMD in Gruen zone 1 was −0.31% ± 1.09%. When considering the change from the two-year DEXA scan to latest follow-up, two patients demonstrated a decrease in BMD and three patients demonstrated an increase in BMD in Gruen zone 1. All patients demonstrated progressive increase in BMD in Gruen zones 2, 3, 4, 5, and 6 from the initial post-op scan until last follow-up with mean annual percent changes ranging from 0.59% ± 0.50% in Gruen zone 6 to 2.78% ± 2.49% in Gruen zone 3. In our cohort, BMD progressively decreased with time in Gruen zone 7 for all patients with a mean decrease of 1.78% + 0.38% annually from the time of the initial post-op DEXA scan until last follow-up. This was consistent with prior reports with shorter term follow-up. Conclusions. Despite the extensively porous coated design of this stem and concerns about distal fixation and related stress shielding, we observed consistent DEXA scan evidence of increases in BMD in Gruen zones 2–6 and limitation of decreases in BMD exclusively to zone 7 and to a lesser extent zone 1. This is unlike reported results with several other extensively porous coated and proximally porous coated implants designed to obtain proximal fixation. These increases in BMD occurred despite the potential age-related decreases in BMD in the proximal femur that one would anticipate over the mean 22-year follow-up in this study. Clearly, “normal” physiologic loading of bone after THA is determined by a complex interaction between location of ingrowth, location and extent of endosteal contact of the implant in the proximal femur, stiffness of the stem and other implant design and patient related factors. The long-term observations of this study suggest that effective loading of the proximal femur occurs with this low-modulus stem and that this concept may have a role in the future of THA

Despite the best of technique, when faced with a sub-capital or per-trochanteric fracture, inevitably there are failures of proximal fixation. These situations provide unique challenges for the reconstructive surgeon. While there are specific issues related to either sub-capital or per-trochanteric fractures, there also are many commonalities. The causes of failure are nonunion, malunion, failure of fixation or avascular necrosis. In all cases, it is imperative to rule out infection. Since the surgery is now elective, the patient's medical status must be optimised prior to the intervention. Basic surgical principles apply to both fracture types. Use the old incision (if possible) and choose an approach that can be extensile. Of course, the old hardware needs to be removed – this task can be quite frustrating, so good preparation and patience is imperative. Retrieve old operative notes to identify the type of hardware so that any special tools needed are available. Hardware can be intra-osseous in location and excavation of the hardware may require bone osteotomy. These patients are at higher risk of post-operative dislocation, so absolute hip stability must be achieved and confirmed in the OR. Bigger heads and dual mobility options improve stability provided that the components are properly positioned and offset and leg length are restored. Subcapital fractures provide certain specific issues related to stem choice. While, my bias is towards THA because of better chance of complete pain relief, especially in community ambulators, certainly bipolar arthroplasties can be a satisfactory solution. Stem fixation can be either cemented or cementless. For per-trochanteric fractures in younger patients, repeat osteosynthesis should be considered if the femoral head is viable. Bone deformity – trochanteric overhang, shaft offset – may necessitate an osteotomy as part of the reconstruction. While proximal fixation primary type stems are often possible, distal fixation revision stems may be required. Any bone defects related to screw holes should be bypassed by the femoral component

Despite the best of technique when faced with a sub-capital or per-trochanteric fracture, inevitably there are failures of proximal fixation. These situations provide unique challenges for the reconstructive surgeon. While there are specific issues related to either sub-capital or per-trochanteric fractures, there also are many commonalities. The causes of failure are nonunion, malunion, failure of fixation or avascular necrosis. In all cases, it is imperative to rule out infection. Since the surgery is now elective, the patient's medical status must be optimised prior to the intervention. Basic surgical principles apply to both fracture types. Use the old incision (if possible) and choose an approach that can be extensile. Of course, the old hardware needs to be removed – this task can be quite frustrating, so good preparation and patience is imperative. Retrieve old OP notes to identify the type of hardware so that any special tools needed are available. Hardware can be intra-osseous in location and excavation of the hardware may require bone osteotomy. These patients are at higher risk of postoperative dislocation, so absolute hip stability must be achieved and confirmed in the OR. Bigger heads and dual mobility options improve stability provided that the components are properly positioned and offset and leg length are restored. Subcapital fractures provide certain specific issues related to stem choice. While, my bias is towards total hip arthroplasty because of better chance of complete pain relief, especially in community ambulators, certainly bipolar arthroplasties can be a satisfactory solution. Stem fixation can be either cemented or cementless. For per-trochanteric fractures in younger patients, repeat osteosynthesis should be considered if the femoral head is viable. Bone deformity – trochanteric overhang, shaft offset – may necessitate an osteotomy as part of the reconstruction. While proximal fixation primary type stems are often possible, distal fixation revision stems may be required. Any bone defects related to screw holes should be bypassed by the femoral component

INTRODUCTION. Modular knee implants are used to manage large bone defects in revision total knee arthroplasty. These implants are confronted with varying fixation characteristics, changes in load transfer or stiffen the bone. In spite of their current clinical use, the influence of modularity on the biomechanical implant-bone behavior (e.g. implant fixation, flexibility, etc.) still is inadequately investigated. Aim of this study is to analyze, if the modularity of a tibial implant could change the biomechanical implant fixation behavior and the implant-bone flexibility. MATERIAL & METHODS. Nine different stem and sleeve combinations of the clinically used tibial revision system Sigma TC3 (DePuy) were compared, each implanted standardized with n=4 in a total of 36 synthetic tibial bones. Four additional un-implanted bones served as reference. Two different cyclic load situations were applied on the implant: 1. Axial torque of ±7Nm around the longitudinal stem axis to determine the rotational implant stability. 2. Varus-valgus-torque of ±3,5Nm to determine the bending behavior of the stem. A high precision optical 3D measurement system allowed simultaneous measuring of spatial micromotions of implant and bone. Based on these micromotions, relative motions at the implant-bone-interface and implant flexibility could be calculated. RESULTS. Lowest relative micromotions were measured along the tibial base component and the sleeve; however, these motions varied depending on the implant construct used. Maximum relative micromotions were detected at the distal end of the implant for all groups, indicating a more proximal fixation of all modular combinations. Regarding varus-valgus-torque measurement, all groups showed a deviant flexibility behavior compared to the reference group. When referred to the un-implanted bone, implants without stems revealed the highest flexibility, whereas implants with shorter stems had lowest flexibility. DISCUSSION & CONCLUSION. All groups showed a more proximal fixation behavior; moreover, both extent and location of fixation could be influenced by varying the modular combination. Larger stems seemed to support a more distal fixation behavior, whereas the implant fixation moved proximal while extending the sleeve. Here the influence of the sleeve on fixation behavior seemed to be dominant compared to the influence of the stem. Concerning varus-valgus-torque, a strong connection between the used stem and implant-bone flexibility seemed to exist. In addition, the influence of the sleeve on flexibility seemed to be rather low. This study showed, that modularity can influence the biomechanical behavior of tibial implants. If these results can be transferred to other tibial implants still remains to be seen

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

Although the Fitmore Hip Stem has been on the market for almost 15 years, it is still not well documented in randomized controlled trials. This study compares the Fitmore stem with the CementLeSs (CLS) in several different clinical and radiological aspects. The hypothesis is that there will be no difference in outcome between stems.

Femoral components in total hip replacements fail in well-known ways. There is vertical sink, posterior rotation and pivot, either distal or mid-stem. In order to sink, the stem moves into valgus and then slides down the inside of the calcar. It does not cut through the calcar. To prevent sink and pivot, a canal filling stem is required. Canal fill prevents the stem from moving into valgus and, therefore, it will not sink. Two centimeters with complete canal fill is adequate in a primary stem. A long stem will give longer canal fill in a revision. Sharp distal flutes will prevent rotation. The distal end of the stem should be polished. One is looking for a distal stability, not distal fixation. If the isthmus is intact, a primary stem can be used. If the isthmus is damaged, a long stem is necessary. If the calcar is intact, a primary neck is adequate. If the calcar is missing down to the level of the lesser trochanter, a calcar replacement neck is required. If there is more than 70 millimeters of completely missing proximal femur, a structural allograft is required. If the proximal femur is damaged, the ability to place a sleeve or collar to seek the best bone available independently of the stem version is very helpful. No matter how poor the proximal bone quality is, it can be supplemented by cerclage wires. The implant will sink only if the cerclage wires break. The advantage of proximal fixation is that loading the proximal femur speeds recovery. The huge disadvantage of distal fixation is removal of the implant should it become necessary. My long term results for the S-ROM stem used in revision are now out over 20 years. There were 119 primary stems with a minimum follow up of 5 years with no revisions for aseptic loosening. There were 262 long stems used. Nine (3.7%) underwent aseptic loosening. Most of these were due to technical errors due to my inexperience in the learning process of revision surgery. Four were dependent on strut-grafts and should have been treated with structural allografts. There were seven cases with structural allografts. Three were revised. Again, these were largely from problems arising from inexperience. I believe proximal modularity with distal stability allows the vast majority of revision cases to be treated with proximal fixation