The management of femoral bone loss is challenging during revision hip arthroplasty. In patients with Paprosky grade IIIB and IV defects, obtaining fixation and rotational stability using traditional surgical constructs is difficult. The use of a custom-made internal proximal femoral replacement prostheses has been proposed as a solution in patients, with severe femoral bone stock loss. However, there is a paucity in the literature on their use and long-term outcomes. We report on the clinical and radiological results of our cohort. We retrospectively reviewed all patients who underwent internal proximal femoral replacement for revision hip arthroplasty between April 1996 and April 2019. All patients had at least 2 years of follow-up time. 160 patients underwent limb salvage at our institution using internal proximal femoral replacement. The mean follow-up was 79.7 months (S.D 41.3). Indications for revision included periprosthetic fractures, aseptic loosening, and deep infection. The mean Oxford hip score increased from 13.8 (0–22) to 31.5 (18–43) (paired t-test, p < 0.001). Kaplan-Meier prosthesis survival analysis with revision as the endpoint was 87% at 5 years. None required revision of the femoral stem. There were four dislocations (5%) and there was failure to eradicate the deep infection in four. This technique allows instant distal fixation, allowing for early mobilisation. Long-term clinical and radiological outcomes are encouraging and the complication rates are acceptable for this patient group

Aims. Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications. Methods. We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship. Results. Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048). Conclusion. DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates. Cite this article: Bone Jt Open 2022;3(3):173–181

Introduction. Modular tapered implants have been suggested as the optimal treatment in patients with severe femoral bone loss undergoing revision total hip arthroplasty (THA). The purpose of this study is to describe minimum 2 year follow up of patients treated with modular tapered prostheses for Paprosky type IIIB and IV femoral bone loss in revision THA. Methods. 44 Consecutive patients with Paprosky type IIIB (23) or IV (21) femurs undergoing revision total hip arthroplasty to cementless modular tapered prostheses were studied. Harris Hip Scores were obtained prior to revision on all patients except those presenting with acute implant failure or periprosthetic fracture. 10 Patients were deceased within 2 years of surgery; the remaining 18 were followed for an average of 42 months (range 25-69 months). Clinical outcomes were measured using the Harris Hip Score, and radiographs were assessed for signs of stem loosening or subsidence >4mm. Results. No further revisions were required in patients who were deceased within 2 years. In those with >2 year follow up, there were 4 additional revisions: 1 for infection, 2 for instability, and 1 for periprosthetic fracture. In patients with surviving implants, the mean Harris Hip Score improved from 33 (range 11-49) pre-operatively to 77 (range 55-100), and there was no radiographic evidence of loosening or subsidence at time of final follow up. Conclusions. These outcomes support the use of modular tapered implants as a safe and effective option for revision arthroplasty of type IIIB and IV femurs

Background. Revision THA presents significant challenges for the surgeon when the proximal femur is deficient or mechanically unreliable. The aim of this study is to assess the clinical and functional results of the use of tumor enndoprosthesis to reconstruct the proximal femur when there is massive bone loss. Patients and Methods. A prospective study was conducted involving 10 cases. The follow up of the cases ranged from 12 months to 30 months with a mean period of an average of 23months. The indications for revision surgery were aseptic loosening in 9 cases and septic loosening in one case Harris hip score was used for pre and postoperative clinical evaluation of the patients. Results. At the latest follow up the Harris Hip scores improved from a preoperative average of 16 (range, 3-47), to a postoperative average of 75.6 (range, 66-94). The complications that we encountered in the study included one case of superficial wound infection, another case developed sciatic nerve palsy postoperatively. No other complications were reported. Conclusion. Revision hip replacement in proximally compromised femurs presents a significant surgical challenge. When there is massive proximal femoral bone loss proximal fitting revision stems do not achieve adequate fixation hence the use of tumor prosthesis is indicated

Introduction and Aims: This study evaluates the effect of risedronate (Actonel) on proximal femoral bone loss after total hip arthroplasty (THA). Studies have shown that alendronate (Fosamax) reduces periprosthetic bone loss after primary THA. We hypothesise that patients who take risedronate, post-THA, will have less bone loss than patients not taking risedronate. Method: All patients in this prospective study undergo uncemented THA and follow the same post-operative protocol. Patients in the study group take five mg of risedronate daily, beginning five to seven days pre-operatively, and continuing for 24 months after surgery. Patients randomised to the control group do not receive risedronate. Dual energy x-ray absorptiometry (DEXA) scans of the operated proximal femur are performed on all patients pre-operatively, three to seven days post-operatively, and then six weeks, six months, one year and two years post-operatively. Longitudinal changes in bone mineral density (BMD) are compared within and between the two groups. Results: Analysis of data for female subjects showed the percent change in BMD (g/cm. 2. ) for the control group at six months was −9.71% and for the study group −4.55%. Longitudinal changes in BMD between groups were examined using repeated measures analysis within each gender and were found to be significantly different between groups of females (p=.05). A similar trend was observed among the male subjects. One and two-year prospective data will be presented at the meeting. Conclusion: Bone loss after THA can increase the rate of failure of THA and cause revision surgery to be more complex and have compromised outcomes. Short-term data reveal significantly decreased bone loss after uncemented THA among patients taking risedronate

Aseptic loosening and osteolysis may cause significant periprosthetic femoral bone destruction, often necessitating bypass of the deficient proximal femur to obtain stable fixation in the distal diaphysis. The purpose of the present study was to report our results of femoral component revision using a distally locked revision femoral stem for the treatment of the severe proximal femoral bone loss. We evaluated 21 hips in 20 patients who underwent revision hip arthroplasty associated with Paprosky grade-IIIB or IV femoral deficiencies. Three hips were associated with a Vancouver type-B3 periprosthetic femoral fracture. The mean age at the time of revision was 70.8 (51–82) years old with 5 men and 15 women. The mean duration of follow-up was 5.1 years. The femoral implant used for the revision was the Cannulok Revision Prosthesis in 16 hips and the Huckstep interlocking stem in five. Gaps between the stem and the host bone were filled and impacted with bone chips and morselized bone prior to stem insertion. One femoral implants were resected because of deep infection Subsidence was absent and stable fixation was achieved in all patients. Non-progressive radiolucent lines in zones 1 and 7 according to Gruen’s classification were detected in five cases. Cortical hypertrophy around the interlocking screws were seen in ten cases. No disadvantages or complications of the interlocking screws were observed. All the fractures have united within three to five months. Intraoperative fractures in the diaphyseal area occurred in five hips in which trochanteric osteotomy was used. A diaphyseal fixation of the femoral stem with distal interlocking screws appears to provide primary axial and rotational stability of the prosthesis and early mobilization. This implant may provide a satisfactory alternative for the management of revision hip surgery in the presence of a loose femoral component with massive bone loss. Longer-term follow-up data from this study will be needed to confirm these outcomes

Aseptic loosening and osteolysis may cause significant periprosthetic femoral bone destruction, often necessitating bypass of the deficient proximal femur to obtain stable fixation in the distal diaphysis. The purpose of the present study was to report our results of femoral component revision using a distally locked revision femoral stem for the treatment of the severe proximal femoral bone loss. We evaluated 21 hips in 20 patients who underwent revision hip arthroplasty associated with Paprosky grade-IIIB or IV femoral deficiencies. Three hips were associated with a Vancouver type-B3 periprosthetic femoral fracture. The mean age at the time of revision was 70.8 (51–82) years old with 5 men and 15 women. The mean duration of follow-up was 5.1 years. The femoral implant used for the revision was the Cannulok Revision Prosthesis in 16 hips and the Huckstep interlocking stem in five. Gaps between the stem and the host bone were filled and impacted with bone chips and morselized bone prior to stem insertion. One femoral implants were resected because of deep infection Subsidence was absent and stable fixation was achieved in all patients. Non-progressive radiolucent lines in zones 1 and 7 according to Gruen’s classification were detected in five cases. Cortical hypertrophy around the interlocking screws were seen in ten cases. No disadvantages or complications of the interlocking screws were observed. All the fractures have united within three to five months. Intraoperative fractures in the diaphyseal area occurred in five hips in which trochanteric osteotomy was used. A diaphyseal fixation of the femoral stem with distal interlocking screws appears to provide primary axial and rotational stability of the prosthesis and early mobilization. This implant may provide a satisfactory alternative for the management of revision hip surgery in the presence of a loose femoral component with massive bone loss. Longer-term follow-up data from this study will be needed to confirm these outcomes

In osteoporosis treatment, current interventions, including pharmaceutical treatments and exercise protocols, suffer from challenges of guaranteed efficacy for patients and poor patient compliance. Moreover, bone loss continues to be a complicating factor for conditions such as spinal cord injury, prescribed bed-rest, and space flight. A low-cost treatment modality could improve patient compliance. Electrical stimulation has been shown to improve bone mass in animal models of disuse, but there have been no studies of the effects of electrical stimulation on bone in the context of bone loss under hormone deficiency such as in post-menopausal osteoporosis. The purpose of this study was to explore the effects of electrical stimulation on changes in bone mass in the ovariectomized rat model of post-menopausal osteoporosis.

All animal protocols were approved by the institutional Animal Research Ethics Board. We developed a custom electrical stimulation device capable of delivering a constant current, 15 Hz sinusoidal signal. We used 30 female Sprague Dawley rats (12–13 weeks old). Half (n=15) were ovariectomized (OVX), and half (n=15) underwent sham OVX surgery (SHAM). Three of each OVX and SHAM animals were sacrificed at baseline. The remaining 24 rats were separated into four equal groups (n=6 per group): OVX electrical stimulation (OVX-stim), OVX no stimulation (OVX-no stim), SHAM electrical stimulation (SHAM-stim), and SHAM no stimulation (SHAM-no stim). While anaesthetized, stimulation groups received transdermal electrical stimulation to the right knee through bilateral skin-mounted electrodes (10 × 10 mm) with electrode gel. The left knee served as a non-stimulated contralateral control. The no-stimulation groups had electrodes placed on the right knee, but not connected. Rats underwent the stim/no-stim procedure for one hour per day for six weeks. Rats were sacrificed (CO2) after six weeks. Femurs and tibias were scanned by microCT focussed on the proximal tibia and distal femur. MicroCT data were analyzed for trabecular bone measures of bone volume fraction (BV/TV), thickness (Tb.Th), and anisotropy, and cortical bone cross-sectional area and second moment of area.

Femurs and tibias from OVX rats had significantly less trabecular bone than SHAM (femur BV/TV = −74.1%, tibia BV/TV = −77.6%). In the distal femur of OVX-stim rats, BV/TV was significantly greater in the stimulated right (11.4%, p < 0 .05) than the non-stimulated contralateral (left). BV/TV in the OVX-stim right femur also tended to be greater than that in the OVX-no-stim right femur, but the difference was not significant (17.7%, p=0.22). There were no differences between stim and no-stim groups for tibial trabecular measures, or cortical bone measures in either the femur or the tibia.

This study presents novel findings that electrical stimulation can partially mitigate bone loss in the OVX rat femur, a model of human post-menopausal bone loss. Further work is needed to explore why there was a differential response of the tibial and femoral bone, and to better understand how bone cells respond to electrical stimulation. The long-term goal of this work is to determine if electrical stimulation could be used as a complementary modality for preventing post-menopausal bone loss.

Introduction: Cementless revision hip arthroplasties require a stable initial fixation that does not compromise a subsequent bone reconstruction. In case of severe femoral bone loss, stems usually requires distal fixation that may induce stress shielding and finally reduce the spontaneous bone reconstruction. We introduced the use of distally locked revision stems in 1993 hoping strong fixation and bone reconstruction. The goal of the current study was to assess if these components fulfill these two objectives. Materials and Methods: 101 cementless femoral revision stems with distal locking by screws (Ultime™ Wright-Cremascoli) were inserted from 1993 to 2001. These stems were smooth distally and porous coated with or without HA 1/3 proximally. The indication to use these components was severe bone loss (Paprosky grade IIC and III in 51%) when press fit distal fixation could not be obtained. The use of bone graft was limited to segmental defects or to treat trochanteric non-union. An extended trochanteric osteotomy was performed in 89%. The revision was performed because of aseptic loosening in 43,4%, periprosthetic fracture in 24,2% and infected loosening in 25,2%. The results were assessed after a mean follow-up of 6 years (5–12). Results: 13 patients deceased and 2 were lost for follow-up. All the extended trochanteric osteotomies healed. Merle d’Aubigné hip score increased from 8.3 to 13.4, but thigh pain was observed in 44%. Bone reconstruction was significant according to Hoffman index at 3 levels of assessment. The 5-year survivorship was 87% considering aseptic revision for any reason. Seventeen repeated femoral procedures were performed: 9 related to thigh pain (because there was no proximal osteointegration) that were revised for short primary stems, 8 because of stem fractures (all occurred at the level of the proximal hole with the same stem size because there was no proximal fixation as long as the stems were smooth or without HA-coating. Discussion: This serie has the longest follow-up using locked revision stems. Despite severe pre-operative bone loss, primary fixation and significant bone reconstruction were obtained for all the cases without extensive bone grafting. The major weakness, thigh pain and stem break, were related to unadequate femoral coating for these cementless stems that did not achieved osteointegration. Conversly, the reoperations were simple, allowing the use of short primary designs as bone reconstruction was achieved in all cases without extensive bone grafting. These locked stems allow a strong primary distal fixation that does not compromise bone regeneration. An improvement of femoral coating (extension to 2/3 and use of hydroxyapatite) may reduce the rate of thigh pain and reoperation

Revision of a failed femoral component in the face of extensive bone loss is a major challenge. When the bone loss extends down below the isthmus it may be difficult to obtain longitudinal stability with a tapered or fully porous coated prosthesis. If subsidence occurs then recurrent dislocation can be an insoluble problem. This study reviews the use of a distally interlocked femoral component designed to address this challenging situation.

We have reviewed 21 cases in which extensive bone loss made the use of an interlocking prosthesis desirable. The average time from surgery was over four years. All patients completed an Oxford hip score and an EO-50. All radiographs were reviewed.

There were 14 males and seven females with an overall average age of 74 years at the time of surgery. Patients had had an average of two previous THR’s, and up to nine previous hip operations. One patient underwent re-revision because of subsidence related to screw cut out. There was one dislocation. Patient satisfaction was high with low Oxford hip scores compared with other revision prostheses, and good EO – 50 ratings.

This type of prosthesis offers a very satisfactory solution to difficult revision situations when bone loss makes the use of regular prostheses difficult. The prosthesis used in this study has a low offset and thus dislocation precautions should be emphasised.

Introduction: An increasing number of patients present for revision hip replacement with severe bone loss. The results of cemented revision in these cases are poor. This study was conducted to determine the medium term clinical and radiological outcome of 50 consecutive revision hip replacements performed using custom femoral stems.

Materials and Method: 50 consecutive hips (49 patients) performed by the senior author between 1992 and 1995 were identified. The indications for revision were aseptic loosening in 42 cases, infection in 7 cases (6 of which were revised using a two-stage technique), and dislocation in one case. The stems are manufactured on the basis of standardised measurement films using specially developed software. The design includes proximal macrogrooves with hydroxyapatite coating, an anterior flare, a lateral flare and a collar. The average follow up was 88.4 months (range 12–111 months). All patients were evaluated radiologically and using Harris, Oxford and WOMAC hip scores.

Results: The patients were assessed by an independent observer. All had severe bone loss according to AAOS and Paprosky classifications. 5 patients died due to causes unrelated to their hip replacement, 5 were lost to follow up or did not respond to questionnaires sent. The remaining patients had average preoperative scores of HHS 40.8 (range 8–87), Oxford 43.5 (range18–56) and WOMAC 82.5 (range 40–120) and had improved to HHS 74.4 (range 19–99), Oxford 25.5(range 12–51) and WOMAC 43.8 (range 13–89).

Conclusions: The use of customised revision stems allows the implant to be tailored to the patient’s bone stock and femoral anatomy. This technique avoids the massive inventory of implants and trials needed for highly modular revision systems, but nevertheless leads to excellent bone implant apposition and interface stability. The clinical results are excellent at medium term review, and the survivorship compares very favourably with other revision series.

We evaluated thirty six patients who underwent revision total hip arthroplasty for Vancouver type B periprosthetic femoral fractures. The implant used was a modular proximal femoral replacement stem cemented distally. All the patients were treated at Wrightington Hospital and included 15 males and 21 females. The primary diagnosis was OA in 28, RA in 2, AVN following femoral neck fractures in 3 and hip dysplasia in 3. The average age of patients was 75 years.

The fractures and bone loss were classified according to the Vancouver classification and included 23 B2 and 13 B2 fractures. The mechanism of injury was minor fall in 24 patients, spontaneous in 8 and intraoperative injury in 4.

Using a trans-trochanteric approach the existing prosthesis was removed and a long stem modular femoral stem was inserted bypassing the area of proximal femoral fracture/bone loss. Patients were typically mobilised within the first post-operative week. The patients were clinically and radiologically followed up at regular intervals. Fracture healing with significant improvement in bone stock was noted in 17 patients under 6 months, 13 patients at 12 months and 6 patients at 18 months.

Our series show that use of distally cemented long stem proximal femoral replacement prosthesis allows restoration of proximal bone stock and fracture healing in patients where conventional prostheses cannot be used because of massive bone loss in the proximal femur. This special modular prosthesis bypasses the area of bone loss/periprosthetic fracture, thus avoiding the need for bone allograft or other major reconstructive surgery in elderly patients.

Containment of bone defects is one of the main requisites for using the bone impaction grafting technique. When the proximal femur is absent, circumferential meshes in combination with impacted bone allografts and long stems could be an alternative method. However, the initial stability of this femoral stems has not been evaluated and we were not able to find any series in the literature that includes a group of patients treated with this method.

This study has two purposes: one is to analyze the initial resistance in vitro to axial and rotational forces of a fresh frozen bovine model with a complete loss of the proximal femur reconstructed with a circumferential metal mesh containing impacted bone allografts and a long polished cemented stem. The second is to present the short-term clinical and radiographic evaluation in a group of patients with massive bone loss of the proximal femur that were reconstructed with this method.

Four femurs with an 8 cm proximal bone defect were reconstructed with a circumferential metal mesh, impacted bone grafts and a cemented long stem (group 1). Results were compared with 4 cases presenting an intact proximal femur in which the same stem was implanted (group 2).

Thirteen patients with complete massive proximal femoral bone defects (average 12 cm long) were reconstructed with a circumferential metal mesh, impacted bone allografts and a long cemented stem (average 217 cm long).

Failure mode was characterized by subsidence under axial load in group one at 617 kg and by periprosthetic fracture in control group at 1335 kg. Under rotational load, group 1 femurs failed at the cement interface at an average of 79 kg and the intact femurs presented a fracture at an average of 260 kg.

At 25 months follow-up, 6 patients had to be reoperated. We observed 2 fractures of the metal mesh at 31 and 48 months in cases reconstructed with a Charnley stem that did not by pass the mesh. Three patients presented one dislocation that needed open reduction in 2 cases. Two acute deep infections were treated with debridement, antibiotics and component retention.

This model presented a 50% resistance to axial load and 30% resistance to rotational load compared to an intact femur with the same implant. However, this resistance is by far higher than the physiologic load occurring in a normal femur during gait.

Although the incidence of complications in this patients was high, this was related to the complexity of the cases. Failures of the system were not observed except in the 2 cases presenting technical defects.

This experimental initial stability and early clinical as well as radiographic results encourage the use of circumferential meshes to contain impacted bone allografts combined with long cemented stems in complex revision hip surgery.

This report concerns an operative technique using inexpensive pre-polymerised cement discs as a means of addressing the bone loss from the posterior femoral condyles found during revision total knee replacement. Bone lost from the posterior condyles in the loosened femoral component of a total knee replacement enlarges the flexion gap at revision. Downsizing the femoral component to fit the remaining bone requires a thicker tibial insert and a proximalised new femoral component to maintain balanced gaps in flexion and extension. Patella infera results from this proximalisation of the joint line and interferes with the extensor apparatus. Some knee systems offer customised components with thickened posterior femoral condyles or provide the surgeon with the option of adding metal augments to the femoral component to manage the posterior femoral bone loss. This technique has been applied to ten cases (follow- up ranging from 15 to 46 months) in which inexpensive pre-polymerised cement spacers were incorporated into the posterior femoral cement mass. This allowed the use of primary stemmed components with preservation of the original joint line position. No case has resulted in loosening although two cases have required further revision due to recurrence of their original infection. At revision of these cases the cement discs remained firmly incorporated in the cement mass. We conclude that this technique is reliable, inexpensive and could be applied to other prosthetic varieties

Subsidence remains a concern when utilizing modern tapered fluted titanium (TFT) femoral stems and may lead to leg length discrepancy, impingement, instability and failure to obtain stem osseointegration. This study aims to compare stem subsidence across three modern TFT stems. Our secondary aim was to investigate the influence of bicortical contact or ‘scratch fit’ on subsidence, as well as the role of intraoperative imaging in maximizing this bicortical contact and preventing stem subsidence. A retrospective review of 271 hip arthroplasties utilizing modern TFT stems in a single institution was performed. Three stem designs were included in the analysis: one monoblock TFT stem (n=91) and two modular TFT stems (Modular A [n=90]; Modular B [n=90]). Patient demographics, Paprosky femoral bone loss classification, bi-cortical contact, utilization of intra-operative imaging and stem subsidence (comparison of initial post-operative radiograph to the latest follow up radiograph - minimum three months) were recorded. There was no statistically significant difference in the amount of subsidence between the three stems (Monoblock: 2.33mm, Modular A: 3.43mm, Modular B: 3.02mm; p=0.191). There was no statistical difference in subsidence >5mm between stems (Monoblock: 9.9%, Modular A: 22.2%, Modular B: 16.7%). Subgroup analysis based on femoral bone loss grading showed no difference in subsidence between stems. Increased bicortical contact was strongly associated with reduced subsidence (p=0.004). Intra-operative imaging was used in 46.5% (126/271) of cases; this was not correlated with bicortical contact (p=0.673) or subsidence (p=0.521). Across all groups, only two stems were revised for subsidence (0.7%). All three modern TFT stems were highly successful and associated with low rates of subsidence, regardless of modular or monoblock design. Surgeons should select the stem that they feel is most clinically appropriate

For over a decade, modular titanium fluted tapered (TFT) stems have demonstrated excellent clinical success for femoral revision total hip arthroplasty (THA) surgery. The aim of this study was to report the short-term outcomes of a novel modern monoblock TFT stem used for revision and complex primary THA with a minimum of 2 years follow-up. We identified 126 patients who received a single monoblock TFT stem - 26 patients for complex THA (failed fracture fixation) and 100 patients for revision THA. The reasons for revision THA included 40 for previous prosthetic joint infection (PJI), 42 for aseptic loosening, 9 for trunnionosis, 9 for periprosthetic fractures. The Paprosky grading for femoral bone loss at the time of surgery and the measured subsidence of femoral stems at 3 months follow-up were determined. We evaluated the number and indications for re-operations. The mean time from surgery was 3.9 years (range 2.0 to 6.9 years). A paired t-test analysis showed significant improvement from pre-operative versus post-operative clinical outcome scores (p<0.001) for HHS (38.76 +/- 15.24vs. 83.42 +/- 15.38), WOMAC (45.6 ± 19.0 vs. 69.9 ± 21.3) and SF-12 Physical component (31.7 ± 8.1 vs. 37.8 ± 11.3) and SF-12 Mental component (48.2 ± 12.2 vs. 51.6 ± 12.5). The Paprosky grading for femoral bone loss was Grade 1 (3.9%), Grade 2 (35.7%), Grade 3A (47.6%), Grade 3B (11.1%) and Grade 4 (1.6%) cases. There were 18 re-operations (14.7%) with 13 for PJI (7 treated with implant retention, 6 treated with a two-staged revision), 4 for instability and one for acetabular aseptic loosening. There were no aseptic failures of the stem. This novel modern monoblock TFT stem provided reliable femoral fixation and has increasingly supplanted the use of modular TFT stems for complex primary and revision surgery in our institution

Aims. With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases. Methods. A retrospective review of 25 patients who underwent PFA for non-neoplastic indications between January 2009 and December 2015 was undertaken. Their clinical and radiological outcome, complication rates, and survival were recorded. All patients had the Stanmore Implant – Modular Endo-prosthetic Tumour System (METS). Results. At mean follow-up of 5.9 years, there were no periprosthetic fractures. Clearance of infection was achieved in 63.6% of cases. One hip was re-revised to pseudo arthroplasty for deep infection. Instability was noted in eight of the hips (32%), of which seven needed further surgery. Out of these eight hips with instability, five had preoperative infection. Deep infection was noted in five of the hips (20%), of which four were primarily revised for infection. One patient had aseptic loosening of the femoral component and awaits revision surgery. The Kaplan-Meier survivorship free of revision of any component for any reason was 72% (95% confidence interval (CI) 51.3% to 92.7%), and for revisions of only femoral component for any reason was 96% (95% CI 86.3% to 105.7%) at five years. Conclusion. Dislocation and infection remain the major cause for failure, particularly in patients with pre-existing infection. The use of dual mobility cups, silver-coated implants, and less aggressive postoperative rehabilitation regimens would possibly aid in the reduction of complications. PFA performed in patients with periprosthetic fracture seem to fair better. This study supports the judicious use of PFA in non-oncological revision hip arthroplasties, and that they be performed by experienced revision arthroplasty surgeons. Cite this article: Bone Jt Open 2022;3(3):229–235

Infected non-unions of proximal femoral fractures are difficult to treat. If debridement and revision fixation is unsuccessful, staged revision arthroplasty may be required. Non-viable tissue must be resected, coupled with the introduction of an antibiotic-eluting temporary spacer prior to definitive reconstruction. Definitive tissue microbiological diagnosis and targeted antibiotic therapy are required. In cases of significant proximal femoral bone loss, spacing options are limited. We present a case of a bisphosphonate-induced subtrochanteric fracture that progressed to infected non-union. Despite multiple washouts and two revision fixations, the infection remained active with an unfavourable antibiogram. The patient required staged revision arthroplasty including a proximal femoral resection. To enable better function by maintaining leg length and offset, a custom-made antibiotic-eluting articulating temporary spacer, the Cement-a-TAN, was fabricated. Using a trochanteric entry cephalocondylar nail as a scaffold, bone cement was moulded in order to fashion an anatomical, patient-specific, proximal femoral spacer. Following resolution of the infection, the Cement-a-TAN was removed and a proximal femoral arthroplasty was successfully performed. Cement-a-TAN is an excellent temporary spacing technique in staged proximal femoral replacement for infected non-union of the proximal femur where there has been significant bone loss. It preserves mobility and maintains leg length, offset and periarticular soft-tissue tension

Failure of the femoral component after a primary or revision THA is commonly associated with some degree of femoral bone loss. Depending on the quantity and quality of the remaining host bone, femoral stem revision can be challenging. Twenty patients with severe proximal femoral bone loss due to prosthetic loosening were treated by Wagner cementless self-locking revision stems with a mean follow up of 24 months (range 18–36 months). The indication of revision surgery was aseptic loosening in 16 patients and septic loosening in 4 cases. At the end of the follow up the mean Harris hip score increased from 35 to 86 points. Definite radiographic evidence of bone regeneration in the bony defects was achieved within 3 months in all patients. Implantation of a Wagner cementless selflocking revision stem provided satisfactory results. The Wagner SL Revision prosthesis, firmly and rotationally stable fixed in the medullary cavity of the healthy bone distal from the original prosthetic bed, with its conical longitudinal ribs and cementless anchorage, bridges the defective prosthetic bed and hereby leads to a condition of relative mechanical stability. With time, there is active ossification in the old prosthetic bed, replacing lost bone

Introduction. The optimal management of severe tibial and/or femoral bone loss in a revision total knee arthroplasty (TKA) has not been established. Reconstructive methods include structural or bulk allografts, impaction bone-grafting with or without mesh augmentation, custum prosthetic components, modular metal augmentations of prosthesis and tumor prosthesis. Recently metaphyseal fixation using porous tantalum cones (Zimmer, Warsaw, IN) has been proposed as alternative strategy for severe bone loss. Objectives. The purposes of this study were to determine the clinical and radiographic outcomes in patients who underwent revision knee arthroplasty with tantalum cones with a minimum of 5-year follow-up. Methods. From November 2005 to August 2008 a total of 26 porous tantalum metaphyseal cones were used to reconstruct severe tibial and/or femoral bone loss in 18 patients during revision TKA at a single institution. There were 12 females and 6 males with an average age of 73 years (range 55–84) at the time of revision. The mean clinical and radiographic follow-up was 6.3 years (range, 5–8). The reasons for revision were aseptic loosening (5 cases) and deep infection (13 cases). A Two stage procedure was used in all septic cases. According to the Anderson Orthopaedic Reseach Institute (AORI) bone defects classification all femoral and tibial defects were rated 2B and 3 (3 T2b, 9 T3, 3 F2b and 10 F3). A femoral cone was inserted in 6 patients, a tibial cone was inserted in 5, a double cone in 6 (femoral and tibial), and a triple cone in 1 (1 femoral and 2 tibial). A constrained condylar implant (LCCK, Zimmer, Warsaw) was inserted in 6 patients and a rotating hinge knee implants (RHK, Zimmer, Warsaw, IN) in 12 pateints. All patients were prospectively followed for clinical and radiographic evaluation preoperatively and postoperatively at 1, 3, 6 months, one year and yearly thereafter. Results. Knee Society knee scores improved from a mean of 31.3 points before surgery to 76.7 points at latest followup (p < 0.001). Knee Society function scores improved from a mean of 21.7 points before surgery to 65.4 points at latest followup (p < 0.001). The average flexion contracture was 6° and the average flection was 88°. At the time of the latest follow-up the average flexion contraction was 3° and the average flexion was 105°. No radiolucent lines were seen between the cones and the adjacent tibial and femoral bone at the latest follow-up. There was no evidence of loosening or migration of any implant at the time of the final follow-up. There have been two reoperations for recurrent infection (11%). Conclusions. Our experience demonstrates excellent clinical and radiographic mid-term outcomes and confirms that metaphyseal fixation with porous tantalum cones can be achieved. Long-term follow up and comparative studies are necessary