Purpose: Treating fractures of the femur in patients with a total hip arthroplasty is a difficult task. The frequency of these fractures is estimated at 1% to 3%. The purpose of this work was to evaluate the long-term clinical and radiological outcome and to search, by type of fracture, for factors predictive of late complications in order to improve indications. Material and methods: Since 1985, we collected data on 29 patients (17 women and 12 men) mean age 73.3 years who had a fracture of the femur after total hip arthroplasty. By definition, intraoperative fractures were excluded. Two independent operators noted epidemiological, therapeutic and imaging data and classed the fractures using the Vancouver classification. Treatments used were noted and clinical and radiological outcomes at mean follow-up of 24 months (6–140) were analysed. Results: Falls were the cause of the fractures in 31 patients (84%). Six of these patients had a revision prosthesis. Five fractures were in a zone of unprotected weakness. The fractures were trochanteric (n=9), periprosthetic (n=18), or below the stem (n=2). Nine patients were treated by isolated osteosynthesis and eleven by replacing the prosthesis. The Beals score was used to assess outcome taking into account the stability and the quality of the implant fixation as well as fracture realignment. In patients whose fracture was around the stem, outcome was excellent in two, good in one, and poor in four. For fractures of the lesser trochanter (n=4), outcome was excellent in two and good in two. For fractures below the stem (n=2), outcome was good in both. There was one case of deep infection. Discussion: Considering the same types of fractures, orthopaedic treatments produced poor results (6/11), unlike prosthesis replacement (2/11) and osteosynthesis (1/9). The number of loosenings was underestimated, leading to failure of orthopaedic treatment. Conclusion: In the event of fracture of the proximal femur in patients with a total hip arthroplasty, any suspected loosening, particularly of a cemented stem, should lead to prosthesis revision rather than orthopaedic treatment or simple osteosynthesis

Background. Revision total ankle arthroplasty (TAA) can be extremely challenging due to bone loss and deformity. We present the results examining the preliminary indications and short term outcomes for the use of the Salto XT revision prosthesis. Material and methods. We conducted an IRB approved prospective review revision TAA performed in two institutions using the Salto XT. There were 40 patients (24 females and 16 males with an average age of 65 years (45–83), who had undergone previous TAA (Agility 27, Salto 4, STAR 4, Buechal Pappas 1), and 4 patients who underwent staged procedures for infection. The primary indications for the revision were loosening and subsidence (34), malalignment (17), cyst formation (8), infection (4). Results. Severe bone loss of the talus (30) and distal tibia (5) caused by erosion or cysts (8) were treated with cancellous bone graft (33), cement (7), or a combination (12). A press fit of the tibial component was obtained in 25 cases, and of the talus in 17. The talar component was seated directly onto the calcaneus in 4 cases supplemented anteriorly by cancellous bone graft. Patients were followed up for an average of 24.2 months (range 12–36 months). The overall complication rate was 25%. An 85% survivorship of the revision TAA was achieved (4 cases of postoperative infection and 2 cases of implant loosening). At the last follow-up visit, the remaining 34 implants were stable and none had loosened nor failed. Conclusion. Revision ankle replacement with bone loss is a technically challenging procedure with acceptable outcomes for the patient but an 85% survivorship even in the short term. We noted the complexity yet feasibility of performing revision TAA, and determined that the stability of the prosthesis was important. The short term survivorship indicates a likely higher rate of failure in the longer term

Introduction: One of the most important factors affecting the outcome of revision THR of the femoral stem is the variability of femoral endosteal geometry after removal of the in-situ stem. A custom made implant would greatly reduce the inventory of the ‘Off the shelf” (OTS) components. This study presents the medium to long-term results of a cohort of patients with this revision prosthesis. Methods: During the period November 1991 to November 1998, 158 patients were implanted with a computer-assisted design and computer-assisted manufactured (CAD-CAM) revision prostheses (Stanmore Implants Worldwide, Biomedical Engineering Unit, RNOH) by the senior author (SMA). There were 97 males and 61 females. The average age was 63.1 years (34.6 – 85.9). The indications for revision surgery were aseptic loosening (135 cases, 85.4 %), peri-prosthetic fractures (6 cases, 3.8 %), infection (12 cases, 7.6%) and liner wear (3 cases, 1.9%). Results: At 10 years all patients reported relief of pre-operative pain and the average hip flexion was 95o (90 o –110o). Oxford, Harris and WOMAC hip scores in the pre-operative and post-operative period were 41.1, 44.2 and 52.4 respectively and 18.2, 89.3 and 12.3 respectively (p< 0.0001, p< 0.0001, p< 0.0001). There were 6 complications (3.8%) in this series; a periprosthetic fracture of the femoral diaphysis (1), posterior dislocation (2), failure secondary to aseptic loosening of the implant (1) and deep vein thromboses (2). Discussion: These ten year results are encouraging and suggest that there is a role for the use of custom implants in revision THR, particularly where the anatomical variance of the proximal femur makes the use of OTS implants unsuitable

Summary Statement

Proximal femoral bony deficits present a surgical and biomechanical challenge to implant longevity in revision hip arthroplasty. This work finds comparable primary stability when a distally fixing tapered fluted stem was compared with a conical design in cadaveric tests.

Purpose: Bone remodelling and osteolysis around total hip arthroplasty (THA) is a highly debated subject in the medical literature. Such bone behaviour is poorly understood around femoral stems used in revision THA. The main problem is to obtain an objective assessment of bone remodelling and bone reconstruction over time, reconstruction techniques being very variable. Conventional radiology is insufficient, but dual energy x-ray absorptiometry (DEXA) provides a means of following changes in the bone around first intention femoral stems.

Material and methods: We studied bone behaviour around revision femoral stems using the non-cemented “P.P. system”. This type of femoral stem is implanted after trochanter osteotomy to facilitate access and stimulate reconstruction. The series included 31 patients who underwent revision total hip arthroplasty. Follow-up examinations included standard radiographs and DEXA of the operated hips, the contralateral hip and the lumbar spine. Periprosthetic zones defined by Grüen were compared with the same zones in the contra-lateral femur. Mean follow-up was six years.

Results: The standard radiographs did not demonstrate any significant change in periprosthetic cortical thickness. The DEXA demonstrated a significant an average 19.97% reduction in bone density in zones 2, 3, 4, 5 and 6. There was no significant difference in zone 7 and an increase in zone 1 (torchanter osteotomy). These figures are to be compared with the variable thickness observed for first intention pros-theses even shortly after implantation.

Discussion: Our results are the first to our knowledge demonstrating the behaviour of bone around revision femoral stems.

Conclusion: Digastric trochanterotomy appears to be an effective means of stimulating reconstruction of the proximal femur. At equivalent follow-up, the quadrangular section of the revision P.P. stem is more favourable in terms of bone loss compared with first intention stems.

Objectives. Preclinical data showed poly(methyl methacrylate) (PMMA) loaded with microsilver to be effective against a variety of bacteria. The purpose of this study was to assess patient safety of PMMA spacers with microsilver in prosthetic hip infections in a prospective cohort study. Methods. A total of 12 patients with prosthetic hip infections were included for a three-stage revision procedure. All patients received either a gentamicin-PMMA spacer (80 g to 160 g PMMA depending on hip joint dimension) with additional loading of 1% (w/w) of microsilver (0.8 g to 1.6 g per spacer) at surgery 1 followed by a gentamicin-PMMA spacer without microsilver at surgery 2 or vice versa. Implantation of the revision prosthesis was carried out at surgery 3. Results. In total, 11 of the 12 patients completed the study. No argyria or considerable differences in laboratory parameters were detected. Silver blood concentrations were below or around the detection limit of 1 ppb in ten of the 11 patients. A maximum of 5.6 ppb at 48 hours after implantation of the silver spacer, which is below the recommended maximum level of 10 ppb, was found in one patient. No silver was detected in the urine. Drainage fluids showed concentrations between 16.1 ppb and 23.3 ppb at 12 hours after implantation of the silver spacers, and between 16.8 ppb to 25.1 ppb at 48 hours after implantation. Pathohistological assessment of the periprosthetic membrane did not reveal any differences between the two groups. Conclusion. Microsilver-loaded gentamicin-PMMA spacers showed good biocompatibility and the broad antimicrobial activity warrants further clinical research to assess its effectivity in reducing infection rates in prosthetic joint infection. Cite this article: V. Alt, M. Rupp, K. Lemberger, T. Bechert, T. Konradt, P. Steinrücke, R. Schnettler, S. Söder, R. Ascherl. Safety assessment of microsilver-loaded poly(methyl methacrylate) (PMMA) cement spacers in patients with prosthetic hip infections: Results of a prospective cohort study. Bone Joint Res 2019;8:387–396. DOI: 10.1302/2046-3758.88.BJR-2018-0270.R1

Introduction and Objective. Evidence in literature is contradicting regarding outcomes of total knee arthroplasty (TKA) in post-traumatic osteoarthritis (PTOA) and whether they are inferior to TKA in primary osteoarthritis (OA). The aim of this review was to find out if any difference exists in the results of TKA between the two indications. Materials and Methods. The electronic databases MEDLINE, EMBASE, The Cochrane Collaboration, and PubMed were searched and screened in duplicate for relevant studies. The selected studies were further subjected to quality assessment using the modified Coleman method. The primary outcome measure was patient reported outcome, and secondary outcome measures were infection, revision, stiffness, and patella tendon rupture. Results. A total of 18 studies involved 1129 patients with a mean age of 60.6 years (range 45.7–69) and follow up of 6.3 years. The time interval from index injury to TKA was 9.1 years. Knee Society Score (KSS) in PTOA reported in 12/18 studies showed functional improvement from 42.5 to 70 post-TKA exceeding minimally clinically important difference. In TKA for primary OA vs PTOA, deep peri-prosthetic joint infection (PJI) was reported in 1.9% vs 5.4% of patients, whilst revision of prosthesis at an average of 6 years post-operatively was performed in 2.6 vs 9.7% of patients. Conclusions. TKA is a successful treatment option for PTOA. However, the risk of significant complications like PJI and implant failure requiring revision is higher than primary OA cases. Patients should be counselled about those risks. Further well-designed comparative cohort-matched studies are needed to compare outcomes between the two populations

Aims

Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres.

Aims

To explore the clinical efficacy of using two different types of articulating spacers in two-stage revision for chronic knee periprosthetic joint infection (kPJI).

Aims

The optimum type of antibiotics and their administration route for treating Gram-negative (GN) periprosthetic joint infection (PJI) remain controversial. This study aimed to determine the GN bacterial species and antibacterial resistance rates related to clinical GN-PJI, and to determine the efficacy and safety of intra-articular (IA) antibiotic injection after one-stage revision in a GN pathogen-induced PJI rat model of total knee arthroplasty.

Aims

Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery.

Aim. To assess the effectiveness of role of frozen section in revision arthroplasty. Method. 21 patients with infected hip arthroplasties were operated in the form of one or two-staged revision hip arthroplasties. A frozen section was obtained intra-operatively and >5 PMN's/ HPF was considered as a positive indicator of infection. Fig 1 llustrating frozen section image. If the frozen section was reported negative (≤5 PMN's/HPF), the revision prosthesis was implanted after a thorough debridement and a wash. If the frozen section was reported as positive, after the debridement a non-articulating antibiotic loaded cement spacer was implanted for 8 weeks, supplemented with 3 weeks of intravenous antibiotics and 3 weeks of oral antibiotics. This was followed by an antibiotic free interval of 2 weeks. The patient was taken up for a revision surgery once the frozen section study was negative (≤5 PMN's/HPF). The patients were followed up for minimum of 1 year to a maximum of 2 years after the revision for any evidence of infection (assessed clinically and serologically, radiologically). Results. 15 patients had a positive frozen section (>5PMN's/HPF) in the first stage and were treated with prosthesis removal and cement spacer insertion for 8 weeks. In the 2nd stage, out of 15 patients, 14 underwent revision arthroplasty, while 1 patient underwent reapplication of the cement spacer. As per the follow up of ESR & CRP values, clinically and radiologically no patients had any evidence of infection. The average follow up was 17.04 months (range 12–24 months). 1 patient had persistently raised ESR (34mm/hr) which may be attributable to other causes Frozen section analysis of PMN's per high power field had 100% specificity in our patients in detecting periprosthetic joint infection. Conclusions. Intraoperative frozen section study is a reliable indicator in predicting a diagnosis of PJI with good accuracy in ruling out this diagnosis. Frozen section study should thus be considered a relevant part of the challenging diagnostic work-up for patients undergoing revision hip arthroplasty

3462 knee prosthesis were implanted between 1.1.1998 and 31.12.2008 (11 years). There were 491 Unis in this group, but infection ocurred only in Total Knee Replacement (TKR) group. We treated 24 patients (0,69 % infection revision rate) with infected TKR in this time period. The follow-up was from 126 to 7 months. The infection agens was diagnosed by preoperative joint aspiration (Staph.aureus 40%, koagulaseneg.Streptococci 20%). We compared 3 methods of treatment: the first group was open debridement + inlay exchange. In this group we treated 10 patients (37%). There was infection recurrence in 20 %. The second group was one-stage exchange: 5 patients (18%) with infection recurrence 60% and two complications (spin-out and component loosening). The third group was two-stage exchange: 12 patients (44%) without infection recurrence (0%) and no complications. Two stage-exchange was performed with custom-made cement tibialspacer and resterilized explanted femoral component which was reimplanted with [[Unsupported Character – & #8222;]]poor“ cement technique as originally described by A.Hofmann. Post-op partial to full-weight bearing with brace 0–90 degrees was allowed. For reimplantation a non- or semiconstrained revision prosthesis with mobile bearing after cca 6 weeks period was used. The prothesis‘ stems were not cemented. Based on our experience we recommend two-stage revision in mostly cases. Use of mobile spacer keeps excellent mobility after revision and prevent excesive scarings which complicate the reimplantation and causes limitation of movement if fixed spacer was used. On the other side we could show that use of mobile spacer do not increase infection recidiv rate in septic knee surgery. A meticulous debridement is, in our opinion, the most important part of surgery, but it was possible in all cases to save the collateral ligaments and to prevent use of constrained revision prosthesis with increased revision rates because of loosening. Debridement + inlay exchange should be limited only for acute cases with short disease history

Purpose of the study: The objective of this work was to analyze outcome in a series of patients with bone anomalies after failed knee arthroplasty who were treated in the same institution with revision prosthesis with use of fragmented and structured bone grafts. Material and methods: Between April 1994 and June 2004, a total of 515 knee arthroplasties were performed at the Italian hospital of Buenos Aires. Among these, 27 were revisions after failure of a primary arthroplasty. Two patients (follow-up less than one year) were excluded from the analysis. Among the 25 patients analyzed, eight were men and 17 women, mean age 67 years (range 41–87). Minimum follow-up was one year, mean 3.5 years, range 3–9 years. The cause of primary arthoplasty failure was aseptic loosening for ten knees, prosthetic infection in eleven, and pain in three and periprosthetic fracture in one. Fragmented or structured allografts were used for reconstruction in 15 patients. Reconstruction concerned the femur or the tibia after removal of the primary prosthesis. For twelve patients, a fragmented allograft was impacted and for three a combined fragmented-structured allograft was used. For 21 reconstructions, the revision prosthesis had intramedul-lary femoral and tibial stems and for 15, complementary elements were added to the prosthetic components on the femoral piece for three, on the tibial piece for four and on both for eight. Conclusion: Use of fragmented and structured allografts combined with complementary elements offers a valid alternative for reconstruction of bone stock loss after failed primary knee arthroplasty

Aim: To review the early complications associated with staged revision hip Arthroplasty utilising the Biomet antibiotic loaded cement spacer. Method: We report on 80 consecutive staged revision hip replacements using the Biomet antibiotic loaded cement system in our institution over 3 years (1999–2002), performed by three consultant surgeons, with a minimum 1 year follow up. Results: Our patients had an average age of 68 (range 48–90) years, with an equal sex distribution. The median time between the first and second stage was 147 (range 50–619) days. Fractures of the Biomet antibiotic loaded acrylic spacer occurred in 11% revisions when associated with an increase in time between stages and there was a 7% dislocation rate. Patients did not receive a revision prosthesis in 19% cases and had early recurrent sepsis following their two stage procedure in 6%. Three patients had a single episode of dislocation of their revision hip prosthesis within a month postoperatively. Two patients had a proximal DVT and one patient had a pulmonary embolus. The mortality within eight weeks was 7%, rising to 10% within a year. This may be related to patient sepsis and comorbidities or the energy expenditure required to mobilise following a first stage procedure that we have analysed. Conclusions: The risks of staged revision hip surgery for infection are substantial when considering the time involved, the energy expenditure required to mobilise following a first stage, the possibility of not achieving a revision hip prosthesis and the mortality rate. The Biomet antibiotic loaded cement system articulates and maintains soft tissue length in the majority of patients for the duration required between stages

The Dual Articular Knee (Biomet®) is a modular revision prosthesis with a mobile bearing. We performed 24 operations on 23 patients: 16 female and 7 male patients. The average age at revision was 71.6 years, range 42–84 y, the average time span between primary TKR and revision was 8 years, range 1–19 y. The average follow up was 25 months, range 3–68 months. Diagnoses at primary TKR were: Osteoarthritis 19, Rheumatoid arthritis 1, Post-traumatic arthrosis 2, s/a medial Unicondylar 1, s/a High Tibial Osteotomy 1. Primary Implants were: Total Condylar (Howmedica) 4 (3 with metal trays and 1 all PE tibia); IB 2 (Zimmer) 9, IB 1 (Zimmer) 2, Miller Galante (Zimmer) 1, AGC (Biomet) 5, Sigma (J& J) 2, Sigma RP (J& J) 1. Inciations for revision were:. Aseptic loosening and PE wear 20, Infection 4 (Organisms: MRSA 1, Enterococcus Faeconium 1, Streptococcus Gr.6 1, Negative Culture 1). Surgical Technique: We used a medial parapatellar approach in 22 knees and the lateral parapatellar approach in 2 knees, osteotomy of the tibial tuberosity was performed in 16 operations and a lateral patellar release in 7. The patellar implant was replaced in 5 knees, left in situ in 4 and not replaced in 15 knees (one of the knees was after a previous patellectomy). Two stage revision was performed in 4 infected knees and in one non-infected. Cement spacers impregnated with antibiotics were used in 3 operations. Original implants as temporary implants with antibiotic loaded cement were used in 2 operations. Results: Results were rated as good if the knee was stable with flexion of 90 degrees or more without evidence of infection and fair with less than 90 degrees of flexion. Good results were obtained in 19 knees, fair in 2, failure due to late infection in one knee. One patient was lost for follow up, one patient died 6 months after surgery of an unrelated cause. Conclusions: The Dual Articular Revision Prosthesis is a useful implant system in cases with satisfactory collateral ligament stability

Aims

The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without.

Aim. Early prosthetic joint infection (PJI) is a feared complication of hip arthroplasty. Debridement, antibiotics and implant retention (DAIR) is attempted to avoid removal of the implant. The aim of this retrospective cohort study was to evaluate the success rate of DAIR in early PJI. Method. All patients who were diagnosed with early PJI and treated with DAIR at our center from 2003 to 2013 were included in the study. During the time period, 5176 primary hip arthroplasties and 555 revision hip arthroplasties were performed. Early PJI was diagnosed in 54 patients (43 primary and 11 revisions). Median follow-up was 5.6 years (range 2.0–12.1). Standard postoperative antibiotic treatment at our centre is vancomycin and rifampicin. Results. Median patient age was 74 years and 29 patients were women. Mean C-reactive protein at time of diagnosis was 119 mg/L (range 4–546). In 41 patients the infection was eradicated with one DAIR median 17.6 days (range 5–44) after index surgery. Twelve patients underwent a second DAIR and two patients needed DAIR 3 times. Eight primary arthroplasties and two revision arthroplasties proceeded to 2-stage revision after index surgery. Two patients (revisions) were left with a spacer only and one patient was put on lifelong antibiotic suppression therapy. The most frequently isolated microorganisms were Staphylococcus aureus in 19 patients (35%) and Coagulase negative Staphylococcus in ten patients (19%) of which five were MRSE. There were no infections with MRSA in our material. Among the ten patients that proceeded to 2-stage revision, five had Staphylococcus aureus, three had polymicrobial flora, one Coagulase negative Staphylococci and one Propionebacterium acnes infection. The most frequently used post-operative parenteral antibiotic treatment was vancomycin in 35 patients and cloxacillin in 15 patients. The subsequent oral treatment was predominantly dicloxacillin in 25 patients and ciprofloxacin in ten patients. Twenty-four patients received rifampicin in addition. These were mainly patients operated after 2009. Intravenous antibiotics were given for median 15.7 days (range 0–60) and continued orally for median 8.1 weeks (range 0–72). Conclusions. In our cohort of 54 patients, 81.4% of primary prothesis and 63.6% of the revision prosthesis were treated successfully with DAIR. This is in accordance with previous studies

Great diffusion of hip prosthetic surgery, in relatively-young patients too, generates as consequence an increase in prosthesis failures associated with limited or massive bone losses, making revision surgery mandatory, even in most advanced degrees of osteolysis. In best surgery strategy planning are essential: - evaluation of osteolysis degree with standard x-Rays; - evaluation of periprosthetic bone turn-over with scintigraphy (both a specific as they give merely qualitative evaluations of bone remodeling); – quantitative evaluation of periprosthetic bone mineral density with periprosthetic mineralometry (D.E.X.A.). Data obtained with these methods allow more accurate decisions, during the pre-operative phase, regarding the most indicated implant for revision surgery: mid or long-stem, with or without omoplastic transplants, with or without materials promoting bone rehabitation. In any case, the surgeon must have all possible solutions in order to eventually change the operative plan during surgical act. Following qualitative and quantitative periprosthetic bone evaluations, we use to classify stem and cup mobilizations with Italian Group for Revision (GIR) classification. According to GIR classification, our actual trends in the choice of revision prostheses, in the most advanced degrees of complex mobilizations of stem and cup, are the following: - GIR 3 (Enlargement of the femoral shaft with thinning of cortical bone and loosing of 2 or more walls; loosening and acetabular deformation with losing of one ore more columns and the bottom). In this degree we prefer a long-stem concept straight prosthesis; this prosthesis allows an immediately more stable implant, due to optimized length, in opposition to rotation forces and assuring force transfer in both proximal and distal direction. When osteolysis is wider, it was necessary a strategy change, searching a more distal locking of the implant, according to Wagner’s criteria. The SL Wagner’s prosthesis restores cohesion with the reabsorbed bone surface, generating a relative stability in the immediate post-op period; in the following 2 months, an intense bone apposition, which brings to a progressive filling of bone losses, takes place. For this purpose, it is not indicated, apart from surgical way used, cutting the muscle insertions around the thinned wall. This revision prosthesis is fixed without the use of cement due to the distal blocking, guaranteed by his conical shape; the stem is straight and it is not fit to the natural front-bending of femoral shaft. For this last explained reason, we follow these guidelines, improving our results, using a cementless anatomic modular stem: with this kind of implant design, that preserves cortical bone of femoral shaft from stress shielding, and the extremely wide (XX combination) choice of head and neck components, we are now able to regain as well as possible, the correct offset and center of rotation. For the acetabular loosening, we use to implant oval cups, that naturally fit the acetabular lesion, with or without bone grafts impaction in bone loss areas.- GIR 4 (Massive proximal bone loss all around the shaft; massive peri-acetabular loss). In the past we implanted wide-resection cemented (Muller) or non cemented (Kotz) prosthesis, originally designed for onchologic patients, to treat complete femoral osteolysis. The wide resection uncemented prosthesis, after follow up, supports the Wagner’s theory of distal support, because in spite of an almost complete bone sacrifice, there is an attempt of periprosthetic corticalization by the femoral bone. Since some years we implant even in this cases a modular distally-anatomic revision prosthesis, this type of prosthesis, thanks to his proximal component, provides a relative primary metaphyseal support, that improves global stability of implant. In massive peri-acetabular loss we prefer the use of oval components with peripheral supports and obturatory hook, with bone graft impaction. Only as “extrema ratio” we choose for the implant a McMinn stemmed cup. From these guidelines, integrated with clinical observation at mid range follow-up, appears clerarly that cementless prosthesis in hip revision surgery, even in most advanced degrees of osteolysis, are really able to guarantee good results for the patient. These patients, previously implanted with hip prosthesis, have intrinsic limitations of hip joint ROM, sometimes associated with muscular impairments; therefore it’s rarely possible to bring back the hip to an optimal degree of function, especially if compared with a normal joint. The goodness of long-term results must be therefore evaluated in relation to patient’s conditions before the operation itself, especially according to bone conditions regarding osteointegration of prosthesis. If follow up of patient is constant, allowing to program with good timing the revision surgery, if necessary, the use of cementless prostheses is a very powerful (nevertheless conservative) instrument for good functional recovery of these patients

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