Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA). We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91 years) were treated for a Vancouver type B1 fracture between 1998 and 2013. The status of the initial arthroplasty was THA in 5 patients and BHA in 6 patients. The original diagnosis was femoral neck fracture in 5 patients, osteoarthritis in 5 patients, and avascular necrosis of femoral head in 1 patient. Seven patients had had a cemented femoral component and 4 had had a cementless femoral component. The mean numbers of previous surgeries were 3.2 times (2 to 5 times). A previous history of fracture in the same femur was found in 7 hips including 5 femoral neck fractures, 3 periprosthetic fractures. The cause of the latest revision surgery was aseptic loosening in 6 hips, periprosthetic fracture in 3 hips, and infection in 2 hips. The average time to fracture after femoral revision using a long stem was 106.5 months (12 to 240 months). The average follow-up was 58.9 months (8 to 180 months). The fracture pattern was a transverse fracture in 6 hips and an oblique fracture in 5 hips. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Seven patients were treated with a locking compression plate and cerclage wiring, and 2 patients were treated with a Dall-Miles system. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with very poor bone quality, which received a femoral revision with a long stem and a locking compression plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful. These finding suggest that a type B1 fracture after revision using a long stem associated with very poor bone quality or bone loss might be considered as a type B3 fracture, and femoral revision might be the treatment of choice

Introduction. The success of cementless total hip arthroplasty (THA), primary as well as for revision, largely depends on the initial stability of the femoral implant. In this respect, several studies have estimated that the micromotion at the bone-implant interface should not exceed 150µm (Jasty 1997, Viceconti 2000) in order to ensure optimal bonding between bone and implant. Therefore, evaluating the initial stability through micromotion measurements serves as a valid method towards reviewing implant design and its potential for uncemented THAs. In general, the methods used to measure the micromotion assume that the implant behaves as a rigid body. While this could be valid for some primary stems (Østbyhaug 2010), studies that support the same assumption related to revision implants were not found. The aim of this study is to assess the initial stability of a femoral revision stem, taking into account possible non-rigid behaviour of the implant. A new in vitro measuring method to determine the micromotion of femoral revision implants is presented. Both implant and bone induced displacements under cyclic load are measured locally. Methods. A Profemur R modular revision stem (MicroPort Orthopedics Inc. Arlington, TN, United States of America) and artificial femora (composite bone 4th generation #3403, Sawbones Europe AB, Malmö, Sweden) prepared by a surgeon were used. The micromotions were measured in proximal-distal, medial-lateral or anterior-posterior directions at four locations situated in two transverse planes, using pin and bushing combinations. At each measuring location an Ø8mm bushing was attached to the bone, and a concentric Ø3mm pin was attached to the implant [Fig.1 and 2]. A supporting structure used to hold either guiding bushings or linear variable displacement transducers (LVDT) is attached to the proximal part of the implant. The whole system was installed on a hydraulic force bench (PC160N, Schenck GmbH, Darmstadt, Germany) and 250 physiological loading cycles were applied [Fig.3]. Results. By combining the local bone and implant displacements, the relative average micromotion appeared to be less than 25µm in the proximal region and less than 50µm in the distal region. These data correspond to a regular implant-bone fit. Also the micromotion is on average larger in the medial-lateral plane than in the posterior-anterior plane. If the implant deformations were not taken into account then the average values for micromotion were overestimated up to 20µm at proximal levels, and up to 140µm at distal levels. Conclusion. Good initial stability is achieved in each case, suggesting a successful long-term outcome. These findings are consistent with a success rate of 96% reported for the used implant over an average of 10 years (Köster 2008). To adequately evaluate the initial stability of femoral implants, the non-rigid behaviour cannot be ignored. Acknowledgments. This research is supported by BVOT (Belgian Association for Orthopaedics and Traumatology) and Impulse Fund KU Leuven

Purpose. To evaluate the radiographic long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Materials and methods. Among 28 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 9 years 6 months to 14 years 5 months (mean, 12, 5 years). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Results. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 5 mm) and 1 stem showed moderate subsidence (about 10 mm) in the cement. But there was no mechanical failure and subsidence at the composit-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation. Conclusion. The result of cemented stem revision with the use of impacted cancellous allograft was good long-terand femoral bone stock deficiency may be reconstructed successfully

Modularity in femoral revision stems was developed to reduce subsidence, leg length discrepancy and dislocation experienced in revision surgery. The Wagner SL Revision Stem (Zimmer, Warsaw, IN) has been known for excellent bony fixation and proximal bony regeneration, but the third-generation proportional neck offset and 135° neck-shaft angle has an unknown track record. Our aim is to study the effect of these design modifications on stem subsidence, dislocation rate and stem survival. We reviewed 76 consecutive femoral revisions (70 patients; 50 M: 20 W; 67.7 yo [range; 37.7 – 86.6 yo]) with the Wagner SL implanted at our institution (2004–2012). No patient was lost to follow-up, but nine had died, and one patient was excluded for a Paprosky type I femoral bone defect. This leaves us 66 hips (60 patients) at 2 to 9.5 years of follow-up (mean 55 months; range, 24–114 months). Indications for revisions included aseptic stem loosening (62.1%), infection (13.6%), acetabular loosening (12.1%), recurrent dislocation (4.5%), periprosthetic (4.5%) and stem fracture (1.5%), and chondrolysis (1.5%). Patients were actively followed up at regular intervals to ascertain revision status and outcome measures including the Merle d'Aubigné (n=53), WOMAC questionnaires (n=59) and radiographs (n=66). Radiographs were evaluated for stem subsidence (mm). One of the surviving 66 stems was revised for recurrent deep infection (1.5%). No patient underwent revision of the femoral stem for aseptic loosening or subsidence. The mean preoperative WOMAC scores (P: 12.8; S: 5.6; F: 51.8) had improved significantly at follow-up (P: 9.7;, S: 4.3; F: 37.6) (p<0.05). The mean Merle D'Aubigné score went from a pre-op of 8.2 (SD: 2.8; range 1 to 14) to a mean of 15.3 (SD: 2.6; range 7 to 18) (p<0,05) at the latest follow-up. During the follow-up period, 3 hips dislocated (4.5%). Each event happened prior to six months after surgery. Only one of these cases dislocated twice. Closed reduction was performed in all cases. None required revision surgery subsequently, and they all remained stable. The stem survivorship is 98.4% at 5 years (0.95 CI: 93–100) and 97.4% at 7.5 years (0.95 CI: 88.9–100). Stem subsidence of 0 to 5 mm was considered as not clinically significant (n=20; 30%). Stem subsidence of 5 to 10 mm occurred in 5 hips (7.6%)and stem subsidence greater than 10 mm only occurred in one hips (1.5%). The third generation Wagner SL conical revision femoral stem has a lower rate of complication than its preceding generations, and is comparable to modular stems performance reported in current literature. These results motivate the authors to continue using monoblock conical revision femoral stems

Cement-in-cement femoral component revision is a useful and commonly practised technique. Onerous and hazardous re-shaping of the original cement mantle is required if the new stem does not seat easily. Furthermore, without removing the entirety of the original cement mantle, the freedom to alter anteversion or leg length is difficult to predict preoperatively. We present data from in vitro experiments testing the compatibility of the top cemented stems according to UK registry figures (NJR 2013). This data augments preoperative planning by indicating which revision stems require minimal or no cement reshaping when being inserted into another stem's mantle. We also present the maximum shortening and anteversion that can be achieved without reshaping the original cement mantle

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. Studies have documented encouraging results with the use of fluted, tapered, modular, titanium stems in revision hip arthroplasty with bone loss. However, radiographic signs of osseointegration and patterns of reconstitution have not been previously categorized. Materials and Methods. 64 consecutive hips with index femoral revision using a particular stem of this design formed the study cohort. Serial radiographs were retrospectively reviewed by an independent observer. Bone loss was determined by Paprosky's classification. Osseointegration was assessed by a slight modification of the criteria of Engh et al. Femoral restoration was classified according to Kolstad et al. Pain and function was documented using Harris Hip Score (HHS). Results. Mean patient age was 68.3 years and radiographic follow-up 6.2 years. 74% femora had type 3 or 4 bone loss. All distal segments were radiographically osseointegrated. Proximal segment radiolucent lines were frequent (40%). Early minor subsidence occured in 4 (6.2%) hips. Definite bony regeneration was documented in 73% femora and stress-shielding in 26%. HHS improved from a pre-operative mean of 50.1 points to 86.2 at most recent follow-up. Discussion. A consistent pattern of bony remodeling and osseointegration occurred which could be applied for assessment of fixation and stability of this stem. The well established criteria of osseointegration for cylindrical cobalt-chrome stems may have to be altered for application to these stems as the mechanism of load transfer is entirely different. Stems with diameter of 18mm or greater are clearly predisposed to stress shielding, predominantly at the mid-shaft region

Multiple joint registries have reported better implant survival for patients aged >75 years undergoing total hip arthroplasty (THA) with cemented implant combinations when compared to hybrid or uncemented implant combinations. However, there is considerable variation within these broad implant categories, and it has therefore been suggested that specific implant combinations should be compared. We analysed the most common contemporary uncemented (Corail/Pinnacle), hybrid (Exeter V40/Trident) and cemented (Exeter V40/Exeter X3) implant combinations in the New Zealand Joint Registry (NZJR) for patients aged >75 years. All THAs performed using the selected implants in the NZJR for patients aged >75 years between 1999 and 2018 were included. Demographic data, implant type, and outcome data including implant survival, reason for revision, and post-operative Oxford Hip Scores were obtained from the NZJR, and detailed survival analyses were performed. Primary outcome was revision for any reason. Reason for revision, including femoral or acetabular failure, and time to revision were recorded. 5427 THAs were included. There were 1105 implantations in the uncemented implant combination group, 3040 in the hybrid implant combination group and 1282 in the cemented implant combination group. Patient reported outcomes were comparable across all groups. Revision rates were comparable between the cemented implant combination (0.31 revisions/100 component years) and the hybrid implant combination (0.40 revisions/100 component years) but were statistically significantly higher in the uncemented implant combination (0.80/100 component years). Femoral-sided revisions were significantly greater in the uncemented implant combination group. The cemented implant and hybrid implant combinations provide equivalent survival and functional outcomes in patients aged over 75 years. Caution is advised if considering use of the uncemented implant combination in this age group, predominantly due to a higher risk of femoral sided revisions. The authors recommend comparison of individual implants rather than broad categories of implants

Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the Duplex. TM. implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned, one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction, more recently, at our institution, we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with a monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with a endofemoral approach. In this approach the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In 2 studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a match cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done with an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this stem more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

The goals of revision total hip on the femoral side are to achieve long term stable fixation, improve quality of life and minimise complications such as intra-operative fracture or dislocation. Ideally these stems will preserve or restore bone stock. Modular titanium stems were first introduced in North America around 2000. They gained popularity as an option for treating Paprosky 3B and 4 defects. Several studies at our institution have compared the modular titanium stems with monoblock cobalt chromium stems. The main outcomes of interest were quality of life. We also looked at complications such as intra-operative fracture and post-operative dislocation. We also compared these 2 stems with respect to restoration or preservation of bone stock. In two studies we showed that modular titanium stems gave superior functional outcomes as well as decreased complications compared to a matched cohort of monoblock cobalt chromium stems. As mentioned one of the initial reasons for introduction of these stems was to address larger femoral defects where failure rates with monoblock cobalt chromium stems were unacceptably high. We followed a group of 65 patients at 5–10 years post-revision with a modular fluted titanium stem. Excellent fixation was obtained with no cases of aseptic loosening. However, there were 5 cases of fracture of the modular junction. Due to concerns of fracture of the modular junction more recently, at our institution we have switched to almost 100% monoblock fluted titanium stems. We recently reviewed our first 100 cases of femoral revision with monoblock stem. Excellent fixation was achieved with no cases of aseptic loosening. Quality of life outcomes were similar to our previous reported series on modular tapered titanium stems. Both monoblock and modular fluted titanium stems can give excellent fixation and excellent functional outcomes. This leaves a choice for the surgeon. For the low volume revision surgeon modular tapered stems are probably the right choice. Higher volume surgeons or surgeons very comfortable with performing femoral revision may want to consider monoblock stems. If one is making the switch it would be easiest to start with a simple case. Such a case would be one that can be done through an endofemoral approach. In this the greater trochanter is available as the key landmark for reaming. After the surgeon is comfortable with this system more complex cases can easily be handled with the monoblock stem. In summary, both modular and monoblock titanium stems are excellent options for femoral revision. As one becomes more familiar with the monoblock stem it can easily become your workhorse for femoral revision. At our institution, we introduced a monoblock titanium stem in 2011. It started out at 50% of cases and now it is virtually used in almost 100% of revision cases

Background. Modular component options can assist the surgeon in addressing complex femoral reconstructions in total hip arthroplasty (THA) by allowing for customization of version control and proximal to distal sizing. Tapered stem fixation has a proven excellent track record in revision THA. Early reports by Cherubino et al. (Surg Technol Int 2010) 65 revision THA with an average follow up of 109 months (range, 76–131) demonstrate satisfactory integration in 100% of cases. Rodriguez et al.(J Arthroplasty 2009) report 96% survival in 102 revision THA at nearly 4 years average follow up. We review the early clinical results of a modular tapered femoral revision system. Methods. A query of our practice's arthroplasty registry revealed 60 patients (61 hips) who signed an IRB-approved general research consent allowing retrospective review, and underwent THA performed with the modular femoral revision system between December 2009 and April 2012. There were 35 men (58%) and 25 women (42%). Mean age was 65.1 years (range, 35–94) and BMI was 31.3 kg/m2 (range, 14–53). Procedures were complex primary in 1 hip, conversion in 6 (10%), revision in 32 (53%), and two-staged exchange for infection in 22 (33%). Two-thirds of the procedures included complete acetabular revision (n=40), while 31% (19) involved liner change only and 2 were isolated femoral revisions. Results. At an average follow-up of 1.5 years (maximum: 3.7 years) there have been no revisions or failures of the femoral component. Average Harris hip scores (0 to 100 possible) improved from 44.2 preoperatively to 66.0 at most recent evaluation, while the pain component (0 to 44 possible) improved from 15.8 to 31.2. Complications requiring surgical intervention included intraoperative periprosthetic femur fracture in one patient returned to the operating suite same day for open reduction internal fixation, which further required incision and debridement for superficial infection at 1 year postoperative; and two patients with dislocation and fracture of the greater trochanter treated with open reduction, revision of the head and liner, and application of cerclage cables, one of which required removal of a migrated claw 10 months later followed 2 weeks subsequently with incision and debridement for a non-healing wound. Postoperative radiographs were available for review for 59 THA in 58 patients. Analysis of the femoral component revealed satisfactory findings in 50 hips (85%) while 9 had radiographic changes that included bone deficit, osteolysis, or radiolucency in one or more zones. Conclusions. The early results of this modular femoral revision system are promising for the treatment of the deficient femur in complex primary and revision total hip arthroplasty. Patients with radiographic changes are advised to return for regular clinical and radiographic follow-up. Survival of the modular femoral component in this series was 100% at mean follow-up of 1.5 years and up to 3.7 years. While Harris hip clinical and pain scores were somewhat low at most recent evaluation, they were significantly improved over preoperative levels

I use monolithic, cylindrical, fully porous coated femoral components for many femoral revisions. Our institutional database holds information on 1000 femoral revisions using extensively porous-coated stems. To date, 27 stems have been re-revised (14 for loosening, 4 for infection, 7 for stem fracture, 2 at time of periprosthetic femoral fracture). Using femoral re-revision for any reason as an end point, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified pre-revision bone stock as a factor affecting femoral fixation. Among the 777 femoral revisions graded for femoral bone loss, 59% of the femurs were graded as having no cortical damage before the revision, 29% had cortical damage extending no more than 10 cm below the lesser trochanter, and 12% had cortical damage that extended more than 10 cm below the lesser trochanter. When the cortical damage involved bone more than 10 cm below the lesser trochanter, the survivorship, using femoral re-revision for any reason or definite radiographic loosening as an end point, was reduced significantly, as compared with femoral revisions with less cortical damage. In addition to patients with Paprosky type 3B and 4 femoral defects there are rare patients with femoral canals smaller than 13.5 mm or larger than 26 mm that are not well suited to this technique. Eight and 10” stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18 mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure

I prefer monolithic, cylindrical, fully porous coated femoral components for most femoral revisions. Our institutional database holds information on 1000 femoral revisions using extensively porous-coated stems. To date, 27 stems have been rerevised (14 for loosening, 4 for infection, 7 for stem fracture, 2 at time of periprosthetic femoral fracture). Using femoral rerevision for any reason as an end point, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified prerevision bone stock as a factor affecting femoral fixation. Among the 777 femoral revisions graded for femoral bone loss, 59% of the femurs were graded as having no cortical damage before the revision, 29% had cortical damage extending no more than 10cm below the lesser trochanter, and 12% had cortical damage that extended more than 10cm below the lesser trochanter. When the cortical damage involved bone more than 10cm below the lesser trochanter, the survivorship, using femoral rerevision for any reason or definite radiographic loosening as an end point, was reduced significantly, as compared with femoral revisions with less cortical damage. In addition to patients with Paprosky type 3B and 4 femoral defects there are rare patients with femoral canals smaller than 13.5mm or larger than 26mm that are not well suited to this technique. Eight and 10-inch stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure

Femoral revision in cemented THA might include some technical difficulties, based on loss of bone stock and cement removal, which might lead to further loss of bone stock, inadequate fixation, cortical perforation or consequent fractures. Femoral impaction grafting, in combination with a primary cemented stem, allows for femoral bone restoration due to incorporation and remodelling of the allograft bone by the host skeleton. Historically it has been first performed and described in Exeter in 1987, utilizing a cemented tapered polished stem in combination with morselised fresh frozen bone grafts. The technique was refined by the development of designated instruments, which have been implemented by the Nijmegen group from Holland. Indications might include all femoral revisions with bone stock loss, while the Endo-Clinic experience is mainly based on revision of cemented stems. Cavitary bone defects affecting meta- and diaphysis leading to a wide or so called “drain pipe” femora, are optimal indications for this technique, especially in young patients. Contraindications are mainly: septical revisions, extensive circumferential cortical bone loss and noncompliance of the patient. Generally, the technique creates a new endosteal surface to host the cemented stem by reconstruction of the cavitary defects with impacted morselised bone graft. This achieves primary stability and restoration of the bone stock. It has been shown, that fresh frozen allograft shows superior mechanical stability than freeze-dried allografts. Incorporation of these grafts has been described in 89%. Technical steps include: removal of failed stem and all cement, reconstruction of segmental bone defects with metal mesh (if necessary), preparation of fresh frozen femoral head allografts with bone mill, optimal bone chip diameter 2–5 mm, larger chips for the calcar area (6–8 mm), insertion of an intramedullary plug including central wire, 2 cm distal the stem tip, introduction of bone chips from proximal to distal, impaction started by distal impactors over central wire, then progressive larger impactors proximal, insertion of a stem “dummy” as proximal impactor and space filler, removal of central wire, retrograde insertion of low viscosity cement (0.5 Gentamycin) with small nozzle syringe, including pressurization, and insertion of standard cemented stem. The cement mantle is of importance, as it acts as the distributor of force between the stem and bone graft and seals the stem. A cement mantle of at least 2 mm has shown favorable results. Post-operative care includes usually touch down weightbearing for 6–8 weeks, followed by 4–6 weeks of gradually increased weightbearing with a total of 12 weeks on crutches. Relevant complications include mainly femoral fractures due to the hardly impacted allograft bone. Subsidence of tapered polished implants might be related to cold flow within the cement mantle, however, could also be related to micro cement mantle fractures, leading to early failure. Subsidence should be less than 5 mm. Survivorship with a defined endpoint as any femoral revision after 10-year follow up has been reported by the Exeter group being over 90%, while survivorship for revision as aseptic loosening being above 98%. Within the last years various other authors and institutions reported about similar excellent survivorships, above 90%. In addition, a long-term follow up by the Swedish arthroplasty registry in more than 1180 patients reported a cumulative survival rate of 94% after 15 years. Impaction grafting might technically be more challenging and more time consuming than cement-free distal fixation techniques. It, however, enables a reliable restoration of bone stock which might especially become important in further revision scenarios in younger patients

Using an institutional database we have identified over 1000 femoral revisions using extensively porous-coated stems. Using femoral re-revision for any reason as an endpoint, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified pre-revision bone stock as a factor affecting femoral fixation. When the cortical damage involved bone more than 10cm below the lesser trochanter, the survivorship, using femoral re-revision for any reason or definite radiographic loosening as an endpoint, was reduced significantly, as compared with femoral revisions with less cortical damage. In addition to patients with Paprosky Type 3B and 4 femoral defects, there are rare patients with femoral canals smaller than 13.5mm or larger than 26mm that are not well suited to this technique. Eight and 10 inch stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure

Femoral revision in cemented THA might include some technical difficulties, based on loss of bone stock and cement removal, which might lead to further loss of bone stock, inadequate fixation, cortical perforation or consequent fractures. Femoral impaction grafting, in combination with a primary cemented stem, allows for femoral bone restoration due to incorporation and remodeling of the allograft bone by the host skeleton. Historically, it has been first performed and described in Exeter in 1987, utilizing a cemented tapered polished stem in combination with morselised fresh frozen bone grafts. The technique was refined by the development of designated instruments, which have been implemented by the Nijmegen group from Holland. Indications might include all femoral revisions with bone stock loss, while the ENDO-Klinik experience is mainly based on revision of cemented stems. Cavitary bone defects affecting meta- and diaphysis leading to a wide or so called “drain pipe” femora, are optimal indications for this technique, especially in young patients. Contraindications are mainly: septical revisions, extensive circumferential cortical bone loss and noncompliance of the patient. Generally the technique creates a new endosteal surface to host the cemented stem by reconstruction of the cavitary defects with impacted morselised bone graft. This achieves primary stability and restoration of the bone stock. It has been shown, that fresh frozen allograft shows superior mechanical stability than freeze-dried allografts. Incorporation of these grafts has been described in 89%. Technical steps include: removal of failed stem and all cement, reconstruction of segmental bone defects with metal mesh (if necessary), preparation of fresh frozen femoral head allografts with bone mill, optimal bone chip diameter 2 – 5 mm, larger chips for the calcar area (6 – 8 mm), insertion of an intramedullary plug including central wire, 2 cm distal to the stem tip, introduction of bone chips from proximal to distal, impaction started by distal impactors over central wire, then progressively larger impactors proximal, insertion of a stem “dummy” as proximal impactor and space filler, removal of central wire, retrograde insertion of low viscosity cement (0.5 Gentamycin) with small nozzle syringe, including pressurization, insertion of standard cemented stem. The cement mantle is of importance, as it acts as the distributor of force between the stem and bone graft and seals the stem. A cement mantle of at least 2 mm has shown favorable results. Originally the technique is described with a polished stem. We use standard brushed stems with comparable results. Postoperative care includes usually touch down weight bearing for 6–8 weeks, followed by 4–6 weeks of gradually increased weightbearing with a total of 12 weeks on crutches. Survivorship with a defined endpoint as any femoral revision after 10 year follow up has been reported by the Exeter group being over 90%. While survivorship for revision related to aseptic loosening being above 98%. Within the last years various other authors and institutions reported similar excellent survivorships, above 90%. In addition a long term follow up by the Swedish arthroplasty registry in more than 1180 patients reported a cumulative survival rate of 94% after 15 years. Impaction grafting might technically be more challenging and more time consuming than cement free distal fixation techniques. It, however, enables a reliable restoration of bone stock which might become important in further revision scenarios in younger patients

BACKGROUND. The most common salvage of a failed metal-on-metal hip resurfacing is to remove both the femoral and acetabular resurfacing components and perform a total hip replacement. The other choices are to perform an acetabular or femoral only revision. A one or two piece acetabular component or a polyethylene bipolar femoral component that matches the retained metal resurfacing acetabular component is used. The considerations in favor of performing a one component resurfacing revision are maintaining the natural femoral head size, limiting the surgical effort for the patient and surgeon, and bone conservation. There are often favorable cost considerations with single component revision surgery. The reasons for femoral component revision are femoral neck fracture, femoral component loosening and an adverse reaction to metal wear debris. Performing a femoral component only revision requires a well fixed and well oriented acetabular component. Acetabular revision is most often performed for an adverse reaction to metal wear debris or loosening. METHODS. 81 acetabular revisions and 46 femoral revisions were evaluated 4 to 14 years after surgery. 83% of patients had their initial surgery at outside institutions. The mean age was 46 and 65% of patients were women. A two piece titanium backed polyethylene component was used in 44 patients and a one or two piece metal component was used in 37. A dual mobility femoral prosthesis mated to a retained metal acetabular component was used for the femoral revisions and no conversions to a metal-on-metal total hip replacement were performed. We selected polyethylene acetabular components for patients with adverse reactions to metal wear debris if their femoral component was less than 48 mm or if there was no matching metal acetabular component available for their femoral component. We used dual mobility components for femoral loosening, femoral neck fractures and adverse reactions to metal wear debris in patients with well-fixed and well oriented metal acetabular components. Dual mobility components were also used if there are any concerns about the femoral component or in some older patients. We performed one component revisions rather than conversion to total hip replacement on 88% of patients presenting with failed resurfacing prostheses. RESULTS. There were no failures with polyethylene acetabular components. There were two failures due to ongoing adverse metal reactions in patients receiving metal revision acetabular components. There was one failure with a dual mobility prosthesis due to accelerated polyethylene wear from undetected edge loading on a retained worn metal acetabular component. There were two infections and one patient with continued pain. There were no dislocations. The average Harris Hip Score was 94. The UCLA activity score was 6 or greater for all but 4 patients. There were 6 revisions to total hip replacement. The Kaplan-Meier survivorship was 94%. 95% of patients rated their outcome as excellent or good. CONCLUSIONS. Failed metal-on-metal hip resurfacing prostheses can be successfully revised without conversion to total hip replacement in most instances. A detailed knowledge of matching prostheses is necessary. Polyethylene prostheses for the acetabular or femoral reconstruction are often needed

I prefer monolithic, cylindrical, fully porous coated femoral components for most femoral revisions. Our institutional database holds information on 1000 femoral revisions using extensively porous-coated stems. To date, 27 stems have been rerevised (14 for loosening, 4 for infection, 7 for stem fracture, 2 at time of periprosthetic femoral fracture). Using femoral rerevision for any reason as an end point, the survivorship is 99 ± 0.8% (95% confidence interval) at 2 years, 97 ± 1.3% at 5 years, 95.6 ± 1.8% at 10 years, and 94.5 ± 2.2% at 15 years. Similar to Moreland and Paprosky, we have identified prerevision bone stock as a factor affecting femoral fixation. Among the 777 femoral revisions graded for femoral bone loss, 59% of the femurs were graded as having no cortical damage before the revision, 29% had cortical damage extending no more than 10 cm below the lesser trochanter, and 12% had cortical damage that extended more than 10 cm below the lesser trochanter. When the cortical damage involved bone more than 10 cm below the lesser trochanter, the survivorship, using femoral rerevision for any reason or definite radiographic loosening as an end point, was reduced significantly, as compared with femoral revisions with less cortical damage. In addition to patients with Paprosky type 3B and 4 femoral defects there are rare patients with femoral canals smaller than 13.5 mm or larger than 26 mm that are not well suited to this technique. Eight and 10” stems 13.5 or smaller should be used with caution if there is no proximal bone support for fear of breaking. Patients with canals larger than 18 mm may be better suited for a titanium tapered stem with flutes. While a monolithic stem is slightly more difficult for a surgeon to insert than a modular femoral stem there is little worry about taper junction failure