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

Abstract

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

Surgical Technique: Transfer of the Anterior Portion of the Gluteus Maximus Muscle for Abductor Deficiency of the Hip

“…The large, patulous joint and poorly constrained ROM predispose the hip to dislocation [5,13]. The series in this article is too small to establish the effect of this procedure on dislocation rate, but addition of a posterior muscle flap in cases of severe capsular deficiency probably stabilizes the hip and protects against instability.…”

“…Loss of the ligament and muscle control of the hip is likely responsible for the high rate of dislocation after revision THA [5,13]. The large, patulous joint and poorly constrained ROM predispose the hip to dislocation [5,13].…”

“…Disruption or total destruction of the abductor muscles of the hip almost always causes a noticeable limp and predisposes to dislocation after revision THA [1,13,14]. Abductor deficiency can be caused by primary disruption of the abductor mechanism, osteolytic destruction of the proximal femoral bone stock in association with failed THA, or destruction of the abductor muscles themselves by the inflammatory process sometimes associated with metalon-metal THA [4,6,9,11].…”

Proximally Versus Fully Porous-coated Femoral Stems: A Multicenter Randomized Trial

“…While many surgeons presume proximally coated stems, or cemented stems, have a lower incidence of thigh pain than fully coated stems, this remains controversial [1,2,17,25,28,30,38]. Most authors recognize the reported incidence of thigh pain will be influenced by the way a patient is asked about its presence, a point best controlled with a prospective randomized blinded clinical trial.…”

“…Femoral bone loss or resorption, so-called stress shielding, around well-fixed femoral components is thought to occur around most, if not all, stem designs [12,32,34,38]. This phenomenon is reportedly exacerbated with fully coated stems [12,15,18].…”