Management of Femoral Bone Loss in Revision Total Hip Arthroplasty

Abstract

Femoral bone loss is frequently encountered during revision total hip arthroplasty. The quality and quantity of remaining bone helps determine the best method for reconstruction. Extensively porous-coated cylindrical stems or titanium fluted tapered devices that achieve fixation in the diaphysis have both demonstrated excellent long-term survivorship. Titanium fluted tapered stems with a modular proximal body allow for more accurate leg length, offset, and version adjustments independent of the distal stem which may optimise hip biomechanics. Intraoperative fractures are more common with cylindrical stems and subsidence with tapered stems, particularly monoblock designs and in both dislocation continues to be one of the most common postoperative complications. In salvage situations in which an ectatic femoral canal is unable to support an uncemented device, impaction bone grafting, allograft-prosthetic composite, or a segmental proximal femoral replacement may be required.

Nonmodular Tapered Fluted Titanium Stems Osseointegrate Reliably at Short Term in Revision THAs

“…We believed that the nonmodular design would show results comparable to published results with modular stems [23,28,30,31,33]. Several studies [6,14,20] support this view, however some of the medium-to long-term studies [6,14] reflect use of early designs of this prosthesis.…”

“…Obtaining fixation in patients with large defects (Paprosky Types IIIB and IV) can be difficult with this design [17]. Numerous authors have reported encouraging clinical and radiologic outcomes with the use of tapered fluted modular titanium stems [22,23,26,30,31,38,39], however, observation of junctional fractures at the modular stems [26] led to increased interest in the use of the nonmodular Wagner SL tapered fluted titanium stem at our institution. We therefore asked: (1) Do repeat revision rates with the Wagner SL stem match published results for this and other implants?…”

Clinical, radiographic, and survivorship analysis of a modular fluted tapered stem in revision hip arthroplasty

“…16,17 In this challenging scenario, modular stems are a popular and attractive choice since implant version, offset, and leg length can be handled independently of each other, thus having the potential to better restore hip biomechanics and make the surgical procedure easier. 18,19 The aims of this study were to determine the shortto mid-term clinical and radiographic outcomes and the survivorship of a modular fluted tapered stem in revision THA.…”

Tapered stem geometry provides superior initial fixation stability to cylindrical stem geometry in the setting of severe bone loss: A finite element analysis

“…Guidance and treatment options for revision THA are often based on pre-planning using the Paprosky femoral bone loss classification. [13][14][15][16][17] This classification grades bone loss into four types, with Type III having two subsections. A Type I femoral defect is defined as having minimal metaphyseal cancellous bone loss and an intact diaphysis.…”

“…This is especially the case for the more severe Type III femoral bone defects commonly seen in revision THA. [13][14][15]17 If more than 4 cm of intact diaphyseal bone is available (Type III-A), porous coated cylindrical stems have been recommended for fixation. If less than 4 cm is available (Type III-B), tapered stems are recommended.…”