Aims. The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique. Methods. We updated the outcomes of our previous study, based on 208 consecutive revisions using IBG and the X-change femoral revision system in combination with a cemented polished stem, performed in our tertiary care institute between 1991 and 2007. Kaplan-Meier survival analyses were used to determine the survival rate of the revisions with endpoint revision for any reason and aseptic loosening. Secondary outcomes were radiological loosening and patient-reported outcome measures. Results. Mean age at revision total hip arthroplasty (THA) was 64.9 years (30 to 86). The most prevalent diagnosis for the femoral revision was aseptic loosening. At review in May 2021, 81 patients (85 hips) were still alive and 118 patients (120 hips; 58%) had died. Three patients (3 hips; 1%) were lost to follow-up at 11, 15, and 16 years after surgery, respectively. Data of all deceased and lost patients were included until final follow-up. The mean follow-up was 13.4 years (0 to 28). During the follow-up, 22 re-revisions were performed. The most common reason for re-revision was infection (n = 12; 54%). The survival with endpoint re-revision for any reason was 86% (95% confidence interval (CI) 79 to 91) at 20 years and 74% (95% CI 43 to 89) at 25 years after surgery. The survival for endpoint re-revision for aseptic loosening was 97% (95% CI 91 to 99) after both 20 and 25 years. Conclusion. We conclude that femoral IBG is a valuable technique that can reconstitute femoral bone loss in the long term. After 25 years of follow-up, few re-revisions for aseptic loosening were required. Also, the overall revision rate is very acceptable at a long follow-up. This technique is especially attractive for younger patients facing femoral revisions with extensive bone loss. Cite this article: Bone Joint J 2022;104-B(9):1039–1046

The August 2023 Hip & Pelvis Roundup. 360. looks at: Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty; Antibiotic length in revision total hip arthroplasty; Preoperative colonization and worse outcomes; Short stem cemented total hip arthroplasty; What are the outcomes of one- versus two-stage revisions in the UK?; To cement or not to cement? The best approach in hemiarthroplasty; Similar re-revisions in cemented and cementless femoral revisions for periprosthetic femoral fractures in total hip arthroplasty; Are hip precautions still needed?

Aims. The aim of this study was to report the long-term follow-up of cemented short Exeter femoral components when used in primary total hip arthroplasty (THA). Methods. We included all primary 394 THAs with a cemented short Exeter femoral component (≤ 125 mm) used in our tertiary referral centre between October 1993 and December 2021. A total of 83 patients (21%) were male. The median age of the patients at the time of surgery was 42 years (interquartile range (IQR) 30 to 55). The main indication for THA was a childhood hip disease (202; 51%). The median follow-up was 6.7 years (IQR 3.1 to 11.0). Kaplan-Meier survival analyses were performed to determine the rates of survival with femoral revision for any indication, for septic loosening, for fracture of the femoral component and for aseptic loosening as endpoints. The indications for revision were evaluated. Fractures of the femoral component were described in detail. Results. The 20-year rate of survival was 85.4% (95% confidence interval (CI) 73.9 to 92.0) with revision for any indication, 96.2% (95% CI 90.5 to 98.5) with revision for septic loosening and 92.7% (95% CI 78.5 to 97.6) with revision for fracture of the femoral component. No femoral components were revised for aseptic loosening. There were 21 revisions of the femoral component; most (seven) as part of a two-stage management of infection. Fracture of the femoral component occurred in four THAs (1.0%) at 6.6, 11.6, 16.5, and 18.2 years of follow-up, respectively. Three of these were transverse fractures and occurred at the level of the lesser trochanter. In one THA, there was a fracture of the neck of the component. Conclusion. THAs using cemented short Exeter femoral components showed acceptable rates of survival of the femoral component at long-term follow-up, in this young cohort of patients. Although fracture is a rare complication of these components, surgeons should be aware of their incidence and possible risk factors. Cite this article: Bone Joint J 2024;106-B(3 Supple A):137–142

Revision after failed femoral components may be technically demanding due to loss of peri-prosthetic bone. This retrospective study evaluated the long-term results of femoral revision using the cementless Wagner Self-Locking stem. Between 1992 and 1998, 68 consecutive hips in 66 patients underwent femoral revision using this implant. A total of 25 patients died from unrelated causes without further revision; the remaining 41 hips in 41 patients (12 men and 29 women) with a mean age of 61 years (29 to 80) were reviewed at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral approach was used in 32 hips. A total of five stems required further revision because of infection in two, progressive subsidence in two and recurrent dislocation in one. Four hips had dislocated and eight stems had subsided ≥ 10 mm. The mean Harris hip score improved from 33 points pre-operatively to 75 points at final follow-up (p < 0.001). In all, 33 stems (91.7%) showed radiological signs of stable bone fixation. The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%) and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship with revision and ≥ 10 mm migration of the stem as the endpoint was 83.6% (95% CI 76.6% to 91.4%). This study shows quite good survival and moderate clinical outcome when using a monoblock tapered titanium stem for supporting the regeneration of bone in complex revision hip surgery.

Goals of femoral revision arthroplasty are to achieve stability of the femoral component, to restore biomechanical function of the hip joint and to restore the femoral bone stock. In order to accomplish such an ideal revision arthroplasty, several points should be reminded before and during the revision arthroplasty such as exposure, removal of the failed component, restoration of bone loss, placement of the new component and hip stability. Appropriate options of femoral components for revision depend on the degree of femoral bone loss. When the bone loss is minimum, a standard length component can be used like in primary total hip arthroplasty (THA). When it is moderate or severe, special components and techniques would be necessary. Loss of bone stock is the most difficult problem in femoral revision surgery. It increases a risk of complications during operation such as fracture or perforation, and also results in difficulty to achieve stability of the component. Even when the bone defect is moderate or severe, immediate fixation of the femoral component should be mainly supported by native bone. Additionally, in the remaining bone loss, bone tissue is grafted as much as possible. Survival rate of revision arthroplasty is low comparing with that of primary THA. In addition to the present revision, a possible next operation in the future should be considered when we plan revision surgery. Cemented femoral revision has a disadvantage of removal of the prosthesis when it is failed. Removal of cemented component has a high possibility of complications including perforation and fracture. During revision arthroplasty of a cemented femoral component using a modern cement technique, removal of the cement mantle is difficult, time-consuming and hazardous. The cement mass distal to the tip of the femoral component is the most difficult to be removed since it is often well fixed. The removal procedure has a high risk of causing femoral perforation or fracture. Furthermore, in re-revision, the cement fixation will be often beyond the isthmus and into distal bone defect. And revised cemented femoral components would be more difficult to be removed. On the contrary, loosened uncemented components will be removed relatively easily. Uncemented stem has the advantage of bone stock restoration. Simultaneous bone graft induces restoration of bone stock. Restored bone tissue will support the component, and this improvement of the bone stock would be beneficial when it is failed again in the future. According to these principles, we prefer uncemented femoral revisions rather than cemented revisions. This paper will show the clinical results of femoral revisions in our department mainly using an uncemented femoral component

Aims. Femoral revision component subsidence has been identified as predicting early failure in revision hip surgery. This comparative cohort study assessed the potential risk factors of subsidence in two commonly used femoral implant designs. Methods. A comparative cohort study was undertaken, analyzing a consecutive series of patients following revision total hip arthroplasties using either a tapered-modular (TM) fluted titanium or a porous-coated cylindrical modular (PCM) titanium femoral component, between April 2006 and May 2018. Clinical and radiological assessment was compared for both treatment cohorts. Risk factors for subsidence were assessed and compared. Results. In total, 65 TM and 35 PCM cases were included. At mean follow-up of seven years (1 to 13), subsidence was noted in both cohorts during the initial three months postoperatively (p < 0.001) then implants stabilized. Subsidence noted in 58.7% (38/65 cases) of the TM cohort (mean 2.3 mm, SD 3.5 mm) compared to 48.8% (17/35) of PCM cohort (mean 1.9 mm, SD 2.6 mm; p = 0.344). Subsidence of PCM cohort were significantly associated with extended trochanteric osteotomy (ETO) (p < 0.041). Although the ETO was used less frequently in PCM stem cohort (7/35), subsidence was noted in 85% (6/7) of them. Significant improvement of the final mean Oxford Hip Score (OHS) was reported in both treatment groups (p < 0.001). Conclusion. Both modular TM and PCM revision femoral components subsided within the femur. TM implants subsided more frequently than PCM components if the femur was intact but with no difference in clinical outcomes. However, if an ETO is performed then a PCM component will subside significantly more and suggests the use of a TM implant may be advisable. Cite this article: Bone Joint J 2020;102-B(6):709–715

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

At the revision surgery of the cemented Total hip arthroplasty (THA), complete removal of an old cement mantle of the femur without loosening is very difficult. It can be associated with complications, such as femoral fracture, perforation and femoral bone loss. Cement-within-cement technique (CWCT) of femoral revision is very useful and advantageous without those complications for special cases. We reviewed the experiential radiological outcomes using CWCT for the cemented femoral revision. Between 1999 and 2006, we performed seventeen of revision THA using CWCT in 17 patients. There were four men and 13 women, with an average age of 75 years (range 68 to 87), with an average follow up of 39 months (range 12 to 87). The reasons for revision surgery were eleven for cup loosening, 5 for recurrent dislocation and one technical failure of stem insertion intra-operatively. An original Charnley stem (Depuy, Leeds, England) was implanted in six cases, an Exeter femoral component (Stryker Benoist Girard, Herouville, Saint-Clair, France) was in 10 and another stem in one. Posterolateral approach without trochanteric osteotmy was performing for all patients. After the femoral component was removed, the cement mantle was examined in detail, to confirm cement-bone interface and cement fracture. The cement mantle was washed with a pulsatile lavage to clean and to be dried. If necessary, the surface of the cement mantle was reamed. A double mix of Simplex P cement (Stryker Limerick, Limerick, Ireland) in liquid phase was inserted within the cement mantle by a cement gun with a thin nozzle(Stryker Instruments Kalamazoo, US). Thereafter suction and pressuriser were used, and a femoral component was inserted. The results of this study were that the intra-operative complication was two fractures of the greater trochanter at the stem removed and was one shaft perforation at a new original Charnley stem inserted. The stem position was one valgus and 3 varus stem position of more than 2 degrees. Radiographic outcomes showed no stem loosening, no radiolucent line at the bone-cement interface, nor any osteolysis in the patients at final follow-up. We conclude that this cement-within-cement technique is good radiographic outcomes up to 87 months and this technique should be used with the thinner femoral component than the previous

Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results when using standard sized Exeter stems. The Exeter 44/00 125 mm short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25mm shorter and has a slimmer body to allow greater flexibility to adjust depth of insertion and version of the stem. However, it is not known if this change in stem length and size effects its longer term performance. We therefore reviewed the clinical outcome and survival of the Exeter 44/00 short stem used for cement-in-cement revision in our unit, with a minimum of 5 years follow up. 166 cases were performed between 2004 and 2010. 103 hips were available for 5 year clinical and radiological follow up, with 91 hips surviving to final review in 2017. At 5 years, 43 hips had died, 13 were revised and 7 were too frail to attend clinical review. The fate of all 166 hips were known and included in the survival analysis. Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1 and pain 1). Kaplan-meier survival analysis revealed 100% survival for aseptic loosening, 96.8% survival for stem failure and 88.9% survival for all causes. This is the largest series with the longest follow up of the Exeter 44/00 short revision stem. The stem performs equally well as standard Exeter stems with regards to aseptic loosening. The single stem fracture occurred secondary to bone loss in chronic infection, highlighting the importance of providing adequate proximal support for the stem. Periprosthetic fracture occurred in 2.4% of this series of revision cases. Larger registry-based studies may provide additional information on the performance of this stem

Purpose: This multicentric retrospective study was conducted to search for indications of femoral revision with a custom-made non-cemented implant. Material and methods: We collected files on femoral revisions using custom-made implants among our working group and among surgeons having a certain experience between 1989 and 1991. Twenty-one patients (13 men and 10 women), mean age 50.1 years (24–81) were operated. This was the first revision for 14, the second for six, and the third for two. Mean follow-up was 35.4 years. The implant was coated with hydroxyapatite in the proximal zone with optional distal locking except for the first cases. The implant was used when the usual implants were poorly adapted. Data acquisition was achieved with previous calibrated computed tomography. The problem was to distinguish residual bone from cement or the prior implant. Information was exchanged between the engineer and the surgeon in order to define the stem shape and anchorage. Regular clinical follow-up was performed, noting the Postel Merle d’Aubligné score. The radiographic assessment focused on the absence of prosthesis descent and lucent lines. Results: The PMA score improved from 9.6 (6–14; 2.4; 4.26; 2.91) to 14 (8–18; 4.61; 5.05; 4.25). Complications were dislocation in three hips, one requiring cup replacement and the other neck replacement. Early descent of the femoral stem was also noted in one hip which required revision. Late descent at 13 years was managed by a simple procedure in one hip (SOFCOT stage I). Discussion: The early failures were related to the severity of the initial lesions (or rather their underestimation) and to defective initial distal stabilisation. Late failures resulted from the absence of bioreactive coating. We have had no experience with impacted grafting. The indication for custom-made implants are exceptional (less than 2% of our revisions) and can be divided into four categories: extramedullary (very long neck/varus) the implant avoiding the use of balls; extrapolation (femur too small or too large requiring under- or oversized implant); dysmorphism (excessive curvature, osteotomy or fracture sequelae, narrow metaphysic with wide diaphysis); gap filling (weight-bearing zone). Conclusion: The advantage of a custom-made implant is the choice of anchorage and the simplification of the operative procedure. It is often the only solution in complex situations but requires close collaboration with the engineer (virtual intervention) and implies significant cost

Endoprosthetic reconstruction following resection of 31 tumours of the proximal femur in 30 patients was performed using a Wagner SL femoral revision stem. The mean follow-up was 25.6 months (0.6 to 130.0). Of the 28 patients with a metastasis, 27 died within a mean follow-up period of 18.1 months (0.6 to 56.3) after the operation, and the remaining patient was excluded from the study 44.4 months post-operatively when the stem was removed. The two patients with primary bone tumours were still alive at the latest follow-up of 81.0 and 130.0 months, respectively. One stem only was removed for suspected low-grade infection 44.4 months post-operatively. The worst-case survival rate with removal of the stem for any cause and/or loss to follow-up was 80.0% (95% confidence interval 44.9 to 100) at 130.0 months. The mean Karnofsky index increased from 44.2% (20% to 70%) pre-operatively to 59.7% (0% to 100%) post-operatively, and the mean Merle d’Aubigné score improved from 4.5 (0 to 15) to 12.0 (0 to 18). The mean post-operative Musculoskeletal Tumour Society score was 62.4% (3.3% to 100%). The Wagner SL femoral revision stem offers an alternative to special tumour prostheses for the treatment of primary and secondary tumours of the proximal femur. The mid-term results are very promising, but long-term experience is necessary

Aims

The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes.

To evaluate the radiographic mid-to long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Among 27 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 36 months to 10 years, 3 months (mean, 76.6 months). 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. Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 0.005m) and 1 stem showed moderate subsidence (about 0.008m) in the cement. But there was no mechanical failure and subsidence at the composite-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. The result of cemented stem revision with the use of impacted cancellous allograft was good mid-to long-term. And femoral bone stock deficiency may be reconstructed successfully

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

Objective: Revision total hip arthroplasty in cases of proximal femoral bone loss due to osteolysis and loosening is challenging for surgeon and implants. The use of tapered fluted modular titanium femoral stem in these situations may offer the advantage of better biomechanical reconstruction with a design that ensure primary stability and promotes bone integration. Method: We studied retrospectively 83 cases of femoral reconstruction with the PFM-R stem. Paprosky classification was used to qualify bone defects on preoperative radiological evaluation. Demographic, clinical and intraoperative data were collected, along with any complications. Clinical (W.O.M.A.C. function score) and radiological follow-up was performed at a minimum of 12 months. Results: The mean follow-up was 44 months (23 to 66 months). Five patients were lost to follow-up. 48% of patients had at least one previous revision. The mean post operative WOMAC score was 83. 91% of patients had no significant limb length discrepancy. Stabilization or regression of osteolytic lesions was observed in 75% of revised femur. Complications were 8 dislocations, 7 fractures and 3 infections. A correlation was found between the risk of dislocation and the number of previous revision surgery. Out of 14 cases revised for infection, one had a recurrence. Discussion: This study confirmed the benefits of the PFM-R stem in difficult femoral revision in term of limb length equalization, stability of fixation, regression of osteolytic lesions and improved clinical function

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

Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing ‘cement in cement’ revisions, and this technique is not in widespread use. Since 1989 in Exeter, we have performed a ‘cement within cement’ femoral stem revision on 354 occasions. An Exeter polished tapered stem has been cemented into the existing cement mantle on each occasion. Clinical and radiological follow up of 5 years or longer is available for 156 cases. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. This has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral components or hemi-arthroplasties, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis