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With the increasing incidence of total hip arthroplasty (THA), there is also an expected concurrent increase in revision THA (rTHA), which is known to have a high complication and re-revision rate. In the setting of infection, radical debridement is essential and options for femoral bone loss are limited. One viable solution is cemented modular stems, but limited evidence exists on their use in septic revision. This study aimed to analyze survival and complication related to the use of cemented modular stems in one-stage septic rTHA with severe femoral bone loss. The institutional database of patients who underwent rTHA for septic one-stage revision with cemented modular stems was reviewed. Exclusion criteria were patients aged less than 18 years and nonseptic or 2 stage revisions. Outcomes measured were complication, re-infection, re-operation, and survivorship of the implant. A total of 150 patients were included. The mean age was 68 years (range, 30 to 91), and the mean follow-up was 105 months (range, 1 to 150). Treatment was considered successful in 81.3% of cases. Patients who underwent multiple prior surgeries demonstrated a lower rate of treatment success (P <.001). The main cause of failure was re-infection (11 of 28). Among cases failed for aseptic reasons (17 of 28), loosening of the cemented modular stem was the cause of re-revision in 2 patients (1.3%). The use of modular cemented stems is a viable option in case of septic one-stage rTHA associated with severe femoral bone loss. However, surgeons and patients should be aware that this treatment is still characterized by a high rate of complications, which may lead to further surgeries. III. [ABSTRACT FROM AUTHOR]

demonstrate the possibility of femoral reconstruction in proximal femur bone loss using a custom-made implant for revision THA. Material and methods We report a case of a 72-year-old patient with an extensive Paprosky type IV femoral defect, which was replaced using a custom-made modular component. Results The femoral defect was successfully augmented with a custom-made modular component, and the hip function was restored. The locking mechanism of the constrained system failed at 6 months with the joint remained stable. The patient could ambulate with additional support. VAS, HHS and HOOS scores measured before and after 2 years showed positive dynamics. Discussion Paprosky type IIIB and type IV defects are a challenge for revision hip arthroplasty. There is a variety of surgical options with outcomes being ambiguous. Modular and monoblock tapered stems, the technique of impacted bone graft have been reported to have excellent results in revision THA with Paprosky type III and IV defects. A custom-made femoral component was developed based on the principle of modular stems. Joint stability is a concomitant problem with a severe bone defect that can be addressed with a double mobility or constrained system. Both methods are associated with a sufficient number of complications. Conclusion Replacement of a Paprosky type IV femoral defect with a custom-made modular component demonstrated satisfactory outcomes at a two‑year follow-up. The patient had no complaints, could ambulate unassisted using an elbow crutch and positively evaluated the result of treatment.

Background: Current femoral bone loss classification systems in revision total hip arthroplasty were created at a time when the predominant reconstructive methods used cylindrical porous-coated cobalt-chrome stems. As these stems have largely been replaced by fluted-tapered titanium stems, the ability of these classification systems to help guide implant selection is limited. The purpose of this study was to describe a novel classification system based on contemporary reconstructive techniques. Methods: We reviewed the charts of all patients who underwent femoral component revision at our institution from 2007 through 2019. Preoperative images were reviewed, and FBL was rated according to the Paprosky classification and compared to ratings using our institution’s NCS. Rates of reoperation at the time of most recent follow-up were determined and compared. Results: Four-hundred and forty-two femoral revisions in 330 patients with a mean follow-up duration of 2.7 years were identified. Femoral type according to Paprosky and NCS were Paprosky I (36, 8.1%), II (61, 13.8%), IIIA (180, 40.7%), IIIB (116, 26.2%), and IV (49 11.1%) and NCS 1 (35, 7.9%), 2 (364, 82.4%), 3 (8, 1.8%), 4 (27, 6.1%), and 5 (8, 1.8%). Of the 353 nonstaged rTHAs, there were 42 cases requiring unplanned reoperation (11.9%), including infection (18, 5.1%), instability (10, 2.8%), femoral loosening (5, 1.4%), and various other causes (9, 2.5%). The NCS was more predictive of reoperation than the Paprosky classification (Fisher’s exact test, P = .008 vs P = ns, respectively). Conclusion: We present a novel femoral classification system that can help guide contemporary implant selection.

Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients. However, when significant femoral bone loss is evident at the time of revision surgery, many articulating spacer options are not sufficient to provide stability, and custom modifications of available spacer constructs may be needed to fill the bony void. The goal of this article is to report a surgical technique that can be used in the salvage of failed antibiotic-impregnated spacers where severe femoral bone loss is present.

Patient and implant selection is essential to optimize outcome. Femoral bone loss classifications such as the American Academy of Orthopaedic Surgeons, Gross, and Paprosky classifications permit surgeons to systematically manage bone stock deficiencies and guide implant selection. Here we provide a comprehensive report on the pitfalls and management of this reconstructive challenge. Preoperative planning remains vital to the treatment of femoral bone loss in revision hip arthroplasty and the authors believe it is essential and should include the entire femur. This commonly includes imaging for bone loss such as Judet views or computed tomography scan and must include the entire femur though additional radiographs such as Judet views apply more for acetabular bone loss as opposed to femoral bone loss. All patients should have pre-operative work up to exclude infection. If any of these results area elevated, an aspirate and sampling is required to guide microbiological management. Classically with regards femoral revision surgery, uncemented fixation has proven to give the best outcomes but surgeons must remain flexible and use cemented fixation when necessary. Adequate proximal bone stock permits the use of implants used in primary joint surgery. Implants with proximal modularity can be used in cases where bone stock allows for superb proximal bone support. The vast majority of femoral revisions have inadequate proximal bone stock, thus distally fixed stems should be used and have been shown to provide both axial and rotational stability provided there is an intact isthmus. Taper fluted stems can provide good outcomes even in cases of major bone loss. However, with severe bony loss, impaction grating or the use of a megaprotsthesis is sometimes necessary and is down to surgeon choice and preference. This article has been written as a guide for management and summarises the best evidence available., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-23-31/coif). The special series “Revision Total Hip Arthroplasty” was commissioned by the editorial office without any sponsorship or funding. L.C.H. and M.E.N. report receiving institutional/division fellowship and research support from Depuy Synthes, Stryker, Zimmer-Biomet, and Smith & Nephew, and they are the committees/board members of Canadian Arthroplasty Society. B.A.M. reports receiving consulting fees from Stryker, receiving payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AO foundation, receiving payment for expert testimony from various law firms and receiving institutional/division fellowship and research support from Depuy Synthes, Stryker, Zimmer-Biomet, and Smith & Nephew. He also serves as the Deputy Editor of JBJS. The authors have no other conflicts of interest to disclose., (2024 Annals of Joint. All rights reserved.)

A man in his 30s was involved in a road traffic accident (RTA) and sustained a grade-IIIA distal femur fracture with acute loss of distal two-third of the femur. Initially, damage control surgery was done by an external fixator application. Later, staged limb reconstruction surgery was undertaken as a definitive procedure that involved bifocal distraction osteogenesis involving the proximal tibia and femur along with docking of the corticotomised femoral fragment onto the tibial plateau to achieve knee arthrodesis. The tibial and femoral regenerate together measured 25.8 cm at the end of distraction phase leaving behind a limb length discrepancy of 5 cm. Acute traumatic large bone loss is a rare presentation and is beset with unique management challenges. Limb reconstruction surgery (LRS) with LRS system provides flexibility to tackle individual case-based scenarios and helps achieve limb length, maintain alignment and restore function., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective To evaluate mid‐ to long‐term results of revision total hip arthroplasty for massive femoral bone loss using a cementless modular, fluted, tapered stem. Methods This is a retrospective study performed at a single hospital. During the period of January 2007 to January 2015, 33 patients (34 hips) underwent primary revision surgery with cementless modular, fluted, tapered stems due to femoral bone loss. Sixteen men and 17 women were included in the study, with an average age of 63.9 ± 11.7 years (range, 27 to 88 years). Operative data including operative duration, length of incision, drainage volume and duration, blood loss and transfusion, cases of bone graft and extended trochanteric osteotomy were recorded. Clinical evaluation was performed using Harris hip score (HHS), visual analogue scale (VAS), and patients' satisfaction. Radiographic data including femoral stem fixation, subsidence, integrin of allograft bone, and leg length discrepancy were assessed. Complications and survivorship were evaluated using Kaplan–Meier survival rate. Results The mean follow‐up was 9.1 ± 2.5 years (range, 5–13 years). The Harris hip score was 43.6 ± 11.5 preoperatively and maintained at 86.5 ± 6.6 at the time of latest follow‐up (P

Management of proximal femoral bone loss during hip arthroplasty in young patients is a complex problem due to the need to provide a joint with an increased longevity. While proximal femoral replacement (PFR) would be an easier solution, they are associated with poorer hip scores and decreased prosthesis survival rates which are not ideal while managing young patients. We present a case of proximal femoral bone loss in a young female - following multiple failed osteosynthesis surgeries aimed at addressing a pathological sub-trochanteric fracture - managed successfully with a circumferential allograft during total hip arthroplasty. While there is many literature reporting the use of circumferential allografts during revision hip surgery, this is the first case to the best of our knowledge where we are reporting its successful use in a complex primary hip arthroplasty case. Our successful outcome shows that reconstruction of proximal femoral bone loss using allografts in young patients should be considered prior to use of PFR in them. [ABSTRACT FROM AUTHOR]

Background: Accurate restoration of leg length and proximal femoral geometry is essential for achieving satisfactory outcomes in both primary and revision total hip arthroplasty. Although common landmarks such as the greater trochanter and the lesser trochanter (LT) may be used to measure limb length intraoperatively in primary cases, these landmarks may be absent or disrupted in fractures and revision procedures. We propose the distance between the gluteus maximus tendon gluteal sling (GS) and the center of the femoral head (FHC) as a novel anatomic landmark beyond the zone of injury, which can be used to restore limb length in the setting of proximal femoral bone loss or fracture., Methods: One hundred healthy hips were retrospectively reviewed using MRI to determine the distance between the proximal edge of the GS and the FHC. Additional measurements were collected including the distance between the GS and the greater trochanter and LT, as well as the FHC to the LT and greater trochanter.Results: The distance between the GS and the femoral head was consistent and measured 8.0 cm (±1.88 cm, SD = 0.66). A moderate positive correlation (r = 0.37, P < 0.001) was observed between patient height and GS to FHC distance., Discussion: The distance between the GS and the center of the femoral head consistently measures 8 cm and can be used to set implant height to restore proximal femoral geometry and leg length in total hip arthroplasty with proximal femoral bone loss., Competing Interests: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Bone cement spacers loaded with antibiotic are the gold standard in septic revision. However, the management of massive bone defects constitutes a surgical challenge, requiring the use of different nails, expensive long stems, or cement-coated tumor prostheses for preparing the spacer. In most cases, the knee joint must be sacrificed. We describe a novel technique for preparing a biarticular total femur spacer with the help of a trochanteric nail coated with antibiotic loaded cement, allowing mobility of the hip and knee joints and assisted partial loading until second step surgery. This technique is helpful to maintain the length of the leg, prevent soft tissue contracture, and help eradicate the infection preserving the patient comfort and autonomy while waiting to receive total femoral replacement.

Background: Revision total hip arthroplasty (THA) remains a significant challenge when there is severe femoral bone loss. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with femoral bone loss treated with Zweymüller SLR-Plus stem. Methods: A retrospective review of 82 patients who underwent revision THA using tapered rectangular femoral stem between 1997 and 2007 was undertaken. Of the 82 patients, 9 patients were lost to follow-up and were excluded from the study. The most common reason for revision was aseptic loosening (92%), periprosthetic femur fracture (5%), and infection (3%). Bone loss was categorised preoperatively according to the Paprosky classification. The mean clinical follow-up was 14 years (range 10–19 years). Their mean age at the time of index surgery was 54.7 ± 15.3 (range 30–82) years. Results: The mean Harris Hip Score was significantly improved at final follow-up (68.1 ±10.3) compared with that before the revision surgery (30.4 ± 7.7) (p < 0.0001). Of the 75 stems, 69 (92%) stems were radiographically stable at the last evaluation. Among the 69 stems, 64 hips (85%) had radiographic evidence of bone ingrowth and 5 (5%) had stable fibrous fixation of the stem. Among the 7 hips that were re-revised, 5 hips were re-revised for aseptic loosening, whereas 2 were re-revised for an infection. Kaplan-Meier survivorship analysis, with removal of the stem for any cause as the endpoint, revealed that the 15-year rate of survival of the components was 90% (95% CI, 0.83–0.97). Conclusion: Revision THA in patients with proximal femoral bone loss using Zweymüller SLR-Plus stem led to a high rate of osseointegration of the stem and good clinical results at long-term follow-up. [ABSTRACT FROM AUTHOR]

Abstract Background Management of segmental bone defects is a challenge for orthopedic surgeons. The most commonly used methods are the free vascularized bone transfer, bone transport, and induced membrane technique. However, none of these methods is fully suitable for some cases. Case Report A 41-year-old woman was presented with a Gustilo IIIA left distal femoral fracture (AO 32-C and 33-C) with bone loss. The length of femoral bone loss was 15 cm (12 cm medially and 18 cm laterally). After thorough debridement, the intercondylar fracture was fixed with K-wires, and an external fixator bridged the knee joint. The bone defect was filled with antibiotic cement spacer. After 2 months, the external fixator was removed; the femur was fixed by internal fixation. The induced membrane was opened and the antibiotic cement removed. A free vascularized fibular graft of 18 cm was transferred and the residual bony defect was filled with morcellized cancellous autologous bone graft. At 6 months postoperatively, the graft appeared completely integrated at X-ray and the patient could walk without brace at 11 months postoperatively. Conclusion The distal femur is a large-caliber bone and is under severe stress during weight bearing. When only the induced membrane technique is used, the autologous bone graft seems not enough for the present case. On the other hand, single free vascularized fibular graft also could not provide sufficient strength to allow weight bearing despite significant hypertrophy. Therefore, the induced membrane technique combined with free vascularized fibular graft used in the present case may be an alternative.

Objective: To evaluate mid‐ to long‐term results of revision total hip arthroplasty for massive femoral bone loss using a cementless modular, fluted, tapered stem. Methods: This is a retrospective study performed at a single hospital. During the period of January 2007 to January 2015, 33 patients (34 hips) underwent primary revision surgery with cementless modular, fluted, tapered stems due to femoral bone loss. Sixteen men and 17 women were included in the study, with an average age of 63.9 ± 11.7 years (range, 27 to 88 years). Operative data including operative duration, length of incision, drainage volume and duration, blood loss and transfusion, cases of bone graft and extended trochanteric osteotomy were recorded. Clinical evaluation was performed using Harris hip score (HHS), visual analogue scale (VAS), and patients' satisfaction. Radiographic data including femoral stem fixation, subsidence, integrin of allograft bone, and leg length discrepancy were assessed. Complications and survivorship were evaluated using Kaplan–Meier survival rate. Results: The mean follow‐up was 9.1 ± 2.5 years (range, 5–13 years). The Harris hip score was 43.6 ± 11.5 preoperatively and maintained at 86.5 ± 6.6 at the time of latest follow‐up (P < 0. 05). The X‐ray showed bone ingrowth fixation in 30 hips (88%), fibrous stable fixation in three hips (9%), and instability in one hip (3%). The average stem subsidence was 3.9 ± 2.2 mm (range, 1 to 10 mm). The mean difference in leg length in our study was 3.3 ± 2.7 mm (range, 0 to 10 mm), and the leg length discrepancy in 28 (82%) patients was within 5 mm. No case of junction fracture was observed. Seven (21%) intraoperative fractures occurred in our study. Three (9%) cases with infection were observed after revision. Six (18%) patients had lower limb vein thrombosis. The survivorship of prostheses with re‐revision for any reason was 95% (95% CI, 12.0 to 13.0) at the 10‐year follow‐up. Three (9%) re‐revisions were needed, including one for aseptic loosening, one for dislocation, and one for infection. Conclusion: The mid‐ to long‐term results of revision total hip arthroplasty with the cementless modular, fluted, tapered stems are encouraging for massive femoral bone loss. [ABSTRACT FROM AUTHOR]