Femoral Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management

Abstract

Primary total hip arthroplasty (THA) is one of the most effective procedures for managing end-stage hip arthritis. The burden of revision THA procedures is expected to increase along with the rise in number of primary THAs. The major indications for revision THA include instability, aseptic loosening, infection, osteolysis, wear-related complications, periprosthetic fracture, component malposition, and catastrophic implant fracture. Each of these conditions may be associated with mild or advanced bone loss. Careful patient evaluation and bone loss classification guide preoperative planning and overall patient care. Historically, uncemented fixation has provided the best results, but cemented fixation is required in some cases.

Management of Severe Femoral Bone Loss in Revision Total Hip Arthroplasty

“…Despite modular stems being used in cases with more severe bone loss (65% Paprosky types IIIB and IV femurs vs 35% in the nonmodular group), quality of life scores were higher, there were fewer intraoperative fractures, and there was increased reestablishment of host bone compared with nonmodular stems. 31,45,46 Owing to the subpar results demonstrated with the use of a nonmodular stem in comparison with the results seen with a modular stem, we support the use of modular stems when addressing severe femoral bone loss defects.…”

“…[57][58][59][60] Additional complications include early loosening, instability, stress shielding, limb-length discrepancy, and cost. 31 Haentjens and colleagues 61 evaluated 16 patients, at a mean follow-up of 5 years, treated with the megaprosthesis for failed THA. All patients still required assistive devices for ambulation despite a reduction in pain, and 7 patients suffered a dislocation.…”

“…To facilitate stem removal, the following instruments should be accessible: manufacturer-specific explant tools, flexible osteotomes, trephines, high-speed burrs (eg, pencil tip, carbide tip, metal cutting wheel), ultrasonic cement removal instruments, and universal extraction tools that allow attachment to the stem or taper. 31 The surgeon must weigh the risks and benefits of removing a well-fixed acetabular or femoral component. 32 In the setting of extracting loose femoral stems, it remains important to remove fibrous tissue surrounding the shoulder of the prosthesis to minimize iatrogenic bone loss (Fig.…”

Management of periprosthetic femoral fractures following total hip arthroplasty: a review

“…Impaction bone grafting has been used in large, but contained, metaphyseal bone defects (Paprosky II and III [55]) and stem diameters of 17 mm and above with good results [50]. However, subsidence of the stem with consequent loosening and implant instability remains a concern.…”

Classifying femoral bone deficiency: Picking the right tool for the job

“…For these reasons, the most commonly used, well-described, and successfully implemented classifications for periprosthetic bone loss are the Paprosky femoral and acetabular bone loss classifications. 3,4 Focusing on the femoral side, the Paprosky femoral bone loss classification may be used to describe the location of proximal femoral bone loss, characterize the degree of remaining supportive bone, and imply reconstructive options. 6 Radiographic evaluation for this classification system is performed using plain radiographs to include an AP view of the pelvis, and AP and lateral views of the hip.…”