Recent data project the number of total hip arthroplasty revisions to grow by 137% between 2005 and 20301. Surgeons who manage the failed total hip replacement will find an ever-increasing workload and must have an understanding of the outcomes and treatment options for the failed femoral implant.
Management strategies for femoral implant revision are based on the femoral defect and the quality and quantity of the remaining femoral bone stock. Numerous options are available for femoral reconstruction, including cemented fixation, cementless fixation with use of proximally porous-coated implants, cylindrical extensively porous-coated implants, modular and nonmodular tapered fluted stems, impaction bone-grafting, allograft-prosthetic composites, and proximal femoral replacement (megaprostheses).
Look for this and other related articles in Instructional Course Lectures, Volume 61, which will be published by the American Academy of Orthopaedic Surgeons in February 2012:
- “Approaches for Revision Total Hip Replacement,” by William Jiranek, MD
Careful preoperative planning is a necessary step before any revision arthroplasty. An attempt should be made to identify the implants being revised. The implant manufacturer should be contacted for implant removal devices that may be specific to the implant being revised. Even when an isolated femoral revision is planned, it is beneficial to identify the acetabular implant, as a modular polyethylene exchange may be possible.
The standard evaluation for preoperative planning includes four radiographic views: an anteroposterior view of the pelvis, an anteroposterior view of the affected hip, a frog-leg lateral view, and a shoot-through lateral view of the affected hip2. The radiograph should be examined for areas of osteolysis, stress-shielding, femoral deformity, cortical deficiency, or the amount and location of cement. The radiographs provide substantial information as to the difficulty of implant removal and subsequent reconstruction, while the degree and pattern of bone loss influence the revision implant choice. The bone stock distal to the implant should be visualized and evaluated, as the diaphyseal bone may be essential to obtaining fixation during revision. Additionally, the radiographs should be of sufficient length to determine if a distal implant is present and if it will complicate the proximal reconstruction.
Serial radiographs help to determine whether the femoral stem to be revised is loose or well fixed. Cemented implants that have migrated or subsided, have a fractured cement mantle, or implants that have fractured are definitely loose3,4. A continuous radiolucent line at the cement-bone interface indicates probable loosening, while a noncircumferential radiolucent line indicates possible loosening3,4. Cementless implants that demonstrate progressive subsidence, migration, or divergent radiolucent lines are considered unstable5. These femora typically demonstrate a distal pedestal and proximal cortical hypertrophy. An implant with parallel radiolucent lines and without progressive migration is likely to have stable fibrous ingrowth5. These femora usually do not have focal proximal cortical hypertrophy. A well-ingrown cementless implant does not have reactive lines or evidence of component migration5. These femora typically have proximal stress-shielding.
Clear template overlays or digital templates are used to assess the length and diameter of the proposed revision implant. Templating also helps to determine whether proximal femoral remodeling has occurred. Loose femoral implants are often associated with femoral remodeling into varus alignment and retroversion6. If proximal femoral remodeling has occurred, it may be necessary to perform an extended trochanteric osteotomy to reduce the risks of cortical perforation during reaming, fracture during implant insertion, or undersizing the implant because of varus malpositioning.
Multiple authors have proposed systems to characterize femoral bone loss in the setting of revision hip surgery7-10. Weeden and Paprosky10 described a system based on the quantity of metaphyseal and diaphyseal bone stock (Table I). This system uses a simple algorithm for femoral reconstruction based on the severity of the defect. D'Antonio et al.7 reported the classification system developed by the American Academy of Orthopaedic Surgeons (AAOS) (Table II). While this system is highly descriptive in detailing osseous abnormalities of the femur, it does not provide a guide for reconstructive options based on the femoral defect. Mallory8 developed a system with three basic categories based on the presence or absence of cancellous bone and the extent of femoral cortical deficiency (Table III). While this system is simpler and more useful than that of the AAOS for determining the method of femoral reconstruction, as noted by Della Valle and Paprosky6, it fails to address several critical determinants of reconstruction. Saleh et al.9,11 also developed a system for classifying femoral bone loss, which is both reliable and valid (Table IV).
The classification system devised by Paprosky is based on the principle that as proximal bone becomes weak and unsupportive, the relatively spared diaphyseal bone can be successfully used to provide reliable, long-term fixation10,12-14. The system assigns the femur to one of four categories on the basis of the extent and location of bone loss.
Type I
The femur with a type-I defect has minimal loss of metaphyseal cancellous bone and an intact diaphysis (Fig. 1-A)10. This pattern of bone loss is uncommon in the revision setting and is more common with a failed resurfacing arthroplasty implant or an undersized, non-porous-coated cementless implant6.
Type II
The femur with a type-II defect has extensive metaphyseal cancellous bone loss and minimal diaphyseal loss (Fig. 1-B)10. This is a common finding, particularly in the early stages of aseptic loosening6.
Type IIIA
The femur with a type-IIIA defect has extensive metaphyseal bone loss, leaving it unsupportive. The diaphysis is also involved, but a minimum of 4 cm of cortical bone is available at the isthmus to obtain a scratch fit (Fig. 1-C)10. This is probably the most frequently encountered defect in femoral revision surgery10.
Type IIIB
The femur with a type-IIIB defect again has an unsupportive metaphysis secondary to extensive bone loss. Additionally, the diaphysis is more severely damaged and <4 cm of scratch fit can be obtained at the isthmus (Fig. 1-D)10. This defect seems to be increasing in frequency with improved cementing techniques and the use of longer cementless stems6.
Type IV
The femur with a type-IV defect has extensive metadiaphyseal bone loss. The femoral canal has expanded and the isthmic cortical bone cannot provide reliable fixation (Fig. 1-E). While this pattern of bone loss is rare, its frequency is increasing6,10,15.
To our knowledge, Iorio et al.16 performed the only randomized, prospective trial of femoral component fixation in revision total hip arthroplasty to date. In that study, femoral component fixation with use of third-generation cementing techniques was compared with modular metaphyseal cementless fixation in Paprosky type-I and II femora. With a mean follow-up of eight years, there was no difference in validated outcome measures or five-year survivorship between the two groups. The relative paucity of comparative trials in revision arthroplasty makes interpretation of the results of revision arthroplasty difficult. Because of these shortcomings, it is most beneficial to evaluate the outcomes of different techniques on an individual basis17.
The early results of cemented femoral implant revision had high failure rates. Pellicci et al.18 followed ninety-nine hips for a mean of 8.1 years after revision total hip arthroplasty and reported a 19% rate of rerevision and a 29% rate of femoral loosening. Similarly, Kavanagh et al.19 followed 166 hips for a mean of 4.5 years and reported a 6% rate of rerevision but a 44% rate of radiographic femoral loosening.
These dismal results were accredited to early cementing techniques, and revisions performed with more modern techniques (distal plug, medullary lavage, retrograde cement delivery, and pressurization) have higher rates of success. Callaghan et al.20 reported a 4.3% rate of rerevision in a cohort of 139 hips followed for a mean of 3.6 years, with 16% showing definite mechanical loosening and 29% showing progressive radiolucencies. Rubash and Harris21, in a study of forty-three hips followed for a mean of 6.2 years after revision hip arthroplasty with cement, reported a 2% failure rate due to aseptic loosening, while 11% demonstrated radiographic evidence of femoral component loosening. Estok and Harris22 described the long-term results for this cohort, which included thirty-eight hips that were available for review after a mean follow-up of 11.7 years. They noted a 10.5% rerevision rate for aseptic failure and an additional 10.5% with radiographic evidence of loosening. In a third review of this cohort, Mulroy and Harris23 reported a 26% rate of femoral component loosening at a mean follow-up of 15.1 years.
The so-called third-generation cementing technique that utilized pressurized, vacuum-mixed cement did little to improve the results of previous studies. Eisler et al.24 followed eighty-three consecutive hips after the first revision of the total hip replacement for 1.5 to 6.3 years. At a median follow-up of 3.6 years, the femoral failure rate was 39%.
These generally disappointing failure rates have led to further study in the laboratory in an attempt to understand the failure mechanisms more fully. Biomechanical tests evaluating the shear strength of the cement-bone interface found that a simulated revision setting reduces the interface shear strength to 20.6% of primary strength, while a second revision reduces the shear strength to 6.8% of primary strength25.
Femoral impaction grafting was first reported, to our knowledge, by Simon et al.26 as a technique for femoral revision. The technique is relatively straightforward in concept but is time-consuming and technically demanding27,28. The premise is that a damaged and ectatic femoral canal can be packed with cancellous allograft, creating a neomedullary canal. A highly polished, collarless, double-tapered stem is cemented into the graft bed with use of contemporary cementing techniques. The graft is then vascularized and gradually incorporated with subsequent reconstitution of the deficient femoral bone stock (Figs. 2-A and 2-B). Full-thickness cortical defects can be reconstructed with mesh or cortical strut allografts to contain the morselized cancellous graft.
While some authors have reported worrisome results with impaction grafting29-33, numerous authors have reported short and long-term success with this technique34-38. Meding et al.32 evaluated the results of thirty-four hips followed for a mean of thirty months after femoral impaction grafting. The authors reported a 38% subsidence rate, with a mean subsidence of 10.1 mm and a 12% intraoperative femoral fracture rate. Similarly, Eldridge et al.29 reported massive subsidence (>10 mm) in 11% of seventy-nine hips followed for a mean of 12.6 months. Ornstein et al.27 reported thirty-nine femoral fractures within the first year following 108 femoral component revisions. Sierra et al.39 reviewed a subgroup of femoral revisions with use of stems of ≥220 mm in length, with the hypothesis that the longer stems would decrease the incidence of postoperative femoral fractures. The authors found six of the forty-two hips reviewed required a reoperation. Survival analysis revealed a survival rate of 90% at five and ten years with revision of the stem as the end point. However, with any femoral reoperation as the end point, the survival rate was 82% at both five and ten years.
Similar to other procedures with a steep learning curve, the results of impaction grafting have improved as surgeons have become more comfortable with the procedure. Ornstein et al.34 reported the long-term results of a large cohort of femoral revisions in Sweden. They followed 1305 femoral revisions for five to eighteen years, identifying seventy repeat revisions. Survivorship for all causes of failure was 94% for women and 94.7% for men at fifteen years. Survivorship at fifteen years was 99.1% with aseptic loosening as the end point, 98.6% with infection as the end point, 99.0% with subsidence as the end point, and 98.7% with fracture as the end point. Wraighte and Howard38 reported the results for seventy-five consecutive hips that had revision total hip replacement with a mean follow-up of 10.5 years. Survivorship with any further femoral operation as the end point was 92% at 10.5 years. They also found that subsidence correlated with the preoperative Endo-Klinik bone loss score, and the degree of subsidence at one year had a strong association with long-term subsidence. Halliday et al.36 reported that the survival of 226 hip replacements at ten to eleven years was 90.5%, with any femoral operation as the end point. Mahoney et al.37 reviewed the results of forty-four hips followed for a mean of 4.7 years. With reoperation as the end point, the survivorship was 97%. These data support the use of impaction femoral bone-grafting in select patients with substantial proximal femoral bone loss.
The initial poor outcomes for cemented stems in revision arthroplasty have led some to question their utility and to search for other options. As a result, the use of cementless stems gained popularity. Multiple design philosophies have been utilized in cementless femoral fixation, which have had important effects on the durability of the revision.
The results of femoral implant revision with proximally porous-coated stems have been inferior compared with more modern techniques8,40-43. The primary reason for failure is the inability to obtain stable fixation of the stem in the deficient metaphysis. The results of proximally porous-coated stems in revision surgery can be summarized by the work of Berry et al.44. The authors reviewed a series of 375 total hip arthroplasty revisions performed without cement and with use of at least six different proximally porous-coated femoral components. A survivorship analysis at eight years found that the survival rate, with revision for aseptic femoral failure as the end point, was 58%. The survival rate with aseptic femoral loosening (revision for aseptic loosening or radiographic loosening) as the end point was only 20%. In this series, greater preoperative bone loss correlated with worse survivorship. The authors concluded that the damaged and weakened proximal part of the femur does not provide an optimal environment for initial or long-term biologic fixation.
Fracture of the proximal part of the femur is a frequent complication in revisions with use of proximally porous-coated implants. Berry et al.44 reported a 26% rate of intraoperative fracture. Malkani et al.45 reported a 45.9% incidence of intraoperative femoral fracture. The authors reported an overall five-year survivorship free of moderate pain or revision of 82%; however, the fracture subgroup had survivorship of only 58% at four years. The difference in the survivorship between the groups was significant. Mulliken et al.46 reported a 40% intraoperative fracture rate. The authors did not report the failure rates in the fracture group, but did find that the deficient proximal part of the femur was more likely to fracture and the majority of the failures were in femora with severe proximal bone loss.
The proximally porous-coated modular femoral stems have appeal for cementless femoral revision because of the ability to obtain independent metaphyseal sizing and fixation relative to the diaphyseal portion of the implant. The goal of this technique is to reduce stress-shielding by attaining stable implant fixation in the proximal part of the femur47. This stem type has performed well for revisions with minimal bone loss47-49 (Paprosky types I and II); however, for more difficult cases with more extensive bone loss, the results have been inferior. For example, McCarthy and Lee50, in a retrospective review of the results of revision hip replacement in sixty-seven hips with a mean follow-up of fourteen years, reported that 78% of the femora had Paprosky type-III or IV defects. With revision as the end point, fourteen-year survival was 60%. All aseptic failures were in Paprosky type-IIIB or IV femora. There were no long-term failures in femora classified as Paprosky type-II or IIIA. Bolognesi et al.51 performed a randomized, prospective trial comparing hydroxyapatite-coated metaphyseal sleeves and porous-coated metaphyseal sleeves with use of the S-ROM prosthesis (DePuy, Warsaw, Indiana) in fifty-three patients followed for a mean of four years. The authors found that, with Paprosky type-III defects, the hydroxyapatite-coated sleeve was 2.6 times more likely to achieve osseous ingrowth than the porous-coated sleeve. The authors also reported that regardless of which sleeve was used, the Harris hip scores were significantly worse with worsening bone loss. For the entire cohort, the probability of femoral stem survival, with revision as the end point, was 95% at 3.9 years.
The use of extensively porous-coated femoral stems in revision arthroplasty is based on the principle that bypassing the damaged proximal part of the femur and engaging the diaphysis can reliably provide an ingrown and stable reconstruction (Figs. 3-A and 3-B). Despite concerns over proximal stress-shielding, this technique is popular among surgeons who perform revisions because of the high rate of success and relative ease of technique. The results of revision with cylindrical, extensively porous-coated stems have been excellent10,12,52-55 and are summarized in Table V.
Several authors have reported the difficulty of using cylindrical, extensively porous-coated implants for femoral revision in the face of extensive bone loss10,52,56,57. Weeden and Paprosky10 found that patients with type-II or type-IIIA defects had a 5% failure rate, while patients with type-IIIB defects had a 21% failure rate. Engh et al.57 identified twenty-six hips with bone loss extending ≥10 cm distal to the lesser trochanter that were followed for a mean of 13.3 years. The authors reported a 15% rate of mechanical loosening and a ten-year survivorship of 89%, with femoral revision as the end point. In another study by Engh et al.52, the survival of femoral stems was significantly less if the preoperative bone loss extended >10 cm distal to the lesser trochanter. Sporer and Paprosky56 investigated the failure rates of fifty-one patients with Paprosky type-IIIA, IIIB, or IV femoral defects and reported no failures in seventeen patients with type-IIIA defects. They also found no failures in fifteen patients with type-IIIB femora if the endosteal canal was <19 mm; however, in the eleven patients with type-IIIB femora and an endosteal canal diameter of >19 mm, the mechanical failure rate was 18%. Lastly, three of the eight patients with type-IV femoral defects had mechanical failure. The authors noted that an additional thirteen patients with type-IV femora were treated with either impaction bone-grafting or modular tapered fluted stems, and patients treated with these techniques had no failures at the time of publication.
The concerns over proximal stress-shielding and the difficulty of reconstructing femora with advanced bone loss with use of the cylindrical, extensively porous-coated stems have led to the development of other designs. Several authors have reported a generally favorable experience using the Wagner SL Revision stem (Zimmer, Warsaw, Indiana)58-60. While fixation with the Wagner SL Revision stem was reasonably good, most authors have also reported a relatively high rate of subsidence59,61, leading to the development of the modular, fluted, tapered stems (Figs. 4-A and 4-B)62. The results with the modular, fluted, tapered stems have been excellent, with mid-term survival rates of >95% in several series63-70. The results of revision with modular, fluted, tapered stems are summarized in Table VI.
Richards et al.15 compared outcomes of femoral revisions with use of either a tapered, fluted, modular titanium stem (ZMR hip system; Zimmer) or a cylindrical, nonmodular cobalt-chromium implant (Solution System; DePuy). Despite the fact that patients in the tapered stem group had substantially worse osseous defects (65% had Paprosky type-IIIB and IV defects), the cohort had better WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), Oxford-12, and satisfaction scores. The authors also found that patients with a tapered stem had fewer fractures and more proximal osseous restoration.
Several authors have reported femoral stem fractures distal to the proximal modular junction15,69. Richards et al.15 reported four stem fractures in a cohort of 105 patients, but noted that all fractures occurred at the modular junction of an older design that is no longer in use. While Berry62 warned of the engineering challenges, given the location of this modular junction in a high-stress area, Postak and Greenwald71 found the structural characteristics of the Link MP hip stem (Waldemar Link, Hamburg, Germany) are such that it offers the prospect of in vivo longevity.
Proximal femoral allograft replacement has been used successfully for the reconstruction of massive proximal femoral bone loss in the setting of multiple revision arthroplasties or oncologic resection. The obvious advantages to proximal femoral allograft are the ability to restore bone stock, particularly in younger patients, the provision of a biologic anchor for the abductor complex, and the ability to precisely adjust limb length72. The risks associated with proximal femoral allografts are the risk of disease transmission, graft resorption, and nonunion. Several authors have reported encouraging results of this technique with variable lengths of follow-up. Safir et al.73 reviewed the cases of fifty patients with a mean follow-up of 16.2 years who had been managed with a proximal femoral allograft. Survival at fifteen years was 82.2%, with revision femoral surgery as the end point. Five patients required bone-grafting and plate fixation for symptomatic nonunion of the graft-host junction. The authors reported minor resorption of the graft in 58% of the patients, but only one patient in whom resorption led to failure of the construct. Graham and Stockley74 reviewed the results of twenty-five allografts in twenty-four patients with a mean follow-up of fifty-three months. Two allografts required revision: one for aseptic failure and one for late infection. Another patient required augmentation of the graft-host junction for symptomatic nonunion. Babis et al.75 reported the results for fifty-six patients managed with an allograft-prosthetic composite. Survivorship of the reconstruction was 69% at ten years with twenty-six hips remaining at risk. The authors reported the causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the femoral stem in one, and deep infection in five. The authors also evaluated survival on the basis of the femoral defect and the number of previous revisions. Survival of the reconstructions was significantly worse for hips with Paprosky type-IV defects than for those with type-IIIB defects, and three or more previous femoral revisions significantly affected survival compared with one previous revision.
These results suggest that the use of proximal femoral allografts for massive segmental bone loss in revision total hip arthroplasty can provide durable long-term results, although the survival seems to be adversely affected by the amount of bone loss and the number of previous revisions.
Proximal femoral replacements have been used extensively in the management of proximal femoral bone loss secondary to neoplastic disease76-82. There are few reports regarding the use of these prostheses in non-neoplastic conditions83-86. Parvizi and Sim84 cautioned that these prostheses should be reserved for elderly or sedentary patients with massive proximal bone loss that cannot be reconstructed by other means.
Sim and Chao83 reported encouraging results in a cohort of twenty-one patients who had been followed for twenty-five to ninety-two months after proximal femoral replacement. Two femoral components were revised: one because of recurrent instability and one because of acetabular loosening with substantial bone loss and the patient elected to have the well-fixed prosthesis removed. The authors cautioned that the results were preliminary and that longer-term follow-up might change the results. In a follow-up report, Malkani et al.86 reviewed the 11.1-year results of fifty proximal femoral replacements. They reported that four femoral and seven acetabular components had been revised because of aseptic loosening. With any revision as the end point, survivorship was predicted to be 64% at twelve years following proximal femoral replacement. They also found that eleven of fifty hips had dislocated. Parvizi et al.85 reviewed the cases of forty-three patients who had a proximal femoral replacement for a non-neoplastic condition at a mean of 36.5 months. With revision used as the end point, thirty-seven of forty-three implants had survived at one year and thirty-one of forty-three implants, at five years. Eight patients had hip instability, and six required revision for recurrent dislocation. While the use of proximal femoral replacements can provide functional long-term results, the prostheses should be reserved for salvage situations in which massive proximal femoral bone loss cannot be reconstructed with other techniques.
Revision of a femoral implant is a challenging endeavor when there is substantial proximal bone loss. Numerous reconstructive options have been studied, and surgeons considering revision of a failed femoral prosthesis should be familiar with them. Careful preoperative planning is central to a successful outcome. Part of the preoperative plan will include a critical review of the radiographs in an effort to assess the degree of anticipated bone loss. While several authors have proposed classification schemes for femoral bone loss, the Paprosky classification system provides a useful guide to femoral reconstruction based on the degree of bone loss. The rare type-I defects can be treated with essentially any implant used in primary arthroplasty. The type-II and IIIA defects can be reliably reconstructed with a cylindrical, extensively porous-coated implant. The type-IIIB defect can usually be treated with a tapered, fluted, modular stem. The complex type-IV defect has been treated successfully with impaction grafting, modular tapered stems, allograft-prosthetic composites, and proximal femoral replacements. As technology and techniques have evolved, the success of femoral reconstruction in the face of extensive bone loss has improved. Continued follow-up and further evolution in technique and technology will continue to guide the management of femoral revision.
Kurtz
S;
Ong
K;
Lau
E;
Mowat
F;
Halpern
M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am.
2007;89:780-5.
[PubMed][CrossRef]
Agarwal
S;
Freiberg
AA;
Rubash
HE. Preoperative planning for revision hip arthroplasty. : Callaghan
JJ;
Rosenberg
AG;
Rubash
HE, . The adult hip. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2007. .
Harris
WH;
McCarthy
JC
Jr;
O'Neill
DA. Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am.
1982;64:1063-7.
[PubMed]
O'Neill
DA;
Harris
WH. Failed total hip replacement: assessment by plain radiographs, arthrograms, and aspiration of the hip joint. J Bone Joint Surg Am.
1984;66:540-6.
[PubMed]
Engh
CA;
Bobyn
JD;
Glassman
AH. Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br.
1987;69:45-55.
[PubMed]
Della Valle
CJ;
Paprosky
WG. The femur in revision total hip arthroplasty evaluation and classification. Clin Orthop Relat Res.
2004;420:55-62.
[PubMed][CrossRef]
D'Antonio
J;
McCarthy
JC;
Bargar
WL;
Borden
LS;
Cappelo
WN;
Collis
DK;
Steinberg
ME;
Wedge
JH. Classification of femoral abnormalities in total hip arthroplasty. Clin Orthop Relat Res.
1993;296:133-9.
[PubMed]
Mallory
TH. Preparation of the proximal femur in cementless total hip revision. Clin Orthop Relat Res.
1988;235:47-60.
[PubMed]
Saleh
KJ;
Holtzman
J;
Gafni
A;
Saleh
L;
Davis
A;
Resig
S;
Gross
AE. Reliability and intraoperative validity of preoperative assessment of standardized plain radiographs in predicting bone loss at revision hip surgery. J Bone Joint Surg Am.
2001;83:1040-6.
[PubMed]
Weeden
SH;
Paprosky
WG. Minimal 11-year follow-up of extensively porous-coated stems in femoral revision total hip arthroplasty. J Arthroplasty.
2002;17(
4 Suppl 1):134-7.
[PubMed][CrossRef]
Saleh
KJ;
Holtzman
J;
Gafni
A;
Saleh
L;
Jaroszynski
G;
Wong
P;
Woodgate
I;
Davis
A;
Gross
AE. Development, test reliability and validation of a classification for revision hip arthroplasty. J Orthop Res.
2001;19:50-6.
[PubMed][CrossRef]
Krishnamurthy
AB;
MacDonald
SJ;
Paprosky
WG. 5- to 13-year follow-up study on cementless femoral components in revision surgery. J Arthroplasty.
1997;12:839-47.
[PubMed][CrossRef]
Lawrence
JM;
Engh
CA;
Macalino
GE. Revision total hip arthroplasty. Long-term results without cement. Orthop Clin North Am.
1993;24:635-44.
[PubMed]
Della Valle
CJ;
Paprosky
WG. Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone and Joint Surg Am.
2003;85
Suppl 4:1-6.
Richards
CJ;
Duncan
CP;
Masri
BA;
Garbuz
DS. Femoral revision hip arthroplasty: a comparison of two stem designs. Clin Orthop Relat Res.
2010;468:491-6.
[PubMed][CrossRef]
Iorio
R;
Healy
WL;
Presutti
AH. A prospective outcomes analysis of femoral component fixation in revision total hip arthroplasty. J Arthroplasty.
2008;23:662-9. .
[PubMed][CrossRef]
Barrack
RL;
Folgueras
AJ. Revision total hip arthroplasty: the femoral component. J Am Acad Orthop Surg.
1995;3:79-85.
[PubMed]
Pellicci
PM;
Wilson
PD
Jr;
Sledge
CB;
Salvati
EA;
Ranawat
CS;
Poss
R;
Callaghan
JJ. Long-term results of revision total hip replacement. A follow-up report. J Bone Joint Surg Am.
1985;67:513-6.
[PubMed]
Kavanagh
BF;
Ilstrup
DM;
Fitzgerald
RH
Jr. Revision total hip arthroplasty. J Bone Joint Surg Am.
1985;67:517-26.
[PubMed]
Callaghan
JJ;
Salvati
EA;
Pellicci
PM;
Wilson
PD
Jr;
Ranawat
CS. Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up. J Bone Joint Surg Am.
1985;67:1074-85.
[PubMed]
Rubash
HE;
Harris
WH. Revision of nonseptic, loose, cemented femoral components using modern cementing techniques. J Arthroplasty.
1988;3:241-8.
[PubMed][CrossRef]
Estok
DM
2nd;
Harris
WH. Long-term results of cemented femoral revision surgery using second-generation techniques. An average 11.7-year follow-up evaluation. Clin Orthop Relat Res.
1994;299:190-202.
[PubMed]
Mulroy
WF;
Harris
WH. Revision total hip arthroplasty with use of so-called second-generation cementing techniques for aseptic loosening of the femoral component. A fifteen-year-average follow-up study. J Bone Joint Surg Am.
1996;78:325-30.
[PubMed]
Eisler
T;
Svensson
O;
Iyer
V;
Wejkner
B;
Schmalholz
A;
Larsson
H;
Elmstedt
E. Revision total hip arthroplasty using third-generation cementing technique. J Arthroplasty.
2000;15:974-81.
[PubMed][CrossRef]
Dohmae
Y;
Bechtold
JE;
Sherman
RE;
Puno
RM;
Gustilo
RB. Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res.
1988;236:214-20.
[PubMed]
Simon
JP;
Fowler
JL;
Gie
GA;
Ling
RS;
Timperley
AJ. Impaction cancellous grafting of the femur in cemented total hip revision arthroplasty. J Bone Joint Surg Br.
1991;73(
Suppl 1):73.
[PubMed]
Ornstein
E;
Atroshi
I;
Franzén
H;
Johnsson
R;
Sandquist
P;
Sundberg
M. Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement. J Bone Joint Surg Am.
2002;84:1323-8.
[PubMed]
Oakes
DA;
Cabanela
ME. Impaction bone grafting for revision hip arthroplasty: biology and clinical applications. J Am Acad Orthop Surg.
2006;14:620-8.
[PubMed]
Eldridge
JD;
Smith
EJ;
Hubble
MJ;
Whitehouse
SL;
Learmonth
ID. Massive early subsidence following femoral impaction grafting. J Arthroplasty.
1997;12:535-40.
[PubMed][CrossRef]
Jazrawi
LM;
Della Valle
CJ;
Kummer
FJ;
Adler
EM;
Di Cesare
PE. Catastrophic failure of a cemented, collarless, polished, tapered cobalt-chromium femoral stem used with impaction bone-grafting. A report of two cases. J Bone Joint Surg Am.
1999;81:844-7.
[PubMed]
Masterson
EL;
Masri
BA;
Duncan
CP. The cement mantle in the Exeter impaction allografting technique. A cause for concern. J Arthroplasty.
1997;12:759-64.
[PubMed][CrossRef]
Meding
JB;
Ritter
MA;
Keating
EM;
Faris
PM. Impaction bone-grafting before insertion of a femoral stem with cement in revision total hip arthroplasty. A minimum two-year follow-up study. J Bone Joint Surg Am.
1997;79:1834-41.
[PubMed]
Pekkarinen
J;
Alho
A;
Lepistö
J;
Ylikoski
M;
Ylinen
P;
Paavilainen
T. Impaction bone grafting in revision hip surgery. A high incidence of complications. J Bone Joint Surg Br.
2000;82:103-7.
[PubMed][CrossRef]
Ornstein
E;
Linder
L;
Ranstam
J;
Lewold
S;
Eisler
T;
Torper
M. Femoral impaction bone grafting with the Exeter stem - the Swedish experience: survivorship analysis of 1305 revisions performed between 1989 and 2002. J Bone Joint Surg Br.
2009;91:441-6.
[PubMed][CrossRef]
Edwards
SA;
Pandit
HG;
Grover
ML;
Clarke
HJ. Impaction bone grafting in revision hip surgery. J Arthroplasty.
2003;18:852-9.
[PubMed][CrossRef]
Halliday
BR;
English
HW;
Timperley
AJ;
Gie
GA;
Ling
RS. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg Br.
2003;85:809-17.
[PubMed]
Mahoney
CR;
Fehringer
EV;
Kopjar
B;
Garvin
KL. Femoral revision with impaction grafting and a collarless, polished, tapered stem. Clin Orthop Relat Res.
2005;432:181-7.
[PubMed][CrossRef]
Wraighte
PJ;
Howard
PW. Femoral impaction bone allografting with an Exeter cemented collarless, polished, tapered stem in revision hip replacement: a mean follow-up of 10.5 years. J Bone Joint Surg Br.
2008;90:1000-4.
[PubMed]
Sierra
RJ;
Charity
J;
Tsiridis
E;
Timperley
JA;
Gie
GA. The use of long cemented stems for femoral impaction grafting in revision total hip arthroplasty. J Bone Joint Surg Am.
2008;90:1330-6.
[PubMed][CrossRef]
Gustilo
RB;
Pasternak
HS. Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop Relat Res.
1988;235:111-9.
[PubMed]
Harris
WH;
Krushell
RJ;
Galante
JO. Results of cementless revisions of total hip arthroplasties using the Harris-Galante prosthesis. Clin Orthop Relat Res.
1988;235:120-6.
[PubMed]
Hedley
AK;
Gruen
TA;
Ruoff
DP. Revision of failed total hip arthroplasties with uncemented porous-coated anatomic components. Clin Orthop Relat Res.
1988;235:75-90.
[PubMed]
Woolson
ST;
Delaney
TJ. Failure of a proximally porous-coated femoral prosthesis in revision total hip arthroplasty. J Arthroplasty.
1995;10
Suppl:S22-8.
[PubMed][CrossRef]
Berry
DJ;
Harmsen
WS;
Ilstrup
D;
Lewallen
DG;
Cabanela
ME. Survivorship of uncemented proximally porous-coated femoral components. Clin Orthop Relat Res.
1995;319:168-77.
[PubMed]
Malkani
AL;
Lewallen
DG;
Cabanela
ME;
Wallrichs
SL. Femoral component revision using an uncemented, proximally coated, long-stem prosthesis. J Arthroplasty.
1996;11:411-8.
[PubMed][CrossRef]
Mulliken
BD;
Rorabeck
CH;
Bourne
RB. Uncemented revision total hip arthroplasty: a 4-to-6-year review. Clin Orthop Relat Res.
1996;325:156-62.
[PubMed][CrossRef]
Christie
MJ;
DeBoer
DK;
Tingstad
EM;
Capps
M;
Brinson
MF;
Trick
LW. Clinical experience with a modular noncemented femoral component in revision total hip arthroplasty: 4- to 7-year results. J Arthroplasty.
2000;15:840-8.
[PubMed][CrossRef]
Cameron
HU. The long-term success of modular proximal fixation stems in revision total hip arthroplasty. J Arthroplasty.
2002;17(
4 Suppl 1):138-41.
[PubMed][CrossRef]
Smith
JA;
Dunn
HK;
Manaster
BJ. Cementless femoral revision arthroplasty. 2- to 5-year results with a modular titanium alloy stem. J Arthroplasty.
1997;12:194-201.
[PubMed][CrossRef]
McCarthy
JC;
Lee
JA. Complex revision total hip arthroplasty with modular stems at a mean of 14 years. Clin Orthop Relat Res.
2007;465:166-9.
[PubMed]
Bolognesi
MP;
Pietrobon
R;
Clifford
PE;
Vail
TP. Comparison of a hydroxyapatite-coated sleeve and a porous-coated sleeve with a modular revision hip stem. A prospective, randomized study. J Bone Joint Surg Am.
2004;86:2720-5.
[PubMed]
Engh
CA
Jr;
Hopper
RH
Jr;
Engh CA
Sr. Distal ingrowth components. Clin Orthop Relat Res.
2004;420:135-41.
[PubMed][CrossRef]
Lawrence
JM;
Engh
CA;
Macalino
GE;
Lauro
GR. Outcome of revision hip arthroplasty done without cement. J Bone Joint Surg Am.
1994;76:965-73.
[PubMed]
Moreland
JR;
Bernstein
ML. Femoral revision hip arthroplasty with uncemented, porous-coated stems. Clin Orthop Relat Res.
1995;319:141-50.
[PubMed]
Moreland
JR;
Moreno
MA. Cementless femoral revision arthroplasty of the hip: minimum 5 years followup. Clin Orthop Relat Res.
2001;393:194-201.
[PubMed][CrossRef]
Sporer
SM;
Paprosky
WG. Revision total hip arthroplasty: the limits of fully coated stems. Clin Orthop Relat Res.
2003;417:203-9.
[PubMed]
Engh
CA
Jr;
Ellis
TJ;
Koralewicz
LM;
McAuley
JP;
Engh CA
Sr. Extensively porous-coated femoral revision for severe femoral bone loss: minimum 10-year follow-up. J Arthroplasty.
2002;17:955-60.
[PubMed][CrossRef]
Böhm
P;
Bischel
O. Femoral revision with the Wagner SL revision stem: evaluation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Joint Surg Am.
2001;83:1023-31.
[PubMed][CrossRef]
Kolstad
K;
Adalberth
G;
Mallmin
H;
Milbrink
J;
Sahlstedt
B. The Wagner revision stem for severe osteolysis. 31 hips followed for 1.5-5 years. Acta Orthop Scand.
1996;67:541-4.
[PubMed][CrossRef]
Suominen
S;
Santavirta
S. Revision total hip arthroplasty in deficient proximal femur using a distal load-bearing prosthesis. Ann Chir Gynaecol.
1996;85:253-62.
[PubMed]
Grünig
R;
Morscher
E;
Ochsner
PE. Three-to 7-year results with the uncemented SL femoral revision prosthesis. Arch Orthop Trauma Surg.
1997;116:187-97.
[PubMed][CrossRef]
Berry
DJ. Femoral revision: distal fixation with fluted, tapered grit-blasted stems. J Arthroplasty.
2002;17(
4 Suppl 1):142-6.
[PubMed][CrossRef]
Kwong
LM;
Miller
AJ;
Lubinus
P. A modular distal fixation option for proximal bone loss in revision total hip arthroplasty: a 2- to 6-year follow-up study. J Arthroplasty.
2003;18(
3 Suppl 1):94-7.
[PubMed][CrossRef]
McInnis
DP;
Horne
G;
Devane
PA. Femoral revision with a fluted, tapered, modular stem seventy patients followed for a mean of 3.9 years. J Arthroplasty.
2006;21:372-80.
[PubMed][CrossRef]
Murphy
SB;
Rodriguez
J. Revision total hip arthroplasty with proximal bone loss. J Arthroplasty.
2004;19(
4 Suppl 1):115-9.
[PubMed][CrossRef]
Park
YS;
Moon
YW;
Lim
SJ. Revision total hip arthroplasty using a fluted and tapered modular distal fixation stem with and without extended trochanteric osteotomy. J Arthroplasty.
2007;22:993-9.
[PubMed][CrossRef]
Schuh
A;
Werber
S;
Holzwarth
U;
Zeiler
G. Cementless modular hip revision arthroplasty using the MRP Titan Revision Stem: outcome of 79 hips after an average of 4 years’ follow-up. Arch Orthop Trauma Surg.
2004;124:306-9. .
[PubMed][CrossRef]
Weiss
RJ;
Beckman
MO;
Enocson
A;
Schmalholz
A;
Stark
A. Minimum 5-year follow-up of a cementless, modular, tapered stem in hip revision arthroplasty. J Arthroplasty.
2011;26:16-23. .
[PubMed][CrossRef]
Ovesen
O;
Emmeluth
C;
Hofbauer
C;
Overgaard
S. Revision total hip arthroplasty using a modular tapered stem with distal fixation: good short-term results in 125 revisions. J Arthroplasty.
2010;25:348-54. .
[PubMed][CrossRef]
Wirtz
DC;
Heller
KD;
Holzwarth
U;
Siebert
C;
Pitto
RP;
Zeiler
G;
Blencke
BA;
Forst
R. A modular femoral implant for uncemented stem revision in THR. Int Orthop.
2000;24:134-8.
[PubMed][CrossRef]
Postak
PD;
Greenwald
AS. The influence of modularity on the endurance performance of the LINK MP hip stem. Cleveland: Orthopaedic Research Laboratories; 2001.
Lee
SH;
Ahn
YJ;
Chung
SJ;
Kim
BK;
Hwang
JH. The use of allograft prosthesis composite for extensive proximal femoral bone deficiencies: a 2- to 9.8-year follow-up study. J Arthroplasty.
2009;24:1241-8. .
[PubMed][CrossRef]
Safir
O;
Kellett
CF;
Flint
M;
Backstein
D;
Gross
AE. Revision of the deficient proximal femur with a proximal femoral allograft. Clin Orthop Relat Res.
2009;467:206-12. .
[PubMed][CrossRef]
Graham
NM;
Stockley
I. The use of structural proximal femoral allografts in complex revision hip arthroplasty. J Bone Joint Surg Br.
2004;86:337-43.
[PubMed][CrossRef]
Babis
GC;
Sakellariou
VI;
O'Connor
MI;
Hanssen
AD;
Sim
FH. Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year follow-up study. J Bone Joint Surg Br.
2010;92:349-55.
[PubMed][CrossRef]
Bosquet
M;
Burssens
A;
Mulier
JC. Long term follow-up results of a femoral megaprosthesis. A review of thirteen patients. Arch Orthop Trauma Surg.
1980;97:299-304.
[PubMed][CrossRef]
Donati
D;
Zavatta
M;
Gozzi
E;
Giacomini
S;
Campanacci
L;
Mercuri
M. Modular prosthetic replacement of the proximal femur after resection of a bone tumour a long-term follow-up. J Bone Joint Surg Br.
2001;83:1156-60.
[PubMed][CrossRef]
Kawai
A;
Backus
SI;
Otis
JC;
Inoue
H;
Healey
JH. Gait characteristics of patients after proximal femoral replacement for malignant bone tumour. J Bone Joint Surg Br.
2000;82:666-9.
[PubMed][CrossRef]
Johnsson
R;
Carlsson
A;
Kisch
K;
Moritz
U;
Zetterström
R;
Persson
BM. Function following mega total hip arthroplasty compared with conventional total hip arthroplasty and healthy matched controls. Clin Orthop Relat Res.
1985;192:159-67.
[PubMed]
Morris
HG;
Capanna
R;
Del Ben
M;
Campanacci
D. Prosthetic reconstruction of the proximal femur after resection for bone tumors. J Arthroplasty.
1995;10:293-9.
[PubMed][CrossRef]
Ogilvie
CM;
Wunder
JS;
Ferguson
PC;
Griffin
AM;
Bell
RS. Functional outcome of endoprosthetic proximal femoral replacement. Clin Orthop Relat Res.
2004;426:44-8.
[PubMed][CrossRef]
Zehr
RJ;
Enneking
WF;
Scarborough
MT. Allograft-prosthesis composite versus megaprosthesis in proximal femoral reconstruction. Clin Orthop Relat Res.
1996;322:207-23.
[PubMed][CrossRef]
Sim
FH;
Chao
EY. Hip salvage by proximal femoral replacement. J Bone Joint Surg Am.
1981;63:1228-39.
[PubMed]
Parvizi
J;
Sim
FH. Proximal femoral replacements with megaprostheses. Clin Orthop Relat Res.
2004;420:169-75.
[PubMed][CrossRef]
Parvizi
J;
Tarity
TD;
Slenker
N;
Wade
F;
Trappler
R;
Hozack
WJ;
Sim
FH. Proximal femoral replacement in patients with non-neoplastic conditions. J Bone Joint Surg Am.
2007;89:1036-43.
[PubMed][CrossRef]
Malkani
AL;
Settecerri
JJ;
Sim
FH;
Chao
EY;
Wallrichs
SL. Long-term results of proximal femoral replacement for non-neoplastic disorders. J Bone Joint Surg Br.
1995;77:351-6.
[PubMed]
Rodriguez
JA;
Fada
R;
Murphy
SB;
Rasquinha
VJ;
Ranawat
CS. Two-year to five-year follow-up of femoral defects in femoral revision treated with the link MP modular stem. J Arthroplasty.
2009;24:751-8.
[PubMed][CrossRef]