Cementless Fixation in
Femoral Component Revision
James P. McAuley, M.D., FRCSC Staff Orthopaedic Surgeon Anderson Orthopaedic
Clinic & INOVA Center for Joint
Replacement Associate Professor of
Orthopaedic Surgery University of Maryland Alexandria, VA The
ability to obtain durable, predictable fixation in the presence of
compromised proximal femoral bone stock is one of the major challenges in
revision hip surgery. Cementless fixation which depends on initial
metaphyseal stability and subsequent ingrowth can be particularly
problematic. For similar reasons, cemented fixation in the absence of good
meatphyseal cancellous bone is at high risk of failure, simply because the
desired fixation can often not be obtained in the presence of damaged
proximal femoral bone stock. Several
options to standard long-stem cemented revisions have been proposed,
including the use of distal cementless fixation, structural allograft
reconstruction, and impaction cancellous grafting. The
results of cementless revisions using extensively porous-coated implants have
been published from our center. In the initial 114 hips with mean 8.8 year
follow-up, the mechanical loosening rate was 11.4%. More recent survivorship
analysis of >200 cases is showing better results in subsequent cases.
Paprosky has reported a 2.4% mechanical failure rate in 297 cases with mean
8.3 years follow-up. Moreland reported a 4% revision rate in 175 cases with
average 5 year follow-up. But
what about the “worst case scenarios” of severe proximal femoral bone loss?
Is there a place for cementless revision without attempting to reconstruct
bone stock? From
a series of 275 femoral revisions performed from 1982-1986 at our center, 34
patients (35 hips) had extensive proximal femoral bone loss (extending at least
10 cm below the lesser trochanter) which was addressed only by the use of
long stemmed extensively porous coated femoral components, with no attempt to
reconstruct the femoral deficiency... Seven died and two were lost to
follow-up before 10 years. Six of 26 femoral components (23%) were revised or
radiographically loose at minimum 10 year follow-up (3 revised and 3
radiographically loose). Nineteen (73.1%) were bone ingrown and one was
stable fibrous. Ninety-six percent of patients were satisfied, with 84%
reporting decreased pain. Since most of these cases of severe femoral
deficiency predated the availability of the multiple stem sizes needed for
optimum fit, the use of long stem extensively coated components remains a
reasonable option for dealing with severe bone loss. Cementless
fixation does give the surgeon the greatest potential for dealing with bone
deficiencies and obtaining fixation without the use of allograft
reconstruction.  Previous
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