Cemented Femoral Revision in Total Hip Arthroplasty

CASE STUDIES

Case 1: Cemented Femoral Revision

A 92-year-old woman underwent revision total hip arthroplasty for femoral loosening. Reconstruction used a porous-coated femoral component. Seven years later, she presented with increased thigh pain. Radiographs showed catastrophic failure (fracture) of her femoral component at the proximal third of the diaphyseal aspect of the stem, a loose proximal stem, and a well-fixed distal stem ( Fig. 60.1 , A and B ). The previous surgery included an extended trochanteric osteotomy with wire fixation. She underwent revision of the femoral component to a cemented, long-stem implant with the use of a cortical allograft onlay strut to augment the distal aspect of the previous osteotomy. The osteotomy had healed and was not reopened during the repeat revision surgery. The procedure included removal of the proximally fractured stem, trephining (with cylindrical trephines) over the well-fixed cementless distal stem, and reconstruction with a long-stem calcar revision femoral component using a third-generation cementing technique (see Fig. 60.1 , C and D ).

FIGURE 60.1, Cemented femoral revision. A 92-year-old woman previously underwent revision total hip arthroplasty for femoral loosening. Reconstruction used a porous-coated, cementless femoral component. A and B, She presented with increased thigh pain 7 years postoperatively. C and D, The repeat revision procedure included reconstruction with a long-stem calcar femoral component using third-generation cementing techniques.

Case 2: Cement-In-Cement Technique

An 84-year-old man presented with a displaced femoral neck hip fracture ( Fig. 60.2 , A and B ). He underwent a cemented, bipolar hemiarthroplasty. Surgery was complicated by recurrent anterior dislocation (see Fig. 60.2 , C ). Revision of the femoral component used a cement-in-cement technique (see Fig. 60.2 , D ). A shorter-length and smaller-sized, polished, collarless, tapered stem was employed, incorporating a higher-offset implant. It was cemented in for a longer length, a change in anteversion, and a tripolar construct on the acetabular side, and there were no further dislocations.

$FIGURE 60.2, Cement-in-cement femoral revision. An 84-year-old man presented with a displaced femoral neck hip fracture ( A ) and underwent a cemented, bipolar hemiarthroplasty ( B ). The surgery was complicated by recurrent anterior dislocation ( C ). Revision of the femoral component used a tap-out, cement-in-cement technique ( D ). A shorter and smaller-sized, polished, collarless, tapered stem was used, incorporating a higher-offset implant that was cemented in for a longer length and a tripolar construct on the acetabular side. There were no further dislocations.$

Case 3: Impaction Allografting

A 75-year-old man presented 3 years after a cementless femoral revision. Preoperative anteroposterior and lateral radiographs showed a loose revision with a cementless, fully porous-coated, 8-inch, cobalt-chrome implant that was performed after revision with an extended trochanteric osteotomy ( Fig. 60.3 , A and B ). The implant had subsided, and a circumferential radiolucency was observed. It was revised to a cemented femoral component with impaction grafting (see Fig. 60.3 , C and D ). Proximally, mesh and cables were used to reinforce metaphyseal bone loss and to allow impaction grafting. Distally, a cortical allograft onlay strut and cables were used to reinforce at the stem tip and add mechanical strength to the construct.

FIGURE 60.3, Impaction grafting femoral revision. A and B, Preoperative anteroposterior and lateral radiographs of a loose, cementless, fully porous-coated, 8-inch, cobalt-chrome implant after revision with an extended trochanteric osteotomy. The implant has subsided, and there is a circumferential radiolucency. C and D, Revision used impaction grafting to place a cemented femoral component. Proximally, mesh and cables were used to reinforce metaphyseal bone loss and allow impaction grafting. Distally, a cortical strut onlay allograft and cables were used to reinforce the stem tip to add mechanical strength to the construct distally.

Algorithm

We recommend an algorithmic approach to femoral revision. If the patient is a candidate for a cemented femoral revision, three options may be considered, depending on integrity of the cement mantle and host bone stock. The simplest option is the cement-in-cement technique using a polished, collarless, and tapered cemented stem. Cemented femoral revision is an option only for selected patients. Impaction grafting may be considered using specific allograft techniques and instrumentation.

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Chapter Synopsis

Cemented femoral components in revision total hip arthroplasty provide forgiving reconstruction solutions for an expanding group of patients with specific indications. Immediate fixation, bypass of defects, and local elution of antibiotics are among the benefits. Favorable outcomes may be achieved with proper patient selection, planning, and surgical technique. We discuss the techniques used for cemented femoral revision and impaction grafting.

Important Points

Careful planning and templating are necessary.
Preoperatively, techniques must be selected for removal of cement and cementing.

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