- Email: [email protected]
Classifying femoral bone deficiency: Picking the right tool for the job
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Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/sart
Classifying femoral bone deficiency: Picking the right tool for the job Linda I. Suleimana,*, Roger Erivanb, and Wayne G. Paproskyc a
Northwestern University Feinberg School of Medicine, Chicago, IL, USA CHU Clermont-Ferrand, CNRS, SIGMA Clermont ICCF, Clermont-Ferrand, France c Midwest Orthopaedics at Rush, Central Dupage Hospital, Chicago, IL, USA b
A R T I C L E I N F O
ABSTRA CT
Keywords:
Femoral revision in total hip arthroplasty is challenging with much preparation required by
Revision hip arthroplasty
surgeon in order to have the best outcomes. The Paprosky femoral classification system is
Femoral bone defects
the most commonly used, well-described, and successfully utilized classification system
Classification of femoral bone defects
for periprosthetic femoral bone loss. It is based on the volume of supportive native bone in order to allow appropriate and durable fixation. This article presents an overview of the Paprosky femoral bone loss classification and the options for each type of defect. Ó 2019 Published by Elsevier Inc.
1. Introduction The prevalence of total hip arthroplasty continues to increase with the number of revision surgeries steadily rising [1]. It is important for surgeons to prepare for potentially complicated femoral bone loss by appropriately identifying and anticipating the needs for the revision surgery. When evaluating a patient for a femoral revision, all aspects of the case including the approach, need for an osteotomy and appropriate revision implant must be planned prior to the surgery. In order to identify the implant needed for the revision, surgeons must be able to communicate and describe the type of bone loss. This is typically separated and classified independent of the acetabular side [2,3]. The best classifications that exists in orthopaedics are those that allow surgeons to plan for treatment, predict outcome and anticipate the required equipment needed. The Paprosky femoral bone loss classification is the most well described and successfully implemented categorization system in the world [4]. This is in part due to the straightforward description of each defect and treatment algorithm. There is a significant radiographic intra-observer reliability amongst surgeons with substantial agreement on
implant choice for each type of defect [5]. This classification system is based on proximal femoral bone loss in the metaphysis and diaphysis that directs reconstructive options. This classification system divides femoral bone loss into four categories based on plain radiographs of the pelvis, hip and femur (Table 1). We sought to provide an overview of the Paprosky femoral bone loss classification system with descriptive examples.
1.1. Preoperative evaluation The preoperative evaluation for any revision surgery begins with a comprehensive history and physical examination followed by radiographs. In the setting of femoral bone loss, patients’ history should include a description of the location, timing and duration of pain. Prior to any revision surgery laboratory data should include serum erythrocyte sedimentation rate and C-reactive protein followed by an aspiration if warranted by laboratory markers. If synovial fluid is obtained, the cell count, differential and anaerobic and aerobic cultures should be obtained. When evaluating a loose femoral component, it is important to recognize a few common radiographic indicators. It is often that the proximal femur will remodel into
* Corresponding author. Northwestern University Feinberg School of Medicine, 676 N. St Clair St Suite 1350, Chicago, IL, 60611, USA E-mail address: [email protected] (L.I. Suleiman). https://doi.org/10.1053/j.sart.2019.02.011 1045-4527/Ó 2019 Published by Elsevier Inc.
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Table 1 – Summary of the paprosky femoral bone loss classification system. Type I II III IIIA IIIB IV
Femoral Bone Deficiency Cancellous bone is preserved, may be treated as a primary THA with either cemented or cementless fixation Metaphysis is supportive, and a stem that gains primary fixation in the metaphysis may be used; may not be amenable to cemented fixation given the loss of cancellous bone proximally unless a long cemented stem is utilized. Requires primary fixation in the intact diaphysis Usually reconstructed with fully porous coated stem if diameter < 18mm Typically reconstructed with modular tapered femoral component Most difficult to manage as no isthmus present for distal fixation; may be amenable to impaction grafting or require proximal femoral replacement. Success may also be achieved using modular tapered stems if “three-point” fixation is achieved.
retroversion and varus [6]. This is important to recognize preoperatively to minimize intraoperative complications and plan for the possibility of an extended trochanteric osteotomy to decrease the risk of cortical perforation [3,7,8].
appropriate cement fixation [11]. In addition to a cemented component, a proximally porous coated primary stem are reported to have inferior results [12].
1.3. Type II femoral bone loss 1.2. Type I femoral bone loss Type I femoral defects are characterized by minimal metaphyseal bone loss, an intact diaphysis with no proximal femoral remodeling. The most classic representation of type I bone loss with the use of an Austin Moore prosthesis (Fig. 1). Another common example is a failed hip resurfacing requiring revision of the femoral component. These type of defects are rare and can be managed with a primary cementless component of standard length. Our preference for management of Type I defects are with a standard length fully porous coated implant [9,10]. Since type I defects have preservation of cancellous bone, another option for revision is with a cemented component. However, if cemented components are utilized, it is important to remove any and all fibrous membranous ingrowth and neocortex from the canal to allow
Figure 1 – Paprosky Type I Femoral Defect (A). Preoperative X-Ray of a failed Moore Prosthesis (B). Postoperative X-Ray showing reconstruction with a primary cementless femoral component.
Type II femoral defects are the most common type of defect that we encounter as surgeons. This type of femoral bone loss has extensive metaphyseal bone loss but intact femoral diaphysis. We commonly see type II defects following removal of a loose cemented component (Fig. 2) or early stages of loosening of a cementless femoral component [13,14]. The lack of metaphyseal cancellous bone does not allow for revision with a cemented component [15]. It is important to recognize varus remodeling in type II defects. When attempting to remove the stem from a femur that has undergone varus remodeling, one may be at risk for cortical perforation or fracture. If the proximal femur has undergone varus remodeling, it is best to perform an extended
Figure 2 – Paprosky Type II femoral bone loss in a cemented component.
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trochanteric osteotomy and use a diaphyseal filling implant. Our preference in the management of type II defects is to use distal fixation with a stem that will have at least 4 cm of contact with intact isthmus [16]. Another option is to use a modular metaphyseal sleeve with distal splines. The splines do not gain fixation in the diaphysis but instead provide rotational stability. Modularity allows the surgeon to position the body independent of the distal portion of the implant in order to obtain the necessary femoral version [17].
1.4. Type III femoral bone loss Type III defects are divided into two categories depending on the amount of intact diaphyseal cortex. The quantity of intact diaphyseal bone will determine the necessary distal fixation. In type III femoral defects, there is lack of supportive bone in the metaphysis but there is supporting isthmus. Type IIIA defects have severe metaphyseal bone loss that is nonsupportive, but there is at least 4 cm of intact cortical bone [18]. There must be at least 4 cm of intact diaphyseal bone in order to have ample implant-cortical contact to attain stabilization and osteointegration [19,20]. Type IIIB defects are characterized by the intact diaphyseal cortical bone that has less than 4 cm of supportive bone.
1.5. Type IIIA femoral bone loss management When at least 4 cm of intact diaphysis is intact, extensively porous-coated femoral components can be used for diaphyseal fixation (Fig. 3). The objective is to obtain “scratch fit:
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fixation in the diaphysis. Frequently, eight inch stems are utilized in revision of type IIIA defects, however due to the anterior bow of the femur, there is risk for femoral perforation. Type IIIA defects can also be managed with impaction bone grafting, although it is a less commonly used technique [21,22]. Like type II defects, it is important to recognize torsional remodeling into retroversion of the proximal femur in type IIIA defects. This feature is important to recognize so that you may have a modular tapered stem available. The use of modular tapered stems are advocated for when retroversion is present so that there is independent filling of the proximal and distal portions of the femur. Independent rotation of the proximal and distal segments will allow for correction of the abnormal femoral version.
1.6. Type IIIB femoral bone loss management Comparable to type IIIA defects, the metaphysis is nonsupportive and severely damaged in type IIIB defects. Unlike type IIIA defects, there is less than 4 cm of intact diaphyseal cortical bone (Fig. 4). There is a high level of fibrous fixation when less than 4 cm of distal fixation is available. Type IIIB defects are commonly seen with failed long cemented stems or cementless stems with extensive distal osteolysis [8,23]. There is short segment of intact cortical bone, thus extensively porous coated stems are unable to obtain stability and ingrowth. The use of these extensively porous coated stems is associated with fibrous stable fixation [16]. Our preference is to use a modular tapered stem with antirotational splines that typically allow for 1 to 2 cm of diaphyseal bone contact.
1.7. Type IV femoral bone loss In type IV femoral defects, there is extensive metaphyseal and diaphyseal bone loss with no demonstrable isthmus (Fig. 5) [24,25]. In the past, management of this type of bone loss included the use of fully cemented implants with or without impaction grafting, allograft prosthesis composite reconstruction and megaprosthesis proximal femoral components [26,27]. Our preference today is to use a modular tapered stem similar to that used in a type IIIB defect. Modular tapered stems have been able to achieve stable fixation in cases of
Figure 3 – Paprosky Type IIIA femoral bone loss.
Figure 4 – Paprosky Type IIIB femoral bone loss.
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Figure 5 – Type IV Paprosky femoral bone loss.
type IV defects with extensive femoral bone loss. Early results with the use of modular tapered stems have demonstrated good overall survival at mid-term follow up [28,29].
2. Conclusion Management of femoral bone loss in the revision setting can be challenging for surgeons. The Paprosky femoral bone loss classification is based on the capability of identifying the defect and the ability of an extensively porous coated stem to bypass the nonsupportive femur and achieve fixation in the femoral diaphysis. Understanding this classification system will allow surgeons to appropriately plan and execute a surgical plan to provide the best outcomes for patients.
R EF E RE N C ES
[1] Maradit Kremers H, et al. Prevalence of Total Hip and Knee replacement in the United States. J Bone Joint Surg Am 2015;97:1386–97. € fer W, Kinkel S, Puhl W, Kessler S. [Revision total hip [2] Ka arthroplasty: analysis of the predictive value of a radiographic classification system for assessment of bone stock loss]. Z Orthop Ihre Grenzgeb 2003;141:672–7.
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[3] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [4] Ibrahim DA, Fernando ND. Classifications In Brief: the Paprosky classification of femoral bone loss. Clin Orthop Relat Res 2017;475:917–21. [5] Brown NM, et al. The inter-observer and intra-observer reliability of the Paprosky femoral bone loss classification system. J Arthroplasty 2014;29:1482–4. [6] Puri L, et al. Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg Am 2002;84-A:609–14. [7] Brown JM, et al. Femoral component revision of total hip arthroplasty. Orthopedics 2016;39:e1129–39. [8] Sheth NP, Nelson CL, Paprosky WG. Femoral bone loss in revision total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg 2013;21:601–12. [9] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30. [10] Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop Relat Res 1993: 172–8. [11] Sierra RJ, Cabanela ME. Total hip arthroplasty in patients with underlying fibrous dysplasia. Orthopedics 2009;32:320. [12] Sierra RJ, Cabanela ME. Conversion of failed hip hemiarthroplasties after femoral neck fractures. Clin Orthop Relat Res 2002: 129–39. [13] Engh CA, Glassman AH, Griffin WL, Mayer JG. Results of cementless revision for failed cemented total hip arthroplasty. Clin Orthop Relat Res 1988: 91–110. [14] Holt G, Hook S, Hubble M. Revision total hip arthroplasty: the femoral side using cemented implants. Int Orthop 2011;35: 267–73. [15] Sporer SM, Paprosky WG. Femoral fixation in the face of considerable bone loss: the use of modular stems. Clin Orthop Relat Res 2004: 227–31. [16] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30. [17] Cameron HU. The long-term success of modular proximal fixation stems in revision total hip arthroplasty. J Arthroplasty 2002;17:138–41. [18] Valle CJD, Paprosky WG. Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone Joint Surg Am 2003;85-A (Suppl 4):1–6. [19] Bianchi L, Galante C, Zagra L. The management of femoral bone stock in THA revision: indications and techniques. Hip Int 2014;24(Suppl 10):S37–43. [20] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [21] Gie GA, et al. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1993;75:14–21. [22] Schreurs BW, et al. Femoral component revision with use of impaction bone-grafting and a cemented polished stem. Surgical technique. J Bone Joint Surg Am 2006;88(Suppl 1 Pt 2):259–74. [23] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [24] Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop Relat Res 1993: 172–8. [25] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30.
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[26] Mayle RE, Paprosky WG. Massive bone loss: allograft-prosthetic composites and beyond. J Bone Joint Surg Br 2012;94: 61–4. [27] Rogers BA, et al. Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis. J Arthroplasty 2012;27:829–36. e1.
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[28] Brown NM, et al. Modular tapered implants for severe femoral bone loss in THA: reliable osseointegration but frequent complications. Clin Orthop Relat Res 2015;473:555–60. [29] Cross MB, Paprosky WG. Managing femoral bone loss in revision total hip replacement: fluted tapered modular stems. Bone Joint J 2013;95-B:95–7.
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Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/sart
Classifying femoral bone deficiency: Picking the right tool for the job Linda I. Suleimana,*, Roger Erivanb, and Wayne G. Paproskyc a
Northwestern University Feinberg School of Medicine, Chicago, IL, USA CHU Clermont-Ferrand, CNRS, SIGMA Clermont ICCF, Clermont-Ferrand, France c Midwest Orthopaedics at Rush, Central Dupage Hospital, Chicago, IL, USA b
A R T I C L E I N F O
ABSTRA CT
Keywords:
Femoral revision in total hip arthroplasty is challenging with much preparation required by
Revision hip arthroplasty
surgeon in order to have the best outcomes. The Paprosky femoral classification system is
Femoral bone defects
the most commonly used, well-described, and successfully utilized classification system
Classification of femoral bone defects
for periprosthetic femoral bone loss. It is based on the volume of supportive native bone in order to allow appropriate and durable fixation. This article presents an overview of the Paprosky femoral bone loss classification and the options for each type of defect. Ó 2019 Published by Elsevier Inc.
1. Introduction The prevalence of total hip arthroplasty continues to increase with the number of revision surgeries steadily rising [1]. It is important for surgeons to prepare for potentially complicated femoral bone loss by appropriately identifying and anticipating the needs for the revision surgery. When evaluating a patient for a femoral revision, all aspects of the case including the approach, need for an osteotomy and appropriate revision implant must be planned prior to the surgery. In order to identify the implant needed for the revision, surgeons must be able to communicate and describe the type of bone loss. This is typically separated and classified independent of the acetabular side [2,3]. The best classifications that exists in orthopaedics are those that allow surgeons to plan for treatment, predict outcome and anticipate the required equipment needed. The Paprosky femoral bone loss classification is the most well described and successfully implemented categorization system in the world [4]. This is in part due to the straightforward description of each defect and treatment algorithm. There is a significant radiographic intra-observer reliability amongst surgeons with substantial agreement on
implant choice for each type of defect [5]. This classification system is based on proximal femoral bone loss in the metaphysis and diaphysis that directs reconstructive options. This classification system divides femoral bone loss into four categories based on plain radiographs of the pelvis, hip and femur (Table 1). We sought to provide an overview of the Paprosky femoral bone loss classification system with descriptive examples.
1.1. Preoperative evaluation The preoperative evaluation for any revision surgery begins with a comprehensive history and physical examination followed by radiographs. In the setting of femoral bone loss, patients’ history should include a description of the location, timing and duration of pain. Prior to any revision surgery laboratory data should include serum erythrocyte sedimentation rate and C-reactive protein followed by an aspiration if warranted by laboratory markers. If synovial fluid is obtained, the cell count, differential and anaerobic and aerobic cultures should be obtained. When evaluating a loose femoral component, it is important to recognize a few common radiographic indicators. It is often that the proximal femur will remodel into
* Corresponding author. Northwestern University Feinberg School of Medicine, 676 N. St Clair St Suite 1350, Chicago, IL, 60611, USA E-mail address: [email protected] (L.I. Suleiman). https://doi.org/10.1053/j.sart.2019.02.011 1045-4527/Ó 2019 Published by Elsevier Inc.
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Table 1 – Summary of the paprosky femoral bone loss classification system. Type I II III IIIA IIIB IV
Femoral Bone Deficiency Cancellous bone is preserved, may be treated as a primary THA with either cemented or cementless fixation Metaphysis is supportive, and a stem that gains primary fixation in the metaphysis may be used; may not be amenable to cemented fixation given the loss of cancellous bone proximally unless a long cemented stem is utilized. Requires primary fixation in the intact diaphysis Usually reconstructed with fully porous coated stem if diameter < 18mm Typically reconstructed with modular tapered femoral component Most difficult to manage as no isthmus present for distal fixation; may be amenable to impaction grafting or require proximal femoral replacement. Success may also be achieved using modular tapered stems if “three-point” fixation is achieved.
retroversion and varus [6]. This is important to recognize preoperatively to minimize intraoperative complications and plan for the possibility of an extended trochanteric osteotomy to decrease the risk of cortical perforation [3,7,8].
appropriate cement fixation [11]. In addition to a cemented component, a proximally porous coated primary stem are reported to have inferior results [12].
1.3. Type II femoral bone loss 1.2. Type I femoral bone loss Type I femoral defects are characterized by minimal metaphyseal bone loss, an intact diaphysis with no proximal femoral remodeling. The most classic representation of type I bone loss with the use of an Austin Moore prosthesis (Fig. 1). Another common example is a failed hip resurfacing requiring revision of the femoral component. These type of defects are rare and can be managed with a primary cementless component of standard length. Our preference for management of Type I defects are with a standard length fully porous coated implant [9,10]. Since type I defects have preservation of cancellous bone, another option for revision is with a cemented component. However, if cemented components are utilized, it is important to remove any and all fibrous membranous ingrowth and neocortex from the canal to allow
Figure 1 – Paprosky Type I Femoral Defect (A). Preoperative X-Ray of a failed Moore Prosthesis (B). Postoperative X-Ray showing reconstruction with a primary cementless femoral component.
Type II femoral defects are the most common type of defect that we encounter as surgeons. This type of femoral bone loss has extensive metaphyseal bone loss but intact femoral diaphysis. We commonly see type II defects following removal of a loose cemented component (Fig. 2) or early stages of loosening of a cementless femoral component [13,14]. The lack of metaphyseal cancellous bone does not allow for revision with a cemented component [15]. It is important to recognize varus remodeling in type II defects. When attempting to remove the stem from a femur that has undergone varus remodeling, one may be at risk for cortical perforation or fracture. If the proximal femur has undergone varus remodeling, it is best to perform an extended
Figure 2 – Paprosky Type II femoral bone loss in a cemented component.
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trochanteric osteotomy and use a diaphyseal filling implant. Our preference in the management of type II defects is to use distal fixation with a stem that will have at least 4 cm of contact with intact isthmus [16]. Another option is to use a modular metaphyseal sleeve with distal splines. The splines do not gain fixation in the diaphysis but instead provide rotational stability. Modularity allows the surgeon to position the body independent of the distal portion of the implant in order to obtain the necessary femoral version [17].
1.4. Type III femoral bone loss Type III defects are divided into two categories depending on the amount of intact diaphyseal cortex. The quantity of intact diaphyseal bone will determine the necessary distal fixation. In type III femoral defects, there is lack of supportive bone in the metaphysis but there is supporting isthmus. Type IIIA defects have severe metaphyseal bone loss that is nonsupportive, but there is at least 4 cm of intact cortical bone [18]. There must be at least 4 cm of intact diaphyseal bone in order to have ample implant-cortical contact to attain stabilization and osteointegration [19,20]. Type IIIB defects are characterized by the intact diaphyseal cortical bone that has less than 4 cm of supportive bone.
1.5. Type IIIA femoral bone loss management When at least 4 cm of intact diaphysis is intact, extensively porous-coated femoral components can be used for diaphyseal fixation (Fig. 3). The objective is to obtain “scratch fit:
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fixation in the diaphysis. Frequently, eight inch stems are utilized in revision of type IIIA defects, however due to the anterior bow of the femur, there is risk for femoral perforation. Type IIIA defects can also be managed with impaction bone grafting, although it is a less commonly used technique [21,22]. Like type II defects, it is important to recognize torsional remodeling into retroversion of the proximal femur in type IIIA defects. This feature is important to recognize so that you may have a modular tapered stem available. The use of modular tapered stems are advocated for when retroversion is present so that there is independent filling of the proximal and distal portions of the femur. Independent rotation of the proximal and distal segments will allow for correction of the abnormal femoral version.
1.6. Type IIIB femoral bone loss management Comparable to type IIIA defects, the metaphysis is nonsupportive and severely damaged in type IIIB defects. Unlike type IIIA defects, there is less than 4 cm of intact diaphyseal cortical bone (Fig. 4). There is a high level of fibrous fixation when less than 4 cm of distal fixation is available. Type IIIB defects are commonly seen with failed long cemented stems or cementless stems with extensive distal osteolysis [8,23]. There is short segment of intact cortical bone, thus extensively porous coated stems are unable to obtain stability and ingrowth. The use of these extensively porous coated stems is associated with fibrous stable fixation [16]. Our preference is to use a modular tapered stem with antirotational splines that typically allow for 1 to 2 cm of diaphyseal bone contact.
1.7. Type IV femoral bone loss In type IV femoral defects, there is extensive metaphyseal and diaphyseal bone loss with no demonstrable isthmus (Fig. 5) [24,25]. In the past, management of this type of bone loss included the use of fully cemented implants with or without impaction grafting, allograft prosthesis composite reconstruction and megaprosthesis proximal femoral components [26,27]. Our preference today is to use a modular tapered stem similar to that used in a type IIIB defect. Modular tapered stems have been able to achieve stable fixation in cases of
Figure 3 – Paprosky Type IIIA femoral bone loss.
Figure 4 – Paprosky Type IIIB femoral bone loss.
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Figure 5 – Type IV Paprosky femoral bone loss.
type IV defects with extensive femoral bone loss. Early results with the use of modular tapered stems have demonstrated good overall survival at mid-term follow up [28,29].
2. Conclusion Management of femoral bone loss in the revision setting can be challenging for surgeons. The Paprosky femoral bone loss classification is based on the capability of identifying the defect and the ability of an extensively porous coated stem to bypass the nonsupportive femur and achieve fixation in the femoral diaphysis. Understanding this classification system will allow surgeons to appropriately plan and execute a surgical plan to provide the best outcomes for patients.
R EF E RE N C ES
[1] Maradit Kremers H, et al. Prevalence of Total Hip and Knee replacement in the United States. J Bone Joint Surg Am 2015;97:1386–97. € fer W, Kinkel S, Puhl W, Kessler S. [Revision total hip [2] Ka arthroplasty: analysis of the predictive value of a radiographic classification system for assessment of bone stock loss]. Z Orthop Ihre Grenzgeb 2003;141:672–7.
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[3] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [4] Ibrahim DA, Fernando ND. Classifications In Brief: the Paprosky classification of femoral bone loss. Clin Orthop Relat Res 2017;475:917–21. [5] Brown NM, et al. The inter-observer and intra-observer reliability of the Paprosky femoral bone loss classification system. J Arthroplasty 2014;29:1482–4. [6] Puri L, et al. Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg Am 2002;84-A:609–14. [7] Brown JM, et al. Femoral component revision of total hip arthroplasty. Orthopedics 2016;39:e1129–39. [8] Sheth NP, Nelson CL, Paprosky WG. Femoral bone loss in revision total hip arthroplasty: evaluation and management. J Am Acad Orthop Surg 2013;21:601–12. [9] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30. [10] Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop Relat Res 1993: 172–8. [11] Sierra RJ, Cabanela ME. Total hip arthroplasty in patients with underlying fibrous dysplasia. Orthopedics 2009;32:320. [12] Sierra RJ, Cabanela ME. Conversion of failed hip hemiarthroplasties after femoral neck fractures. Clin Orthop Relat Res 2002: 129–39. [13] Engh CA, Glassman AH, Griffin WL, Mayer JG. Results of cementless revision for failed cemented total hip arthroplasty. Clin Orthop Relat Res 1988: 91–110. [14] Holt G, Hook S, Hubble M. Revision total hip arthroplasty: the femoral side using cemented implants. Int Orthop 2011;35: 267–73. [15] Sporer SM, Paprosky WG. Femoral fixation in the face of considerable bone loss: the use of modular stems. Clin Orthop Relat Res 2004: 227–31. [16] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30. [17] Cameron HU. The long-term success of modular proximal fixation stems in revision total hip arthroplasty. J Arthroplasty 2002;17:138–41. [18] Valle CJD, Paprosky WG. Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone Joint Surg Am 2003;85-A (Suppl 4):1–6. [19] Bianchi L, Galante C, Zagra L. The management of femoral bone stock in THA revision: indications and techniques. Hip Int 2014;24(Suppl 10):S37–43. [20] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [21] Gie GA, et al. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1993;75:14–21. [22] Schreurs BW, et al. Femoral component revision with use of impaction bone-grafting and a cemented polished stem. Surgical technique. J Bone Joint Surg Am 2006;88(Suppl 1 Pt 2):259–74. [23] Sheth NP, Melnic CM, Rozell JC, Paprosky WG. Management of severe femoral bone loss in revision total hip arthroplasty. Orthop Clin North Am 2015;46:329–42. ix. [24] Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop Relat Res 1993: 172–8. [25] Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect 2000;49:119–30.
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[26] Mayle RE, Paprosky WG. Massive bone loss: allograft-prosthetic composites and beyond. J Bone Joint Surg Br 2012;94: 61–4. [27] Rogers BA, et al. Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis. J Arthroplasty 2012;27:829–36. e1.
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[28] Brown NM, et al. Modular tapered implants for severe femoral bone loss in THA: reliable osseointegration but frequent complications. Clin Orthop Relat Res 2015;473:555–60. [29] Cross MB, Paprosky WG. Managing femoral bone loss in revision total hip replacement: fluted tapered modular stems. Bone Joint J 2013;95-B:95–7.