Treatment of femoral bone loss in revision total hip arthroplasty: a clinical practice review

Patient and implant selection is essential to optimize outcome. Femoral bone loss classifications such as the American Academy of Orthopaedic Surgeons, Gross, and Paprosky classifications permit surgeons to systematically manage bone stock deficiencies and guide implant selection. Here we provide a comprehensive report on the pitfalls and management of this reconstructive challenge. Preoperative planning remains vital to the treatment of femoral bone loss in revision hip arthroplasty and the authors believe it is essential and should include the entire femur. This commonly includes imaging for bone loss such as Judet views or computed tomography scan and must include the entire femur though additional radiographs such as Judet views apply more for acetabular bone loss as opposed to femoral bone loss. All patients should have pre-operative work up to exclude infection. If any of these results area elevated, an aspirate and sampling is required to guide microbiological management. Classically with regards femoral revision surgery, uncemented fixation has proven to give the best outcomes but surgeons must remain flexible and use cemented fixation when necessary. Adequate proximal bone stock permits the use of implants used in primary joint surgery. Implants with proximal modularity can be used in cases where bone stock allows for superb proximal bone support. The vast majority of femoral revisions have inadequate proximal bone stock, thus distally fixed stems should be used and have been shown to provide both axial and rotational stability provided there is an intact isthmus. Taper fluted stems can provide good outcomes even in cases of major bone loss. However, with severe bony loss, impaction grating or the use of a megaprotsthesis is sometimes necessary and is down to surgeon choice and preference. This article has been written as a guide for management and summarises the best evidence available.