The Survivorship of Revision Total Hip Replacement With Severe Proximal Bone Deficiency Using a Modular Taper Fluted Prosthesis

The Survivorship of Revision Total Hip Replacement With Severe Proximal Bone Deficiency Using a Modular Taper Fluted Prosthesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article The Survivorship of Revision Total Hip Replacement With Severe Proximal Bone Deficiency Using a Modular Taper Fluted Prosthesis Siddharth Govilkar, Maulik Gandhi, Davinder Bhachu, John-Paul Whittaker, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-27900/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Contemporary uncemented femoral revision hip systems have become commonly used over the past decade and have enabled the reconstruction of leg length, offset and anteversionas independent variables through the use of modular junctions. Modular junction failures between the proximal body and distal stem have been described withrevision systems, although this is rare. We sought to identify the survivorship of one revision system in a salvage arthroplasty scenario where no host bone support of the modular junction was present. Methods From a series of 136 patients, 15 patients (16 hips) were identified without host bone support of the modular junction with a mean radiological follow up of over 6 years(76 months +/- 35 months). Results There have been no cases of prosthetic fracture over the follow-up duration, withtwo revisions performed for reasons of aseptic loosening and infection. The mean BMI of the study group was 30.2 with 78% of the cohort classified as overweight or obese. Conclusion It is well recognised that, host bone support of the modular junction is preferable, however the satisfactory outcomes over the midterm in these complex patients suggests that modular revision systems remain an option. Orthopedics hip modular junction failures revision arthroplasty Figures Figure 1 Background According to the National Joint Registry Report 2019, revision hip replacements contributed 10% of the hip arthroplasty workload in the UK totaling 101 561 primary & revision hip replacements [ 1 ]. The development of uncemented modular femoral revision hip systems have allowed for fixation in distal host bone whilst allowing for independent length control of offset and anteversion through the use of taper junctions with the proximal segment of the revision prosthesis [ 2 ]. In this study, we examined our experience with a single design, tapered, fluted, modular, titanium, uncemented revision system. A number of published series highlights the success of the system presented in this study with midterm follow-up [ 24 – 27 ]. Our aim was to identify mechanical failures at the proximal body-distal stem modular junction of the revision system (Stryker® Cone-Conical system, Stryker, Newbury, United Kingdom) in patients with severe loss of proximal host bone. We sought to clarify whether the continued use of the system in cases with absent proximal host bone coverage over the proximal body-distal stem modular junction is justified, not least given the alternative surgical options of a proximal femoral replacement, structural bulk allograft-prosthesis composite or revision monoblock stem[ 28 – 31 ]. The failure of differing designs of modular junction have been described as occurring through a multitude of mechanisms including corrosion (fretting/galvanic/crevice/pitting/inter-granular) [ 3 – 5 ] and mechanical failure of modular, distal-fit systems [ 6 – 9 ]. In the early years of these devices, systemic failures led to the withdrawal of a similar revision system [ 10 ]. Mechanical failure occurs through fatigue with repetitive cyclical loading of the modular junction between the proximal body and the distal stem [ 6 ], which represents the most biomechanically stressed area of the revision. Risk factors for failure of both titanium alloy [ 7 , 8 ] and cobalt chrome [ 11 ] revision femoral components include excessive body weight, inadequate proximal bony support, poor preoperative bone stock, osteolysis, loosening, high levels of physical activity, and/or implant under-sizing [ 7 , 8 , 11 , 12 ]. Since mechanical failures were reported in the early designs of modular, distal-fit systems [ 6 – 10 ], the modular junction design has evolved, incorporating a strengthened junction [ 9 ]. Reinforcing the proximal body-distal stem modular junction by using a strengthened junction design and advances in metallurgy, have reported reduced the rate of failure from 18.5–0% [ 9 ]. These results have encouraged the use of modular revision hip arthroplasty implants with reinforced junctions, particularly in patients with known risk factors for failure [ 8 , 9 ]. Manufacturing methods used to improve the taper strength of titanium-based femoral prostheses can be either mechanical (swaging, burnishing and shot peening) or non-mechanical (heat treatment, nitride impregnation and anodizing) [ 13 ]. Mechanical treatments affect the surface to a depth of approximately 0.25 mm – 0.50 mm [ 14 , 15 ], whilst non-mechanical treatments affect to a depth of less than 0.1 mm [ 13 ]. The increased depth conferred by mechanical treatment ultimately enhances the fatigue strength of the taper when compared to non-mechanical treatment [ 16 ]. It is unclear if the improved mid-term survivorship is the result of the strengthened junction design only (withstanding junction failure), or if there is a pre-requisite that the revision prosthesis modular junction must be covered by host bone. Rodriguez et al. concluded “failure to achieve osseointegration of the “proximal segment” did not compromise clinical function or distal function, but due to risk of implant fracture, regular follow up is desirable” [ 22 ]. There is a single report detailing the use of tapered, fluted, modular titanium stems with severe femoral bone loss [ 23 ]. In that study, one of 16 cases required revision for septic loosening [ 23 ]. Other published studies do not specify the degree of host bone support of the modular junction between the proximal body and distal stem immediately post operatively, although radiological evidence of loosening around the proximal components at the time of proximal body-distal stem junction failure have been observed in some cases [ 6 , 8 ]. There are published case series involving modular, distal fit revision systems that have demonstrated a greater than 5-year mean survivorship with no reported modular failures, although host bone support of the modular junction is unclear [ 17 – 20 ]. We believe the increased strength at the proximal body-distal stem junction and the surgical technique to cover this junction with host bone may have contributed for the decrease in mechanical failures reported. The strengthened design at the proximal body-distal stem modular junction is intended to help decrease local stress. Maximal stress is expected, even with a strengthened junction, when there is no proximal bony coverage of the prosthesis [ 21 ]. Methods A single design modular taper fluted femoral revision system was assessed in this study, in patients with severe proximal femoral bone loss. This was a retrospective, observational study, approved by the local research department advising no further ethical approval was required [ 32 ]. A consecutive series of patients with femoral bone deficiency (classified as Paprosky IIIB or IV [ 33 ]) receiving revision hip surgery using the modular taper fluted modular titanium system were identified. Two observers independently reviewed the host bone coverage over the proximal body-distal stem modular junction using postoperative radiographs. Absent support of the modular junction by host bone was defined as the lack of bone proximal to, and at the level of the proximal modular junction on at least 3 prosthetic surfaces viewed on antero-posterior (AP) and lateral radiographs of the proximal femur. If there was a consensus that there was deficient proximal host bone coverage over the modular junction at a minimum of two years of follow-up, the patient was entered into the study. The Kappa inter-observer agreement (κ) between the two observers was calculated using Cohen’s Kappa with squared weighting (statistics software R, version 3.0.3 (R Foundation for Statistical Computing)). Radiographs of representative cases from our study group, with modular proximal body-distal stem junction unsupported by host bone are shown in Fig. 1 . The operation record, clinical notes, and radiographs of study participants were reviewed. The primary endpoint was radiographic evidence of proximal body-distal stem modular junction failure. The secondary endpoint was revision for any other cause. All procedures were performed by, or under the supervision of, consultant revision hip surgeons using the surgical technique described by the manufacturer. The results are presented as means ± standard deviations (SD). The revision system used in our study consists of a distal fluted stem and proximal conical body made using a titanium alloy, Ti-6 Al-4V (Restoration Cone Conical, Stryker). The conical proximal bodies are circumferentially plasma sprayed with pure titanium and then over-sprayed with hydroxyapatite. A number of cone body diameters and lengths with variably sized offset options are available to allow correction of vertical and horizontal offsets. The manufacturing process for the system is designed to provide rotational and axial diaphyseal stability. The modular taper junction involves a “shot peening process” (mechanical treatment) to harden the taper junction and enhanced fatigue stress. Results Fifteen of 136 patients (representing 16 hips) receiving a single design modular Restoration revision hip prosthesis over a seven-year period met the inclusion criteria (Table 1 ). Details of the implant components used are summarized in Table 2 . There was excellent and significance Kappa inter-observer agreement between the two observers’ radiographic assessment of proximal host bone coverage (κ = 0.757, p < 0.0001). We present the results of clinical with radiographic follow-up and clinical follow-up in Table 1 . Table 1 Patient Demographics. Case Age at surgery in years BMI Indication for surgery Implant Survivorship (months) Clinical & Radiographic Clinical only 1 69.8 29 Aseptic loosening 112 112 2 58.2 33.5 2nd stage for infection 81 84 3 69.8 35 Painful girdlestone 57 86 (died) 4 67.1 21.4 Aseptic loosening 1 25 (died) 5 38.7 31 Aseptic loosening 92 95 6 63.1 24 2nd stage for infection 43* (revised) 43* (revised) 7 71.8 27.5 Aseptic loosening 115 115 8 75.3 27 2nd stage for infection 111 111 9 72.5 29 Aseptic loosening 97 97 10 80.4 26 Aseptic loosening 68 68 11 64.1 29 2nd stage for infection 117 117 12 65 31.2 2nd stage for infection 73 73 13 64.2 34 Aseptic loosening 28* (revised) 28* (revised) 14 64.2 36.5 2nd stage for infection 59 59 15 75.8 41 Aseptic loosening 42 80 (died) 16 79.7 27.8 Periprosthetic fracture 115 121 Table 2 Details of implant components used per case (* original acetabulum retained). Case Proximal body size Distal stem (length x diameter) Stem (straight or bowed) Femoral head (material, size) Acetabular component size 1 23 + 10 155 × 17 Straight SS, 28(+ 4) 40 2 25 + 20 195 × 17 Straight CoCr, 40(+ 8) 58 3 20 + 0 195 × 14 Straight CoCr, 44(+ 4) 70 4 27 + 60 195 × 21 Straight CoCr, 40 (-4) 58 5 29 + 0 155 × 15 Straight CoCr, 28(-4) 58 6 21 + 10 155 × 15 Straight CoCr, 28 (+ 0) 50* 7 31 + 30 235 × 20 Bowed SS, 36 (+ 0) 66 8 25 + 0 155 × 16 Straight CoCr, 40 (+ 0) 58 9 21 + 0 155 × 14 Straight CoCr, 40 (-4) 56 10 25 + 0 225 × 15 Straight CoCr, 36 (+ 0) 54 11 34 + 30 155 × 19 Straight CoCr, 32 (+ 12) 64 12 27 + 20 235 × 15 Bowed CoCr, 28 (+ 4) 56 13 21 + 10 155 × 15 Straight CoCr, 40 (+ 0) 60 14 23 + 20 195 × 18 Straight CoCr, 36 (+ 0) 60 15 19 + 10 195 × 17 Straight CoCr, 36 (+ 5) 56 16 23 + 40 155 × 17 Straight SS, 22.225 (+ 0) 40* Seven females and eight males were in the study group; one female had revision hip surgery, resulting in a final study group of 16 revision hip replacements. The mean age at surgery was 67.5 years (38.7 years to 80.4 years; SD 9.9 years). The mean survivorship of the unsupported junction to most recent follow-up with radiographs was over 6 years (1 month to 117 months; mean 76 months +/- 35 months). The mean survivorship of the unsupported junction to most recent clinical follow-up with documented survivorship was just under 7 years (25 months to 121 months; mean 82 months +/- 31 months). The mean body mass index (BMI) was 30.2 (21.4 to 41 +/- 4.9), with 78% of patients being categorized as overweight or obese. No proximal body-distal stem junction failures were identified during the follow-up period. Revisions were required for reasons unrelated to the femoral prosthesis in two cases: the first for aseptic loosening of an acetabular component and the second for infection. Revision surgery was therefore required in 11.8% of cases. Overall, stem survival was 100% at a mean follow-up of over 5 years (64.8 months +/- 32 months) and implant survival due to any cause was 88.2%. Discussion Revision hip surgery is challenging, especially when there is significant proximal femoral bone loss [ 2 ]. Surgical options in these arthroplasty salvage cases may include proximal femoral allograft-prosthesis composite reconstruction, proximal femoral replacement, and uncemented distal stem fixation [ 24 ]. Although the clinical outcomes of uncemented distal fit femoral stems are generally favorable [ 9 , 24 , 34 – 37 ], reports have described mechanical failures at the modular junction [ 3 , 4 , 8 ] or in areas where laser etching of the stem has been used [ 9 ]. There is evidence that proximal bony reconstitution can improve clinical outcomes, quality of life measures, and implant survivorship [ 8 , 26 , 27 , 34 – 38 ]. The stem survival of the revision system we used has been reported to be 96% at a mean follow-up of 42 months [ 24 ], and 94% at a mean follow-up of 4.5 years [ 25 ]. Holt et al reported on 46 patients with a mean BMI categorized as overweight and included patients with host bone support of the proximal body-distal stem modular junction [ 24 ]. It is our opinion that our obese patient cohort placed more stress at the proximal body-distal stem modular junction by having a higher mean BMI and no host bone support at the modular junction. Palumbo et al reported on 18 patients with a follow-up period similar to ours, however they do not report on the patients’ weight or post-operative host bone coverage of the junction [ 25 ]. Time from surgery to modular junction or stem failure of other comparable revision stems reveals a mean failure time of 47 months (+/- 25 months) [ 8 ], with our longest single case including radiographic follow-up being 115 months. We have not identified any prosthetic failures to the femoral component in our study despite the longer mean follow up time, although it is well recognized that mechanical failure is related to the dimensions of the device, material properties and the applied mechanical forces over time. Therefore the authors suggest caution with the use of smaller stem diameters particularly in patients with expected high demands or raised BMI. A lack of proximal femoral host bone leaving the proximal body-distal stem modular junction unsupported immediately post operatively has been identified as a risk factor for proximal body-distal stem modular junction failures in multiple revision systems currently used in clinical practice [ 7 , 8 , 11 ]. This suggests that the construction of this system is able to withstand fatigue of the proximal body-distal stem modular junction. There is limited evidence in current literature reviewing the clinical and radiological survivorship of total hip replacement revisions beyond a mean of 5 year follow up, in patient with severe proximal bone loss [ 24 – 27 ]. Although underlying risk factors always need to be considered before, during, and after revision, our results provide reassurance that the proximal body-distal stem junction of the contemporary revision prosthesis can prevent interface failures and can be used with confidence over the medium term even in the absence of proximal femoral bony support. Abbreviations BMI Body Mass Index References 12th Annual Report. 2015: National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. 2015. Rodriguez JA, Deshmukh AJ, Klauser WU, Rasquinha VJ, Lubinus P, Ranawat CS. Patterns of Osseointegration and Remodeling in Femoral Revision With Bone Loss Using Modular, Tapered, Fluted, Titanium Stems. J Arthroplasty. 2011;26:1409–17.e1. 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Results of revision total hip arthroplasty with modular, titanium-tapered femoral stems in severe proximal metaphyseal and diaphyseal bone loss. J Arthroplasty. 2013;28:690–4. Restrepo C, Mashadi M, Parvizi J, Austin MS, Hozack WJ. Modular Femoral Stems for Revision Total Hip Arthroplasty. Clin Orthop Relat Res 2011:476–82. Stimac JD, Boles J, Parkes N, Gonzalez Della Valle A, Boettner F, Westrich GH. Revision Total Hip Arthroplasty With Modular Femoral Stems. J Arthroplasty. 2014;29:2167–70. Lee PTH, Clayton R, Safir O, Backstein DJ, Gross AE. Structural allograft as an option for treating infected hip arthroplasty with massive bone loss. Clin Orthop Relat Res. 2011;469:1016–23. Babis GC, Sakellariou VI, O’Connor MI, Hanssen a D, Sim FH. Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year follow-up study. J Bone Joint Surg Br. 2010;92-B:349–55. Graham NM, Stockley I. The use of structural proximal femoral allografts in complex revision hip arthroplasty. J Bone Joint Surg Br. 2004;86-B:337–43. Mayle RE Jr, Paprosky WG. Massive bone loss: Allograft-prosthetic composites and beyond. J Bone Joint Surg Br. 2012;94-B:61–4. Health Research Authority. - Is my study research? Do I need NHS REC approval? n.d. http://www.hra-decisiontools.org.uk/ (accessed July 29, 2015). Della Valle C, Paprosky W. The femur in revision total hip arthroplasty evaluation and classification. Clin Orthop Relat Res 2004:55–62. Park M, Lee J, Park J, Ham D, Rhee Y. A Distal Fluted, Proximal Modular Femoral Prosthesis in Revision Hip Arthroplasty. J Arthroplasty. 2009;00:0–6. 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. Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE. Revision total hip arthroplasty with a porous-coated modular stem: 5 to 10 years follow-up. Clin Orthop Relat Res. 2010;468:1310–5. Richards CJ, Duncan CP, Masri B, a, Garbuz DS. Femoral revision hip arthroplasty: a comparison of two stem designs. Clin Orthop Relat Res. 2010;468:491–6. March G, Dehghan N, Gala L. Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty. J Arthroplast. 2014;29:2171–4. Acetabular defect classification and Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and. surgical reconstruction in. revision arthroplasty: a 6-year follow-up evaluation. J Arthroplasty. 1994;9:33–44. Supplementary Files IRBstatement.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-27900","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":689838,"identity":"e5ebd272-15f2-4f95-8be2-45620a9b867c","order_by":0,"name":"Siddharth Govilkar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDACZgYDCQYGCTl+hsMHGBgbYMIHCGqxMJZsPJZApBYGsJaKxA2HzxgQp0W+nXnjjQ81Eokz2858k/i5w0aOgf3wAWaeM3isOMxWbDnjmIRxP8/ZbZK9Z9KMGXjSEph5buDRwsxjJs3bICE7c8bZbRK8bYcTGyR4gIIf8DisGaKFccP9N88k/xKjheEwRIvihgNn2KQRtuBzGMwvkg3HjK1l29KM2YB+OTgHj/fl+w+DQqwOFJUPb75ts5HjZz988MGbY3gchgRYJEAkGwOhiEQCzPj8PApGwSgYBSMYAADN3VI3G98qRwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-6895-460X","institution":"Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Siddharth","middleName":"","lastName":"Govilkar","suffix":""},{"id":689839,"identity":"a0a05ce9-b032-4f9c-ae95-42aaed5d2a90","order_by":1,"name":"Maulik Gandhi","email":"","orcid":"","institution":"Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maulik","middleName":"","lastName":"Gandhi","suffix":""},{"id":689840,"identity":"e96d93cc-4835-4f27-a687-38fb9dedf462","order_by":2,"name":"Davinder Bhachu","email":"","orcid":"","institution":"The Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Davinder","middleName":"","lastName":"Bhachu","suffix":""},{"id":689841,"identity":"b24e4d1c-2c05-4e80-b3da-4b77fb5304db","order_by":3,"name":"John-Paul Whittaker","email":"","orcid":"","institution":"Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"John-Paul","middleName":"","lastName":"Whittaker","suffix":""},{"id":689842,"identity":"1073d49a-94e3-43fd-885a-c508c4f63d5c","order_by":4,"name":"Christopher Evans","email":"","orcid":"","institution":"Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Evans","suffix":""},{"id":689843,"identity":"def1ab90-8d07-4c2b-a4e0-e2fa8424bb79","order_by":5,"name":"Richard Spencer-Jones","email":"","orcid":"","institution":"Robert Jones and Agnes Hunt Orthopaedic Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Spencer-Jones","suffix":""}],"badges":[],"createdAt":"2020-05-08 08:46:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-27900/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-27900/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1369291,"identity":"04684614-5156-44a6-9d6d-f09b1a758f48","added_by":"auto","created_at":"2020-06-19 13:54:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57790,"visible":true,"origin":"","legend":"(A-D) – Plain Radiographs of Representative Cases with Unsupported Modular Proximal Body-Distal Stem Junction. 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The development of uncemented modular femoral revision hip systems have allowed for fixation in distal host bone whilst allowing for independent length control of offset and anteversion through the use of taper junctions with the proximal segment of the revision prosthesis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we examined our experience with a single design, tapered, fluted, modular, titanium, uncemented revision system. A number of published series highlights the success of the system presented in this study with midterm follow-up [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur aim was to identify mechanical failures at the proximal body-distal stem modular junction of the revision system (Stryker\u0026reg; Cone-Conical system, Stryker, Newbury, United Kingdom) in patients with severe loss of proximal host bone. We sought to clarify whether the continued use of the system in cases with absent proximal host bone coverage over the proximal body-distal stem modular junction is justified, not least given the alternative surgical options of a proximal femoral replacement, structural bulk allograft-prosthesis composite or revision monoblock stem[\u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe failure of differing designs of modular junction have been described as occurring through a multitude of mechanisms including corrosion (fretting/galvanic/crevice/pitting/inter-granular) [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and mechanical failure of modular, distal-fit systems [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the early years of these devices, systemic failures led to the withdrawal of a similar revision system [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Mechanical failure occurs through fatigue with repetitive cyclical loading of the modular junction between the proximal body and the distal stem [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which represents the most biomechanically stressed area of the revision. Risk factors for failure of both titanium alloy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and cobalt chrome [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] revision femoral components include excessive body weight, inadequate proximal bony support, poor preoperative bone stock, osteolysis, loosening, high levels of physical activity, and/or implant under-sizing [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince mechanical failures were reported in the early designs of modular, distal-fit systems [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the modular junction design has evolved, incorporating a strengthened junction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Reinforcing the proximal body-distal stem modular junction by using a strengthened junction design and advances in metallurgy, have reported reduced the rate of failure from 18.5\u0026ndash;0% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These results have encouraged the use of modular revision hip arthroplasty implants with reinforced junctions, particularly in patients with known risk factors for failure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Manufacturing methods used to improve the taper strength of titanium-based femoral prostheses can be either mechanical (swaging, burnishing and shot peening) or non-mechanical (heat treatment, nitride impregnation and anodizing) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Mechanical treatments affect the surface to a depth of approximately 0.25\u0026nbsp;mm \u0026ndash; 0.50\u0026nbsp;mm [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], whilst non-mechanical treatments affect to a depth of less than 0.1\u0026nbsp;mm [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The increased depth conferred by mechanical treatment ultimately enhances the fatigue strength of the taper when compared to non-mechanical treatment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is unclear if the improved mid-term survivorship is the result of the strengthened junction design only (withstanding junction failure), or if there is a pre-requisite that the revision prosthesis modular junction must be covered by host bone. Rodriguez et al. concluded \u0026ldquo;failure to achieve osseointegration of the \u0026ldquo;proximal segment\u0026rdquo; did not compromise clinical function or distal function, but due to risk of implant fracture, regular follow up is desirable\u0026rdquo; [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. There is a single report detailing the use of tapered, fluted, modular titanium stems with severe femoral bone loss [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In that study, one of 16 cases required revision for septic loosening [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Other published studies do not specify the degree of host bone support of the modular junction between the proximal body and distal stem immediately post operatively, although radiological evidence of loosening around the proximal components at the time of proximal body-distal stem junction failure have been observed in some cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are published case series involving modular, distal fit revision systems that have demonstrated a greater than 5-year mean survivorship with no reported modular failures, although host bone support of the modular junction is unclear [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We believe the increased strength at the proximal body-distal stem junction and the surgical technique to cover this junction with host bone may have contributed for the decrease in mechanical failures reported. The strengthened design at the proximal body-distal stem modular junction is intended to help decrease local stress. Maximal stress is expected, even with a strengthened junction, when there is no proximal bony coverage of the prosthesis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eA single design modular taper fluted femoral revision system was assessed in this study, in patients with severe proximal femoral bone loss. This was a retrospective, observational study, approved by the local research department advising no further ethical approval was required [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA consecutive series of patients with femoral bone deficiency (classified as Paprosky IIIB or IV [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]) receiving revision hip surgery using the modular taper fluted modular titanium system were identified. Two observers independently reviewed the host bone coverage over the proximal body-distal stem modular junction using postoperative radiographs. Absent support of the modular junction by host bone was defined as the lack of bone proximal to, and at the level of the proximal modular junction on at least 3 prosthetic surfaces viewed on antero-posterior (AP) and lateral radiographs of the proximal femur. If there was a consensus that there was deficient proximal host bone coverage over the modular junction at a minimum of two years of follow-up, the patient was entered into the study. The Kappa inter-observer agreement (κ) between the two observers was calculated using Cohen\u0026rsquo;s Kappa with squared weighting (statistics software R, version 3.0.3 (R Foundation for Statistical Computing)). Radiographs of representative cases from our study group, with modular proximal body-distal stem junction unsupported by host bone are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The operation record, clinical notes, and radiographs of study participants were reviewed. The primary endpoint was radiographic evidence of proximal body-distal stem modular junction failure. The secondary endpoint was revision for any other cause. All procedures were performed by, or under the supervision of, consultant revision hip surgeons using the surgical technique described by the manufacturer. The results are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD).\u003c/p\u003e \u003cp\u003eThe revision system used in our study consists of a distal fluted stem and proximal conical body made using a titanium alloy, Ti-6 Al-4V (Restoration Cone Conical, Stryker). The conical proximal bodies are circumferentially plasma sprayed with pure titanium and then over-sprayed with hydroxyapatite. A number of cone body diameters and lengths with variably sized offset options are available to allow correction of vertical and horizontal offsets. The manufacturing process for the system is designed to provide rotational and axial diaphyseal stability. The modular taper junction involves a \u0026ldquo;shot peening process\u0026rdquo; (mechanical treatment) to harden the taper junction and enhanced fatigue stress.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Results","content":" \u003cp\u003eFifteen of 136 patients (representing 16 hips) receiving a single design modular Restoration revision hip prosthesis over a seven-year period met the inclusion criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Details of the implant components used are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There was excellent and significance Kappa inter-observer agreement between the two observers\u0026rsquo; radiographic assessment of proximal host bone coverage (κ\u0026thinsp;=\u0026thinsp;0.757, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). We present the results of clinical with radiographic follow-up and clinical follow-up in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge at surgery in years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndication for surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eImplant Survivorship (months)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical \u0026amp; Radiographic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClinical only\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePainful girdlestone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e86 (died)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 (died)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43* (revised)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43* (revised)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28* (revised)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28* (revised)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd stage for infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAseptic loosening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80 (died)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeriprosthetic fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of implant components used per case (* original acetabulum retained).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProximal body size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistal stem (length x diameter)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStem (straight or bowed)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemoral head (material,\u003c/p\u003e \u003cp\u003esize)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcetabular component size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e23\u0026thinsp;+\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSS, 28(+\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e25\u0026thinsp;+\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e195\u0026thinsp;\u0026times;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 40(+\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e20\u0026thinsp;+\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e195\u0026thinsp;\u0026times;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 44(+\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e27\u0026thinsp;+\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e195\u0026thinsp;\u0026times;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 40 (-4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e29\u0026thinsp;+\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 28(-4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e21\u0026thinsp;+\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 28 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e31\u0026thinsp;+\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e235\u0026thinsp;\u0026times;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSS, 36 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e25\u0026thinsp;+\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 40 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e21\u0026thinsp;+\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 40 (-4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e25\u0026thinsp;+\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e225\u0026thinsp;\u0026times;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 36 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e34\u0026thinsp;+\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 32 (+\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e27\u0026thinsp;+\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e235\u0026thinsp;\u0026times;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 28 (+\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e21\u0026thinsp;+\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 40 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e23\u0026thinsp;+\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e195\u0026thinsp;\u0026times;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 36 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e19\u0026thinsp;+\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e195\u0026thinsp;\u0026times;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoCr, 36 (+\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e23\u0026thinsp;+\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c3\"\u003e \u003cp\u003e155\u0026thinsp;\u0026times;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStraight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSS, 22.225 (+\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSeven females and eight males were in the study group; one female had revision hip surgery, resulting in a final study group of 16 revision hip replacements. The mean age at surgery was 67.5\u0026nbsp;years (38.7\u0026nbsp;years to 80.4 years; SD 9.9\u0026nbsp;years). The mean survivorship of the unsupported junction to most recent follow-up with radiographs was over 6\u0026nbsp;years (1\u0026nbsp;month to 117 months; mean 76\u0026nbsp;months +/- 35\u0026nbsp;months). The mean survivorship of the unsupported junction to most recent clinical follow-up with documented survivorship was just under 7\u0026nbsp;years (25\u0026nbsp;months to 121 months; mean 82\u0026nbsp;months +/- 31\u0026nbsp;months). The mean body mass index (BMI) was 30.2 (21.4 to 41 +/- 4.9), with 78% of patients being categorized as overweight or obese.\u003c/p\u003e \u003cp\u003eNo proximal body-distal stem junction failures were identified during the follow-up period. Revisions were required for reasons unrelated to the femoral prosthesis in two cases: the first for aseptic loosening of an acetabular component and the second for infection. Revision surgery was therefore required in 11.8% of cases.\u003c/p\u003e \u003cp\u003eOverall, stem survival was 100% at a mean follow-up of over 5\u0026nbsp;years (64.8\u0026nbsp;months +/- 32\u0026nbsp;months) and implant survival due to any cause was 88.2%.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eRevision hip surgery is challenging, especially when there is significant proximal femoral bone loss [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Surgical options in these arthroplasty salvage cases may include proximal femoral allograft-prosthesis composite reconstruction, proximal femoral replacement, and uncemented distal stem fixation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although the clinical outcomes of uncemented distal fit femoral stems are generally favorable [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], reports have described mechanical failures at the modular junction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] or in areas where laser etching of the stem has been used [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. There is evidence that proximal bony reconstitution can improve clinical outcomes, quality of life measures, and implant survivorship [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe stem survival of the revision system we used has been reported to be 96% at a mean follow-up of 42\u0026nbsp;months [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and 94% at a mean follow-up of 4.5\u0026nbsp;years [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Holt et al reported on 46 patients with a mean BMI categorized as overweight and included patients with host bone support of the proximal body-distal stem modular junction [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It is our opinion that our obese patient cohort placed more stress at the proximal body-distal stem modular junction by having a higher mean BMI and no host bone support at the modular junction. Palumbo et al reported on 18 patients with a follow-up period similar to ours, however they do not report on the patients\u0026rsquo; weight or post-operative host bone coverage of the junction [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTime from surgery to modular junction or stem failure of other comparable revision stems reveals a mean failure time of 47 months (+/- 25 months) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], with our longest single case including radiographic follow-up being 115 months.\u003c/p\u003e \u003cp\u003eWe have not identified any prosthetic failures to the femoral component in our study despite the longer mean follow up time, although it is well recognized that mechanical failure is related to the dimensions of the device, material properties and the applied mechanical forces over time.\u003c/p\u003e \u003cp\u003eTherefore the authors suggest caution with the use of smaller stem diameters particularly in patients with expected high demands or raised BMI.\u003c/p\u003e \u003cp\u003eA lack of proximal femoral host bone leaving the proximal body-distal stem modular junction unsupported immediately post operatively has been identified as a risk factor for proximal body-distal stem modular junction failures in multiple revision systems currently used in clinical practice [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This suggests that the construction of this system is able to withstand fatigue of the proximal body-distal stem modular junction. There is limited evidence in current literature reviewing the clinical and radiological survivorship of total hip replacement revisions beyond a mean of 5\u0026nbsp;year follow up, in patient with severe proximal bone loss [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough underlying risk factors always need to be considered before, during, and after revision, our results provide reassurance that the proximal body-distal stem junction of the contemporary revision prosthesis can prevent interface failures and can be used with confidence over the medium term even in the absence of proximal femoral bony support.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cb\u003eBody Mass Index\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"References","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003e12th Annual Report. 2015: National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. 2015.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRodriguez JA, Deshmukh AJ, Klauser WU, Rasquinha VJ, Lubinus P, Ranawat CS. Patterns of Osseointegration and Remodeling in Femoral Revision With Bone Loss Using Modular, Tapered, Fluted, Titanium Stems. J Arthroplasty. 2011;26:1409\u0026ndash;17.e1.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCooper HJ, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, et al. Corrosion at the Head-Neck Taper as a Cause. J Bone Jt Surgery Am Vol. 2012;94:1655\u0026ndash;61.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eJacobs JJ, Cooper HJ, Urban RM, Wixson RL, Valle CJ, Della. What Do We Know About Taper Corrosion in Total Hip Arthroplasty ? J Arthroplasty. 2014;29:668\u0026ndash;9.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePivec R, Meneghini RM, Hozack WJ, Westrich GH, Mont M a. Modular taper junction corrosion and failure: How to approach a recalled total hip arthroplasty implant. J Arthroplasty 2014;29:1\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eEfe T, Schmitt J. Case Report Analyses of Prosthesis Stem Failures in Noncemented Modular Hip Revision Prostheses. J Arthroplasty. 2011;26:665.e7\u0026ndash;12.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eButtaro M, Mayor MB, Van Citters D, Piccaluga F. Fatigue fracture of a proximally modular, distally tapered fluted implant with diaphyseal fixation. J Arthroplasty. 2007;22:780\u0026ndash;3.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eLakstein D, Eliaz N, Levi O, Backstein D, Kosashvili Y, Safir O, et al. Fracture of cementless femoral stems at the mid-stem junction in modular revision hip arthroplasty systems. J Bone Joint Surg Am. 2011;93:57\u0026ndash;65.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eVan Houwelingen AP, Duncan CP, Masri BA, Greidanus NV, Garbuz DS. High survival of modular tapered stems for proximal femoral bone defects at 5 to 10 years followup hip. Clin Orthop Relat Res. 2013;471:454\u0026ndash;62.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eFemoral stem fractures in. Zimmer modular revision (ZMR) hip systems. TGA News. 2003;40:17.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBusch CA, Charles MN, Haydon CM, Bourne RB, Rorabeck CH, Macdonald SJ, et al. Fractures of distally-fixed femoral stems after revision arthroplasty. J Bone Joint Surg Br. 2005;87:1333\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eNorman P, Iyengar S, Svensson I, Flivik G. Fatigue Fracture in Dual Modular Revision Total Hip Arthroplasty Stems. Failure Analysis and Computed Tomography Diagnostics in Two Cases. J Arthroplast. 2014;29:850\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eWatanabe Y, Hasegawa N, Endo H, Marui E, Aoki Y. An effect of peening on fretting fatigue. Proc. 7th Int. Conf. Shot Peen. Warsaw, Pol., 1999, p.\u0026nbsp;127\u0026ndash;34.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDrechsler A, Kiese J, Wagner L. Effects of shot peening and roller-burnishing on fatigue performance of various titanium alloys. Proc. 7th Int. Conf. Shot Peen. Warsaw, Pol., 1999, p.\u0026nbsp;145\u0026ndash;52.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCompany MI. Shot Peening Applications 9th edition. Curtiss Wright; 2005.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eStryker. Technical Report No. MT03051. 2002.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eAmanatullah DF, Howard JL, Siman H, Trousdale RT, Mabry TM, Berry DJ. Revision total hip arthroplasty in patients with extensive proximal femoral bone loss using a fluted tapered modular femoral component. Bone Joint J. 2015;97-B:312\u0026ndash;7.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eMarch GMJ, Dehghan N, Gala L, Spangehl MJ, Kim PR. Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty. J Arthroplasty. 2014;29:2171\u0026ndash;4.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eFink B, Urbansky K, Schuster P. Mid term results with the curved modular tapered, fluted titanium Revitan stem in revision hip replacement. Bone Joint J. 2014;96 B:889\u0026ndash;95.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePelt C, Madsen W, Erickson J, Gililland J, Anderson M, Peters C. Revision Total Hip Arthroplasty with a Modular Cementless Femoral Stem. J Arthroplasty. 2014;29:1803\u0026ndash;7.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCrowninshield RD, Maloney WJ, Wentz DH, Levine DL. The role of proximal femoral support in stress development within hip prostheses. Clin Orthop Relat Res 2004:176\u0026ndash;80.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRodriguez J, Deshmukh AJ, Robinson J, Cornell CN, Rasquinha VJ, Ranawat AS, et al. Reproducible fixation with a tapered, fluted, modular, titanium stem in revision hip arthroplasty at 8\u0026ndash;15 years follow-up. J Arthroplasty. 2014;29:214\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSporer SM, Paprosky WG. Femoral Fixation in the Face of Considerable Bone Loss. Clin Orthop Relat Res. 2004;429:227\u0026ndash;31.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eHolt G, McCaul J, Jones B, Ingram R, Stark A. Outcome After Femoral Revision Using the Restoration Cone/Conical Femoral Revision Stem. Orthopedics 2011;34:11.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePalumbo BT, Morrison KL, Baumgarten AS, Stein MI, Haidukewych GJ, Bernasek TL. Results of revision total hip arthroplasty with modular, titanium-tapered femoral stems in severe proximal metaphyseal and diaphyseal bone loss. J Arthroplasty. 2013;28:690\u0026ndash;4.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRestrepo C, Mashadi M, Parvizi J, Austin MS, Hozack WJ. Modular Femoral Stems for Revision Total Hip Arthroplasty. Clin Orthop Relat Res 2011:476\u0026ndash;82.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eStimac JD, Boles J, Parkes N, Gonzalez Della Valle A, Boettner F, Westrich GH. Revision Total Hip Arthroplasty With Modular Femoral Stems. J Arthroplasty. 2014;29:2167\u0026ndash;70.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eLee PTH, Clayton R, Safir O, Backstein DJ, Gross AE. Structural allograft as an option for treating infected hip arthroplasty with massive bone loss. Clin Orthop Relat Res. 2011;469:1016\u0026ndash;23.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBabis GC, Sakellariou VI, O\u0026rsquo;Connor MI, Hanssen a D, Sim FH. Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year follow-up study. J Bone Joint Surg Br. 2010;92-B:349\u0026ndash;55.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eGraham NM, Stockley I. The use of structural proximal femoral allografts in complex revision hip arthroplasty. J Bone Joint Surg Br. 2004;86-B:337\u0026ndash;43.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eMayle RE Jr, Paprosky WG. Massive bone loss: Allograft-prosthetic composites and beyond. J Bone Joint Surg Br. 2012;94-B:61\u0026ndash;4.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eHealth Research Authority. - Is my study research? Do I need NHS REC approval? n.d. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.hra-decisiontools.org.uk/\u003c/span\u003e\u003c/span\u003e (accessed July 29, 2015).\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDella Valle C, Paprosky W. The femur in revision total hip arthroplasty evaluation and classification. Clin Orthop Relat Res 2004:55\u0026ndash;62.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003ePark M, Lee J, Park J, Ham D, Rhee Y. A Distal Fluted, Proximal Modular Femoral Prosthesis in Revision Hip Arthroplasty. J Arthroplasty. 2009;00:0\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eWeiss 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\u0026ndash;23.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eLakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE. Revision total hip arthroplasty with a porous-coated modular stem: 5 to 10 years follow-up. Clin Orthop Relat Res. 2010;468:1310\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eRichards CJ, Duncan CP, Masri B, a, Garbuz DS. Femoral revision hip arthroplasty: a comparison of two stem designs. Clin Orthop Relat Res. 2010;468:491\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eMarch G, Dehghan N, Gala L. Proximal Femoral Arthroplasty in Patients Undergoing Revision Hip Arthroplasty. J Arthroplast. 2014;29:2171\u0026ndash;4.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cdiv class=\"PublisherLocation\"\u003eAcetabular defect classification and\u003c/div\u003e \u003cspan\u003ePaprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003esurgical reconstruction in. revision arthroplasty: a 6-year follow-up evaluation. J Arthroplasty. 1994;9:33\u0026ndash;44.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hip, modular, junction, failures, revision, arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-27900/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-27900/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eContemporary uncemented femoral revision hip systems have become commonly used over the past decade and have enabled the reconstruction of leg length, offset and anteversionas independent variables through the use of modular junctions. Modular junction failures between the proximal body and distal stem have been described withrevision systems, although this is rare. We sought to identify the survivorship of one revision system in a salvage arthroplasty scenario where no host bone support of the modular junction was present.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFrom a series of 136 patients, 15 patients (16 hips) were identified without host bone support of the modular junction with a mean radiological follow up of over 6 years(76 months +/- 35 months).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThere have been no cases of prosthetic fracture over the follow-up duration, withtwo revisions performed for reasons of aseptic loosening and infection. The mean BMI of the study group was 30.2 with 78% of the cohort classified as overweight or obese.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eIt is well recognised that, host bone support of the modular junction is preferable, however the satisfactory outcomes over the midterm in these complex patients suggests that modular revision systems remain an option.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"The Survivorship of Revision Total Hip Replacement With Severe Proximal Bone Deficiency Using a Modular Taper Fluted Prosthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-19 13:54:01","doi":"10.21203/rs.3.rs-27900/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0695f9e6-a5e4-4f0e-a8fd-bc3bec1d152b","owner":[],"postedDate":"June 19th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":125042,"name":"Orthopedics"}],"tags":[],"updatedAt":"2020-07-12T17:48:30+00:00","versionOfRecord":[],"versionCreatedAt":"2020-06-19 13:54:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-27900","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-27900","identity":"rs-27900","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}