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Mattia Loppini Department of Biomedical Sciences, Humanitas University, Italy; Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Center, Italy

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Guido Grappiolo Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Center, Italy

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  • Over the last two decades, several conservative femoral prostheses have been designed. The goals of conservative stems include: the spearing of the trochanteric bone stock; a more physiological loading in the proximal femur reducing the risk of stress shielding; and to avoid a long stem into the diaphysis preventing impingement with the femoral cortex and thigh pain.

  • All stems designed to be less invasive than conventional uncemented stems are commonly named ‘short stems’. However, this term is misleading because it refers to a heterogeneous group of stems deeply different in terms of design, biomechanics and bearing. In the short-term follow-up, all conservative stems provided excellent survivorship. However, variable rates of complications were reported, including stem malalignment, incorrect stem sizing and intra-operative fracture.

  • Radiostereometric analysis (RSA) studies demonstrated that some conservative stems were affected by an early slight migration and rotation within the first months after surgery, followed by a secondary stable fixation. Dual-energy x-ray absorptiometry (DEXA) studies demonstrated an implant-specific pattern of bone remodelling.

  • Although the vast majority of stems demonstrated a good osseointegration, some prostheses transferred loads particularly to the lateral and distal-medial regions, favouring proximal stress shielding and bone atrophy in the great trochanter and calcar regions.

Cite this article: EFORT Open Rev 2018;3:149-159. DOI: 10.1302/2058-5241.3.170052

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Guido Grappiolo IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via

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Edoardo Guazzoni IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Department of Orthopaedics and Traumatology, IRCCS Fondazione Policlinico San Matteo, University of Pavia, Pavia, Italy

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Francesco Manlio Gambaro Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy

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Mattia Loppini IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy

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Mattia Loppini Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy
IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via Magliotto 2, Savona, Italy

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Francesco Manlio Gambaro Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy
IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy

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Marco di Maio Università degli Studi di Trieste, Piazzale Europa 1, Trieste, Italy

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Guido Grappiolo IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via Magliotto 2, Savona, Italy

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  • The number of primary total hip arthroplasties (THAs) and revisions is expected to steadily grow in the future. The femoral revision surgery can be technically demanding whether severe bone defects need to be addressed.

  • The femoral revision aims to obtain a proper primary stability of the stem with a more proximal fixation as possible. Several authors previously proposed classification systems to describe the morphology of the bony femoral defect and to drive accordingly the surgeon in the revision procedure.

  • The previous classifications mainly considered cortical and medullary bone at the level of the defect of poor quality by definition. Therefore, the surgical strategies aimed to achieve a distal fixation bypassing the defect or to fill the defect with bone impaction grafting or structured bone grafts up to the replacement of the proximal femur with megaprosthesis.

  • The consensus on a comprehensive and reliable classification system and management algorithm is still lacking. A new classification system should be developed taking into account the bone quality. The rationale of a new classification is that ‘functional’ residual bone stock could be present at the level of the defect. Therefore, it can be used to achieve a primary (mechanical) and secondary (biological) stability of the implants with a femoral fixation more proximal as possible.

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Mattia Loppini Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona – Università degli Studi di Genova, Savona, Italy

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Francesco Manlio Gambaro Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy

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Rob G H H Nelissen Landelijke Registratie Orthopedische Implantaten (Dutch Arthroplasty Register), ’s Hertogenbosch, The Netherlands
Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands

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Guido Grappiolo IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona – Università degli Studi di Genova, Savona, Italy

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  • The study investigated the existing guidelines on the quality and frequency of the follow-up visits after total hip replacement surgery and assessed the level of evidence of these recommendations.

  • The review process was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional works were retrieved by direct investigation of the available guidelines of the most important orthopedic societies and regulatory agencies.

  • The current systematic review of the literature resulted in zero original papers, four guidelines for routine follow-up and three guidelines for special cases. Concerning the quality of evidence behind them, these guidelines were not evidence based but drafted from expert consensus.

  • The most important finding of this review is the large variation of recommendations in the follow-up schedule after total hip arthroplasty and the lack of evidence-based indications. Indeed, all the above-reported guidelines are the result of a consensus among experts in the field (level of recommendation class D ‘very low’) and not based on clinical studies.

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Charles Rivière MSK Lab, Imperial College London, UK; South West London Elective Orthopaedic Centre, UK

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Guido Grappiolo Unit of Hip Diseases and Joint Replacement Surgery, Humanitas Clinical and Research Center, Italy

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Charles A. Engh Jr Anderson Orthopaedic Research Institute, USA

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Jean-Pierre Vidalain Artro Group, France

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Antonia-F. Chen Rothman Institute of Orthopaedics, USA

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Nicolas Boehler Orthopaedic Department, Kepleruniklinikum Linz, Austria

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Jihad Matta Hôpital Maisonneuve-Rosemont, Canada

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Pascal-André Vendittoli Hôpital Maisonneuve-Rosemont, Université de Montréal, Canada

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  • Bone remodelling around a stem is an unavoidable long-term physiological process highly related to implant design. For some predisposed patients, it can lead to periprosthetic bone loss secondary to severe stress-shielding, which is thought to be detrimental by contributing to late loosening, late periprosthetic fracture, and thus rendering revision surgery more complicated.

  • However, these concerns remain theoretical, since late loosening has yet to be documented among bone ingrowth cementless stems demonstrating periprosthetic bone loss associated with stress-shielding.

  • Because none of the stems replicate the physiological load pattern on the proximal femur, each stem design is associated with a specific load pattern leading to specific adaptive periprosthetic bone remodelling. In their daily practice, orthopaedic surgeons need to differentiate physiological long-term bone remodelling patterns from pathological conditions such as loosening, sepsis or osteolysis.

  • To aid in that process, we decided to clarify the behaviour of the five most used femoral stems. In order to provide translational knowledge, we decided to gather the designers’ and experts’ knowledge and experience related to the design rationale and the long-term bone remodelling of the following femoral stems we deemed ‘legendary’ and still commonly used: Corail (Depuy); Taperloc (Biomet); AML (Depuy); Alloclassic (Zimmer); and CLS-Spotorno (Zimmer).

Cite this article: EFORT Open Rev 2018;3:45-57. DOI: 10.1302/2058-5241.3.170024

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