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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.
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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.
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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.
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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
Fondazione Livio Sciutto Onlus, Campus Savona - Università degli Studi di Genova, Via
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Department of Orthopaedics and Traumatology, IRCCS Fondazione Policlinico San Matteo, University of Pavia, Pavia, Italy
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Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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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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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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IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, Italy
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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.
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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.
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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.
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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.
IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Fondazione Livio Sciutto Onlus, Campus Savona – Università degli Studi di Genova, Savona, Italy
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Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
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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.
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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.
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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.
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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.
