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Radionuclide bone scan and MRI
3%
223/7264
Open reduction internal fixation with a cable plate and allograft strut
4%
314/7264
Revision arthroplasty with a fully coated cementless stem, cable wiring, and bone graft
59%
4254/7264
Revision arthroplasty with a modular, tapered stem and bone grafting of the diaphyseal fixation
26%
1857/7264
Revision arthroplasty with a total femur prosthesis
8%
565/7264
Select Answer to see Preferred Response
The radiograph is consistent with a periprosthetic femur fracture, with a loose femoral stem, and a Paprosky IIIA femoral defect. This is best treated with a fully-coated cementless stem with metaphyseal onlay allograft. Paprosky devised a classification for femoral bone loss following THA. The classification is as follows: Type I: minimal metaphyseal bone loss and intact diaphyseal fixation Type II: extensive metaphyseal bone loss with intact diaphyseal fixation Type IIIA: severe metaphyseal bone loss with greater than 4 cm of diaphyseal bone preservation for distal fixation. Type IIIB: severe metaphyseal bone loss and less than 4 cm of diaphyseal bone preservation for distal fixation Type IV: extensive metaphyseal and diaphyseal bone loss. Type IIIA may be treated with a fully coated stem. Type IIIB should consider a tapered, modular stem and/or bone grafting. Type IV likely needs a megaprosthesis. In this patient, given the preserved diaphyseal bone, revision arthroplasty with a fully coated femoral stem is the most appropriate treatment. The Sporer article reviews a case series of patients undergoing revision hip arthroplasty for femoral bone loss. Type IIIB defects with a femoral canal less than 19 mm may be treated with a fully porous-coated stem. However, patients with Type IIIB defect and a cavernous canal greater than 19 mm or a Type IV defect may need a modular tapered stem or a bone grafting procedure. The Paprosky article summarizes his classification of femoral bone loss in revision hip arthroplasty and provides an algorithm for treatment. Extensively porous-coated, diaphyseal filling femoral components showed excellent results in Paprosky IIIA defects. Radiograph A shows a total hip arthroplasty with severe metaphyseal bone loss and a supportive diaphysis. Incorrect Answers: Answer 1: No additional work-up is required prior to revision arthroplasty if laboratory results are negative for infection. Answer 2: Given the amount of bone loss and the loose femoral stem, fixation of the fracture/defect would not be advisable. Answers 4,5: These would be reasonable options if extensive bone loss was seen in the diaphysis.
2.2
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