Abstract: Introduction: Revision hip replacement following failed previous hip arthroplasty or internal fixation (dynamic hip screw for intertrochanteric fractures) presents a major surgical challenge. Proximal fitting revision stems do not achieve adequate fixation. Distal fixation with long-stemmed extensively coated cementless implants (like the Solutionâ„¢ system) affords a suitable alternative. We present our results of 25 patients treated with extensively coated cementless revision stems.
Materials and Methods: Twenty five patients with severely compromised proximal femora following either failed hip arthroplasty or failed internal fixation (dynamic hip screw fixation for intertrochanteric fractures) were operated by the senior author over a two-year period. six patients had aseptic loosening of their femoral stems following cemented hip replacements, with severe thinning of their proximal cortices and impending stress fractures. Ten patients had secondary hip arthritis following failure of implants for comminuted intertrochanteric or subtrochanteric femoral fractures. Nine patients had peri-implant fracture following previous primary hip replacement. All patients were treated by removal of implant (cemented or uncemented stems/DHS implants) and insertion of long-stemmed extensively coated cementless revision (‘Solution™ DePuy, Warsaw (IN), US’) stems along with press-fit acetabular component (Duraloc Cup, DePuy, Warsaw (IN), US). Nine patient with peri-implant fracture and five having compromised proximal femora after inter trochanteric fracture needed osteotomy and undergone encerclage wiring. One patient had protrusion of acetabular cup with deficient acetabular wall in which anti protrusion cage was used.
Results: All patients were primarily kept in bed on physiotherapy for six weeks and then gradually progressed to weight-bearing walking over the next six to eight weeks. The Harris Hip Scores and patient satisfaction were used for final evaluation. We achieved good results in the two years duration of study. Out of 25 patients, cerclage wiring was done for peri-implant fractures and osteotomy in 14 patients. One patient had a intraoperative fracture extending into subtrochantric area while hammering in the stem. Post cerclage wiring, she was put on a long knee brace and her mobilization was delayed to 12 weeks.
Conclusions: The extensively coated cementless (‘Solution™’) femoral stem provides a reasonable ‘solution’ to the deficient femur in hip revision. The proximal femoral deficiences can be relatively easily adressed and distal fixation can be achieved with this stem. Extreme care needs to be taken to avoid fractures and penetration of the femoral shaft, which can, however, be managed by cerclage wiring. successful outcome can be assured by preservation of the functional continuity of the abduction apparatus, care to recognize and prevent distal extension of fracture while inserting the stem and supervised gradual rehabilitation post operatively.
