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. 2020 Oct 6;14:29–33. doi: 10.1016/j.jcot.2020.09.033

Role of a bone conserving short stem femoral component in revision total hip arthroplasty: A case report

Babaji Thorat 1,∗, Avtar Singh 1, Rajeev Vohra 1
PMCID: PMC7920142  PMID: 33717893

Abstract

Choice of the implant during revision total hip arthroplasty (THA) is crucial in younger patients due to the impaired quality of bone and deficient bone stock. The short femoral stem provides an appealing unorthodox alternative implant in young patients undergoing primary total hip arthroplasty. A classic revision total hip arthroplasty predominantly describes the use of conventional or long stem for revision of the femoral component. However, little is known about the use of short femoral stem in revision THA.

This case report discusses the revision of cemented conventional femoral stem using a bone-conserving short-stem femoral implant with circumferential metaphyseal fixation, which is seldom reported in the literature. Associated benefits are less aggressive surgery with a reduction in blood loss, magnitude and duration of surgery by avoiding the removal of distal cement in the femur canal, thus making the femoral component revision easier. Moreover, it facilitates postoperative rehabilitation and recovery as well. Also, it preserves the femoral bone stock and offers a long term solution especially in young patients retaining the choice of using a conventional or long stem femoral implant should a second revision becomes imperative.

Keywords: Revision, Total hip arthroplasty, Short femoral stem, Femoral component revision

1. Introduction

Considering the broadened indications, increase in life expectancy and the overwhelming success of primary total hip arthroplasty (THA), there is a rapid increase in the incidence of THA in young patients, thereby, the revision rate is expected to follow the same curve.1

Aseptic loosening is the major cause of late failure of THA and is responsible for up to 55% of THA revision surgeries.2 Previous literature describes the frequent use of conventional or long femoral stems for revision of femoral component.3 Cementless femoral component fixation needs maximised fitting, immediate press-fit stability, and optimal bone ingrowth for long-term survivorship. However, the above requirements are not easily met during revision of aseptic loosening due to osteolysis and osteoporosis.3

Here, we report use of a bone conserving cementless metaphyseal short femoral stem for revision THA of a patient with aseptic loosening of primary cemented THA.

2. Case discussion

A 55-year-old male presented to our emergency department with severe right hip pain. He was trying to sit in a chair when he felt a click in right hip followed by severe right hip pain. His right lower limb was shortened and rotated internally, however, observed to be neurovascularly intact. He had a surgical history of right-sided cemented metal-on-polyethylene bearing primary THA using a Charnley stem done elsewhere 18 years back for avascular necrosis of right hip.

Standard radiographs revealed posterior hip dislocation along with aseptic loosening of the cemented acetabular component with an increased inclination of the cup (Fig. 1). Computed tomography (CT) scan of pelvis showed zones of lucency at cement and bone interface on acetabular side with migration of cup with a well-fixed stable femoral component (Fig. 2).

Fig. 1.

Fig. 1

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Preoperative radiograph of a 55-year old male patient showing right hip dislocation with aseptic loosening of the cemented cup with the change in position after 18 years after implantation.

Fig. 2.

Fig. 2

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Computed tomography scan images showing radiolucent zones around the acetabular component between cement and bone interface.

Intraoperative findings during revision THA revealed loosening and migration of the acetabular component with wear of polyethylene cup without any evidence of infection. Acetabular implant came out easily along with whole cement followed by a revision with the cementless metallic shell [56mm OD (Outer Diameter)] and ultra-high-molecular-weight polyethylene liner [56mm OD, 36mm ID (Inner Diameter)]. However, the previous well-fixed cemented Charnley stem with 22.225mm head diameter was not compatible with a large cup diameter of 56mm. Therefore, stem along with cement from proximal femur was removed cautiously, leaving behind the cement in femoral canal to minimise the iatrogenic damage to host bone. The proximal femur was broached until size 5 to insert short stem size 5. A bone conserving cementless metaphyseal anchored short stem high offset femoral component [SMF™ STIKTITE™, Smith & Nephew, Memphis (TN), USA] was used for femoral component revision4 (Fig. 3).

Fig. 3.

Fig. 3

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Photograph showing the Short Modular Femoral stem (SMF™) (Smith & Nephew Inc., Memphis) having proximally STIKTITE porous-coated titanium alloy (Ti–6Al–4V) tapered femoral hip stems.

We were able to obtain good immediate stability using cementless fixation. After reduction, the hip stable with a satisfactory range of movement without any impingement or subluxation (Fig. 4). He was discharged on 5th postoperative day and allowed to bear weight as tolerated with posterior hip precautions. He recovered well with a satisfactory range of hip motion and returned to his normal life (Fig. 4). At 2-year follow-up, he was asymptomatic with a modified Hip Harris score of 89 and a Western Ontario and McMaster Universities Arthritis Index (WOMAC) score of 11, with a radiologically stable well-fixed implant (Fig. 5).

Fig. 4.

Fig. 4

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Immediate postoperative anteroposterior and lateral radiographs showing appropriate alignment of the components.

Fig. 5.

Fig. 5

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Postoperative radiographic and clinical images after revision THA showing well fixed stable implant and range of movements at 2-year follow-up and the leftout cement in the distal portion of femoral canal.

3. Discussion

With the rise in the number of primary THA in young patients, the revision THA rate has also increased.1,2 Evidence shows that short hip stems are mainly used for primary THA, while, the majority of revision THA is carried out with conventional or long femoral stem.5 Conventional/long stems have proven excellent long term results, but, have a problem of stress shielding and thigh pain.6,7

Functional outcome and implant survival after revision THA depend mainly on bone deficiency, quality of bone and soft tissue damage.8 Femoral bone stock preservation is very crucial to improve clinical outcome in young patients undergoing revision THA keeping in mind the need for implant revision in future.1,4 The challenge in our case was to remove the well-fixed cement in the distal femoral canal while maintaining the integrity of the femur shaft without additional surgery. Cortical window or various osteotomies are described to remove cement in the femoral canal.8 Although available, these procedures are very aggressive for young patients and associated with a high risk of breaking the cortical integrity of the femur shaft, and need diaphyseal fit long femoral stem.

In our case, good quality intact proximal femoral bone stock helped us revising the femoral component with a short stem while leaving cement inside distal canal in situ. Short stem used in our case is a cementless high offset Short Monolithic Femoral (SMF) metaphyseally-anchored short stem having STIKTITER porous coating of titanium alloy (Ti–6Al–4V) over the proximal part compatible with high demand femoral head bearing options.4 This tapered short stem allows for a slightly higher neck resection as compared to the conventional stem, therefore, conserving proximal femoral bone stock and achieves good primary stability if those prerequisites are met. To our knowledge, this stem had previously been used only as a primary implant.

Sanguesa-Nebot et al., reported use of ProximaR short-stem having similar resection level and size at the proximal part as compared with conventional stem, during revision of a broken cementless conventional stem.9

Previous studies report good functional and long-term survival rates for various short-stem designs.10 Short stem in revision THA allowed distal cement in femoral canal to left in situ and has several advantages including less bone and soft tissue trauma, reduced blood loss and surgical time, facilitate the femoral cavity preparation, component insertion and revision surgery. Thus, responsible for quicker postoperative recovery, immediate mobilization, early rehabilitation and return to work, and a reduced hospital stay.4,9,10

Short stem is a desirable soft tissue and bone stock conserving femoral component which maintains bone stock for future revision if needed. Also, it avoids the use of revision femoral implant which has an inferior outcome and facilitate the use of conventional implant should a revision becomes necessary.10 Besides, short stems have a more physiological load distribution at the proximal femur metaphysis, thereby, reducing proximal stress shielding and thigh pain, enhanced proximal bone remodelling and simplified revisions if needed in future.6,10

Shorter stems can be helpful in revision THA to avoid diaphyseal femur perforation by allowing the operating surgeon to obtain a more anatomical broaching insertion vector. However, the surgeon should always keep in mind the possibility of stem subsidence, intra or perioperative periprosthetic femur fracture in patients with compromised proximal femoral bone stock, dysplastic femur and difficulty during insertion of short stem in Dorr type A Femora.

The short hip stems are compatible with all acetabular cups, bearing surfaces and head sizes used for primary and revision hip arthroplasty. Owing to these advantages, short femoral stem provides an appealing unorthodox alternative implant for young patients undergoing primary and revision total hip arthroplasty. Furthermore, this can be an implant of choice in Asian races of short stature having a narrow femoral diaphysis and curved femurs that conflict with traditional length stems.

Consent

“The authors certify that they have obtained all appropriate written informed consent from the patient included in this report. In the form, the patient has given his/her consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.”

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Babaji Thorat: Writing - original draft, Resources, Methodology, Data curation. Avtar Singh: Conceptualization, Investigation, Writing - review & editing. Rajeev Vohra: Writing - review & editing, Supervision, Investigation.

Declaration of competing interest

The authors declare that our manuscript is an original publication and the data is case report is real. The authors report no conflicts of interest.

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