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Revision Hip replacement: Adler Pantheon proximal femoral EPR, extra-cortical plates and patient specific cutting jig

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Common indications for single stage revision hip arthroplasty include aseptic loosening, instability, pain, osteolysis , implant wear , periprosthetic fracture, and infection . Both instability and infection become the leading indications for a second revision, highlighting the increased risk of instability and infection following the first revision of a hip replacement compared to that of primary hip replacement (https://reports.njrcentre.org.uk/Portals/0/PDFdownloads/NJR%2019th%20Annual%20Report%202022.pdf).

This case has undergone multiple previous revisions firstly for aseptic loosening to a modular, fluted titanium stem complicated by a periprosthetic fracture which was surgically stabilised using a plate, cables and screws. This second revision failed due to non-union. The patient was referred for consideration of a total femoral endoprosthetic replacement due to extensive bone loss and distal non-union, which in this context is associated with a high risk of failure due to infection and functional loss according to Christ et al. and Putman et al. (https://journals.sagepub.com/doi/pdf/10.1177/1120700019864867/)(https://www.sciencedirect.com/science/article/pii/S1877056819300714.)

To avoid a total femoral replacement,  I prefer, when possible, to use a long proximal femoral replacement to preserve the non-arthritic knee joint and soft-tissue attachments, which is associated with particular challenges, most significantly the minimal residual femoral bone for osseointegration. The ‘modular-custom’ design of the Adler Pantheon system combines a customised short-stem endoprosthetic porous collar with endosteal stem. This makes best use of endosteal osseintegration with minimal residual bone, and extra-cortical plates provide additional primary stability and to harness additional periosteal osseointegration from the external cortices, for longevity.  A fully modular proximal femoral endoprosthetic replacement enables on-table adjustment of leg length and rotation . Agluna silver coating has been shown to minimise the risk of early prothetic joint infection, the leading cause of early failure and revision with endorpstheitic replacements according to Wafa et al. (https://boneandjoint.org.uk/Article/10.1302/0301-620X.97B2.34554). Trochanteric reattachment of the osteotomised greater trochanter should preserve abductor and quadriceps muscle attachments for optimal function and stability (https://sarcoma-website.s3.us-east-2.amazonaws.com/2022/12/Outcomes_After_Abductor_Reattachment_to_Proximal.7.pdf).

The Adler Panthenon is modular, which assists it being easily re-revised to a total femoral replacement at a later date, if necessary.

OrthOracle readers will also find the following instructional techniques of interest:

Proximal femoral endoprosthesis: Adler Pantheon for reconstruction after radical excision of femoral metastasis and trochanteric reattachment using Kinamed SuperCables

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Author: Jonathan Stevenson FRCS (Tr & Orth)

Institution: The Royal Orthopaedic Hospital, Birmingham, UK

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.

In the USA contact: fda.gov
In the UK contact: gov.uk
In the EU contact: ema.europa.eu

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