Arthroplasty Today 17 (2022) 36e42

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Arthroplasty Today
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Original research

Endofemoral Shooting Technique for Removing Well-fixed Cementless

Stems
Kenichi Oe, MD, PhD *, Hirokazu Iida, MD, PhD, Takashi Toyoda, MD,
Tomohisa Nakamura, MD, PhD, Naofumi Okamoto, MD, PhD, Takanori Saito, MD, PhD
Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background: The removal of a well-fixed cementless stem poses technical challenges. The aim of this
Received 2 February 2022 study was to evaluate the outcomes of our endofemoral extraction technique established in 2001.
Received in revised form Methods: Between January 2001 and December 2016, 118 consecutive revisions following bipolar or total
6 July 2022
hip arthroplasty, which required cementless femoral stem removal, were performed at our institution.
Accepted 8 July 2022
This retrospective study evaluated 106 patients (108 hips) who were followed up for a mean of 9.2 years
Available online 15 August 2022
(range, 5-20 years). The patients included 15 men and 91 women with a mean age of 65 years (range, 33-
87 years). Endofemoral extracted stem removal was performed as follows. Multiple Kirschner wires were
Keywords:
Extraction of femoral stem
sequentially inserted into the interface between the implant and cortical bone, after which the implant
Endofemoral removal was detached using a thin chisel. After the cementless stem was removed, it was replaced with a
Cementless stem cemented stem using an autograft, as needed. Radiological loosening of the femoral stem was defined as
Femoral revision definite or probable loosening, based on the criteria of Harris et al. Prosthesis survival was analyzed using
Total hip arthroplasty the Kaplan-Meier method, with the endpoint set as repeat revision surgery for stem loosening or femoral
fracture.
Results: Re-revision surgery was performed in 7 hips. Stem loosening was observed in 4 hips, and the
mean subsidence was 0.3 mm (0-3 mm). The 10-year survival rate was 97.7% (95% confidence interval,
93.2-100).
Conclusions: Our technique for removing well-fixed cementless stems yielded successful results.
© 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee
Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction In 1995, Younger et al. [4] introduced a new extended proximal

femoral osteotomy for the removal of well-fixed cementless stems;
Cementless fixation in total hip arthroplasty (THA) has been the technique is based on an extended transfemoral osteotomy
increasingly used worldwide although this trend is paradoxical (ETO). ETO is the most widely used method to remove well-fixed
given the registry data representing nationwide THA results [1]. cementless stems, and some analogous osteotomies have been re-
Furthermore, the number of revision THAs has inevitably increased ported [5-7]. However, such osteotomies are invasive and associ-
[2]. Some revision THAs require the removal of well-fixed femoral ated with numerous complications, including intraoperative
cementless stems because of periprosthetic joint infection, dislo- fracture, weakness of the abductor mechanism, and postoperative
cation, periprosthetic fracture, and other reasons. However, fracture or stem loosening [6,8-10]. Some longitudinal split
removal of well-fixed femoral cementless stems remains chal- osteotomies have also been reported recently [7,11,12]. Although
lenging, often leading to complications such as femoral perforation, ETOs demonstrated good results [13,14], it is better to not use these
poor bone stock, and fracture [3]. osteotomies.
We have performed an endofemoral shooting technique for the
removal of well-fixed cementless stems since 2001. Our technique
can avoid an ETO or split procedure although it has technical re-
* Corresponding author. Department of Orthopaedic Surgery, Kansai Medical
quirements. This study aimed to retrospectively evaluate the clin-
University, 2-5-1 Shinmachi, Hirakata, Osaka 573-1010, Japan. Tel.: þ81 72 804
2436.
ical results of our technique. We hypothesized that our technique
E-mail address: [email protected] would be effective for removing well-fixed cementless stems.

https://doi.org/10.1016/j.artd.2022.07.007
2352-3441/© 2022 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 K. Oe et al. / Arthroplasty Today 17 (2022) 36e42 37

Table 1 fibrous ingrowth in 5 hips, and unstable implant in 0 hips. The

Preoperative patient characteristics. implanted stem was classified into the following types based on the
Characteristics Value removal of cementless stem: (1) category A, designed to stabilize in
Number of hips 108
the proximal metaphysis with a cancellous bone bed (eg, Austin-
Age at surgery (y), mean (range) 65 (3387) Moore type); (2) category B, designed to obtain metaphyseal
Sex, male:female 15:93 proximal cortical contact (eg, taper-wedge type, fit-and-fill type,
Follow-up period (y), mean (range) 9.2 (520) anatomic type, modular type); (3) category C, designed to engage in
Reason for revision
the metaphyseal-diaphyseal junction and proximal diaphysis with
Periprosthetic infection 40
Migration or subsidence of bipolar hip arthroplasty 18 edges (eg, Wagner type, Zweymuller type); and (4) category D,
Cup loosening 17 designed to engage proximal and distal cortical bone in the
Stem loosening 12 diaphysis (eg, full-porous type, long-stem type) (Tables 1 and 2).
Stem migration 10
Implant breakage 7
Recurrent dislocation 5 Endofemoral shooting technique
Osteolysis 4
Postoperative thigh pain 3 The transgluteal approach in the lateral position was used in all
Periprosthetic fracture 2 the patients [16]. After incision through the skin and tensor fascia
Engh’s classification
Fixation 64
latae, a longitudinal incision was made using cutting diathermy.
Fixation by bone ingrowth 39 The hip was dislocated, and the femoral head was removed. First,
Stable fibrous ingrowth 5 the acetabular component was revised in accordance with preop-
Unstable implant 0 erative planning, if necessary. For removal of the endofemoral
Cementless stem design
extracted stem, disrupted bony overgrowth around the proximal
Category A 17
Category B 69 stem was removed with a rongeur and osteotome to make it easier
Category C 3 to insert wires. Second, multiple 2.0-mm Kirschner wires were
Category D 19 sequentially shot to the interface between the cortical bone and the
implant in a circumferential manner. Third, the implant was de-
Material and methods tached using a thin and flexible osteotome (Fig. 1). To prevent
slipping down a forged path, a Kirschner wire was left in, whereas
Study design and patients another wire was inserted accompanying the first wire. If this was
unsuccessful, this process was carefully repeated, especially
Between January 2001 and December 2016, 118 consecutive focusing on the porous surface of the stem. If still impossible, an
revisions following bipolar hip arthroplasty (BHA) or THA, which anterior window (approximately 1 cm  1 cm) was made with an
required cementless femoral stem removal, were performed by 4 osteotome, and wires were sequentially inserted. Regardless of the
experienced surgeons at our institution. This retrospective cohort cementless stem type, the same method was used for the removal,
study included 106 patients (108 hips) who were followed up for at and no fluoroscopy was used.
least 5 years; 4 patients died from unrelated causes, and 6 patients After removing the cementless stem, the cemented THAs were
were lost to follow-up (follow-up rate, 92%). The patients included revised. In the acetabulum, we randomly used 2 implant types
15 men and 91 women, and the mean patient age at the time of between January 2001 and December 2012: (1) the K-MAX CLHO
surgery was 65 years (range, 33-87 years). The mean duration of flanged cup (KYOCERA Medical, Osaka, Japan) and (2) the Charnley
clinical follow-up was 9.2 years (range, 5-20 years). The reasons for Elite plus cup (DePuy International, Leeds, United Kingdom). Be-
revision THA were periprosthetic infection in 40 hips, migration or tween January 2013 and December 2016, the K-MAX CLHO flanged
subsidence of BHA in 18 hips, cup loosening in 17 hips, stem loos- cup was used. Structural allografts and KT plate (KYOCERA Medical)
ening in 12 hips, stem migration in 10 hips, implant breakage in 7 were used for massive bone defects if necessary [17,18]. In the fe-
hips, recurrent dislocation in 5 hips, osteolysis in 4 hips, post- mur, a variety of cemented stems with a 22.225-mm or 26-mm
operative thigh pain in 3 hips, and periprosthetic fracture in 2 hips. head were used.
Our institutional review board (2,021,152) approved this prospec- For the selection of implanted stem types, the intraoperative
tive cohort study. Each patient provided informed consent for in- condition and defect of the femur were classified as follows: type I,
clusion in the published findings. healthy femur; type II, thin cortical bone or presence of partial
defect; type III, functionally intact gluteus medius in spite of
Variables proximal broad defect; and type IV, functional breakdown of
gluteus medius and huge defect (Fig. 2). Type I was selected as the
Fixation between the cementless stem and femoral bone at the normal stem: SC stem (KYOCERA Medical) in 38 hips, HS-3 stem
time of revision was categorized according to Engh’s classification (KYOCERA Medical) in 23 hips, C stem (DePuy International) in 8
[15]: fixation in 64 hips, fixation by bone ingrowth in 39 hips, stable hips, and HS32 narrow stem (KYOCERA Medical) in 1 hip. Type II,

Table 2
Classification of cementless stem designs for the removal.

Category Design and concept of cementless stem Type

A Designed to stabilize in the proximal metaphysis with a cancellous bone bed Austin-Moore type
B Designed to obtain metaphyseal proximal cortical contact Taper-wedge type
Fit-and-fill type
Anatomic type
Modular type
C Designed to engage in the metaphyseal-diaphyseal junction and proximal diaphysis with edges Wagner type
Zweymuller type
D Designed to engage proximal and distal cortical bone in the diaphysis Full-porous type
Long-stem type
38 K. Oe et al. / Arthroplasty Today 17 (2022) 36e42

Figure 1. Intraoperative photograph of the left hip in the lateral position. (a) Multiple 2.0-mm Kirschner wires are sequentially shot to the interface between the implant and
cortical bone. (b) Multiple 2.0-mm Kirschner wires are inserted in a circumferential manner. (c) The implant is detached using a thin and flexible osteotome. Through an anterior
window, the direction of Kirschner wires or osteotome could be confirmed. (d) Cementless stem is removed.

Figure 2. Classification of the intraoperative condition and bone defect: Type I, Healthy femur; type II, thin cortical bone or presence of partial defect; type III, functionally intact
gluteus medius in spite of proximal broad defect; and type IV, functional breakdown of gluteus medius and huge defect.
 K. Oe et al. / Arthroplasty Today 17 (2022) 36e42 39

Table 3
Intraoperative conditions and reconstruction implants.

Type Implant classification (additional autograft) Reconstruction stem (n)

I Normal stem (partial augmentation if necessary) SC stem (38)

HS-3 stem (23)
C stem (8)
HS32 narrow stem (1)
II Long stem (partial augmentation) HS-3 long stem (24)
SC long stem (4)
PHS type 1 long stem (2)
PHS type 7 long stem (1)
III Long stem (proximal cerclage reconstruction) HS-3 long stem (3)
SC long stem (1)
Charnley Elite long stem (1)
IV Mega-prosthesis (proximal cerclage reconstruction if necessary) PHS type 1 long stem (1)
KLS mega-prosthesis stem (1)

which was considered instability of the stem, was selected as the assessment, anteroposterior radiographs of the pelvis were evalu-
long stem: HS-3 long stem (KYOCERA Medical) in 24 hips, SC long ated using a ruler (Carestream Health Japan Co., Ltd., Tokyo, Japan).
stem (KYOCERA Medical) in 4 hips, PHS type 1 long stem (KYOCERA Subsidence of the femoral stem was evaluated according to the
Medical) in 2 hips, and PHS type 7 long stem (KYOCERA Medical) in method by Fowler et al. [23]. Cement interdigitation was assessed
1 hip. In the absence of cortical bone, the strut onlay allograft was using the classification by Barrack et al. [24]. Radiological loosening
augmented using Ethibond (Johnson & Johnson K.K., Tokyo, Japan). of the femoral stem was defined as definite or probable loosening
Type III was selected as the long stem, and the proximal broad based on the criteria of Harris et al. [25].
defect was cylindrically reconstructed with the strut onlay allo-
grafts: HS-3 long stem in 3 hips, SC long stem in 1 hip, and Charnley
Statistical analyses
Elite long stem (DePuy International) in 1 hip. We augmented the
strut onlay allografts using Ethibond or ultra-high-molecular-
Comparisons between measurements were performed using
weight polyethylene fiber cable (NESPLON Cable System; Alfresa
Student’s t-test. Prosthesis survival was determined using the
Pharma Co., Osaka, Japan) [19]. Type IV was selected as the mega-
Kaplan-Meier method with 95% confidence intervals (CIs). The
prosthesis: PHS type1 long stem (KYOCERA Medical) in 1 hip, and
study endpoint was repeat revision surgery for stem loosening or
KLS mega-prosthesis stem (KYOCERA Medical) in 1 hip (Table 3).
femoral fracture. All statistical analyses were performed using SAS
The HS-3 stem is a smooth-collared tapered stem, whereas the SC
9.2 (SAS Institute Inc., Cary, NC). P < .05 was considered statistically
stem and C stem are polished collarless tapered stems. The HS-3
significant.
stem was used initially but was replaced with SC stem or C stem
since 2005. For the long stem, the HS-3 long stem was used initially
but was replaced with the SC long stem since 2016. In the cases of Results
intramedullary lost bone stock, modified impaction bone grafting,
which does not impact cancellous allografts but compresses them The mean Merle d’Aubigne
Clinical Score significantly improved
using a reversed reamer, was combined with revision THA [20,21]. from 10.4 points (range, 2-15 points) preoperatively to 15.4 points
All components were fixed with an ENDURANCE Bone Cement (range, 9-18 points) at the last follow-up (P < .05). A repeat revision
(DePuy CMW, Blackpool, United Kingdom) using the third- surgery was performed in 7 patients for the following indications:
generation cement technique. After implantation, a dislocation periprosthetic infection in 3 (2.8%) patients; recurrent dislocation, 2
test was performed. Full weight-bearing was allowed as soon as (1.9%) patients; and stem loosening, 2 (1.9%) patients. The mean
possible although the patients were encouraged to use a cane for up subsidence was 0.3 mm (0-3 mm) at the final follow-up or imme-
to 3 months. diately before revision surgery. With respect to Barrack’s classifi-
cation, 35, 71, and 0 hips were categorized as grade A, B, and C or D,
Follow-up protocol respectively. Stem loosening was observed in 4 hips, probable
loosening in 3 hips, and definite loosening in 1 hip (Table 4). One
Postoperative follow-ups were performed at 2 weeks, 3 months, hip with definite stem loosening was noted in a 75-year-old woman
6 months, 1 year, and annually thereafter. A retrospective analysis who underwent revision THA using a long stem for a periprosthetic
was performed by 2 blinded orthopedic surgeons. For clinical fracture 7 years prior. Re-revision THA was performed for peri-
assessment, the Merle d’Aubigne
and Postel grading system was prosthetic fractures due to stem loosening. Another hip with
used preoperatively and at the last follow-up [22]. Perioperative and probable stem loosening was noted in a 67-year-old man who
postoperative complications were also recorded. For radiological underwent revision THA using a normal stem for periprosthetic

Table 4
Patients with stem loosening.

Case no. Age/sex Cementless Indication for revision Intraoperative Reconstruction Harris’s Duration from
stem design condition stem classification revision to
re-revision

1 56/F Category B Periprosthetic infection Type I HS-3 Probable loosening (-)

2 75/F Category B Implant breakage Type I HS-3 Probable loosening (-)
3 52/M Category B Periprosthetic infection Type I HS-3 Probable loosening 15 y
4 68/F Category B Periprosthetic fracture Type II HS-3 long Definite loosening 7y
40 K. Oe et al. / Arthroplasty Today 17 (2022) 36e42

Table 5 based osteotomy; n ¼ 367) and Wagner’s osteotomy (anterior

Relationship between the cementless stem design and intraoperative condition. approach-based osteotomy; n ¼ 245) at a single institution. They
Stem design (n) Intraoperative condition (n) Repeat revision (n) found nonunion of the ETO occurred in 2%, ETO fragment migration
Category A (17) Type I (12) None
of >1 cm in 7%, intraoperative fracture of the ETO diaphyseal
Type II (4) None fragment in 4%, postoperative fracture of the ETO diaphyseal frag-
Type III (1) None ment in 0.5%, and postoperative fracture of the greater trochanter
Type IV (0) (-) in 7%. The 10-year rates of survival without revision for aseptic
Category B (69) Type I (47) Infection (3), loosening (1)
loosening and without femoral or acetabular component removal
Type II (21) Dislocation (1), loosening (1)
Type III (1) None or revision for any reason were 97% and 91%, respectively. Malahias
Type IV (0) (-) et al. [13] systematically reviewed 1478 ETOs and reported a 93.1%
Category C (3) Type I (1) None union rate of the ETO and a 7.1% rate of radiographic femoral stem
Type II (2) None
subsidence >5 mm. However, these studies were limited because
Type III (0) (-)
Type IV (0) (-)
they included results without the removal of well-fixed femoral
Category D (19) Type I (10) Dislocation (1) cementless stems. In addition, they did not describe postoperative
Type II (4) None management and the duration of hospitalization. ETO has inherent
Type III (3) None risks, including not only nonunion and fracture of the ETO but also
Type IV (2) None
altered rehabilitation and the need for repeat operations [3,9].
Furthermore, there are other disadvantages to ETO. For example,
infection 15 years ago. Re-revision THA was performed for thigh ETO always requires a longer stem to bypass the osteotomy, which
pain. may have severe consequences in the additional revision. In addi-
The relationship between cementless stem design and intra- tion, it was initially not approved for patients with fragile or thin
operative condition is shown in Table 5. In category D, there were cortical bone.
some type III and IV catastrophic intraoperative conditions. The 10- Regarding endofemoral extraction for the removal of well-
year survival rate with repeat revision surgery for stem loosening or fixed femoral cementless stems, Shah et al. [26] reported 3
femoral fracture was 97.7% (95% CI, 93.2-100). The 15-year survival cases using the Steinman pin technique. They described that
rate was 73.3% (95% CI, 31.7-100). Steinman pins may have a lower profile than the larger osteo-
tomes often used for extraction. In addition, they used a rota-
Discussion tional mechanism to break the interface rather than an axial
wedging force. Similar to their concept, our technique involves
Removal of well-fixed femoral cementless stems is challenging multiple Kirschner wires that are sequentially shot in a circum-
because it is associated with complications such as femoral perfo- ferential manner, avoiding going in the same way. Although this
ration, bone loss, and fracture [3]. ETOs are commonly utilized to technique might make it challenging to remove well-fixed
remove well-fixed femoral cementless stems, and excellent out- cementless stems depending on the type of implant, it allows
comes have been reported. Abdel et al. [14] analyzed 612 ETOs, for the removal of well-fixed cementless stems in all patients.
including Younger and Paprosky’s osteotomy (lateral approach- The 10-year survival rate was 97.7% under repeat revision surgery

Figure 3. Difficult case 1. (a) Anteroposterior radiograph from a 51-year-old woman who underwent primary THA (stem design category D: full-porous stem) for secondary
osteoarthritis due to dysplasia 20 years ago and underwent revision THA because of periprosthetic infection. (b) Intraoperative photograph: right hip in lateral position. Intra-
operative condition is type III, and an HS-3 long stem (KYOCERA Medical, Osaka, Japan) is selected with a proximal cerclage reconstruction. (c) Anteroposterior radiograph at 8 years
postoperatively showing no evidence of loosening.
 K. Oe et al. / Arthroplasty Today 17 (2022) 36e42 41

Figure 4. Difficult case 2. (a) Anteroposterior radiograph from a 70-year-old woman who underwent bipolar hip arthroplasty (stem design category D: long stem) for femoral neck
fracture 3 years ago and underwent revision THA because of periprosthetic infection. (b) Intraoperative photograph: right hip in lateral position. Intraoperative condition is type IV,
and a PHS type 1 long stem (KYOCERA Medical, Osaka, Japan) is selected with a constrained cup. (c) Anteroposterior radiograph at 7 years postoperatively showing no evidence of
loosening.

for stem loosening or femoral fracture as the endpoint. However, Acknowledgments

care should be taken when handling category D because there
were some type III and IV catastrophic intraoperative conditions. The authors would like to thank Nami Okada for providing the
It is necessary to prepare not only allografts but also mega- manufacturer’s knowledge and Tomomi Oe for their contributions
prosthesis in the case of category D (Figs. 3 and 4). Using fluo- as the supervisor and all stuffs involving this study.
roscopy may be recommended until beginners get used to this
technique. Well-fixed cementless stems should always be Conflicts of interest
removable because as periprosthetic infection, periprosthetic
fracture, adverse reactions to metal debris, and even dislocation The authors declare there are no conflicts of interest.
can occur. Patients who undergo primary THA have a probability For full disclosure statements refer to https://doi.org/10.1016/j.
of needing a revision THA. artd.2022.07.007.
There were some limitations to this study. First, we retro-
spectively evaluated the patients without a control group. All the
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