Four stem fractures in a 12-year follow-up study of 9,135 patients with Exeter hip stems at seven teaching facilities in Japan.

BACKGROUND: Although excellent long-term results have been reported for the Exeter stem, stem fracture is recognized as a rare complication. However, there have been no reports on the incidence and risk factors for stem fractures based on detailed population information. This study aimed to clarify the incidence of Exeter hip stem fracture based on detailed population information from seven Exeter stem teaching centers in Japan and to examine the risk factors for stem fracture. METHODS: A total of 8,499 primary total hip arthroplasties (THA) and 636 revision hip arthroplasties (revisions) performed at seven Exeter teaching hospitals between 1999 and 2021 were included and retrospectively investigated based on medical records. RESULTS: Stem fractures were identified in two primary THA (fracture rate: 0.02%) and two revision THA (fracture rate: 0.21%) cases. The stem length was ≤125 mm in three out of these four cases. Revision and 30 stem were the risk factors for stem fractures. Weight and body mass index (BMI) were not significantly associated with the occurrence of stem fractures. CONCLUSIONS: In Western countries, the incidence of Exeter stem fractures is reportedly 0.017-0.15% for primary THA and 0.99-1.21% for revision THA. In this study, the incidence of primary THA was 0.02%, which is similar to the lowest reported rate, whereas the incidence of revision THA was 0.21%, which is lower than that reported in previous studies. Revision surgery had the same risk factors as those reported in the West-namely, stem length ≤125 mm (except for the 30 stem) and BMI, which were not risk factors in Japanese patients.

Multi-center study of use of the Exeter stem in Japan: a 10-year follow-up report.

PURPOSE: Since the introduction of the Exeter stem for clinical use in Japan in 1996, the number of stems used has continued to rise owing to its favorable results. We investigated the outcomes of patients who had previously undergone total hip arthroplasty with the Exeter stem in Japan with a 10-year + follow-up period. METHODS: This retrospective cohort study used clinical and radiographic data of 682 cases of primary total hip arthroplasty performed using the Exeter stem. RESULTS: The mean postoperative follow-up period was 13.3 years. Femoral-side revision was required in 14 hips, with no cases of aseptic stem loosening-associated revision observed. Kaplan-Meier survival analysis predicted 97.3% 15-year survival when revision for any reason was used as the endpoint. CONCLUSION: The obtained findings suggested the excellent long-term stability of the Exeter stem for primary total hip arthroplasty in Japan.

Impaction bone grafting for femoral revision hip arthroplasty with Exeter stem in Japan: An extended 10- to 15-year stem survival analysis of the previously reported series.

BACKGROUND: Femoral impaction bone grafting (IBG) was introduced in the late 1990s in Japan and has gradually become recognized as a useful option for femoral revision. The aim of the present study was to retrospectively analyze 10 to 15 years of clinical results of femoral revision arthroplasties of IBG using Exeter stem performed by experienced Japanese surgeons. METHODS: We investigated radiographic and clinical records more than 2 years after surgery in 99 hips of 93 patients. The average age was 66.3 years (36-84 years) and the average follow-up period was 11 years (2-23 years and 8 months). Merle d'Aubigné and Postel hip score was used for clinical assessment, and re-operations for any reason were recorded. The survival curve was estimated using Kaplan-Meier method. RESULTS: The mean Merle d'Aubigné and Postel hip score improved from 9.0 points to 14.5 points at the final follow-up. Re-operations were undertaken in 15 hips of 14 patients for aseptic acetabular component loosening (n = 1 hip), recurrent dislocation (n = 2 hips), infection (n = 4 hips), and periprosthetic femoral fracture (n = 8 hips). The survival rates at 10 and 15 years after operation were 87.1% and 81.1% with any type of re-operation as the endpoint, 92.2% and 92.2% with stem removal or exchange as the endpoint, 94.9% and 88.1% with re-operation for periprosthetic femoral fracture as the endpoint, and 99.0% and 99.0% with re-operation for aseptic stem loosening as the endpoint, respectively. CONCLUSIONS: The present study showed encouraging results of femoral IBG over 10 years by experienced surgeons in Japan. Although femoral IBG is recognized as a technically complex procedure, survivorship of the stem is excellent, with a 15-year stem survival rate of 99.0% at the end point of aseptic loosening.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture.

AIMS: The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively. PATIENTS AND METHODS: Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups. RESULTS: The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters. CONCLUSION: Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus. LEVEL OF EVIDENCE: III; case-control comparative study.

Usefulness of nutritional assessment using Geriatric Nutritional Risk Index as an independent predictor of 30-day mortality after hip fracture surgery.

INTRODUCTION: The Geriatric Nutritional Risk Index (GNRI) is an objective nutritional status assessment tool used for predicting mortality risk in hospitalized patients. However, it is unclear whether GNRI reflects short-term mortality for hip fracture patients after surgery. We examined the usefulness of the nutritional status assessed by the GNRI and identified cutoff scores that predict mortality risk. Does GNRI on admission predict the mortality after surgery for hip fracture? HYPOTHESIS: Evaluation of GNRI could help identify patients at higher risk of 30-day mortality after hip fracture surgery. MATERIALS AND METHODS: This retrospective study used data from 1040 patients who underwent hip fracture surgery. Fatalities within 30 days after hip fracture surgery were investigated. The GNRI was calculated on admission in all patients as follows: 14.89×serum albumin (g/dL)+41.7×body mass index/22. Receiver operating characteristic (ROC) curves were used to calculate the area under the curve (AUC) and the optimal cutoff score that could predict 30-day mortality after hip fracture surgery. This cutoff score was used for comparing the mortality rates between patient groups with a GNRI higher and lower than the cutoff score using Fisher's exact test. Logistic regression analysis was used to determine risk factors of 30-day mortality. RESULTS: There were 17 fatalities (1.6%) in the cohort. The ROC-AUC value was 0.811, and the cutoff GNRI was 75.4. Mortality was significantly higher in the group with a GNRI<75.4 compared with the group with a GNRI≥75.4 (odds ratio [OR], 22.99; 95% confidence interval [95% CI], 7.55-78.05; p=0.00000004). A GNRI<75.4 was a significant predictor of mortality within 30-days after hip fracture surgery (OR, 27.1; 95% CI, 8.57-85.9; p≤0.0001). DISCUSSION: Our results show that nutritional status assessment using GNRI can help predict 30-day mortality among geriatric patients undergoing surgery for hip fracture. The GNRI is a simple and accurate tool for predicting the risk of mortality after hip fracture surgery. LEVEL OF EVIDENCE: IV; case series study.

Multi-centre study of cement-in-cement and in-cement femoral revision total hip arthroplasty using polished, stainless steel stems.

BACKGROUND: Exposure of the acetabular component during revision total hip arthroplasty is often difficult and stems are often difficult to remove. Polished and tapered cemented stems are easily removed and can be easily reconstructed by either cement-in-cement or in-cement technique. This study was a retrospective review of the medium-term outcomes of revision total hip arthroplasty conducted with the Exeter stem fixed by cement-in-cement or in-cement method in four institutions. METHODS: This study included hips (n = 103) reconstructed by cement-in-cement or in-cement technique on the femoral side during revision total hip arthroplasty in four institutions between 2003 and 2015. The mean age at surgery was 71.1 years (range, 43-86 years), and the mean follow-up period was 5.6 years (range, 0-13 years). RESULTS: Revision arthroplasty was required for acetabular component complications in 69 hips, for dislocation in 25, for infection in eight, and for stem fracture in one hip. Re-revision was required in 10 hips for: infection (n = 6), acetabular component complications (n = 3), and dislocation (n = 1). No radiographic loosening, cement fractures, or osteolysis of the femoral components were observed. Ten-year survival rate was 99% with the endpoint of femoral revision surgery, and 100% with the endpoint of femoral aseptic loosening. CONCLUSIONS: The medium-term outcomes of revision total hip arthroplasty on the femoral side conducted using the cement-in-cement or in-cement technique were favourable, with no cases of aseptic loosening. As long as the bone-cement interface remains robust, there is no need to remove all the cement, and the cement-in-cement or in-cement technique should be used for reconstruction.

The effects of patient characteristics and stem alignment on distal femoral cortical hypertrophy after cemented polished tapered stem implantation.

BACKGROUND: The objective of this study was to evaluate the results of over 10 years of total hip arthroplasty (THA) practice with ExeterTM stems and the clinical relevance of distal femoral cortical hypertrophy (DFCH). METHODS: We retrospectively reviewed 127 hips (120 patients) that had undergone THA with ExeterTM stems between 2004 and 2007. Kaplan-Meier survival analyses for the stem of all 127 hips were performed using different endpoints. Of 127 hips, 100 (94 patients) had complete 10-year follow-up data, including the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) as the patient-reported outcomes, and the clinical relevance of DFCH was analyzed using multivariable logistic regression analysis. RESULTS: The survival of the stem with the endpoint of re-operation for loosening, > 5-mm subsidence, and re-operation for any reason were 100%, 99.1% (95% CI 97.5-100%), and 98.3% (95% CI 96.0-100%), respectively. Of 100 hips followed completely for 10 years, DFCH occurred in 20 hips (20%). The satisfaction and pain visual analog scale of JHEQ revealed high satisfaction and less pain in patients with DFCH. By multivariate logistic regression analysis, body weight > 55 kg (odds ratio: 2.88, p = 0.035) and varus stem alignment (odds ratio: 6.56, p = 0.003) were found to be predictors for DFCH. CONCLUSIONS: The incidence of DFCH with the ExeterTM stem was 20%. A body weight > 55 kg and varus stem alignment are predictors for future DFCH. DFCH with the ExeterTM stem indicates a good outcome with less hip pain.

Peri-prosthetic bone remodeling and change in bone mineral density in the femur after cemented polished tapered stem implantation.

OBJECTIVE: We examined longitudinal changes in bone mineral density (BMD) around the femur for 5 years after total hip arthroplasty (THA) using cemented collarless polished double-tapered stem implantation and investigated the influence of BMD changes on radiological remodeling of the femur. MATERIALS AND METHODS: Sixty hips from 56 patients who underwent cemented THA with a collarless polished double-tapered stem were included. BMD was measured 2 weeks postoperatively (baseline), 3 months, 6 months, 1 year and annually thereafter until 5 years after surgery using dual-energy X-ray absorptiometry on the lumbar spine and proximal femur of the operated side according to the Gruen's zone classification. We analyzed predictable factors for BMD preservation in the proximal femur and compared radiological remodeling of the femur and changes in BMD. RESULTS: BMD at 5 years in zone 7 decreased less than 10%, whereas BMD in zone 1 increased to over the baseline (+ 1.9%). Multiple linear regression analyses revealed that body weight was a predictor for positive BMD change in the proximal femur. The frequency of radiolucency of the femur was significantly lower in patients who exhibited an increase in BMD at 5 years compared with BMD at 2 weeks in zone 7. CONCLUSION: BMD preservation of the proximal femur after cemented collarless polished double-tapered stem implantation was more effective in heavier patients. Furthermore, the frequency of radiolucency around the stem was significantly lower in patients who exceeded 100% of the baseline BMD in zone 7 at 5 years.

Accuracy of Percutaneous Lumbosacral Pedicle Screw Placement Using the Oblique Fluoroscopic View Based on Computed Tomography Evaluations.

STUDY DESIGN: Retrospective. PURPOSE: This study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS). OVERVIEW OF LITERATURE: Although PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures. METHODS: We retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, <2 mm, 2-4 mm, or >4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time. RESULTS: Inaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes. CONCLUSIONS: Minimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.

Favorable Results of Primary Total Hip Arthroplasty With Acetabular Impaction Bone Grafting for Large Segmental Bone Defects in Dysplastic Hips.

BACKGROUND: The aim of the present study was to assess midterm results after acetabular impaction bone grafting (IBG) in primary total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with large acetabular segmental defect. METHODS: Primary THA with IBG for DDH with large acetabular segmental defect was performed in 40 hips of 38 patients. The average age was 61.6 years (range: 33-82 years), and the average follow-up period was 7.5 years (range: 3-10.3 years). The Merle d'Aubigné and Postel hip score and complications were assessed. For radiological assessment, postoperative location of the hip rotation center, the socket inclination angle, and the socket center-edge angle were assessed. Kaplan-Meier survival analysis was performed with the end points of any type of reoperation and aseptic acetabular loosening. RESULTS: The mean Merle d'Aubigné and Postel hip score improved from 10.4 points to 16.2 points at the final follow-up. Reoperation was performed in 1 case for acute infection without loosening. In 39 out of 40 hips (97.5%), the center of hip rotation was located beneath the "high hip center." The average socket inclination angle was 39.3° (range: 30°-54°), and the average socket center-edge angle was -11.8° (range: -23° to 9°). Survival rate of acetabular component at 8 years with the end point of any reoperation and of aseptic loosening was 96.6% (95% confidence interval: 89.9%-100%) and 100%, respectively. CONCLUSION: Acetabular IBG represents one of the useful options for restoring a normal hip center and acetabular bone stock in primary THA for DDH with large acetabular defect.

Bone restoration with cemented Exeter universal stem - Three-years longitudinal DEXA study in 165 hips for femur.

BACKGROUND: The pattern of strain distribution in the proximal femur changes following total hip arthroplasty (THA) and decreases in bone mineral density (BMD) occur around the stem following cemented and uncemented THA. We herein prospectively examined changes in BMD for 3 years after THA with a cemented Exeter universal stem. METHODS: One hundred and sixty five hips from 150 patients who underwent unilateral THA were included as a cohort. Our patients included 20 men (20 hips) and 130 women (145 hips) with a mean age of 63.9 years. BMD was measured 2 weeks postoperatively (baseline) and 3, 6 12, 18, 24, 30, and 36 months (3 years) after surgery using dual-energy X-ray absorptiometry (DEXA) on the lumbar spine and proximal femur of the operated side according to the Gruen zone classification. We quantified longitudinal changes in BMD for more than 3 years after surgery and detected several factors which affected these changes. RESULTS: In the first year, BMD in the most proximal femur showed a 5.5% reduction at the lateral side (zone 1) and 13% reduction at the medial side (zone 7), with no significant BMD reductions being observed thereafter. BMD reductions at 3 years were the most apparent at the proximal medial part of the femur (zone 7; -10.3%), while BMD ratio change in zone 1 was over the baseline (+2.9%). Especially in zone 7, the BMD ratio decreased with female, decreases in weight, decreases in height, decreases in BMI, and increases in age at the time of surgery. CONCLUSIONS: Bone restoration is expected with a cemented Exeter universal stem. Male patients, a younger age, a high body weight, being tall, and a high BMI were identified as factors associated with the restoration of BMD in proximal femur.

Proximal femoral reconstruction with impaction bone grafting and circumferential metal mesh.

INTRODUCTION: Impaction bone grafting (IBG) using a circumferential metal mesh is one of the options that allow restoration of the femoral bone stock and stability of the implant in revision hip arthroplasty. Here we examine the clinical and radiographic outcome of this procedure using a cemented stem, including experimental analysis of the initial stability of mesh-grafted bone-cemented stem complexes. METHODS: We retrospectively reviewed six hips (six patients) that had undergone femoral revisions with a circumferential metal mesh, impacted bone allografts, and a cemented stem. The mean follow-up period was 3.9 years (range 2.4-4.8 years). Hip joint function was evaluated using the Japanese Orthopaedic Association hip score, and radiographic changes were determined from radiographs. The initial resistance of mesh-grafted bone-cemented stem complexes to axial and rotational force was measured in a composite bone model with various segmental losses of the proximal femur. RESULTS: The hip score improved from 50 (range 10-84) preoperatively to a mean of 74 (range 67-88) at the final follow-up. The overall implant survival rate was 100 % at five years when radiological loosening or revision for any reason was used as the endpoint. No stem subsided more than 3 mm vertically within one year after implantation. Computed tomography showed reconstitution of the femoral canal in a metal mesh. In mechanical analyses, there was no relationship between IBG reconstruction rates under axial compression and stem subsidence or failure load. In contrast, under rotational load, the rotation angles of the stem to the stainless steel mesh were strongly affected by the IBG reconstruction rate. CONCLUSIONS: The short-term results show good outcomes for reconstruction of proximal bone loss with IBG and a circumferential mesh. The procedure should be applied in cases where the circumferential proximal bone loss is less than half the length of the implanted stem.

Eccentric rotational acetabular osteotomy for acetabular dysplasia and osteoarthritis: follow-up at a mean duration of twenty years.

BACKGROUND: The aim of the eccentric rotational acetabular osteotomy is to correct the deficient acetabular coverage in the dysplastic hip in order to limit the development of secondary osteoarthritis. The purpose of this study was to investigate the results in patients managed with an eccentric rotational acetabular osteotomy after a mean of twenty years. METHODS: The clinical and radiographic outcomes for the first 126 consecutive patients (132 hips) who underwent an eccentric rotational acetabular osteotomy at our institution were retrospectively evaluated. One hundred and twenty-four patients (130 hips) were evaluated; 117 were women (123 hips). The mean patient age was thirty-seven years (range, fifteen to fifty-nine years) at the time of surgery, and the average duration of follow-up was twenty years. Twenty-three hips in twenty-two patients were also treated with intertrochanteric valgus osteotomy at the time of the eccentric rotational acetabular osteotomy to further improve joint congruency. RESULTS: The mean preoperative Harris hip score of 70 points (range, 51 to 90 points) improved to a mean of 88 points (range, 35 to 100 points) at the final follow-up. Thirty hips had a fair clinical outcome (Harris hip score, <80 points). In seventeen hips, the eccentric rotational acetabular osteotomy was converted to a total hip arthroplasty. The cumulative survivorship at fifteen years and at the final follow-up at twenty-three years was 97% and 80%, respectively. Four factors led to a poor outcome: a small (≤2.0-mm) preoperative minimum joint space, joint incongruence, simultaneous intertrochanteric valgus osteotomy, and lateral subluxation of the femoral head postoperatively. CONCLUSIONS: Eccentric rotational acetabular osteotomy is an effective surgical procedure for treating symptomatic dysplastic hips before, and in the early stages of, osteoarthritis. The majority of patients maintained excellent or good native hip function at a mean of twenty years after surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gender difference does not affect the outcomes of eccentric rotational acetabular osteotomy used in hip dysplasia.

INTRODUCTION: Various types of periacetabular osteotomies have been proposed to treat acetabular dysplasia for young and active patients. Acetabular dysplasia is prevalent in women and rare in men, therefore few reports exist concerning periacetabular osteotomy of male patients. The purpose of this study is to clarify the gender differences in surgical techniques, radiographic and clinical outcomes. MATERIALS AND METHODS: Between 1989 and 2007, we performed 530 eccentric rotational acetabular osteotomies and followed them annually for more than five years. Thirty-six male patients were investigated. As a control group, 72 female patients were matched for age and preoperative stage of osteoarthritis at the time of surgery. We evaluated operative time and blood loss, radiographic parameters, Harris Hip Score (HHS) and survival rate. We investigated the clinical and radiographic differences between men and women. RESULTS: The mean operative time was 148 min in males and 135 min in females. The bleeding during surgery was 445 g in males and 351 g in females. HHS improved 94.1 points in males and 93.5 points in women postoperatively. The mean CE angle improved 31.7° in males and 35.1° in females. The mean AHI was 90.8% in males and 94.1% in females postoperatively. The survival rate of male patients were 92.8% and that of female patients were 98.1%. CONCLUSIONS: The mean operative time and the blood loss were not significantly different between male and female patients. Postoperative CE angle tended to be smaller in male than female patients. The survival rate was not significantly different between males and females. Gender difference did not affect the clinical outcomes of ERAO in patients with hip dysplasia.

Massive bone defect compromises postoperative cup survivorship of acetabular revision hip arthroplasty with impaction bone grafting.

We evaluated 66 acetabular revision arthroplasties using cemented cup with impaction bone grafting (IBG) to detect the extent that bone defect affects the outcome. We defined the maximum acetabular defect distance (MADD), which indicates the greatest depth of the grafted layer. Cup survival analysis with aseptic loosening as the endpoint revealed that the "MADD≤20mm" group showed higher survivorship than the "MADD>20mm" group (95% vs. 74%, P=0.034), and that the simple-wall-defect group (none or one mesh used) showed higher survivorship than the complex-wall-defect group (two meshes used) (96% vs. 73%, P=0.044). A favorable indication for acetabular IBG reconstruction is cases in which those cups can be placed at≤20mm MADD with a simple wall defect.

Epidural hematoma associated with spinal fracture in diffuse idiopathic skeletal hyperostosis.

The authors describe the clinical findings, radiographic appearance and surgical treatment of a spinal epidural hematoma (SEH) associated with spinal fracture in diffuse idiopathic skeletal hyperostosis (DISH). An 81-year-old male patient injured after falling from a 2.5 m tree presented with severe back pain. On plain radiographs and CT images, DISH with anterolateral osteophytes and fused thoracolumbar vertebrae was found along with a T12 fracture. Patient was initially treated with bed rest followed by placement into a body cast. Three weeks later, he presented with incomplete paraplegia of his lower limbs. CT images did not reveal any fracture displacement, but MRI images showed an epidural hematoma compressing the dura mater. The patient was successfully treated by posterior fixation surgery using pedicle screws and rod with vertebroplasty. We aimed to report a unique case of a SEH complicating a spinal fracture in DISH.

Complete bone remodeling after calcar reconstruction with metal wire mesh and impaction bone grafting: a case report.

We report the histological findings of a reconstructed calcar region four years after femoral impaction bone grafting using metal wire mesh for a case with massive defect of the proximal part of the femur. Thin cortical bone was formed just beneath the metal wire mesh and viable trabecular bone containing a small amount of granulation tissue was observed even at the bone-cement interface. Almost no necrotic bone was seen throughout the remodeled bony layer. Histological findings of the present case suggest that calcar reconstruction with impaction bone grafting using a metal wire mesh is a biologically and mechanically favorable reconstruction method for femoral revision cases combined with proximal medial segmental cortex defect.