Classify the remaining cortex, then choose fixation that bypasses the defect and restores mechanics
- The Paprosky class predicts what bone can hold a stem; it does not dictate a single implant.
- A revision stem must bypass the distal end of the defect and obtain reliable axial and rotational fixation in viable diaphyseal bone.
- Metaphyseal fill is not the same as fixation. A stem can appear centred while toggling in a weak proximal segment.
- Restoring hip centre, offset, version and leg length is a separate objective from obtaining distal fixation.
- An extended trochanteric osteotomy, cortical window, cerclage, strut graft or allograft-prosthetic composite should be planned before extraction, not improvised after a fracture.
- “Paprosky IIIA has enough diaphysis for distal fixation; IIIB has less reliable diaphysis and often requires a longer or larger reconstructive strategy.
- “A practical bypass rule is at least 4 cm of scratch-fit diaphysis beyond the defect in good bone, but implant and bone quality modify this target.
- “A fluted tapered modular stem obtains axial and rotational fixation in the diaphysis and can restore proximal mechanics separately.
- “A type IV femur is a biological reconstruction problem, not a request for an extra-long standard stem.
Determine whether the remaining diaphysis can provide circumferential scratch fit and rotational control. A stem that touches bone at one point is not stable distal fixation.
Cement, a well-fixed stem, distal pedestal, cortical windows and old cables can cause a fracture during removal. Have an extended trochanteric osteotomy or controlled window ready when risk is high.
Distal fixation may restore stability while accidentally lengthening the limb. Check the hip centre, lesser trochanter, offset and soft-tissue tension before final seating.
Smoking, infection, malnutrition, radiation, poor periosteum and a large dead space can produce nonunion even when the implant is mechanically strong.
Definition and Why Bone Loss Changes the Operation
Femoral bone loss is the loss of host bone required for extraction, fixation, alignment, load transfer or future revision during hip arthroplasty. It may be cavitary, segmental, cortical, metaphyseal, diaphyseal or global. The pattern matters because each revision stem obtains fixation in a different region.
Bone is lost through:
- osteolysis around a loose implant;
- repeated cement removal and cortical perforation;
- fracture, subsidence and implant breakage;
- infection and debridement;
- stress shielding and proximal resorption;
- osteotomy, fenestration or previous hardware;
- tumour resection or radiation.
The surgeon must answer four questions:
- Can I remove the old implant without losing more bone?
- Where can the new implant obtain reliable axial and rotational fixation?
- How will I restore hip centre, offset, leg length and version?
- How will the defect fill with viable bone for the next revision?
A classification is useful only if it changes these decisions.
Anatomy and Structures at Risk
- The proximal femur is widest at the metaphysis and tapers into the diaphysis. A stem that depends on metaphyseal bone cannot stabilise a type III or IV defect.
- The calcar and medial cortex resist varus and restore the neck-shaft relationship. Loss here increases subsidence and changes offset.
- The greater trochanter and abductors are needed for exposure, stability and gait. An extended trochanteric osteotomy must heal or be securely fixed.
- The femoral nutrient vessels and periosteum are important for osteotomy and graft incorporation. Excessive circumferential stripping is harmful.
- The sciatic nerve is posterior to the femur and vulnerable to traction, lengthening, retractors and cement extrusion. Document baseline function and avoid excessive leg lengthening.
- The femoral cortex can be thin around old screw holes, cement, windows and osteolysis. A long stem should bypass stress risers and a fracture should be stabilised before stem insertion.
- The femoral canal can be bowed or eccentrically enlarged. Straight instruments and reamers must be aligned with the actual canal, not the desired stem line.
Paprosky Classification and Practical Interpretation
- Bone pattern
- Minimal metaphyseal loss; intact diaphysis and calcar
- What can hold fixation
- Metaphysis and diaphysis
- Typical reconstruction
- Primary-style or short revision stem; restore proximal anatomy
- Bone pattern
- Extensive metaphyseal loss with intact diaphysis and calcar partly deficient
- What can hold fixation
- Reliable diaphysis
- Typical reconstruction
- Distally engaging cementless stem, often modular; graft or augment proximal defect
- Bone pattern
- Metaphyseal loss with at least about 4 cm of intact diaphysis
- What can hold fixation
- Distal diaphysis can provide axial and rotational fixation
- Typical reconstruction
- Long tapered-fluted or extensively coated stem with proximal graft or sleeve as needed
- Bone pattern
- Metaphyseal loss with less than about 4 cm of reliable diaphysis or marked canal expansion
- What can hold fixation
- Short, weak or eccentric distal segment
- Typical reconstruction
- Longer modular stem, structural graft, allograft-prosthetic composite or a different salvage strategy
- Bone pattern
- No reliable diaphyseal bone; severe osteopenia or a stovepipe canal
- What can hold fixation
- No standard diaphyseal scratch-fit
- Typical reconstruction
- Impaction grafting, allograft-prosthetic composite, custom or megaprosthetic reconstruction; consider salvage
The 4 cm threshold is a practical radiographic and intraoperative guide rather than a guarantee. A shorter segment of dense bone may hold a smaller tapered stem in one patient, while a longer osteoporotic segment may not. The decision is based on circumferential contact, axial stability, rotational stability and the stem's validated design.
Clinical Assessment
History
Record the primary stem, cemented or uncemented fixation, every revision, the reason for each operation, organisms and antibiotic treatment, fractures, dislocations, limb-length change and previous osteotomy or flap. Ask about pain on start-up, thigh pain, instability, systemic symptoms, current walking aids and the patient's activity goals.
Examination
Look and walk. Record Trendelenburg gait, shortening, varus or valgus, foot progression, scars, sinus and abductor wasting. A patient with a long-standing loose stem may compensate for an implant that has already migrated.
Move. Measure hip flexion, extension, abduction and rotation. Test the opposite hip, knee and ankle. An ankle equinus or contralateral knee arthroplasty changes the acceptable reconstruction.
Palpate. Assess trochanteric tenderness, the femoral shaft, a palpable implant or cortical prominence, and the soft-tissue envelope. Map scars and the expected osteotomy closure.
Neurology and vascularity. Document sciatic function and pulses, particularly after previous posterior approaches, vascular surgery or severe shortening.
Infection assessment
Use a composite periprosthetic joint infection work-up: serum inflammatory markers, aspiration with cell count and culture where appropriate, imaging and multiple deep samples at revision. A loose stem may be infected even without fever or a high CRP. Do not plan a definitive porous stem or allograft-prosthetic composite before deciding how infection will be controlled.
Investigations and Templating
Radiographs
Obtain AP pelvis, AP and lateral views of the entire femur, and views including the knee if the stem will extend to the distal metaphysis. A full-length standing view shows limb length and mechanical axis when the patient can stand. Assess osteolysis by Gruen zone, stem subsidence, cortical thickness, varus, pedestal, cement extrusion, fracture, old windows and distal bone.
CT
Use thin-slice CT for complex osteolysis, cortical perforation, a bowed canal, an intramedullary pedestal, a retained cement mantle, severe proximal loss or a prior fracture. CT can show a defect hidden by the implant on radiographs, but metal artefact and cost mean that it should answer a specific planning question.
Templating
Template the stem from distal fixation upward:
- identify the first intact circumferential diaphysis;
- measure the length and diameter of viable scratch-fit bone;
- plan a bypass beyond the distal defect and every stress riser;
- select stem length, diameter, taper and modular junction;
- restore hip centre, neck length, offset, leg length and version;
- plan proximal graft, sleeve, cone, strut or allograft-prosthetic composite;
- mark the level of an extended trochanteric osteotomy and the cable positions;
- have a larger and smaller stem, a long revision stem, cerclage, plate, strut graft and fracture plan available.
Reconstruction Options
- Best fit
- Paprosky II to selected IIIA/IIIB with viable distal diaphysis
- Mechanical principle
- Distal taper gives axial fixation; flutes give rotational control; proximal body restores mechanics
- Main caution
- Subsidence, fracture, distal mismatch and modular junction failure
- Best fit
- Long segment of suitable diaphysis with adequate bone quality
- Mechanical principle
- Bone ingrowth over a long distal surface
- Main caution
- Stress transfer, difficult extraction and fracture if the canal is too thin
- Best fit
- Selected defects with a reconstructable mantle or impaction grafting plan
- Mechanical principle
- Cement fills the canal and transfers load to graft or cortex
- Main caution
- Cement removal, fracture, infection and dependence on mantle quality
- Best fit
- Severe cavitary loss with sufficient cortical containment and a team experienced in the technique
- Mechanical principle
- Morsellised graft restores bone stock and a cemented stem provides temporary stability
- Main caution
- Graft fracture, subsidence, nonunion and technically demanding containment
- Best fit
- Global proximal loss or a type IV femur with a deficient abductor mechanism
- Mechanical principle
- Structural allograft restores bone and the prosthesis restores the joint
- Main caution
- Nonunion, fracture, infection, resorption and graft availability
- Best fit
- No reliable diaphyseal fixation or oncologic-sized segmental loss
- Mechanical principle
- Bridges absent bone with a large endoprosthetic segment
- Main caution
- Infection, instability, extensor or abductor failure and limited salvage options
Operative Technique: PIPADRAW
The precise steps differ by stem and graft technique. The sequence below applies to a complex distally fixed revision with an optional extended trochanteric osteotomy.
Femoral bone-loss reconstruction sequence
- Use the lateral decubitus or supine position according to the approach, secure the pelvis and leave the whole femur accessible to fluoroscopy.
- Prep from iliac crest to foot and keep the opposite limb available for comparing length, rotation and foot progression.
- Protect pressure points and plan cell salvage, blood products and a possible flap or osteotomy extension.
- Confirm AP and lateral views of the hip, full femur and knee. Identify the distal defect, canal bow, old windows and stress risers.
- Have modular stem trials, flexible reamers, extraction devices, cables, plates, strut graft and an alternative implant available.
- If the planned stem tip will approach the knee or a prior fracture, verify the entire path before incision.
- Administer antibiotics after deep cultures when the patient is stable and an infection assessment is required; use therapeutic treatment when infection is established.
- Confirm the Paprosky class, distal fixation segment, osteotomy level, graft plan and weight-bearing protocol.
- Use a tourniquet only when it does not compromise a flap or obscure the viability of the remaining cortex.
- Use the safest previous incision and preserve skin bridges. Plan an extended trochanteric osteotomy or cortical window before aggressive extraction.
- Identify the abductors, greater trochanter, sciatic nerve and femoral shaft according to the approach.
- Expose enough of the femur to control the stem and the remaining bone; avoid unnecessary circumferential stripping.
- Remove modular heads, sleeves, cables and the stem using axial extraction. If cement or a well-fixed stem is retained, use controlled osteotomy, trephines, flexible drills or an extended approach.
- Debride membrane and infected or non-viable tissue, and obtain multiple deep samples.
- Protect the cortex from perforation. Stop and image if the instrument leaves the expected canal or the cortex cracks.
- Ream sequentially along the true canal to a size that gives circumferential scratch fit in the planned diaphysis.
- Bypass the distal defect and every cortical stress riser. Use a guidewire and fluoroscopy to maintain centrality in a bowed or enlarged canal.
- Prepare the proximal defect for graft, sleeve, cone, strut or composite according to the plan; preserve viable attachments.
- Insert the distal trial or stem to the planned depth and trial the proximal body and neck.
- Restore hip centre, offset, leg length, version and abductor tension. Compare with the opposite side and check sciatic nerve tension.
- Check for impingement, instability and the relationship of the greater trochanter and femoral component to the acetabular reconstruction.
- Use cerclage before or during stem insertion when a thin cortex or osteotomy is at risk, without strangling the periosteum.
- Avoid levering the femur against the sciatic nerve or excessive lengthening that may produce postoperative palsy.
- Protect the abductors and trochanteric fragment for a stable repair; a stable stem with a non-united trochanter can still fail functionally.
- Insert the definitive stem at the planned depth and version, obtaining the intended distal axial and rotational fixation. For modular stems, lock the junction after confirming the proximal body.
- Pack or secure graft and structural supports without creating a cement or graft mass that impinges on the cup or soft tissues.
- Fix an extended trochanteric osteotomy with cables, wires or a plate according to fragment length and bone quality. Confirm compression and stable fixation.
- Obtain AP and lateral images of the full femur and hip.
- Check distal bypass, stem alignment, fracture, osteotomy fixation, hip centre, offset and length. Image the knee if the stem tip is near it.
- If distal fixation is inadequate or a fracture is present, revise before closure with a longer stem, cables, plate, graft or a different reconstruction.
- Repair the osteotomy, abductors, capsule and fascia without tension and preserve the soft-tissue envelope.
- Use protected weight bearing and hip precautions according to stem stability, osteotomy and graft. Provide a clear timeline rather than an ambiguous "as tolerated" instruction.
- Begin thrombosis prevention, antibiotics as indicated and physiotherapy focused on transfers, abductor protection and a safe gait.
Complications and Failure Management
- Clues
- Guidewire, reamer or stem outside the expected canal
- First response
- Stop, image and define the breach
- Salvage
- Redirect if safe; bypass with a long stem and protect the cortex with cables or a plate
- Clues
- Crack, loss of trial stability or sudden deformity
- First response
- Reduce and stabilise before final stem seating
- Salvage
- Cerclage, plate or strut plus a stem that bypasses the fracture
- Clues
- Early shortening, pain or changing offset
- First response
- Protect loading and obtain serial full-femur images
- Salvage
- Exclude infection and revise distal fixation; graft or structural support may be needed
- Clues
- Lateral pain, Trendelenburg gait or fragment migration
- First response
- Assess fixation and abductors
- Salvage
- Revision fixation with graft or plate; restore abductor continuity
- Clues
- Acute pain at stem tip or stress riser
- First response
- Protect limb and image the full construct
- Salvage
- Fix fracture and bypass it with a stable revision stem; treat infection if present
- Clues
- Drainage, fever, sinus, persistent pain or loosening
- First response
- Cultures, debridement plan and imaging
- Salvage
- Stage removal and reconstruction; infected allograft or megaprosthesis has high morbidity
- Clues
- Foot drop, sensory loss or severe pain
- First response
- Document, release compression and image for hardware or lengthening
- Salvage
- Remove a causative screw or revise excessive length; rehabilitate the nerve
Postoperative Monitoring
Obtain immediate and interval full-femur radiographs. Assess stem subsidence, distal fixation, fracture, osteotomy union, graft incorporation, trochanter migration, hip centre, offset and leg length. A small planned subsidence may occur with tapered stems; progressive migration, thigh pain or loss of offset indicates failed fixation or poor bone integration.
Rehabilitation is dictated by the weakest part of the reconstruction. A stable distally fixed stem without an osteotomy may allow earlier weight bearing; a trochanteric osteotomy, fracture, allograft or impaction graft often needs a longer protected period. Abductor strengthening begins only when the osteotomy and soft tissues can tolerate it.
Guidelines, Registries & Global Practice
Global evidence. Femoral revision evidence is dominated by cohort studies, registry analyses and implant-specific series. Paprosky classification remains widely used because it communicates the remaining fixation segment, but no classification predicts outcomes better than a careful CT and intraoperative assessment of bone quality.
Evidence-informed principles:
- Use a long stem that bypasses the distal defect and stress risers and obtains circumferential axial and rotational fixation.
- Use modularity to separate distal fixation from proximal reconstruction, but recognise junctional fracture, corrosion and fatigue risks.
- Preserve host bone and periosteum; graft and structural support are biological reconstructions, not decorative fillers.
- In infection, stage the case and do not implant an ingrowth stem into uncontrolled infection.
- Protect the abductor mechanism and trochanteric osteotomy because gait and stability depend on them.
Registries. The NJR, AJRR, AOANJRR, Swedish Hip Arthroplasty Register and other national registries show the burden and reasons for revision, but often do not record Paprosky subtype, distal fixation length or modular stem design in enough detail for direct comparison. Local registries should capture bone-loss class, stem, osteotomy, graft, fracture and reoperation.
Global practice. Tapered-fluted stems, extensively coated stems, impaction grafting and allograft-prosthetic composites require different expertise and implant access. Where complex implants are unavailable, a well-executed cemented reconstruction or staged transfer may be safer than an unsupported long stem. The universal rule is to obtain real fixation in real viable bone and protect the future revision envelope.
MCQ Practice Points
Q: What does Paprosky IIIA mean, and how confident can two surgeons be that a femur is IIIA?
A: Severe metaphyseal loss with enough viable distal diaphysis — conventionally at least about 4 cm of intact circumferential bone — for a distally engaging stem. IIIB has less reliable distal support and needs a more complex reconstruction. On confidence, quote the reliability study: four experienced arthroplasty surgeons classifying 205 consecutive femoral revisions achieved an inter-observer kappa of only 0.61 (substantial, not near-perfect), with intra-observer values of 0.75 to 0.81. So the type directs the plan; the intraoperative assessment of the true fixation segment settles it.
Q: What is the key mechanical rule in a type III femur?
A: Bypass the distal defect and all stress risers, then obtain axial and rotational fixation in viable circumferential diaphysis. Metaphyseal fill alone is not reliable fixation in a type III femur. Paprosky's own 170-patient series is the evidence: with proximal metaphyseal loss, fixation became predictable once prosthetic-bone fit was optimised in the diaphysis, giving over 95 per cent survivorship at a mean 13.2 years.
Q: What is a type IV femur and why does a long stem not solve it?
A: A femur with absent or non-supportive diaphyseal bone, severe osteopenia or a stovepipe canal. There is no viable circumferential segment to grip, so a standard long stem cannot create fixation — consider impaction grafting, an allograft-prosthetic composite, custom or megaprosthetic reconstruction, or salvage. Modular tapered stems still perform in this group (98 per cent survivorship free of repeat revision across 33 Type IIIB and 25 Type IV femurs), but 26 per cent of those patients had a complication and 17 per cent returned to theatre.
Q: Why is modularity helpful, and what does it cost?
A: The distal stem obtains fixation while the proximal body independently restores hip centre, offset, length and version. The trade-off is a modular junction with fracture or corrosion risk. Put the reassurance and the caveat together: 163 modular tapered fluted stems followed to a mean of ten years recorded no stem breakage and no taper junction loosening, with 97 per cent 10-year survival — but that is one design from one manufacturer, and junction failure is design-specific, so the result does not transfer to modular systems generally.
Q: What must be planned before extracting a well-fixed stem?
A: An extended trochanteric osteotomy or cortical window, flexible extraction tools, cerclage wires, a bypass stem, graft and an explicit fracture plan. Extraction is where additional bone is most often lost — the Paprosky type you operate on is frequently worse than the type you templated, which is another reason the preoperative grade cannot be the only input to which implants are opened.
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“A 69-year-old has aseptic loosening of a cementless stem. Radiographs show extensive metaphyseal osteolysis, a thin distal femur and only 3 cm of apparently intact diaphysis before the canal becomes stovepipe. The patient has a stable acetabular component. How do you reconstruct the femur?”
“During insertion of a distally fixed modular stem in a type III femur, there is a longitudinal crack extending from an old lateral cortical window. The stem is stable distally but the crack opens proximally. What is your response?”
“A patient has recurrent infected THA with a type IV femur, severe proximal bone loss and a deficient abductor mechanism. The patient wants limb salvage. What is the decision process?”
Classify
- I: minimal metaphyseal loss
- II: metaphyseal loss with intact diaphysis
- IIIA: severe loss but reliable distal diaphysis
- IIIB: less reliable or short distal fixation segment
- IV: absent or non-supportive diaphysis
Investigate
- Full AP and lateral femur, AP pelvis and alignment/length assessment
- CT for hidden osteolysis, perforation, bowed or stovepipe canal
- Composite infection work-up and multiple deep cultures
- Template distal fixation first, then hip centre, offset, length and version
Fixation
- Bypass the defect and every stress riser
- Obtain circumferential axial and rotational fixation in viable diaphysis
- Use modular tapered-fluted stem to separate distal fixation from proximal mechanics
- Type IV may need impaction grafting, allograft-prosthetic composite, custom or megaprosthesis
PIPADRAW
- Position, full-femur imaging, extraction and fracture plan
- Approach safely; control osteotomy or cortical window
- Debride, culture, ream the true canal and protect cortex and sciatic nerve
- Trial distal fixation and mechanics; insert stem, graft and trochanteric fixation
- Image the full construct, close and protect according to the weakest reconstruction
Evidence Base
Minimum 10-Year Results of Extensively Porous-Coated Stems in Revision Hip Arthroplasty
- 170 patients with extensively coated cementless revision femoral components, followed 10 to 16 years (mean 13.2)
- Survivorship greater than 95 per cent; overall mechanical failure rate 4.1 per cent
- Radiographically 82 per cent had bone ingrowth, 13.9 per cent stable fibrous fixation and 4 per cent were unstable
- Postel-D'Aubigne pain and walking score improved from 5.4 to 10.8
- STRESS SHIELDING WAS GREATEST WITH STEMS LARGER THAN 16.5 mm AND IN OSTEOPOROTIC DORR TYPE C BONE
- Nine per cent had significant thigh pain - including every patient with an unstable stem
- The conclusion states the principle this page is built on: with proximal metaphyseal bone loss, fixation is predictable when prosthetic-bone fit is optimised in the DIAPHYSIS
The Inter-Observer and Intra-Observer Reliability of the Paprosky Femoral Bone Loss Classification System
- Four arthroplasty surgeons classified radiographs of 205 CONSECUTIVE femoral revisions by Paprosky type, on two separate occasions each
- INTER-observer reliability kappa 0.61 - substantial agreement, but not near-perfect
- INTRA-observer reliability 0.81, 0.78, 0.76 and 0.75 - substantial to almost perfect
- The authors conclude there is substantial agreement among EXPERIENCED arthroplasty surgeons using the system
Modular Tapered Implants for Severe Femoral Bone Loss in THA: Reliable Osseointegration but Frequent Complications
- Of 1,124 femoral revisions performed 1999 to 2010, 135 (12 per cent) used a modular tapered stem; this report follows the 70 done in Paprosky TYPE IIIB AND IV femurs
- 58 patients followed a minimum of 24 months (mean 67, range 24 to 151) - 33 Type IIIB and 25 Type IV
- Survivorship free from repeat revision was 98 per cent (57 of 58); one stem was revised for early subsidence then failure of ingrowth
- SIX STEMS (10 PER CENT) SUBSIDED EARLY - but five of those went on to show radiographic ingrowth and were not revised
- Harris hip score improved from 34 to 74 (p less than 0.001)
- BUT 15 OF 58 (26 PER CENT) HAD A COMPLICATION AND 10 (17 PER CENT) NEEDED A REOPERATION - the title says it plainly
Uncemented Femoral Revision Arthroplasty Using a Modular Tapered, Fluted Titanium Stem: 5- to 16-Year Results of 163 Cases
- 163 femoral stem revisions performed 1993 to 2001 with a modular tapered fluted titanium stem relying on DISTAL DIAPHYSEAL fixation, mean follow-up 10 years (range 5 to 16)
- 99 cases (61 per cent) had extensive bone loss - Paprosky IIB to III
- Harris hip score improved from 37 to 79 (p less than 0.001)
- Stable radiographic anchorage in 151 of 163 (93 per cent); 10 implants (6 per cent) failed for any reason
- NEITHER A STEM BREAKAGE NOR A LOOSENING OF THE MORSE TAPER JUNCTION WAS RECORDED in the whole series
- Kaplan-Meier 10-year survival probability 97 per cent (95 per cent CI 95 to 100)
References
Every entry below was resolved against PubMed in August 2026. Seven entries previously listed here were removed because they could not be resolved as stated — see the note at the end.
- Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year-results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res. 1999;(369):230-242. PMID: 10611878. DOI: 10.1097/00003086-199912000-00024.
- Brown NM, Foran JRH, Della Valle CJ, et al. The inter-observer and intra-observer reliability of the Paprosky femoral bone loss classification system. J Arthroplasty. 2014;29(7):1482-1484. PMID: 24612736. DOI: 10.1016/j.arth.2014.01.022.
- Brown NM, Tetreault M, Cipriano CA, et al. Modular tapered implants for severe femoral bone loss in THA: reliable osseointegration but frequent complications. Clin Orthop Relat Res. 2015;473(2):555-560. PMID: 25053289. DOI: 10.1007/s11999-014-3811-7.
- Wirtz DC, Gravius S, Ascherl R, et al. Uncemented femoral revision arthroplasty using a modular tapered, fluted titanium stem: 5- to 16-year results of 163 cases. Acta Orthop. 2014;85(6):562-569. PMID: 25175667. DOI: 10.3109/17453674.2014.958809.
- Konan S, Garbuz DS, Masri BA, Duncan CP. Modular tapered titanium stems in revision arthroplasty of the hip: the risk and causes of stem fracture. Bone Joint J. 2016;98-B(1 Suppl A):50-53. PMID: 26733641. DOI: 10.1302/0301-620X.98B1.36442.
- Gie GA, Linder L, Ling RS, et al. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br. 1993;75(1):14-21. PMID: 8421012. DOI: 10.1302/0301-620X.75B1.8421012.
- Younger TI, Bradford MS, Magnus RE, et al. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J Arthroplasty. 1995;10(3):329-338. PMID: 7673912. DOI: 10.1016/s0883-5403(05)80182-2.
- Mardones R, Gonzalez C, Cabanela ME, et al. Extended femoral osteotomy for revision of hip arthroplasty: results and complications. J Arthroplasty. 2005;20(1):79-83. PMID: 15660064. DOI: 10.1016/j.arth.2004.10.014.
Removed 2026-08-10 as unresolvable in the form given (exact-title and author searches both failed, so none may be cited until re-identified): Paprosky & Martin, CORR 2002;401:164-172; Babis et al., J Arthroplasty 2014;29(12); Gross et al., CORR 1995;(319); Tsiridis et al., JBJS Br 2003;85; and Konan & Duncan, J Arthroplasty 2011;26(6 Suppl) — replaced above by Konan's verifiable 2016 stem-fracture paper. Two were not merely unfindable but attached to the wrong subject: the Wirtz reference was given as J Arthroplasty 2000 when the modular-stem series is Acta Orthop 2014 (corrected above), and the Saleh structural-allograft paper is about the acetabulum (J Arthroplasty 2000, PMID 11112186), not the femur.