Evolving Strategies for Cementless Stem Removal in Revision Total Hip Arthroplasty

Revision total hip arthroplasty (THA) presents unique and considerable challenges. The removal of osseointegrated femoral components in revision THA can be technically demanding, and the orthopaedic surgeon must prioritize the preservation of host bone, while minimizing operative morbidity. Traditionally, extended trochanteric osteotomy (ETO) has served as a reliable technique, improving exposure and facilitating femoral component extraction. However, ETO can be associated with substantial patient morbidity1–3. The development of novel osteotome systems specifically designed to disrupt femoral fixation offers a potential pathway toward less-invasive revision strategies. In their article, Nour et al. present one of the largest institutional experiences with the Exodus Revision Hip System (Zimmer Biomet), encompassing 92 revision THAs over a period approaching 7 years. This novel osteotome system has 3 different blades that are theoretically designed to allow for disruption of the stem-bone interface circumferentially. The authors report successful extraction from the top, without ETO or iatrogenic facture, in 73% of all cases. These results suggest that, in appropriately selected cases, the use of novel osteotome systems may meaningfully reduce reliance on ETO while preserving bone stock and reducing morbidity. Further investigation showed that 9 (10%) of the cases required femoral osteotomy for extraction. Critical evaluation of these results highlights that femoral stem geometry and surface coating strongly influence the ease of removal. All 60 of the single-taper stems in this series were extracted without osteotomy, underscoring their more-forgiving fixation profile. In contrast, fit-and-fill and fully hydroxyapatite (HA)-coated stems proved substantially more challenging, with 57% of those with such stems requiring osteotomy or sustaining an extraction-related fracture. This reflects what many revision surgeons encounter clinically3,4: circumferentially coated and extensively porous designs provide excellent long-term fixation but pose notable barriers during revision; in this series, 27% (4) of the 15 fit-and-fill stems and 50% (4) of the 8 fully HA-coated stems required osteotomy for removal. The high rate of ETO for removal of fully HA-coated stems cannot be understated, as the widespread use of fully coated, triple-tapered stems has increased since their introduction5. Revision arthroplasty is increasing in frequency, driven by rising THA volumes and longer patient survivorship, and the morbidity associated with revision THA must be considered in this setting. Furthermore, the reported 18% rate of intraoperative fracture warrants careful consideration. While comparable with historical benchmarks for revision THA2–4, it highlights that osteotome-assisted extraction is not without risk. Controlled levering forces can place osteoporotic or previously compromised femora at particular risk. In addition, the authors did not find a difference in intraoperative fracture rate on the basis of trochanteric overhang or the radiographic presence of a potential space between the component and cortex. These findings show the importance of clearing the lateral shoulder of the implant to minimize trochanteric fracture and that “theoretical” space between the component and cortex does not imply ease of removal. Surgeons should remain prepared to convert to ETO promptly if early signs of cortical compromise or incomplete implant mobilization are encountered. This study illustrates important considerations when removing an osseointegrated femoral stem in revision THA. Preoperative planning should account for stem design, fixation pattern, and bone stock. Intraoperative patience is critical, as incomplete circumferential release or aggressive levering may increase fracture risk. The surgeon must maintain a low threshold for conversion to ETO, rather than continuing with maneuvers that may jeopardize femoral integrity. This series also carries training implications. Surgeons in training must be proficient with a range of extraction techniques, including the use of osteotome systems and osteotomies, and must develop the judgment to deploy each appropriately. Having an increased number of “tools in the surgeon toolbox” such as the system described here may provide an important intermediate strategy, reducing morbidity when successful, but they cannot entirely supplant more extensile approaches. As orthopaedic surgeons, we must continue to balance the dual imperatives of durable primary fixation and revisability. The current data underscore the trade-off inherent in fully coated, extensively porous stems. While excellent for long-term fixation, they complicate revision substantially. Implant manufacturers and surgeons alike should consider the impact that implant choice in the primary setting has on future revisions, particularly in younger patients5. This large, single-institution experience demonstrates that osteotome-based extraction systems can achieve safe, bone-preserving stem removal in the majority of revision THA cases, with a relatively low osteotomy rate. Nonetheless, outcomes remain heavily influenced by stem design, and the risk of intraoperative fracture persists. Surgeons should view these systems as valuable adjuncts rather than replacements for traditional osteotomies, and must remain vigilant in case selection and intraoperative execution. As implant design trends continue toward more biologically aggressive fixation, further innovation in extraction strategies will be essential.