Extensive Femoral Bone Loss Following Two-Stage Periprosthetic Joint Infection Treatment - Persistent Challenges in Proximal Femoral Replacement

Sep 28, 2026

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Proximal femoral replacement (PFR) is increasingly used for non-oncological reconstruction, yet evidence remains limited for its role after 2-stage revision treatment of periprosthetic joint infection (PJI) with extensive femoral bone loss. This single-center retrospective study evaluates clinical and functional outcomes, complication patterns, and prosthesis survivorship in patients undergoing PFR for severe defects (Paprosky 3B/4), with follow-up of at least 24 months. Functional status used MSTS and failure classification followed Henderson.

LanguageEnglish

CategoryHealthcare

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Pages10

Reading Time25 min

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Background

Methods

Patient inclusion and exclusion criteria

Results

Conclusions

Arthroplasty Today 36 (2025) 101906 Contents lists available at ScienceDirect Arthroplasty Today journal homepage: [http://www . arthroplastytoday . org/](http://www . arthroplastytoday . org/) | Original Research
Extensive Femoral Bone Loss Following Two-Stage Periprosthetic Joint Infection Treatment: Persistent Challenges in Proximal Femoral Replacement
Nelo J.Z. Chihal Lima, MD*, Vasfi Karatosun, MD
_
Department of Orthopaedic Surgery and Traumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey | | | | --- | --- | --- | | a r t i c l e i n f o | | a b s t r a c t | | Article history:
Received 17 June 2025
Received in revised form
24 September 2025
Accepted 11 October 2025
Available online xxx | | Background: Proximal femoral replacement (PFR) has gained popularity in nononcological reconstruction surgeries over recent decades. However, there is sparse literature on its application in extensive bone defects following 2-stage revision treatment for periprosthetic joint infection (PJI). This study retrospectively evaluates the clinical and functional outcomes, complication rates, and prosthesis survivorship in patients undergoing PFR surgery for severe bone defects due to 2-stage PJI treatment. Method: This single-center retrospective study analyzed patients who underwent PFR as part of a 2-stage treatment for hip arthroplasty-related PJI between 2010 and 2020. All patients had extensive proximal femoral bone loss (Paprosky type 3B and 4) before the PFR surgery. Inclusion required a minimum follow-up period of 24 months. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS), while PFR prosthesis failure was classified according to Henderson's Classification. Combined PFR and acetabular prosthesis survival was determined using Kaplan—Meier survival curves.
Results: Thirty-four patients (21 women and 13 men, average age 72.9) were included in the study. The mean follow-up was 75 months (range: 24-132). Pre-PFR surgeries averaged 3.88 per patient (range: 2- 13). Mechanical complications were present in 7 patients (20.6%), nonmechanical complications in 8 (23.5%), and 2 patients (5.9%) had both. The mean MSTS score was 66.74%. The all-cause complicationfree survival rate was 80% in the second year and decreased to 52% by the fifth year. The all-cause revision-free rate was 73 % in the second year and decreased to 47% by the fifth year.
Conclusions: PFR is effective for limb salvage in complex cases but comes with high mechanical and non-mechanical complications and moderate to poor survival rates. While larger femoral heads and constrained liners help reduce dislocation, infection remains a significant issue. The gap between high MSTS scores and difficulties in daily activities signals a need for improved functional assessment tools. These findings highlight the persistent challenges in managing PJIs.
© 2025 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/](http://creativecommons.org/)[ ](http://creativecommons.org/)licenses/by-nc-nd/4.0/). | | Keywords:
Periprosthetic joint infection Proximal femoral replacement Revision arthroplasty Implant survival
MSTS | | | Introduction Periprosthetic joint infection (PJI) is one of the most common and serious complications after arthroplasty, often necessitating revision surgery [1]. It is a severe condition that contributes to significant morbidity and can have a higher mortality rate than many cancers [2-5]. Treatments for PJI, particularly single or 2-stage approaches, can cause considerable bone loss in both the _ * Corresponding author. nciralti Mahallesi, Mithatpas¸ a [cad. no:1606](cad. no:1606), Balçova, Izmir 35410, Türkiye. E-mail address: [nelochihal@gmail.com](nelochihal@gmail.com) proximal femur and acetabulum. Addressing th

FAQs

What clinical outcomes did the study evaluate for PFR after 2-stage PJI treatment?

The study assessed clinical and functional outcomes, complication rates, and prosthesis survivorship in patients treated with PFR for severe proximal femoral bone defects after 2-stage PJI revision.

How were functional outcomes and prosthesis failure classified?

Functional outcomes were measured using the Musculoskeletal Tumor Society Score (MSTS). Prosthesis failure was classified according to Henderson's Classification.

What did the survival analysis show over time?

All-cause complication-free survival was 80% at the second year and declined to 52% by the fifth year; all-cause revision-free rate was 73% at the second year and declined to 47% by the fifth year.

Sep 28, 2026

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