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Table I. Number of revisions stem were introduced. This series contains the first patients
at the initial procedure of
femoral impaction grafting in whom these were used as well as all the patients who had
during revision hip replacement impaction grafting without dedicated instrumentation (the
Number uninstrumented group). The latter comprised the initial
Revision of hips group of 68, operated on between mid-1987 and April 1989,
1st 161 whose preliminary results were published in 199321 and a
2nd 38 further group of 35 patients (previously unreported) who
3rd 7 underwent surgery between April 1989 and April 1994. In
4th 7
>4 2 all of these patients, we undertook distal impaction using
Staged for infection 11 plug sizers and proximal impaction with oversized trial fem-
oral components. From 1992 onwards, the Mark I X-Change
(Howmedica) instruments became available and eventually
Table II. The Endo-Klinik all impaction grafting operations were carried out using this
grades for 193 hips which
underwent femoral impaction
equipment.22,23 We carried out 123 operations in this series
grafting during revision hip with these instruments.
replacement In the uninstrumented group, femoral impaction grafting
Number was performed as described by Gie et al21 in 1993. Where
Endo-Klinik grade of hips needed, the femur was reconstructed with metalwork using
1 12 fine meshes and wires (Fig. 1). Proximal impaction of the
2 106 graft is crucial with this technique and, when necessary, we
3 62
4 6
extended the reconstruction to a position just proximal to
Not scored 7 the level of the lesser trochanter so that bone could be ade-
Total 193 quately compacted in the reformed femoral tube up to this
level. We prepared unwashed allograft chips, 2 to 4 mm in
size from fresh frozen femoral heads. In most cases, the
grade-3 and six with grade-4 loss. Long-stemmed compo- chips were produced in a bone mill and though they were
nents were not available at the time of surgery for patients in mainly cancellous, some also contained fragments of corti-
this series and, after the results of the early experience of cal bone.
impaction grafting, were not thought to be necessary. The Mark I X-Change instruments24 were used in the
In 1992, specialised instruments22,23 designed to instrumented group. At the end of the procedure, the goal
improve the performance of the operation with the Exeter was to have packed the bone so tightly that it would prove
Radiographs showing a) a periprosthetic fracture around a matt-surfaced stem with a loose socket; b) reduction
and fixation of the fracture with a plate and the use of fine mesh to contain the graft in Gruen zone VI and c) at
follow-up at five years. The fracture has healed and the clinical result was good.
Table III. The preoperative and postoperative Charnley scores for vertical dimension of the radiolucency craniolateral to the
patients who underwent femoral impaction grafting during revision hip
replacement shoulder of the stem in Zone 1,26 as described by Fowler et
al,30 through the use of digitised x-rays and the Orthochart
Number Range of
Charnley group of hips Pain Function movement system.
Preoperatively
Clinical assessment and survivorship analysis. The Charnley
A 53 2.6 2.2 3.9 modification of the Merle dAubign-Postel classification31
B 83 3.1 2.2 3.8 was used. Scores are given (Table III) for all 193 hips in the
C 53 2.6 2.2 3.8 patients surviving more than two years excluding the group
Mean grade 2.8 2.2 3.8
Postoperatively
designated as failures. In addition, Oxford hip scores32 were
A 23 5.3 4.7 5.5 obtained at final review. We calculated the survivorship
B 67 5.4 4.2 5.3 analysis of the femoral component using the life-table
C 103 5.4 2.9 5.1 method for all patients, using both clinical and radiological
Mean grade 5.3 3.9 5.3
results as endpoints.1,2,33-36
Results
impossible to twist the phantom, which is the proximal Intraoperative problems. There were 17 intraoperative
impactor, within the mantle of graft or extract it by hand fractures. In eight, the fracture was appropriately treated at
alone. After a trial reduction for leg length and stability the the initial operation and healed satisfactorily. In eight, the
phantom was removed using a slap hammer. Cement was fracture was missed at the time of surgery and in one it was
then delivered into the neo-medullary canal in a retrograde treated inadequately with one wire. These nine hips devel-
fashion using a gun with a tapered spout and pressurised oped further complications. There were seven femoral per-
before the stem was introduced to the rehearsed depth. A forations at the time of surgery. All but one of these was
sorbothane horse-collar25 was then applied to maintain recognised and dealt with appropriately without sequelae.
pressure until polymerisation. Postoperatively, patients One went on to fracture through the compromised area of
were mobilised touch-weight-bearing with crutches on the bone.
second postoperative day. There were no deaths in these patients attributable to the
Radiological assessment. Preoperative, postoperative and revision surgery.
final follow-up films were analysed by four surgeons (BRH, Failures. There have been five femoral reoperations due to
HWE, GAG and AJT). We noted the hips which were desig- deep infection (2.2%). Two hips (1%) developed early post-
nated as failures, for whatever reason and those which had operative infection. There were three later infections. One
undergone further femoral surgery. Twelve patients died followed an acetabular revision, one an open reduction for
with less than two years follow-up and their radiographs dislocation and one was caused by the haematogenous
were not included. Radiographs were not available for 23 of spread of an urinary tract infection 11 years after surgery.
the 193 hips in patients surviving more than two years who Twelve (5%) femoral reoperations were carried out for
were not designated as failures; 170 radiographs in patients fracture or aseptic loosening. There were two revisions for
with surviving femoral components who had radiological mechanical loosening and five in the nine patients with
follow-up for more than two years were therefore analysed missed or inadequately treated intraoperative fractures. One
in detail. Initial assessment included alignment of the stem, required a reoperation but was unfit for surgery and subse-
evidence of radiolucencies at the cement-graft and graft- quently died at 35 months after revision, one stem subsided
host interfaces, and a record of the Gruen zones26 in which more than 20 mm and had pain, another subsided and
cortical bone stock was compromised. Later assessment rotated within the femur but had no pain and one migrated
included the appearance or progress of lucent lines, the painfully into marked varus and had subsided 6 mm. The
appearance of the graft including trabecular changes and two symptomatic patients elected to have no further surgery.
cortical healing, as defined by Gie et al,21 the latter being Of nine postoperative fractures, four required no treat-
sought particularly in those zones in which the cortex was ment (two had an isolated fracture of the greater trochanter)
judged to have been compromised before the grafting opera- and five required plating with the stem remaining in situ.
tion. These occurred at 4, 18, 27, 74 and 103 months post-opera-
Even using radiostereometric analysis (RSA),27,28 which tion.
was not available in Exeter when this study was being The overall rate of aseptic loosening including reopera-
undertaken, the accurate measurement of migration of the tion for fracture or mechanical loosening and those desig-
stem following impaction grafting and the exact identifica- nated as failures which have not had further surgery is
tion of where it is occurring is difficult, and without it, therefore 7% (16/221).
impossible.29 However, the geometry of the stem lends Survivorship analysis. Survivorship with any femoral
itself to the reasonably accurate assessment of its subsid- reoperation as the endpoint was 90.5% (confidence interval,
ence within the cement and this was done by measuring the 82 to 98)1 at 10 to 11 years (Fig. 2) and using femoral
VOL. 85-B, No. 6, AUGUST 2003
812 B. R. HALLIDAY, H. W. ENGLISH, A. J. TIMPERLEY, G. A. GIE, R. S. M. LING
100
90
80
70
Survivorship (%)
60
Fig. 2
50
Survivorship with any femoral re-operation for
40 any cause as the endpoint.
30
20
10
0
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8 - 9 9 - 10 10 - 11 11 - 12
Years since operation
100
90
Survivorship (%)
80
70
60 Fig. 3
50
Survivorship with revision for symptomatic loos-
40 ening of the femoral component as the endpoint.
30
20
10
0
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8 - 9 9 - 10 10 - 11 11 - 12 12 - 13 13 - 14
Years since operation
100
90
Survivorship (%)
80
70
60 Fig. 4
50
Survivorship with mechanical loosening of the
40 femoral component, whether revised or not as the
30 endpoint.
20
10
0
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8 - 9 9 - 10 10 - 11 11 - 12 12 - 13 13 - 14
Years since operation
reoperation for symptomatic aseptic loosening as the end- drift of patients from Charnley category A to category C.
point the survivorship was 99.1% (confidence interval, 96 to Significant improvements in pain relief, function and range
100)2 (Fig. 3). A survivorship curve was also constructed of movement were seen at follow-up. Function was predict-
for those stems which were designated as being loose, ably more compromised in category C patients. The mean
whether operated on or not (Fig. 4). grading of pain for hips in the Endo-Klinik grades 1, 2, 3
Clinical status. Pre- and postoperative scores are shown in and 4 loss of bone stock were 4.6, 5.36, 5.47 and 5.50. The
Table III. As may be expected with time there was a gradual low score in grade 1 hips, of which there were 12, was influ-
THE JOURNAL OF BONE AND JOINT SURGERY
FEMORAL IMPACTION GRAFTING WITH CEMENT IN REVISION TOTAL HIP REPLACEMENT 813
Table IV. Varus to valgus alignment of 170 surviving stems following Table VI. The mean subsidence of the stems
femoral impaction grafting during revision hip replacement increased according to the Endo-Klinik grade in
the patients who underwent femoral impaction
Varus Neutral Valgus grafting with cement during revision hip
Degrees 11 to 6 5 to 3 2 to 0 to 2 3 to 5 6 to 10 replacement
Number 9 26 129 5 1
Endo-Klinik grade Mean subsidence (mm)
(%) 5 15 76 3 1
1 0.9
2 2.9
3 6.3
4 12.0
Table V. Last outcome scores for the 14 hips with more than 10 mm of
subsidence, including Oxford scores when available
Charnley score
Table VII. Brooker classfication of
Subsidence Range of Oxford Femoral heterotopic ossification in 170 of the patients
(mm) Grade Pain Function movement score grade who underwent femoral impaction grafting
45 C 6 3 5 24 3 during revision hip replacement
45 C 6 1 5 32 4 Number of
25 C 5 2 3 3 Brooker Grade patients % of group
25 B 5 4 5 2
0 58 34
25 B 6 5 6 13 3
1 79 46
25 B 6 3 5 20 3
2 11 6
25 B 5 4 4 2
3 8 5
20 A 6 4 6 22 3
4 2 1
17 C 6 2 4 44 2
Not scored 12 7
15 B 6 6 5 14 2
14 B 6 4 5 17 3
13 C 6 2 4 3
11 C 6 3 4 23 3
11 B 6 5 5 14 3 scores of the 14 stems which subsided more than 10 mm are
Mean 5.8 3.4 4.7 22.9 shown in Table V. They are not classified as failures. the
mean subsidence increased with increasing severity of loss
of bone stock according to the EndoKlinik Classification
enced by two who underwent impaction grafting for septic (Table VI).
loosening and scored 3 for pain. The incidence of heterotopic bone formation is presented
Radiological assessment in Table VII. All patients who were able to tolerate non-ster-
The postoperative femoral alignment is presented in Table oidal anti-inflammatory medication were treated with
IV. The two stems re-revised for symptomatic aseptic loos- indomethacin37 for between three and five days periopera-
ening had subsided into varus and 76% of stems were within tively in an effort to reduce this complication.
2 of neutral. Later graft appearance
Subsidence. The incidence and extent of subsidence at the Trabecular incorporation. There was trabecular incorpora-
stem-cement interface is shown in Figure 5. The clinical tion in 335 of the assessable Gruen zones, which repre-
sented 28% of the total zones and remodelling in 409 zones,
which represented 34%. No definite change or a difficulty in
interpreting the appearances, such as when bone was
Subsidence obscured by mesh or cement, was noted in 446 zones
100 (37%).
90 Cortical healing was judged to have occurred in 343 of the
80 zones (87%) in which cortical compromise had been present
Number of patients
in terms of clinical outcome and survivorship of the femoral loading. They suggested that the design of the implant
component have been good. There have been significant which is used in impaction grafting must be able to accom-
improvements in scores for pain, function and movement, as modate such viscoelastic deformation of the graft without
well as in the Oxford Hip scores, which have been main- causing loosening at the interfaces.
tained into the second decade of review and associated with The polished Exeter Universal stem, which is of a force
continuing benign x-ray appearances. closed48 or taper-slip49 design was used in all cases in
Only two of the twelve femoral re-revisions were carried this series. RSA has revealed that in primary interventions
out for recurrent aseptic loosening. The most common indi- this device migrates axially within the cement mantle more
cation for re-operation on the femur was an intra- or post- than any other type of stem which has been studied50 and
operative fracture. This constituted all of the remaining ten yet there is no associated migration between the cement and
cases of femoral reoperation. In five hips a fracture was not the bone.51-54 This is a unique pattern of migration as far as
noticed at the time of the original impaction grafting so that cemented stems are concerned and is associated with
further surgery was a consequence of surgical error and improved torsional stability,55-57 probably because the load-
might, therefore, have been avoided. The remaining five ing regime which axial movement of the stem within the
fractures occurred after surgery and none required a revision cement imposes on the interfaces and the cement is predom-
of the femoral component. The fractures were reduced and inantly compression.56,58-62 The issue is whether the stem
fixed with a plate leaving the stems and proximal femoral behaves in the same way when used in impaction grafting
reconstructions intact. and whether this mechanical behaviour confers any benefit
The incidence of postoperative femoral fracture has, in that scenario.
however, lead us to re-examine our indications for the use Ornstein et al53 have studied the use of the Exeter stem in
of a longer stem. Although in two cases the fracture was impaction grafting and have shown by RSA, modified to
associated with a significant traumatic episode, in three include marker beads in the cement as well as the bone, that
there was poor quality bone at the level of the tip of the stem as well as subsidence at the stem cement interface, there is
and a fracture occurred through this area. Since 1997, subsidence of the cement in relation to the femur by approx-
instruments have been in use that allow impaction of the imately 0.3 mm which occurs mainly during the first three
graft along the whole length of long stems, so that weak- postoperative months and thereafter stabilises. This move-
ened areas of bone near the tip can be bypassed. This ment must occur at one or more of the cement graft inter-
change in technique has, so far, substantially reduced the face, within the graft itself, or at the graft host interface.
incidence of postoperative fracture. Extramedullary aug- Even RSA cannot currently clarify these matters, however,
mentation of femora and shorter stems are now reserved for but movement within the graft with further impaction under
younger patients where there is more concern over the use load from rolling and sliding of the bone chips and the vis-
of longer stems. coelastic deformations described by Giesen et al45 seem the
Radiologically the appearance of the graft is difficult to most likely. The evidence from Ornsteins work supports the
interpret.38 Where cortical and trabecular remodelling are view that the device when used with impaction grafting,
clearly seen, Linder39 showed that this corresponds to behaves in the same way as it does in primary interven-
viable new bone. In the present series, trabecular remodel- tions.53
ling was seen in a third of the zones which were analysed. Whether this mechanical behaviour confers any benefit
There was cortical healing in 87% of zones where there had in impaction grafting can only be clarified by long-term
previously been cortical compromise, emphasising the value studies. In the short term, good results with impaction
of impaction grafting in reconstituting lost bone. As far as grafting have been reported using a variety of different
radiolucent lines are concerned, the appearances must be stems of shape closed48 design.7,10-12,15,40,63 In the only
regarded as very satisfactory and there has been no recur- randomised, prospective, radiostereometric study known to
rence of focal femoral lysis. the authors40 in which a force closed48 or taper-slip49
The issue of subsidence of the stem in femoral impaction stem (the Exeter) has been compared with a shape
grafting has attracted considerable attention.16,17,19,20 Its closed48 or composite beam49 stem (the Charnley Elite
extent and pattern depend on many factors including the plus) in impaction grafting, there was no difference in the
geometry of the stem,40 surgical technique7,41-43 and the clinical outcome or apparent bony remodelling at two
physical nature of the graft.43-47 With regard to the latter, years, by which time the mean subsidence between the
Brewster et al44 demonstrated experimentally that in con- stem and the femur was 1.7 mm with the Exeter and 0.2
tained bone defects the graft behaves as a friable aggregate, mm with the Elite. The technique of RSA used in this study
and its resistance to load depends on the distribution of par- could not determine at which interface the subsidence had
ticle size, the adequacy of graft compaction and the applica- occurred. Van Doorn et al40 reported that on plain X-rays
tion of loads normal to the material. Giesen et al45 no debonding of the stem-cement interface, no fractures of
concluded from their experimental work on the mechanical the cement and no radiolucencies were seen in either
and viscoelastic behaviour of graft that in clinical use it was group. Even in primary interventions, every Exeter stem
bound to be subjected to permanent deformation following debonds at this interface51-54,62 and this radiographic
THE JOURNAL OF BONE AND JOINT SURGERY
FEMORAL IMPACTION GRAFTING WITH CEMENT IN REVISION TOTAL HIP REPLACEMENT 815
(a) Preoperative, (b) postoperative and (c) 10-year radiographs of an impaction grafted femur. The subsidence
between stem and cement appears to have stopped by 10 years in this very active patient. Dramatic cortical
healing is seen in Gruen zones 2 and 3. Trabecular remodelling is evident both medially and laterally around
the stem.
6
years is a poor prognostic feature of cemented stems in pri- 3
mary interventions.56 0
0 3 24 36 60 108
The maximum subsidence of the Exeter stem recorded at Follow-up (months)
two years by van Doorn et al40 was 3 mm. In the present
series, no stem with subsidence of 3 mm at two years has Patient 3
yet failed due to aseptic loosening and subsidence signifi- 15
cantly greater than this is evidently compatible with good 12
9
mm
25. Heyse-Moore GH, Ling RSM. Current cement techniques. In: Marti 47. Dunlop DG, Brewster NT, Madabushi SP, et al. Techniques to
RK, ed. Progress in cemented total hip surgery and revision. Excerpta improve the shear strength of impacted bone graft. J Bone Joint Surg
Medica, Amsterdam 1983;71-86. [Am] 2003;85-A:639-46.
26. Gruen TA, McNeice G, Amstutz HC. Modes of failure of cemented 48. Huiskes R, Verdonschot N, Nivbrant B. Migration, stem shape and
stem-type femoral components. Clin Orthop 1979;141:17-27. surface finish. Clin Orthop 1998;355:103-12.
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prostheses: review of methodology and clinical results. Clin Orthop tion of hip implant design and surface finish: micromotion of cemented
1997;344:94-110. femoral stems. Scientific exhibit presented at the 67th Annual Meeting
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1995;66:418-24. after THA: a comparison of Charnley elite and Exeter femoral stems
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31. Charnley J. Numerical grading of clinical results. In: Low friction Exeter stem migrate at the stem-cement interface or/and at the cement-
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