Reduced Femoral Component Subsidence with Improved Impaction Grafting at Revision Hip Arthroplasty
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Despite stem subsidence being a major complication of femoral impaction bone grafting in cemented revision hip arthroplasty, few studies have distinguished subsidence at the prosthesis-cement interface from that at the cement-bone interface. It is unknown how technique developments intended to improve the procedure influence stability of the stem.
We used a sensitive technique to measure subsidence of a cemented polished collarless double-taper stem at each interface after femoral impaction grafting and compared subsidence, radiographic loosening, complications, and reoperations over three series of hips defined by technique developments.
Patients and Methods
Three series were defined: Series 1 (n = 23, irradiated allograft), Series 2 (n = 12, double-washed, size-profiled graft, nonirradiated bone, long stems as required), and Series 3 (n = 21, modular tamps). Stem subsidence was analyzed with Ein Bild Röntgen Analyse software. Radiographic loosening, complications, and reoperations were also determined.
The median subsidence at 12 months for Series 1, 2, and 3 were 2.1, 0.5, and 0.7 mm at the prosthesis-cement interface and 1.3, 0.1, and 0.1 mm at the cement-bone interface. There were two postoperative Vancouver B periprosthetic fractures in Series 1, four hips were revised for loosening in Series 1, and there were no fractures or loosening in Series 2 and 3 at minimum 2 years’ followup. There were no surviving hips radiographically classified as possibly or probably loose.
Evolution in techniques of femoral impaction grafting in this study were associated with reduced subsidence of the stem at both the prosthesis-cement interface and cement-bone interface when compared to the original series. Concurrent with reduced stem subsidence was the absence of periprosthetic fracture, radiographic loosening, and complications requiring rerevision.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
- Alfaro-Adrian J, Gill HS, Murray DW. Cement migration after THR: a comparison of Charnley Elite and Exeter femoral stems using RSA. J Bone Joint Surg Br. 1999;81:130–134. CrossRef
- Barker R, Takahashi T, Toms A, Gregson P, Kuiper JH. Reconstruction of femoral defects in revision hip surgery: risk of fracture and stem migration after impaction bone grafting. J Bone Joint Surg Br. 2006;88:832–836. CrossRef
- Biedermann R, Krismer M, Stockl B, Mayrhofer P, Ornstein E, Franzen H. Accuracy of EBRA-FCA in the measurement of migration of femoral components of total hip replacement: Einzel-Bild-Röntgen-Analyse-femoral component analysis. J Bone Joint Surg Br. 1999;81:266–272. CrossRef
- Biedermann R, Stockl B, Krismer M, Mayrhofer P, Ornstein E, Franzén H. Evaluation of accuracy and precision of bone markers for the measurement of migration of hip prostheses: a comparison of conventional measurements. J Bone Joint Surg Br. 2001;83:767–771. CrossRef
- Brewster NT, Gillespie WJ, Howie CR, Madabhushi SP, Usmani AS, Fairbairn DR. Mechanical considerations in impaction bone grafting. J Bone Joint Surg Br. 1999;81:118–124. CrossRef
- Cabanela ME, Trousdale RT, Berry DJ. Impacted cancellous graft plus cement in hip revision. Clin Orthop Relat Res. 2003;417:175–182.
- Dunlop DG, Brewster NT, Madabjushi SP, Usmani AS, Pankaj P, Howie CR. Techniques to improve the shear strength of impacted bone graft. J Bone Joint Surg Am. 2003;85:639–646.
- Edwards SA, Pandit HG, Grover ML, Clarke HJ. Impaction bone grafting in revision hip surgery. J Arthroplasty. 2003;18:852–859. CrossRef
- Eldridge JD, Smith EJ, Hubble MJ, Whitehouse SL, Learmonth ID. Massive early subsidence following femoral impaction grafting. J Arthroplasty. 1997;12:S35–S40. CrossRef
- Elting JJ, Mikhail WE, Zicat BA, Hubbell JC, Lane LE, House B. Preliminary report of impaction grafting for exchange femoral arthroplasty. Clin Orthop Relat Res. 1995;319:159–167.
- Engelbrecht E, Heinert K. Klassifikation und Behandlungsricgtlinien von Knochensubstanzverlusten bei Revisionsoperationen am Hüftgelenk-mittelfristige Ergebnisse. Primär und Revisionsalloarthroplastik Hüft und Kniegelank. Berlin, Germany: Springer-Verlag; 1987:189–201.
- Farfalli GL, Buttaro MA, Piccaluga F. Femoral fractures in revision hip surgeries with impacted bone allograft. Clin Orthop Relat Res. 2007;462:130–136. CrossRef
- Fowler JL, Gie GA, Lee AJ, Ling RS. Experience with the Exeter total hip replacement since 1970. Orthop Clin North Am. 1988;19:477–489. Erratum in: Orthop Clin North Am. 1989;20:preceding 519.
- Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br. 1993;75:14–21
- Gokhale S, Soliman A, Dantas JP, Richardson JB, Cook F, Kuiper JH, Jones P. Variables affecting initial stability of impaction grafting for hip revision. Clin Orthop Relat Res. 2005;432:174–180. CrossRef
- Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction grafting with cement in revision total hip replacement. J Bone Joint Surg Br. 2003;85:809–817.
- Harris WH, McCarthy JC, O’Neil DA. Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am. 1982;64:1063–1067.
- Hassaballa M, Mehendale S, Poniatowski S, Kalantzis G, Smith E, Learmonth ID. Subsidence of the stem after impaction bone grafting for revision hip replacement using irradiated bone. J Bone Joint Surg Br. 2009;91:37–43.
- Höstner J, Hultmark P, Kärrholm J, Malchau H, Tveit M. Impaction technique and graft treatment in revisions of the femoral component: laboratory studies and clinical validation. J Arthroplasty. 2001;16:76–82. CrossRef
- Howie DW, Wimhurst JA, McGee MA, Carbone TA, Badaruddin BS. Revision total hip replacement using cemented collarless double-taper femoral components. J Bone Joint Surg Br. 2007;89:879–886. CrossRef
- Karrholm J, Hultmark P, Carlsson L, Malchau H. Subsidence of a non-polished stem in revisions of the hip using impaction allograft: evaluation with radiostereometry and dual-energy x-ray absorptiometry. J Bone Joint Surg Br. 1999;81:135–142. CrossRef
- Mahoney CR, Fehringer EV, Kopjar B, Garvin KL. Femoral revision with impaction grafting and a collarless, polished, tapered stem. Clin Orthop Relat Res. 2005;432:181–187. CrossRef
- Malchau H, Kärrholm J, Wang YX, Herberts P. Accuracy of migration analysis in hip arthroplasty: digitized and conventional radiography, compared to radiostereometry in 51 patients. Acta Orthop Scand. 1995;66:418–424. CrossRef
- Masterson EL, Masri BA, Duncan CP. The cement mantle in the Exeter impaction allografting technique: a cause for concern. J Arthroplasty. 1997;12:759–764. CrossRef
- Meding JB, Ritter MA, Keating EM, Faris PM. Impaction bone-grafting before insertion of a femoral stem with cement in revision total hip arthroplasty: a minimum two-year follow-up study. J Bone Joint Surg Am. 1997;79:1834–1841.
- Nelson IW, Bulstrode CJ, Mowat AG. Femoral allografts in revision of the hip replacement. J Bone Joint Surg Br. 1990;72:151–152.
- Nivbrant B, Kärrholm J, Röhrl S, Hassander H, Wesslén B. Bone cement with reduced proportion of monomer in total hip arthroplasty: preclinical evaluation and randomized study of 47 cases with 5 years’ follow-up. Acta Orthop Scand. 2001;72:572–584. CrossRef
- Oakley J, Kuiper JH. Factors affecting the cohesion of impaction bone graft. J Bone Joint Surg Br. 2006;88:828–831. CrossRef
- Ornstein E, Franzen H, Johnsson R, Karlsson MK, Linder L, Sundberg M. Hip revision using the Exeter stem, impacted morselized allograft bone and cement: a consecutive 5-year radiostereometric and radiographic study in 15 hips. Acta Orthop Scand. 2004;75:533–543. CrossRef
- Ornstein E, Linder L, Ranstam J, Lewold S, Eisler T, Torper M. Femoral impaction bone grafting with the Exeter stem—the Swedish Experience: survivorship analysis of 1305 revisions performed between 1989 and 2002. J Bone Joint Surg Br. 2009;91:441–446. CrossRef
- Panjabi MM, Trumble T, Hult E, Southwick WO. Effect of femoral stem length on stress raisers associated with revision hip arthroplasty. J Orthop Res. 1985;3:447–455. CrossRef
- Pekkarinen J, Alho A, Lepisto J, Ylikoski M, Ylinen P, Paavilainen T. Impaction bone grafting in revision hip surgery: a high incidence of complications. J Bone Joint Surg Br. 2000;82:103–107. CrossRef
- Robinson DE, Lee MB, Smith EJ, Learmonth ID. Femoral impaction grafting in revision hip arthroplasty with irradiated bone. J Arthroplasty. 2002;17:834–840. CrossRef
- Schreurs BW, Arts JJ, Verdonschot N, Buma P, Slooff TJ, Gardeniers JW. Femoral component revision with use of compaction bone-grafting and a cemented polished stem. J Bone Joint Surg Am. 2005;87:2499–2507. CrossRef
- Sierra RJ, Charity J, Tsiridis E, Timperley JA, Gie GA. The use of long cemented stems for femoral impaction grafting in revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1330–1336. CrossRef
- Simon JP, Fowler JL, Gie GA, Ling RS, Timperley AJ. Impaction cancellous grafting of the femur in cemented total hip revision arthroplasty. J Bone Joint Surg Br. 1991;73(Suppl 1):73.
- Stefánsdőttir A, Franzén H, Johnsson R, Ornstein E, Sundberg M. Movement pattern of the Exeter stem: a radiostereometric analysis of 22 primary hip arthroplasties followed for 5 years. Acta Orthop Scand. 2004;75:408–414. CrossRef
- Thanner J, Freij-Larsson C, Kärrholm J, Malchau H, Wesslén B. Evaluation of Boneloc. Chemical and mechanical properties, and a randomized clinical study of 30 total hip arthroplasties. Acta Orthop Scand. 1995;66:207–214. CrossRef
- Toms AD, Barker RL, Jones RS, Kuiper JH. Impaction bone-grafting in revision joint replacement surgery. J Bone Joint Surg Am. 2004;86:2050–2060.
- Ullmark G. Bigger size and defatting of bone chips will increase cup stability. Arch Orthop Trauma Surg. 2000;120:445–447. CrossRef
- van Biezen FC, ten Have BL, Verhaar JA. Impaction bone-grafting of severely defective femora in revision total hip surgery: 21 hips followed for 41-85 months. Acta Orthop Scand. 2000;71:135–142. CrossRef
- van Doorn WJ, ten Have BL, van Biezen FC, Hop WC, Ginai AZ, Verhaar JA. Migration of the femoral stem after impaction bone grafting: first results of an ongoing, randomised study of the Exeter and Elite Plus femoral stems using radiostereometric analysis. J Bone Joint Surg Br. 2002;84:825–831. CrossRef
- Wraighte PJ, Howard PW. Femoral impaction bone allografting with an Exeter cemented collarless, polished, tapered stem in revision hip replacement: a mean follow-up of 10.5 years. J Bone Joint Surg Br. 2008;90:1000–1004.
- Yates PJ, Burston BJ, Whitley E, Bannister GC. Collarless polished tapered stem. Clinical and radiological results at a minimum of ten years’ follow-up. J Bone Joint Surg Br. 2008;90:16–22.
- Yim SJ, Kim MY, Suh YS. Impaction allograft with cement for the revision of the femoral component: a minimum 39-month follow-up study with the use of the Exeter stem in Asian hips. Int Orthop. 2007;31:297–302. CrossRef
- Reduced Femoral Component Subsidence with Improved Impaction Grafting at Revision Hip Arthroplasty
Clinical Orthopaedics and Related Research®
Volume 468, Issue 12 , pp 3314-3321
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- 1. Department of Orthopaedics and Trauma, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
- 2. Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, SA, Australia