Aims

Bone stock restoration of acetabular bone defects using impaction bone grafting (IBG) in total hip arthroplasty may facilitate future re-revision in the event of failure of the reconstruction. We hypothesized that the acetabular bone defect during re-revision surgery after IBG was smaller than during the previous revision surgery. The clinical and radiological results of re-revisions with repeated use of IBG were also analyzed.

In revision total hip replacement, bone loss can be managed by impacting porous bone chips. In order to guarantee sufficient mechanical strength, the bone chips have to be compacted. The aim of this study was to determine in an in vitro simulation whether the use of a pneumatic hammer leads to higher primary stability than manual impaction. Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. From these measurements bulk density, contact stiffness, impaction hardness and penetration resistance were calculated for different durations of impaction.

We found that the pneumatic method reached higher values of impaction hardness, contact stiffness and bulk density suggesting an increase in stability of the implant. No significant differences were found between the two different methods concerning the penetration resistance. The pneumatic method might reduce the risk of fracture in vivo, as force peaks are smaller and applied for a shorter period. Results from manual impaction showed higher variability and depend much on the experience of the surgeon. The pneumatic hammer is a suitable tool to standardise the impaction process.

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification.

The Mayo hip score improved from a mean of 32 (sd ± 18) to 62 (sd ± 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united.

The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases.

In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

This review summarises the technique of impaction grafting with mesh augmentation for the treatment of uncontained acetabular defects in revision hip arthroplasty. The ideal acetabular revision should restore bone stock, use a small socket in the near-anatomic position, and provide durable fixation. Impaction bone grafting, which has been in use for over 40 years, offers the ability to achieve these goals in uncontained defects. The precepts of modern, revision impaction grafting are that the segmental or cavitary defects must be supported with a mesh; the contained cavity is filled with vigorously impacted morselised fresh-frozen allograft; and finally, acrylic cement is used to stabilise the graft and provide rigid, long-lasting fixation of the revised acetabular component. Favourable results have been published with this technique. While having its limitations, it is a viable option to address large acetabular defects in revision arthroplasty. Cite this article: Bone Joint J 2017;99-B(1 Supple A):25–30

This study was to analyze the minimum ten years clinical and radiological results of revision total hip arthroplasties using allogenic impaction bone graft and cemented cup in acetabular bone deficiency.

Fifty two revision total hip arthroplasties that had been performed in forty nine patients between March 1992 and June 1997 and had followed more than minimum ten years were included in this study. The clinical and radiological results were evaluated by Harris hip score and roentgenography including anterior-posterior view of pelvis and lateral view of operated hip.

The mean Harris hip score was 47 points preoperatively, 81 points at three years, 84 points at seven years, and 82 points at ten years after revision. In radiological evaluation, osseous union between grafted bone and host bone was seen within four months in 47 hips, a complete grafted bone-cement radiolucent line of two millimeter or more in at least one zone was seen in 5 hips at two years, 7 hips at seven years, and 2 hip at 10 years follow-up.

We recommend the technique using allogenic impaction bone graft and cemented cup to reconstruct the acetabular cavitary defect in revision total hip arthroplasties.

In this retrospective study, we investigated the results of revision total hip replacement (THR) using a cemented long-stemmed Exeter femoral component, with a minimum length of 205 mm in patients with extensive femoral bone defects. The study included 37 consecutive patients with a mean age of 76 years (39 to 93) and a mean follow-up of nine years (5 to 16). A total of 26 patients (70%) had a pre-operative Endo-Klinik score of 3 or 4. Impaction bone grafting was used in 24 patients (65%). At the time of evaluation, 22 patients (59%) were still alive and were evaluated clinically and radiologically. A total of 14 patients died during follow-up and their data were included until the time of their death. One reconstruction failed after five years and five months owing to recurrent dislocation: the hip was converted to an excision arthroplasty. Intra-operative fractures or fissures were encountered in nine patients (24%), but none occurred during impaction of the bone graft. Post-operative peri-prosthetic fractures occurred in two patients (5%); both were treated with plate fixation. At nine years, survival with the endpoint of all-cause re-revision was 96.3% (95% CI 76.4 to 99.5); including re-operations for any reason, it was 80.7% (95% CI 56.3 to 92.3%). There were no re-revisions for aseptic loosening. The survival of long stem cemented femoral components following revision THR is satisfactory in a fragile population with extensive femoral defects. Cite this article: Bone Joint J 2014; 96-B:1207–13

Aims

The aim of this study is to report the long-term outcomes of instrumented femoral revisions with impaction allograft bone grafting (IBG) using the X-change femoral revision system at 30 years after introduction of the technique.

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

The April 2024 Hip & Pelvis Roundup. 360. looks at: Impaction bone grafting for femoral revision hip arthroplasty with the Exeter stem; Effect of preoperative corticosteroids on postoperative glucose control in total joint replacement; Tranexamic acid in patients with a history of venous thromboembolism; Bisphosphonate use may be associated with an increased risk of periprosthetic hip fracture; A balanced approach: exploring the impact of surgical techniques on hip arthroplasty outcomes; A leap forward in hip arthroplasty: dual-mobility bearings reduce groin pain; A new perspective on complications: the link between blood glucose and joint infection risks

Aims. The aim of this study was to determine the outcome of all primary total hip arthroplasties (THAs) and their subsequent revision procedures in patients aged under 50 years performed at our institution. Methods. All 1,049 primary THAs which were undertaken in 860 patients aged under 50 years between 1988 and 2018 in our tertiary care institution were included. We used cemented implants in both primary and revision surgery. Impaction bone grafting was used in patients with acetabular or femoral bone defects. Kaplan-Meier analyses were used to determine the survival of primary and revision THA with the endpoint of revision for any reason, and of revision for aseptic loosening. Results. The mean age of the patients at the time of the initial THA was 38.6 years (SD 9.3). The mean follow-up of the THA was 8.7 years (2.0 to 31.5). The rate of survival for all primary THAs, acetabular components only, and femoral components only at 20 years’ follow-up with the endpoint of revision for any reason, was 66.7% (95% confidence interval (CI) 60.5 to 72.2), 69.1% (95% CI 63.0 to 74.4), and 83.2% (95% CI 78.1 to 87.3), respectively. A total of 138 revisions were performed. The mean age at the time of revision was 48.2 years (23 to 72). Survival of all subsequent revision procedures, revised acetabular, and revised femoral components at 15 years’ follow-up with the endpoint of revision for any reason was 70.3% (95% CI 56.1 to 80.7), 69.7% (95% CI 54.3 to 80.7), and 76.2% (95% CI 57.8 to 87.4), respectively. A Girdlestone excision arthroplasty was required in six of 860 patients (0.7%). Conclusion. The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. We showed that our philosophy of using impaction bone grafting in patients with acetabular and femoral defects is a very suitable option when treating young patients. Surgeons should realize that knowledge of the outcome of subsequent revision surgery, which is inevitable in young patients, must be communicated to this group of patients prior to their initial THA. Cite this article: Bone Joint J 2022;104-B(3):368–375

Introduction. When ankle arthroplasty fails the options are revision to arthrodesis or revision to arthroplasty. We report early outcomes of revision procedures for failed total replacement. Methods. Retrospective review of prospectively collected data including post-operative complications, union, survivorship and PROMS scores to compare revision to arthrodesis and revision to arthroplasty. Results. 31 revision procedures (10 revision to arthrodesis and 21 revision to arthroplasty) were performed for failed primary ankle arthroplasty (30 patients) between January 2012 and June 2019. 23 males: 8 females, average age of 68. Indications for revisions were aseptic loosening (13), cysts/lysis (6), pain (5), periprosthetic infection (3), fracture (2), fibula erosion (1), polyethylene dislocation (1). Union rate following arthrodesis was 77.9% after primary revision procedure. Impaction bone grafting technique was utilised in seven patients with a union rate of 83%. Survivorship following revision to arthroplasty was 100% at two years; 87.5% at three years and 75% at four years Failed revision arthroplasty was revised to arthrodesis successfully. Median MOxFQ was 73.5 for the arthrodesis group versus 17 in the arthroplasty group (p=0.02). Median AOS was 87 for the arthrodesis group versus 12 for the arthroplasty group (p=0.04). Discussion. This study demonstrated the potential advantages in the short term of revision arthroplasty over conversion to arthrodesis with statistically significant improvements in MOxFQ and AOS within the first two years following revision

Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland. A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored. 33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy. Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate

Introduction: Revision hip surgery is predicted to rise significantly over the coming decades. There is therefore likely to be an increasing need to overcome the large bone loss and cavitatory defects encountered in failed primary hip replacements. Impaction bone grafting (IBG) is a recognised technique for replacing lost bone stock. Achieving optimal graft impaction is a difficult surgical skill with a significant learning curve, balancing the need to achieve sufficient compaction to provide primary stability versus the need to keep impaction forces to a minimum to prevent iatrogenic fracture. In this study we have developed a revision acetabular model to test the hypothesis that the use of vibration and drainage with a new custom made perforated tamp could reduce the peak stresses imparted to the acetabulum during the impaction process and also improve the reliability and reproducibility of the impaction technique. Methods: Composite Sawbone hemi Pelvis models were used, with identical contained cavitatory defects created (Paprosky Type 2a). A strain gauge was attached to the medial wall of each hemi pelvis. A custom set of IBG tamps were made, and coupled a pneumatic hammer used to generate the vibrations. A standard impaction technique was used for the control group and the new vibration impaction for the experimental group. The cavity was progressively filled with morsellised allograft in 6 set steps for both groups with strain gauge readings taken during all impaction to monitor peak stresses. A standard Exeter Contemporary cup was then cemented into the graft bed for both groups. The models were mechanically loaded according to the protocol developed by Westphal et al at the angle of the joint reaction force during heel strike for a total of 50 000 cycles. 3D assessment of any micro motion post mechanical testing and degree of graft compaction was done with high resolution micro CT. Results: Vibration impaction lead to a significant reduction in the peak stresses during the impaction process throughout the 6 steps (e.g. Step 1: 34.6 vs 110.8 MPa p=0.03). There was also far less variability in the peak stresses in the vibration group compared to standard impaction both in sequential impactions by the same surgeon and between different surgeons. One medial wall fracture occurred in the control group only. There was no difference in the degree of graft compaction or in the subsidence of the implant post cyclical loading. Conclusion: Impaction bone grafting can be a difficult surgical skill with a significant learning curve. We believe that this new technique of applying vibration coupled with drainage to the IBG process in the acetabulum can reduce the risk of intraoperative fracture whilst achieving good graft compaction and implant stability. This technique therefore has the potential to widen the ‘safety margins’ of IBG and reduce the learning curve allowing more widespread adoption of the technique for replacing lost bone stock

Loss of bone stock is a major problem in revision surgery of the hip. Impaction bone grafting of the femur is frequently used when dealing with deficient bone stock. In this retrospective study a consecutive series of 68 patients (69 hips) who had revision of a hip replacement with femoral impaction grafting were reviewed. Irradiated bone allograft was used in all hips. Radiological measurement of subsidence of the stem, incorporation of the graft and remodelling was carried out and showed incorporation of the graft in 26 of 69 hips (38%). However, there was no evidence of trabecular remodelling. Moderate subsidence of 5 mm to 10 mm occurred in ten hips (14.5%), and massive subsidence of > 10 mm in five (7.2%). The results of this study are less favourable than those of others describing studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling noted in other series raises the question as to whether irradiated bone graft may be a significant factor influencing the post-operative outcome

Introduction. Impaction bone grafting (IBG) is a reliable technique for acetabular revision surgery with large segmental defects. However, bone graft resorption and cup migration are some of the limitations of this tecnique. We assess frequency and outcome of these complications in a large acetabular IBG series. Patients and Methods. We analysed 330 consecutive hips that received acetabular IBG and a cemented cup in revision surgery with large bone defects (Paprosky types 3A and 3B). Fresh-frozen femoral head allograft was morselized manually. The mean follow-up was 17 years (3–26). All data were prospectively collected. Kaplan-Meier survivorship analysis was performed. Changes in different paremeters regarding cup position were assessed pre- and postoperatively and at the follow- up controls. Only variations greater than 5º and 3 mm were considered. Results. The mean Harris Hip Score improved from 48.3+8.5 to 84.6+12.8 at final follow-up. The radiological analysis showed cup migration in 42 hips. The mean appearance time was 4.3 years (range, 1–25). Migration was progressive and painful in 27 hips (67.5%) requiring cup revision. Lateral mesh was more frequently associated with migrated cups (p=0.034). Cup tilt was found in 37 out 42 migrated cups, however cranial migration was more frequent in progressive migrated cups (p=0.02). There were 34 re-revisions, 27 due to aseptic cup loosening, 6 due to dislocation and one due to infection. The survival rate for any cause at 16 years was 81.2% (95% Confidence Interval (CI): 74.0 to 88.4) and for aseptic cup loosening was 83.4% (95% CI: 76.2–90.6). In all surviving hips trabecular incorporation was observed without radiolucent lines. Conclusions. IBG continues to be a reliable technique for large defects in acetabular revision surgery. Bone graft resorption and cup migration was not frequent in this large series and one-third of cases were not progressive. Cup migration was more frequent in cases with a segmental roof defect in which a lateral mesh was used

Femoral revision after cemented total hip arthroplasty (THA) might include technical difficulties, following essential cement removal, which might lead to further loss of bone and consequently inadequate fixation of the subsequent revision stem. Bone loss may occur because of implant loosening or polyethylene wear, and should be addressed at time of revision surgery. Stem revision can be performed with modular cementless reconstruction stems involving the diaphysis for fixation, or alternatively with restoration of the bone stock of the proximal femur with the use of allografts. Impaction bone grafting (IBG) has been widely used in revision surgery for the acetabulum, and subsequently for the femur in Paprosky defects Type 1 or 2. In combination with a regular length cemented stem, impaction grafting allows for restoration of femoral bone stock through incorporation and remodeling of the proximal femur. Cavitary bone defects affecting the metaphysis and partly the diaphysis leading to a wide femoral canal are ideal indications for this technique. In case of combined segmental-cavitary defects a metal mesh is used to contain the defect which is then filled and impacted with bone grafts. Cancellous allograft bone chips of 2 to 4 mm size are used, and tapered into the canal with rods of increasing diameters. To impact the bone chips into the femoral canal a dummy of the dimensions of the definitive cemented stem is inserted and tapped into the femur to ensure that the chips are firmly impacted. Finally, a standard stem is implanted into the newly created medullary canal using bone cement. To date several studies from Europe have shown favorable results with this technique, with some excellent long-term results reported. Advantages of IBG include the restoration of the bone stock in the proximal femur, the use of standard length cemented stems and preserving the diaphysis for re-revision. As disadvantages of the technique: longer surgical time, increased blood loss and the necessity of a bone bank can be mentioned

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (. sd. 1.5) (10.0 to 16.0). Kaplan–Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose. . Cite this article: Bone Joint J 2014;96-B:188–94

Background. Impaction bone grafting (IBG) using a circumferential metal mesh is one of the options that allow restoration of the femoral bone stock and stability of the implant in hip arthroplasty. Here we examined the clinical and radiographic outcome of this procedure with a cemented stem and analyzed experimentally the initial stability of mesh–grafted bone–cemented stem complexes. Methods. We retrospectively reviewed 6 hips (6 patients) that had undergone femoral revisions with a circumferential metal mesh, impacted bone allografts, and a cemented stem. The mean follow-up period was 2.9 years (range, 1.4–3.8 years). Hip joint function was evaluated with the Japanese Orthopaedic Association hip score, and radiographic changes were determined from radiographs. The initial resistance of cemented stem complexes to axial and rotational force was measured in a composite bone model with various segmental losses of the proximal femur. Results. The hip score improved from 50 (range, 10–84) preoperatively to a mean of 74 (range, 67–88) at the final follow-up. The overall implant survival rate was 100% at 4 years when radiological loosening or revision for any reason was used as the endpoint. No stem subsided more than 3 mm vertically within 1 year after implantation. Computed tomography showed reconstitution of the femoral canal in a metal mesh. In mechanical analyses, there was no influence on the stem stability to axial compression during the repeated axial compression test between IBG reconstruction rates. On the other hand, for IBG reconstruction rate of 66.7%, grafted bone-Sawbone juntion was buckled under the axial breaking force. In contrast, under rotational load, the rotation angles of the stainless mesh were strongly affected by the IBG reconstruction rate. Conclusions. The short-term results show good outcomes for reconstruction of proximal bone loss with impaction bone allografts and a circumferential mesh. The procedure should be applied in cases where the circumferential proximal bone loss is less than half of the stem length implanted

Introduction. Impaction bone grafting for reconstitution of acetabular bone stock in revision hip surgery has been used for nearly 30 years. We report results in a group of patients upon whom data has been collected prospectively with a minimum ten year follow-up. Material and Methods. Acetabular impaction grafting was performed in 305 hips in 293 patients revised for aseptic loosening between 1995 and 2001. In this series 33% of cases required stainless steel meshes to reconstruct medial wall or rim defects prior to graft impaction. These meshes were the the only implants used for this purpose in this series. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of 10 years following the index operation; mean follow-up was 12.4 years (SD 1.5; range 10.0–16.0). Results. Kaplan-Meier survivorship with revision for aseptic loosening as the endpoint was 86% (95% CI 81.1 to 90.9%). Clinical scores for pain relief and function remained satisfactory (mean OHS 33.3, Harris hip score for pain 36.7, Harris hip score for function 27.3). Of the 125 hips still available with at least 10 years of radiographic follow-up, 97 appeared stable and 28 were judged to be radiologically loose; however, there was no significant difference in the pain and function scores between the two groups. The overall complication rate was 11.5%, including 1% peri-operative death, 3.3% dislocation and 0.3% deep infection. Discussion. This is the largest series of medium- to long-term results of acetabular impaction bone grafting with a cemented cup for revision hip arthroplasty reported to date. The technique is particularly successful when used for Paprosky grade 1 and 2 deficiencies; grade 3 deficiencies may be better managed with a different method for reconstructing larger defects e.g. trabecular metal augments. Conclusion. This series shows good long-term results for impaction bone grafting of acetabular deficiencies in revision hip surgery, with survivorship of 86% for aseptic loosening at 13.5 years and satisfactory clinical outcomes

Impaction bone grafting with a cemented polished double-taper stem as a technique for revision of the femoral component was introduced in 1987 at our institution. As at January 2000, 540 cases in 487 patients had been performed. All procedures have been studied prospectively and there are no patients lost to follow-up. We present the survivorship and outcome data for these patients. Survivorship at 15 years is 90.6 percent [95 percent confidence interval: 88–93 percent]. Clinical scores show marked and sustained improvement. There have been 45 failures [8.3 percent]. Technical error contributed to 13 of the 24 non-infective complications, but with improved technique plus the addition of long stemmed impaction grafting, there have been no technical errors since 1996. Our results show that revision of the femoral component with impaction bone grafting is a reliable and durable technique with an acceptably low complication rate and with excellent survivorship at 15 years