Oper Orthop Traumatol 2014 · 26:156–161DOI 10.1007/s00064-013-0272-1Received: 31. Juli 2013Revised: 8. Dezember 2013Accepted: 22. Januar 2014Online publiziert: 5. April 2014© Springer-Verlag Berlin Heidelberg 2014

I.C. Heyligers1 · B.W. Schreurs2 · E.H. van Haaren3

1 Department of Orthopaedics, Atrium MC, Heerlen, SHE, Faculty of

Health, Medicine and Life Sciences, University Maastricht2 Department of Orthopaedics, Radboud University, Nijmegen3 Department of Orthopaedics, Orbis MC, Sittard

Femoral revision with impaction bone grafting and a cemented polished tapered stem

Introductory remarks

In femoral revision surgery, one of the main topics is how to deal with bone loss. When bone loss (according to the En-doklinik classification) is treated with ex-tra cement and/or an increased stem size, bone stock is not restored. Bone graft im-paction however, is a technique to restore bone loss, thus creating a stable situation for the future. In this technique, loading of the graft plays an important role in ini-tiation of the graft remodeling process. Therefore, a polished double-tapered ce-mented stem is used (Exeter; Stryker Or-thopedics, Mahwah, NJ, USA). Because of the specific stem design and the surgical technique, forces on the stem are trans-mitted to the bone graft, whereby the graft is loaded. Special metal meshes and cer-clage wires can be used to restore segmen-tal defects (Stryker). By virtue of the dif-ferent stem options, the centre of rotation can be defined by the surgeon. In this way, bone loss is treated, bone stock is restored and the desired centre of rotation is cre-ated.

Surgical principle and objective

Femoral segmental defects are treated with metal meshes and cerclages (Stryk-er). Stems of different sizes with differ-ent lengths and offsets are available. The

length of the stem dictates the position of a polyethylene plug that is fixed about 2 cm below the distal part of the stem us-ing a central rod. The central rod incor-porates a scale to measure the distance proximal to the plug. Special hollow im-paction instruments of increasing dia-meter are available to indicate the level of impaction, without incurring the risk of splitting the femur. Following bone im-paction, when the level is reached where the stem itself can be introduced, impac-tion instruments of different sizes and off-sets are used. When long stems are used, a central canal is created in the impacted bone using a core reamer. Trial reduction can be performed with the final impactor. When the surgeon is satisfied, the final stem is fixed using cement. A cement gun is used during cementation. A distal cen-tralizer is fixed to the distal point of the stem. After introduction of the stem dur-ing hardening of the cement, the proxi mal part is closed with a specially designed seal. This pressurizing technique results in increased cement penetration of the impacted bone bed.

Advantages

FConserved restoration of bone lossFReconstruction of center of rotation

FWell-fixed stem in femora with cav-itary and/or segmental defects (En-doklinik classification grade 4)

Disadvantages

FTechnically demanding procedureFLonger surgery timeFAllograft bone from a bone bank is

requiredFStandard postoperative protocol is

12 weeks on crutches

Indications

FFemoral stem revision with bone loss (up to Endoklinik grade 4)

Contraindications

FOne-stage revision in cases of septic loosening

FExtensive circumferential proximal femoral cortical bone loss; distal fixa-tion with a long stem is advised

FNoncompliant patient

Patient information

FFresh frozen donor bone will be usedFPartial weight bearing for 3 monthsFPotential complications of revision

surgery (infection, dislocation, neu-

RedaktionD.C. Wirtz, BonnZeichnerR. Himmelhan, Heidelberg

156 |  Operative Orthopädie und Traumatologie 2 · 2014

Operative Techniken

Abstract · Zusammenfassung

Oper Orthop Traumatol 2014 · 26:156–161 DOI 10.1007/s00064-013-0272-1© Springer-Verlag Berlin Heidelberg 2014

I.C. Heyligers · B.W. Schreurs · E.H. van HaarenFemoral revision with impaction bone grafting and a cemented polished tapered stem

AbstractObjective. Biological repair of femoral bone loss using bone impaction grafting. Recon-struction of the centre of rotation of the hip using a cemented stem, the size and offset of which are at the discretion of the surgeon.Indications. Femoral implant loosening with bone loss.Contraindications. Infection, neurological disorders, noncompliant patient.Surgical technique. Extraction of the loose femoral implant, cortical reconstruction us-ing meshes if required, impaction bone graft-ing with special instruments, cement fixation of a polished tapered stem.Postoperative management. Individual-ized period of bed rest and limited weight bearing.

Results. Impaction bone grafting and a ce-mented polished stem were used to perform 33 femoral reconstructions. After a mean fol-low-up of 15 years, no femoral reconstruc-tion had to be revised. One unrecognized in-traoperative fracture healed after nonsurgical treatment, three postoperative femoral frac-tures healed after plate fixation with the stem left in situ. The average Harris Hip Score im-proved from 49 prior to surgery to 85 points thereafter. Kaplan–Meier analysis with fem-oral revision for any reason as the end point showed a survival rate of 100%.

KeywordsBone loss · Rotation · Segmental defects · Harris Hip Score · Allograft

Femurrevision mit Impaction-Bone-Grafting-Technik und einem zementierten angeschliffenen, abgeschrägten Schaft

ZusammenfassungOperationsziel. Biologische Rekonstruktion von Knochenverlusten des Femurs mittels Impaction-Bone-Grafting-Technik. Rekon-struktion des Hüftrotationszentrums mit ei-nem zementierten Schaft, dessen Länge und Offset im Ermessen des Operateurs liegen.Indikationen. Femurimplantatlockerung mit Knochenverlust.Kontraindikationen. Infektion, neurolo-gische Erkrankungen, unkooperativer Patient.Operationstechnik. Entfernung des gelock-erten Femurimplantats, Kortikalisrekonstruk-tion, ggf. mit Netzen, Impaction-Bone-Graft-ing-Technik mit speziellen Instrumenten, Ze-mentfixation eines angeschliffenen, abge-schrägten Schafts.Weiterbehandlung. Individualisierte Phase der Bettruhe und Teilbelastung.Ergebnisse. Die Impaction-Bone-Grafting-Technik mit zementierten, angeschliffenen

Schaft wurden für 33 Femurrekonstruktionen verwendet. Bei einer durchschnittlichen Nachbeobachtungsphase von 15 Jahren musste keine Femurrekonstruktion revidiert werden. Eine unerkannte intraoperative Frak-tur heilte unter konservativer Behandlung aus, 3 postoperative Femurfrakturen heil-ten nach Plattenfixation mit in situ belassen-em Schaft. Der durchschnittliche Harris-Hip-Score verbesserte sich von präoperativ 49 auf postoperativ 85 Punkte. Die Kaplan-Mei-er-Analyse bei Femurrevision aus jeglichem Grund als Endpunkt ergab eine Überleben-srate von 100%.

SchlüsselwörterKnochenverlust · Rotation · Segmentaler Defekte · Harris Hip Score · Allotransplantat

rological complaints, loosening, frac-ture)

Preoperative workup

FSeptic loosening must be excluded by joint aspiration

FTemplating of the femur on pelvis an-teroposterior (AP) and lateral X-rays

FSelect size, length and offset of revi-sion implant

FDetermine position of distal plug

Instruments and implants

FInstruments for stem and cement re-moval (chisels, osteotomes, drills, stem extraction set)

FDouble-tapered polished stem design of different lengths (200, 205, 220, 240, 260 mm), offsets (35.5, 37.5, 44, 50 mm) and sizes (0–5; Exeter, Stryk-er)

FLow viscosity bone cement (Simplex, Stryker)

FA special cement syringe with a long, narrow nozzle (Stryker)

FBone bank boneFIf needed, metal meshes to recon-

struct the femurFSpecific instruments for impaction

(X-change femoral revision system, Stryker)

FPreparation of bone graft before or during surgery (2–8 mm of fresh fro-zen femoral head allograft after care-ful removal of cartilage)

Anesthesia and positioning

FGeneral anesthesiaFAntibiotic prophylaxis (1000 mg ce-

fazolin after obtaining specimen for microbiological assessment and twice/8 h postoperatively)

FPatient well fixed in lateral position

157Operative Orthopädie und Traumatologie 2 · 2014  | 

Surgical technique (.Fig. 1, 2, 3, 4, 5, 6, 7)

Fig. 1 8 The desired stem implant is selected by templating (size, offset, potential extra length) and the plug position is defined (used with per-mission from Stryker)

Fig. 2 8 The patient is positioned in lateral po-sition, with the pelvis well fixed to the table. We prefer a posterolateral approach (model draw-ing used with permission from Stryker)

Fig. 3 7 Lytic femoral lesions need to be treated with metal meshes and cerclage wires (and po-tentially with strut grafts and plates) to prevent

femoral damage during impaction and to create a stable situation. The femoral canal is closed

with a polyethylene plug attached to a scaled guide wire using a sliding hammer. The plug po-

sition is at least 2 cm below the distal tip of the chosen stem or below the most distal lytic area of the cortex. When a suitable cement plug can

be used, this is left in place and a guide wire is screwed inside (model drawing used with per-

mission from Stryker)

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Operative Techniken

Fig. 4 8 The correctly sized proximal impactor can easily be put over the guide wire into the femoral canal. The height of the distal impac-tors with different diameters is indicated on each one by a marker. In this way, the surgeon knows the depth the impactors can be used to without incurring the risk of splitting the femur. When the distal plug and central rod are in place, the distal canal is carefully washed out. After careful removal of cartilage, fresh frozen femoral head allografts are milled into bone chips of 2–5 mm (bone mill from Spierings Med-ical Technique, Nijmegen, Netherlands). The bone chips are put into the canal and impacted layer by layer using the several distal impac-tors. Impaction of the allograft bone chips must be performed with sufficient intensity. To prevent distal migration of the plug, the im-paction of the first layer of about 1 cm on top of the plug is done by hand; thereafter the sliding hammer is used (model drawing used with permission from Stryker)

Fig. 5 8 When the distal impaction line is reached, the proximal impactors are used. By alternating distal and proximal impactors, the graft in the mid-stem region is adequately packed; thereafter the proximal impactor is used. In this way, the canal is filled from bottom to top, step-by-step and layer-by-layer. The proximal impactor should become tight within the impacted bone graft, in the position indicated by templating. Final proximal impac-tion (5–8 cm) is achieved with separate impactors. Absolute torsional and axial stability of the proximal impactor is required, so tight that the sliding hammer must be used to withdraw it from the bone bed. Trial reduction can be performed with the proximal impactor; in most cases the central rod can be left in place (model drawing used with permission from Stryker)

159Operative Orthopädie und Traumatologie 2 · 2014  | 

Fig. 6 8 When, based on trial reduction, the surgeon is satisfied with the stem position and fixation in the impacted graft, the impactor is left in place until just before cement insertion. There must be absolute torsion-al and axial stability of the final proximal impactor, which means that it cannot be removed without using the sliding hammer. The retrograde cement is then applied using the tapered gun spout (Stryker). Relatively low viscosity cement (Simplex, Stryker) and extensive pressurizing is rec-ommended for adequate penetration into the graft. Afterwards, the stem is inserted into the predetermined position using the leg length gauge. Pressure on the cement and closure of the proximal canal must be main-tained with the seal until the cement has polymerized (model drawing used with permission from Stryker) Fig. 7 8 When a long stem is used, the plug is fixed 2 cm below the dis-

tal stem tip. Distal impaction is performed with the long stem guide wire, which has a smaller diameter, using the same impactors as for the prima-ry stem. Proximal impaction is then performed as described for the primary stem. To enable insertion of the long stem, the distal impacted bone now has to be cored with the specific graft corer, which has depth markers for the specific stems used over the guide wire (model drawing used with per-mission from Stryker)

Special surgical considerations

160 |  Operative Orthopädie und Traumatologie 2 · 2014

Operative Techniken

Postoperative management

FAnticoagulation therapyFProphylaxis of periprosthetic ossifica-

tions (indometazine)FBed rest individualized according to

general condition and compliance of the patient; this can range from a few days to a few weeks

FTouch weight bearing for 3 months due to the process of bone remodel-ing

FGradually increasing loading thereaf-ter

FSubsidence of 2–5 mm of the stem in the cement mantle can be seen

Errors, hazards, complications

FThe distal plug must be positioned 2 cm below the most distal lytic area. When this position is below the isth-mus, a temporary Kirschner wire (K-wire) is drilled through the bone to block the plug

FA potential split or fracture of the fe-mur during impaction must be recog-nized and treated with cerclage wires or cables (and plate if necessary)

FEarly postoperative infections are treated with antibiotics based on swab results and if necessary surgical debridement

FLate postoperative infections (3–6 months postoperative) are treated with a two-stage procedure.

Results

Femoral reconstructions with bone im-paction grafting and cement fixation of a polished tapered stem in 33 consecu-tive patients were followed for a mini-mum of 15 years. Maximum follow-up was 20 years; average age of the patients at surgery was 63 years. No patient was lost to follow-up and all patients who died during follow-up were included. One stem was revised again for mechan-ical reasons during rerevision of an ace-tabular cup. The probability of survival at 17 years of follow-up was 96% (95% con-fidence interval, CI: 72–99%) with fem-oral rerevision for any reason as the end point and 100% (95% one-sided CI, 69–100%) with rerevision for aseptic loosen-

ing as the end point. The average subsid-ence was 3 mm. Although three early fem-oral fractures occurred after surgery, no late fractures or other complications were seen. All fractures healed after plate fix-ation and all stems were left in situ. The probability of survival of femoral compo-nent revisions with impaction bone graft-ing and a cemented polished stem was ex-cellent, with a mean of 17 years. The av-erage Harris Hip Score improved from 49 prior to surgery to 85 points after sur-gery. Kaplan–Meier analysis with femoral revision for any reason as the end point showed a survival rate of 100%.

Corresponding address

Prof. Dr. I.C. HeyligersDepartment of Orthopaedics, Atrium MC Heer-len, SHE, Faculty of Health, Medicine and Life Sciences, University Maastricht6401 HeerlenThe Netherlandsi.heyligers@atriummc.nl

Compliance with ethical guidelinesConflict of interest. A commercial entity, Stryk-er, paid or directed, or agreed to pay or direct bene-fits to a research fund, foundation, educational institu-tion or other charitable or nonprofit organization with which the authors are affiliated or associated. The au-thors did not receive grants or outside funding in sup-port of their research for or preparation of this manu-script. They did not receive payments or other benefits, or a commitment or agreement to provide such ben-efits from a commercial entity. I.C. Heyligers, B.W. Sch-reurs and E.H. van Haaren state that there are no con-flicts of interest. The accompanying manuscript does not include studies on humans or animals.

References

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2. Dunlop DG, Brewster NT, Madabhushi SP et al (2003) Techniques to improve the shear strength of impacted bone graft: the effect of particle size and washing of the graft. J Bone Joint Surg Am 85:639–646

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4. Halliday BR, English HW, Timperly AJ et al (2003) Femoral impaction grafting with cement in revi-sion total hip replacement. Evolution of the tech-nique and results. J Bone Joint Surg Br 85:809–817

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