Comparison of absorbable poly-l-lactide and metallic intramedullary rods in the fixation of femoral shaft osteotomies: an experimental study in rabbits

An osteotomy of the distal femoral diaphysis was fixed with an intramedullary self-reinforced poly-l-lactide (SR-PLLA) rod in 22 and with a metallic rod in 38 skeletally mature rabbits. Histomorphometric and quantitative computed tomography (QCT) were performed to assess time-related changes in the consolidation process of the osteotomy of cortical bone and development of the external callus. The follow-up times were 8, 16, 24, and 48 weeks for radiologic and 16, 24, and 48 weeks for histologic studies; 19/22 of the SR-PLLA and 34/38 of the metallic fixed osteotomies healed during the observation periods. On microscopic evaluation, no difference was found in histologic parameters such as external callus area and fraction, and endosteal callus area and fraction between SR-PLLA and metallic fixed osteotomies. The total external callus area increased up to 16 weeks and subsequently decreased linearly over time in both experimental groups. However, the mean endosteal bone area and fraction decreased after 16 weeks in metallic fixated femora, while in the SR-PLLA fixated femora, both these values increased, being greater in the SR-PLLA group. The mean external callus QCT density decreased after 8 weeks in both experimental groups, the decrease being greater in the SR-PLLA group. Nevertheless, no significant difference was detected between SR-PLLA and metallic fixed femora in any of the follow-ups. These results suggest that both SR-PLLA and metallic rods are suitable in the fixation of femoral shaft osteotomies in rabbits. Furthermore, SR-PLLA rod fixation seems to have a minor stress-shielding effect. Received: June 22, 2000 / Accepted: October 19, 2000     

Totally absorbable fixation in the treatment of fractures of the distal femoral epiphyses

Nine adolescent patients with a femoral fracture involving the physeal plate were treated by using self-reinforced absorbable polyglycolide (SR-PGA) and poly-L-lactide (SR-PLLA) screws with a follow-up for an average of 2 years and 2 months. During the follow-up all but one of the femurs became skeletally mature. In two of nine patients a clinically significant growth disturbance occurred. The average length difference of the femurs was –5 mm (ranging from +8 mm ––41 mm). One valgus deformity was noted. In four patients a lengthening and in four patients a shortening of the operated femur were registered at the end of follow-up. Open reduction and fixation with absorbable screws seem to be suitable for the fixation of distal femoral fractures in adolescents.     

Tissue response to polyglycolide and polylactide pins in cancellous bone

An absorbable self-reinforced polyglycolide (SR-PGA) pin, 2.0 mm in diameter and 15 mm in length, was implanted in the trabecular bone areas of the distal femur of 51 rats and a biodegradable self-reinforced poly-l-lactide (SR-PLLA) pin of the same size was inserted into the distal femur of the other hind leg of the same rats. The intact femora of eight non-operated rats were used as controls. Tissue reaction to the implants was examined within standardized sample fields radiographically, histologically, histomorphometrically, microradiographically and using oxytetracycline fluorescence studies. The follow-up periods of the groups consisting of five operated rats and one intact control rat were 1, 3, 6, 12, 24, 36, 48 and 52 weeks. Eleven extra rats were operated on to ensure five samples in each follow-up group for the final analyses. The first signs of degradation of the SR-PGA pin were seen at 3 weeks, and the pin was totally degraded by 36 weeks. No signs of degradation of the SR-PLLA pin were observed during the follow-up period. Active new bone formation was seen close to the implant profile at 1 week in both groups. At 12 weeks the mean fractional osteoid formation surface was statistically significantly (P < 0.01) higher in the SR-PGA-implanted specimens than in the SR-PLLA-implanted specimens. At that time there were also statistically significantly (P < 0.05) more phagocyting macrophages in the SR-PGA-implanted specimens than in the SR-PLLA-implanted specimens, which is in accordance with the degradation behaviour of both implants. The biocompatibility of polyglycolide and polylactide proved to be good. Received: 25 March 1997     

Fixation of osteotomies of the distal femur with absorbable, self-reinforced, poly-L-lactide plates

Osteotomies of the distal femur were fixed with two self-reinforced poly-L-lactic acid (SR-PLLA) plates and metallic screws placed through the plates on each side of the femur in 23 adult rabbits. They were followed-up after 3, 6, 12 and 24 weeks. After killing, radiological, histological, microradiographic and oxytetracycline fluorescence studies were performed. Except for one histologically confirmed fibrotic non-union at 24 weeks, the osteotomies healed, including one involving a rabbit which had suffered an ipsilateral femoral shaft fracture of unknown cause. No malformations were observed, and the macroscopically detected swelling was a normal postoperative reaction. This study showed that SR-PLLA plates implanted on both sides on the bone are suitable for the fixation of weight-bearing cancellous bone osteotomies in rabbits.     

The tissue-implant interface during degradation of absorbable polyglycolide fracture fixation screws in the rabbit femur.

A transverse transcondylar osteotomy of the distal femur was fixed with an axially placed absorbable fracture fixation screw made of polyglycolide (PGA) in 25 rabbits. Changes at the tissue-implant interface accompanying degradation of the screw were examined histologically, histomorphometrically, and microradiographically seven, 20, 40, 80, and 250 days after implantation. At seven days postimplantation, a layer of fibroblasts was seen surrounding the implant, and new bone formation was discernible in the host tissues adjacent to this membranous structure. At 20 days postimplantation, the geometry of the screw was still intact and the tissue-implant boundary was distinct. The first signs of invasion of vascular granulation tissue into the implant were observed 40 days after implantation, at which time the osteotomies were united. The apparent walling-off response by formation of new trabecular bone outlining the PGA profile continued, with the greatest mean trabecular bone volume fraction at the interface, 23.9%, measured at 40 days. A significant decrease in the new bone volume occurred between 40 and 80 days postimplantation. The intensity of the foreign-body reaction seen was histologically moderate. The giant cell count was highest at 80 days postimplantation, when the migratory activity of phagocytic cells had transported intracellular particulate polymeric debris 400-800 microns away from the original tissue-implant boundary. At 250 days postimplantation, no birefringent polymeric material could be seen in the specimens. No contraindications for the clinical application of PGA implants emerged in this study.     

Polymeric debris from absorbable polyglycolide screws and pins. Intraosseous migration studied in rabbits.

The migration of polymeric particles during degradation of absorbable implants made of polyglycolide was investigated in the cancellous bone of distal rabbit femur by using a transverse osteotomy model. The osteotomy was fixed either with a 4.5 x 25 mm screw or with two 1.5 x 30 mm pins. The histologic sections obtained at 3, 6, 12, and 36 weeks were morphometrically analyzed using polarized-light microscopy. The migration of the polymeric debris into the host-tissues showed two different patterns. On the one hand, particles were in all specimens seen lying intracellularly in phagocytic cells in a regular front close to the original tissue-implant boundary. In addition, in several specimens there occurred expansions filled with largely extracellular polymeric particles that bulged into the hematopoietic bone marrow up to 2.8 mm from the original implant cavity. This kind of particle migration over long distances could not be explained by cellular transport, but may have been caused by an increased osmotic pressure that developed within the implant cavity during depolymerization of polyglycolide.     

Fixation of experimental osteotomy of the distal femur with biodegradable thread in rabbits

A distal femoral osteotomy on 24 rabbits was fixed with biodegradable polyglycolic acid (PGA) thread pulled through drill holes made on both sides of the osteotomy. Follow-up times were one, three, six, 12 and 24 weeks. The distal part of each femur was removed, fixed in alcohol, embedded in methylmethacrylate, sawed to 80 microns thick for oxytetracycline (OTC)-labeling studies and microradiography, and sectioned at 5 microns for histologic studies. As judged by histologic microradiographic, and OTC-labeling studies, 19 of 24 osteotomies were healing normally; after six weeks of follow-up examination, union of 11 of 14 osteotomies was observed on radiographs. On the basis of the present study, PGA threads may be promising for the fixation of osteotomies of the metaphyseal cancellous bone in rabbits.     

股骨皮质骨开窗技术在髋关节翻修术中的应用

目的 探讨股骨前外侧皮质骨开窗技术在髋关节翻修术中取出股骨远端稳定固定骨水泥的价值.方法 2005年5月至2009年6月,共14例(14髋)因各种原因致髋关节置换术后失败患者接受全髋关节翻修手术.其中男性10例,女性4例,年龄54～75岁,平均66岁.翻修原因为股骨头置换术后髋臼磨损5例、全髋关节置换术后假体周围骨溶解并松动6例、骨水泥柄股骨近端骨溶解柄断裂1例、髋臼骨溶解假体松动翻修同时行股骨柄翻修1例,感染后二期翻修时远端骨水泥取出困难1例.14例(14髋)股骨柄均为骨水泥同定.术中按术前计划开窗部位、开窗范围于股骨皮质骨开一长方形骨窗.通过骨窗直视下彻底清除髓腔内稳定固定的骨水泥,修整股骨髓腔.植入翻修柄后将皮质骨开窗骨瓣原位回植,双股钢丝捆绑固定.术后定期随访拍摄x线片.观察皮质骨开窗骨瓣与周围骨愈合情况、骨瓣有无移位、股骨柄有无下沉以及有无捆绑钢丝断裂等.结果 10例患者术后获得随访,平均随访时间24.6个月.股骨皮质骨开窗长度2.5～6.0 cm,平均3.4 cm,宽度0.8～1.4 cm,平均1.2 cm.股骨开窗远端以远部分发生纵形劈裂骨折1例.无术中皮质骨穿孔及股骨干骨折.向远段扩大开窗1例,扩大长度1.5 cm.开窗部位皮质骨骨瓣原位回植选择2～3道双股钢丝固定,平均2.3道.随访期间2例发牛假体柄下沉(平均2.5 mm),无皮质骨瓣移位以及捆绑钢丝断裂,术后3～5个月皮质骨瓣已于周围骨纤维愈合.随访期间无一例因各种原因致再次翻修.结论 股骨皮质骨开窗技术在髋关节翻修术中有助于直视下彻底取出股骨髓腔远端稳定固定的骨水泥,同时不会造成股骨骨丢失、不影响翻修柄植入后的稳定固定.     

Degradation and tissue replacement of an absorbable polyglycolide screw in the fixation of rabbit femoral osteotomies.

Degradation and tissue replacement of a totally absorbable polyglycolide screw, 4.5 millimeters in diameter and thirty millimeters in length, were studied histologically, morphometrically, and radiographically at sequential stages of resorption at as long as thirty-six weeks after fixation of a transverse distal femoral osteotomy in rabbits. The initial mean shear force to failure was 95.0 newtons for the specimens that had been fixed with the polyglycolide screw compared with 257.0 newtons for the distal part of the contralateral, intact femur. The physical appearance of the screw was unaltered at three weeks. The first histological signs of degradation were seen at six weeks, along the thread ridge. Premature breakage of the screw resulted in gross displacement and non-union of the osteotomy in one animal. The degradation of polyglycolide was accompanied histologically by a typical non-specific foreign-body reaction. This kind of tissue response seemed to be associated with an osteolytic proximal expansion of the implant cavity that was suggestive of increased pressure within the cavity during degradation of the screw. In eight specimens, a wall of new bone formed around this area of osteolysis and demarcated the implant cavity from the surrounding normal cancellous bone. Seventy-four per cent of the periphery and 28 per cent of the central core of the screw had been resorbed at twelve weeks. At thirty-six weeks, no polymeric material could be discerned, and the predominant tissue component within the implant cavity was loose connective tissue. The volume fractions of trabecular bone and hematopoietic bone marrow were significantly lower (p less than 0.01) than those of the intact, control side, but the degree of restoration of tissue varied considerably from animal to animal.     

Tissue response to bioabsorbable self-reinforced polylevolactide and polyglycolide pins implanted intra-articularly and directly into the bone on different levels

Self-reinforced poly-l-lactide (SR-PLLA) and self-reinforced polyglycolide (SR-PGA) pins were implanted intra-articularly and directly into the bone of the distal femur of rats at three levels: above, on the same level, and under the surface. For the controls only channels were drilled, or the controls were not operated at all. The follow-up times were 3, 6, and 12 weeks for SR-PGA and 3, 6, 12, and 24 weeks for SR-PLLA. The macroscopic appearance and histologically the villus reaction, the mononuclear phagocytosis and giant cells, the neutrophils, the lymphocytes, the plasma cells, the eosinophils, and the mast cells were analyzed. In the histologic analysis, the most favorable implantation depth was found to be under the surface where the contact between the implants and bone was best, and the orifice was covered with new trabecular bone at 3 weeks. This was especially seen in intra-articular implantation. In general, the tissue responses were mild, and could also be explained in the statistical analysis by a normal postoperative tissue response and faster biodegradation of PGA. Received: 21 August 1997     

Absorbable polyglycolide screws in internal fixation of femoral osteotomies in rabbits

In 20 rabbits, a transverse distal femoral osteotomy was fixed using a 4.5 by 30-mm absorbable screw made of polyglycolide. No postoperative external support was used. The consolidation of the osteotomy was investigated histologically, morphometrically, and microradiographically in groups of 4 to 6 rabbits that were followed for 3, 6, 12, or 36 weeks. Fourteen osteotomies showed solid bony union; and in 3, several bone trabeculae were seen to bridge a still partially ununited osteotomy. In another 3 rabbits, each with a follow-up time of 12 or 36 weeks, no convincing signs of progressing consolidation could be seen. Only 1 of these rabbits showed displacement of the distal fraament.     

Absorbable polyglycolide screws in internal fixation of femoral osteotomies in rabbits.

In 20 rabbits, a transverse distal femoral osteotomy was fixed using a 4.5 by 30-mm absorbable screw made of polyglycolide. No postoperative external support was used. The consolidation of the osteotomy was investigated histologically, morphometrically, and microradiographically in groups of 4 to 6 rabbits that were followed for 3, 6, 12, or 36 weeks. Fourteen osteotomies showed solid bony union; and in 3, several bone trabeculae were seen to bridge a still partially ununited osteotomy. In another 3 rabbits, each with a follow-up time of 12 or 36 weeks, no convincing signs of progressing consolidation could be seen. Only 1 of these rabbits showed displacement of the distal fragment.     

Femoral supracondylar focal dome osteotomy with plate fixation for acute correction of frontal plane knee deformity

Focal dome osteotomy (FDO) allows deformity correction without secondary translational deformity. The purpose of this study was to evaluate the degree of correction and knee functional outcome after correction of frontal knee deformity using femoral supracondylar FDO fixed with plate and screws. A prospective study included 12 consecutive cases of femoral frontal plane deformity that underwent correction using supracondylar focal osteotomy fixed by plate and screws. Average age was 27 years, while mean follow-up was 2.1 years. Functional assessment was done using the Hospital for Special Surgery (HSS) knee score. The HSS knee score improved from 85 to 96.8 points. Desired correction was achieved in all cases. Postoperative mechanical axis analysis on long film and scanogram showed no secondary deformity. The overall postoperative mechanical axis was at 3.2 mm medially (range 2–5 mm). Autogenous bone graft was not used in any case, and uneventful osteotomy union was achieved at a mean of 13.8 weeks. Minor complications were encountered in two cases. There were no implant failures or reoperations. Supracondylar FDO of the femur with plate fixation is a reproducible technique that can produce full correction of distal femoral frontal plane deformity, while avoiding creating a secondary deformity. Knee function was improved with good patient satisfaction.     

Verlängerung der unteren Extremität mit dem Intramedullary Skeletal Kinetic Distractor (ISKD)

OBJECTIVE: Callus distraction of the femur or tibia with an intramedullary distractor, which lengthens mechanically through alternating rotations of at least 3 degrees. INDICATIONS: Femoral or tibial shortening between 20 and 80 mm. Angular and rotational deformities can be corrected at the osteotomy site. CONTRAINDICATIONS: Open epiphyses. Small medullary canal (after intramedullary reaming femoral diameter < 14.5 mm, tibial diameter < 12.5 mm). Severe deformities. Insufficient compliance. Osteitis. Soft-tissue infections. SURGICAL TECHNIQUE: Supine position. Femoral shaft osteotomy at the proximal or middle third by multiple drill holes completed with a chisel. For lengthening of the tibia, osteotomy with a Gigli saw is preferred. Control of the rotation by two parallel 3.0-mm Kirschner wires. Correction of angular or rotational deformities. Via stab incision reaming of the medullary canal with a flexible reamer. The femur is overreamed 2.0 mm and the tibia 1.5 mm above the desired implant diameter. Insertion of the Intramedullary Skeletal Kinetic Distractor (ISKD) into the medullary canal and distal locking in freehand technique. Control of the rotation and of the osteotomy gap. Proximal locking with an aiming device. For femoral lengthening 3 days and for tibial lengthening 5 days postoperatively the distraction is begun by increasing mobilization with partial weight bearing, to achieve daily distraction of 1 mm. In case of insufficient distraction, additional rotations are performed by the patient while checking the external monitor that displays the daily and total distraction length. RESULTS: Intramedullary lengthening with the ISKD was performed in four patients having an average age of 29 years (18-36 years). Two femoral shortenings were combined with complex rotational and angular deformities. The average lengthening of three femora and one tibia was 31 mm (26-40 mm). The average intraoperative blood loss was 230 ml (110-320 ml), the mean surgical time 108 min (90-145 min). The average daily distraction amounted to 1.2 mm (0.9-1.8 mm). Full weight bearing was permitted after 10 weeks (7-14 weeks), return to regular work after 11 weeks (7-16 weeks). At follow-up examination of an average of 2.3 years postoperatively the knee range of motion was full. Consolidation was noted 80 days (51-111 days) postoperatively with an average consolidation index of 2.9 days/mm (1.8-4.1 days/mm). No complications were observed. According to the Paley Score all patients had an excellent outcome.     

Corrective osteotomy of the distal femur with fixator assistance: A novel technique of minimally invasive osteosynthesis

Purpose

Varus or valgus deformity of the distal femur may progress into knee osteoarthritis. To delay or prevent this, various types of corrective osteotomy techniques have been used to shift the mechanical axis from the diseased compartment to the healthy one. We introduced a new, minimally invasive osteotomy of the distal femur with the assistance of temporary external fixation.

Intraosseous cellular response to biodegradable fracture fixation screws made of polyglycolide or polylactide

Summary As biodegradable pins and screws have increasingly been used in the internal fixation of fractures, sterile inflammatory reactions have occasionally occurred. The aim of the present experimental study was to assess the cellular response within cancellous bone to biodegradable polyester screws. In 45 rabbis a transverse distal femoral osteotomy was fixed with a 4.5 × 30 mm screw made either of polyglycolide (PGA, in 20 rabbits) or polylactide (PLA, in 25 rabbits). The follow-up times were 3, 6, 12, 36 or 48 weeks. The time-related and spatial characteristics of the cellular response were examined histomorphometrically using standardised sample fields under polarised-light microscopy. Polymorphonuclear granulocytes and mononuclear round cells were scarce in all follow-up groups. The occurrence of phagocytic cells (mononuclear macrophages and foreign-body giant cells) was highest in the PGA-fixed 12-week specimens. The giant cells seemed to adhere to the implant surface at an early stage, whereas the ultimate digestion and clearing of the decomposing polymeric material later on were performed by macrophages invading the implant body. No PGA was left in the 36-week specimens, while the gross geometry of the PLA screws was still intact at 48 weeks. In conclusion, the inflammatory response to these polymers was quite mild. Thus it seems probable that some other additional factors must influence the occurrence of the clinical inflammatory reactions.     

A knee-sparing distal femoral endoprosthesis using hydroxyapatite-coated extracortical plates. Preliminary results

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102 degrees (20 degrees to 120 degrees) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%). There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.     

Biodegradation and strength retention of poly-L-lactide screws in vivo. An experimental long-term study in sheep.

BACKGROUND AND AIMS: Poly-L-lactide implants have gained popularity in the fixation of fractures and osteotomies in the past decade. The aim of the present experimental long-term study was to examine the degradation and strength retention of self-reinforced poly-L-lactide (SR-PLLA) lag-screws and the bone tissue response. MATERIAL AND METHODS: A total of 27 young adult sheep were used. Self-reinforced poly-L-lactide (SR-PLLA) lag-screws of 6.3 mm were implanted in the left proximal femur of nine sheep. At two, three and five years three of the sheep were sacrificed and the degradation was studied radiologically, microradiographically and histologically. For the strength retention measurements five SR-PLLA lag-screws of 6.3 mm and five lag-screws of 4.5 mm were implanted in the subcutaneous tissue of the five sheep and lag-screws of 6.3 mm for the pull-out test in the left proximal femur of 20 sheep. At 0, 12, 18, 24, 32, and 36 weeks bending and shear strength, molecular weight and pull-out measurements were performed. RESULTS: At five years no SR-PLLA material could be seen. The implant area was surrounded by high density bone with bone ingrowth in the screw area. At 36 weeks the bending strength of the 6.3 mm screws had decreased from 257.9 MPa to 36.4 MPa and the shear strength from 131.8 MPa to 19.8 MPa. The pull-out strength of the lag-screws of 6.3 mm in diameter decreased from 1507 N to 331 N in 24 weeks. CONCLUSIONS: SR-PLLA lag-screws showed high initial values, a controlled strength retention and gradual degradation process making the use of them safe also in demanding fixations.     

Fixation of experimental osteotomies with absorbable polylactic acid screws.

Absorbable screws made of self-reinforced poly-L-lactic acid (SR-PLLA) and poly-DL/L-lactic acid (SR-PDLLA/PLLA) were used for fixation of cancellous bone osteotomies of the distal femur in rabbits. The initial molecular weight of PLLA was 260.000 and that of PDLLA 100.000. The follow-up times were from one week to 96 weeks. Seventy-two rabbits were operated on, 36 in the PLLA group and 36 in the PDLLA/PLLA group. After sacrifice, radiographic, micro-radiographic, histologic, histo-morphometric, and oxytetracycline-labelling studies were performed. In the PLLA group 34/36 (94%) osteotomies and in the PDLLA/PLLA group 31/36 (86%) osteotomies healed without delay or angular deformity. The present investigation shows that absorbable SR-polylactic acid screws are suitable for fixation of weight loading cancellous bone osteotomies in rabbits. Based on these promising results, a clinical study where cancellous bone fractures are fixed with SR-PLLA screws has been started.     

Collarless polished tapered impaction grafting of the femur during revision total hip arthroplasty: pitfalls of the surgical technique and follow-up in 31 cases

Impacting morcellized allograft bone into the femur during revision total hip arthroplasty is a simple concept with the goal of rebuilding femoral bone stock and providing secure fixation to the femoral stem. Using the collarless polished tapered (CPT, Zimmer, Warsaw, IN) stem impaction grafting system, we became concerned about the discrepancy between the straightforward concept and precise execution of the technique. In this study, we examined 31 consecutive procedures to determine intraoperative difficulties and report on the clinical outcome of 30 cases at an average follow-up of 31 months. Modified Harris Hip Scores averaged 41 points preoperatively and improved to 86 points at follow-up. Nineteen cases were performed on intact femora, whereas 12 cases had disrupted femoral integrity, either extended trochanteric osteotomy or periprosthetic fracture. Successful outcome was seen in all cases with an intact femur, and restoration of femoral integrity was key to successful outcome in cases with compromised femoral integrity. Among cases with disrupted femoral integrity, 3 distal fractures occurred as a result of the rigid CPT cement plug, and 2 complete femoral fractures occurred as a result of bone impaction, for a technique-related fracture rate of 16%. Difficulty packing bone distally occurred in 94% of cases and was associated with varus and valgus stem alignment and medial and lateral stem displacement. Complete cement mantles were seen in 77% of cases. No stem subsidence was seen in 15 of 30 cases (50%). Stem subsidence of <5 mm was seen in 10 of 30, stem subsidence of 6 to 8 mm was seen in 4 of 30, and stem subsidence of >10 mm was seen in 1 patient (4%). Of the patients, 87% thought the procedure improved their function, and 97% would recommend it to a friend with a failed femoral component. Although we hope that the instruments for this procedure can improve, we endorse the concept of impaction grafting with the CPT stem as a successful way of dealing with revision femoral surgery.