Midterm results of femoral impaction bone grafting with an allograft combined with hydroxyapatite in revision total hip arthroplasty

The purpose of this study was to evaluate the outcome of femoral impaction bone grafting with an allograft combined with hydroxyapatite (HA). Fifty-four consecutive femoral reconstructions that were performed with the use of frozen morselized allografts and HA were followed up retrospectively. The average follow-up period was 92 months. A femoral head and HA were mixed and used as allograft. The average Merle d'Aubigné clinical score improved from 8.9 preoperatively to 13.1 points postoperatively. Stem subsidence was seen in 26 hips; however, it was not progressive after 1 year postoperatively. Cortical repair was detected at an average of 7 months postoperatively. Impaction bone grafting with an allograft combined with HA provided favorable results, with bone remodeling and less subsidence.     

Optimizing the fat and water content of impaction bone allograft

Fresh morselized impacted bone graft usually fails due to shear forces. The presence of fat, water, and marrow particles act as interparticle lubricants, reducing the interlocking of particles and allowing the graft to move more freely. Furthermore, the presence of this incompressible fluid damps and resists compressive forces during impaction, preventing the graft particles from moving into a closer formation. We believe there exists an ideal concentration of fat and water that will maximize resistance to shear forces. We performed mechanical shear testing in vitro on morselized human femoral heads, varying the amount of fat and water to determine their optimum concentrations. Level of fat and water were determined that increased strength by 36% over unaltered bone graft. This is most closely approximated in an operating room by washing and subsequently squeezing the bone graft. Optimizing the fat and water content of bone graft produces a stronger graft that is more resistant to shear stresses, protecting the surgical construct until bone growth can occur. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 243–248, 2013     

打压植骨结合金属网重建全髋关节翻修术中髋臼侧严重骨缺损

[目的]探讨在全髋关节翻修术中使用打压植骨技术结合金属网重建严重髋臼骨缺损的方法和效果。[方法]2001年12月至2006年1月应用打压植骨技术结合金属网重建严重髋臼侧骨缺损的患者共有21例21髋,男6例,女15例;翻修时平均年龄为51.9岁（38-77岁）。采用美国骨科医师协会（AAOS）分型,本组患者骨缺损均为AAOSⅢ型（混合型骨缺损）。采用金属网将非包容性骨缺损转变为包容性骨缺损,然后采用7-10 mm的深低温冷冻骨颗粒,使用打压植骨技术恢复骨量,重建髋关节的正常解剖形态,使用骨水泥将聚乙烯臼杯固定于理想的生物力学位置。拍摄术后3 d、3个月、1年及每年随访时的双髋正位片,以泪滴为参照,观察聚乙烯臼杯位置的变化及骨水泥层透亮线的变化,并进行Harris髋关节评分比较。[结果]平均随访2.8年（1-5年）,Harris评分从术前平均46.4分提高到术后81.3分,未发现臼杯松动病例。术后1例脱位,1例有坐骨神经受损症状。[结论]在髋关节翻修术中采用打压植骨技术并结合应用金属网的方法能较好地重建髋臼侧严重骨缺损,恢复骨量,辅助髋臼安放在理想的生物力学位置,并能提供良好的早期稳定性。     

Nonunion of extended trochanteric osteotomies in impaction grafting femoral revisions

Extended trochanteric osteotomies have been recommended to facilitate femoral component removal, femoral cement removal, and acetabular exposure in cases of difficult revision hip arthroplasty. Complications due to the osteotomy have been rare and no nonunions have been reported when this osteotomy has been used in conjunction with extensively porous-coated implants. It has been suggested that the osteotomy should also work well with impaction grafting revisions. This is a report of two cases of nonunion of extended trochanteric osteotomies in which the impaction grafting technique was used.     

Impaction bone grafting with proximal and distal femoral arthroplasty

Capacious diaphyses and poor bone stock in revision arthroplasty can lead to fracture and poor component fixation. Impaction bone grafting can be performed in salvage reconstructions in cases with extensive circumferential bone loss. We present a consecutive series of patients who underwent proximal or distal femoral reconstructions in combination with impaction bone grafting. The average age was 62 years, and the mean follow-up was 36 months (range, 24-84). No revisions were performed for mechanical failure, and radiographs revealed no evidence of implant loosening. No patient complained of end-of-stem thigh pain. There were 3 failures: 1 for periprosthetic fracture, 1 for instability, and 1 for infection. Impaction bone grafting can be used in combination with proximal and distal femoral arthroplasty to successfully manage cases with extensive bone loss after failed hip and knee arthroplasty. The procedure reconstitutes necessary bone stock, improves stress shielding, and provides immediate fixation in capacious canals.     

应用解剖型骨水泥股骨假体结合冻干骨打压植骨进行髋关节翻修

[目的]探讨结合应用解剖型骨水泥股骨假体和冷冻干燥颗粒骨打压植骨(IBG)进行股骨翻修的可行性及临床效果。[方法]作者在2001年1月～2005年12月期间,在髋关节翻修中,有49例在股骨翻修中应用解剖型骨水泥柄结合冷冻干燥颗粒骨打压植骨技术,其中有36例(73%)存在严重的骨缺损(Paprosky分型ⅢB或Ⅳ)。平均随访时间为35.3个月(26～52个月)。通过Harris评分和X线片对结果进行评价。[结果]Harris评分从术前的平均44.6分提高到最后评估时的平均88.3分,Harris评分优良率为89.8%。X线片未显示有明显的股骨假体下沉。1例出现术后感染,1例出现术后脱位,感染率及脱位率均为2%,3例出现了术中股骨骨折及股骨柄穿孔,其发生率为6.1%,但这些与假体及植骨材料选择无关。[结论]使用解剖型骨水泥股骨假体结合异体冷冻干燥颗粒骨打压植骨技术,对有严重骨缺损的股骨进行翻修是可行的,并且中短期的临床效果满意,长期效果还有待观察。     

Cells seeded on MBG scaffold survive impaction grafting technique: Potential application of cell-seeded biomaterials for revision arthroplasty.

The objective of this study was to investigate the potential application of cell-seeded biomaterials for revision arthroplasty and the reconstruction of major joints using the impaction grafting technique. Using morselized cancellous bone graft as a porous scaffold, MG63 cells were seeded on the scaffold and impacted into an acetabulum cup model using a mechanical device constructed from data obtained during impaction grafting by an orthopedic surgeon. Immediately after impaction, cells were trypsinized from the scaffold and processed for cell survival rates using the double-stranded DNA PicoGreen assay. Significant reductions in viable cells were observed between the fifth impact and both the first and second impacts (p < 0.01 and p < 0.05, respectively). Cell survival rate was 21.5% after five impacts. The biological performance of cell-seeded biomaterials may be enhanced by these surviving cells. Compared to allograft bone that is not osteogenic, a cell-seeded biomaterial might also be a suitable substitute for allograft bone for major joint reconstruction at revision arthroplasty.     

Impaction grafting using a cemented porous-coated modular acetabular component

Reconstruction of major acetabular defects continues to challenge surgeons. There are many surgical options for these situations, including oversized hemispherical cups, oblong cups, acetabular cages, bulk allografts, and impaction allografting. We present the case of a modification to the impaction grafting technique for acetabular reconstruction. In our case, a porous-coated modular titanium acetabular component was cemented in place instead of an all-polyethylene acetabular component, which is the standard technique for impaction grafting reconstruction. The use of the modular component allowed a greater number of surgical options at the time of surgery. At 5 years from surgery, the patient has a successful reconstruction and the radiographs continue to look excellent.     

The role of vibration and drainage in femoral impaction bone grafting

Vibration is commonly used in civil engineering applications to efficiently compact aggregates. This study examined the effect of vibration and drainage on bone graft compaction and cement penetration in an in vitro femoral impaction bone grafting model with the use of 3-dimensional micro-computed tomographic imaging. Three regions were analyzed. In the middle and proximal femoral regions, there was a significant increase in the proportion of bone grafts with a reciprocal reduction in water and air in the vibration-assisted group (P < .01) as compared with the control group, suggesting tighter graft compaction. Cement volume was also significantly reduced in the middle region in the vibration-assisted group. No difference was observed in the distal region. This study demonstrates the value of vibration and drainage in bone graft compaction, with implications therein for clinical application and outcome.     

Femoral impaction grafting

Femoral impaction grafting is a reconstruction option applicable to both simple and complex femoral component revisions. It is one of the preferred techniques for reconstructing large femoral defects when the isthmus is non-supportive. The available level of evidence is primarily derived from case series, which shows a mean survivorship of 90.5%, with revision or re-operation as the end-point, with an average follow-up of 11 years. The rate of femoral fracture requiring re-operation or revision of the component varies between several large case series, ranging from 2.5% to 9%, with an average of 5.4%.     

Optimizing the grain size distribution of allografts in bone impaction grafting

In bone impaction grafting, allografts in the form of bone chips are used for reconstruction of defects and to induce bone remodeling. Optimizing grain size distribution of this allograft material should help prevent implant subsidence by achieving higher primary stability of the graft. We evaluated the influence of grain size distribution on the mechanical stability of allograft material. Bone tissue was rinsed, and the grain size distribution of the allograft material was determined by performing a sieve analysis. Uniaxial compression tests were carried out before and after a standardized compaction procedure for samples with controlled grain size distribution and a control group. Allografts with controlled grain size distribution showed a yield limit almost twice as high as in the control group after a standardized compaction procedure. A better interlocking between bone particles was observed compared to the control group. Thus, grain size distribution has a major impact on the mechanical stability of bone grafts. By controlling the grain size distribution of allograft material, a tighter packing can be achieved and subsequently implant subsidence of implants could be avoided. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:1024–1029, 2014.     

同种异体颗粒骨打压植骨联合不同类型假体在严重髋臼骨缺损翻修中的应用

目的探讨对严重髋臼骨缺损患者采用同种异体颗粒骨打压植骨联合骨水泥型或非骨水泥型假体翻修的早中期疗效。方法回顾分析2011年2月-2018年5月采用同种异体颗粒骨打压植骨联合假体翻修治疗的42例(44髋)严重髋臼骨缺损患者临床资料,其中采用骨水泥型臼杯24例(24髋)、非骨水泥型臼杯18例(20髋)。男17例,女25例;年龄22~84岁,平均62.8岁。初次人工全髋关节置换术距该次翻修术时间为2.5~12.0年,平均8.3年。翻修原因:假体无菌性松动31例(32髋),假体周围感染11例(12髋)。按照髋臼骨缺损Paprosky分型标准:ⅢA型28例(29髋),ⅢB型14例(15髋)。术前髋关节Harris评分为(22.25±10.31)分。髋关节旋转中心高度为(3.67±0.63)cm,双下肢长度差值为(3.41±0.64)cm。结果手术时间为130~245 min,平均186 min。术中出血量600~2400 mL,平均840 mL。术后引流量250~1450 mL,平均556 mL。术后1例出现切口浅表感染,其余患者切口均Ⅰ期愈合。患者均获随访,随访时间6~87个月,平均48.6个月。末次随访时Harris评分为(85.85±9.31)分,与术前比较差异有统计学意义(t=18.563,P=0.000)。影像学复查显示同种异体骨与宿主骨逐步融合,未见明显骨吸收。末次随访时,髋关节旋转中心高度为(1.01±0.21)cm,与术前比较差异有统计学意义(t=17.549,P=0.000);双下肢长度差值为(0.62±0.51)cm,与术前比较差异有统计学意义(t=14.211,P=0.000)。与术前相比,末次随访骨水泥组、非骨水泥组Harris评分明显提高,髋关节旋转中心高度下降且均在Ranawat三角内,双下肢长度差值亦减小,差异均有统计学意义(P<0.05);两组髋关节旋转中心高度比较差异有统计学意义(t=2.095,P=0.042),Harris评分及双下肢长度差值比较差异无统计学意义(P>0.05)。结论对于PaproskyⅢ型髋臼骨缺损患者,根据缺损程度选择同种异体颗粒骨打压植骨联合骨水泥型或非骨水泥型假体翻修,均可有效重建髋关节,并获得较好的早中期疗效。     

Mechanical properties of 7–10 mm bone grafts and small slurry grafts in impaction bone grafting

We compared the mechanical properties of morselized cancellous bone grafts of two sizes: 7–10 mm bone and small slurry bone (about 2 mm). The in vitro test was designed to simulate the hammer and impactor system for impaction bone grafting used in hip arthroplasty clinical practice. The 7–10 mm bone grafts showed higher height, elastic modulus, and massive extrusion strength than those of the small slurry bone grafts. No difference was found in yield strength. The bone mineral density of the 7–10 mm grafts continued to increase during impaction and became higher than that of the small slurry bone grafts after 10 impactions. Our results demonstrated that the small slurry bone grafts exhibit worse mechanical properties as compared with the 7–10 mm bone grafts, which implies that the use of this material in reconstruction of a bone defect in the acetabulum should be limited. © 2011 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29: 1491–1495, 2011     

Stability differentials for proximal vs distal fusion of total hip arthroplasty femoral impaction grafts

In impaction grafting for revision joint arthroplasty, the morselized cancellous bone ideally remodels into a new contiguous lattice. However, the use of biologically active factors may sometimes be indicated to enhance fusion. The purpose of this study was to determine the stability of femoral impaction-graft constructs for which either only the proximal or distal half of the morselized cancellous bone volume was modeled as fused. Fusing the proximal half of the impaction-graft volume resulted in a higher femoral stem stability than did fusing the distal half. This proximal graft fusion also resulted in a stem stability that was similar to that of fusing the entire graft. These results emphasize the importance of proximal fixation of an impaction-grafted femoral stem.     

Femoral impaction grafting in revision total hip arthroplasty: a follow-up of 540 hips

Between 1987 and 1999, 540 revision total hip arthroplasties in 487 patients were performed at our institution using the femoral impaction grafting technique with a cemented femoral stem. All patients were prospectively followed up for 2 to 15 years postoperatively with no loss to follow-up. A total of 494 hips remained successfully in situ at an average of 6.7years. The 10-year survival rate was 98.0% (95% confidence interval, 96.2-99.8) with aseptic loosening as the end point and 84.2% (95% confidence interval, 78.5-89.9) for reoperation for any reason. Indication for surgery and the use of any kind of reinforcement significantly influenced outcome (P < .001). This is the largest known series of revision THA with femoral impaction grafting, and the results support continued use of this technique.     

Results of Wagner SL revision stem with impaction bone grafting in revision total hip arthroplasty

Background:

As the number of total hip arthroplasties (THAs) performed increases, so do the number of required revisions. Impaction bone grafting with Wagner SL Revision stem is a good option for managing bone deficiencies arising from aseptic osteolysis. We studied the results of cementless diaphyseal fixation in femoral revision after total hip arthroplasty and whether there was spontaneous regeneration of bone stock in the proximal femur after the use of Wagner SL Revision stem (Zimmer, Warsaw, IN, USA) with impaction bone grafting.

Materials and Methods:

We performed 53 hip revisions using impaction bone grafting and Wagner SL Revision stems in 48 patients; (5 cases were bilateral) for variety of indications ranging from aseptic osteolysis to preiprosthetic fractures. The average age was 59 years (range 44-68 years). There were 42 male and 6 female patients. Four patients died after surgery for reasons unrelated to surgery. 44 patients were available for complete analysis.

Results:

The mean Harris Hip Score was 42 before surgery and improved to 86 by the final followup evaluation at a mean point of 5.5 years. Of the 44 patients, 87% (n=39) had excellent results and 10% (n=5) had good results. The stem survival rate was 98% (n=43).

Conclusion:

Short term results for revision THA with impaction bone grafting and Wagner SL revision stems are encouraging. However, it is necessary to obtain long term results through periodic followup evaluation, as rate of complications may increase in future.     

A preclinical study of stem subsidence and graft incorporation after femoral impaction grafting using porous hydroxyapatite as a bone graft extender

This preclinical in vivo screening study compared bone graft incorporation and stem subsidence in cemented hemiarthroplasty after femoral impaction bone grafting with either morselized allograft bone (n = 5, control group) or a 1:1 mix of allograft and porous hydroxyapatite ceramics (HA) granules (n = 5, HA group). At 14 weeks, there was excellent bone graft incorporation by bone, and the stems were well fixed in both groups. The median subsidence at the cement-bone interface, measured using radiostereometric analysis, was 0.14 and 0.93 mm in the control and HA groups, respectively. The comparable histologic results between groups and good stem fixation in this study support the conduct of a larger scale investigation of the use of porous HA in femoral impaction bone grafting at revision hip arthroplasty.     

The effect of preoperative planning and impaction grafting surgical technique on intraoperative and postoperative complication rate for femoral revision patients with moderate to severe bone loss mean 4.7-year results

This study reports the results of 41 revision hips, implanted by a single surgeon using impaction grafting (mean follow-up, 4.7 years). All hips had Paprosky scores of III or IV. Harris hip scores improved from 43 to 82. There was 1 intraoperative and 2 postoperative fractures. A single stem was revised during the study. Radiographic review showed the 40 unrevised stems to be stable, and graft incorporation was seen in at least 1 zone in 100% of the femurs. There was no stem subsidence greater than 2.5 mm. The results of this study demonstrate that preoperative planning and a surgical technique, which emphasizes femoral support and vigorous impaction grafting, resulted in an acceptable incidence of complications.     

Impaction grafting for femoral component revision using a non-polished bead-blasted chrome cobalt stem-average 8 1/2-year follow-up

Impaction grafting for femoral component revision in patients with significant bone loss has been reported using a tapered polished femoral component that is meant to subside. This study reports our results of femoral component revision using impaction grafting with a bead-blasted chrome cobalt stem designed not to subside. Forty-eight femoral component revisions using impaction grafting were retrospectively reviewed with a minimum 6 1/2-year follow-up. There were 2 failures due to aseptic loosening of the femoral component (4%). There were 22 total complications, and the overall failure rate was 21%. Impaction grafting for femoral component revision using a bead-blasted chrome cobalt stem in patients with a large femoral canal diameter has shown good results with respect to aseptic loosening with minimal subsidence.     

Revision arthroplasty with impaction bone grafting and Charnley-Kerboull cemented stem. Surgical technique and results

We report here the study of a personal series of 129 consecutive femoral impaction grafting during hip revision replacement performed between January 1991 and December 2005. The indication for the revision of the femoral component was aseptic loosening in 127 hips and septic loosening in two. The precise locations of the segmental defects and osteolytic areas were determined and classified, with use of the Endo-Klinik System, as follows: grade 2 in 75 hips, grade 3 in 43, and grade 4 in 11. Removal of the components, debris and cement was done with special care to achieve a complete resection of fibrous tissue in the medullary canal to ensure a direct contact between the graft and the host bone. Before impaction grafting, femoral segmental bone defects or windows were reconstructed and reinforced with strut allograft and cerclage wires. We used in all hips a special revision set of instruments specially designed for impaction grafting. All the acetabular cups were also revised. Clinical and radiologic evaluation was performed at six weeks, three months, six months and one year. Then, patients were reviewed every year for the first five postoperative years and every two years thereafter. A survivorship analysis was performed to determine the overall success of the procedure. Failure was defined as an implant that had been revised or that was radiologically loosened at the time of follow-up. The survival curve was derived from the cumulative survival rate over time, as calculated from the actuarial life table. At the last follow-up evaluation, seven patients (seven hips) had died and two (two hips) were lost to follow-up. The follow-up of these nine patients ranged from two to ten years. One hundred and twenty patients (120 hips) were reviewed with a mean follow-up of 8.2 years (range, two to 16 years). The average follow-up of the whole series was 8.4 years (range, two to 16 years). At the time of the final review 1 of the 129 hips had migration of the stem’s cement mantle relative to the bone (5 mm) with lucent lines at the graft-host interface in three Gruen zones. Another one had migration within the cement (8 mm) with lucent line at the distal graft-host interface and a distal fracture of the cement mantle. These two stems were considered as definitely loosed according to the criteria of Johnston et al. but none of them was revised. The remaining 127 hips showed no radiological changes at the latest examination concerning stem migration and radiolucent lines. One acetabular definite loosening occurred at ten years and was revised at 11 years postoperatively. In this respect, of the 129 hips, only one hip was revised at 11 years’ follow-up (0.7%). The survivorship analysis, with radiologic loosening as the endpoint, yielded a 98% cumulative survival rate for the femoral component and for the acetabular component, 99% at eleven years follow-up. The survival rate with revision for any reason as the endpoint was 99.4% at eleven years follow-up. The results observed in this series, regarding the need for a repeat revision for any reason, are in agreement with the excellent outcome reported by other authors using similar technique. Nevertheless two main differences must be emphasized when comparing the results of this study with the others. The first one is the low rate of subsidence and the second is the absence of postoperative femoral fracture. The quality of bone grafting and the use of a Kerboull stem, double tapered and polish, were associated with the very low rate of distal migration. The unconditional reconstruction of distal bone deficiency or weakness with bone graft strut appeared efficient to prevent the occurrence of femoral fracture, despite the unique use or standard stems.