Operative Techniken Oper Orthop Traumatol 2014 · 26:156–161 DOI 10.1007/s00064-013-0272-1 Received: 31. Juli 2013 Revised: 8. Dezember 2013 Accepted: 22. Januar 2014 Online publiziert: 5. April 2014 © Springer-Verlag Berlin Heidelberg 2014 Redaktion
D.C. Wirtz, Bonn Zeichner
R. Himmelhan, Heidelberg
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 Maastricht 2 Department of Orthopaedics, Radboud University, Nijmegen 3 Department of Orthopaedics, Orbis MC, Sittard
Femoral revision with impaction bone grafting and a cemented polished tapered stem
In femoral revision surgery, one of the main topics is how to deal with bone loss. When bone loss (according to the Endoklinik classification) is treated with extra cement and/or an increased stem size, bone stock is not restored. Bone graft impaction 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 initiation of the graft remodeling process. Therefore, a polished double-tapered cemented stem is used (Exeter; Stryker Orthopedics, Mahwah, NJ, USA). Because of the specific stem design and the surgical technique, forces on the stem are transmitted to the bone graft, whereby the graft is loaded. Special metal meshes and cerclage wires can be used to restore segmental defects (Stryker). By virtue of the different 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 created.
length of the stem dictates the position of a polyethylene plug that is fixed about 2 cm below the distal part of the stem using a central rod. The central rod incorporates a scale to measure the distance proximal to the plug. Special hollow impaction instruments of increasing dia meter are available to indicate the level of impaction, without incurring the risk of splitting the femur. Following bone impaction, when the level is reached where the stem itself can be introduced, impaction instruments of different sizes and offsets 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 centralizer is fixed to the distal point of the stem. After introduction of the stem during hardening of the cement, the proximal part is closed with a specially designed seal. This pressurizing technique results in increased cement penetration of the impacted bone bed.
Surgical principle and objective
Advantages
Femoral segmental defects are treated with metal meshes and cerclages (Stryker). Stems of different sizes with different lengths and offsets are available. The
F Conserved restoration of bone loss F Reconstruction of center of rotation
Introductory remarks
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Operative Orthopädie und Traumatologie 2 · 2014
F Well-fixed stem in femora with cavitary and/or segmental defects (Endoklinik classification grade 4)
Disadvantages F Technically demanding procedure F Longer surgery time F Allograft bone from a bone bank is required F Standard postoperative protocol is 12 weeks on crutches
Indications F Femoral stem revision with bone loss (up to Endoklinik grade 4)
Contraindications F One-stage revision in cases of septic loosening F Extensive circumferential proximal femoral cortical bone loss; distal fixation with a long stem is advised F Noncompliant patient
Patient information F Fresh frozen donor bone will be used F Partial weight bearing for 3 months F Potential complications of revision surgery (infection, dislocation, neu-
Abstract · Zusammenfassung rological complaints, loosening, fracture)
Preoperative workup F Septic loosening must be excluded by joint aspiration F Templating of the femur on pelvis anteroposterior (AP) and lateral X-rays F Select size, length and offset of revision implant F Determine position of distal plug
Instruments and implants F Instruments for stem and cement removal (chisels, osteotomes, drills, stem extraction set) F Double-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, Stryker) F Low viscosity bone cement (Simplex, Stryker) F A special cement syringe with a long, narrow nozzle (Stryker) F Bone bank bone F If needed, metal meshes to reconstruct the femur F Specific instruments for impaction (X-change femoral revision system, Stryker) F Preparation of bone graft before or during surgery (2–8 mm of fresh frozen femoral head allograft after careful removal of cartilage)
Anesthesia and positioning F General anesthesia F Antibiotic prophylaxis (1000 mg cefazolin after obtaining specimen for microbiological assessment and twice/8 h postoperatively) F Patient well fixed in lateral position
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 Haaren
Femoral revision with impaction bone grafting and a cemented polished tapered stem Abstract Objective. Biological repair of femoral bone loss using bone impaction grafting. Reconstruction 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 using meshes if required, impaction bone grafting with special instruments, cement fixation of a polished tapered stem. Postoperative management. Individualized period of bed rest and limited weight bearing.
Results. Impaction bone grafting and a cemented polished stem were used to perform 33 femoral reconstructions. After a mean follow-up of 15 years, no femoral reconstruction had to be revised. One unrecognized intraoperative fracture healed after nonsurgical treatment, three postoperative femoral fractures healed after plate fixation with the stem left in situ. The average Harris Hip Score improved from 49 prior to surgery to 85 points thereafter. Kaplan–Meier analysis with femoral revision for any reason as the end point showed a survival rate of 100%. Keywords Bone loss · Rotation · Segmental defects · Harris Hip Score · Allograft
Femurrevision mit Impaction-Bone-Grafting-Technik und einem zementierten angeschliffenen, abgeschrägten Schaft Zusammenfassung Operationsziel. Biologische Rekonstruktion von Knochenverlusten des Femurs mittels Impaction-Bone-Grafting-Technik. Rekonstruktion des Hüftrotationszentrums mit einem zementierten Schaft, dessen Länge und Offset im Ermessen des Operateurs liegen. Indikationen. Femurimplantatlockerung mit Knochenverlust. Kontraindikationen. Infektion, neurologische Erkrankungen, unkooperativer Patient. Operationstechnik. Entfernung des gelockerten Femurimplantats, Kortikalisrekonstruktion, ggf. mit Netzen, Impaction-Bone-Grafting-Technik mit speziellen Instrumenten, Zementfixation eines angeschliffenen, abgeschrägten Schafts. Weiterbehandlung. Individualisierte Phase der Bettruhe und Teilbelastung. Ergebnisse. Die Impaction-Bone-GraftingTechnik mit zementierten, angeschliffenen
Schaft wurden für 33 Femurrekonstruktionen verwendet. Bei einer durchschnittlichen Nachbeobachtungsphase von 15 Jahren musste keine Femurrekonstruktion revidiert werden. Eine unerkannte intraoperative Fraktur heilte unter konservativer Behandlung aus, 3 postoperative Femurfrakturen heil ten nach Plattenfixation mit in situ belassenem Schaft. Der durchschnittliche Harris-HipScore verbesserte sich von präoperativ 49 auf postoperativ 85 Punkte. Die Kaplan-Meier-Analyse bei Femurrevision aus jeglichem Grundals Endpunkt ergab eine Überlebensrate von 100%. Schlüsselwörter Knochenverlust · Rotation · Segmentaler Defekte · Harris Hip Score · Allotransplantat
Operative Orthopädie und Traumatologie 2 · 2014
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Operative Techniken
Surgical technique (. Fig. 1, 2, 3, 4, 5, 6, 7)
Fig. 2 8 The patient is positioned in lateral position, with the pelvis well fixed to the table. We prefer a posterolateral approach (model drawing used with permission from Stryker) Fig. 1 8 The desired stem implant is selected by templating (size, offset, potential extra length) and the plug position is defined (used with permission from Stryker)
Fig. 3 7 Lytic femoral lesions need to be treated with metal meshes and cerclage wires (and potentially 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 position 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 permission from Stryker)
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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 impactors 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 Medical Technique, Nijmegen, Netherlands). The bone chips are put into the canal and impacted layer by layer using the several distal impactors. Impaction of the allograft bone chips must be performed with sufficient intensity. To prevent distal migration of the plug, the impaction 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 midstem 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 layerby-layer. The proximal impactor should become tight within the impacted bone graft, in the position indicated by templating. Final proximal impaction (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)
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Operative Techniken
Special surgical considerations
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 torsional 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 recommended 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 maintained with the seal until the cement has polymerized (model drawing used with permission from Stryker)
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Fig. 7 8 When a long stem is used, the plug is fixed 2 cm below the distal stem tip. Distal impaction is performed with the long stem guide wire, which has a smaller diameter, using the same impactors as for the primary 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 permission from Stryker)
Postoperative management F Anticoagulation therapy F Prophylaxis of periprosthetic ossifications (indometazine) F Bed rest individualized according to general condition and compliance of the patient; this can range from a few days to a few weeks F Touch weight bearing for 3 months due to the process of bone remodeling F Gradually increasing loading thereafter F Subsidence of 2–5 mm of the stem in the cement mantle can be seen
Errors, hazards, complications F The distal plug must be positioned 2 cm below the most distal lytic area. When this position is below the isthmus, a temporary Kirschner wire (Kwire) is drilled through the bone to block the plug F A potential split or fracture of the femur during impaction must be recognized and treated with cerclage wires or cables (and plate if necessary) F Early postoperative infections are treated with antibiotics based on swab results and if necessary surgical debridement F Late postoperative infections (3– 6 months postoperative) are treated with a two-stage procedure.
Results Femoral reconstructions with bone impaction grafting and cement fixation of a polished tapered stem in 33 consecutive patients were followed for a minimum 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 mechanical reasons during rerevision of an acetabular cup. The probability of survival at 17 years of follow-up was 96% (95% confidence interval, CI: 72–99%) with femoral 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 subsidence was 3 mm. Although three early femoral fractures occurred after surgery, no late fractures or other complications were seen. All fractures healed after plate fixation and all stems were left in situ. The probability of survival of femoral component revisions with impaction bone grafting and a cemented polished stem was excellent, with a mean of 17 years. The average Harris Hip Score improved from 49 prior to surgery to 85 points after surgery. 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. Heyligers Department of Orthopaedics, Atrium MC Heerlen, SHE, Faculty of Health, Medicine and Life Sciences, University Maastricht 6401 Heerlen The Netherlands [email protected]
Compliance with ethical guidelines Conflict of interest. A commercial entity, Stryker, paid or directed, or agreed to pay or direct benefits to a research fund, foundation, educational institution or other charitable or nonprofit organization with which the authors are affiliated or associated. The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits, or a commitment or agreement to provide such benefits from a commercial entity. I.C. Heyligers, B.W. Schreurs and E.H. van Haaren state that there are no conflicts of interest.
5. Nelissen RG, Bauer TW, Weidenhielm LR et al (1995) Revision hip arthroplasty with the use of cement and impaction grafting. Histological analysis of four cases. J Bone Joint Surg Am 77:412–422 6. Stroet MA te, Gardeniers JW, Verdonschot N et al (2012) Femoral component revision with use of impaction bone-grafting and a cemented polished stem: a concise follow-up, at fifteen to twenty years, of a previous report. J Bone Joint Surg Am 94(23) 7. Schreurs BW, Buma P, Huiskes R et al (1994) Morsellized allografts for fixation of the hip prosthesis femoral component. A mechanical and histological study in the goat. Acta Orthop Scand 65:267– 275 8. Schreurs BW, Huiskes R, Slooff TJ (1991) The initial stability of cemented and noncemented stems, fixated with a bone grafting technique. Orthop Trans 15:439–440 9. Van Donk S der, Weernink T, Buma P et al (2003) Rinsing allografts improves bone and tissue ingrowth. Clin Orthop Relat Res 408:302–310 10. Haaren EH van, Smit TH, Phipps K et al (2005) Tricacium-phosphate and hydroxyapatite bone-graft extender for use in impaction grafting revision surgery. An in vitro study on human femora. J Bone Joint Surg Br 87(2):267–271 11. Haaren EH van, Smit TH, Veen AJ van der et al (2005) A bioresorbable molding mesh for impaction grafting revision hip surgery. Clin Orthop Relat Res 432:167–173 12. Haaren EH van, Zwaard BC van der, Veen AJ van der et al (2008) Effect of long-term preservation on the mechanical properties of cortical bone. Acta Orthopaedica 79(5):708–716
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References 1. Bolder SB, Schreurs BW, Verdonschot N et al (2004) Wire mesh allows more revascularization than a strut in impaction bone grafting: an animal study in goats. Clin Orthop Relat Res 423:280–286 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 3. Gie GA, Linder L, Ling RS et al (1993) Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 75:14–21 4. Halliday BR, English HW, Timperly AJ et al (2003) Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg Br 85:809–817
Operative Orthopädie und Traumatologie 2 · 2014
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D.C. Wirtz, Bonn Zeichner
R. Himmelhan, Heidelberg
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 Maastricht 2 Department of Orthopaedics, Radboud University, Nijmegen 3 Department of Orthopaedics, Orbis MC, Sittard
Femoral revision with impaction bone grafting and a cemented polished tapered stem
In femoral revision surgery, one of the main topics is how to deal with bone loss. When bone loss (according to the Endoklinik classification) is treated with extra cement and/or an increased stem size, bone stock is not restored. Bone graft impaction 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 initiation of the graft remodeling process. Therefore, a polished double-tapered cemented stem is used (Exeter; Stryker Orthopedics, Mahwah, NJ, USA). Because of the specific stem design and the surgical technique, forces on the stem are transmitted to the bone graft, whereby the graft is loaded. Special metal meshes and cerclage wires can be used to restore segmental defects (Stryker). By virtue of the different 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 created.
length of the stem dictates the position of a polyethylene plug that is fixed about 2 cm below the distal part of the stem using a central rod. The central rod incorporates a scale to measure the distance proximal to the plug. Special hollow impaction instruments of increasing dia meter are available to indicate the level of impaction, without incurring the risk of splitting the femur. Following bone impaction, when the level is reached where the stem itself can be introduced, impaction instruments of different sizes and offsets 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 centralizer is fixed to the distal point of the stem. After introduction of the stem during hardening of the cement, the proximal part is closed with a specially designed seal. This pressurizing technique results in increased cement penetration of the impacted bone bed.
Surgical principle and objective
Advantages
Femoral segmental defects are treated with metal meshes and cerclages (Stryker). Stems of different sizes with different lengths and offsets are available. The
F Conserved restoration of bone loss F Reconstruction of center of rotation
Introductory remarks
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Operative Orthopädie und Traumatologie 2 · 2014
F Well-fixed stem in femora with cavitary and/or segmental defects (Endoklinik classification grade 4)
Disadvantages F Technically demanding procedure F Longer surgery time F Allograft bone from a bone bank is required F Standard postoperative protocol is 12 weeks on crutches
Indications F Femoral stem revision with bone loss (up to Endoklinik grade 4)
Contraindications F One-stage revision in cases of septic loosening F Extensive circumferential proximal femoral cortical bone loss; distal fixation with a long stem is advised F Noncompliant patient
Patient information F Fresh frozen donor bone will be used F Partial weight bearing for 3 months F Potential complications of revision surgery (infection, dislocation, neu-
Abstract · Zusammenfassung rological complaints, loosening, fracture)
Preoperative workup F Septic loosening must be excluded by joint aspiration F Templating of the femur on pelvis anteroposterior (AP) and lateral X-rays F Select size, length and offset of revision implant F Determine position of distal plug
Instruments and implants F Instruments for stem and cement removal (chisels, osteotomes, drills, stem extraction set) F Double-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, Stryker) F Low viscosity bone cement (Simplex, Stryker) F A special cement syringe with a long, narrow nozzle (Stryker) F Bone bank bone F If needed, metal meshes to reconstruct the femur F Specific instruments for impaction (X-change femoral revision system, Stryker) F Preparation of bone graft before or during surgery (2–8 mm of fresh frozen femoral head allograft after careful removal of cartilage)
Anesthesia and positioning F General anesthesia F Antibiotic prophylaxis (1000 mg cefazolin after obtaining specimen for microbiological assessment and twice/8 h postoperatively) F Patient well fixed in lateral position
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 Haaren
Femoral revision with impaction bone grafting and a cemented polished tapered stem Abstract Objective. Biological repair of femoral bone loss using bone impaction grafting. Reconstruction 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 using meshes if required, impaction bone grafting with special instruments, cement fixation of a polished tapered stem. Postoperative management. Individualized period of bed rest and limited weight bearing.
Results. Impaction bone grafting and a cemented polished stem were used to perform 33 femoral reconstructions. After a mean follow-up of 15 years, no femoral reconstruction had to be revised. One unrecognized intraoperative fracture healed after nonsurgical treatment, three postoperative femoral fractures healed after plate fixation with the stem left in situ. The average Harris Hip Score improved from 49 prior to surgery to 85 points thereafter. Kaplan–Meier analysis with femoral revision for any reason as the end point showed a survival rate of 100%. Keywords Bone loss · Rotation · Segmental defects · Harris Hip Score · Allograft
Femurrevision mit Impaction-Bone-Grafting-Technik und einem zementierten angeschliffenen, abgeschrägten Schaft Zusammenfassung Operationsziel. Biologische Rekonstruktion von Knochenverlusten des Femurs mittels Impaction-Bone-Grafting-Technik. Rekonstruktion des Hüftrotationszentrums mit einem zementierten Schaft, dessen Länge und Offset im Ermessen des Operateurs liegen. Indikationen. Femurimplantatlockerung mit Knochenverlust. Kontraindikationen. Infektion, neurologische Erkrankungen, unkooperativer Patient. Operationstechnik. Entfernung des gelockerten Femurimplantats, Kortikalisrekonstruktion, ggf. mit Netzen, Impaction-Bone-Grafting-Technik mit speziellen Instrumenten, Zementfixation eines angeschliffenen, abgeschrägten Schafts. Weiterbehandlung. Individualisierte Phase der Bettruhe und Teilbelastung. Ergebnisse. Die Impaction-Bone-GraftingTechnik mit zementierten, angeschliffenen
Schaft wurden für 33 Femurrekonstruktionen verwendet. Bei einer durchschnittlichen Nachbeobachtungsphase von 15 Jahren musste keine Femurrekonstruktion revidiert werden. Eine unerkannte intraoperative Fraktur heilte unter konservativer Behandlung aus, 3 postoperative Femurfrakturen heil ten nach Plattenfixation mit in situ belassenem Schaft. Der durchschnittliche Harris-HipScore verbesserte sich von präoperativ 49 auf postoperativ 85 Punkte. Die Kaplan-Meier-Analyse bei Femurrevision aus jeglichem Grundals Endpunkt ergab eine Überlebensrate von 100%. Schlüsselwörter Knochenverlust · Rotation · Segmentaler Defekte · Harris Hip Score · Allotransplantat
Operative Orthopädie und Traumatologie 2 · 2014
| 157
Operative Techniken
Surgical technique (. Fig. 1, 2, 3, 4, 5, 6, 7)
Fig. 2 8 The patient is positioned in lateral position, with the pelvis well fixed to the table. We prefer a posterolateral approach (model drawing used with permission from Stryker) Fig. 1 8 The desired stem implant is selected by templating (size, offset, potential extra length) and the plug position is defined (used with permission from Stryker)
Fig. 3 7 Lytic femoral lesions need to be treated with metal meshes and cerclage wires (and potentially 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 position 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 permission from Stryker)
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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 impactors 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 Medical Technique, Nijmegen, Netherlands). The bone chips are put into the canal and impacted layer by layer using the several distal impactors. Impaction of the allograft bone chips must be performed with sufficient intensity. To prevent distal migration of the plug, the impaction 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 midstem 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 layerby-layer. The proximal impactor should become tight within the impacted bone graft, in the position indicated by templating. Final proximal impaction (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)
Operative Orthopädie und Traumatologie 2 · 2014
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Operative Techniken
Special surgical considerations
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 torsional 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 recommended 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 maintained with the seal until the cement has polymerized (model drawing used with permission from Stryker)
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Fig. 7 8 When a long stem is used, the plug is fixed 2 cm below the distal stem tip. Distal impaction is performed with the long stem guide wire, which has a smaller diameter, using the same impactors as for the primary 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 permission from Stryker)
Postoperative management F Anticoagulation therapy F Prophylaxis of periprosthetic ossifications (indometazine) F Bed rest individualized according to general condition and compliance of the patient; this can range from a few days to a few weeks F Touch weight bearing for 3 months due to the process of bone remodeling F Gradually increasing loading thereafter F Subsidence of 2–5 mm of the stem in the cement mantle can be seen
Errors, hazards, complications F The distal plug must be positioned 2 cm below the most distal lytic area. When this position is below the isthmus, a temporary Kirschner wire (Kwire) is drilled through the bone to block the plug F A potential split or fracture of the femur during impaction must be recognized and treated with cerclage wires or cables (and plate if necessary) F Early postoperative infections are treated with antibiotics based on swab results and if necessary surgical debridement F Late postoperative infections (3– 6 months postoperative) are treated with a two-stage procedure.
Results Femoral reconstructions with bone impaction grafting and cement fixation of a polished tapered stem in 33 consecutive patients were followed for a minimum 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 mechanical reasons during rerevision of an acetabular cup. The probability of survival at 17 years of follow-up was 96% (95% confidence interval, CI: 72–99%) with femoral 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 subsidence was 3 mm. Although three early femoral fractures occurred after surgery, no late fractures or other complications were seen. All fractures healed after plate fixation and all stems were left in situ. The probability of survival of femoral component revisions with impaction bone grafting and a cemented polished stem was excellent, with a mean of 17 years. The average Harris Hip Score improved from 49 prior to surgery to 85 points after surgery. 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. Heyligers Department of Orthopaedics, Atrium MC Heerlen, SHE, Faculty of Health, Medicine and Life Sciences, University Maastricht 6401 Heerlen The Netherlands [email protected]
Compliance with ethical guidelines Conflict of interest. A commercial entity, Stryker, paid or directed, or agreed to pay or direct benefits to a research fund, foundation, educational institution or other charitable or nonprofit organization with which the authors are affiliated or associated. The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits, or a commitment or agreement to provide such benefits from a commercial entity. I.C. Heyligers, B.W. Schreurs and E.H. van Haaren state that there are no conflicts of interest.
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References 1. Bolder SB, Schreurs BW, Verdonschot N et al (2004) Wire mesh allows more revascularization than a strut in impaction bone grafting: an animal study in goats. Clin Orthop Relat Res 423:280–286 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 3. Gie GA, Linder L, Ling RS et al (1993) Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 75:14–21 4. Halliday BR, English HW, Timperly AJ et al (2003) Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Joint Surg Br 85:809–817
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