Aims. We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH). Methods. This retrospective comparative study included 81 patients with ONFH; 37 patients (40 hips) underwent CVO with BIG (BIG group) and 44 patients (47 hips) underwent CVO alone (CVO group). Patients in the BIG group were followed-up for a mean of 12.2 years (10.0 to 16.5). Patients in the CVO group were followed-up for a mean of 14.5 years (10.0 to 21.0). Assessment parameters included the Harris Hip Score (HHS), Oxford Hip Score (OHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), complication rates, and survival rates, with conversion to total hip arthroplasty (THA) and radiological failure as the endpoints. Results. There were no significant differences in preoperative and postoperative HHS or postoperative OHS and JHEQ between the BIG group and the CVO group. Complication rates were comparable between groups. Ten-year survival rates with conversion to THA and radiological failure as the endpoints were not significantly different between groups. Successful CVO (postoperative coverage ratio of more than one-third) exhibited better ten-year survival rates with radiological failure as the endpoint in the BIG group (91.4%) than in the CVO group (77.7%), but this difference was not significant (p = 0.079). Conclusion. Long-term outcomes of CVO with BIG were favourable when proper patient selection and accurate surgery are performed. However, this study did not show improvements in treatment results with the concomitant use of BIG. Cite this article: Bone Joint J 2021;103-B(4):665–671

Background and purpose. The two most common complications of femoral impaction bone grafting are femoral fracture and massive implant subsidence. We investigated fracture forces and implant subsidence rates in embalmed human femurs undergoing impaction grafting. The study consisted of two arms, the first examining the force at which femoral fracture occurs in the embalmed human femur, and the second examining whether significant graft implant/subsidence occurs following impaction at a set force at two different impaction frequencies. Methods. Using a standardized impaction grafting technique with modifications, an initial group of 17 femurs underwent complete destructive impaction testing, allowing sequentially increased, controlled impaction forces to be applied until femoral fracture occurred. A second group of 8 femurs underwent impaction bone grafting at constant force, at an impaction frequency of 1 Hz or 10 Hz. An Exeter stem was cemented into the neomedullary canals. These constructs underwent subsidence testing simulating the first 2 months of postoperative weight bearing. Results. No femur fractured below an impaction force of 0.5 kN. 15/17 of the femurs fractured at or above 1.6 kN of applied force. In the second group of 8 femurs, all of which underwent femoral impaction grafting at 1.6 kN, there was no correlation between implant subsidence and frequency of impaction. Average subsidence was 3.2 (1–9) mm. Interpretation. It is possible to calculate a force below which no fracture occurs in the embalmed human femur undergoing impaction grafting. Higher impaction frequency at constant force did not reduce rates of implant subsidence in this experiment

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship.

Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression.

Introduction. Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasties (TKAs). However, if the diaphysis has been previously violated (as in revision of a failed stemmed implant), the resultant sclerotic canal can impair cemented stem fixation, which is vital for cone ingrowth and long-term fixation. We report the outcomes of our novel solution to this problem, in which impaction grafting and a cemented stem in the diaphysis was combined with an uncemented metaphyseal cone for revision TKAs with severely compromised bone. Methods. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems in a novel fashion for 35 revision TKAs. Mean age at revision TKA was 70 years, with 63% being male. Patients had a mean of 4 prior knee arthroplasty procedures. Indications for the revision with this construct were aseptic loosening (80%) and two-stage re-implantation for periprosthetic infection (PJI; 20%). Mean follow-up was 3 years. Results. Survivorship free from revision of the cone/impaction grafting construct due to aseptic loosening was 100% at 5 years. Survivorships free from any revision of the cone/impaction grafting construct and free from any reoperation were 92% and 73% at 5 years, respectively. Six knees (17%) required a reoperation (4 for infection/wound issues and 2 for periprosthetic fractures). Radiographically, 97% of cones were ingrown (1 loose cone in setting of PJI). In all but one case, impacted diaphyseal bone graft appeared to have incorporated radiographically. Conclusions. When presented with a sclerotic diaphysis and substantial metaphyseal bone loss, this innovative technique combining diaphyseal impaction grafting with a metaphyseal cone provided near universal success in regards to implant fixation. Moreover, radiographs revealed incorporation of the bone graft, and ingrowth of the cones. While long-term follow-up is required, this novel technique provides an excellent option in the most difficult of revision TKAs. For figures, tables, or references, please contact authors directly

Objective. The purpose of this study was to determine the outcomes of revision ankle replacements, using the Invision implant and impaction allograft for massive talar dome defects following primary ankle replacement failure. Outcomes were assessed in terms of bone graft incorporation; improvement in patient reported outcome measures (PROMs); and survivorship of the revision ankle arthroplasty. Methods. A retrospective review of prospectively collected data identified eleven patients who had massive bone cysts and underwent revision of a failed primary total ankle replacement to the Invision revision system, combined with impaction grafting using morselized femoral head allograft. These revisions occurred at a single high volume ankle arthroplasty centre. Computed tomography (CT) scans were used to assess bone graft incorporation and the Manchester-Oxford Foot Questionnaire (MOXFQ) and EQ-5D scores were used pre and post operatively to assess PROMs. Results. The mean follow up was 18 months (12–48months). In all eleven patients, improvement was reported in the post-operative MOXFQ and EQ-5D scores. CT scans showed bone graft incorporation in all cases. None of the patients have required further surgery and are continue to do well clinically at latest follow up. Conclusions. In the short term, this study confirms revision ankle replacements with the Invision prosthesis and impaction with morselized femoral head allograft is a suitable revision option for primary ankle replacement failure with massive talar bone loss. Long term follow up continues of these complex patients

To assess the outcome of periprosthetic femoral fractures (Vancouver B3 type) around loose stems treated by impaction grafting revision, 106 B3 fractures were reviewed. To assess the association between those who healed and those who did not for the factors of interest such as stem length, impaction grafting and the combination of the above, odd ratios along with their 95% CI and their p-values were reported. Logistic regression in STATA version 7.0 employed. 75 out of 89 fractures treated with long stem revision and 10 out of 17 with sort stem healed. 74 out of 89 fractures treated with impaction grafting and 11 out of 17 treated without impaction grafting healed. 66 out of 75 fractures treated with long stem and impaction grafting and 9 out of 14 treated with with long stem but no impaction grafting healed. 8 out of 14 fractures treated with short stem and impaction healed. Average healing 8.5 months. Those treated with long stem are almost four times more likely to heal than those treated with short stem (odds ratio = 3.75 95%CI: 1.21–11.6 p=0.022) and those with impaction grafting are also more likely, but not statistically significant, to heal than those without impaction grafting (odds ratio = 2.69, 95%CI: 0.86– 8.45 p=0.090). Furthermore, those with long stem and impaction are significantly more likely to heal than those without impaction grafting and those with short stem and impaction grafting (odds ratios = 4.07, 95%CI: 1.10 – 15.0 p=0.035 and 5.5, 95%CI: 1.54 – 19.6 p=0.009 respectively). Impaction grafting is an increasingly popular technique for the restoration of femoral bone stock. It can successfully be applied to periprosthetic femoral fractures but a long stem should be used to bypass the distal fracture line

Impaction grafting is an excellent option for acetabular revision. It is technique specific and very popular in England and the Netherlands and to some degree in other European centers. The long term published results are excellent. It is, however, technique dependent and the best results are for contained cavitary defects. If the defect is segmental and can be contained by a single mesh and impaction grafting, the results are still quite good. If, however, there is a larger segmental defect of greater than 50% of the acetabulum or a pelvic discontinuity, other options should be considered. Segmental defects of 25–50% can be managed by minor column (shelf) or figure of 7 structural allografts with good long term results. Porous metal augments are now a good option with promising early to mid-term results. Segmental defects of greater than 50% require a structural graft or porous augment usually protected by a cage. If there is an associated pelvic discontinuity then a cup cage is a better solution. An important question is does impaction grafting facilitate rerevision surgery? There is no evidence to support this but some histological studies of impacted allograft would suggest that it may. On the other hand there are papers that show that structural allografts do restore bone stock for further revision surgery. Also the results of impaction grafting are best in the hands of surgeons comfortable with using cement on the acetabular side, and one of the reasons why this technique is not as popular in North America

Summary. A laboratory based study investigating fracture forces and implant subsidence rates in embalmed human femurs undergoing impaction grafting. Methods. Human femurs were harvested from cadavers for destructive impaction testing. An initial group of femurs underwent destructive impaction testing, using the impaction grafting technique as described by Gie et al, modified, allowing increasing, controlled impaction forces to be applied until femoral fracture occurred. A second group of embalmed human femurs underwent impaction bone grafting at constant force, with varied impaction frequencies. An Exeter stem was cemented into the neo-medullary canals. These constructs underwent subsidence testing simulating the first 2 months post-operative weight-bearing. Results. In a group of 17 femurs, none fractured below a 0.5kN impaction force. 82% of the femurs fractured at or above 1.6kN of applied force. No massive implant subsidence occurred in the second group of 8 femurs, all undergoing femoral impaction grafting at 1.6kN. There was no correlation between implant subsidence and frequency of impaction. Average subsidence was 3.2mm. Conclusions. It is possible to calculate a force below which no fracture occurs in the embalmed human femur undergoing impaction grafting. Increasing impaction frequency, at constant force, doesn't decrease rates of implant subsidence

Introduction: The impaction grafting technique appears to be a very useful method for revising failed THA with extensive cavitary proximal femoral bone loss. However, its use with short, polished stems has been associated with femoral fractures, stem subsidence and instability. This study describes a new surgical impaction grafting technique and reports the results using blasted femoral stems of variable lengths, with variable head-neck offsets and lengths. Methods – Results: Fifteen revision THA using an impaction grafting technique were performed. Minimum follow-up was five years. Preoperative diagnosis was aseptic loosening of cemented femoral stems in 11 cases, and uncemented stems in four cases. Thirteen of the 15 revision cases with impaction grafting were cemented. Three revision cases were performed using stems less than 150 mm in length, the remainder utilised stems from 165 mm – 315 mm in length. Neck lengths of the revision implants ranged from 40 – 80 mm, including four calcar replacements. Intraoperative fractures occurred in two cases and were successfully treated with cerclage wires. There were two postoperative fractures, both in patients with stems less than 150 mm. Both were successfully treated with plates and onlay allografts. At most recent follow-up, all patients were pain-free. All patients were ambulating unlimited distances. Two patients required canes. All stems were well fixed radiographically with no evidence of progressive radiolucencies or subsidence. The graft appeared to be incorporating. The surgical technique consists of: 1.) removal of previously failed implant and cement; 2.) placement of cerclage wires around femur into which graft will be impacted; 3.) introduction of impacted allograft; 4.) radially impacting with tapered, polished, smooth straight impactors to a distance into femur that permits firm engagement with endosteal cortex for a distance of at least 3 cm; 5.) use of polished, smooth broaches to create final shape of cavity; 6.) trial reduction using polished broaches; and 7.) insertion of implant with or without cement. Discussion – Conclusions: This report describes a new technique for impaction grafting in revision THA. This study suggests that the use of rough surfaced, long femoral stems with variable head-neck lengths and offsets in conjunction with the impaction grafting technique may reduce the incidence of subsidence, femoral fractures, and dislocations that can occur when this revision technique is used with short, polished stems

Purpose:. Tuberosity healing in hemiarthroplasty for proximal humerus fractures remains problematic. Improved implant design and better techniques for tuberosity fixation have not been met with improved clinical results. The etiology for tuberosity failure is multifactorial; however thermal injury to host bone is a known effect of using polymethylmethacrylate for implant fixation. We hypothesized that the effect of thermal injury at the tuberosity shaft junction could be diminished by utilizing an impaction grafting technique for hemiarthroplasty stems. Methods:. Five matched pairs of cadaveric humeri were skeletonized and hemiarthroplasty stems were implanted in the proximal humeri in two groups. The first group had full cementation utilized from the surgical neck to 2 cm distal to the stem (cement group) and the second group had distal cementation with autologous cancellous bone graft impacted in the proximal 2.5 cm of the stem (impaction grafting group). Thermocouples were used to measure the inner cortical temperature at the tip of the stem, surgical neck, and at the level of the cement-graft interface for both treatment groups (see Fig. 1). Experiments were initiated with the humeri fully submerged in 0.9% sodium chloride and all three thermocouples registering a temperature of 37 ± 1°C. Statistical analyses were performed with a one-sided, paired t-test. Results:. The maximum recorded cortical bone temperature at the surgical neck was significantly decreased by 23% from 52.4 ± 8.1°C in the cement group to 40.4 ± 4.8°C in the impaction grafting group (p = 0.037). We identified no significant differences in maximum recorded temperature at the cement-graft interface between the impaction grafting group (44.3 ± 6.3°C) and the cement group (47.4 ± 6.4°C) (p = 0.254). A similar finding was observed between groups at the tip of the hemiarthroplasty stem (impaction grafting group 54.2 ± 5.7°C; cemented group 52.3 ± 7.3°C, p = 0.303). Conclusion:. Given the known threshold of 47°C as the onset of permanent thermal injury to bone,. 1. impaction grafting maintains the temperature at the surgical neck during cementation below this critical value. Impaction grafting may serve as a beneficial surgical technique to mitigate the effects of thermal injury on tuberosity healing in proximal humeral hemiarthroplasty for fracture

There has been an evolution in revision hip arthroplasty towards cementless reconstruction. Whilst cemented arthroplasty works well in the primary setting, the difficulty with achieving cement fixation in femoral revisions has led to a move towards removal of cement, where it was present, and the use of ingrowth components. These have included proximally loading or, more commonly, distally fixed stems. We have been through various iterations of these, notably with extensively porous coated cobalt chrome stems and recently with taper-fluted titanium stems. As a result of this, cemented stems have become much less popular in the revision setting. Allied to concerns about fixation and longevity of cemented fixation revision, there were also worries in relation to bone cement implantation syndrome when large cement loads were pressurised into the femoral canal at the time of stem cementation. This was particularly the case with longer stems. Technical measures are available to reduce that risk but the fear is nevertheless there. In spite of this direction of travel and these concerns, there is, however, still a role for cemented stems in revision hip arthroplasty. This role is indeed expanding. First and foremost, the use of cement allows for local antibiotic delivery using a variety of drugs both instilled in the cement at the time of manufacture or added by the surgeon when the cement is mixed. This has advantages when dealing with periprosthetic infection. Thus, cement can be used both as interval spacers but also for definitive fixation when dealing with periprosthetic hip infection. The reconstitution of bone stock is always attractive, particularly in younger patients or those with stove pipe canals. This is achieved well using impaction grafting with cement and is another extremely good use of cement. In the very elderly or those in whom proximal femoral resection is needed at the time of revision surgery, distal fixation with cement provides a good solution for immediate weight bearing and does not have the high a risk of fracture seen with large cementless stems. Cement is also useful in cases of proximal femoral deformity or where cement has been used in a primary arthroplasty previously. We have learnt that if the cement is well-fixed then the bond of cement-to-cement is excellent and therefore retention of the cement mantle and recementation into that previous mantle is a great advantage. This avoids the risks of cement removal and allows for much easier fixation. Stems have been designed specifically to allow this cement-in-cement technique. It can be used most readily with polished tapered stems - tap out a stem, gain access at the time of revision surgery and reinsert it. It is, however, now increasingly used when any cemented stems are removed provided that the cement mantle is well fixed. The existing mantle is either wide enough to accommodate the cement-in-cement revision or can be expanded using manual instruments or ultrasonic tools. The cement interface is then dried and a new stem cemented in place. Whilst the direction of travel in revision hip arthroplasty has been towards cementless fixation, particularly with tapered distally fixed designs, the reality is that there is still a role for cement for its properties of immediate fixation, reduced fracture risk, local antibiotic delivery, impaction grafting and cement-in-cement revision

Introduction: In the past, surgeons have found impaction bone grafting technically difficult leading to its limited use. This paper reviews the long term results and developments in instrumentation and techniques aimed at simplifying femoral impaction grafting at revision hip replacement. The expanded indications for this procedure are reviewed and recent results of stem fixation using radiostereometric analysis (RSA) are reported. Methods: The impaction bone grafting procedure, using a cemented collarless polished double taper stem, has been used in 66 hips (median patient age 63yrs) since 1993. The technique has undergone numerous developments. Modular tamps have been used in the last 29 hips and in the last seven hips, a pneumatic mechanical vibration device has been used in place of manual impaction. Stem subsidence at both the prosthesis-cement and cement-graft/bone interfaces was measured, more recently using radiostereometric analysis. Results: There was a high early incidence of failure in the initial cases but there have been no further revisions for mechanical failure at up to 15 years. Technique developments have resulted in dramatic improvements in stem fixation achieved. In the modular tamp cases, the mean stem subsidence at the cement-bone interface at 12 months was 0.07mm (0 to 0.7mm) at 12 months. The stem subsidence in the hips where the mechanical vibration device was used was 0.05mm (0 to 0.06mm). Femoral impaction grafting offers special advantages in younger patients include standard femoral stem revision and at the second stage of two stage revision for infection. Discussion and Conclusion: A stable cement-bone interface is achieved using advanced techniques of femoral impaction grafting that includes the use of modular impaction instruments. Early results of mechanical vibration impaction are encouraging. Femoral impaction grafting restores bone and new techniques simplify the femoral revision procedure

Introduction. Total hip arthroplasties (THAs) in young patients are associated with high failure rates. We always use cemented total hip implants, however, in cases with acetabular bone stock loss we perform bone impaction grafting. Our purpose was to evaluate the outcome of 69 consecutive primary cemented total hips in patients younger than 30 years followed between 2 to 18 years. Methods. Between 1988 and 2004, 69 consecutive primary cemented THAs (mainly Exeters) were performed in 48 patients (32 women, 16 men) younger than thirty years. Average age at time of operation was 25 years (range, 16 to 29 years). Twenty-nine hips (42%) underwent acetabular bone impaction grafting because of acetabular bone loss. Mean follow-up was 10 years (range, 2 to 18 years). Revisions were determined, Harris Hip Score (HHS), and Oxford Hip Questionnaire Score (OHQS) were obtained and radiographs were analyzed. Survival was calculated using the Kaplan-Meier method. Results. No patients were lost to follow-up, but 3 patients (4 hips) died during follow-up, none of whom had underwent revision. Eight revisions were performed: 3 septic loosenings (6, 7, and 8 years post-operative) and 5 aseptic cup loosenings (2, 3, 4, 5, and 9 years post-operative). No stems were loose. The average HHS and OHQS at follow-up were 89 points (range, 55 to 100 points) and 19 points (range, 12 to 42 points), respectively. Using Kaplan-Meier analysis, the cumulative survival with revision for any reason as end point was 83% (95% CI, 69 - 92%) at 10 years. Excluding the infections, the survival rate was 90% (95% CI, 77 - 96%) with revision for aseptic loosening. The outcome of the patients who underwent acetabular bone impaction grafting was comparable to the primary cemented hips with a survival of 89% (95% CI, 62 - 97%) with revision for any reason as an end point. Excluding the infections, the survival rate was 95% (95% confidence interval, 72 - 99%) at ten years with revision for aseptic loosening as the end point. Conclusion. Primary cemented total hip arthroplasties in very young patients show satisfactory medium-term results, however, in cases with acetabular bone stock loss, a reconstruction with bone impaction grafting is advisable

The principles of acetabular reconstruction include the creation of a stable acetabular bed, secure prosthetic fixation with freedom of orientation, bony reconstitution, and the restoration of a normal hip centre of rotation with acceptable biomechanics. Acetabular impaction grafting, particularly with cemented implants, has been shown to be a reliable means of acetabular revision. Whilst our practice is heavily weighted towards cementless revision of the acetabulum with impaction grafting, there is a large body of evidence from Tom Slooff and his successors that cemented revision with impaction grafting undertaken with strict attention to technical detail is associated with excellent long terms results in all ages and across a number of underlying pathologies including dysplasia and rheumatoid arthritis. We use revision to a cementless hemispherical porous-coated acetabular cup for most isolated cavitary or segmental defects and for many combined deficiencies. Morsellised allograft is packed in using chips of varied size and a combination of impaction and reverse reaming is used in order to create a hemisphere. There is increasing evidence for the use of synthetic grafts, usually mixed with allograft, in this setting. The reconstruction relies on the ability to achieve biological fixation of the component to the underlying host bone. This requires intimate host bone contact, and rigid implant stability. It is important to achieve host bone contact in a least part of the dome and posterior column – when this is possible, and particularly when there is a good rim fit, we have not found it absolutely necessary to have contact with host bone over 50% of the surface. Once the decision to attempt a cementless reconstruction is made, hemispherical reamers are used to prepare the acetabular cavity. Sequentially larger reamers are used until there is three-point contact with the ilium, ischium and pubis. Acetabular reaming should be performed in the desired orientation of the final implant, with approximately 200 of anteversion and 400 of abduction (or lateral opening). Removing residual posterior column bone should be avoided. Reaming to bleeding bone is desirable. Morsellised allograft is inserted and packed and/or reverse reamed into any cavitary defects. This method can also be applied to medial wall uncontained defects by placing the graft onto the medial membrane or obturator internus muscle, and gently packing it down before inserting the cementless acetabular component. Either the reamer heads or trial cups can be used to trial prior to choosing and inserting the definitive implant. The fixation is augmented with screws in all cases. Incorporation of the graft may be helped by the use of autologous bone marrow. Cementless acetabular components with impaction grafting should not be used when the host biology does not allow for stability or for bone ingrowth. This includes the severely osteopenic pelvis, pelvic osteonecrosis after irradiation, tumours, and metabolic bone disorders. They should also not be used in the presence of pelvic discontinuity unless the structure of the pelvic ring has been restored with a plate, or specialised materials/porous metals are used. The challenge of reconstituting the acetabulum depends on the degree and type of bone loss. The principles of maximising host bone-implant contact and implant stability have borne fruit in our experience with cementless revision. The advantages of bone grafting in acetabular reconstruction include the ability to restore bone stock, to rebuild a normal hip center and hip biomechanics and to increase bone stock for future revisions

Introduction. Especially in young patients, total hip implants with proven long-term follow-up data should be used. Despite this, almost all patients under 30 years old will face a revision of their hip prosthesis during their life time because of their life expectancy. Therefore, all the used implants should be revisable with reliable outcome. Although, several studies have evaluated the outcome of different THA implants in patients under 30, only few report the long term follow-up of 10 years or more. None of them present the outcome of the revised total hips. Methods. We retrospectively reviewed prospectively collected data of 48 consecutive patients (69 hips), all received a cemented implant and in case of acetabular bone stock deficiency (29 hips), a reconstruction with bone impaction grafting (BIG) was performed. Mean age at surgery was 24.6 years (range, 16.0–29.0 years). Two patients were lost to follow-up. As far as we know, no revisions are performed in these two patients and their data are included in the study up to their last radiographic control. All failed hips were revised with again cemented implants and, if needed, bone impaction grafting. For the primary THA Kaplan-Meier survival curves at 10- and 15-year endpoint revision for any reason and revision for aseptic loosening were calculated. Separate survival rates at 10- and 15- year were calculated for the BIG group versus the non-BIG group. The outcome of the revised hips was studied and reported with re-revision as the endpoint. Results. Mean follow-up of all 69 hips was 11.5 years (range 2–23.4 years). During follow-up 13 revisions were performed. No stem revisions occurred, except in 3 septic failures. The 10- and 15-year survival rates with endpoint revision for any reason were 86% (95%-CI: 74–92%) and 75% (95%-CI:59-86%), the same endpoints revision for aseptic loosening were 90% (95%-CI: 79–96%) and 82% (95%-CI: 65–92%), respectively. The 10- and 15-year survival rates with endpoint revision for any reason in the BIG group were 93% (95%-CI: 74–98%) and 83% (95%-CI:49-95%), whereas for the non-BIG group the rates were 81% (95%-CI: 69–91%) and 71% (95%-CI:50-84%). None of the 13 revisions needed a re-revision within 10 years after re-implantation, although one cup failed after 13 years. Conclusion. This study shows that cemented primary total hip implants in patients under 30 years have acceptable outcomes at 10 and 15 years after surgery. Remarkably, the outcomes of the bone impaction grafting technique are superior to non BIG hips, the BIG-group shows a higher survival percentage as the non-BIG group. However, the most interesting part of the study is that the revised hips, all again re-cemented and, if needed, reconstructed with bone impaction grafting were performing well with no re-revisions within 10 years after surgery

The most challenging aspect of acetabular revision is the management of bone loss compromising implant fixation and stability. Several options, including both nonbiologic and biologic fixation, are available for acetabular revision. Biologic fixation is considered the best solution for revision surgery because it aims to restore the detoriated bone stock by using structural or cancellous allografts and a cemented polyethylene cup with impaction grafting with or without an antiprotrusio cage. With this technique, reliable and durable fixation of cemented acetabular components depend on the incorporation of allografts. Impaction grafting with use of morselized bone is a biological fixation alternative as defined by Sloof in 1984. He reported 94% survival in 11 years. Best results of this technique are obtained in contained or cavitary defects because the skeleton, while weakened, is basically intact. In these defects the anterior and posterior columns and the peripheral supporting bone for the acetabular component are intact. However, uncontained, or segmental, defects are more of a challenge. If the patient has a large segmental defect and there is no possibility of placing the implant against host bone or of restoring nearly normal anatomy, then the use of a structural bone graft may be indicated. In our revision arthroplasty series, despite the success of impaction grafting on the femoral side and on cavitary defects of the acetabulum, we had early loosening in segmentary defects with mesh or structural allograft reconstruction of the acetabular wall and impaction. Retrospectively, we have compared the survival of acetabular cup revisions with impaction grafting technique with or without reconstruction cages in 40 hips of 39 patients. There were 15 hips without cage support and 25 hips with cage reconstruction. Patient demographics and preoperative hip scores were comparable in each group. After 4 years of follow-up we have evaluated 26.3% aseptic loosening in impaction grafting alone, and 8.3% loosening in impaction with cage reconstruction. We have concluded that the metal cage allows for a better stability, protects the cancellous graft micromotion and eventually leading to a better incorporation in segmentary defects. Impaction of the cancellous bone cubes without a cage support in segmentary acetabular defects may prone to fail because of the micromotion between the cement and the graft which is not contained in stable walls

Introduction and Aims: This paper presents a treatment plan for femoral stem revision that has been developed based on long-term studies of revision total hip replacement (THR) using cemented stems, cementless proximal fixation stems, cemented stems with impaction grafting and modular titanium long stems. Method: The clinical and radiographic results of femoral stem revision were compared using the following techniques: 1) a standard or long cemented collarless double taper Exeter or CPT stems (CCDT stems) [n=190]; 2) a proximally porous coated mid to long cementless stem [n=56]; 3) two series of CCDT stems with impaction grafting n=34]; and 4) a modular grit-blasted titanium taper stem [n=13] used for severe cortical damage. Treatment decisions were made based on the age of the patient, the appearance of the pre-operative radiograph and the extent of bone deficiency at surgery. Follow-up was from 17 to two years. Results: Only one hip was lost to follow-up. In the CCDT group, at a median follow-up of five years (range 2–17 years), two standard length stems and one long stem had been re-revised for loosening (1.5%) and seven stems had been re-revised for other reasons. Survivorship to re-revision for loosening at eight years was 95% (95%CI=85–100%) for both standard and long stems. There was a trend for better longer-term results for long stems. The extent of pre-operative bone loss did not influence results. For the cementless proximal fixation group, at a median follow-up of 10 years, re-revision of the stem for loosening occurred in 20%. Importantly, these poor results could have been predicted from short-term results. The initial series of femoral impaction grafting with CCDT stems and irradiated bone had a small incidence of stem loosening and periprosthetic fracture. The majority of stems subsided, but at a median follow-up of eight years there were no further re-revisions. In the second series, usually with non-irradiated allograft with mesh containment, there was minimal stem subsidence and no re-revision. The grit blasted titanium taper stem has dealt with periprosthetic fratures and severe proximal cortical loss, but with some cases of subsidence and femoral fracture. Conclusion: Based on these results, our treatment plan for routine femoral revision in middle-aged and elderly patients without severe proximal deficiency is a polished CCDT long stem. In younger patients, impaction grafting is recommended, provided deficient bone is protected. Cementless modular stems are reserved for femurs with severe proximal cortical deficiency

Restoration of bone stock is the single greatest challenge facing the revision hip surgeon today. This has been dealt with by means of impaction grafting with morsellised allograft from donor femoral heads. Alternatives to allograft have been sought. This study investigates the use of a porous biphasic ceramic in impaction grafting of the femur. Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave 2 and group four 10% allograft and 90% BoneSave as the graft material. Function was assessed by measuring peak vertical reaction forces. Changes in bone mineral density were measured by DEXA scanning. Loosening and subsidence were assessed radiographically and by examination of explanted specimens. All outcome measures showed no statistically significant difference between the four groups after eighteen months of full function. Conclusion: When used as allograft expanders, Bone-Save and similar porous biphasic ceramics perform as well as pure allograft in impaction grafting of the femur

Irradiating allograft bone may compromise the mechanical stability of the prosthesis-bone construct, potentially having adverse effects on the outcome of femoral impaction grafting at revision hip replacement. This in vitro study aimed to determine the effect of irradiation of allograft bone used in femoral impaction grafting on initial prosthesis stability. Morsellised ovine femoral head bone was irradiated at 0 kGy (control), 15 kGy and 60 kGy. For each group, six ovine femurs were implanted with a cemented polished double taper stem following femoral impaction bone grafting. Dynamic hip joint loading was applied to the femoral head using a servo-hydraulic materials testing machine. The primary outcome was stem micromotion. Tri-axial micromotion of the stem relative to the bone at two sites was measured using linear variable differential transformers and non-contact laser motion transducers. Statistical analysis was performed using SPSS. Compared to the control and 15 kGy groups, specimens in the 60 kGy group demonstrated statistically significant greater micromotion in the axial, antero-posterior and medio-lateral axes. A multi-factorial post-hoc power analysis based on the overall effect of group size indicated a power of 0.7. There was no difference in micromotion between the control and 15 kGy groups. The average micromotion in the axial axes was 63μm in the control and 59μm in the 15 kGy group. The results of this study suggest that a maximum irradiation dose of 15 kGy may not affect initial prosthesis stability following femoral impaction grafting in this model and provide the basis for us to now proceed to in-vivo studies examining the effect of irradiated bone on implant stability over time

Acetabular impaction grafting (AIG) for the reconstruction of acetabular defects in total hip arthroplasty has the potential to recreate anatomy whilst also allowing the restoration of bone stock. The incorporation of impacted, morcellised bone graft has been demonstrated in histological studies and is a well established technique in revision hip surgery where there is loss of bone stock. We have studied our results of fullAIG when used in primary total hip arthroplasty, with particular emphasis on the results of AIG in cavitary and segmental defects. Between 1995 and 2003, 129 cemented primary THAs were performed using full acetabular impaction grafting to reconstruct acetabular deficiencies. These were classified as cavitary in 74 and segmental in 55 hips. Eighty-one patients were reviewed at mean 9.1 (6.2–14.3) years post-operatively. There were seven acetabular component revisions due to aseptic loosening, and a further 11 cases that had migrated »5 mm or tilted »5° on radiological review — ten of which reported no symptoms. Kaplan–Meier analysis of revisions for aseptic loosening demonstrates 100% survival at nine years for cavitary defects compared to 82.6% for segmental defects. Our results suggest that the medium-term survival of this technique is excellent when used for purely cavitary defects but less predictable when used with large rim meshes in segmental defects