Introduction: Impaction allografting is a technique that is used at revision where the bone stock in the femur is poor. Femoral heads are ground to create morsellised bone, which is impacted down the femur prior to the cementing a new stem into the canal. The results of this technique are variable and there is a high incidence of stem migration. This variation in results may be due to the degree of bone loss or the techniques used to impact the graft. The aim of this study was to quantify the forces currently used in revision hip surgery with impaction allografting.

Methods: To enable these measurements the Exeter slap hammer (Stryker Howmedica) was altered to include a load washer. The load washer had a special cable welded to it so that sterilisation could still be conducted in an autoclave. During surgery the end of the load washer cable is passed to the operator, who is able to connect it to a laptop computer. A specially written Labview program is then used to store the data and determine the impaction forces. The load washer is mounted within the hammer at the point of impact between the sliding mass and the hammer, consequently it is reading the force transmitted to the hammer, not that transmitted to the graft chips. Calibration was performed in an in vitro experiment with a second load washer, which found that the force in the hammer is three times that in the impactor. The force is so much less because it is taken up in the hammer’s inertia.

Conclusions: The impaction forces have been measured during eight operations performed by three different surgeons. The study shows variability between surgeons, and variability between patients operated on by the same surgeon. These readings show that the forces travelling through the impactor range between three to eleven time body weight.

Introduction: Wear particle induced osteolysis is one of the main reasons for revision total hip replacements (THRs). Loss in bone stock as a result of aseptic loosening is responsible for inferior results in revision THRs. Results from impaction grafting to fill osteolytic defects are frequently inconsistent. Our hypothesis is that the combination of autologous mesenchymal stem cells (MSCs) and allograft will enhance bone regeneration. This study asks whether: MSCs with allograft scaffolds survive at a normal impaction force during revision THRs.

Method: MSCs were isolated from a sheep iliac crest aspirate, expanded in culture and seeded onto irradiated sheep allografts (n=9). Viability of MSCs was assayed with alamar blue with absorbance measured on day 4 (before impaction). The constructs were then impacted using forces 3, 6, and 9 kN extrapolated in surgery then assayed daily for 6 days. The control was 0 kN. Samples were resin embedded after 10 days for histology and pieces of graft were taken for scanning electron microscopy (SEM).

Results: The 0KN control shows an MSC growth curve with a lag period and log phase. Compared with the control, the 3 and 6 kN showed initial reduction in cell proliferation measured by alamar blue (^p=0.015, ^p=0.002) but recovered by day 8, while 9kN showed a significant reduction (^p=0.011) over the time (Figure 1).

For cell proliferation over time, 3 and 6 kN showed no differences, but 9 kN showed a significant difference between day 4 and day 8 (^p=0.031). SEM and histological analysis showed a network of cuboidal cells on the allograft surface.

Conclusions: The results showed that MSCs recovered from impaction of 3 and 6 kN after an initial reduction in metabolism and exceeded original cell seeding densities with no significant difference in proliferation. Viability of MSCs were not effected by impaction forces up to 6 kN. This study shows that stem cells mixed with allograft are a potential method for repairing bone defects in revision total hip replacements.

Introduction: ApaPore is a synthetic bone graft extender, made from Hydroxyapatite. It is designed to be used as a 50:50 combination by volume with morcelised bone graft. A typical use for such a product may be in impaction allografting during revision hip surgery. The aim of this study was to compare the mechanical stability of stems inserted using impaction allografting where the graft was composed of a 50:50 mixture of ApaPore and allograft with only allograft.

Methods: Twelve large left sawbones were used in this study, the femoral head was cut off each one and the equivalent cancellous bone was cored out to resemble a femur at revision. Impaction allograft was performed on six of the sawbones, with rinsed human morsellised graft. This procedure was repeated on the remaining six sawbones, with graft produced as a 50:50 mixture by volume of rinsed allograft and blood soaked Apapore. The mechanical test was performed in the red rocket, a six station hydraulic loading machine. The sawbones were mounted in the anatomical position of 7 degrees valgus and 9 degrees posteriorly and the test was run in batches of three. Sinusoidal loading at 2Hz was applied under the following loads: 600N, 1kN, 1.4kN, 1.8kN and 2.2kN, each loading step lasting for 5000 cycles. Migration of the stem during loading was measured using LVDT. Vertical displacement of the prosthesis head was measured using digital height callipers at the beginning and end of each loading step. X-Rays were taken before and after mechanical testing.

Results: There is a significant difference between the groups in the overall displacement of the prosthesis head, measured with the digital height calipers, (Mann-Whitney U Test p=0.01). Total average head movement allograft group: 3.5mm and ApaPore group: 1.8mm. The total average subsidence measured with the LVDT’s was 0.295 mm in the allograft group and 0.119mm in the ApaPore/Allograft group. A sideways displacement of the prosthesis head was observed on the x-rays, which is a direct relationship of head rotation, measurements showed a significantly less rotation in the ApaPore/Allograft group (Mann-Whitney U Test p=0.002).

Conclusions: Rotation of the stem in all planes during loading resulted in a greater observed displacement of the prosthesis head than that measured by the LVDT’s. These results show that ApaPore, when used as a bone graft extender is able to reduce initial rotation and subsidence of the stem. Further research needs to be undertaken to investigate the long-term feasibility of using ApaPore.

Introduction: Impaction allografting allows an initial stable function of revision hip replacements and a method of reconstituting the bone stock. A previous in-vivo ovine study has found that the density of impacted morsellised allograft reduces after six weeks but recovers by twelve weeks. This reduction in density during remodelling may also correspond with a reduced mechanical strength. A probable cause of the low density is osteoclastic bone resorption prior to vascular in growth and the formation of new bone by osteoblasts. BoneSave is a 4–6mm porous granules of hydroxyapatite and tricalcium phosphate, and is designed as be used as a 50:50 mix with morsellised allograft. Bonesave takes a long time to be resorbed and replaced with bone compared with allograft. We hypothesised that the inclusion of BoneSave could slow resorption down and hence maintain the mechanical strength of the graft during remodelling. This study investigated the mechanical strength of BoneSave mixed with allograft at six and twelve weeks after insertion into a defect, with pure allograft as a control.

Methods: Twelve yews were used in this study, half were terminated at six weeks the remainder at twelve. The test site was a 15mm diameter hole, approximately 10mm deep, in the medial femoral condyle. Both femurs were operated on consecutively, with allograft on one side and a BoneSave/allograft mix on the other. After euthanasia the distal femurs were removed and CT scans performed to evaluate density. Sixteen millimetre discs were cut from each femur, exposing the test site 4 mm from its proximal end. These graft site was then subjected to non-destructive compression tests in Zwick loading machine. Bone remodelling in the graft was determined using histology.

Results: Wilcoxon paired test were used to compare densities of the allograft group with the BoneSave group at 6 and 12 weeks, at both time points there was a significant difference between the groups (p< 0.05). There was no statistical difference in the density of the allograft groups between 6 and 12 weeks, or the Bonesave groups between 6 and 12 weeks using the Mann-Whitney U test (p> 0.05). There was no significant difference between the stiffness of the two groups at both time points using the Mann Whitney U test (p> 0.05).

Discussion and Conclusion: This result was unexpected in the allograft group because in a previous study looking at different sized allograft chips there was a significant difference between the density at 6 and 12 weeks. The most likely cause for this is that lower forces were used to impact the graft in this experiment compared with the graft size study. This would have resulted in lower density at time zero, so perhaps this lower density didn’t invoke such a large resorption response. Bone-Save is able to maintain mechanical strength during remodelling when used as a bone graft extender.

Impacted morsellised allografts have been used successfully to address the problem of poor bone stock in revision surgery. However, there are concerns about the transmission of pathogens, the high cost and the shortage of supply of donor bone. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), have been developed to minimise the use of donor bone. In a human cadaver model we have evaluated the surgical and mechanical feasibility of a TCP/HA bone-graft extender during impaction grafting revision surgery.

A TCP/HA allograft mix increased the risk of producing a fissure in the femur during the impaction procedure, but provided a higher initial mechanical stability when compared with bone graft alone. The implications of the use of this type of graft extender in impaction grafting revision surgery are discussed.