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Cemented Revision Total Hip Arthroplasty With Femoral Impaction Bone Grafting

March 01, 2020

Contributors: Markus Baker, FRCS, MBBS; Stuart Adam Callary, PhD; Donald Howie, MD, PhD; Jakub Maurycy Jagiello, FRCS (Ortho); Peter Smitham, FRACS, FRCS (Ortho), PhD; Lucian B Solomon, FAOrthA, MD, PhD; ROUMEN Botev STAMENKOV, MD, MS; Mukai Chimutengwende-Gordon, FRCS (Ortho), MBChB, PhD

2020 AWARD WINNER Femoral impaction bone grafting allows for restoration of bone stock during revision total hip arthroplasty and may decrease the length of the stem required. Long-stemmed uncemented implants that are commonly used during revision total hip arthroplasty may be difficult to re-revise and are associated with thigh pain. This video describes the surgical technique for femoral impaction bone grafting used at the Royal Adelaide Hospital. The video discusses the case presentation of a 39-year-old patient who underwent femoral impaction bone grafting during the second stage of revision total hip arthroplasty for the management of infection. A cemented, collarless, polished double-taper stem was used for femoral impaction bone grafting. A posterior surgical approach was used. After femoral canal preparation, trial reduction was performed to determine leg lengths. After the correct stem insertion depth was determined, the bone reference point was marked. The bone reference point is the level where the shoulder of the implant meets the greater trochanter and is used throughout the procedure to guide the depth of impaction. A bone plug was inserted with the use of a guidewire to the required depth. Bone graft was then inserted into the femoral canal and impacted with the use of a tamp to construct the bone graft mantle. If proximal femoral defects are present, mesh is applied and secured with the use of cerclage wires to contain the proximal graft. Our technique improves previous methods by using modular tamps and nonirradiated, size-profiled bone graft. Modular tamps allow the surgeon to concentrate on distal femoral impaction, leg lengths, and version before proximal femoral reconstruction. After the femoral canal is solidly and evenly filled with bone graft, a stem with a wingless distal centralizer is cemented into the femur. Early stem subsidence (within the first 2 years postoperatively) is a predictor of later cemented stem failure. Improvements in our impaction grafting surgical technique are associated with decreased subsidence of the stem and the cement within the femoral bone. In a series of 21 patients who underwent revision total hip arthroplasty via the technique demonstrated in this video, median subsidence of the stem and the cement relative to bone, was 0.7 mm and 0.1 mm, respectively. This was considerably less than that associated with our original technique (2.1 mm and 1.3 mm, respectively, at a follow-up of 12 months postoperatively). In addition, we have shown that this technique is successful for staged revision total hip arthroplasty for the management of infection. In a prospective cohort of 29 patients who underwent femoral impaction bone grafting at final reconstruction of the femur after staged revision total hip arthroplasty for the management of infection, a subsidence pattern similar to that of primary total hip arthroplasty was observed, despite severe femoral defects and osteotomies. At a minimum follow-up of 2 years, median stem and cement subsidence relative to bone was 1.8 mm and 0.1 mm, respectively. Infection was successfully eradicated in 93% of the patients. Femoral impaction bone grafting may be used to restore bone stock during revision total hip arthroplasty and allows for the use of a shorter stem, especially in patients with substantial femoral defects. This is particularly beneficial in young and middle-aged patients who are likely to require additional revision procedures in the future.

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