Femoral impaction bone allografting with an Exeter cemented collarless, polished, tapered stem in revision hip replacement

Abstract

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998. The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification. The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively. Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97).

What is the Long-term Survival of Impaction Allografting of the Femur?

“…Schreurs et al reported 33 patients with 33 hips followed for an average of 10.4 years with a 100% survival for aseptic loosening and 85% for any reason [20]. Wraighte and Howard reported 75 patients with 75 hips also followed for over 10 years with 92% survival at 10.5 years [27]. Sierra et al reported 40 patients all treated with longer stems with a 90% survival at 10 years [23] (Table 2).…”

“…The treatment has been described using extensively coated femoral stems [3,13,26], modular stems with distal tapers [10,12,14,15,17,19,22], and impaction bone grafting with cemented polished stems [4,7,16,21,23,25,27]. Femoral impaction grafting, first reported by Gie et al in 1993 [5], has the advantage of adding bone to the deficient femur, but it is a time-consuming procedure with reported risks of fracture ranging from 5% to 12% [1,5,7,9].…”

“…Additionally, one patient had a trochanteric nonunion and one patient sustained a dislocation. Several authors have reported high survival (77%-100%) at 5 to 19 years for femoral bone impaction grafting [4,7,16,21,23,25,27]. Halliday et al [7], reporting findings of the developers of the technique, found a survivorship of 90.5% at 11 years for femoral reoperation and 99.1% at 11 years for femoral revision for aseptic loosening as the end point.…”

Classifications In Brief: The Paprosky Classification of Femoral Bone Loss

“…Although modularity has potential benefits, fracture at the modular junction and corrosion reactions present challenging complications [6]. Other potential revision options that have shown favorable outcomes in younger and elderly populations with Type III defects include impaction grafting and impaction grafting with cementation [34,35,38]. Good outcomes (improved pain and function) with acceptable complication rates also can be achieved in Type III defects with proximal femoral replacement [16,27,31].…”

“…Paprosky Type IV defects are those with severe metaphyseal and diaphyseal bone loss, typically with severe ectasia (pronounced expansion of endosteal bone with profound cortical thinning) of the femoral canal making uncemented fixation unreliable. Reconstruction options usually are limited to proximal femoral replacements, impaction grafting with a cemented stem, and allograft prostheses composites [16,27,31,34,35,38].…”