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Impaction grafting useful in hip revision with severe bone loss
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ORLANDO, U.S.A. – An ongoing British study has found that proximal femoral impaction grafting with the Oxford Trimodular Stem (Corin Group PLC) is reliable in difficult revision hip surgery.
Longer follow-up is necessary, but mean midterm results at 4.7 years are encouraging, showing that the device effectively restores deficient proximal femoral bone using a small amount of allograft bone, said Peter McLardy-Smith, MA, FRCS, of the Nuffield Orthopaedic Centre in Oxford, England.
Mean Oxford Hip Scores significantly improved from 45.3 to 24.1 and worst-case survivorship was 94% in hip revision cases with seriously deficient bone. Researchers found no aseptic loosening revisions or adverse radiographic features.
“Proximal impaction grafting with cement allows for antibiotic delivery, which can be useful. It allows for cementless bypass at the distal defects, which allows spontaneous healing of distal defects, and it makes for ease of re-revision because cement is only in the metaphysis,” McLardy-Smith said at the 22nd Annual Current Concepts in Joint Replacement Winter 2005 Meeting.
Revision with severe bone loss
From 1999 to 2002, surgeons at Nuffield Orthopaedic Centre revised 72 consecutive hips in 69 patients using the Oxford Trimodular Stem. Patients had a mean age of 65 years, and mean time to revision was 8.5 years.
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Causes for revision included 57 aseptic loosenings, eight infections and seven periprosthetic fractures. Four cases required perioperative femoral osteotomy, and surgeons treated the infections with two-stage revisions.
All patients had severe proximal bone loss, usually from the tip of the greater trochanter to below the lesser trochanter, McLardy-Smith said. Surgeons used trial stems and reamers to test length, orientation and stability and used a mean 1.8 femoral heads per patient.
“We used mesh cerclage wire in place over the defects, and into that we impacted hand-morselized fresh, frozen allograft,” McLardy-Smith said. Surgeons cemented a polished, tapered wedge into the construct that had bone within the mesh covering the defects, and used a seal in the shape of the wedge to impact the cement.
Researchers reviewed the patients preoperatively and at the mean follow-up of 4.7 years using a standardized clinical examination, radiographs and the Oxford Hip Score Questionnaire.
“We had complications … as you would expect for this kind of surgery,” McLardy-Smith said. “Radiologically there’s been no gross subsidence, no construct failure and no further osteolysis.”
The Oxford Trimodular Stem offers a metaphyseal wedge that slides and rotates on the proximal portion of the stem. The stem aligns the wedge and supports the weakened diaphyseal bone, allowing for proximal bone loading.
For more information:
- McLardy-Smith, P. Proximal femoral impaction grafting: When half a loaf will do. #54. Presented at 22nd Annual Current Concepts in Joint Replacement Winter 2005 Meeting. Dec. 14-17, 2005. Orlando, U.S.A.