Femoral revision grafting shows good long-term results

Using bone impaction grafting with fresh frozen bone grafts and a cemented polished stem nearly doubled Harris score.

No femoral reconstruction revisions were required and there was a nearly double average Harris hip score in a study of patients who underwent impaction bone grafting with fresh frozen morsellized bone chips and a polished cemented stem.

“I think there’s very good survival with this technique,” said Berend Willem Schreurs, MD, PhD, who presented the study at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting. Schreurs is with the department of orthopedic surgery, Radboud University Nijmegen Medical Centre, the Netherlands. “We had no revision of any femoral reconstruction,” he said.

Schreurs and colleagues conducted a prospective study of 33 femoral reconstructions done between 1991 and 1996 in 24 women and nine men, average age 63 years. The purpose of the study, performed eight to 13 years after the procedures, was to determine long-term outcomes of the technique.

Posterolateral approach

The surgeons performed all procedures with a posterolateral approach. The investigators used the X-Change impaction system with a cemented polished Exeter stem (Stryker Orthopaedics).

Hip defects included three hips with grade 1 defects, 14 with grade 2, 12 with grade 3 and four with grade 4, according to the Endoklinik classification system. “If they had a cortical defect, we repaired it by metal mesh,” Schreurs said.

Initially patients were kept in bed for six weeks and then used crutches for three months after the reconstructions, he said. With growing experience patients were mobilized earlier.

No reconstructions required revision after an average follow-up of 10.4 years, Schreurs said.

The average Harris hip score for patients improved from 49 to 85, he said. Harris hip score is a joint evaluation system frequently used to measure outcomes after total hip replacement surgery.

“Of course we had complications,” he said, including three patients who had femoral fractures at the level of the prosthesis. “We were able treat all fractures by plating and all healed.”

Learning curve a factor

There were also some cases of subsidence. Most occurred in the first year, with an average shift of 3 mm. Of the cases where the stems subsided more than 5 mm, three were in patients who had been treated within the first two years of the study. “I think this had something to do with the learning curve — after we started with this technique, they were operated on earlier,” Schreurs said.

One patient had high stem migration in the first half year. “Nowadays we would consider re-operation on this patient,” he said. Researchers instead ordered six weeks in bed to stabilize the hip. She recovered and her reconstruction held well for five years, until the time of her death, Schreurs said.

Radiologically, there were no failures. With the endpoint being femoral revision for any reason, aseptic loosening or radiological loosening, the survival rate was 100% in all situations. All patients remained in the study except for eight patients who died.

For more information:
Schreurs BW, Arts CJ, Gardeniers JWM, et al. Result at 8 to 13 years of femoral revision using impaction bone grafting and a cemented polished stem. #280. Presented at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting, Feb. 23-27, 2005. Washington.