Impaction Bone Grafting With Cemented Stems

Impaction Bone Grafting With Cemented Stems

Ashton H. Goldman

Rafael J. Sierra

Key Concepts

  • The most common indication for impaction grafting is the stove-pipe Paprosky type IV femur in a younger patient.

  • Other indications include an ectatic femur over a distal diaphyseal blockade prohibiting press-fit fixation (a long diaphyseal cement plug, a long stemmed revision total knee arthroplasty component, old fracture deformity, etc.)

  • Femoral impaction grafting follows 5 steps: diaphyseal stabilization, diaphyseal grafting, metaphyseal fixation, metaphyseal grafting, and cementation of implant.

  • Intraoperative and postoperative femur fractures are not uncommon with this technique. Longer cemented implants may mitigate the risk of postoperative fracture when diaphyseal defects can be bypassed.

  • An extended trochanteric osteotomy for implant removal is not a contraindication to femoral impaction grafting.

Sterile Instruments and Implants

  • Plates or struts for diaphyseal stabilization

  • Wires or cables per surgeon preference

  • Wire mesh if desired for metaphyseal stabilization

  • Cement restrictor with wire suited for cannulated impactors

  • Bone chips of varying sizes (3-8 mm is preferred)

  • Femoral impaction system: distal impactors, phantom implants, square-end impactor, half-moon impactor

  • Cement

  • Polished tapered stem designed for cementation with the taper-slip philosophy

Surgical Approaches

  • The posterior approach most commonly is used because of ease of access to femoral canal and extensile nature.

  • The anterolateral approach can be used as well.

  • Extended trochanteric osteotomy or Wagner-type osteotomy can be performed as well if needed for implant removal. Very secure subsequent fixation of the osteotomy is needed before impaction grafting.

Preoperative Planning

  • Templating is important to plan for an implant that (1) recreates appropriate length and offset and (2) bypasses area of bony deficiency.

  • Determine whether extended trochanteric osteotomy is likely to be needed for prior stem removal.

  • Assess deficiencies to determine whether a plate, strut, or mesh will be required for reconstruction.

Bone, Implant, and Soft Tissue Techniques

Dec 14, 2019 | Posted by in ORTHOPEDIC | Comments Off on Impaction Bone Grafting With Cemented Stems

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