SE M I N A R S I N A R T H R O P L A S T Y 28 (2017) 267–271

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Femoral impaction grafting

Ashton H. Goldman, MD and Rafael J. Sierra, MD*
Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905

article info abstra ct

Keywords: Femoral impaction grafting is a utilitarian technique for femoral defects. With modern
Femoral impaction grafting implants, its role may be limited to Paprosky 3B and 4 type femoral deficiencies, especially
Total hip arthroplasty in the younger patient. With appropriate technique, mid- and long-term results have
Paprosky 3B/4 proven this technique to be globally reliable. Periprosthetic fracture is not uncommon with
Femoral reconstruction this technique; however, strategies to mitigate the risk have been developed. A thorough
Cement understanding of the history, technique, results and complications of this technique is
essential for the revision hip surgeon in order to obtain successful results in the most
complex femoral reconstruction cases.
& 2018 Elsevier Inc. All rights reserved.

1. Introduction Progressive impaction occurs over trial implants in order to

The goals of femoral reconstruction in revision total hip
arthroplasty (THA) are not only to create a durable long-term
reconstruction with a stable implant, but if possible, preserve
and/or restore bone stock. Different techniques have been used
to restore bone stock at the time of revision THA. Allograft
prosthetic composites have been shown at midterm to provide
adequate fixation and stability. More recently, the use of modern
tapered modular stems has been associated with proximal bony
reconstitution as long as the soft tissues around the proximal
implant remain vascular. Finally, the technique of impaction
grafting has been shown to be viable option providing a durable
reconstruction and preservation of proximal bone stock with
reported both mid-term and long-term excellent results [1–9].
Over time, improvements have been made in the technique
which limit complications and improve outcomes. Understand-
ing the indications, technique, and complications will allow a
surgeon to effectively employ this procedure for some of their
most challenging revision cases.
recreate a host bone bed in which a stable prosthesis can be
cemented into place. Today, the most common indication is
for the Paprosky 3B femurs in young patients where proximal
restoration of bone is desired or if distal fixation is not ideal or
4 type femurs where there is a lack of proximal bone stock and
there is compromise of the isthmus. Other special cases may
also prove this technique to be inviting. Patients with fibrous
dysplasia of their proximal femurs where distal fixation is
compromised may be candidates as well. The newly packed
cancellous bone can create a new endosteal bed for cementing
(Fig. 1). Furthermore, an ectatic proximal femur over a well
fixed distal cement plug is another scenario consider impac-
tion grafting. This allows the surgeon to perform the recon-
struction without removing the distal cement to get in a longer
diaphyseal engaging stem. Other case examples follow similar
principles that challenge whether jeopardizing the host bone
to remove distal diaphyseal blockades to uncemented fixation
is necessary, if a portion of the diaphysis and metaphysis is
appropriate for impaction grafting.

1.1. Indications
2. Technique
The technique of impaction grafting involves the tight packing
of multiple sizes of cancellous bone chips into a closed Templating is important in order to select the correct size
femoral canal or a canal that can be reconstructed and closed. that bypasses the bony deficiency for the planned femoral

⁎
Corresponding author.
E-mail address: sierra.rafael@mayo.edu (R.J. Sierra)

https://doi.org/10.1053/j.sart.2018.02.010
1045-4527/& 2018 Elsevier Inc. All rights reserved.
268 SE M I N A R S I N AR T H R O P L A S T Y 28 (2017) 267–271

Figure 1 – A 27 year female with fibrous dysplasia of the proximal femur. (A) Shows preoperative radiographs and previous
hardware. (B) Shows the bone preparation following impaction grafting with an newly created cancellous endosteal
template for the cemented femoral stem. (C) Shows the cemented femoral stem in place. (D) Post operative radiographs
following impaction grafting.
 SE M I N A R S I N AR
Figure 2 – (A) Demonstrates the identification of a cortical
defect that must be stabilized with either a plate, strut or
mesh. If the cortex is intact, simply reinforcing with cerclage
wires or cables is appropriate. (B) Demonstrates the
placement of the distal cement plug with the creation of an
impacted distal bone plug resting on top of the cement
restrictor by using a cannulated impactor.
stem. Following removal of the current stem, removal of
fibrous debris is completed in order to maximize the host
bone contact for graft incorporation. Recreating and stabiliz-
ing the diaphysis is then undertaken with struts, plates, or
reinforcement mesh and wires (Fig. 2). The revision technique
is reliant on having a physical constraint for the graft and
must be done without devascularization of the host bone or
soft tissues. After placing a distal intramedullary plug, bone
chips of varying sizes (3–8 mm) are placed in the canal over a
guide wire. Typically the smaller the chips are placed more
distally. After a small amount of bone is placed in the canal, a
cannulated distal impactor is placed over the wire to impact
the graft in order to create a 2 cm packed cancellous base
below the planned implant (Fig. 3A). Once the diaphysis is
impacted and filled with cancellous graft, the graft is
impacted against the diaphysis with the use of progressively
larger cannulated phantom implants (Fig. 3B). One must take
care during this step as it is critical to impact as much bone
as possible. With the phantom implant acting as a template,
reconstruction of the proximal metaphysis can be under-
taken if necessary with wires and mesh to contain any
uncontained defects (Fig. 3C). Allograft chips are then added
T H R O P L A S T Y 28 (2017) 267–271 269
to the metaphysis around the phantom implant and
impacted with the use of square and half-moon tamps
(Fig. 3D). Once a stable well-impacted tube has been recre-
ated, the bone is dried and pressurized cement fills the canal
followed by a polished, tapered cemented stem. Slow pro-
gressive insertion of stem into the canal as the cement is
polymerizing allows outward directed hoop stresses to fur-
ther impact the graft against the host bone. It is also
important to keep pressurization of the cement during
insertion. A thumb on around the calcar to prevent cement
extrusion is useful. An expedient insertion with cement that
is still in the liquid phase will allow excess cement to expand
out of the top of the metaphysis rather than expand against
the placed graft. Slow insertion of the stem in the correct
version while the cement in the doughy or working phase is
critical for optimal compaction of the graft of the host bone
by the cement.
With modern uncemented implants, it is not uncommon for
stem removal to require the use of an extended trochanteric
osteotomy (ETO). While the ETO facilitates improved acetab-
ular exposure as well as access to the femoral canal, its use
has caused reservation when considering a patient for impac-
tion grafting as some have suggested cement extrusion can
cause non-union of the osteotomy [10,11]. Larger studies have
not shown this to be the case. Charity et al. [12] demonstrated
100% union rate of the ETO by 6 months in 18 cases with an
average of 10 year follow-up. Furthermore, no revisions were
performed for aseptic loosening. Garcia-Rey et al. showed
similar results with 100% healing in 14 cases where an ETO
was employed with use of impaction grafting. With appropri-
ate recreation of the endosteal tube and appropriate impaction
prior to cementation this concern can be abated.
3. Outcomes
Outcomes of femoral impaction have been encouraging
world-wide, but its use in the United States continues to be
limited, likely given the unfamiliarity to the technique. The
major advantage of this procedure, while not only creating a
reliable and durable construct to restore function, is recre-
ation of the endosteum. Follow up radiographic and histo-
logic studies have shown that there is reincorporation of the
allograft to living bone and this increases with the longevity
of the implant [13]. In this study, as early as one month
postoperatively, woven bone was seen to perculate into the
impacted graft. Over the next year, increases in osteoid and
mineralization occurred from the periphery inwards via a
fibrous intermediary. By 48 months, the midportion and
distal aspects of the graft had complete bone reconstitution
confirmed with radiographs while the metaphyseal area
demonstrated a mix of new bone and fibrous material [13].
This steady incorporation has led to reliable results low rates
of aseptic loosening at mid- and long-term follow up (Table 1)
[3–7,9]. The authors recommend the use of fresh frozen
allograft rather than irradiated bone as there has been some
concern with incorporation and remodeling [14]. Table 1
demonstrates uniformly good results with the technique
across several countries. The latest data from the Exeter
group in the United Kingdom reviewed 705 cases over nearly
270 SE M I N A R S I N AR T H R O P L A S T Y 28 (2017) 267–271

Figure 3 – shows the steps of femoral impaction grafting. (A) The distal cement plug with guide wire. Fresh frozen allograft is
impacted with a cannulated tamp. (B) Further impaction of the diaphyseal allograft with cannulated phantom prosthesis. (C)
The phantom prosthesis based off the preoperative template used as a guide for reconstruction of the proximal metaphysis.
(D) Final impaction of the metaphyseal place allograft with a squared tamp. A stem is then cemented into the newly created
intramedullary canal (not shown).

a 30-year period. With an average follow up of nearly 15
years, femoral aseptic loosening was only 1.2%. With the
evolution of technique, they were able to see improvement
over time. These promising results are not site specific as can
be seen from the study by Stroet et al. They found a 99%
survival for aseptic loosening rate and a femoral survival rate
including all cause failure at 95% at an average of 10.6 years
[9]. These more recent, larger studies are consistent with
other studies listed in the table; however, femoral revisions
were slightly higher than the aseptic loosening rate due to
infection, periprosthetic fracture, malpositioning, and stem
breakage [8]. Therefore avoiding these complications is
essential for long-term survival.
4. Complications
Periprosthetic fractures, both early and late, are common with
this technique with reports in the literature between 4% and
10% [1,2,15]. A predisposition for fracture occurs when a stiff
implant construct is placed right above a weak ectatic femur
creating a considerable stress riser. Creation of a stable load
sharing construct in the face of jeopardized bone is critical to
prevent this complication. Sierra et al. showed that bypassing
the areas of cortical deficiencies or femoral fractures with a
long cemented stem was an effective method to mitigate this
risk and other studies confirmed these findings [2,16]. Other
fractures discovered at the time of surgery, whether it be
calcar cracks or cortical perforations, need to be treated with
appropriate principles. Given the likely poor bone quality
proximally and relatively high prevalence of calcar fractures
with impaction grafting, prophylactic wiring of the calcar has
been recommended to further decrease this risk [2].
This method of recreating the endosteal femur is highly
demanding technically and requires attention to detail to
ensure lasting results as achieved in the aforementioned
studies. Some degree of subsidence (5 mm) can be expected
in the first 2 years due to the taper slip geometry of the
implant but further subsidence can be related to quality of
the bone graft used and technique. Wraighte and Howard

Table 1 – Favorable Mid- to Long-term Survival Rates of Impaction Grafting Across a Several Countries. Note that all Cause
Survival is Lower Compared to Aseptic Loosening, Which is Related to Periprosthetic Fractures, Infection, etc

Author Country n Follow up (yrs) Loosening Surv (%) All Cause Surv (%)

Ornstein Swedish 1305 8.1 (5–18) 99 94

Lamberton UK 540 6.7 (2–15) 98 84
Garcia-Cimbrelo Spain 81 10.4 (5–17) 99 80
Garvin United States 78 12.8 (12–18.8) 98 93
Wraighte UK 75 10.4 (6.3–14.1) 98 99
te Stroet Netherlands 208 10.6 (4.7–20.9) 99 95
Wilson UK 705 14.7 (9.8–28.3) 98.8 88
 SE M I N A R S I N AR
also demonstrated that preoperative bone loss was a predic-
tor of postoperative subsidence and should be considered
with templating [7]. Taking time to recreate the canal with
fresh frozen cancellous bone chips rather than irradiated
bone or another substitute may improve results [14]. Proper
cement technique with appropriate pressurization is critical
to create a mantle that will not fracture and lead to pro-
gressive subsidence.
Stem choice is another variable that may jeopardize results.
As previously mentioned, using a stem with a tapered-slip
geometry rather than a composite beam is important in order
not to place all the stress at the distal aspect of the construct
where it is prone to fracture. A taper-slip helps by providing
compressive forces across the entire cement mantle thereby
further impacting the bone as it gently subsides a few
millimeters in the first few years. Later subsidence of a few
millimeters may also be related to creep within the cement
mantle. Attempts to combat early subsidence a polished
tapered stem in the cement mantle have been unsuccessful.
Uncemented stems have been shown to have a 50% failure
rate [17] likely related to the inability to create a continuous
equal pressure circumferentially along the entire endosteal
tube. Similarly beaded cemented implants thought to prevent
subsidence through increase strength at the implant-cement
interface have shown to have a high rate of complications
[18]. The current authors recommend the use of stem that is
well-established for impaction grafting: a polished tapered
stainless steel stem.
5. Conclusion
Femoral impaction grafting is a reliable technique with appro-
priate stem choice and attention to detail regarding meticulous
impaction and cement technique. Recognition of calcar cracks
and cortical deficiencies must be identified and stabilized in
ensure a stable tube to allow allograft incorporation. Subsi-
dence is not uncommon with this technique and must be
considered with regards to preoperative planning. With the
identification of complications, most notably periprosthetic
fractures, an evolution of the technique has lessened the
burden of this complication. The success of modular conical
stems may limit this technique to Paprosky type 4 femurs and
other special cases; however, it is appropriate for a revision
surgeon to consider this as a weapon in their armamentarium
when treating a difficult femoral revision.
6. Disclosures
Ashton H. Goldman has nothing to disclose.
Rafael J. Sierra Royalties from Zimmer Biomet, Link
Orthopedics, Board of Directors: MAOA, Muller Foundation,
Publishing royalties from Springer.
7. Acknowledgment
The authors would like to thank Frank Corl for his work on
the illustrations for this paper.
T H R O P L A S T Y 28 (2017) 267–271 271
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