JBJS | Impaction Allografting with Cement for Revision of the Femoral Component. A Minimum Four-Year Follow-up Study with Use of a Precoated Femoral Stem*

The Journal of Bone & Joint Surgery, Volume 81, Issue 8

Articles | August 01, 1999

Impaction Allografting with Cement for Revision of the Femoral Component. A Minimum Four-Year Follow-up Study with Use of a Precoated Femoral Stem*

SETH S. LEOPOLD, M.D.†; RICHARD A. BERGER, M.D.†; AARON G. ROSENBERG, M.D.†; JOSHUA J. JACOBS, M.D.†; LAURA R. QUIGLEY, M.S., R.N.†; JORGE O. GALANTE, M.D.†, CHICAGO, ILLINOIS

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Investigation performed at the Department of Orthopaedic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago

The Journal of Bone & Joint Surgery. 1999; 81:1080-92

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Abstract

Background: Cancellous impaction allografting with cement for revision of the femoral component has conventionally been performed with a polished, tapered implant, which was designed to allow subsidence of the component. However, subsidence has been associated with pain in the thigh, dislocation of the hip, and revision of the component. This prospective study tested the hypothesis that good clinical results can be achieved—without subsidence of the component—with use of impaction allografting and a precoated, collared, straight stem for difficult femoral revisions.Methods: Twenty-nine patients had revision of the femoral component with use of impaction allografting with cement and a Harris Precoat stem. Impaction allografting was performed when loss of metaphyseal and diaphyseal bone precluded revision with more straightforward techniques or when reconstitution of bone was considered a specific goal of the reconstruction (as was sometimes the case with revision of the component in younger patients). The patients were followed prospectively and were evaluated with use of the Harris hip score and serial radiographs. The patients were followed for a minimum of four years (mean, sixty-three months), except for four who died.Results: Four patients died before the minimum four-year follow-up period had elapsed; all four had the prosthesis in place at the time of death. The Harris hip scores improved from a preoperative mean of 54 points (poor) (range, 21 to 91 points) to a mean of 87 points (good) (range, 41 to 100 points) at the time of the most recent follow-up. Kaplan-Meier survivorship analysis, with aseptic loosening as the end point, was 92 percent (95 percent confidence interval, 82 to 100 percent) at six years; one additional hip failed because of a hematogenous infection at seventy-three months postoperatively, for an overall failure rate of 12 percent (three of twenty-five patients) at the time of the most recent follow-up. Two hips needed a repeat revision; one was revised because of subsidence of the stem with recurrent osteolysis and the other, in a patient who had hemodialysis, because of late sepsis. A third femoral component subsided and failed but was not revised. Radiographic evidence of bone-stock reconstitution was observed in six (29 percent) of the twenty-one patients for whom radiographs were available. As in other series of patients managed with impaction allografting, the complication rate was high; excluding the revisions, three reoperations were performed, and six patients had either intraoperative femoral fracture or perforation necessitating cerclage wiring or cortical strut allografting and cerclage wiring at the time of the procedure. There were six nonunions in eighteen patients who had been operated on with a transtrochanteric approach.Conclusions: Difficult revisions of the femoral component with use of impaction allografting and a precoated stem provided satisfactory clinical and radiographic results at the time of intermediate-term follow-up. However, the high rate of complications in our series led us to refine our indications for the procedure.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Loosening of the femoral component after total hip arthroplasty is often associated with loss of proximal femoral bone stock. In this setting, some revision techniques are performed with the goal of providing a stable and durable reconstruction despite the loss of bone^{13,22,24,35,37,40,41}, whereas others—including impaction allografting—are done in an attempt to reconstitute the bone-deficient proximal aspect of the femur as well^{1,8,10,11,16,32,42}.

Reports from several centers have presented the short-term follow-up results of cancellous impaction grafting with cement for revision of the femoral component. Early results were encouraging^11,16, but recent studies from other centers demonstrated a high rate of massive, symptomatic subsidence¹⁰ and frequent perioperative femoral fractures³², both during and after the operation.

In all of the clinical series of which we are aware, this technique has been performed with the Exeter stem (Howmedica, Rutherford, New Jersey, and Howmedica International, Staines, Middlesex, England) or the CPT (collarless, polished, tapered) stem (Zimmer, Warsaw, Indiana), both of which are double-tapered, highly polished, collarless devices^{10,11,16,30,32}. Advocates for the use of these devices with this technique have stated that subsidence in this setting does not lead to clinical failure¹⁶. In fact, subsidence of these wedge-shaped stems is said to be necessary to load the bone graft properly^11,16. However, a previous study of femoral components inserted with more traditional means of cement fixation suggested that subsidence is detrimental²⁰, and the results of two other clinical series raised concerns about the frequency and amount of subsidence of double-tapered stems inserted after impaction grafting^10,32.

The goals of impaction grafting include reconstitution of bone stock and stable fixation. If these goals can be met with a device that was not designed to subside, use of such a stem seems potentially advantageous. This prospective study tests the hypothesis that good clinical results can be achieved with difficult revisions of the femoral component involving use of cancellous impaction allografting and a precoated, collared, straight stem that has been used extensively for femoral reconstruction with cement^4,33,39. The results were evaluated after a minimum of four years of follow-up.

*Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received, but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated.

†Department of Orthopaedic Surgery, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Suite 1063, Chicago, Illinois 60612.

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Figs.1-A through 1-D: Radiographs of a patient who had a repeat revision. Fig. 1-A: Radiograph made before the index revision, demonstrating aseptic loosening and femoral osteolysis at the tip of a cemented femoral component, with widening of the metaphysis and the proximal part of the diaphysis in an active sixty-nine-year-old patient.

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Fig. 1-B: Radiograph made three months after impaction allografting. The osteolytic lesion was removed with a curet, and excellent alignment of the stem and an excellent cement mantle were achieved. Migration of the trochanteric osteotomy fragment occurred early.

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Fig. 1-C: At three years postoperatively, the osteolysis had not recurred and the stem-graft-cement composite was stable. The cables used for trochanteric fixation had been removed because of bursitis, but some third-body debris from fretting of these cables wa still visible in the joint. The clinical result at this time was good, with a Harris hip score¹⁹ of 85 points.

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Fig. 1-D: At fifty-three months, the osteolytic lesion had recurred (arrows), the stem was aseptically loose, and the patient was asymptomatic. Repeat revision of the femoral component was subsequently performed.

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Figs. 2-A, 2-B, and 2-C: Radiographs of a patient who had failure of the revision but did not have a repeat revision because of poor health. Fig. 2-A: Radiograph made before the index revision, demonstrating aseptic loosening of a cemented nonmodular titanium femoral component, which was causing symptoms, that developed nine years after the primary arthroplasty in a seventy-one-year-old woman who had severe rheumatoid arthritis. There is marked proximal bone loss, with widening of the endosteal canal, cortical thinning, and discontinuity of the lateral femoral cortex.

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Fig. 2-B: Radiograph made three months after impaction allografting. Impaction allografting was used for revision of the femoral component. The varus deformity was not corrected at the time of the revision arthroplasty, and there appears to be a cement void between the tip of the stem and the cement plug (grade-D cementing technique³).

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At twenty-six months, the stem had subsided and the varus deformity had progressed. The patient had symptomatic aseptic loosening and a poor clinical result, but she did not have a repeat revision because of severe medical comorbidities.

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Kaplan-Meier survivorship curve, with aseptic loosening (both clinical and radiographic) as the end point).

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Kaplan-Meier survivorship curve, with failure for any reason (infection and aseptic loosening) as the end point).

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Figs. 4-A, 4-B, and 4-C: Radiographs of a patient who had successful revision. Fig. 4-A: Radiograph made before the index revision, demonstrating an aseptically loose cemented revision femoral component in an eighty-three-year-old man. There is extensive endosteal osteolysis with severe cortical thinning extending into the diaphysis.

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Fig. 4-B: Radiograph made seven weeks after impaction allografting and insertion of a precoated femoral stem.

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Fig. 4-C: At fifty-one months postoperatively, the reconstruction was stable, without evidence of subsidence. There appeared to be some graft-remodeling, which was seen in 29 percent (six) of the twenty-one patients in this series for whom radiographs were available. The Harris hip score¹⁹ was 81 points, and the patient reported that the hip was pain-free.

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TABLE I HARRIS HIP SCORE¹⁹ AND CLINICAL END POINTS FOR PATIENTS WHO HAD REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING

*Twenty-three patients were alive and had not had a revision at the time of the most recent follow-up. †The values are given as the mean with the range in parentheses. ‡The values are given as the number of patients with the percentage in parentheses. §If the two patients who had a repeat revision are included, twenty-one (84 percent) of twenty-five had a good or excellent result.

	Preop. (N = 25)	Follow-up (N = 23)*
Hip score† (points)	54 (21—91)	87 (41—100)
Clinical end points‡
Slight or no pain	7 (28)	22 (96)
Use of a cane or crutches	19 (76)	9 (39)
Moderate or severe limp	21 (84)	2 (9)
Good or excellent result	—	21 (91)§

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TABLE I HARRIS HIP SCORE¹⁹ AND CLINICAL END POINTS FOR PATIENTS WHO HAD REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING

	Preop. (N = 25)	Follow-up (N = 23)*
Hip score† (points)	54 (21—91)	87 (41—100)
Clinical end points‡
Slight or no pain	7 (28)	22 (96)
Use of a cane or crutches	19 (76)	9 (39)
Moderate or severe limp	21 (84)	2 (9)
Good or excellent result	—	21 (91)§

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TABLE II RADIOGRAPHIC RESULTS* OF REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING AT THE MOST RECENT FOLLOW-UP EVALUATION

*A total of twenty-one radiographs were analyzed. †One patient in this group had cortical hypertrophy in addition to the cancellous change.

	No. (Percent) of Patients
Criteria of Rush-Presbyterian-St. Luke's
Medical Center
Stable (no subsidence)	19 (90)
Remodeling of cancellous graft (increased radiodensity)	3 (14)†
Resorption of cancellous graft (decreased radiodensity)	4 (19)†
Cortical hypertrophy	3 (14)
Cortical atrophy (continued proximal wasting)	1 (5)
No change (cancellous or cortical)	12 (57)
Criteria of Gie et al.¹⁶
No change	12 (57)
Localized resorption	5 (24)
Cortical repair	2 (10)
Trabecular remodeling	1 (5)
Trabecular incorporation	0
Cortical repair and trabecular remodeling	1 (5)
Cortical repair and trabecular incorporation	0

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TABLE II RADIOGRAPHIC RESULTS* OF REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING AT THE MOST RECENT FOLLOW-UP EVALUATION

*A total of twenty-one radiographs were analyzed. †One patient in this group had cortical hypertrophy in addition to the cancellous change.

	No. (Percent) of Patients
Criteria of Rush-Presbyterian-St. Luke's
Medical Center
Stable (no subsidence)	19 (90)
Remodeling of cancellous graft (increased radiodensity)	3 (14)†
Resorption of cancellous graft (decreased radiodensity)	4 (19)†
Cortical hypertrophy	3 (14)
Cortical atrophy (continued proximal wasting)	1 (5)
No change (cancellous or cortical)	12 (57)
Criteria of Gie et al.¹⁶
No change	12 (57)
Localized resorption	5 (24)
Cortical repair	2 (10)
Trabecular remodeling	1 (5)
Trabecular incorporation	0
Cortical repair and trabecular remodeling	1 (5)
Cortical repair and trabecular incorporation	0

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TABLE III FINDINGS IN CLINICAL STUDIES OF IMPACTION ALLOGRAFTING

*Subsidence of more than one millimeter, except where otherwise noted, including migration of the stem at either the stem-cement or the composite-femur interface. †Subsidence of more than five millimeters. ‡Subsidence of more than ten millimeters. §Revision only (clinical failures were not quantified in the study). #The percentage is based on twenty-five patients, as four patients died. **The percentage is based on twenty-one patients for whom radiographs were available at the time of the minimum four-year follow-up.

Study	No. of Patients	Duration of Follow-up (mos.)		No. (Percent) of Good or Excellent Results	No. (Percent) of Femoral Fractures	No. (Percent) of Dislocations	No. (Percent) of Subsidence*	No. (Percent) of Failures or Repeat Revisions	No. (Percent) of Radio- graphic Healing
Min.	Mean
Polished tapered stems
Gie et al.¹⁶	56	18	30	NA	4 (7)	3 (5)	11 (20)	2 (4)	50 (89)
Elting et al.¹¹	56	24	31	50 (89)	3 (5)	2 (4)	27 (48)	3 (5)	49 (88)
Eldridge et al.¹⁰	79	6	13	NA	NA	NA	18 (23)†	8 (10)	NA
Meding et al.³²	34	24	30	28 (82)	8 (24)	1 (3)	15 (44)	3 (9)	32 (94)
Masterson et al.³⁰	35	NA	NA	NA	6 (17)	2 (6)	7 (20)‡	1 (3)§	NA
Precoated collared stems (present study)	29	48	63	21 (84)#	6 (24)#	1 (4)#	2 (10)**	3 (12)#	6 (29)**

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TABLE III FINDINGS IN CLINICAL STUDIES OF IMPACTION ALLOGRAFTING

Study	No. of Patients	Duration of Follow-up (mos.)		No. (Percent) of Good or Excellent Results	No. (Percent) of Femoral Fractures	No. (Percent) of Dislocations	No. (Percent) of Subsidence*	No. (Percent) of Failures or Repeat Revisions	No. (Percent) of Radio- graphic Healing
Min.	Mean
Polished tapered stems
Gie et al.¹⁶	56	18	30	NA	4 (7)	3 (5)	11 (20)	2 (4)	50 (89)
Elting et al.¹¹	56	24	31	50 (89)	3 (5)	2 (4)	27 (48)	3 (5)	49 (88)
Eldridge et al.¹⁰	79	6	13	NA	NA	NA	18 (23)†	8 (10)	NA
Meding et al.³²	34	24	30	28 (82)	8 (24)	1 (3)	15 (44)	3 (9)	32 (94)
Masterson et al.³⁰	35	NA	NA	NA	6 (17)	2 (6)	7 (20)‡	1 (3)§	NA
Precoated collared stems (present study)	29	48	63	21 (84)#	6 (24)#	1 (4)#	2 (10)**	3 (12)#	6 (29)**

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patients

Between August 1991 and December 1993, twenty-nine patients had a revision of the femoral component with use of cancellous impaction allografting with cement. The patients were prospectively followed, and none were lost to follow-up. This cohort represents our initial experience with the described technique.

Four patients died before the minimum four-year follow-up period had elapsed: one died of pulmonary embolism at six weeks postoperatively and three, of unrelated causes at a mean of twenty-six months postoperatively. Of the twenty-five patients who were followed for at least four years, twenty-one both had radiographs made and had a clinical examination that included use of a standardized hip form and the remaining four were interviewed by telephone. These four patients did not return to our clinic for radiographic and clinical examination despite substantial efforts to have them do so. The mean duration of follow-up of the patients who were alive at four years was sixty-three months (range, forty-eight to eighty-two months). In the entire cohort of twenty-nine patients, the mean age at the time of the operation was sixty-four years (range, thirty-three to eighty-three years) and the mean number of previous operations on the affected hip was 1.6 (one, two, or three). The preoperative diagnosis was aseptic loosening of the femoral component in twenty-seven patients. The other two patients had the index procedure as a second-stage reimplantation after previous removal of the femoral component because of infection.

Patients who needed revision of the femoral component were included in our study if it was desirable to reconstitute proximal bone stock (as in a younger patient who had severe loss of metaphyseal bone) or if press-fitting into the remaining endosteum without cement would have required an overly large stem. All patients had the procedure performed with the same operative technique and the same type of femoral component by one of the four of us who are senior staff surgeons (R. A. B., A. G. R., J. J. J., and J. O. G.).

During the twenty-nine-month period of this study, the four of us who are surgeons performed a total of eighty-seven revisions of the femoral component. A standard cementing technique was used in thirty-one of those revisions; a fully porous-coated press-fit stem (AML; DePuy, Warsaw, Indiana), in nineteen (two of which involved use of a component that was more than eighteen millimeters in diameter); an allograft-prosthetic composite, in three; a proximally coated press-fit femoral stem, in three; and impaction grafting with a Harris CDH stem (Zimmer), in two. Thus, 33 percent (twenty-nine) of the eighty-seven revisions of the femoral stem performed during that time involved impaction grafting and a standard precoated stem. The technique was used for patients who had more severe femoral bone-stock deficiency.

Prostheses and Operative Technique

All twenty-nine of the patients were managed with a standard-length, straight, collared, forged cobalt-chromium femoral component that was circumferentially precoated with polymethylmethacrylate on the proximal one-third of the stem (Harris Precoat; Zimmer). The acetabular component was revised at the same procedure in twenty-two (76 percent) of the twenty-nine patients. A commercially pure titanium hemispherical cup (Harris-Galante II; Zimmer) was implanted with titanium-alloy screws for initial fixation without cement in twenty-one patients, and an all-polyethylene cup was inserted without cement in one patient.

Body-exhaust suits and operating rooms with vertical laminar airflow were used for all procedures. Antibiotic prophylaxis was used for all patients once specimens had been obtained for intraoperative culture.

A standard transtrochanteric approach was used in eighteen (62 percent) of the twenty-nine patients, and a posterior approach was used in the other eleven (38 percent).

Cancellous Impaction Grafting

Cancellous impaction grafting with cement was done with a technique similar to that described by Gie et al.^16,17. The femur was exposed, and its endosteum was thoroughly debrided of cement, debris, neocortex, and fibrous membrane. Any areas of attenuated cortex or cortical defects were exposed and reinforced with use of cortical strut allografts or were contained with Dacron mesh. A guide-rod was inserted into a canal-restricting plug, and the plug was inserted two centimeters distal to the anticipated location of the tip of the stem. Care was taken to place the rod in neutral alignment. Nonirradiated fresh-frozen morseled allograft bone was then introduced into the canal and packed tightly with cannulated tamps (provided by the manufacturer) until no more graft could be added and the final tamp was rotationally stable. These tamps were shaped to the contours of the Harris Precoat stem and were sized to allow a circumferential two-millimeter-thick cement mantle around the stem. The final tamp was left in the neo-endosteum thus created, and a trial reduction was performed. The tamp and the guide-rod were then removed, and cement (Simplex; Howmedica) was injected into the canal and pressurized. Finally, the femoral stem was inserted, excess cement was removed, and the cement was allowed to harden.

Postoperative Care

Thromboprophylaxis with warfarin was administered routinely for the first postoperative month, and antibiotics were administered for forty-eight hours postoperatively. So-called toe-touch weight-bearing with two crutches was used for twelve weeks.

Clinical and Radiographic Analysis

Clinical scores were calculated with the Harris hip-rating system¹⁹ both preoperatively and at the time of the most recent follow-up. Preoperative data were prospectively gathered on standardized forms and maintained in a computer database. All clinical evaluations were performed by observers other than the operating surgeon. Preoperative, postoperative, and follow-up radiographs were examined by one observer who was not involved in either the operation or the clinical evaluation of the patients.

That observer used the Endo-Klinik system¹², a simple four-grade descriptive classification employed in what we believe to be the first published study of impaction grafting¹⁶, to grade the femoral bone stock on the basis of the preoperative radiographs. According to the Endo-Klinik scale, two (7 percent) of the patients had grade-I bone stock (aseptic loosening without widening of the intramedullary cavity), eighteen (62 percent) had grade-II (endosteal erosion and mild widening of the intramedullary cavity), eight (28 percent) had grade-III (expansile widening of the proximal part of the femur), and one (3 percent) had grade-IV (gross destruction of the proximal part of the femur with severe diaphyseal widening).

The same observer also analyzed all postoperative radiographs. The cementing technique was graded according to accepted criteria^3,37. The most recent radiographs were evaluated for signs of loosening of the component, and subsidence and changes in the position of the component were measured with a digitizing tablet (Sigma Scan; Jandel Scientific, Corte Madera, California) as previously described²⁹. Radiographs were evaluated for evidence of lucency or debonding at the stem-cement interface, fracture of the cement, osteolysis, and a complete radiolucent line at the bone-cement or graft-host interface on both anteroposterior and lateral radiographs.

New or progressive heterotopic ossification was graded according to the classification system of Brooker et al.⁷.

The criteria of Gie et al.¹⁶ were used to grade incorporation of the cancellous allograft. Because of concerns about interobserver and intraobserver reliability²³, the radiographs were also evaluated with a simpler method. The appearance of the cancellous graft on the most recent follow-up radiographs was compared with the postoperative appearance and described as either unchanged, less radiopaque, or more radiopaque; the cortical bone stock was characterized as unchanged, hypertrophied, or atrophied. Care was taken to account for differences between radiographic technique, position, and degree of penetration so that these would not be misinterpreted as changes in the status of the bone graft or cortex. The appearance of the cortical bone distal to the implant and the cancellous bone in the pelvis a distance from the implant were used to control for these differences in technique.

Statistical Methods

Kaplan-Meier curves²¹ were calculated to assess the rates of aseptic loosening over the period of this study. The preoperative and postoperative hip scores were compared with use of the nonparametric paired sign test. Analyses were performed with SPSS statistical software (version 7.5; SPSS, Chicago, Illinois).

Results

Introduction | Materials and Methods | Results | Discussion | References

Clinical and Radiographic Results

All four patients who died before the four-year follow-up period had elapsed had a well functioning hip prosthesis at the time of death. None of the four had any radiographic signs of subsidence, and, excluding the patient who died in the perioperative period (at six weeks, because of a pulmonary embolism), the mean Harris hip score in the subgroup was 88 points (76, 90, and 98 points).

Of the twenty-five patients who were still living at a minimum of four years postoperatively, twenty-two (88 percent) had a well functioning prosthesis. Two patients had a repeat revision. One revision was performed at fifty-three months because of recurrent femoral osteolysis and painful subsidence of the stem (Figs. 1-A, 1-B, 1-C, 1-D), and the other (a resection arthroplasty) was done at seventy-three months because of hematogenous sepsis. A third patient had painful subsidence and clinical failure at twenty-six months. In that patient, the femur had had a varus deformity at the junction of the metaphysis and the proximal part of the diaphysis, but an osteotomy had not been done before the index revision of the femoral component (Figs. 2-A, 2-B, and 2-C). The patient did not have a subsequent revision because of poor health. Kaplan-Meier analysis²¹, with aseptic loosening as the end point, revealed a rate of survival of 92 percent (95 percent confidence interval, 82 to 100 percent) at six years (Fig. 3-A). The overall failure rate for the entire series, taking into account both revision for any reason and radiographic evidence of subsidence, was 12 percent (three of twenty-five) (Fig. 3-B). Neither of the two patients in whom this procedure was performed as a second-stage reimplantation after removal of the component because of infection had had a recurrent infection at the time of the most recent follow-up.

The Harris hip scores improved from a mean of 54 points (range, 21 to 91 points) preoperatively to a mean of 87 points (range, 41 to 100 points) at the time of the most recent follow-up (p < 0.0005). Preoperatively, seven (24 percent) of the twenty-nine patients rated pain as none or slight; at the most recent follow-up evaluation, twenty-two (96 percent) of the twenty-three patients who had not had a revision and were alive rated pain as none or slight. Similarly, twenty-three (79 percent) of the twenty-nine patients used a cane or crutches preoperatively, whereas nine (39 percent) of the twenty-three did so at the time of the most recent follow-up. Twenty-one (91 percent) of the twenty-three patients who had not had a revision and had been followed for at least four years had a good or excellent result, defined as a Harris hip score of at least 80 points (Table I). The patient in whom the stem failed but was not revised was included in all analyses.

Of the twenty-nine patients, none had grade-A cementing technique³ (so-called whiteout), one (3 percent) had grade-B, one had grade-C1, fourteen (48 percent) had grade-C2, and thirteen (45 percent) had grade-D. Review of the radiographs available at the time of the most recent follow-up revealed that nineteen (90 percent) of the twenty-one femoral components were stable, without any measurable subsidence. Apart from the two stems with known aseptic loosening, no stem had visible radiolucency or debonding at the stem-cement or cement-bone interface, fracture of the cement, or visible femoral or pelvic osteolysis. With care taken to account for differences in radiographic technique, it was determined that six (29 percent) of the twenty-one hips demonstrated some reconstitution of femoral bone stock or visible incorporation of the graft, twelve (57 percent) showed neither reconstitution nor progressive loss of bone stock, and the remaining three (14 percent) had continued loss of cortical or cancellous bone (Table II). With the numbers available, no association could be detected between the preoperative Endo-Klinik grade¹² or the grade of the cementing technique³ and any radiographic or clinical end point (reconstitution of bone stock, subsidence of the stem, or the hip score). No patient had progressive heterotopic ossification, defined as an increase of one grade⁷ or more compared with the radiographic appearance before the index revision.

Complications

Intraoperative complications included a femoral fracture in four (14 percent) of the twenty-nine patients; all of these fractures were recognized intraoperatively and treated with cerclage wiring. In addition, two patients (7 percent) had a diaphyseal perforation, which was recognized and treated with cortical strut allografting and cerclage wiring. None of these six patients had a repeat revision. The fractures occurred either during impaction of the trial rasps into the neo-endosteum or during removal of the cement. The perforations occurred during the removal of cement through osteolytic or ectatic diaphyseal areas.

There were four early postoperative complications. These included two nerve palsies (one sciatic and one peroneal), neither of which resolved completely; one hip dislocation at six months, which was treated closed and had not recurred by the time of the most recent follow-up; and one compartment syndrome, in the patient who had the sciatic nerve palsy. The compartment syndrome involved the contralateral gluteal compartment following the six-hour operation in the lateral position. It was diagnosed in the immediate postoperative period on clinical examination and with direct manometry, and an emergency fasciotomy was performed. The patient subsequently had myoglobinuria and acute renal failure requiring a short period of dialysis but eventually had full recovery of renal function.

There were two other reoperations, in addition to the revision and the resection arthroplasty. One patient was managed with removal of allograft struts and a quadricepsplasty at two months postoperatively because of stiffness of the knee, and another had removal of a trochanteric cable-grip at eighteen months because of bursitis.

Six of the eighteen patients managed with trochanteric osteotomy had nonunion with migration. One of these patients had the single episode of hip dislocation described earlier. Another was the patient who had the reoperation for the removal of painful trochanteric hardware. At that reoperation, the fibrous trochanteric nonunion was found to be stable. In five of the six patients who had a trochanteric nonunion, debris from the braided cables used for trochanteric fixation was visible in the joint radiographically. One of those patients had severe polyethylene wear, osteolysis, and revision of the femoral component because of subsidence.

Appearance of the Allograft at the Repeat Revision

The two repeat revisions allowed direct examination of the allograft-cement composite mantle. As described, one of the repeat revisions was performed because of subsidence of the femoral component and recurrent osteolysis. This patient had fretting and breakage of braided trochanteric cables, with substantial polyethylene wear from third-body debris. Osteolysis and subsidence of the component followed, with symptomatic loosening. At the repeat revision, the mantle of cancellous allograft proximally was observed to be bleeding and healed to the cortex despite the loose stem. Finding and dividing the plane between the allograft-cement mantle and the original cortical bone was extremely difficult. At the time of the resection arthroplasty in the patient who had late hematogenous sepsis, the femoral component was found to be solidly bonded to the allograft-cement mantle. In that patient as well, the allograft was bleeding and healed to cortical bone.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

We performed a prospective clinical study to evaluate the results of revision of a femoral component with use of impaction allografting and a textured, precoated, collared stem. The hypothesis that this technique can produce satisfactory clinical results with a stem that is neither polished and tapered nor designed to permit subsidence seemed to be valid after a minimum of four years (mean, sixty-three months) of follow-up.

Four years of follow-up is too short to determine whether this reconstructive technique will ultimately succeed. At this time, we can only compare its early results with those of established techniques to verify that it does not result in early failure. In the present series, which represents our initial experience with this technically demanding procedure, the rate of prosthetic survival, according to Kaplan-Meier analysis²¹, was 92 percent (95 percent confidence interval, 82 to 100 percent) at six years when the end point was aseptic loosening, and the overall survival rate was 88 percent (twenty-two of twenty-five hips) when the one hematogenous infection was included in the analysis. In addition, twenty-one (91 percent) of the twenty-three patients who had not had a revision and had been followed for at least four years had a good or excellent clinical result (a Harris hip score of at least 80 points). These findings are comparable with the results after similar durations of follow-up in the best contemporary series of revisions performed with cement, in which rates of loosening and failure were reported to be 7 percent (twenty-five of 351)⁴⁰ and 10 percent (five of forty-nine)⁴¹ at six years. In addition, it did not appear that patients who had bone-stock deficiency had been preselected in those studies as they had been in ours (Figs. 4-A, 4-B, and 4-C). Whether revision of the femoral component with impaction grafting will prove durable over the long term remains to be seen.

Previous studies of impaction allografting of which we are aware have demonstrated rates of revision ranging from 3 percent [one of thirty-five]³⁰ to 10 percent (eight of seventy-nine)¹⁰. However, the mean durations of follow-up in those reports were quite short, with none longer than thirty-one months^{10,11,16,30,32}. In addition, variation in the criteria for inclusion of patients in studies of impaction grafting renders interpretation of the literature more complicated, and direct comparisons of failure rates are probably misleading. One of the coauthors of the original report on impaction grafting expressed reservations about using the technique for the most challenging cases²⁶, which was what was done in our series and others^30,32. Considering the longer follow-up and stricter inclusion criteria used in the present study, the rate of revision and the clinical results compare favorably with those of other reports (Table III). For example, the proportion of patients in this study who had severe bone-stock deficiency (grades III and IV according to the Endo-Klinik scale¹²) is more than double that in the study by Gie et al.¹⁶. In another series¹¹, more than one-third (nineteen) of the fifty-six patients had a minimally damaged (grade-I¹²) femur compared with only 7 percent (two) of the twenty-nine patients in the present series.

As far as we know, all other studies of impaction allografting^{10,11,16,30,32} have involved stems that differed substantially, with regard to surface and geometry, from the stems used in our series. Both the Exeter and the CPT stems are collarless, polished, and tapered, and they are thought to allow subsidence within the cement mantle without causing symptomatic loosening¹⁶. Several millimeters of subsidence is tolerated by some designs of stems when they are used for primary total hip arthroplasty performed with cement^27,28, but more severe subsidence typically results in failure⁵. The precoated stem that was used in the present series was designed to achieve initial stability⁶ and a bond with the cement-bone graft composite^4,33,39. Unlike the situation with polished stems, any debonding or subsidence of precoated stems leads to failure of a primary total hip arthroplasty performed with cement³⁴. In the present series, this was found to be true for revision arthroplasties performed with impaction allografting; both components that subsided caused symptoms.

The contention that subsidence is desirable when impaction grafting is performed with a polished, tapered stem^11,16 has been called into question. It was believed that these devices subsided because of so-called cold flow of the cement, allowing the wedge-shaped stem to become more tightly fixed as it subsided^11,14,16. More recent reports have shown that this does not always occur. Masterson et al.³⁰ found a high prevalence of early fracture of the cement around stems that subsided, an observation that does not support the hypothesis that cold flow is the mechanism of subsidence. In another study, roentgen stereophotogrammetric analysis was used to arrive at the same conclusion¹⁵. Subsidence may be massive^10,30, and it may continue for an unpredictable period of time postoperatively³²; such subsidence has been convincingly associated with pain in the thigh¹⁰ and prosthetic dislocation³⁰.

Achieving a circumferential cement mantle is important to the success of a femoral stem inserted with cement^9,36, and an inadequate cementing technique appears to be one cause of subsidence of stems inserted after impaction allografting^30,31; however, obtaining a consistent cement mantle with impaction grafting is difficult. Masterson et al.^30,31 found that, when stems had been inserted after use of the original Exeter rasps, which were not oversized, 40 percent of the zones described by Gruen et al.¹⁸ had no visible cement. Cementing of the Precoat and CPT systems, both of which are implanted after the use of rasps that are larger than the final implant, left complete voids in 14 and 15 percent of the zones, respectively³¹. In the present study, we did not perform an analysis according to the zones of Gruen et al. but instead used a clinically validated system of grading the cementing technique on the basis of good-quality anteroposterior and lateral radiographs for each patient^3,37. This approach is somewhat stricter than a zonal analysis because even one large void results in a grade-D mantle. As assessed with this method, 93 percent (twenty-seven) of the twenty-nine hips had an unsatisfactory cement mantle (grade C2 or D). This finding highlights the technical difficulty of obtaining a consistent cement mantle with impaction allografting, even when specially designed, oversized rasps are used. However, the presence of morseled allograft pieces in the cement may render analysis of these hips with conventional methods—such as the zonal analysis^30,31 or the technique used in our study^3,37—inadequate or misleading.

In most of the clinical studies of impaction grafting of which we are aware, histological healing or incorporation of the cancellous allograft was inferred from plain radiographs^11,16,32, despite the poorly established relationship between apparent radiographic remodeling of cancellous allograft and the actual viability of the graft^25,38. In the present study, we found convincing evidence of bone-graft remodeling in only six (29 percent) of twenty-one patients at the time of the most recent follow-up; this rate is much lower than that reported in other series^16,32. It is not possible to determine from these data whether the low rate of radiographic evidence of bone-remodeling in our series represents an actual difference in the biology of the stem-graft-host composite or simply a stricter interpretation of the radiographs. The intraoperative appearance of the graft-host junction in the two patients who had a repeat revision, as well as the fact that all but two stems remained radiographically stable after a mean duration of follow-up of more than five years, supports the contention that bone-healing is taking place but is not seen on plain radiographs, as has been reported elsewhere³⁸.

The prevalence of serious complications and reoperations in the present series of twenty-nine patients was high: six patients (21 percent) had an intraoperative femoral fracture or perforation, and three (10 percent) had a reoperation other than a revision. The technique is also time-consuming, technically demanding, and expensive. On the basis of these issues and reports that have documented excellent intermediate and long-term results with large, extensively coated femoral stems inserted without cement^2,13,24, we have narrowed our indications for impaction allografting. In our opinion, impaction allografting is most appropriate for a patient who needs revision of the femoral component and has severe loss of bone from the proximal aspect of the femur, a patulous or severely ectatic proximal part of the diaphysis, thin cortices, and a large-diameter canal (typically more than eighteen millimeters). In such patients, distal fixation without cement may be compromised by an inability to obtain rotational stability of the prosthesis and the potential for proximal stress-shielding, and traditional revision with cement might be unsatisfactory because of the condition of the remaining endosteum.

There are a number of variables that may affect the outcome of a revision of the femoral component with impaction allografting. Series in which similar implants and similar inclusion criteria were used may still differ with respect to the cement (the technique, the type, or the viscosity), the allograft (the source, the consistency, or whether there was pretreatment with radiation or freeze-drying), the operative approach, and the postoperative care, to name but a few potentially important factors. The effects of these variables on the clinical results of impaction grafting are, for the most part, not yet known.

NOTE: The authors thank Susan Shott, Ph.D., for statistical analysis; Paul Sauer, M.D., for preliminary radiographic analysis; and Karen Kiafeta, B.S., for technical assistance.

References

Introduction | Materials and Methods | Results | Discussion | References

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Chandler, H.; Clark, J.; Murphy, S.; McCarthy, J.; Penenberg, B.; Danylhuk, K.; and Roehr, B.: Reconstruction of major segmental loss of the proximal femur in revision total hip arthroplasty. Clin. Orthop.,298: 67-74, 1994.29867 1994 [PubMed]

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Eldridge, J. D.; Smith, E. J.; Hubble, M. J.; Whitehouse, S. L.; and Learmonth, I. D.: Massive early subsidence following femoral impaction grafting. J. Arthroplasty,12: 535-540, 1997.12535 1997 [PubMed]

Elting, J. J.; Mikhail, W. E. M.; Zicat, B. A.; Hubbell, J. C.; Lane, L. E.; and House, B.: Preliminary report of impaction grafting for exchange femoral arthroplasty. Clin. Orthop.,319: 159-167, 1995.319159 1995 [PubMed]

Engelbrecht, E., and Heinert, K.: Klassifikation und Behandlungsrichtlinien von Knochensubstanzverlusten bei Revisionoperationen am Huftgelenk—mittelfristige Ergebnisse. Primare und Revisionsalloarthroplastik Hrsh—Endo-Klinik, Hamburg, pp. 189-201. Berlin, Springer, 1987.

Engh, C. A.; Glassman, A. H.; Griffin, W. L.; and Mayer, J. G.: Results of cementless revision for failed cemented total hip arthroplasty. Clin. Orthop.,235: 91-110, 1988.23591 1988 [PubMed]

Fowler, J. L.; Gie, G. A.; Lee, A. J.; and Ling, R. S.: Experience with the Exeter total hip replacement since 1970. Orthop. Clin. North America,19: 477-489, 1988.19477 1988

Franzén, H.; Toksvig-Larsen, S.; Lidgren, L.; and Önnerfält, R.: Early migration of femoral components revised with impacted cancellous allografts and cement. A preliminary report of five patients. J. Bone and Joint Surg.,77-B(6): 862-864, 1995.77-B(6)862 1995

Gie, G. A.; Linder, L.; Ling, R. S. M.; Simon, J.-P.; Slooff, T. J. J. H.; and Timperley, A. J.: Impacted cancellous allografts and cement for revision total hip arthroplasty. J. Bone and Joint Surg.,75-B(1): 14-21, 1993.75-B(1)14 1993

Gie, G. A.; Linder, L.; Ling, R. S.; Simon, J. P.; Slooff, T. J.; and Timperley, A. J.: Contained morselized allograft in revision total hip arthroplasty. Surgical technique. Orthop. Clin. North America,24: 717-725, 1993.24717 1993

Gruen, T. A.; McNeice, G. M.; and Amstutz, H. C.: "Modes of failure" of cemented stem-type femoral components. A radiographic analysis of loosening. Clin. Orthop.,141: 17-27, 1979.14117 1979 [PubMed]

Harris, W. H.: Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J. Bone and Joint Surg.,51-A: 737-755, June 1969.51-A737 1969

Harris, W. H.; McCarthy, J. C., Jr.; and O'Neill, D. A.: Femoral component loosening using contemporary techniques of femoral cement fixation. J. Bone and Joint Surg.,64-A: 1063-1067, Sept. 1982.64-A1063 1982

Kaplan, E. L., and Meier, P.: Nonparametric estimation from incomplete observations. J. Am. Statist. Assn.,53: 457-481, 1958.53457 1958

Katz, R. P.; Callaghan, J. J.; Sullivan, P. M.; and Johnston, R. C.: Results of cemented femoral revision total hip arthroplasty using improved cementing techniques. Clin. Orthop.,319: 178-183, 1995.319178 1995 [PubMed]

Kerry, R.; Campbell, D.; Garbuz, D.; Masri, B.; and Duncan, C.: Classification systems for bone loss in revision THA. An exercise in imprecise precision? Read at the Annual Meeting of the Hip Society, London, Ontario, Canada, Sept. 26, 1998.

Lawrence, J. M.; Engh, C. A.; Macalino, G. E.; and Lauro, G. R.: Outcome of revision hip arthroplasty done without cement. J. Bone and Joint Surg.,76-A: 965-973, July 1994.76-A965 1994

Ling, R. S. M.; Timperley, A. J.; and Linder, L.: Histological findings in a case of cemented femoral revision treated by endosteal impaction grafting [abstract]. Acta Orthop. Scandinavica, Supplementum 248, p. 29, 1992.

Ling, R. S. M.: Femoral component revision using impacted morsellised cancellous graft [letter]. J. Bone and Joint Surg.,79-B(5): 874, 1997.79-B(5)874 1997

Madey, S. M.; Callaghan, J. J.; Olejniczak, J. P.; Goetz, D. D.; and Johnston, R. C.: Charnley total hip arthroplasty with use of improved techniques of cementing. The results after a minimum of fifteen years of follow-up. J. Bone and Joint Surg.,79-A: 53-64, Jan. 1997.79-A53 1997

Marston, R. A.; Cobb, A. G.; and Bentley, G.: Stanmore compared with Charnley total hip replacement. A prospective study of 413 arthroplasties. J. Bone and Joint Surg.,78-B(2): 178-184, 1996.78-B(2)178 1996

Martell, J. M.; Pierson, R. H., III; Jacobs, J. J.; Rosenberg, A. G.; Maley, M.; and Galante, J. O.: Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J. Bone and Joint Surg.,75-A: 554-571, April 1993.75-A554 1993

Masterson, E. L.; Masri, B. A.; and Duncan, C. P.: The cement mantle in the Exeter impaction allografting technique. A cause for concern. J. Arthroplasty,12: 759-764, 1997.12759 1997 [PubMed]

Masterson, E. L.; Masri, B. A.; Duncan, C. P.; Rosenberg, A.; Cabanela, M.; and Gross, M.: The cement mantle in femoral impaction allografting. A comparison of three systems from four centres. J. Bone and Joint Surg.,79-B(6): 908-913, 1997.79-B(6)908 1997

Meding, J. B.; Ritter, M. A.; Keating, E. M.; and Faris, P. M.: Impaction bone-grafting before insertion of a femoral stem with cement in revision total hip arthroplasty. A minimum two-year follow-up study. J. Bone and Joint Surg.,79-A: 1834-1841, Dec. 1997.79-A1834 1997

Mohler, C. G.; Kull, L. R.; Martell, J. M.; Rosenberg, A. G.; and Galante, J. O.: Total hip replacement with insertion of an acetabular component without cement and a femoral component with cement. Four to seven-year results. J. Bone and Joint Surg.,77-A: 86-96, Jan. 1995.77-A86 1995

Mohler, C. G.; Callaghan, J. J.; Collis, D. K.; and Johnston, R. C.: Early loosening of the femoral component at the cement-prosthesis interface after total hip replacement. J. Bone and Joint Surg.,77-A: 1315-1322, Sept. 1995.77-A1315 1995

Moreland, J. R., and Bernstein, M. L.: Femoral revision hip arthroplasty with uncemented, porous-coated stems. Clin. Orthop.,319: 141-150, 1995.319141 1995 [PubMed]

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Mulroy, W. F., and Harris, W. H.: Revision total hip arthroplasty with use of so-called second-generation cementing techniques for aseptic loosening of the femoral component. A fifteen-year-average follow-up study. J. Bone and Joint Surg.,78-A: 325-330, March 1996.78-A325 1996

Nelissen, R. G. H. H.; Bauer, T. W.; Weidenhielm, L. R. A.; LeGolvan, D. P.; and Mikhail, W. E. M.: Revision hip arthroplasty with the use of cement and impaction grafting. Histological analysis of four cases. J. Bone and Joint Surg.,77-A: 412-422, March 1995.77-A412 1995

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Weber, K. L.; Callaghan, J. J.; Goetz, D. D.; and Johnston, R. C.: Revision of a failed cemented total hip prosthesis with insertion of an acetabular component without cement and a femoral component with cement. A five to eight-year follow-up study. J. Bone and Joint Surg.,78-A: 982-994, July 1996.78-A982 1996

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Kaplan-Meier survivorship curve, with aseptic loosening (both clinical and radiographic) as the end point).

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Kaplan-Meier survivorship curve, with failure for any reason (infection and aseptic loosening) as the end point).

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Fig. 4-B: Radiograph made seven weeks after impaction allografting and insertion of a precoated femoral stem.

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TABLE I HARRIS HIP SCORE¹⁹ AND CLINICAL END POINTS FOR PATIENTS WHO HAD REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING

	Preop. (N = 25)	Follow-up (N = 23)*
Hip score† (points)	54 (21—91)	87 (41—100)
Clinical end points‡
Slight or no pain	7 (28)	22 (96)
Use of a cane or crutches	19 (76)	9 (39)
Moderate or severe limp	21 (84)	2 (9)
Good or excellent result	—	21 (91)§

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TABLE I HARRIS HIP SCORE¹⁹ AND CLINICAL END POINTS FOR PATIENTS WHO HAD REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING

	Preop. (N = 25)	Follow-up (N = 23)*
Hip score† (points)	54 (21—91)	87 (41—100)
Clinical end points‡
Slight or no pain	7 (28)	22 (96)
Use of a cane or crutches	19 (76)	9 (39)
Moderate or severe limp	21 (84)	2 (9)
Good or excellent result	—	21 (91)§

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TABLE II RADIOGRAPHIC RESULTS* OF REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING AT THE MOST RECENT FOLLOW-UP EVALUATION

*A total of twenty-one radiographs were analyzed. †One patient in this group had cortical hypertrophy in addition to the cancellous change.

	No. (Percent) of Patients
Criteria of Rush-Presbyterian-St. Luke's
Medical Center
Stable (no subsidence)	19 (90)
Remodeling of cancellous graft (increased radiodensity)	3 (14)†
Resorption of cancellous graft (decreased radiodensity)	4 (19)†
Cortical hypertrophy	3 (14)
Cortical atrophy (continued proximal wasting)	1 (5)
No change (cancellous or cortical)	12 (57)
Criteria of Gie et al.¹⁶
No change	12 (57)
Localized resorption	5 (24)
Cortical repair	2 (10)
Trabecular remodeling	1 (5)
Trabecular incorporation	0
Cortical repair and trabecular remodeling	1 (5)
Cortical repair and trabecular incorporation	0

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TABLE II RADIOGRAPHIC RESULTS* OF REVISION OF THE FEMORAL COMPONENT WITH IMPACTION ALLOGRAFTING AT THE MOST RECENT FOLLOW-UP EVALUATION

*A total of twenty-one radiographs were analyzed. †One patient in this group had cortical hypertrophy in addition to the cancellous change.

	No. (Percent) of Patients
Criteria of Rush-Presbyterian-St. Luke's
Medical Center
Stable (no subsidence)	19 (90)
Remodeling of cancellous graft (increased radiodensity)	3 (14)†
Resorption of cancellous graft (decreased radiodensity)	4 (19)†
Cortical hypertrophy	3 (14)
Cortical atrophy (continued proximal wasting)	1 (5)
No change (cancellous or cortical)	12 (57)
Criteria of Gie et al.¹⁶
No change	12 (57)
Localized resorption	5 (24)
Cortical repair	2 (10)
Trabecular remodeling	1 (5)
Trabecular incorporation	0
Cortical repair and trabecular remodeling	1 (5)
Cortical repair and trabecular incorporation	0

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TABLE III FINDINGS IN CLINICAL STUDIES OF IMPACTION ALLOGRAFTING

Study	No. of Patients	Duration of Follow-up (mos.)		No. (Percent) of Good or Excellent Results	No. (Percent) of Femoral Fractures	No. (Percent) of Dislocations	No. (Percent) of Subsidence*	No. (Percent) of Failures or Repeat Revisions	No. (Percent) of Radio- graphic Healing
Min.	Mean
Polished tapered stems
Gie et al.¹⁶	56	18	30	NA	4 (7)	3 (5)	11 (20)	2 (4)	50 (89)
Elting et al.¹¹	56	24	31	50 (89)	3 (5)	2 (4)	27 (48)	3 (5)	49 (88)
Eldridge et al.¹⁰	79	6	13	NA	NA	NA	18 (23)†	8 (10)	NA
Meding et al.³²	34	24	30	28 (82)	8 (24)	1 (3)	15 (44)	3 (9)	32 (94)
Masterson et al.³⁰	35	NA	NA	NA	6 (17)	2 (6)	7 (20)‡	1 (3)§	NA
Precoated collared stems (present study)	29	48	63	21 (84)#	6 (24)#	1 (4)#	2 (10)**	3 (12)#	6 (29)**

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TABLE III FINDINGS IN CLINICAL STUDIES OF IMPACTION ALLOGRAFTING

Study	No. of Patients	Duration of Follow-up (mos.)		No. (Percent) of Good or Excellent Results	No. (Percent) of Femoral Fractures	No. (Percent) of Dislocations	No. (Percent) of Subsidence*	No. (Percent) of Failures or Repeat Revisions	No. (Percent) of Radio- graphic Healing
Min.	Mean
Polished tapered stems
Gie et al.¹⁶	56	18	30	NA	4 (7)	3 (5)	11 (20)	2 (4)	50 (89)
Elting et al.¹¹	56	24	31	50 (89)	3 (5)	2 (4)	27 (48)	3 (5)	49 (88)
Eldridge et al.¹⁰	79	6	13	NA	NA	NA	18 (23)†	8 (10)	NA
Meding et al.³²	34	24	30	28 (82)	8 (24)	1 (3)	15 (44)	3 (9)	32 (94)
Masterson et al.³⁰	35	NA	NA	NA	6 (17)	2 (6)	7 (20)‡	1 (3)§	NA
Precoated collared stems (present study)	29	48	63	21 (84)#	6 (24)#	1 (4)#	2 (10)**	3 (12)#	6 (29)**