1. Femoral Component Revision with Use of Impaction Bone- Grafting and a Cemented Polished Stem by B. Willem Schreurs, J.J. Chris Arts, Nico Verdonschot, Pieter Buma, Tom J.J.H. Slooff, and Jean W.M. Gardeniers JBJS Essent Surg Tech Volume os-88(1 suppl 2):259-274 September 1, 2006 ©2006 by The Journal of Bone and Joint Surgery, Inc.

2. Careful preplanning with use of special templates is essential to be aware of areas with cortical weakness and areas that need to be reconstructed with mesh, strut graft, or a plate; to plan the position of the plug; and to select the size of the proximal i... B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

3. Cortical wall defects should be exposed and repaired with use of metal mesh on the outside of the femur. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

4. Femoral head reamer set used to facilitate the removal of cartilage from the femoral head. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

5. The intramedullary plug, which is mounted on the central wire, is inserted at the preplanned position. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

6. The next step is to establish how far each size of distal impactor can be inserted into the femoral canal before it jams against the femoral cortical walls. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

7. After the correct size of the proximal impactor has been chosen, attention is focused on segmental osseous defects in the calcar region. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

8. Reconstruction of the calcar area with a metal mesh and cerclage wires. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

9. The reconstruction with bone graft is started. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

10. The canal is filled with solid impacted graft until the distal impaction line is reached. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

11. Next, the most proximal area is filled layer by layer and impacted with use of the previously selected proximal impactor. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

12. Intraoperative view of the impaction procedure, with a distal impactor (left) or a proximal impactor (right) mounted on the sliding hammer. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

13. Impaction should be very tight, especially in the calcar region, where larger bone chips (6 to 8 mm) can be used. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

14. View of the reconstructed calcar area just after removal of the proximal impactor. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

15. A cement syringe with a small-diameter nozzle is used to inject the cement distally in the graft reconstruction. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

16. A centralizer without wings is used on the tip of the prosthesis to guide it through the reconstruction. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

17. Radiograph made three years after reconstruction with femoral impaction bone-grafting. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

18. For patients with bone stock lysis or deficiency at or beyond the tip of the primary stem, a special set of instruments was developed to bypass the weak area with impacted bone graft in combination with a long Exeter stem. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.

19. Fig. 18-A Preoperative radiograph showing a failed cemented total hip prosthesis. B. Willem Schreurs et al. J Bone Joint Surg Am 2006;os- 88:259-274 ©2006 by The Journal of Bone and Joint Surgery, Inc.