FEMORAL RECONSTRUCTION

WITH ALLOGRAFTS

M. Kerboull

Revision with a cemented prosthesis

Femoral restoration with allografts

Standard femoral component

Perfectly suitable to a sound cemented fixation

MAIN SPECIFICATIONSFOR A SOUND CEMENTED PROSTHESIS

A polished stem (Ra 0.04 m) ( < 0.1 m )

with a rectangular cross section

A tapered shape with a taper angle of 5°

Cement and bone subjected only to pressure stresses

No shear stresses at the cement bone interface

Endomedullary reconstruction with impacted cancellous graft

Cortical reinforcement with strut grafts

Replacement of a destroyed proximal femur with massive allograft

Endomedullary reconstruction with a massive femoral graft

4 TECHNIQUES

ENDOMEDULLARY FEMORAL RECONSTRUCTION

WITH MASSIVE FEMORAL ALLOGRAFT

« Double sheath technique »

INDICATIONS

This technique has been used

-since 1988- concurrently with the « impaction grafting »- preferred in cases of severe femoral structural defects- more logical to repair cortical defects with cortical grafts

ITS MAIN INDICATION IS EXTENSIVE OSTEOLYSIS DUE TO AGGRESSIVE GRANULOMATOSIS

THAT HAS THINNED DOWN CORTICES

WIDENING THE MEDULLARY CANAL

AND LOOSENING THE FEMORAL COMPONENT

PRINCIPLES OF THE SURGICAL TECHNIQUE

To repair the femoral cortex where it is

destroyed, inside the medullary canal,

by lining it with a femoral cortical graft

A. After prosthesis and cement removal, reaming and cleaning the medullary canal

B. A massive proximal femoral allograft is introduced through the cervical orifice

A. The graft has to be carrefully shaped so that it excactly and tightly fits the medullary canal all over the extent of the pathologic area without splitting thin cortices

B. Section of the greater trochanter of the graft at the level of the trochanteric osteotomy- obturation of the medullary canal of the graft and host bone by impacted cancellous bone- lining of proximal graft with a strut fragment

C. Then a standard femoral component can be cemented into the graft

The femoral component is a sheath for the prosthesis and the widened proximal part of the femur a sheath for the graft.This technique requires a bone bank well supplied with proximal femoral allografts. This is relatively rare, and the main limitation of the procedure is the difficulty finding a suitable graft.

Some examples to illustrate

this technique

DUR.

06.9604.95

Loosening of a rough titanium stem Bone restoration with a massive graft

ALB.

09.98 10.98

Loosening of the matte stemwith femoral osteolysis

Bone reconstruction

BEA.

03.9705.98

A big matte stemFemoral restoration 1 y. PO

De.G.R.

09.97 11.97

Another case of femoralloosening with osteolysis

Double sheath technique 2 months. PO

GAR.

09.99 12.99

Cement bone loosening of a bigmatte titanium stem

Bone restoration withMassive intra medullary allograft3 months PO

ROB.

06.91 09.93

Major destruction of femoral cortices

Bone restoration with massivegraft and strut graft

ROB.

09.9809.98

Same case. 7 y. POAP view

Lateral view

Extremely severe cortical bone loss

03.98 10.99 03.03

Double sheath techniqueUsing a 250 mm stem anda long graft

X-rays 5 y. PO

BEG.

03.98 03.98

Lateral diaphysal cortical defect Restoration with massive graft and a 200 mm stem

BEG.

(2 y. PO)

07.0007.00

At 2 y. PO excellent bone union between graft and host bone

BEG.

03.98 07.00 12.02 12.02

Same case AP radiograph 5 y. PO

2007

9 years PO AP view

Excellent function

09.88

GRO.

07.88

Loosening of the femoral component Reconstruction with massive intra medullary graft

GRO.

1 m. PO 2 y. PO

Radiological bone union between the graft on host femoral cortices has been regularly obtained within a year after surgery. Demarcation between graft on host bone visible in the immediate postoperative time has progressively diasappeared, the gap being filled with new bone.

GRO.

03.99 03.99

Same case 11 y. PO. We can hardly distinguish the graft from the host bone

JAN.

03.9102.98

Another case, radiological result at 7 y. PO

JAN.

07.02

And at 11 y. PO

TRA.

05.88 02.89

The first case operated on in 1988 with the double sheath technique

TRA.

01.99 (10 y. PO) 02.02 (13 y. PO)

2010

X-rays 22 y. PO

MATERIAL

17 WOMEN 9 MEN

Average age 67 y. (53 to 83)

Operated on from 1988 to 2000

27 femoral reconstructions associated with

24 acetabular reconstructions

CHARNLEY-KERBOULL PROSTHESIS

22 Standard

5 Long stem (200 to 250 mm)

MATERIAL

PRIMARY DIAGNOSIS

25 coxarthrosis

16 primary

9 secondary

1 osteonecrosis

1 rheumatoid arthritis

MATERIAL

PREVIOUS FAILURE OF THR

Average 2,1 (1 to 8)

LOOSENINGS :

- Femoral 27 (mechanical 24, septic 3)

- Acetabular 24 (mechanical 21, septic 3)

FEMORAL DEFICIENCIES

SOFCOT

• TYPE III 17• TYPE IV 10

AAOS

• TYPE III 27

Level II 9

Level III 18

CLASSIFICATION

FOLLOW-UP

Physical and radiological examination at 6 w., 3 m., 1 y. and then every one or two years.

AVERAGE FOLLOW-UP 9 y. (3 to 22 y.)

LOST 0

DECEASED 4 (5 hips)

between 2 and 6 y. PO

COMPLICATIONS

3 NON UNION OF THE GREATER TROCHANTER

2 revised, 1united

1 LATE DISLOCATION

1 FEMORAL FRACTURE (at 2 y.)

united after plating

1 FATIGUE FRACTURE OF THE FEMUR (1 y. PO)

spontaneously united

BER.

02.97 10.97 (8 m. PO)

BER.

(11 m. PO)

01.98 01.98

BER.

11.98 03.03

This fracture spontaneously united X-rays 6 y. PO

CLINICAL RESULTS (d’Aubigné score)

PAIN 3 5.9

MOTION 5.2 5.8

STABILITY AND WALKING 3.4 5.6

GLOBAL FUNCTION 11.6 17.4

EXCELLENT (18) 18

VERY GOOD (17) 5

GOOD (16) 1

FAIR (15) 2

POOR (14) 1

23

RADIOLOGICAL RESULTS

SUCCESSES 25

Graft host-bone union

No loosening

No resorption of the graft

No subsidence of the graft

POTENTIAL FAILURE 1

Partial resorption of the graft

No loosening

ACTUAL FAILURE 1

Partial resorption of the graft

Femoral loosening

Not revised

LOZ.

06.90 03.91Reccurent loosening due to chronic infection. Femoral reconstruction with massive intra medullary graft

Early (9 months) resorption of the graft and loosening of the stem

LOZ.

05.94 (4 y. PO)

11.97 (7 y. PO)

He couldn’t be reoperated on because of poor cardiovascular conditions

Despite this failure, this reconstruction procedure seems to be valuable and reliable enough to allow us to extend this short series.