Page 1 of 5

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Macpherson GJ, Gotterbarm T, Aldinger PR, Mau H, Breusch SJ. Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature. Hard Tissue 2013 Apr 04;2(3):25. Co

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Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case

report and review of the literatureGJ Macpherson1*, T Gotterbarm2, PR Aldinger3, H Mau4, SJ Breusch1

AbstractIntroductionThe management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient’s bone. This case report dis-cusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty.Case reportWe present the operative technique and long-term fate of a bivalved fem-oral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement.ConclusionThe use of femoral allograft for aug-menting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case

represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treat-ment of long-bone periprosthetic fractures with poor bone stock.

IntroductionData from joint registries indicate an increase in the number of primary and revision knee arthroplasties be-ing performed each year internation-ally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and 20301. Periprosthetic supracondylar femo-ral fractures can occur intraopera-tively and postoperatively, with an overall incidence of 0.3–2.5% above primary total knee arthroplasties (TKAs)2–7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38%3,6–8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixa-tion4,5,9. Periprosthetic fractures are more common in the elderly popula-tion and in females7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock3,9–11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction

of locked plate technology has revolutionized surgery in the pres-ence of osteoporotic bone12, the use of a combination of cortical femoral allograft and compression plate13 or a bivalved total femoral allograft5,14 may be indicated when a peripros-thetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminu-tion. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group.

In this case report, we aim to provide further evidence that a bi-valved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the pa-tient’s bone stock. This technique can provide a reliable long-term solution in this complex fracture group.

Case reportOne month after primary TKA for val-gus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-present-ed with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with fem-oral head structural allograft.

Three months after discharge, she fell and sustained a spiral peripros-thetic fracture around the femoral stem (Figure 1).

* Corresponding author Email: gavin.macpherson@nhs.net1 Department of Orthopaedic Surgery, The Roy-

al Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK

2 Stiftung Orthopädische Universitätsklinik, Schlierbacher Landstraße 200a, 69118 Hei-delberg, Germany

3 Orthopädischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D-70176 Stuttgart, Germany

4 Endoklinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany

Page 2 of 5

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Macpherson GJ, Gotterbarm T, Aldinger PR, Mau H, Breusch SJ. Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature. Hard Tissue 2013 Apr 04;2(3):25. Com

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Due to the poor bone stock, it was decided to treat the fracture with a total femoral allograft. The donor femur was bivalved and prepared/shaped with high-speed burrs15 to fit the host femur (Figure 2).

After primary fracture reduction with two lag screws and cerclages, the allografts were placed medially and laterally, leaving the vascula-ture along the linea aspera intact. The allografts were temporarily held around the reduced femur with steri-lized hose clamps whilst cerclage wires were sequentially tightened in grooves that had been burred on the outer surface of the allograft to stop the cerclage sliding (Figure 3).

After partial weight bearing for 6 weeks, the patient was walking un-aided at 3 months having achieved full knee extension and 85° flexion. Radiographic allograft integration proximally and distally was observed after 2 years. Four years postop-eratively, she re-presented with an ipsilateral femoral neck fracture and underwent an uncomplicated ce-mented total hip replacement (THR) via a transgluteal approach. Intra-operatively, the proximal allograft docking revealed a smooth contin-ues structure of allograft merging into the host femur. The latest radio-graphs were taken at 8 and 10 years (Figures 4 and 5).

DiscussionThe use of bivalved total femoral al-lograft in the treatment of femoral periprosthetic fractures is not a new technique and has been widely re-ported following fractures around hip arthroplasty implants16–18. Wang et al. in 2002 recommended the use of a combination of compression plate and cortical strut allograft. They reported a 100% union rate but did have one case of osteomyelitis and one malunion after a maximum follow-up of 68 months13. When bi-valved total femoral allografting is compared with locked plate fixation, the use of a cortical allograft and a

Figure 1: Spiral periprosthetic fracture around an uncemented stemmed revision total knee arthroplasty.

Figure 2: Bivalved femoral cortical allograft. Note notches prepared with a high-speed burr. After graft placement, grooves were burred to accommodate the cerclage wires.

Figure 3: Intraoperative image after tightening of all but one cerclage wires. Note one of two temporary hose clamps that were removed prior to wound closure.

locked plate is stiffer than a locked plate alone but is not as stiff as us-ing two locked plates positioned or-thogonally19. The similar modulus of

elasticity between the cortical allo-graft and the host bone reduces the effect of stress shielding20. The use of cortical allograft has the potential

Page 3 of 5

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Macpherson GJ, Gotterbarm T, Aldinger PR, Mau H, Breusch SJ. Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature. Hard Tissue 2013 Apr 04;2(3):25. Co

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In this case of rheumatoid arthritis, we were confronted with extreme-ly poor stock in a patient who had previously sustained multiple os-teoporotic fractures including distal radius and lumbar vertebrae. The initial lateral condyle sinter fracture had occurred after a simple stum-ble, hence meeting the criteria for a pathological fracture secondary to osteoporosis. At revision of the femo-ral component, an allograft femoral head was used to correct the recur-rent valgus deformity and restore de-ficient lateral condyle bone stock. At the time, it was noted that the cancel-lous bone was so weak that it could be indented by digital pressure. Therefore, when the patient re-pre-sented with the second, now dia-physeal periprosthetic fracture, the decision was made to treat the frac-ture with a total bivalved allograft to improve bone stock, as we did not trust internal fixation devices to pro-vide reliable stability to allow mobili-zation of her TKA, which would have been at significant risk of stiffness.

ConclusionTo our knowledge, this case represents the longest (11-year) follow-up of a bivalved total femoral allograft above a stemmed revision TKA published. The radiographs and intraoperative findings during hip replacement have confirmed bony incorporation. In this particular case, the absence of the potential alterna-tive of a locking plate with multiple screws crossing the canal has al-lowed straight forward implantation of a THA, which otherwise would have not been the case. In our opin-ion, bivalved total femoral allograft should be considered for peripros-thetic fractures above TKAs where there is reduced bone stock and/or fracture comminution. The potential advantages of cortical allograft—increased bone stock, reduced stress shielding, acceptable rates of union and customization of the graft—must be weighted against the

Figure 4: (a) and (b): Follow-up radiographs 8 years following bivalved total femoral allograft. Note previous allograft augmented lateral femoral condyle fixed with two cancellous screws. Distal and proximal allograft incorporation and remodelling is evident.

to add to the bone stock if the graft incorporates into the host bone15 and is therefore particularly useful in this patient population who are known to be commonly affected by osteo-porosis21,22. Fracture union rates of 89–100% have been reported with the use of cortical allografts with or without plate fixation for femoral periprosthetic fractures13,16,23,24, and the addition of allograft may enhance the bony union by stimulating the fracture to heal25.

Cortical allografts allow for cus-tomization of the fixation without the expense of having a customized implant manufactured. Shaping the graft to complement the host femur adds to the complexity of the sur-gery and may make the procedure more demanding than either tradi-tional internal fixation methods or the use of an endoprosthesis. The increased complexity of the surgery demands more extensive soft-tissue dissection and periosteal stripping26, which may account for a high rate of

complications, reported as high as 17%27 with deep infection occurring at a rate of 4–13%27–31. The large mass of dead bone may increase the deep infection rate as the devitalized bone allows proliferation of bacteria leading to infection. Disease trans-mission is possible with the use of allograft, but contemporary bone bank protocols have reduced this risk32–34.

The process of incorporation of a strut has been described as go-ing through a number of definable stages (creeping substitution)35. Complete reabsorption is rarely seen in practice; however the stages that precede this reabsorption have been observed in this case and in-clude round off, scalloping, bridging and cancellization35. The most re-cent radiological examination of this patient demonstrated cancellization, but not reabsorption, and this indi-cates revascularization of the corti-cal graft35, which was evident at THR implantation.

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Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Macpherson GJ, Gotterbarm T, Aldinger PR, Mau H, Breusch SJ. Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature. Hard Tissue 2013 Apr 04;2(3):25. Com

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hinges. J Bone Joint Surg Br. 1991 Sep; 73(5):757–61. 9. Culp R, Schmidt R, Hanks G, Mak A, Es-terhai J, Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res. 1987 Sep;222:212–22. 10. Cain PR, Rubash HE, Wissinger HA,McClain EJ. Periprosthetic femoral frac-tures following total knee arthroplasty. Clin Orthop Relat Res. 1986 Jul;208:205. 11. Johnston AT, Tsiridis E, Eyres KS,Toms AD. Periprosthetic fractures in the distal femur following total knee replace-ment: A review and guide to manage-ment. Knee. 2011 Jun;19(3):156–62.12. Greiwe RM, Archdeacon MT. Lock-ing plate technology: current concepts. J Knee Surg. 2007 Jan;20(1):50–5. 13. Wang J-W, Wang C-J. Supracondylarfractures of the femur above total knee ar-throplasties with cortical allograft struts. J Arthroplasty. 2002 Apr;17(3):365–72. 14. Chandler HP, Penenberg BL. Bone stock deficiency in total hip replacement: Classification and management. Slack Inc; 1989. 15. Chandler HP, Tigges RG. InstructionalCourse Lectures, The American Academy of Orthopaedic Surgeons – The role of allografts in the treatment of peripros-thetic femoral fractures. J Bone Joint Surg Am. J Bone Joint Surg.1997 Sep; 79(9):1422–32. 16. Emerson RH, Malinin TI, Cuellar AD,Head WC, Peters PC. Cortical strut allo-grafts in the reconstruction of the femur in revision total hip arthroplasty. A basic science and clinical study. Clin Orthop Relat Res. 1992 Dec;(285):35–44. 17. Haddad FS, Garbuz DS, Masri BA, Dun-can CP. Structural proximal femoral allo-grafts for failed total hip replacements: a minimum review of five years. J Bone Joint Surg Br. 2000 Aug;82(6):830–6. 18. Head WC, Malinin TI. Results of onlayallografts. Clin Orthop Relat Res. 2000 Feb;(371):108–12. 19. Choi JK, Gardner TR, Yoon E, Morrison TA, Macaulay WB, Geller JA. The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthet-ic femur fractures. J Arthroplasty. 2010 Sep;25(6 Suppl.):124–8. 20. Mihalko WM, Beaudoin AJ, Cardea JA,Krause WR. Finite-element modelling of femoral shaft fracture fixation techniques post total hip arthroplasty. J Biomech. 1992 May;25(5):469–76.

arthroplasty. J Bone Joint Surg Am. 1986 Jan;68(1):29–43. 4. Figgie MP, Goldberg VM, Figgie HE,Sobel M. The results of treatment of su-pracondylar fracture above total knee arthroplasty. J Arthroplasty. 1990 Sep; 5(3):267–76. 5. Sisto DJ, Lachiewicz PF, Insall JN. Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop Relat Res. 1985 Jun; 196:265–72. 6. Meek R, Norwood T, Smith R, Brenkel I, Howie C. The risk of peri-prosthetic frac-ture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011 Jan;93(1):96–101. 7. Berry DJ. Epidemiology: hip andknee. Orthop Clin North Am. 1999 Apr;30(2):183–90. 8. Inglis A, Walker P. Revision of failedknee replacements using fixed- axis

potential disadvantages—increased complexity of surgery, risk of infec-tion and disease transmission.

Abbreviations listTHA, total hip replacement; TKA, total knee arthroplasty

References1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr;89(4):780–5. 2. Ritter MA, Faris PM, Keating EM.

Anterior femoral notching and ipsilat-eral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty. 1988;3(2):185–7. 3. Merkel KD, Johnson EW. Supracondy-lar fracture of the femur after total knee

Figure 5: Routine 10-year follow-up radiograph of the pelvis. Note bony incorporation of allograft proximally.

ConsentWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Macpherson GJ, Gotterbarm T, Aldinger PR, Mau H, Breusch SJ. Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature. Hard Tissue 2013 Apr 04;2(3):25. Co

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utho

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para

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read

and

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d th

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31. Ivory JP, Thomas IH. Audit of a bone bank. J Bone Joint Surg Br. 1993 May; 75(3):355–7. 32. Campbell DG, Li P, Stephenson AJ, Oakeshott RD. Sterilization of HIV by gamma irradiation. Int Orthop. 1994 Jun; 18(3):172–6. 33. Conrad E, Gretch DR, Obermey-er MS, Moogk MS, Sayers M, Wilson JJ, et al. Transmission of the hepatitis-C virus by tissue transplantation. J Bone Joint Surg Am. 1995 Feb;77(2): 214–24. 34. Fideler BM, Vangsness CT, Moore T, Li Z, Rasheed S. Effects of gamma irra-diation on the human immunodeficiency virus: a study in frozen human bone-pa-tellar ligament-bone grafts obtained from infected cadavera. J Bone Joint Surg Am. 1994;76(7):1032–5. 35. Emerson R Jr. Basic science of onlay allografts: a review. Instr Course Lect. 2000;49:97–102.

26. Brady O, Garbuz D, Masri B, Duncan C. The treatment of periprosthetic frac-tures of the femur using cortical onlay allograft struts. Orthop Clin North Am. 1999 Apr;30(2):249–57. 27. Parvizi J, Rapuri VR, Purtill JJ, Sharkey PF, Rothman RH, Hozack WJ. Treatment protocol for proximal femoral peripros-thetic fractures. J Bone Joint Surg Am. 2004;86-A Suppl. 2:8–16. 28. Dick HM, Strauch RJ. Infection of mas-sive bone allografts. Clin Orthop Relat Res. 1994 Sep;306:46–53. 29. Lord CF, Gebhardt MC, Tomford WW, Mankin HJ. Infection in bone allografts. Incidence, nature, and treatment. J Bone Joint Surg Am. 1988 Mar;70(3):369–76. 30. Tomford WW, Thongphasuk J, Mankin HJ, Ferraro MJ. Frozen musculoskeletal allografts. A study of the clinical inci-dence and causes of infection associated with their use. J Bone Joint Surg Am. 1990 Sep;72(8):1137–43.

21. Head W, Malinin T, Mallory T, Emerson R. Onlay cortical allografting for the fe-mur. Orthop Clin North Am. 1998 Apr; 29(2):307–12. 22. Head WC, Wagner RA, Emerson RH, Malinin TI. Restoration of femoral bone stock in revision total hip arthro-plasty. Orthop Clin North Am. 1993 Oct;24(4):697–703. 23. Barden B, Knoch von M, Fitzek JG, Löer F. Periprosthetic fractures with ex-tensive bone loss treated with onlay strut allografts. Int Orthop. 2003;27(3):164–7. 24. Haddad FS, Duncan CP, Berry DJ, Lewallen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am. 2002 Jun;84-A(6):945–50. 25. Haddad FS, Duncan CP. Cortical on-lay allograft struts in the treatment of periprosthetic femoral fractures. Instr Course Lect. 2003;52:291–300.