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 SPECIFICATIONS FOR 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 4 TECHNIQUES 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 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 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. 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 Some examples to illustrate this technique DUR. 04.95 Loosening of a rough titanium stem 06.96 Bone restoration with a massive graft ALB. 09.98 Loosening of the matte stem with femoral osteolysis 10.98 Bone reconstruction BEA. 03.97 A big matte stem 05.98 Femoral restoration 1 y. PO De.G.R. 09.97 Another case of femoral loosening with osteolysis 11.97 Double sheath technique 2 months. PO GAR. 09.99 Cement bone loosening of a big matte titanium stem 12.99 Bone restoration with Massive intra medullary allograft 3 months PO ROB. 06.91 Major destruction of femoral cortices 09.93 Bone restoration with massive graft and strut graft ROB. 09.98 Same case. 7 y. PO AP view 09.98 Lateral view 03.98 Extremely severe cortical bone loss 10.99 Double sheath technique Using a 250 mm stem and a long graft 03.03 X-rays 5 y. PO BEG. 03.98 Lateral diaphysal cortical defect 03.98 Restoration with massive graft and a 200 mm stem BEG. (2 y. PO) 07.00 07.00 At 2 y. PO excellent bone union between graft and host bone BEG. 03.98 Same case 07.00 12.02 12.02 AP radiograph 5 y. PO 9 years PO AP view Excellent function 2007 GRO. 07.88 Loosening of the femoral component 09.88 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. 03.91 02.98 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) X-rays 22 y. PO 2010 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 - Acetabular 27 (mechanical 24, septic 3) 24 (mechanical 21, septic 3) FEMORAL DEFICIENCIES CLASSIFICATION AAOS SOFCOT • TYPE III • TYPE IV 17 10 • TYPE III Level II Level III 27 9 18 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 DECEASED 0 4 (5 hips) between 2 and 6 y. PO COMPLICATIONS 3 1 1 1 NON UNION OF THE GREATER TROCHANTER 2 revised, 1united LATE DISLOCATION FEMORAL FRACTURE (at 2 y.) united after plating 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 This fracture spontaneously united 03.03 X-rays 6 y. PO CLINICAL RESULTS (d’Aubigné score) PAIN MOTION STABILITY AND WALKING 3 5.2 3.4 5.9 5.8 5.6 GLOBAL FUNCTION 11.6 17.4 EXCELLENT VERY GOOD GOOD FAIR POOR (18) (17) (16) (15) (14) 18 5 1 2 1 23 RADIOLOGICAL RESULTS SUCCESSES Graft host-bone union No loosening No resorption of the graft No subsidence of the graft 25 POTENTIAL FAILURE Partial resorption of the graft No loosening 1 ACTUAL FAILURE Partial resorption of the graft Femoral loosening Not revised 1 LOZ. 06.90 Reccurent loosening due to chronic infection. Femoral reconstruction with massive intra medullary graft 03.91 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.