Femoral reconstruction with allografts

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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.
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