Proximal femoral reconstructions with bone impaction grafting and metal mesh

Revision Total Hip Arthroplasty Using a Tibial Cone and Impaction Grafting for Severe Femoral Bone Loss: A Case Report

CASE

An 84-year-old woman presented 6 years after revision total hip arthroplasty (rTHA) with worsening hip pain and a Paprosky classification IIIB femoral defect. rTHA was performed using a proximal femur replacement. Given her osteoporosis and poor bone stock, a tibial cone and impaction grafting (IG) were used for megaprosthesis fixation. At the 33-month follow-up, the patient was pain-free and radiographs demonstrated a well-fixed implant.

CONCLUSION

In the setting of massive defects of poor-quality bone, novel use of a tibial cone and IG can be implemented to achieve implant fixation and maximize patient outcomes.

The major proximal femoral defects: megaprosthesis in non oncological patients - A case series

We identified 39 patients (23 female and 16 male) underwent hip revisions through mega-prosthesis. The most common causes were periprosthetic fractures, periprosthetic osteolysis and consequences of infected arthroplasty. The average follow-up was 5 years (2.1 to 6.5), and average age was 69 years (47 to 78). At the final follow-up all the implants resulted functional and osteointegrated. The Merle D'Aubignè and Postel hip rating scale was used for the evaluation, better results were observed in periprosthetic fractures. Postoperative complications occurred in eight patients. Thus, megaprosthesis were a reasonable surgical option in the management of major femoral defects.

Favorable mid-to-long-term results of impaction bone grafting using a fresh frozen allograft bone with cemented stem for the treatment of Paprosky IV femoral bone defects

BACKGROUND

Femoral revision surgery in patients with substantial bone loss is challenging. Impaction bone grafting using a cemented stem can be a good solution for reconstruction of the femur with poor bone stock and extensive bone loss. This study aimed to evaluate the mid-to-long-term clinical and radiographic results of impaction bone grafting using a cemented stem for Paprosky IV femoral bone defects.

METHODS

Thirteen patients (13 hips) who underwent revision total hip arthroplasty with impaction bone grafting using a cemented stem and were followed up for at least 5 years were enrolled in this study. In all patients, a sufficient amount of fresh frozen bone of good quality was used. When cortical segmental defects were present, peripheral reinforcement with metal mesh and strut allograft was performed. The average follow-up duration was 11.1 (range, 5.3-15.1) years. The clinical and radiographic outcomes were reviewed at the final follow-up.

RESULTS

The average Harris hip score was 82.5 (range, 79-94), and the average University of California, Los Angeles activity score was 5.6 (range, 4-8) at the final follow-up. Radiographic assessment revealed an average femoral component subsidence level of 0.67 (range, 0.05-2.81) mm. There were no complications, except one case (7.6%) of periprosthetic fracture.

CONCLUSIONS

Impaction bone grafting using a cemented stem yielded excellent mid-to-long-term outcomes. It is a reliable technique for Paprosky IV femoral bone defects, and even when severe femoral cortical bone defects are present, long-term stability can be obtained using a metal mesh and/or strut allograft.

The Use of Megaprostheses in Nononcologic Lower-Extremity Total Joint Arthroplasty: A Critical Analysis Review

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As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function.

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Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise.

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Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function.

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Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status.

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Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs.

Distal femoral impaction bone grafting in revision for tumor endoprosthesis

BACKGROUND

Reconstruction using tumor endoprosthesis has been widely used in cases with large bone defects caused by bone and soft tissue tumor resection of the distal femur which extend into the knee joint. However, reconstruction failure can lead to major problems in the long term. We have been performing impaction bone grafting with allogeneic cancellous bone during revision surgery for tumor endoprosthesis of the distal femur to compensate for the thinness and fragility of the remaining femur. The aim of this study is to examine the surgical method, problems, and clinical outcomes of revision surgery with impaction bone grafting.

METHODS

Three patients who underwent revision surgery for tumor endoprosthesis using impaction bone grafting at our institution with more than 2 years of follow-up were included.

RESULTS

Union between the graft and host bone were achieved in all cases. The mean time to radiographic union was 1.0 year (0.6-1.5 years). Although intraoperative penetration to the anterior cortex of the distal femur occurred in 2 cases, there were no postoperative fractures. There were no failures of tumor endoprosthesis at final observation.

CONCLUSION

Good short-term results were observed in 3 patients who underwent revision tumor endoprosthesis with impaction bone grafting following a bone and soft tissue tumor resection of the distal femur. The method was considered to be a useful treatment option. Impaction bone grafting is an established surgical option that can be applied to revision surgery for tumor endoprosthesis.

Aggressive granulomatosis of the hip: a forgotten mode of aseptic failure

PURPOSE

It has been acknowledged that implant wear correlates with the risk for periprosthetic osteolysis, being aggressive granulomatosis the worst expression of bone resorption. We sought to determine the clinical, radiological, and histological features of aggressive granulomatosis after primary total hip arthroplasty (THA).

METHODS

We included nine cases with aggressive granulomatosis of the hip around cemented stems. Indications for revision THA consisted of progressive signs of extensive bone resorption or implant loosening. Mean follow-up since revision THA was 143 months (SD ± 59.4). We analysed clinical outcomes, component loosening and gross as well as histological characteristics of the granulomatous lesions.

RESULTS

Overall mean time between primary THA and revision surgery was 81 months (SD ± 20.8). All of the cases evidenced multiple ovoid tumour-like lesions around the stem with extensive bone loss. Only one case reported thigh pain before revision surgery, with radiological evidence of stem loosening; the remaining cases were asymptomatic with well-fixed implants. Gross anatomy findings revealed metallosis in the femoral canal and inside the cystic lesions. Pathology analysis showed monocyte-macrophage-dominated adverse foreign-body-type tissue reaction with fibroblastic reactive zones and granulomatous inflammation.

CONCLUSIONS

We found a prevalence of 1% of this aseptic mode of implant failure. Since most of the retrieved stems were not loose, we did not find any alarming clinical symptoms anticipating implant failure. In this scenario, surgeons should be aware of the rapidly progressive nature of this entity and propose a revision THA in a timely fashion.

Proximal femoral replacement in non-oncologic patients undergoing revision total hip arthroplasty

PURPOSE

Proximal femoral replacements (PFRs) have been recently utilized in complex revision arthroplasties where proximal femoral bone is compromised. The purpose of this study is to evaluate the clinical outcomes, complications, and survivorship of PFRs as a salvage treatment for severe bone loss after non-oncologic revision total hip arthroplasty.

METHODS

This is a retrospective review of all patients who underwent femoral revision surgery using a single design PFR between 2004 and 2013 at our institution. Forty patients (41 hips) were included with a mean age of 64 years (29-90). According to Paprosky classification, 15 femurs had type IIIB defect, and 26 had type IV defect. Patients were followed for a mean of five years (2-10). The average length of reconstruction was 150 mm (81-261). A Kaplan-Meier analysis was used to determine the survival of the PFR.

RESULTS

A total of nine patients (9 PFRs, 22%) were re-operated upon. Three re-operations were for infection, two for dislocation, two for aseptic loosening, and two for periprosthetic fracture. The survivorship at five years was 95.1% for revision of the femoral stem for aseptic loosening. We did not find length of the segmental reconstruction or the indication for revision, to be a risk factor for implant failure or re-revision.

CONCLUSIONS

Proximal femoral replacements have shown an acceptable survivorship in non-oncologic revision hip arthroplasties for severe proximal femoral bone loss. The frequent use of constrained liners may decrease the risk of dislocation due to the loss of the abductor mechanism encountered in these complex reconstructions.

Proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss

Aims

Loss or absence of proximal femoral bone in revision total hip arthroplasty (THA) remains a significant challenge. While the main indication for the use of proximal femoral replacements (PFRs) is in the treatment of malignant disease, they have a valuable role in revision THA for loosening, fracture and infection in patients with bone loss. Our aim was to determine the clinical outcomes, implant survivorship, and complications of PFRs used in revision THA for indications other than malignancy.

Patients and Methods

A retrospective review of 44 patients who underwent revision THA using a PFR between 2000 and 2013 was undertaken. Their mean age was 79 years (53 to 97); 31 (70%) were women. The bone loss was classified as Paprosky IIIB or IV in all patients. The mean follow-up was six years (2 to 12), at which time 22 patients had died and five were lost to follow-up.

Results

The mean Harris Hip Score improved from 42.8 (25.9 to 82.9) pre-operatively to 68.5 (21.0 to 87.7) post-operatively (p = 0.0009). A total of two PFRs had been revised, one for periprosthetic infection eight years post-operatively and one for aseptic loosening six years post-operatively. The Kaplan-Meier survivorship free of any revision or removal of an implant was 86% at five years and 66% years at ten years. A total of 12 patients (27%) had a complication including six with a dislocation.

Conclusion

PFRs provide a useful salvage option for patients, particularly the elderly with massive proximal femoral bone loss who require revision THA, with significant clinical improvement. While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. The judicious use of larger femoral heads, dual-mobility constructs, or constrained liners may help to minimise the risk of dislocation. Cite this article: Bone Joint J 2017;99-B:325–9.

Nickel-Titanium Shape-Memory Sawtooth-Arm Embracing Clamp for Complex Femoral Revision Hip Arthroplasty

PURPOSES

To examine the clinical outcomes of patients treated with a nickel-titanium shape-memory sawtooth-arm embracing clamp (Ni-Ti SSEC) in complex femoral revision surgery.

METHODS

We retrospectively evaluated the outcomes for 21 complex femoral revision hip arthroplasties that we treated using an Ni-Ti SSEC. The Ni-Ti SSEC was used for various procedures, including the fixation of extremely long cortical windows (11 patients), femoral shaft osteotomy (4 patients), an extended trochanteric osteotomy (3 patients), and protection of a penetrated femoral cortex by a primary stem (3 patients). All patients received follow-up care for an average of 48.2 months.

RESULTS

The mean time of Ni-Ti SSEC insertion intraoperatively was 6 minutes. The mean Harris Hip Score improved from 21.2 points before revision surgery to 83.1 points at the most recent examination. No implant failures or malunions occurred. Dislocation and deep infection occurred in 1 case during the follow-up period.

CONCLUSIONS

Our results show that the embracing clamp is a simple and valid method for fixing osteotomies in treating complex femoral revision surgery.

Fracture of the C-Stem cemented femoral component in revision hip surgery using bone impaction grafting technique: report of 9 cases

We present a series of 9 fractures of a C-Stem femoral component (6 long stems and 3 conventional stems) that had been implanted with the use of impaction bone grafting (IBG). The length of the long fractured stems was 240 mm in 4 cases and 200 mm in 2. The patients presented had an average BMI of 26.5 and an average of 2.7 previous hip surgeries (range 2-5 surgeries) before the stem fracture. A total of 5 cases presented with a metal mesh fracture in addition to the fractured stem. Bending of the stems or stem defects was not observed in any case. Typical fracture waves consistent with fatigue failure were clearly visible on all the cut surfaces, starting anterolaterally and propagating to the medial side. Although fatigue fracture of a modern cemented tapered polished femoral stem is a rare event, stress due to the absence of proximal femoral bone support could be sufficient to put this stem at a higher risk for fatigue fracture in non-obese patients.

[Clinical-radiological evaluation of the impaction allografting and cemented rod technique in revision knee surgery]

OBJECTIVE

Long term clinical and radiological evaluation of results, survival, and peri- operative and post-operative complications of the patients who have been operated on for revision total hip arthroplasty using the impaction allografting and cemented rod technique.

MATERIAL AND METHODS

An observational, analytical, prospective and non-random study was conducted on 26 patients who underwent revision total hip arthroplasty in our Hospital (1997-98). They were clinically and radiologically assessed, and a survival analysis of the implant was performed.

RESULTS

Statistically significant differences were identified in the pre- and post-operative values, according to Harris and Merle D́Aubigne scores. The femoral components survival was considered as an endpoint of the revision replacement, which was 84% at a mean of 13 years. There were 9 intraoperative complications (6 were fractures) and they significantly affected the length of hospital stay. No post-operative complications were observed in 70% of the patients. None of the analysed variables had any influence on the radiological subsidence of the femoral component.

DISCUSSION

Several techniques aim to solve the bone stock deficiency in revision total hip arthroplasty, but only impaction grafting attempts to recover it.

CONCLUSIONS

The Ling's technique shows an improvement over the Merle D́Aubigne and Harris scores, in the medium-long term. The intraoperative complications are mainly an increase in the length of hospital stay and the number of days needed to be able to sit down. Ling's technique is a good option to consider in young patients where it is foreseeable that there is a new revision surgery in the future.

Revision total hip arthroplasty in patients with extensive proximal femoral bone loss using a fluted tapered modular femoral component

Revision total hip arthroplasty (THA) is challenging when there is severe loss of bone in the proximal femur. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision THA in patients with severe proximal femoral bone loss treated with a fluted, tapered, modular femoral component. Between January 1998 and December 2004, 92 revision THAs were performed in 92 patients using a single fluted, tapered, modular femoral stem design. Pre-operative diagnoses included aseptic loosening, infection and peri-prosthetic fracture. Bone loss was categorised pre-operatively as Paprosky types III-IV, or Vancouver B3 in patients with a peri-prosthetic fracture. The mean clinical follow-up was 6.4 years (2 to 12). A total of 47 patients had peri-operative complications, 27 of whom required further surgery. However, most of these further operations involved retention of a well-fixed femoral stem, and 88/92 femoral components (97%) remained in situ. Of the four components requiring revision, three were revised for infection and were well fixed at the time of revision; only one (1%) was revised for aseptic loosening. The most common complications were post-operative instability (17 hips, 19%) and intra-operative femoral fracture during insertion of the stem (11 hips, 12%). Diaphyseal stress shielding was noted in 20 hips (22%). There were no fractures of the femoral component. At the final follow-up 78% of patients had minimal or no pain. Revision THA in patients with extensive proximal femoral bone loss using the Link MP fluted, tapered, modular stem led to a high rate of osseointegration of the stem at mid-term follow-up. Cite this article: Bone Joint J 2015; 97-B:312-17.

Proximal femoral reconstruction with impaction bone grafting and circumferential metal mesh

INTRODUCTION

Impaction bone grafting (IBG) using a circumferential metal mesh is one of the options that allow restoration of the femoral bone stock and stability of the implant in revision hip arthroplasty. Here we examine the clinical and radiographic outcome of this procedure using a cemented stem, including experimental analysis of the initial stability of mesh-grafted bone-cemented stem complexes.

METHODS

We retrospectively reviewed six hips (six patients) that had undergone femoral revisions with a circumferential metal mesh, impacted bone allografts, and a cemented stem. The mean follow-up period was 3.9 years (range 2.4-4.8 years). Hip joint function was evaluated using the Japanese Orthopaedic Association hip score, and radiographic changes were determined from radiographs. The initial resistance of mesh-grafted bone-cemented stem complexes to axial and rotational force was measured in a composite bone model with various segmental losses of the proximal femur.

RESULTS

The hip score improved from 50 (range 10-84) preoperatively to a mean of 74 (range 67-88) at the final follow-up. The overall implant survival rate was 100 % at five years when radiological loosening or revision for any reason was used as the endpoint. No stem subsided more than 3 mm vertically within one year after implantation. Computed tomography showed reconstitution of the femoral canal in a metal mesh. In mechanical analyses, there was no relationship between IBG reconstruction rates under axial compression and stem subsidence or failure load. In contrast, under rotational load, the rotation angles of the stem to the stainless steel mesh were strongly affected by the IBG reconstruction rate.

CONCLUSIONS

The short-term results show good outcomes for reconstruction of proximal bone loss with IBG and a circumferential mesh. The procedure should be applied in cases where the circumferential proximal bone loss is less than half the length of the implanted stem.

Proximal femoral reconstruction after aseptic loosening following proximal femoral replacement for Ewing sarcoma: a case report with one-year follow-up

We report the case of a 30-year-old patient initially treated for a proximal femoral Ewing's sarcoma when 12 years old. Index treatment comprised tumour resection and total hip arthroplasty. Two years later revision for aseptic loosening was performed. Subsequently, six further surgical revisons were performed for varying causes. At the age of 23 years the proximal femur was resected and a proximal femoral endoprosthesis implanted.Eighteen years after initial diagnosis the patient presented with recurrent aseptc loosening. Both the proximal femur and acetabulum were reconstructed. For acetabular reconstruction a structural allograft and a tantalum cup were utilised. Reconstruction of the femur utilsed extensive wire mesh and circlage wiring with impaction bone allograft into which a femoral stem was implanted.At one-year follow-up the patient was pain free, had no evidence of infection with satisfactory radiographs and no evidence of implant loosening. This is the first case reporting an extended proximal femoral reconstruction with a wire mesh in combination with impaction bone grafting in an aseptic loosened proximal femoral replacement following Ewing's Sarcoma.

Age-dependent fracture risk in hip revisions with radial impaction grafting technique: a 5-10 year medium-term follow-up study

Radial impaction grafting (RIG) potentially improves the durability and reliability of cementing the femoral components in revision total hip arthroplasty (THA). In this multicenter, prospective study, 88 revision THAs (87 patients) with RIG technique were performed. The average follow-up time was 7.0 years (range, 5.0-10.2). There were 14 femur fractures: 2 intraoperative, 5 within 3 months after surgery, and 7 later in the postoperative stage (range, 5-84 months). Sixteen patients were lost to follow-up and 20 died without stem re-revision. None of the patients have been re-revised for any reason during follow-up. Age was observed to be a significant factor for determining fracture risk. In conclusion, RIG can be considered a reliable surgical technique, especially for younger patients.

Femoral impaction grafting

Femoral impaction grafting is a reconstruction option applicable to both simple and complex femoral component revisions. It is one of the preferred techniques for reconstructing large femoral defects when the isthmus is non-supportive. The available level of evidence is primarily derived from case series, which shows a mean survivorship of 90.5%, with revision or re-operation as the end-point, with an average follow-up of 11 years. The rate of femoral fracture requiring re-operation or revision of the component varies between several large case series, ranging from 2.5% to 9%, with an average of 5.4%.

The extent of the bone defect affects the outcome of femoral reconstruction in revision surgery with impacted bone grafting: a five- to 17-year follow-up study

We report the results of 79 patients (81 hips) who underwent impaction grafting at revision hip replacement using the Exeter femoral stem. Their mean age was 64 years (31 to 83). According to the Endoklinik classification, 20 hips had a type 2 bone defect, 40 had type 3, and 21 had type 4. The mean follow-up for unrevised stems was 10.4 years (5 to 17). There were 12 re-operations due to intra- and post-operative fractures, infection (one hip) and aseptic loosening (one hip). All re-operations affected type 3 (6 hips) and 4 (6 hips) bone defects. The survival rate for re-operation for any cause was 100% for type 2, 81.2% (95% confidence interval (CI) 67.1 to 95.3) for type 3, and 70.8% (95% CI 51.1 to 90.5) for type 4 defects at 14 years. The survival rate with further revision for aseptic loosening as the end point was 98.6% (95% CI 95.8 to 100). The final clinical score was higher for patients with type 2 bone defects than type 4 regarding pain, function and range of movement. Limp was most frequent in the type 4 group (p < 0.001). The mean subsidence of the stem was 2.3 mm (SD 3.7) for hips with a type 2 defect, 4.3 mm (SD 7.2) for type 3 and 9.6 mm (SD 10.8) for type 4 (p = 0.022). The impacted bone grafting technique has good clinical results in femoral revision. However, major bone defects affect clinical outcome and also result in more operative complications.

Impaction bone grafting with proximal and distal femoral arthroplasty

Capacious diaphyses and poor bone stock in revision arthroplasty can lead to fracture and poor component fixation. Impaction bone grafting can be performed in salvage reconstructions in cases with extensive circumferential bone loss. We present a consecutive series of patients who underwent proximal or distal femoral reconstructions in combination with impaction bone grafting. The average age was 62 years, and the mean follow-up was 36 months (range, 24-84). No revisions were performed for mechanical failure, and radiographs revealed no evidence of implant loosening. No patient complained of end-of-stem thigh pain. There were 3 failures: 1 for periprosthetic fracture, 1 for instability, and 1 for infection. Impaction bone grafting can be used in combination with proximal and distal femoral arthroplasty to successfully manage cases with extensive bone loss after failed hip and knee arthroplasty. The procedure reconstitutes necessary bone stock, improves stress shielding, and provides immediate fixation in capacious canals.