femoral reconstruction with allografts m. kerboull
TRANSCRIPT
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FEMORAL RECONSTRUCTION
WITH ALLOGRAFTS
M. Kerboull
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Revision with a cemented prosthesis
Femoral restoration with allografts
Standard femoral component
Perfectly suitable to a sound cemented fixation
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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
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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
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ENDOMEDULLARY FEMORAL RECONSTRUCTION
WITH MASSIVE FEMORAL ALLOGRAFT
« Double sheath technique »
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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
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ITS MAIN INDICATION IS EXTENSIVE OSTEOLYSIS DUE TO AGGRESSIVE GRANULOMATOSIS
THAT HAS THINNED DOWN CORTICES
WIDENING THE MEDULLARY CANAL
AND LOOSENING THE FEMORAL COMPONENT
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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
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A. After prosthesis and cement removal, reaming and cleaning the medullary canal
B. A massive proximal femoral allograft is introduced through the cervical orifice
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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.
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Some examples to illustrate
this technique
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DUR.
06.9604.95
Loosening of a rough titanium stem Bone restoration with a massive graft
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ALB.
09.98 10.98
Loosening of the matte stemwith femoral osteolysis
Bone reconstruction
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BEA.
03.9705.98
A big matte stemFemoral restoration 1 y. PO
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De.G.R.
09.97 11.97
Another case of femoralloosening with osteolysis
Double sheath technique 2 months. PO
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GAR.
09.99 12.99
Cement bone loosening of a bigmatte titanium stem
Bone restoration withMassive intra medullary allograft3 months PO
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ROB.
06.91 09.93
Major destruction of femoral cortices
Bone restoration with massivegraft and strut graft
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ROB.
09.9809.98
Same case. 7 y. POAP view
Lateral view
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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
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BEG.
03.98 03.98
Lateral diaphysal cortical defect Restoration with massive graft and a 200 mm stem
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BEG.
(2 y. PO)
07.0007.00
At 2 y. PO excellent bone union between graft and host bone
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BEG.
03.98 07.00 12.02 12.02
Same case AP radiograph 5 y. PO
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2007
9 years PO AP view
Excellent function
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09.88
GRO.
07.88
Loosening of the femoral component Reconstruction with massive intra medullary graft
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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.
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GRO.
03.99 03.99
Same case 11 y. PO. We can hardly distinguish the graft from the host bone
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JAN.
03.9102.98
Another case, radiological result at 7 y. PO
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JAN.
07.02
And at 11 y. PO
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TRA.
05.88 02.89
The first case operated on in 1988 with the double sheath technique
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TRA.
01.99 (10 y. PO) 02.02 (13 y. PO)
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2010
X-rays 22 y. PO
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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)
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MATERIAL
PRIMARY DIAGNOSIS
25 coxarthrosis
16 primary
9 secondary
1 osteonecrosis
1 rheumatoid arthritis
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MATERIAL
PREVIOUS FAILURE OF THR
Average 2,1 (1 to 8)
LOOSENINGS :
- Femoral 27 (mechanical 24, septic 3)
- Acetabular 24 (mechanical 21, septic 3)
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FEMORAL DEFICIENCIES
SOFCOT
• TYPE III 17• TYPE IV 10
AAOS
• TYPE III 27
Level II 9
Level III 18
CLASSIFICATION
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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
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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
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BER.
02.97 10.97 (8 m. PO)
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BER.
(11 m. PO)
01.98 01.98
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BER.
11.98 03.03
This fracture spontaneously united X-rays 6 y. PO
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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
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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
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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
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LOZ.
05.94 (4 y. PO)
11.97 (7 y. PO)
He couldn’t be reoperated on because of poor cardiovascular conditions
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Despite this failure, this reconstruction procedure seems to be valuable and reliable enough to allow us to extend this short series.