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Reconstruction of bone defects with impacted allograft in femoral stem revision surgery

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Abstract

A retrospective clinical review was done on 54 revision hip patients. Radiological analysis examined the Gross and AAOS classifications, stem position, cement mantles, allograft and evolution (subsidence, resorption and remodelling). The Harris Hip score was used for clinical assessment. We used bone bank allograft and a polished non-collared stem LD. The follow-up period was 60.5 months (19.4–152.4), and the average age 68.5 (range: 22–85). There were 21 females and 33 males. The surgical approach was: lateral (5.56%) posterior (91.4%); trochanteric osteotomy: 25.9%; associated acetabular revision: 59.3%; previous operations: 1.9. The preoperative Harris score was 35 (28–40) and rose to 81 (50–99) postoperatively. The stem alignment was neutral (44.44%), varus (38.89%) and valgus (16.67%). The femur/stem diameter relationship was 1.8 (1.2–2.7). There were no changes in stem alignment in 94.4%. An adequate cement mantle was: proximal zone (61.1%), medium zone (27.8%) and distal zone (16.7%). The rate of any subsidence was 38.9% (progressive: 12.96%). The rate of complications was 40.7% and included periprosthetic fracture: 14.8%; superficial infection: 1.9%; deep late infection: 1.9%; dislocation: 3.7%; heterotopic ossification: 13%. The rate of new stem revision was 16.6%. The clinical and radiological success rate was 77.78%. A greater incidence of revisions has been found in stem malalignment, progressive subsidence, a Harris increase of <20 points, allograft resorption, small diameter stems and inadequate cement mantle. We recommend hard impaction and a cement mantle of at least 2 mm. Non-progressive subsidence does not increase stem loosening. The technique has been useful in recovering bone stock in a severely defective femur and achieves a stable reconstruction. The level of evidence was therapeutic study level III-2 (retrospective cohort study; see the instructions to the authors for a complete description of the levels of evidence).

Résumé

Une étude rétrospective a été réalisée chez 54 patients avec une analyse radiographie, selon la classification de Gross et de l’AAOS avec analyse de la position de la pièce fémorale, de l’aspect du manteau de ciment et de l’évolution de l’allogreffe (migration, résorption, remodelage). Les évaluations cliniques ont été réalisées selon le score de Harris. Nous avons utilisé une allogreffe de banque et une pièce fémorale polie sans appui sur le Merckel (LD). Le suivi a été de 60.5 mois (19.4 à 152.4), l’âge moyen de 68.5 (22 à 85). Vingt et un patients étaient de sexe féminin et 33 de sexe masculin. La voie d’abord a été latérale (5.56%), postérieure dans 91.4%. L’ostéotomie du grand trochanter a été réalisée dans 25.9%. Une révision de la cupule acétabulaire a eu lieu dans 59.3%. Tous ces patients présentaient en moyenne 1.9 intervention, le score préopératoire de Harris était de 35 (28 à 40) et post-opératoire de 81 (50 à 99). La pièce fémorale était en position neutre dans 44.44%, en varus dans 38.89% et en valgus dans 16.67%. La relation entre le diamètre du fémur et la pièce fémorale était de 1.8 (1.2–2.7). Aucune modification de la pièce fémorale n’a été observée dans 94.4% des cas avec un bon aspect du manteau du ciment proximal dans 61.1%, médial (27.8%), distal (16.7%). Aucune migration n’a été observée dans 38.9% (progressive: 12.96%). Les complications sont au nombre de 40.7%: fracture périprothétique 14.8%, infection superficielle 1.9%, infection profonde 1.9%, luxation 3.7%, ossifications hétérotopiques 13%, nouvelle révision 16.6%. Nous avons observé un succès dans ré-intervention dans 77.78%. En conclusion, les critères de révision ont été la mauvaise position de la pièce fémorale et une migration progressive de celle-ci, un score de Harris inférieur à 20 points, une résorption de l’allogreffe, une petit diamètre de la pièce fémorale et un aspect inadéquat du manteau de ciment. Nous recommandons l’impaction à frottement dur avec un manteau de ciment d’au moins 2 mm. Aucune migration progressive ne doit survenir. Cette technique est utile pour retrouver un bon stock osseux.

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Authors and Affiliations

  1. Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico San Carlos de Madrid, Madrid, Spain

    Alberto Francés, Enrique Moro, Juan-Luis Cebrian, Fernando Marco, Antonio García-López, David Serfaty & Luis López-Durán

  2. Valleinclán 8, no. 5, piso 3A, Boadilla del Monte, 28660, Madrid, Spain

    Alberto Francés

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  1. Alberto Francés
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  2. Enrique Moro
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  3. Juan-Luis Cebrian
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  4. Fernando Marco
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  5. Antonio García-López
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  6. David Serfaty
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  7. Luis López-Durán
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Correspondence to Alberto Francés.

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Francés, A., Moro, E., Cebrian, JL. et al. Reconstruction of bone defects with impacted allograft in femoral stem revision surgery. International Orthopaedics (SICO 31, 457–464 (2007). https://doi.org/10.1007/s00264-006-0211-y

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  • DOI: https://doi.org/10.1007/s00264-006-0211-y

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