The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 5

Scientific Articles | May 01, 2006

Proximal Femoral Allograft Treatment of Vancouver Type-B3 Periprosthetic Femoral Fractures After Total Hip Arthroplasty

Anthony C. Maury, MSc, FRCS(T&O)¹; Ari Pressman, MD, FRCSC¹; Barry Cayen, MD¹; Paul Zalzal, MD, FRCSC¹; David Backstein, MD, FRCSC¹; Allan Gross, MD, FRCSC¹

¹ Mount Sinai Hospital, 600 University Avenue, Suite 476A, Toronto, ON M5G 1X5, Canada. E-mail address for A.C. Maury: acjamaury@doctors.org

View Disclosures and Other Information

Note: A.C. Maury would like to acknowledge the generous sponsorship of his clinical fellowship at Mount Sinai Hospital, Toronto, Ontario, Canada, by the John Charnley Trust, which facilitated completion of this study.

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the John Charnley Trust. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at Mount Sinai Hospital, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 May 01;88(5):953-958. doi: 10.2106/JBJS.E.00120

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Abstract

Background: Periprosthetic femoral fractures following total hip arthroplasty are becoming more prevalent. When a fracture occurs in a femur with substantial proximal bone deficiency, the surgical options for revision are limited. One option includes the use of a proximal femoral allograft.

Methods: We retrospectively assessed the results and complications of the use of a proximal femoral allograft to treat twenty-five Vancouver type-B₃ periprosthetic fractures in twenty-four patients. The mean duration of follow-up was 5.1 years. Clinical results were graded with use of the Harris hip score. Radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Failure of the procedure was defined as the need for revision surgery requiring graft removal.

Results: The mean postoperative Harris hip score was 70.8. At the time of the final follow-up, twenty-one of the twenty-four patients reported no or mild pain and twenty-three patients were able to walk; fifteen required a walking aid. The greater trochanter united in seventeen of the twenty-five hips, and osseous union of the allograft to the host femur occurred in twenty hips. There was mild graft resorption in four hips and moderate graft resorption in two. Four (16%) of the twenty-five hips required repeat revision.

Conclusions: The use of a proximal femoral allograft for the treatment of a Vancouver type-B₃ periprosthetic femoral fracture can provide a satisfactory result in terms of pain relief and function at five years.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Periprosthetic femoral fractures occur at a rate of 0.1% to 6% following total hip arthroplasty^1-3. Fracture comminution, bone deficiency, and femoral component loosening make the treatment of these fractures particularly challenging^1,2,4,5, and successful treatment strategies for fractures occurring around a loose femoral component with inadequate bone stock remain elusive^6-13. Duncan and Masri⁶ classified fractures into three patterns with use of the so-called Vancouver classification system.

Current treatment options include traction, cast-bracing, open reduction and internal fixation supplemented by cortical strut-grafting, and revision arthroplasty^14-19. In instances of extreme bone deficiency, revision arthroplasty options are limited to the use of a long-stemmed, uncemented femoral component or a proximal femoral replacement with either a tumor-type megaprosthesis or an allograft-prosthesis composite.

The present retrospective review describes the clinical and radiographic results, at a mean of 5.1 years postoperatively, for a series of periprosthetic fractures that were treated with a proximal femoral allograft.

Materials and Methods

Materials and Methods | Results | Discussion | References

We retrieved, from our institution's joint registry, the records for a consecutive series of thirty-four patients with thirty-five Vancouver type-B₃ fractures that had been treated between 1989 and 2001. All patients had been managed with revision arthroplasty with use of a proximal femoral allograft by the senior author (A.G.). At the time of the final review, fifteen patients had died and two had been lost to follow-up, leaving seventeen living patients (eighteen hips). Of the fifteen patients who died, seven patients (seven hips) had been followed for at least two years and therefore were included in the study. Thus, the study group consisted of twenty-four patients (twenty-five hips) with a mean duration of follow-up of 5.1 years (range, two to 12.7 years).

The clinical record and radiographs of each patient were retrospectively reviewed. The Harris hip score was calculated. All patients had initially been seen as the result of an acute periprosthetic fracture; therefore, no preoperative Harris hip scores had been obtained. The diagnosis at the time of primary hip arthroplasty was osteoarthritis for nineteen hips, degenerative hip dysplasia for two, rheumatoid arthritis for two, osteonecrosis for one, and ankylosing spondylitis for one.

Radiographic assessment consisted of fracture classification with use of the Vancouver method⁶. All fractures were classified as type B₃ as they were located around or just distal to a loose femoral component and were associated with inadequate proximal femoral bone stock⁶ (Figs. 1-A and 1-B). Postoperative radiographs were assessed for evidence of trochanteric union, host-allograft union, allograft resorption, and component loosening or fracture. Union was defined as the presence of osseous trabeculae crossing the trochanteric osteotomy site or the allograft-host junction. Radiolucent lines were assessed according to the zones defined by Gruen et al.²⁰. Allograft resorption was defined as mild if there was partial-thickness resorption of one cortex measuring <1 cm in length, as moderate if there was partial-thickness resorption of one cortex measuring >1 cm in length, and as severe if there was any evidence of full-thickness cortical resorption. An implant was defined as loose if there was evidence of migration into varus, subsidence of >3 mm, or fracture of the cement mantle. Failure of the procedure was defined as the need for revision surgery requiring graft removal.

Operative Technique

The allograft used in these procedures was stored at -70°C after irradiation with 2.5 Mrad in accordance with the American Association of Tissue Banks guidelines²¹. Graft preparation was performed on a separate surgical table by a second surgical team while fracture exposure was being performed by the operating surgeon.

Details of the surgical technique are shown in Figures 2-A through 2-F. The fracture was approached with use of a sliding trochanteric osteotomy²². The deficient femoral shaft was osteotomized in the coronal plane. Care was taken to minimize soft-tissue stripping from the femur. To maximize stability at the graft-host junction, a step or oblique cut was made in the host femur. An allograft was chosen that best matched the host bone size radiographically but that would also allow at least a 2-mm-thick implant-bone cement mantle after reaming and broaching. A femoral component length was chosen to allow at least four cortical diameters of implant beyond the anticipated host-allograft junction. The femoral component (Johnson and Johnson, Raynham, Massachusetts) had a matte finish. Seventeen 254-cm, eight 270-cm, and ten 300-cm stems were implanted. The mean length of the proximal femoral allograft was 14.5 cm (range, 9 to 25 cm).

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Figs. 1-A and 1-B: Figs. 1-A and 1-B Preoperative (Fig. 1-A) and postoperative (Fig. 1-B) radiographs of a Vancouver type-B periprosthetic femoral fracture that was treated with proximal femoral allograft femoral revision and cementless socket revision. The graft-host junction was further stabilized with allograft cortical struts and cerclage wires.

The femoral component was cemented into the allograft, and the cement was allowed to polymerize on a separate table; this ensured that no cement would enter the graft-host junction. The allograft-prosthesis composite was then impacted without cement into the host femur. The residual osteotomized host bone was fixed around the junction of the graft and the distal part of the host femur with its soft-tissue attachments intact with use of cerclage wires and the addition of autograft bone that had been obtained from the femur during the process of extracting and débriding the loose implant. The greater trochanter was reattached by passing cerclage wires around the lesser trochanter of the allograft and the greater trochanter of the host.

Postoperatively, patients were managed with intravenous antibiotics for five days and were mobilized without weight-bearing until there was radiographic evidence of allograft-host union, usually at three to six months.

Results

Materials and Methods | Results | Discussion | References

Clinical Results

Eight patients had died and two had been lost to follow-up less than two years postoperatively. The mean Harris hip score for the eight patients who had died was 62.5 (range, 25 to 98) after a mean duration of follow-up of 1.1 years (range, 0.1 to 1.9 years). Three of these patients had reported no pain, four had reported mild pain, and one had reported severe pain. Clinical data were available at six months postoperatively for the two patients who had been lost to follow-up. At that time, both patients had been able to walk with crutches. The Harris hip scores for these two patients were 62 and 29.

The study group included twenty-five hips in twenty-four patients (thirteen men and eleven women) who had had a mean age of 70.2 years (range, sixty to eighty-one years) at the time of surgery. The mean duration of follow-up was 5.1 years (range, two to 12.7 years). The mean postoperative Harris hip score at a minimum of two years of follow-up was 70.8 (range, 18.2 to 95.5). At the time of the final follow-up, twenty-one of twenty-four patients reported no or mild pain. Twenty-three of the twenty-four patients were able to walk; fifteen required a walking aid. Walking distance was limited for all twenty-three patients: two were able to walk in the house only, thirteen were able to walk one to four blocks, and eight were able to walk five to six blocks.

Eighteen patients had a mild abductor lurch, and six patients had a severe lurch. Seventeen hips (in sixteen patients) had a positive Trendelenburg sign.

Radiographic Results

The greater trochanter united in seventeen of the twenty-five hips, and osseous union of the allograft to the host femur occurred in twenty hips. Trochanteric nonunion with >1 cm of migration of the greater trochanter occurred in six hips (24%). The host bone and the proximal femoral allograft failed to unite in four hips (16%). Allograft resorption occurred in six hips (24%). Resorption was seen in Gruen zones 2 and 7 in four hips, Gruen zones 2 and 3 in one hip, and Gruen zones 6 and 7 in one hip. Resorption was mild in four hips and moderate in two. There were no instances of severe resorption necessitating revision surgery.

Three femora had loosening of the proximal femoral allograft as defined by composite subsidence in excess of 3 mm (range, 4 to 8 mm) or progressive varus angulation of the construct. These femora were treated with another proximal femoral allograft; all of these revision allografts have been successful to date.

Of the four hips in which the host bone-allograft junction failed to unite, two hips were treated with observation as they were not painful, one went on to achieve union following internal fixation and bone-grafting of the host-graft junction, and one was revised with a second proximal femoral allograft. There were no deep infections.

Other Complications

Two patients sustained a postoperative hip dislocation and were managed with closed reduction. The dislocation occurred at fourteen months postoperatively in one hip and at twenty months postoperatively in the other, and neither recurred. There were six medical complications in the perioperative period, including two instances of deep venous thrombosis, two myocardial infarctions, one cerebrovascular accident, and one episode of renal failure resulting in death at one month after surgery.

Overall Results

Four (16%) of the twenty-five hips that had been treated with a proximal femoral allograft because of Vancouver type-B₃ periprosthetic fracture had a failure and required repeat revision after a mean duration of follow-up of 5.1 years (range, two to 12.7 years).

Discussion

Materials and Methods | Results | Discussion | References

Periprosthetic fractures about a well-fixed stem (Vancouver type-B₁ fractures) can be treated with internal fixation, and fractures about a loose implant in a femur with adequate bone stock (Vancouver type-B₂ fractures) can be treated with revision hip arthroplasty⁶. However, in the case of a periprosthetic fracture about a loose stem with inadequate bone stock (Vancouver type-B₃ fractures), the challenge is to simultaneously achieve implant and fracture stability. The surgical options include proximal femoral replacement with either a megaprosthesis or an allograft-prosthesis composite²³ or the use of a long uncemented bypass femoral stem with distal fixation²⁴.

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Figs. 2-A, 2-B, 2-C, 2-D, 2-E, and 2-F: Figs. 2-A through 2-F Illustrations depicting the operative procedure. Fig. 2-A Illustration showing a periprosthetic fracture at the tip of the femoral component, with extensive loss of proximal femoral bone stock. A sliding trochanteric osteotomy has been performed. The trochanteric fragment with the attached glutei and vastus lateralis is retracted anteriorly. The posterior centimeter of the greater trochanter with the insertion of the external rotators and the posterior capsule is left attached to the femur to reduce the risk of posterior dislocation. The host femur will undergo an osteotomy in the coronal plane (dotted line) that is carried distally to the fracture site. Fig. 2-B An opening-wedge lateral cortical osteotomy of the proximal part of the femur has been performed to allow removal of the hip component and cement. Fig. 2-C The proximal femoral allograft-cemented femoral component construct with a step-cut distal osteotomy is ready for insertion into the distal part of the host femur. Fig. 2-D The allograft-femoral component construct is inserted into the distal part of the femur and is stabilized by the step-cut junction. A reasonable alternative is to create an oblique junction, which provides a good bone interface and is easier to adjust for optimal anteversion of the femoral component. Locally available host femoral autograft obtained during débridement is added to the host-graft junction. Fig. 2-E The residual proximal part of the host femur and its soft-tissue attachments are secured around the proximal femoral allograft with cerclage wires ideally reaching the graft-host junction to provide a vascularized bone graft to this region. Fig. 2-F The greater trochanter has been attached to the allograft with two cerclage wires. The wires are anchored with drill-holes through the allograft, the lesser trochanter, and the host greater trochanter.

The use of a megaprosthesis was described by Springer et al. in a report involving a limited number of patients²³. The technique has the advantage of initial construct stability that allows immediate patient mobilization. However, Duncan and Masri⁶ reported a higher dislocation rate in comparison with that associated with the use of a proximal femoral allograft and recommended the use of either a bipolar prosthesis or a constrained acetabular liner in conjunction with a megaprosthesis. Additionally, the fixation of a megaprosthesis with or without cement requires the presence of at least 6 cm of diaphyseal bone, which we believe may not be possible in the case of severe bone stock deficiency. Other disadvantages of megaprostheses include the lack of viable soft tissues for reattachment and very limited treatment options should additional revision surgery become necessary. A megaprosthesis therefore may be indicated for patients with a limited life expectancy in whom early mobilization with unrestricted weight-bearing is paramount and who have at least 6 cm of intact diaphyseal bone to achieve adequate fixation.

Berry reported good early results in a study of eight patients with Vancouver type-B₃ fractures that were treated with a long, uncemented, fluted stem²⁴. Although the follow-up period in that report was short (mean, 1.5 years; range, one to two years), the same technique was used successfully in two other reports on revision surgery in the absence of femoral fracture^25,26. This type of stem relies on fixation in the femoral diaphysis for initial stability. Its utility is therefore limited if bone stock deficiency extends beyond the femoral isthmus as distal fixation may be tenuous.

The allograft-prosthesis composite described here offers the advantages of bone stock reconstitution, reattachment of soft tissues to the construct, and the possibility of osseous union of the host greater trochanter. Furthermore, it also can be used in situations in which bone deficiency extends beyond the femoral isthmus. However, absolute construct stability is not conferred until the host-graft junction unites, which usually necessitates a three to six-month period of non-weight-bearing. We are not aware of any other study on the use of proximal femoral allograft to treat Vancouver type-B₃ fractures. However, we are encouraged because one of us (A.G.) and colleagues used the same technique for revision arthroplasty in the absence of femoral fracture and reported satisfactory results after nine to fifteen years of follow-up²⁷. Although the numbers were smaller and the duration of follow-up was shorter in the current report than in the previous report, the functional results and success rates to date are similar.

Certain steps of the technique are essential. First, the cementing technique should include pressurized cementing of the prosthesis into a clean and dry allograft to gain a cement mantle of at least 2 mm; however, a consequence of using a stem that allows a 2-mm cement mantle is that it will not be readily possible to gain a press-fit between the distal part of the stem and the host femoral canal because of the size mismatch of the narrow stem and the large host diaphysis. Second, the femoral stem must be long enough to bypass the host-allograft junction by four cortical diameters. Third, adjunctive screws or plates should be avoided because they may weaken the graft. Fourth, rigid stabilization of the graft-host junction with strut grafts and cerclage wires should be achieved. Fifth, femoral autograft (obtained during the process of extracting and débriding the loose implant) should be placed at the graft-host junction. Sixth, using the host, osteotomized vascularized bone to wrap around the junction can provide a vascular bed for osseous union.

Unfortunately, we were not able to identify any risk factors associated with the occurrence of periprosthetic fracture such as stem design, the presence of stress-shielding, or osteoporosis. Nor were we able to identify any predictors of failure of the proximal femoral allograft in terms of the nature of the cut (step or oblique) at the graft-host junction, the cement mantle thickness, or the prosthesis or allograft length. Two of the composites that subsided were in younger active patients with ages of sixty and sixty-two years, but no loosening of the prosthesis within the allograft had occurred.

Why allograft resorption occurred predominantly in Gruen zones 2 and 7 is unclear. These two zones represent the most proximal part of the graft, and stress-shielding could only occur in the presence of vascularized bone. The only sources of vascularity are a united graft-host junction and the osteotomized proximal part of the host femur that was wrapped around the construct.

In conclusion, treatment of a Vancouver type-B₃ periprosthetic fracture is particularly challenging, and, while no single technique is ideal, the present study demonstrated that the use of a proximal femoral allograft offers a reliable option to obtain a stable construct and can provide a satisfactory result at five years. However, patients should be cautioned that their postoperative functional goals should be limited. ?

References

Materials and Methods | Results | Discussion | References

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Topics

fracture ; femoral fractures ; femur ; tissue transplants ; hip replacement arthroplasty ; allografting ; periprosthetic fractures

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Anthony C. Maury, Ari Pressman, Barry Cayen, Paul Zalzal, David Backstein, Allan Gross; Proximal Femoral Allograft Treatment of Vancouver Type-B3 Periprosthetic Femoral Fractures After Total Hip Arthroplasty. The Journal of Bone & Joint Surgery. 2006 May;88(5):953-958.

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