The Journal of Bone & Joint Surgery

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

Scientific Articles | May 01, 2006

Revision Total Hip Arthroplasty with a Custom Cementless Stem with Distal Cross-Locking Screws: Early Results in Femora with Large Proximal Segmental Deficiencies

Nicholas Sotereanos, MD¹; Jeffrey Sewecke, DO¹; George J. Raukar, MD¹; Patrick J. DeMeo, MD¹; Konstantinos Bargiotas, MD¹; David Wohlrab, MD¹

¹ Division of Adult Reconstruction and Joint Replacement, Allegheny Orthopaedic Associates, Federal North, 1307 Federal Street, Second Floor, Pittsburgh, PA 15212. E-mail address for N. Sotereanos: nsotereanos@usa.net

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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. 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 Allegheny General Hospital, West Penn Allegheny Health System, Pittsburgh, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 May 01;88(5):1079-1084. doi: 10.2106/JBJS.E.00141

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Abstract

Background: Revision total hip arthroplasty in the setting of a large proximal segmental femoral deficiency and/or discontinuity between the proximal and distal parts of the femur remains a challenging problem. We describe the use of a cementless stem with distal cross-locking screws to provide stability of the femoral implant in this situation.

Methods: Seventeen custom fully porous and hydroxyapatite-coated titanium femoral stems with distal cross-locking titanium screws were implanted in sixteen patients during revision total hip arthroplasty. Preoperatively, all of the patients had Paprosky grade-IIIB or IV femoral deficiencies. At the time of follow-up, the Harris hip scores were calculated and radiographs were made. A successful result was defined as a postoperative increase in the Harris hip score of >20 points, a radiographically stable implant, and no additional femoral reconstruction.

Results: At the time of final follow-up, at a mean of 5.3 years postoperatively, the result was successful in sixteen of the seventeen hips, the mean Harris hip score had improved from 35 to 76 points, and all implants were clinically and radiographically stable. There were no postoperative infections or hip dislocations.

Conclusions: The use of a custom femoral stem with distal cross-locking screws can provide at least intermediate-term clinical and radiographic stability in patients with Paprosky grade-IIIB or IV femoral deficiencies. Longer follow-up will be required to determine the longevity of these implants.

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

Figures in this Article

Severe femoral deficiencies after failed total hip arthroplasty pose a substantial reconstructive challenge^1-3, especially when there is a large segmental deficiency of the proximal part of the femur, discontinuity between the proximal and distal parts of the femur, or a diaphysis that is either too patulous or too short to afford sufficient fixation of a revision stem.

The current alternatives for treating this difficult problem include use of a long canal-filling femoral stem, a proximal allograft-prosthesis composite, and a custom or modular proximal femoral megaprosthesis. However, when <6 cm of diaphyseal bone is available and/or the diaphyseal cortical diameter is >18 mm, obtaining rotational stability of these constructs can be difficult^3,4. Custom, fully porous and hydroxyapatite-coated femoral components with distal cross-locking screws were developed to obtain improved fixation in femora with these severe bone defects.

In this study, we describe the operative technique and the early clinical and radiographic results of the use of this type of prosthesis.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Between January 1996 and April 2002, the senior author (N.S.) implanted seventeen custom fully porous and hydroxyapatite-coated titanium proximal femoral replacements with cross-locking screws in sixteen patients. Fifteen of the seventeen implants were manufactured by DePuy Orthopaedics (Warsaw, Indiana). These implants were collarless and made of fully porous-coated titanium with a hydroxyapatite surface coating. Two distal 6.5-mm holes running from lateral to medial facilitated cross-locking with 5.0-mm titanium screws or bolts (Fig. 1). The other two implants, also fabricated from porous-coated titanium with a hydroxyapatite coating, were manufactured by Stryker Howmedica Osteonics (Allendale, New Jersey). These prostheses were collared and had two distal 6.5-mm holes for cross-locking.

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Fig. 1: Custom, fully porous, hydroxyapatite-coated femoral stem with holes for distal cross-locking (DePuy Orthopaedics, Warsaw, Indiana).

Patients

There were seven women and nine men. Their mean age at the time of revision surgery was fifty-four years (range, thirty-nine to seventy-four years). A mean of three previous hip operations (range, one to five) had been performed before the revision (Table I). Two patients (two hips) had had a previous infection of the involved hip. Both were treated initially with resection arthroplasty and then with staged reimplantation. One patient (one hip) (Case 17) underwent revision because of a Vancouver type-B3⁵ periprosthetic femoral fracture (see Appendix). Twelve patients (thirteen hips) underwent revision because of aseptic loosening following the most recent arthroplasty. One cross-locked stem was revised, because of broken cross-locking screws, to a larger cross-locked stem. All femora had Paprosky grade-IIIB or IV femoral deficiencies as seen on preoperative radiographs^2,3 (Table I). The postoperative follow-up evaluations were performed at three, six, nine, and twelve months postoperatively and then annually. The average time until the final evaluation was 5.3 years (range, 3.2 to 7.4 years).

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TABLE I Patient Data

						Harris Hip Score⁶(points)
Case	Age (yr)	Duration of Follow-up (yr)	No. of Previous Operations	Previous Infection	Paprosky Grade of Femoral Defect	Preop.	Follow-up	Type of Follow-up	Type of Implant^*	Stem Diameter (mm)	Allograft Stents
1	68	5.1	3	No	IIIB	30	82	Clinical	PFR	19	No
2	57	6.5	3	No	IIIB	34	78	Clinical	PFR	18.5	No
3	56	6.3	5	No	IIIB	29	76	Clinical	PFR	22.5	Yes
4	48	5.1	4	Yes	IV	18	40	Telephone	PFR	22	Yes
5	39	7.4	2	No	IIIB	42	87	Clinical	PFR	21	No
6	53	5.8	3	No	IIIB	50	85	Clinical	PFR	19.5t	No
7†	52	4.9	4	No	IIIB	30	74	Clinical	Restoration	19	No
8†	51	5.3	3	No	IIIB	36	75	Clinical	Restoration	19.5	No
9	54	6.2	3	No	IIIB	45	75	Clinical	PFR	19.5	No
10	49	6.1	2	No	IIIB	30	72	Telephone	PFR	19	No
11	63	5.2	2	No	IIIB	35	79	Clinical	PFR	18	No
12	74	5.5	3	No	IIIB	41	76	Clinical	PFR	19.5	No
13	55	4.9	3	Yes	IV	25	60	Clinical	PFR	18.5	Yes
14	52	4	2	No	IIIB	53	85	Clinical	PFR	20	No
15	56	3.2	3	No	IIIB	35	78	Clinical	PFR	19.5	No
16	50	3.9	4	No	IIIB	32	85	Clinical	PFR	18	No
17	49	4.6	3	No	IIIB	33	85	Telephone	PFR	19	No

The Restoration prosthesis was manufactured by Stryker Howmedica Osteonics (Allendale, New Jersey), and the PFR (Proximal Femoral Replacement) stem was manufactured by DePuy Orthopaedics (Warsaw, Indiana)Same patient

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TABLE I Patient Data

						Harris Hip Score⁶(points)
Case	Age (yr)	Duration of Follow-up (yr)	No. of Previous Operations	Previous Infection	Paprosky Grade of Femoral Defect	Preop.	Follow-up	Type of Follow-up	Type of Implant^*	Stem Diameter (mm)	Allograft Stents
1	68	5.1	3	No	IIIB	30	82	Clinical	PFR	19	No
2	57	6.5	3	No	IIIB	34	78	Clinical	PFR	18.5	No
3	56	6.3	5	No	IIIB	29	76	Clinical	PFR	22.5	Yes
4	48	5.1	4	Yes	IV	18	40	Telephone	PFR	22	Yes
5	39	7.4	2	No	IIIB	42	87	Clinical	PFR	21	No
6	53	5.8	3	No	IIIB	50	85	Clinical	PFR	19.5t	No
7†	52	4.9	4	No	IIIB	30	74	Clinical	Restoration	19	No
8†	51	5.3	3	No	IIIB	36	75	Clinical	Restoration	19.5	No
9	54	6.2	3	No	IIIB	45	75	Clinical	PFR	19.5	No
10	49	6.1	2	No	IIIB	30	72	Telephone	PFR	19	No
11	63	5.2	2	No	IIIB	35	79	Clinical	PFR	18	No
12	74	5.5	3	No	IIIB	41	76	Clinical	PFR	19.5	No
13	55	4.9	3	Yes	IV	25	60	Clinical	PFR	18.5	Yes
14	52	4	2	No	IIIB	53	85	Clinical	PFR	20	No
15	56	3.2	3	No	IIIB	35	78	Clinical	PFR	19.5	No
16	50	3.9	4	No	IIIB	32	85	Clinical	PFR	18	No
17	49	4.6	3	No	IIIB	33	85	Telephone	PFR	19	No

Preoperatively, the patients were evaluated clinically with use of the Harris hip score⁶ and radiographically with anteroposterior pelvic, full-length anteroposterior, and lateral views of the femur. Templating of the radiographs was used to determine the length and diameter of the implant. Magnification of the radiographs was assumed to be 20% with the use of corresponding 20% magnified templates. In addition, the actual diameter of the implant to be revised was ascertained from the medical record and was used to standardize the magnification.

Operative Technique

At least six weeks was required for implant production. Non-custom fully porous-coated femoral implants were also ordered to be available at the time of the surgery. The initial three implants in the series were further customized by the senior surgeon in the hospital's machine shop by drilling two distal 6.5-mm holes in the implant with use of a standard drill-press and cobalt-chromium drill-bits. The distal holes in the subsequent implants were provided by the manufacturers.

With the patient in the lateral decubitus position, previous skin incisions were marked and were used or modified to allow an anterolateral modified Hardinge approach. Tissue specimens were obtained for analysis of fresh-frozen sections, Gram-staining, counts of polymorphonuclear cells per high-powered field, and culture. Somatosensory evoked potentials were monitored in all patients intraoperatively.

The femoral component was exposed in all patients with use of an anterior-opening extended proximal femoral osteotomy. The component, any residual hardware, and cement were then removed under image-intensifier guidance. A guide rod was placed in the remaining distal part of the femur, over which reamers of increasing diameters were progressively used until they engaged the femoral diaphyseal cortex.

For canals with a cortex of <3 mm in width, the reamers were used in reverse until engagement of the cortex was seen on anteroposterior and lateral fluoroscopic views. We also made radiographs intraoperatively to confirm the maximum diameter of the reamer that engaged the cortices, and we measured the length of diaphysis available for fixation of the prosthesis. When isthmus contact was <6 cm in length or if the operating surgeon thought that the quality of the diaphyseal bone was inadequate, we used one or two distal cross-locking screws. Femoral trial components were then implanted to determine the optimal component diameter, version, and length. Rotational stability was tested manually. We used an implant that was 1 mm larger in diameter than the size of the last reamer. The mean femoral diameter of the implanted stems was 19.5 mm (range, 18 to 22.5 mm) (Table I). The length of all of the custom implants received from the manufacturer was 328 mm. Using a high-speed carbide burr, we shortened the prostheses by between 2 and 6 cm intraoperatively for four patients. If new distal holes for cross-locking were necessary, they were drilled in the hospital machine shop and the implant was resterilized. (This was done for two hips.) The cross-locking screws were then inserted with the guidance of the image intensifier. In three hips, allograft struts were wired into place across the femur-implant junction (Table I). The site of the extended proximal femoral osteotomy was then secured with multiple double-stranded 18-gauge wires.

Postoperatively, a custom brace set at 30° of abduction and 20° of flexion was fitted and was worn for twelve weeks. The patients were allowed toe-touch weight-bearing (<10 kg) while wearing the brace and using a walker or crutches.

Postoperative Evaluation

Harris hip scores⁶ were determined at the time of final followup. Three patients were not available for clinical evaluation, and the Harris questionnaire was administered during a telephone interview. A successful result was defined, according to the criteria of Gross et al.⁷, as a postoperative increase in the Harris hip score of >20 points, a radiographically stable implant, and no need for additional surgery for femoral reconstruction. The radiographic evaluation of fixation was done with use of the criteria of Engh et al.⁸.

All patients were informed preoperatively that they might receive a custom implant and that data concerning their treatment would be submitted for publication. Approval for data collection was obtained from our institutional review board.

Results

Materials and Methods | Results | Discussion | Appendix | References

The result was successful for sixteen of the seventeen hips at a mean of 5.3 years (range, 3.2 to 7.4 years) postoperatively. The Harris hip score improved from a mean of 35 points (range, 18 to 53 points) to a mean of 76 points (range, 40 to 87 points). All implants were clinically and radiographically stable at the time of the latest follow-up. There were no postoperative infections or dislocations. A concomitant revision of the acetabular component was performed in six hips. In two other hips, the acetabular liner was exchanged at the time of the stem revision.

Radiographic evaluation revealed evidence of cortical thickening and the presence of spot welds⁸ contacting the porous implant surfaces in the distal femoral bone segment in all patients (Fig. 2). The allograft struts had incorporated in two of the three femora in which they had been used.

Complications

One patient (Case 15), a fifty-six-year-old woman who had undergone multiple previous femoral reconstructions, required an additional procedure because of subsidence of the cross-locked fully porous and hydroxyapatite-coated femoral implant, which had a diameter of 19.5 mm. The implant subsided with an associated fracture of the cross-locking screws at six weeks postoperatively. (At the time of the procedure, titanium cross-locking bolts were unavailable and we used 6.5-mm titanium cancellous screws.) One year later, the patient underwent another revision with a 22.5-mm-diameter fully porous and hydroxyapatite-coated proximal femoral component that was cross-locked. This component had remained stable for six years at the time of writing. One other patient required evacuation of a hematoma in the immediate postoperative period.

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Figs. 2-A and 2-B: Case 3, a man who was fifty-six years old at the time of the index operation. Anteroposterior (Fig. 2-A) and lateral (Fig. 2-B) radiographs of the left hip and femur two years after successful revision with a 19.5 × 328-mm fully porous and hydroxyapatite-coated proximal femoral component with cross-locking screws. The site of the distal cross-locking screw and an anterior spot weld are shown.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

The results of revision of a failed femoral component with use of a proximally porous-coated tapered femoral stem with distal cross-locking screws have recently been reported. Learmonth et al.⁹ treated Vancouver type-B2 periprosthetic fractures with a proximally porous-coated cementless femoral stem (BiCONTACT; Aesculap, Tuttlingen, Germany) with distal interlocking screws in twenty-two patients. All of the fractures healed, but five of the twenty-two femoral components subsided >5 mm and had associated fractures of the distal interlocking screws. On the basis of these results, Learmonth et al. discontinued the use of the implant. Although our experience with the use of this prosthesis to treat a periprosthetic fracture was limited to only one patient with a Vancouver type-B3 fracture, that patient had a good result at 4.6 years postoperatively.

Mahomed et al.¹⁰ reported that distal interlocking of a press-fit femoral prosthesis increased torsional stability by 320% and axial stability by 230%. They concluded that this initial increase in stability may improve biological fixation.

Kim et al.¹¹ reported the results of sixty-eight femoral revisions done with a cementless proximally porous-coated stem with distal interlocking screws (BiCONTACT) in patients with class-I through IV femoral defects² according to the system of the American Academy of Orthopaedic Surgeons (AAOS). The largest stem diameter that they used was 16 mm. At the time of follow-up, at a mean of forty months (range, thirty-six to forty-nine months), all components were stable and there were no radiographic signs of loosening or subsidence. Kim et al. did not discuss the use of this implant and technique for more severe femoral deficiencies or in femora with larger-diameter diaphyseal canals. In our series, we successfully treated femoral defects that were more severe than those treated by Kim et al.¹¹, and we used stems of larger diameters.

Gross et al.⁷ reported the results at a mean of eleven years following the use of sixty-three allograft-prosthesis composites in sixty patients. There were fourteen failures, five of which were due to infection; four, to nonunion; two, to dislocation; and three, to late symptomatic loosening. The overall success rate was 78%. Gross et al. have since modified their technique by using extended trochanteric osteotomies rather than transverse osteotomies for exposure and by using a step-cut osteotomy at the allograft-host junction. They augment the allograft-host junction with cortical strut allografts when a distal press-fit of the stem is not obtained.

Barrack et al.¹² reported their findings at a mean of four years following nine femoral reconstructions with a distal femoral allograft-prosthesis composite. Complications included two early dislocations and two cases of trochanteric migration. According to their criteria, the overall success rate was 100% at the time of intermediate-term follow-up. In a study of twenty-one patients with proximal femoral deficiencies who required total hip arthroplasty with a special segmental cemented replacement, Sim and Chao¹³ reported no femoral loosening, according to clinical or radiographic criteria, after durations of follow-up ranging from twenty-five to ninety-two months.

Our encouraging early results are similar to those of Barrack et al.¹², Sim and Chao¹³, and Gross et al.⁷. We think that our technique provides improved initial rotational control and reduces the likelihood of subsidence of the stem, especially when the technique is used for reconstruction of severe femoral deficiencies. The main disadvantage of this or any custom prosthesis is a waiting time of six to eight weeks for its manufacture.

We recommend cross-locking if there is <6 cm of stem-diaphysis contact and/or the diameter of the canal is =18 mm. Preserving the proximal femoral sleeve of bone allows soft-tissue reattachment.

The possible hazards associated with this technique are an increased risk of femoral fracture secondary to the drilling of the holes for the distal interlocking screws and insertion of a porous-coated cementless implant that is oversized by 1 mm into a femur with atrophic cortices. Also, implants with a diameter of <14 mm have a high risk of fracture unless they are used as part of a structured allograft composite^4,14. We are encouraged by our 94% success rate, absence of dislocations and infections, and only one case of subsidence, which was attributable to a technical error. Longer-term follow-up is required to determine the efficacy of this technique for the reconstruction of severely bone-deficient femora.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

Tables showing the Vancouver system for classification of fractures of the femur following total hip arthroplasty⁵ and the Paprosky system for classification of femoral defects in revision total hip arthroplasty^2,3 are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

D'Antonio J, McCarthy JC, Bargar WL, Borden LS, Cappelo WN, Collis DK, Steinberg ME, Wedge JH. Classification of femoral abnormalities in total hip arthroplasty. Clin Orthop Relat Res. 1993;296: 133-9.296133 1993 [PubMed]

Della Valle CJ, Paprosky WG. The femur in revision total hip arthroplasty evaluation and classification. Clin Orthop Relat Res. 2004;420: 55-62.42055 2004 [CrossRef]

Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss using distal bypass fixation. Instr Course Lect. 2000;49: 119-30.49119 2000 [PubMed]

Blackley HR, Davis AM, Hutchison CR, Gross AE. Proximal femoral allografts for reconstruction of bone stock in revision arthroplasty of the hip. A nine to fifteen-year follow-up. J Bone Joint Surg Am. 2001;83: 346-54.83346 2001

Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004;420: 80-95.42080 2004 [CrossRef]

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51: 737-55.51737 1969 [PubMed]

Gross AE, Hutchison CR, Alexeeff M, Mahomed N, Leitch K, Morsi E. Proximal femoral allografts for reconstruction of bone stock in revision arthroplasty of the hip. Clin Orthop Relat Res. 1995;319: 151-8.319151 1995

Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res. 1990;257: 107-28. Erratum in: Clin Orthop Relat Res. 1992; 284:310-2.257107 1990 [PubMed]

Learmonth ID. The management of periprosthetic fractures around the femoral stem. J Bone Joint Surg Br. 2004;86: 13-9.8613 2004

Mahomed N, Schatzker J, Hearn T. Biomechanical analysis of a distally interlocked press-fit femoral total hip prosthesis. J Arthroplasty. 1993;8: 129-32.8129 1993 [PubMed][CrossRef]

Kim YM, Kim HJ, Song WS, Yoo JJ. Experiences with the BiCONTACT revision stems with distal interlocking. J Arthroplasty. 2004;19: 27-34.1927 2004 [PubMed][CrossRef]

Barrack RL, Wolfe MW, Michas P, Frentz B. Distal femoral allograft for massive proximal femoral deficiency. Acta Orthop Scand. 2000;71: 90-4.7190 2000 [PubMed][CrossRef]

Sim FH, Chao EY. Hip salvage by proximal femoral replacement. J Bone Joint Surg Am. 1981;63: 1228-39.631228 1981 [PubMed]

Malkani AL, Settecerri JJ, Sim FH, Chao EY, Wallrichs SL. Long-term results of proximal femoral replacement for non-neoplastic disorders. J Bone Joint Surg Br. 1995;77: 351-6.77351 1995 [PubMed]

Topics

durapatite ; femur ; hip joint ; hydroxyapatites ; prosthesis implantation ; reconstructive surgical procedures ; hip replacement arthroplasty ; allografting

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Nicholas Sotereanos, Jeffrey Sewecke, George J. Raukar, Patrick J. DeMeo, Konstantinos Bargiotas, David Wohlrab; Revision Total Hip Arthroplasty with a Custom Cementless Stem with Distal Cross-Locking ScrewsEarly Results in Femora with Large Proximal Segmental Deficiencies. The Journal of Bone & Joint Surgery. 2006 May;88(5):1079-1084.

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