Proximal femoral bone defects reconstructed with calcar metal mesh, impacted bone allografts, and cemented stem in revision hip surgery
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Published:
Aug 20, 2012
Keywords:
Revision hip surgery, Femoral bone loss, Metal mesh
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Abstract
BackgroundOne of the essential requisites for the impaction grafting method is containment of the impacted cancellous bone within the medullary cavity. In patients with segmental bone loss, this procedure can be performed with metal mesh on the outside of the femur. Although the combination between metal meshes and impacted bone allografts is commonly used clinically, data in literature is lacking. Objective: To analyse the results in cases with proximal femoral bone defects reconstructed with a calcar metal mesh, impacted bone allografts, and a cemented stem in revision hip surgery.MethodsWe prospectively followed 91 cases with proximal femoral bone defects reconstructed between 2002 and 2006 with a calcar metal mesh, impacted bone allografts, and a cemented stem. Patients’ average age was 66 years (range, 32-88 years); there 64 females and 27 males. Femoral deficiencies were classified according to the Endoklinik: 50 cases presented a grade 3 defect, 38 cases presented a grade 4 defect and 2 cases a grade 1. We implanted 44 short conventional stems and 47 long stems. Results: Reconstruction survival was 98% after a minimum follow-up of 31 months and a maximum of 87 months. We observed one fracture of the metal mesh and femoral long stem that was reoperated and a traumatic asymptomatic fracture of the metal mesh that did not require surgery 1.5 years after this episode. 97 Average stem subsidence was 3.6 mm. We observed 8 dislocations (9%), 7 infections (8%) and 2 periprosthetic fractures. Conclusions: Although the incidence of complications in these patients was high, this could be related to the complexity of the cases. Mesh failures were not observed except in the two cases presenting massive femoral bone loss and trauma. Patients with calcar femoral defects may be candidates for biological femoral reconstructions using metal mesh, impacted bone allografts and a cemented stem.
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Buttaro, M., Gozalbes, V., Comba, F., Zanotti, G., & Piccaluga, F. (2012). Proximal femoral bone defects reconstructed with calcar metal mesh, impacted bone allografts, and cemented stem in revision hip surgery. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 77(2), 96-103. https://doi.org/10.15417/48
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Clinical Research
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References
1. Gie GA, Linder L, Ling RSM, Simon JP, Slooff TJJH, Timperley AJ. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg (Br) 1993;75-B:14-21.
2. Slooff TJ, Schimmel JW, Buma P. Cemented fixation with bone grafts. Orthop Clin North Am 1993;24(4):667-77.
3. Boldt JG, Dilawari P, Agarwal S, Drabu K. Revision total hip arthroplasty using impaction bone grafting with cemented nonpolished stems and Charnley cups. J Arthroplasty 2001;16 (8):943-52.
4. Piccaluga F, González Della Valle A, Encinas JC, Pusso R. Femoral stem revision with impaction grafting and a Charnley stem. A two- to twelve-year follow-up study. J Bone Joint Surg (Br) 2002;84-B:544-9.
5. English H, Timperley AJ, Dunlop D, Gie G. Impaction grafting of the femur in two-stage revision for infected total hip replacement. J Bone Joint Surg (Br) 2002 ;84-B:700-5.
6. Buttaro M, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. J Bone Joint Surg (Br) 2005 87-B (3):314-9.
7. Bolder SB, Schreurs BW, Verdonschot N, Veth RP, Buma P. Wire mesh allows more revascularization than a strut in impaction bone grafting: an animal study in goats. Clin Orthop Relat Res 2004;423:280-6.
8. Bolder SB, Schreurs BW, Verdonschot N, Ling RS, Slooff TJ. The initial stability of an exeter femoral stem after impaction bone grafting in combination with segmental defect reconstruction. J Arthroplasty 2004;19(5):598-604.
9. Buttaro M, Comba F, Piccaluga F. Proximal femoral reconstructions with bone impaction grafting and metal mesh. Clin Orthop Related Res 2009;467(9):2325-34.
10. Merle d’Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg (Am) 1954; 36-A:451-455.
11. Engelbrecht E, Heinert K. Klassifikation und Behandlungsrichtlinien von Knochensubsanzverlusten bei Revisions operationen am Huftgelenk mittelfrsige Ergebnisse. Primare und Revision salloarthroplastik Hrsg-Endo-Klinik, Hamburg. Springer-Verlag, Berlin, 1987:189-201.
12. Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cement less revision total hip arthroplasty. Clin Orthop Relat Res 1993;(295):172.
13. Núñez L, Buttaro M, Pusso R, Morandi A, Piccaluga F. The value of intraoperative frozen section analysis in revision hip surgery. Acta Orthop 2007;78(2):226–30.
14. Fawcett K, Barr AR. Tissue banking. Arlington, Virginia: American Association of Tissue Banks; 1987.
15. Gruen TA, Mc Neice GM, Amstutz HC. Modes of failure of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979;141:17-27.
16. Harris WH, McGann WA. Loosening of the femoral component after use of the medullary plug cemented technique: followup note with a minimum 5-year follow-up. J Bone Joint Surg 1986;68:1064.
17. Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg (Br) 1980;62-B(4):450-3.
18. Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;(420):80-95.
19. Levinthal GS. Titanium, a metal for surgery. J Bone Joint Surg 1951;33-A: 473.
20. Lockey MW, Hahn GW, Corgill DA. Mandibular fractures. Metallic implant fixation using vitallium mesh. Arch Otolaryngol 1966;84(4):451-6.
21. Heiple K, Burstein A, Gradisar I, Gribay R. Engineering principle in the reinforcement of methylmethacrylate. Orthopaedic Research Society, Dallas, Texas, 1974.
22. Schmur DS, Lee D. Stiffness and inelastic deformation in acrylic-titanium composite implant materials under compression. J Biomed Mater Res 1983;17:973.
23. Taitsman JP, Saha S. Tensile strength of wire-reinforced bone cement and twisted stainless-steel wire. J Bone Joint Surg 1977; 59-A:419-25.
24. Attias N, Lehman RE, Bodell LS, Lindsey RW. Surgical management of a long segmental defect of the humerus using a cylindrical titanium mesh cage and plates: a case report. J Orthop Trauma 2005;19(3):211-6.
25. Attias N, Lindsey RW. Case reports: Management of large segmental tibial defects using a cylindrical mesh cage. Clin Orthop Relat Res 2006;450:259-66.
26. Lindsey RW, Gugala Z, Milne E, Sun M, Gannon FH, Latta LL. The efficacy of cylindrical titanium mesh cage for the reconstruction of a critical-size canine segmental femoral diaphyseal defect. J Orthop Res 2006;24(7):1438-53.
27. Ling RS, Timperley AJ, Linder L. Histology of cancellous impaction grafting in the femur. A case report. J Bone Joint Surg (Br) 1993:75(5):693-6.
28. Muscolo DL, Ayerza MA. Allografts. En Rosenberg AG. The adult hip. Philadelphia: Lippincott-Raven; 1998.
29. Bohm P, Bischel O. Femoral revision with the Wagner SL revision stem: evaluation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Joint Surg Am 2001;83-A(7):1023.
30. Wagner H. Revision prosthesis for the hip joint in severe bone loss. Orthopade 1987;16(4):295.
31. Woolson ST, Milbauer JP, Bobyn JD, Yue S, Maloney WJ. Fatigue fracture of a forged cobalt-chromium-molybdenum femoral component inserted with cement. A report of ten cases. J Bone Joint Surg Am 1997;79(12):1842.
32. Buttaro M, Mayor M, Van Citters D, Piccaluga F. Fracture of a proximally modular, distally tapered fluted implant with diaphyseal fixation. A Case Report. En prensa, J Arthroplasty.
33. Klein G, Parvizi J, Rapuri V, Wolf C, Hozack W, Sharkey P, Purtill J. Proximal femoral replacement for the treatment of periprosthetic fractures. J Bone Joint Surg Am 2005; 87(8):1777-81.
34. Friesecke C, Plutat J, Block A. Revision arthroplasty with use of a total femur prosthesis. J Bone Joint Surg 2005;87(12): 2693-701.
35. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Statistical Ass 1958;53:457-81.
2. Slooff TJ, Schimmel JW, Buma P. Cemented fixation with bone grafts. Orthop Clin North Am 1993;24(4):667-77.
3. Boldt JG, Dilawari P, Agarwal S, Drabu K. Revision total hip arthroplasty using impaction bone grafting with cemented nonpolished stems and Charnley cups. J Arthroplasty 2001;16 (8):943-52.
4. Piccaluga F, González Della Valle A, Encinas JC, Pusso R. Femoral stem revision with impaction grafting and a Charnley stem. A two- to twelve-year follow-up study. J Bone Joint Surg (Br) 2002;84-B:544-9.
5. English H, Timperley AJ, Dunlop D, Gie G. Impaction grafting of the femur in two-stage revision for infected total hip replacement. J Bone Joint Surg (Br) 2002 ;84-B:700-5.
6. Buttaro M, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. J Bone Joint Surg (Br) 2005 87-B (3):314-9.
7. Bolder SB, Schreurs BW, Verdonschot N, Veth RP, Buma P. Wire mesh allows more revascularization than a strut in impaction bone grafting: an animal study in goats. Clin Orthop Relat Res 2004;423:280-6.
8. Bolder SB, Schreurs BW, Verdonschot N, Ling RS, Slooff TJ. The initial stability of an exeter femoral stem after impaction bone grafting in combination with segmental defect reconstruction. J Arthroplasty 2004;19(5):598-604.
9. Buttaro M, Comba F, Piccaluga F. Proximal femoral reconstructions with bone impaction grafting and metal mesh. Clin Orthop Related Res 2009;467(9):2325-34.
10. Merle d’Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg (Am) 1954; 36-A:451-455.
11. Engelbrecht E, Heinert K. Klassifikation und Behandlungsrichtlinien von Knochensubsanzverlusten bei Revisions operationen am Huftgelenk mittelfrsige Ergebnisse. Primare und Revision salloarthroplastik Hrsg-Endo-Klinik, Hamburg. Springer-Verlag, Berlin, 1987:189-201.
12. Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cement less revision total hip arthroplasty. Clin Orthop Relat Res 1993;(295):172.
13. Núñez L, Buttaro M, Pusso R, Morandi A, Piccaluga F. The value of intraoperative frozen section analysis in revision hip surgery. Acta Orthop 2007;78(2):226–30.
14. Fawcett K, Barr AR. Tissue banking. Arlington, Virginia: American Association of Tissue Banks; 1987.
15. Gruen TA, Mc Neice GM, Amstutz HC. Modes of failure of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979;141:17-27.
16. Harris WH, McGann WA. Loosening of the femoral component after use of the medullary plug cemented technique: followup note with a minimum 5-year follow-up. J Bone Joint Surg 1986;68:1064.
17. Loudon JR, Charnley J. Subsidence of the femoral prosthesis in total hip replacement in relation to the design of the stem. J Bone Joint Surg (Br) 1980;62-B(4):450-3.
18. Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;(420):80-95.
19. Levinthal GS. Titanium, a metal for surgery. J Bone Joint Surg 1951;33-A: 473.
20. Lockey MW, Hahn GW, Corgill DA. Mandibular fractures. Metallic implant fixation using vitallium mesh. Arch Otolaryngol 1966;84(4):451-6.
21. Heiple K, Burstein A, Gradisar I, Gribay R. Engineering principle in the reinforcement of methylmethacrylate. Orthopaedic Research Society, Dallas, Texas, 1974.
22. Schmur DS, Lee D. Stiffness and inelastic deformation in acrylic-titanium composite implant materials under compression. J Biomed Mater Res 1983;17:973.
23. Taitsman JP, Saha S. Tensile strength of wire-reinforced bone cement and twisted stainless-steel wire. J Bone Joint Surg 1977; 59-A:419-25.
24. Attias N, Lehman RE, Bodell LS, Lindsey RW. Surgical management of a long segmental defect of the humerus using a cylindrical titanium mesh cage and plates: a case report. J Orthop Trauma 2005;19(3):211-6.
25. Attias N, Lindsey RW. Case reports: Management of large segmental tibial defects using a cylindrical mesh cage. Clin Orthop Relat Res 2006;450:259-66.
26. Lindsey RW, Gugala Z, Milne E, Sun M, Gannon FH, Latta LL. The efficacy of cylindrical titanium mesh cage for the reconstruction of a critical-size canine segmental femoral diaphyseal defect. J Orthop Res 2006;24(7):1438-53.
27. Ling RS, Timperley AJ, Linder L. Histology of cancellous impaction grafting in the femur. A case report. J Bone Joint Surg (Br) 1993:75(5):693-6.
28. Muscolo DL, Ayerza MA. Allografts. En Rosenberg AG. The adult hip. Philadelphia: Lippincott-Raven; 1998.
29. Bohm P, Bischel O. Femoral revision with the Wagner SL revision stem: evaluation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Joint Surg Am 2001;83-A(7):1023.
30. Wagner H. Revision prosthesis for the hip joint in severe bone loss. Orthopade 1987;16(4):295.
31. Woolson ST, Milbauer JP, Bobyn JD, Yue S, Maloney WJ. Fatigue fracture of a forged cobalt-chromium-molybdenum femoral component inserted with cement. A report of ten cases. J Bone Joint Surg Am 1997;79(12):1842.
32. Buttaro M, Mayor M, Van Citters D, Piccaluga F. Fracture of a proximally modular, distally tapered fluted implant with diaphyseal fixation. A Case Report. En prensa, J Arthroplasty.
33. Klein G, Parvizi J, Rapuri V, Wolf C, Hozack W, Sharkey P, Purtill J. Proximal femoral replacement for the treatment of periprosthetic fractures. J Bone Joint Surg Am 2005; 87(8):1777-81.
34. Friesecke C, Plutat J, Block A. Revision arthroplasty with use of a total femur prosthesis. J Bone Joint Surg 2005;87(12): 2693-701.
35. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Statistical Ass 1958;53:457-81.