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Impaction bone grafting for periprosthetic fractures around a total hip arthroplasty
Injury, Int. J. Care Injured 45 (2014) 1674–1680
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Injury journal homepage: www.elsevier.com/locate/injury
Review
Impaction bone grafting for periprosthetic fractures around a total hip arthroplasty Bishoy Youssef a,b, George Pavlou a,b, Nikhil Shah a,b, George Macheras a,b, Eleftherios Tsiridis a,b,* a b
Academic Orthopaedic Unit, PapaGeorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Hellas Wrightington Specialist Orthopaedic Hospital, Wrightington, Wigan and Leigh NHS Trust, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 27 July 2014
The incidence of periprosthetic fractures has been reported to be between 1 and 20.9% and appears to be on the rise. Fractures that occur around the femoral stem, particularly when the stem is loose or there is a loss of bone stock pose a technical challenge. These are rare injuries and there is considerable debate regarding their optimal treatment. Reconstruction with large segment endoprosthetic replacement is an acceptable solution for elderly patients who have limited functional demands and where the prosthesis is expected to outlive the patient. The younger patient poses a much greater challenge, the bone must be reconstituted and the femoral canal geometry must sufficiently restored to allow the stable insertion of a prosthesis. There are very few techniques that exist in this scenario. One such technique is impaction bone grafting and revision to a long smooth tapered cemented stem. This allows the restoration of bone stock and the stable insertion of a prosthesis. The aim of this article is to discuss the theory behind impaction bone grafting, the technical aspects and challenges of this technique, including fracture reduction methods, and to appraise all the literature available on impaction bone grafting for periprosthetic fractures. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Periprosthetic fractures Impaction bone grafting Total hip replacement
Contents Introduction . . . . . . . . . . . . . . Impaction bone grafting . . . . Literature review . . . . . . . . . . Discussion . . . . . . . . . . . . . . . Conflict of interest statement References . . . . . . . . . . . . . . .
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Introduction The incidence of periprosthetic fractures found at revision surgery for primary cemented hip replacements has been reported to be between 1 and 3.6% for cemented prosthesis and 3–20.9% for uncemented prosthesis. As one would expect there is also a significant incidence of periprosthetic fractures for revision procedures, with a 6.3% rate during cemented procedures and a 17.6% rate for uncemented procedures [1–5]. There has been
* Corresponding author. Tel.: +30 2310 390 599. E-mail address: [email protected] (E. Tsiridis). http://dx.doi.org/10.1016/j.injury.2014.07.028 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
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considerable debate with regard to the optimal treatment of these injuries, particularly those that occur around the femoral stem. Pavlou et al. conducted a review of 202 periprosthetic fractures treated at 2 specialist centres, they found that those fractures that had occurred around a well fixed stem had shorter union times and increased union rate when treated with stem revision than those treated with plate fixation. Fracture union was also more likely to occur when stem revision with bone grafting was undertaken for a periprosthetic fracture around a loose stem when compared with open reduction and internal fixation alone [6,7]. The Vancouver classification system is the most widely used and understood system for classifying fractures about the femoral stem [8]. Type A occur around the trochanters are normally only
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treated if the patient is symptomatic. Type C occurs well distal to the stem and theses fractures can be treated independently of the prosthesis with a method that best suits the personality of the fracture. Occasionally the stem does require revision, and in this scenario this is normally performed after the fracture has united. This article will concentrate on Vancouver B2 and B3 fractures. These fractures occur around the femoral implant and the implant is either loose, B2, or loose and the surrounding bone stock is deficient. In general the accepted treatment of choice for Vancouver B2 fractures is revision of the implant [8,11]. A cemented long stem revision is often the most appropriate implant for the more elderly with a simple fracture pattern [12]. Alternatively a long uncemented stem, which can be coated to allow osseous integration and contain flutes, grooves or slots to achieve distal fixation can treat type B2 fractures, which have adequate bone stock. Type B3 fractures pose the greatest challenge. A loose stem within a femur that has insufficient bone stock either due to gross osteolysis or significant fracture comminution has few reconstructive options. There are short to medium published results available on the use of extensively coated femoral components designed to encourage bone on growth onto the prosthesis. The results appear to be promising, however there is concern regarding stress shielding of the proximal femur [13,14]. Proximally coated long stem femoral components have also been used with some success however failure of osteointegration of the prosthesis has been noted [15,16]. A combination of prosthetic replacement combined with allograft has also been used with an 85% success rate in 262 patients using a proximal femoral replacement combined with a femoral allograft [17]. The use of tumour prosthesis, including total femoral replacement, has also been described to treat a loose implant in the face severe bone loss, however this is very much a salvage procedure and should be reserved for those patients’ who have a low functional demand [18]. The technique of impaction bone grafting of the femur for periprosthetic fractures can be used to good effect when there is bone loss around a loose femoral component, Vancouver B3 fractures. It is also a useful technique for Vancouver B2 fractures where the bone stock is sufficient to perform a revision, but reconstitution of the proximal femur with bone and the insertion of cemented stem is considered advantageous. This would typically be a young patient in whom re-revision in the future maybe necessary and restoring the bone stock to as near normal as possible may simplify the procedure. An example of a B3 fracture with a loose acetabular component is shown in Fig. 1. Its subsequent treatment using a long stem revision with mesh, impaction bone grafting and strut allografting is shown in Fig. 2. Impaction bone grafting The technique of using morselised fresh frozen cancellous allograft bone chips into an area of bony deficiency is not a new concept. It was first described for the reconstruction of acetabular protrusio [19] and was subsequently popularised by the Exeter group for revision surgery of the acetabulum as a method of restoring acetabular bone stock prior to insertion of the acetabular component. Femoral impaction bone graft aims to restore femoral bone stock by impacting fresh frozen cortico-cancellous bone chips into the canal to create a neo-endosteum prior to implantation of the cemented femoral component. It is also useful in revision of the femoral component where following removal of the femoral stem, all that remains of the inside of the canal is a smooth endosteal surface without sufficient cancellous bone that would allow adequate cementation of the femoral stem. It also has a role in the
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Fig. 1. A Vancouver B3 fracture of the femur with an associated periprosthetic acetabular fracture.
use of uncemented femoral prosthesis where this technique can be used to sufficiently reconstitute the bone stock to allow sufficient initial stability and scratch-fit of the component. The technique can be applied to any age group, it is perhaps of even greater importance in younger patients to try and restore their bone stock. It is not applicable in all cases particularly when there is severe proximal femoral bone loss exceeding 10 cm. It should also be considered as part of the armamentarium of revision surgery as due to the time consuming nature of the surgery it may not be appropriate for medically unfit patients where a shorter procedure that is also appropriate can be achieved (Table 1). Literature review A detailed literature search was conducted to identify all the relevant articles discussing impaction bone grafting for the treatment of periprosthetic fractures. A Medline search was
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Preoperative planning • • • •
History: Fitness for surgery, medical co-morbidities and evidence of previous infection. Examination: Previous scars, skin and soft tissue condition. Work-up: FBC, ESR, CRP. Joint luid aspiration. Plain ilm radiology: Full length high quality AP and lateral views of the pelvis and femur.
Equipment requirements • • • •
• • • • •
Femoral head allograft, onlay cortical strut grafts and reconstruction meshes. Stainless steel wires, cerclage cables and bone reduction forceps. Canal plugs. A range of the chosen implant in different lengths and offsets.
Approach and fracture reduction Lateral decubitus position. Posterolateral incision, preferably incorporating the previous incision. Aspirate hip prior to opening the capsule. 5-6 deep tissue samples. Fracture site can often act as an osteotomy site to aid removal of the implant. Temporary reduction achieved using the phantom stem and a combination of wires, cables and bone holding forceps.
Impaction bone grafting • • • • • • •
• • • •
Removal of the intramembranous canal. Distally plug the femoral canal. Insert a guidewire into the femoral canal. Bone chips of approximately 2-4mm are created by hand and impacted into the distal femur. A phantom stem is inserted, in the appropriate version and driven into the distal bone plug. Bone chips of 5-10mm in size are used in the proximal femur around the phantom implant. The phantom stem is then withdrawn and the neoendosteum is ready to accept a cemented, collarless, polished tapered stem with a wingless stem centraliser.
Postoperative mobilisation Touch weight bearing for 6 weeks. Partial weight bear from 6 weeks to 12 weeks. Full weight bear from 3 months. It will take a minimum of 12 months for the graft to incorporate and remodel.
Fig. 2. The post-operative image of the fractures treated with revision of both the femoral and acetabular components. A long cemented stem and a cemented socket were used. The defects were reconstructed using wire mesh and impaction bone grafting.
conducted between 1990 and 2013 using the OVID search engine (REF), with the key words ‘‘periprosthetic fracture’’, ‘‘impaction bone grafting’’, ‘‘fracture’’ and ‘‘surgery’’ and with MeSH (Medline/ Pubmed’s article indexing terminology) subject headings. The inclusion criteria included all reports on surgical treatment of periprosthetic fractures with the use of impaction bone grafting in the English language. Due to the paucity of literature available regarding this technique all articles were included in this review. The technique of impaction bone grafting to treat periprosthetic fractures was first described in the literature in a form of two case reports by Tsiridis and Gie in 2001 [25]. They describe the technique to treat mal-united femoral fractures adjacent to loose total hip replacements in a 74-year-old and a 38-year-old man. Both had satisfactory results and with radiographic evidence of graft incorporation into the host bone. In the discussion they describe the evolution of the technique where a cementless long stem Exeter was combined with impaction bone grafting to restore severe femoral bone loss. However they noted that the stem began to migrate distally. They felt that in retrospect the addition of cement would have improved the result and would have prevented the migration of the prosthesis. A case report published in 2007 discusses the combined use a strut allograft with impaction grafting to treat a complex B3 periprosthetic fracture with a Paprosky IV femoral deficiency [26]. The authors used a whole length femoral strut graft with an impaction bone grafting with a long stem cemented revision. He was awaiting a 3rd revision hip replacement when he sustained a periprosthetic fracture. An extended trochanteric osteotomy was utilised to remove the existing prosthesis and cement. A whole femur was bivalved and the metaphyseal sections removed to provide cancellous bone for the impaction bone grafting. One strut was hammered into the distal metaphysis to provide stability for the distal femur. The second strut was applied posteromedially. The canal was then impaction bone grafted to the level of the calcar using the method previously described. At 12 months the fracture had united clinically and radiologically. The authors noted that the use of an intramedullary strut created a narrower stronger tube to contain the impaction bone graft. Tsiridis et al. reported on the results of 106 type B2 and B3 periprosthetic fractures [27]. The largest series of periprosthetic fractures using this technique. 75 patients were treated with a long-stem revision and impaction bone grafting. 14 had cemented long stem revision without impaction bone revisions. 14 short stem revision with impaction bone grafting and 3 without impaction bone grafting. Long was differentiated from short on whether it bypassed the distal extent of the fracture by at least 1 cortical diameter. The difference in stems reflected a change in practice with a short stem combined with 2–4 mm bone chips used prior to 1996. The technique was changed to use a long stem implant with bone chips of a different size for the proximal and distal impaction. The change was brought about as a result of the high non-union rate of 43% with the previous technique and laboratory studies examining the impaction bone grafting technique [8–31]. Nine patients who were treated with long stem revision and impaction bone grafting also had additional strut grafts of which three had two grafts inserted. One short stem revision with impaction bone grafting had two strut grafts used to supplement fixation and one patient who had a short stem revision without impaction bone grafting also underwent strut allografting. A retrospective review of the notes and plain film radiographs was performed by two of the authors who were not involved in the surgery. The radiographs were assessed to examine the type of stem, mode of fixation and time to union. The Harris hip score was calculated at 52 weeks post surgery and was available for 66 of the
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Table 1 A summary of the results from studies that have investigated the role of impaction bone grafting for the treatment of periprosthetic fractures. Authors (year) Tsiridis and Gie (2002)
No. of patients 2
Periprosthetic fracture type
Treatment
Follow up
Complications
Outcome
1. Malunited femoral fracture with a loose total hip replacement. 2. Loose total hip replacement with marked osteolysis of the proximal femur and a periprosthetic fracture that had malunited in 308 of varus. Vancouver B2/B3
1. Cemented long stem revision with cerclage wires and a mesh on the proximal femur and impaction bone grafting (IBG). Mal-union not addressed. 2. Osteotomy, revision to a long stem with IBG and supplemental internal fixation with a plate.
1. 12 months 2. 84 months
None
1. Graft incorporation. 2. Graft incorporation and union of the osteotomy.
75 Cemented long stem revision with IBG. 14 long stem revision without IBG. 14 short stem revision with IBG. 3 short stem revision without IBG.
Not specified
80.2% union rate. 88% long stem with IBG. 57.1% short stem with IBG. Mean time to union 7.44 months (3–12). Harris Hip Score Mean 81 (55–91) recorded in 66 patients all with united fractures.
The femur was reconstructed with an intramedullary and extramedullary strut graft, cerclage wires, mesh and IBG. A long cemented femoral stem was inserted. Cemented long stem revision with IBG. A Mennen plate was used as a temporary reduction device and to assist in containing the bone graft. IBG combined with a cemented long stem revision, bypassing the fracture by at least 2 cortical diameters.
48 months
21 (19.8%) non union rate. 9 long stem with IBG. 5 long stem without IBG. 6 short stem with IBG. 1short stem without IBG. 4 (3.7%) infection rate. 2 long stem with IBG. 2 short stem with IBG. None
84 months (72–96)
None
56 months (27–90)
1 patient sustained 2 dislocations. 1 heterotopic bone ossification. 1 greater trochanter avulsion requiring ORIF.
Bony union 8 months (6–10). Charnley-d’AubignePostel scores 5, 3 and 6. Bony union achieved in all cases. Mean Harris Hip Score 73.8 (39–92). 6 out of 7 patients rated the procedure as good or excellent.
Tsiridis et al. (2004)
106
Tsiridis et al. (2007)
1
Vancouver B3
Tsiridis et al. (2007)
3
All Vancouver B3
Lee et al. (2010)
7
Vancouver B2 and B3
106 patients at the one-year mark. 88% of the fractures treated with long stem revision and impaction bone grafting successfully united compared with 57.1% of the short stem revisions with impaction bone grafting. The failure rate of the short stems and impaction bone grafting was five times higher compared with long stem prosthesis. Long stem with impaction bone grafting was significantly more likely to unite than without impaction bone grafting. The mean length of union time was 7.44 months (3–12). The mean Harris hip score was 81 (55–91). There were 21 nonunions (19.8%) and 4 infections (3.7%). In 2007 Tsiridis and colleagues reported on the treatment of a series of three patients who underwent revision impaction bone grafting with a Mennen plate for Vancouver B3 periprosthetic fractures. The impaction bone grafting technique was the same as has been previously described in the text with one exception, the Mennen plate was not used in this series to stabilise the fracture but contain the graft during the impaction process and as an aid to fracture reduction while the stem was inserted rather than for osteosynthesis of the fracture [32]. The plate, which has been described as para-skeletal clamp on system [33], was originally designed to treat fractures involving non-weight bearing bones [34–36]. Its role in the management of periprosthetic fractures has had variable success, with reports of failures related to mal-union, non-union and mechanical failure [37,38]. Moderate success was realised when it was combined with biological fixation in the form of cortical allograft for revision arthroplasty. Kligman et al.
Bony union was achieved at 12 months.
described its use combined with strut allografts for revision hip and shoulder arthroplasty. They had satisfactory results in 11 out of 12 patients. They felt that plate was useful in maintaining bony stability during reaming and reduction of the prosthesis [39]. The patients in Tsiridis’ series were followed up for a median follow up of 84 months, no infections were encountered with outcome scores of 5,3 and 6 based on the Charnley-Merle d’Aubigne´-Postel outcome measure. It’s use is now more of historical interest and it no longer has a role in modern periprosthetic fracture management. Lee et al. reported on the results of impaction bone grafting to treat seven patients’ with B2/B3 periprosthetic fractures around a total hip arthroplasty [21]. They chose this technique over a conventional uncemented long fully porous coated femoral component because they felt that the femoral canal geometry at the isthmus precluded their use. Their concern was that significant fracture comminution at the level of the isthmus would not provide the 4–8 cm of scratch fit necessary to allow successful implantation of the prosthesis. The femoral component used was a Spectron stem (Smith and Nephew, Memphis, TN). This is a nonpolished collared, cobalt chrome stem with a longitudinal taper that is designed to be cemented. The stem was templated to bypass the distal extent of the fracture by at least 2 cortical diameters. The canals were impaction bone grafted. They used 4 mm sized fresh frozen irradiated allograft croutons. In two patients they required the use of a mesh to contain the bone graft. One patient had a
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combined technique with the use to a strut allograft to reconstruct the proximal femur. No structural allografts were used to bypass the fracture site. The patients’ clinical outcome was assessed with the Harris hip score and a radiographic assessment was performed by a surgeon who was not involved in the surgery. The patients had a mean follow up of 56 months. The mean Harris hip score was 73.8 (39–92). Out of the seven patients; six patients were rated as having a good or excellent result, five patients had no pain, one had mild pain, and one had severe pain. Four patients did not require any walking aides, two used a walking stick for long walks and one required a walking stick at all times. All seven patients had radiographic evidence of complete fracture healing with good incorporation of the cortico-cancellous grafts with no evidence of loosening. A mean of 4.3 mm of subsidence of the stem was noted in their cohort of patients. They commented that a mean of 5.1 mm stem subsidence was reported in a series of long stem Exeter prostheses (Stryker, Rutherford, NJ) with impaction bone grafting for revision hip replacements [40]. However this is a known design feature of smooth polished double tapered stem. None of their cohort of patients required revision for infection or aseptic loosening of the femoral component. One patient developed asymptomatic heterotopic bone ossification and one patient required an open reduction and internal fixation of the greater trochanter, which avulsed at 80 months post operation. There are no major case series that solely involve the treatment of type B3 fractures in the literature. They are difficult injuries to treat and have a significant complication rate. There is no one single remedy that is suitable for all patients and each patient’s injury should be assessed and a specifically tailored plan to treat their injury should be sought. In the young the restoration of bone stock should be of paramount importance, this can be achieved by impaction bone grafting. This technique will enable the entire femoral canal’s bone stock to be restored prior to cementation of a tapered stem. Whereas an uncemented allograft prosthesis composite will not address the proximal bone loss and relies on distal fixation. Strut allografts also require adequate host femur. It is a biologically sound concept and if it incorporates early it will result in a sound biomechanical construct [41–44]. Impaction bone grafting is also a more biological procedure reconstructing the bone from the inside out. This will allow easier revascularisation of the bone and subsequent remodelling [45,46]. Wong et al. have reported on 15 B3 fractures treated with an allograft prosthesis composite and found that 93.3% healed using this technique [47]. In the elderly or very infirm tumour prostheses can be used, which will allow immediate weight bearing and have satisfactory clinical outcomes [18] Malkani et al. have demonstrated a 64% survivorship at 12 years when using proximal femoral replacements for the treatment of this type of problem [48]. The soft tissues can be reattached to the prosthesis using polytetrafluoroethylene coated tubes. Impaction bone grafting cannot only restore proximal femoral bone stock but is also useful when distal fixation cannot be achieved. This is particularly useful where the fracture extends or comminution exists below the isthmus that will not allow a stable distal fix to be achieved using a long cementless stem. This loss of rotational and axial stability is encountered when there is extensive proximal femoral bone loss, less than 4 cm of diaphysis distally or a canal width of greater than 18 mm [49]. There are case series looking at the use of fluted tapered cementless stems to treat B3 fractures. They can create a stable three-point fixation within the femoral canal. Berry et al. reported on this technique in 7 patients with B3 fractures and found that all the implants had remained stable and the fractures had united at a mean of 2 years [50]. Mulay et al. treated 24 patients with fluted tapered cementless stems to treat B2 and B3 fractures and found that 91% of the fractures had healed, however the technique was not
without complication with five dislocations and two non-unions [51]. Discussion Periprosthetic fractures in relation to a hip prosthesis are not a new phenomenon and was first described in 1954. Horwitz described a fracture around a hemiarthroplasty that was treated with cerclage wiring and internal fixation [52]. The incidence of periprosthetic fracture has been reported in the Mayo clinic series as affecting 0.3% of 20,859 primary cemented hip replacements and an occurring in 5.4% in 3121 primary cementless hip replacements. The rate increased to 3.6% in cemented revisions and 20.9% in cementless revisions [53]. The incidence of these injuries appears to be rising with data from the Swedish Hip Arthoplasty Register demonstrating an increase in yearly incidence from 0.045% to 0.13% of all total hip replacements performed from 1979 to 2000. The purported reasons for the rise are the increasing demand in the elderly in whom osteopenic bone and increased falls risk will lead to these fractures and younger patients with active lifestyles who are at risk of higher energy trauma [54]. Each treatment strategy is tailored to suit the patient and the personality of the fracture. Type B3 fractures which involve implant loosening and poor bone stock pose a significant treatment challenge. Elderly patients who will not tolerate prolonged procedures or are unable to remain non-weightbearing for significant periods of time may be better served with an endoprosthetic replacement. The treatment of younger patients is more controversial. In the younger patient we believe that priority should be given to the restoration of bone stock. Where severe bone loss in encountered in the proximal femur, a proximal femoral allograft composite can be created with the host femur bivalved and wrapped around a cemented allograft uncemented host stem interface [55]. Cortical struts can be applied orthogonally and combined with plating. They offer an external source of bone graft. They do need to be contoured to the shape of host femur and care must be taken to maintain the femoral blood supply when applying strut grafts. The technique of impaction bone grafting was first described by Hastings and Parker in 1975 [56]. The Nijmegen group in the Netherlands have a large and long standing experience of acetabular reconstruction using impaction bone grafting. The technique is applied to the reconstruction of bony defects in complex primary and revision hip arthroplasty. They consider it to be a biological technique that can reconstitute the bone that has been lost. Schimmel et al. examined graft incorporation and speed of consolidation into the host bone in an experimental study on Dutch milk goats. Histological analysis had shown that the grafts had incorporated with the trabecular bone bed within 3 weeks. The initial impaction technique is sufficient to provide early stability and at 12 weeks very little of the bone graft was still present, it had been replaced with new trabecular bony structure of lamellar bone. The presence of a fibrous membrane in some areas of the bone cement interface was noted. Nevertheless they felt that this technique was biological and could be used to treat small and large acetabular defects [57]. They have been able to translate these results into clinical practice. They have published the results of a consecutive series of 62 acetabular revisions for a mean of 16.5 years. The survivorship with revision for any reason as the endpoint was 79% at 15 years [58]. The technique converts a cavitatory defect into a tightly packed solid form of bone that will allow cementation of a prosthesis. Restoration of bone stock is particular attractive in younger patients, where re-revision is a real possibility. This method can achieve immediate implant stability. It can allow the use of normal implants with a normal cementing technique. The technique is not
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applicable to all patients. Pelvic irradiation limits the potential for the graft to revascularise and incorporate and therefore this technique is probably not appropriate for this group of patients. The majority of data available for this technique refers to its use for cemented sockets and cages to restore acetabular defects [59–64]. Histological studies have demonstrated that bone stock does reconstitute over time [57]. Supplemental stainless steel meshes can be used to convert segmental defects into contained defects that will provide sufficient resistance to allow impaction bone grafting. The allograft of choice is morselized cancellous bone. The choice is based on its open structure allowing angiogenesis and subsequent early remodelling. The ideal size of the bone chips appears to 8–10 mm in diameter allowing a more porous and permeable graft [65,66]. Smaller bone chips of 2–4 mm in size are required for the distal femur. The bone can be morselized by hand or by commercial mills that are able to produce bone chips of a specific size. Morselizing it by hand creates fragments of different sizes, this has been shown to reduce the shear that occurs between particles. This same technique does however technically reduce the permeability of the graft [67]. The graft is then washed, this is to remove excess fat, this is important because it increases the force required to displace the graft and improves its resistance to shear [68]. Compacting the bone graft is probably the most operatordependant part of the technique and done well increases the initial stability of the implant and can improve the longevity of the revised acetabular component [64]. The authors at the forefront of this technique have focused on the vigour that is required to successfully compact the graft to achieve this initial stability. The impaction vigour is defined as the energy applied per impact. The number of cycles also influences the degree of compaction [69,70]. One must take care not to propagate the fracture with this technique, Intra-operative fracture of the femur is a described complication of impaction bone grafting [71]. In summary a successful impaction bone grafting technique relies on the appropriate size and quantity of graft, the removal of fat from the graft, the amount of force used to compact it and the number of blows used [70,72–74]. Impaction bone grafting offers a unique opportunity to restore the femoral bone stock from the inside out and when combined with a cemented long stem can provide consistent and reliable results. Conflict of interest statement There are no conflicts of interest, there are no external sources of finance or relationships with people or organisations that could bias the work. References [1] Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 2007;38:651–4. [2] Garcia-Cimbrelo E, Munuera L, Gil-Garay E. Femoral shaft fractures after cemented total hip arthroplasty. Int Orthop 1992;16:97–100. [3] Lowenhielm G, Hansson LI, Ka¨rrholm J. Fractures of the lower extremity after total hip replacement. Arch Orthop Trauma Surg 1989;108:141–3. [4] Mont MA, Maar DC, Krackow KA, Hungerford DS. Hoop-stress fractures of the proximal femur during hip arthroplasty: management and results in 19 cases. J Bone Joint Surg Br 1992;74:257–60. [5] Stuchin SA. Femoral shaft fracture in porous and press-fit total hip arthroplasty. Orthop Rev 1990;19:153–9. [6] Pavlou G, Panteliadis P, Macdonald D, Timperley JA, Gie G, Bancroft G, Tsiridis E. A review of 202 periprosthetic fractures – stem revision and allograft improves outcome for type B fractures. Hip Int 2011;21:21–9. [7] Tsiridis E, Pavlou G, Venkatesh R, Bobak P, Gie G. Periprosthetic femoral fractures around hip arthroplasty: current concepts in their management. Hip Int 2009;2:75–86.
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[8] Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293–304. [9] Pritchett JW. Fracture of the greater trochanter after hip replacement. Clin Orthop Relat Res 2001;390:221–6. [10] Moazen M, Mak JH, Etchels LW, Jin Z, Wilcox RK, Jones AC, et al. Periprosthetic femoral fracture – a biomechanical comparison between Vancouver type B1 and B2 fixation methods. J Arthroplasty 2013. http://dx.doi.org/10.1016/ j.arth.2013.08.010. S0883-5403(13)00601-3 [Epub ahead of print]. [11] Lewallen DG, Berry DJ. Periprosthetic fractures of the femur after total hip arthroplasty: treatment and results to date. Instr Course Lect 1998;47:243–9. [12] Cook PH, Newman JH. Fractures of the femur in relation to cemented hip prostheses. J Bone Joint Surg Br 1988;70:386–9. [13] Macdonald SJ, Paprosky WG, Jablonsky WS, Magnus RG. Periprosthetic femoral fractures treated with a long-stem cementless component. J Arthroplasty 2001;16:379–83. [14] Moran MC. Treatment of periprosthetic fractures around total hip arthroplasty with an extensively coated femoral component. J Arthroplasty 1996;11:981–8. [15] Kavanagh BF. Femoral fracture associated with total hip arthroplasty. Orthop Clin North Am 1992;23:249–57. [16] Malkani AL, Lewallen DG, Cabanela ME, Wallrichs SL. Femoral component revision using an uncemented, proximally coated, long-stem prosthesis. J Arthroplasty 1996;11:411–8. [17] Head WC, Emerson Jr RH, Malinin TI. Structural bone grafting for femoral reconstruction. Clin Orthop Relat Res 1999;369:223–9. [18] Youssef B, Jeys L, George B, Abudu A, Carter S, Tillman R, et al. The use of endoprosthetic replacements for non-tumour limb salvage surgery (Abstract). J Bone Joint Surg Br 2011;93(Suppl. 1):5–6. [19] Slooff TJJH, Huiskes R, van Horn J, Lemmens AJ. Bone grafting in total hip replacement for acetabular protrusion. Acta Orthop Scand 1984;55:593–6. [20] Charity J, Lamberton AD, Gie GA, Timperley AJ. Grafting: impaction or strut. In: Barrack RL, Rosenberg AG., editors. Master techniques in orthopaedic surgery. The hip. 2nd ed., Philadelphia: Lippincott Williams and Wilkins; 2005 . p. 367–84. [21] Lee GC, Nelson CL, Virmani S, Manikonda K, Israelite CL, Garino JP. Management of periprosthetic femur fractures with severe bone loss using impaction bone grafting technique. J Arthroplasty 2010;25:405–9. [22] Tsiridis E, Gie GA. Mal-united femoral fractures adjacent to loose total hip arthroplasties. Salvage with impaction grafting. A case report. Injury 2002;33: 81–3. [23] Tsiridis E, Narvani AA, Charity J, Timperley JA, Gie GA. Intramedullary strut substitution and impaction allografting cemented revision for the treatment of a periprosthetic fracture in a severely compromised femur. J Arthroplasty 2007;22:277–82. [24] Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral allografting and cemented revision for periprosthetic femoral fractures. J Bone Joint Surg Br 2004;86:1124–32. [25] Bavadekar A, Cornu O, Godts B, Delloye C, Van Tomme J, Banse X. Stiffness and compactness of morsellized grafts during impaction: an in vitro study with human femoral heads. Acta Orthop Scand 2001;72:470–6. [26] Brewster NT, Gillespie WJ, Howie CR, Madabhushi SP, Usmani AS, Fairbairn DR. Mechanical considerations in impaction bone grafting. J Bone Joint Surg Br 1999;81:118–24. [27] Ullmark G, Nilsson O. Impacted corticocancellous allografts: recoil and strength. J Arthroplasty 1999;14:1019–23. [28] Giesen EB, Lamerigts NM, Verdonschot N, Buma P, Schreurs BW, Huiskes R. Mechanical characteristics of impacted morsellised bone grafts used in revision of total hip arthroplasty. J Bone Joint Surg Br 1999;8:1052–7. [29] Radcliffe SN, Smith DN. The Mennen plate in periprosthetic hip fractures. Injury 1996;27:27–30. [30] Uchio Y, Shu N, Nishikawa U, Takata K, Ochi M. Mennen plate fixation for fractures of the femoral shaft after ipsilateral hip arthroplasty. J Trauma 1997;42:1157–60. [31] Ahuja S, Chatterji S. The Mennen femoral plate for fixation of periprosthetic femoral fractures following hip arthroplasty. Injury 2002;33:47–50. [32] Tsiridis E, Amin MS, Charity J, Narvani AA, Timperley J, Gie GA. Impaction allografting revision for B3 periprosthetic femoral fractures using a Mennen plate to contain the graft: a technical report. Acta Orthop Belg 2007;73:332–8. [33] Mennen U. A new bone-holding clamp for use during internal fixation of fractures. S Afr Med J 1981;60:580–1. [34] Mennen U. The paraskeletal clamp-on plate: Part I. A new alternative for returning the surgically reduced position of bone fractures. S Afr Med J 1984;66:167–70. [35] Mennen U. The paraskeletal clamp-on plate: Part II. Clinical experience with fractures of the radius and/or ulna. S Afr Med J 1984;66:170–2. [36] Mennen U. Use of a clamp-on plate for forearm fractures. Orthopaedics 1989;12:39–43. [37] Kamineni S, Ware HE. The Mennen plate: unsuitable for elderly femoral periprosthetic fractures. Injury 1999;30:257–60. [38] Noorda RJ, Winsman PJ. Mennen plate fixation for the treatment of periprosthetic femoral fractures: a multicenter study of thirty-six fractures. J Bone Joint Surg Am 2002;84:2211–5. [39] Kligman M, Othrimski I, Roffman M. Mennen plate in hip and shoulder joint replacement. Bull Hosp Jt Dis 1997;56:84–7. [40] Sierra RF, Charity J, Tsiridis E, Timperley JA, Gie GA. The use of long cemented stems for femoral impaction grafting in revision total hip arthroplasty. J Bone Joint Surg Am 2008;90:1330–6.
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[41] Chandler HP, King D, Limbird R, Hedley A, McCarthy J, Penenberg B, et al. The use of cortical allograft struts for fixation of fractures associated with wellfixed total joint prostheses. Semin Arthroplasty 1993;4:99–107. [42] Chandler HP, Tigges RG. The role of allografts in the treatment of periprosthetic femoral fractures. Instr Course Lect 1998;47:257–64. [43] Emerson Jr RH. Basic science of onlay allografts: a review. Instr Course Lect 2000;49:97–102. [44] Haddad FS, Duncan CP, Berry DJ, Lewellen DG, Gross AE, Chandler HP. Periprosthetic femoral fractures around well-fixed implants: use of cortical onlay allografts with or without a plate. J Bone Joint Surg Am 2002;84:945–50. [45] Callaghan JJ, Heiner AD, Brown TD. The basic science of impaction allografting in revision hip surgery. Instr Course Lect 2000;49:103–10. [46] Slooff TJJ, Schreurs BW, Buma P, Gardeniers JWM. Impaction morsellized allografting and cement. Instr Course Lect 1999;48:79–89. [47] Wong P, Gross AE. The use of structural allografts for treating periprosthetic fractures about the hip and knee. Orthop Clin North Am 1999;30:259–64. [48] Malkani AL, Settecerri JJ, Sim FH. Long term results of proximal femoral replacements for non-neoplastic disorders. J Bone Joint Surg Br 1995;77: 351–6. [49] Morgan HD, McCallister W, Cho MS, Casnellie MT, Leopold SS. Impaction allografting for femoral component revision: clinical update. Clin Orthop Relat Res 2004;420:160–8. [50] Berry DJ. Treatment of Vancouver B3 periprosthetic femur fractures with a fluted tapered stem. Clin Orthop Relat Res 2003;417:224–31. [51] Mulay S, Hassan T, Birtwistle S, Power R. Management of types B2 and B3 femoral periprosthetic fractures by a tapered, fluted, and distally fixed stem. J Arthroplasty 2005;20:751–6. [52] Lindahl H. Epidemiology of periprosthetic femur fractures around a total hip replacement. Injury 2007;38:651–4. [53] Berry DJ. Epidemiology hip and knee. Clin Orthop Relat Res 1999;30:183–9. [54] Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20: 857–65. [55] Kellet CF, Boscainos PJ, Maury AC, Pressman A, Cayen B, Zalzal P, et al. Proximal femoral allograft treatment of Vancouver type-B3 periprosthetic femoral fractures after total hip arthroplasty. Surgical technique. J Bone Joint Surg Am 2007;89(Supp. 2 (Pt. 1)):68–79. [56] Hastings DE, Parker SM. Protrusio acetabuli in rheumatoid arthritis. Clin Orthop Relat Res 1975;108:76–83. [57] Schimmel JW, Buma P, Versleyen D, Huiskes R, Slooff TJ. Acetabular reconstruction with impacted morselized cancellous allografts in cemented hip arthroplasty: a histological and biomechanical study on the goat. J Arthroplasty 1998;13:438–48. [58] Schreurs BW, Bolder SB, Gardeniers JW, Verdonschot N, Slooff TJ, Veth RP. Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. A 15- to 20-year follow-up. J Bone Joint Surg Br 2004;86:492–7.
[59] Gie GA, Linder L, Ling RS, Simon JP, Slooff TJ, Timperley AJ. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1993;75:14–21. [60] Slooff TJ, Buma P, Schreurs BW, Schimmel JW, Huiskes R, Gardeniers J. Acetabular and femoral reconstruction with impacted graft and cement. Clin Orthop Relat Res 1996;324:108–15. [61] Comba F, Buttaro M, Pusso R, Piccaluga F. Acetabular reconstruction with impacted bone allografts and cemented acetabular components: a 2- to 13year follow-up study of 142 aseptic revisions. J Bone Joint Surg Br 2006;88:865–9. [62] Wang JW, Fong CY, Su YS, Yu HN. Acetabular revision with morsellised allogenic bone graft and a cemented metal-backed component. J Bone Joint Surg Br 2006;88:586–91. [63] Azuma T, Yasuda H, Okagaki K, Sakai K. Compressed allograft chips for acetabular reconstruction in revision hip arthroplasty. J Bone Joint Surg Br 1994;76:740–4. [64] Slooff TJ, Schimmel JW, Buma P. Cemented fixation with bone grafts. Orthop Clin North Am 1993;24:667–77. [65] Eldridge JDJ, Hubble MJW, Nelson K, Smith EJ, Learmonth ID. The effect of bone chip size on initial stability following femoral impaction grafting. J Bone Joint Surg Br 1997;79(Suppl. 3):364. [66] Wallace IW, Ammon PR, Beave RJ. How should bone be milled? J Bone Joint Surg Br 1997;79(Suppl. 3):365–6. [67] Dunlop DG, Brewster NT, Madabhushi SP, Usmani AS, Pankaj P, Howie CR. Techniques to improve the shear strength of impacted bone graft: the effect of particle size and washing of the graft. J Bone Joint Surg Am 2003;85:639–46. [68] Hostner J, Hultmark P, Karrholm J, Malchau H, Tveit M. Impaction technique and graft treatment in revisions of the femoral component: laboratory studies and clinical validation. J Arthroplasty 2001;16:76–82. [69] Sawicki A, Swidzinski W. Elastic moduli of non-cohesive particulate materials. Powder Technol 1998;96:24–32. [70] Kuiper JH, Soliman A, Cheah K, Richardson J. Stability of impaction-grafted hip and knee prostheses: surgical technique, implant design, and graft compaction. In: Delloye C, Bannister G, editors. Impaction bone grafting in revision arthroplasty. New York: Marcel Dekker; 2004. p. 75–94. [71] Ornstein E, Atroshi I, Franzeb H, Jonsson R, Sanquist P, Sunberg M. Early complications after one hundred and forty-four consecutive hip revisions with impacted morselized allograft bone and cement. J Bone Joint Surg Am 2002;84:1323–8. [72] Dunlop DG, Brewster NT, Madabhushi SP, Usmani AS, Pankaj P, Howie CR. Techniques to improve the shear strength of impacted bone graft: the effect of particle size and washing of the graft. J Bone Joint Surg Am 2003;85:639–44. [73] Ullmark G. Bigger size and defatting of bone chips will increase cup stability. Arch Orthop Trauma Surg 2000;120:445–7. [74] Verdonschot N, Schreurs B, van Unen J, Slooff T, Huiskes R. Cup stability after acetabulum reconstruction with morsellized grafts is less surgical dependent when larger grafts are used. Trans Orthop Res Soc 1999;24:867.
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Review
Impaction bone grafting for periprosthetic fractures around a total hip arthroplasty Bishoy Youssef a,b, George Pavlou a,b, Nikhil Shah a,b, George Macheras a,b, Eleftherios Tsiridis a,b,* a b
Academic Orthopaedic Unit, PapaGeorgiou General Hospital, Aristotle University Medical School, Thessaloniki, Hellas Wrightington Specialist Orthopaedic Hospital, Wrightington, Wigan and Leigh NHS Trust, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 27 July 2014
The incidence of periprosthetic fractures has been reported to be between 1 and 20.9% and appears to be on the rise. Fractures that occur around the femoral stem, particularly when the stem is loose or there is a loss of bone stock pose a technical challenge. These are rare injuries and there is considerable debate regarding their optimal treatment. Reconstruction with large segment endoprosthetic replacement is an acceptable solution for elderly patients who have limited functional demands and where the prosthesis is expected to outlive the patient. The younger patient poses a much greater challenge, the bone must be reconstituted and the femoral canal geometry must sufficiently restored to allow the stable insertion of a prosthesis. There are very few techniques that exist in this scenario. One such technique is impaction bone grafting and revision to a long smooth tapered cemented stem. This allows the restoration of bone stock and the stable insertion of a prosthesis. The aim of this article is to discuss the theory behind impaction bone grafting, the technical aspects and challenges of this technique, including fracture reduction methods, and to appraise all the literature available on impaction bone grafting for periprosthetic fractures. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Periprosthetic fractures Impaction bone grafting Total hip replacement
Contents Introduction . . . . . . . . . . . . . . Impaction bone grafting . . . . Literature review . . . . . . . . . . Discussion . . . . . . . . . . . . . . . Conflict of interest statement References . . . . . . . . . . . . . . .
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Introduction The incidence of periprosthetic fractures found at revision surgery for primary cemented hip replacements has been reported to be between 1 and 3.6% for cemented prosthesis and 3–20.9% for uncemented prosthesis. As one would expect there is also a significant incidence of periprosthetic fractures for revision procedures, with a 6.3% rate during cemented procedures and a 17.6% rate for uncemented procedures [1–5]. There has been
* Corresponding author. Tel.: +30 2310 390 599. E-mail address: [email protected] (E. Tsiridis). http://dx.doi.org/10.1016/j.injury.2014.07.028 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
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considerable debate with regard to the optimal treatment of these injuries, particularly those that occur around the femoral stem. Pavlou et al. conducted a review of 202 periprosthetic fractures treated at 2 specialist centres, they found that those fractures that had occurred around a well fixed stem had shorter union times and increased union rate when treated with stem revision than those treated with plate fixation. Fracture union was also more likely to occur when stem revision with bone grafting was undertaken for a periprosthetic fracture around a loose stem when compared with open reduction and internal fixation alone [6,7]. The Vancouver classification system is the most widely used and understood system for classifying fractures about the femoral stem [8]. Type A occur around the trochanters are normally only
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treated if the patient is symptomatic. Type C occurs well distal to the stem and theses fractures can be treated independently of the prosthesis with a method that best suits the personality of the fracture. Occasionally the stem does require revision, and in this scenario this is normally performed after the fracture has united. This article will concentrate on Vancouver B2 and B3 fractures. These fractures occur around the femoral implant and the implant is either loose, B2, or loose and the surrounding bone stock is deficient. In general the accepted treatment of choice for Vancouver B2 fractures is revision of the implant [8,11]. A cemented long stem revision is often the most appropriate implant for the more elderly with a simple fracture pattern [12]. Alternatively a long uncemented stem, which can be coated to allow osseous integration and contain flutes, grooves or slots to achieve distal fixation can treat type B2 fractures, which have adequate bone stock. Type B3 fractures pose the greatest challenge. A loose stem within a femur that has insufficient bone stock either due to gross osteolysis or significant fracture comminution has few reconstructive options. There are short to medium published results available on the use of extensively coated femoral components designed to encourage bone on growth onto the prosthesis. The results appear to be promising, however there is concern regarding stress shielding of the proximal femur [13,14]. Proximally coated long stem femoral components have also been used with some success however failure of osteointegration of the prosthesis has been noted [15,16]. A combination of prosthetic replacement combined with allograft has also been used with an 85% success rate in 262 patients using a proximal femoral replacement combined with a femoral allograft [17]. The use of tumour prosthesis, including total femoral replacement, has also been described to treat a loose implant in the face severe bone loss, however this is very much a salvage procedure and should be reserved for those patients’ who have a low functional demand [18]. The technique of impaction bone grafting of the femur for periprosthetic fractures can be used to good effect when there is bone loss around a loose femoral component, Vancouver B3 fractures. It is also a useful technique for Vancouver B2 fractures where the bone stock is sufficient to perform a revision, but reconstitution of the proximal femur with bone and the insertion of cemented stem is considered advantageous. This would typically be a young patient in whom re-revision in the future maybe necessary and restoring the bone stock to as near normal as possible may simplify the procedure. An example of a B3 fracture with a loose acetabular component is shown in Fig. 1. Its subsequent treatment using a long stem revision with mesh, impaction bone grafting and strut allografting is shown in Fig. 2. Impaction bone grafting The technique of using morselised fresh frozen cancellous allograft bone chips into an area of bony deficiency is not a new concept. It was first described for the reconstruction of acetabular protrusio [19] and was subsequently popularised by the Exeter group for revision surgery of the acetabulum as a method of restoring acetabular bone stock prior to insertion of the acetabular component. Femoral impaction bone graft aims to restore femoral bone stock by impacting fresh frozen cortico-cancellous bone chips into the canal to create a neo-endosteum prior to implantation of the cemented femoral component. It is also useful in revision of the femoral component where following removal of the femoral stem, all that remains of the inside of the canal is a smooth endosteal surface without sufficient cancellous bone that would allow adequate cementation of the femoral stem. It also has a role in the
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Fig. 1. A Vancouver B3 fracture of the femur with an associated periprosthetic acetabular fracture.
use of uncemented femoral prosthesis where this technique can be used to sufficiently reconstitute the bone stock to allow sufficient initial stability and scratch-fit of the component. The technique can be applied to any age group, it is perhaps of even greater importance in younger patients to try and restore their bone stock. It is not applicable in all cases particularly when there is severe proximal femoral bone loss exceeding 10 cm. It should also be considered as part of the armamentarium of revision surgery as due to the time consuming nature of the surgery it may not be appropriate for medically unfit patients where a shorter procedure that is also appropriate can be achieved (Table 1). Literature review A detailed literature search was conducted to identify all the relevant articles discussing impaction bone grafting for the treatment of periprosthetic fractures. A Medline search was
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Preoperative planning • • • •
History: Fitness for surgery, medical co-morbidities and evidence of previous infection. Examination: Previous scars, skin and soft tissue condition. Work-up: FBC, ESR, CRP. Joint luid aspiration. Plain ilm radiology: Full length high quality AP and lateral views of the pelvis and femur.
Equipment requirements • • • •
• • • • •
Femoral head allograft, onlay cortical strut grafts and reconstruction meshes. Stainless steel wires, cerclage cables and bone reduction forceps. Canal plugs. A range of the chosen implant in different lengths and offsets.
Approach and fracture reduction Lateral decubitus position. Posterolateral incision, preferably incorporating the previous incision. Aspirate hip prior to opening the capsule. 5-6 deep tissue samples. Fracture site can often act as an osteotomy site to aid removal of the implant. Temporary reduction achieved using the phantom stem and a combination of wires, cables and bone holding forceps.
Impaction bone grafting • • • • • • •
• • • •
Removal of the intramembranous canal. Distally plug the femoral canal. Insert a guidewire into the femoral canal. Bone chips of approximately 2-4mm are created by hand and impacted into the distal femur. A phantom stem is inserted, in the appropriate version and driven into the distal bone plug. Bone chips of 5-10mm in size are used in the proximal femur around the phantom implant. The phantom stem is then withdrawn and the neoendosteum is ready to accept a cemented, collarless, polished tapered stem with a wingless stem centraliser.
Postoperative mobilisation Touch weight bearing for 6 weeks. Partial weight bear from 6 weeks to 12 weeks. Full weight bear from 3 months. It will take a minimum of 12 months for the graft to incorporate and remodel.
Fig. 2. The post-operative image of the fractures treated with revision of both the femoral and acetabular components. A long cemented stem and a cemented socket were used. The defects were reconstructed using wire mesh and impaction bone grafting.
conducted between 1990 and 2013 using the OVID search engine (REF), with the key words ‘‘periprosthetic fracture’’, ‘‘impaction bone grafting’’, ‘‘fracture’’ and ‘‘surgery’’ and with MeSH (Medline/ Pubmed’s article indexing terminology) subject headings. The inclusion criteria included all reports on surgical treatment of periprosthetic fractures with the use of impaction bone grafting in the English language. Due to the paucity of literature available regarding this technique all articles were included in this review. The technique of impaction bone grafting to treat periprosthetic fractures was first described in the literature in a form of two case reports by Tsiridis and Gie in 2001 [25]. They describe the technique to treat mal-united femoral fractures adjacent to loose total hip replacements in a 74-year-old and a 38-year-old man. Both had satisfactory results and with radiographic evidence of graft incorporation into the host bone. In the discussion they describe the evolution of the technique where a cementless long stem Exeter was combined with impaction bone grafting to restore severe femoral bone loss. However they noted that the stem began to migrate distally. They felt that in retrospect the addition of cement would have improved the result and would have prevented the migration of the prosthesis. A case report published in 2007 discusses the combined use a strut allograft with impaction grafting to treat a complex B3 periprosthetic fracture with a Paprosky IV femoral deficiency [26]. The authors used a whole length femoral strut graft with an impaction bone grafting with a long stem cemented revision. He was awaiting a 3rd revision hip replacement when he sustained a periprosthetic fracture. An extended trochanteric osteotomy was utilised to remove the existing prosthesis and cement. A whole femur was bivalved and the metaphyseal sections removed to provide cancellous bone for the impaction bone grafting. One strut was hammered into the distal metaphysis to provide stability for the distal femur. The second strut was applied posteromedially. The canal was then impaction bone grafted to the level of the calcar using the method previously described. At 12 months the fracture had united clinically and radiologically. The authors noted that the use of an intramedullary strut created a narrower stronger tube to contain the impaction bone graft. Tsiridis et al. reported on the results of 106 type B2 and B3 periprosthetic fractures [27]. The largest series of periprosthetic fractures using this technique. 75 patients were treated with a long-stem revision and impaction bone grafting. 14 had cemented long stem revision without impaction bone revisions. 14 short stem revision with impaction bone grafting and 3 without impaction bone grafting. Long was differentiated from short on whether it bypassed the distal extent of the fracture by at least 1 cortical diameter. The difference in stems reflected a change in practice with a short stem combined with 2–4 mm bone chips used prior to 1996. The technique was changed to use a long stem implant with bone chips of a different size for the proximal and distal impaction. The change was brought about as a result of the high non-union rate of 43% with the previous technique and laboratory studies examining the impaction bone grafting technique [8–31]. Nine patients who were treated with long stem revision and impaction bone grafting also had additional strut grafts of which three had two grafts inserted. One short stem revision with impaction bone grafting had two strut grafts used to supplement fixation and one patient who had a short stem revision without impaction bone grafting also underwent strut allografting. A retrospective review of the notes and plain film radiographs was performed by two of the authors who were not involved in the surgery. The radiographs were assessed to examine the type of stem, mode of fixation and time to union. The Harris hip score was calculated at 52 weeks post surgery and was available for 66 of the
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Table 1 A summary of the results from studies that have investigated the role of impaction bone grafting for the treatment of periprosthetic fractures. Authors (year) Tsiridis and Gie (2002)
No. of patients 2
Periprosthetic fracture type
Treatment
Follow up
Complications
Outcome
1. Malunited femoral fracture with a loose total hip replacement. 2. Loose total hip replacement with marked osteolysis of the proximal femur and a periprosthetic fracture that had malunited in 308 of varus. Vancouver B2/B3
1. Cemented long stem revision with cerclage wires and a mesh on the proximal femur and impaction bone grafting (IBG). Mal-union not addressed. 2. Osteotomy, revision to a long stem with IBG and supplemental internal fixation with a plate.
1. 12 months 2. 84 months
None
1. Graft incorporation. 2. Graft incorporation and union of the osteotomy.
75 Cemented long stem revision with IBG. 14 long stem revision without IBG. 14 short stem revision with IBG. 3 short stem revision without IBG.
Not specified
80.2% union rate. 88% long stem with IBG. 57.1% short stem with IBG. Mean time to union 7.44 months (3–12). Harris Hip Score Mean 81 (55–91) recorded in 66 patients all with united fractures.
The femur was reconstructed with an intramedullary and extramedullary strut graft, cerclage wires, mesh and IBG. A long cemented femoral stem was inserted. Cemented long stem revision with IBG. A Mennen plate was used as a temporary reduction device and to assist in containing the bone graft. IBG combined with a cemented long stem revision, bypassing the fracture by at least 2 cortical diameters.
48 months
21 (19.8%) non union rate. 9 long stem with IBG. 5 long stem without IBG. 6 short stem with IBG. 1short stem without IBG. 4 (3.7%) infection rate. 2 long stem with IBG. 2 short stem with IBG. None
84 months (72–96)
None
56 months (27–90)
1 patient sustained 2 dislocations. 1 heterotopic bone ossification. 1 greater trochanter avulsion requiring ORIF.
Bony union 8 months (6–10). Charnley-d’AubignePostel scores 5, 3 and 6. Bony union achieved in all cases. Mean Harris Hip Score 73.8 (39–92). 6 out of 7 patients rated the procedure as good or excellent.
Tsiridis et al. (2004)
106
Tsiridis et al. (2007)
1
Vancouver B3
Tsiridis et al. (2007)
3
All Vancouver B3
Lee et al. (2010)
7
Vancouver B2 and B3
106 patients at the one-year mark. 88% of the fractures treated with long stem revision and impaction bone grafting successfully united compared with 57.1% of the short stem revisions with impaction bone grafting. The failure rate of the short stems and impaction bone grafting was five times higher compared with long stem prosthesis. Long stem with impaction bone grafting was significantly more likely to unite than without impaction bone grafting. The mean length of union time was 7.44 months (3–12). The mean Harris hip score was 81 (55–91). There were 21 nonunions (19.8%) and 4 infections (3.7%). In 2007 Tsiridis and colleagues reported on the treatment of a series of three patients who underwent revision impaction bone grafting with a Mennen plate for Vancouver B3 periprosthetic fractures. The impaction bone grafting technique was the same as has been previously described in the text with one exception, the Mennen plate was not used in this series to stabilise the fracture but contain the graft during the impaction process and as an aid to fracture reduction while the stem was inserted rather than for osteosynthesis of the fracture [32]. The plate, which has been described as para-skeletal clamp on system [33], was originally designed to treat fractures involving non-weight bearing bones [34–36]. Its role in the management of periprosthetic fractures has had variable success, with reports of failures related to mal-union, non-union and mechanical failure [37,38]. Moderate success was realised when it was combined with biological fixation in the form of cortical allograft for revision arthroplasty. Kligman et al.
Bony union was achieved at 12 months.
described its use combined with strut allografts for revision hip and shoulder arthroplasty. They had satisfactory results in 11 out of 12 patients. They felt that plate was useful in maintaining bony stability during reaming and reduction of the prosthesis [39]. The patients in Tsiridis’ series were followed up for a median follow up of 84 months, no infections were encountered with outcome scores of 5,3 and 6 based on the Charnley-Merle d’Aubigne´-Postel outcome measure. It’s use is now more of historical interest and it no longer has a role in modern periprosthetic fracture management. Lee et al. reported on the results of impaction bone grafting to treat seven patients’ with B2/B3 periprosthetic fractures around a total hip arthroplasty [21]. They chose this technique over a conventional uncemented long fully porous coated femoral component because they felt that the femoral canal geometry at the isthmus precluded their use. Their concern was that significant fracture comminution at the level of the isthmus would not provide the 4–8 cm of scratch fit necessary to allow successful implantation of the prosthesis. The femoral component used was a Spectron stem (Smith and Nephew, Memphis, TN). This is a nonpolished collared, cobalt chrome stem with a longitudinal taper that is designed to be cemented. The stem was templated to bypass the distal extent of the fracture by at least 2 cortical diameters. The canals were impaction bone grafted. They used 4 mm sized fresh frozen irradiated allograft croutons. In two patients they required the use of a mesh to contain the bone graft. One patient had a
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combined technique with the use to a strut allograft to reconstruct the proximal femur. No structural allografts were used to bypass the fracture site. The patients’ clinical outcome was assessed with the Harris hip score and a radiographic assessment was performed by a surgeon who was not involved in the surgery. The patients had a mean follow up of 56 months. The mean Harris hip score was 73.8 (39–92). Out of the seven patients; six patients were rated as having a good or excellent result, five patients had no pain, one had mild pain, and one had severe pain. Four patients did not require any walking aides, two used a walking stick for long walks and one required a walking stick at all times. All seven patients had radiographic evidence of complete fracture healing with good incorporation of the cortico-cancellous grafts with no evidence of loosening. A mean of 4.3 mm of subsidence of the stem was noted in their cohort of patients. They commented that a mean of 5.1 mm stem subsidence was reported in a series of long stem Exeter prostheses (Stryker, Rutherford, NJ) with impaction bone grafting for revision hip replacements [40]. However this is a known design feature of smooth polished double tapered stem. None of their cohort of patients required revision for infection or aseptic loosening of the femoral component. One patient developed asymptomatic heterotopic bone ossification and one patient required an open reduction and internal fixation of the greater trochanter, which avulsed at 80 months post operation. There are no major case series that solely involve the treatment of type B3 fractures in the literature. They are difficult injuries to treat and have a significant complication rate. There is no one single remedy that is suitable for all patients and each patient’s injury should be assessed and a specifically tailored plan to treat their injury should be sought. In the young the restoration of bone stock should be of paramount importance, this can be achieved by impaction bone grafting. This technique will enable the entire femoral canal’s bone stock to be restored prior to cementation of a tapered stem. Whereas an uncemented allograft prosthesis composite will not address the proximal bone loss and relies on distal fixation. Strut allografts also require adequate host femur. It is a biologically sound concept and if it incorporates early it will result in a sound biomechanical construct [41–44]. Impaction bone grafting is also a more biological procedure reconstructing the bone from the inside out. This will allow easier revascularisation of the bone and subsequent remodelling [45,46]. Wong et al. have reported on 15 B3 fractures treated with an allograft prosthesis composite and found that 93.3% healed using this technique [47]. In the elderly or very infirm tumour prostheses can be used, which will allow immediate weight bearing and have satisfactory clinical outcomes [18] Malkani et al. have demonstrated a 64% survivorship at 12 years when using proximal femoral replacements for the treatment of this type of problem [48]. The soft tissues can be reattached to the prosthesis using polytetrafluoroethylene coated tubes. Impaction bone grafting cannot only restore proximal femoral bone stock but is also useful when distal fixation cannot be achieved. This is particularly useful where the fracture extends or comminution exists below the isthmus that will not allow a stable distal fix to be achieved using a long cementless stem. This loss of rotational and axial stability is encountered when there is extensive proximal femoral bone loss, less than 4 cm of diaphysis distally or a canal width of greater than 18 mm [49]. There are case series looking at the use of fluted tapered cementless stems to treat B3 fractures. They can create a stable three-point fixation within the femoral canal. Berry et al. reported on this technique in 7 patients with B3 fractures and found that all the implants had remained stable and the fractures had united at a mean of 2 years [50]. Mulay et al. treated 24 patients with fluted tapered cementless stems to treat B2 and B3 fractures and found that 91% of the fractures had healed, however the technique was not
without complication with five dislocations and two non-unions [51]. Discussion Periprosthetic fractures in relation to a hip prosthesis are not a new phenomenon and was first described in 1954. Horwitz described a fracture around a hemiarthroplasty that was treated with cerclage wiring and internal fixation [52]. The incidence of periprosthetic fracture has been reported in the Mayo clinic series as affecting 0.3% of 20,859 primary cemented hip replacements and an occurring in 5.4% in 3121 primary cementless hip replacements. The rate increased to 3.6% in cemented revisions and 20.9% in cementless revisions [53]. The incidence of these injuries appears to be rising with data from the Swedish Hip Arthoplasty Register demonstrating an increase in yearly incidence from 0.045% to 0.13% of all total hip replacements performed from 1979 to 2000. The purported reasons for the rise are the increasing demand in the elderly in whom osteopenic bone and increased falls risk will lead to these fractures and younger patients with active lifestyles who are at risk of higher energy trauma [54]. Each treatment strategy is tailored to suit the patient and the personality of the fracture. Type B3 fractures which involve implant loosening and poor bone stock pose a significant treatment challenge. Elderly patients who will not tolerate prolonged procedures or are unable to remain non-weightbearing for significant periods of time may be better served with an endoprosthetic replacement. The treatment of younger patients is more controversial. In the younger patient we believe that priority should be given to the restoration of bone stock. Where severe bone loss in encountered in the proximal femur, a proximal femoral allograft composite can be created with the host femur bivalved and wrapped around a cemented allograft uncemented host stem interface [55]. Cortical struts can be applied orthogonally and combined with plating. They offer an external source of bone graft. They do need to be contoured to the shape of host femur and care must be taken to maintain the femoral blood supply when applying strut grafts. The technique of impaction bone grafting was first described by Hastings and Parker in 1975 [56]. The Nijmegen group in the Netherlands have a large and long standing experience of acetabular reconstruction using impaction bone grafting. The technique is applied to the reconstruction of bony defects in complex primary and revision hip arthroplasty. They consider it to be a biological technique that can reconstitute the bone that has been lost. Schimmel et al. examined graft incorporation and speed of consolidation into the host bone in an experimental study on Dutch milk goats. Histological analysis had shown that the grafts had incorporated with the trabecular bone bed within 3 weeks. The initial impaction technique is sufficient to provide early stability and at 12 weeks very little of the bone graft was still present, it had been replaced with new trabecular bony structure of lamellar bone. The presence of a fibrous membrane in some areas of the bone cement interface was noted. Nevertheless they felt that this technique was biological and could be used to treat small and large acetabular defects [57]. They have been able to translate these results into clinical practice. They have published the results of a consecutive series of 62 acetabular revisions for a mean of 16.5 years. The survivorship with revision for any reason as the endpoint was 79% at 15 years [58]. The technique converts a cavitatory defect into a tightly packed solid form of bone that will allow cementation of a prosthesis. Restoration of bone stock is particular attractive in younger patients, where re-revision is a real possibility. This method can achieve immediate implant stability. It can allow the use of normal implants with a normal cementing technique. The technique is not
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applicable to all patients. Pelvic irradiation limits the potential for the graft to revascularise and incorporate and therefore this technique is probably not appropriate for this group of patients. The majority of data available for this technique refers to its use for cemented sockets and cages to restore acetabular defects [59–64]. Histological studies have demonstrated that bone stock does reconstitute over time [57]. Supplemental stainless steel meshes can be used to convert segmental defects into contained defects that will provide sufficient resistance to allow impaction bone grafting. The allograft of choice is morselized cancellous bone. The choice is based on its open structure allowing angiogenesis and subsequent early remodelling. The ideal size of the bone chips appears to 8–10 mm in diameter allowing a more porous and permeable graft [65,66]. Smaller bone chips of 2–4 mm in size are required for the distal femur. The bone can be morselized by hand or by commercial mills that are able to produce bone chips of a specific size. Morselizing it by hand creates fragments of different sizes, this has been shown to reduce the shear that occurs between particles. This same technique does however technically reduce the permeability of the graft [67]. The graft is then washed, this is to remove excess fat, this is important because it increases the force required to displace the graft and improves its resistance to shear [68]. Compacting the bone graft is probably the most operatordependant part of the technique and done well increases the initial stability of the implant and can improve the longevity of the revised acetabular component [64]. The authors at the forefront of this technique have focused on the vigour that is required to successfully compact the graft to achieve this initial stability. The impaction vigour is defined as the energy applied per impact. The number of cycles also influences the degree of compaction [69,70]. One must take care not to propagate the fracture with this technique, Intra-operative fracture of the femur is a described complication of impaction bone grafting [71]. In summary a successful impaction bone grafting technique relies on the appropriate size and quantity of graft, the removal of fat from the graft, the amount of force used to compact it and the number of blows used [70,72–74]. Impaction bone grafting offers a unique opportunity to restore the femoral bone stock from the inside out and when combined with a cemented long stem can provide consistent and reliable results. Conflict of interest statement There are no conflicts of interest, there are no external sources of finance or relationships with people or organisations that could bias the work. References [1] Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury 2007;38:651–4. [2] Garcia-Cimbrelo E, Munuera L, Gil-Garay E. Femoral shaft fractures after cemented total hip arthroplasty. Int Orthop 1992;16:97–100. [3] Lowenhielm G, Hansson LI, Ka¨rrholm J. Fractures of the lower extremity after total hip replacement. Arch Orthop Trauma Surg 1989;108:141–3. [4] Mont MA, Maar DC, Krackow KA, Hungerford DS. Hoop-stress fractures of the proximal femur during hip arthroplasty: management and results in 19 cases. J Bone Joint Surg Br 1992;74:257–60. [5] Stuchin SA. Femoral shaft fracture in porous and press-fit total hip arthroplasty. Orthop Rev 1990;19:153–9. [6] Pavlou G, Panteliadis P, Macdonald D, Timperley JA, Gie G, Bancroft G, Tsiridis E. A review of 202 periprosthetic fractures – stem revision and allograft improves outcome for type B fractures. Hip Int 2011;21:21–9. [7] Tsiridis E, Pavlou G, Venkatesh R, Bobak P, Gie G. Periprosthetic femoral fractures around hip arthroplasty: current concepts in their management. Hip Int 2009;2:75–86.
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