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Revision total hip arthroplasty – Salvage procedures using bone allografts in Japan
Journal of Orthopaedic Science xxx (2017) 1e8
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Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Instructional Lecture
Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan Katsufumi Uchiyama a, *, Gen Inoue a, Naonobu Takahira b, Masashi Takaso a a b
Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 August 2016 Received in revised form 6 January 2017 Accepted 17 January 2017 Available online xxx
Total hip arthroplasty (THA) and hemiarthroplasty have improved hip joint function of patients suffering from hip disease or trauma with excellent clinical results and long-term survivorship. Conversely, there has been an increase in the number of revision surgeries after THA and hemiarthroplasty due to bone deficiency. The reconstruction of deficient bone remains a challenging problem following THA. While performing revision surgery, we have previously classified the preoperative bone deficiency using X-ray, CT and three-dimensional CT imaging according to location and severity of the deficiencies. We then predicted the shape and amount of the required bone allograft and the type of implant. Due to the accepted reconstruction methods of bone deficiency following revision surgeries, it is important to preoperatively assess the site and size of the bone deficiency to be repaired in the revision THA (re-THA). Bone allograft makes it possible to repair massive bone deficiency, recover bone stock, and improve longterm implant stability. Performing bone allograft will require a bone bank for harvesting, treating, and storing bone in Japan. © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Total hip arthroplasty (THA) and hemiarthroplasty have resulted in improvement in hip joint function for patients experiencing femoral neck fracture, osteoarthritis, or avascular necrosis of the femoral head. Furthermore, the number of revision surgeries after THA and hemiarthroplasty with bone deficiency due to prosthesis loosening with massive osteolysis, stress shielding, periprosthetic femoral fracture, or infection has increased. While bone autograft is the best filling material for bone deficiency, harvesting of bone involves invasion into the healthy portions of the body and limits the amount, morphology, and quality of the bone for harvest. Bone allograft is useful for massive bone deficiency that cannot be repaired by bone autografting, but use of bone allograft requires heating to prevent bacterial contamination and the transmission of infectious disease as well as cryopreservation in order to reduce
* Corresponding author. Fax: þ81 42 778 5850. E-mail addresses: [email protected] (K. Uchiyama), [email protected] (G. Inoue), [email protected] (N. Takahira), [email protected] (M. Takaso).
antigenicity. Establishing a bone bank is an essential part of being able to supply safe, high-quality allografts; however, Japan currently has only three bone banks (Tokai regional tissue bank, Kumamoto bone bank, and Kitasato university hospital bone bank) that have been certified by the Japanese Society of Tissue Transplantation. Therefore, it is important to construct a distribution system for bone allografts in Japan. This report addresses the procedure used to salvage bone allografts to reconstruct bone deficiency during revision total hip arthroplasty. We further assess the status of tissue handling, including the harvesting, storage, sterilization, basic study, and shipping of bone allografts. 2. Classification of bone deficiency of revision THA and reconstruction of bone deficiency with bone allografts 2.1. Reconstruction of acetabular bone deficiency The reconstruction of massive acetabular bone defects remains a challenging problem in revision THA [1]. Several methods of acetabular reconstruction have been described, including massive structural allografts, impaction bone grafting, oversized hemispheric cups, and acetabular reconstruction cages. However, none of those methods has been shown to predictably yield favorable
http://dx.doi.org/10.1016/j.jos.2017.01.023 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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results in the setting of massive periacetabular bone loss. We believe that acetabular bone defects should be reconstructed with bone allografting to restore the bone stock, thereby facilitating future revision surgery, particularly in young patients. Additionally, placing the acetabular component in the correct anatomical position decreases the risk of impingement and dislocation [2]. It is important to assess the site and size of the bone deficiency that requires repair in revision THA. We classified preoperative acetabular bone deficiency using X-ray, CT, and three-dimensional CT imaging according to their location and severity into types A through D, according to the classification system [3,4]. We then attempted to predict the shape and amount of the required bone allograft, and the type of implant (Fig. 1). In this classification system, type A bone defects (lateral defects) are subdivided into A-1 (minor defect) and A-2 (major defect). In cases where the center of rotation of the head of the femoral component is more medial than the bone graft, bone defects are classified as A-1, while bone grafting beyond the center of rotation is required for bone defects classified as A-2. A standard hemispherical cup or Müller ring (Zimmer Inc, Warsaw, IN, USA) is used with slightly morselized bone and cancellous bone at rim of the acetabular implant in type A patients. Type B defects (central defects) can be further classified as B-1 (i.e., central defect without penetration of the medial wall) and B-2 (i.e., central defect with penetration). This sub-classification is necessary because B-1 type bone defects can be restored using bone chip grafting, whereas inner-wall penetration in B-2 type bone defects can be better restored by grafting with a bone block. In type B patients, a Ganz reinforcement ring (Zimmer Inc, Warsaw,
IN, USA) is used without a strut screw. A bone defect mainly presenting in the cranial region is classified as type C (cranial type), which is treated using a Ganz ring with strut screw or a KT plate (KYOCERA Medical, Osaka, Japan). In type D bone defects, a craniocentral bone defect retaining the medial wall of the acetabulum is classified as D-1 (without penetration). A bone defect showing minor penetration of the medial wall is classified as D-2, and a bone defect with major penetration is classified as D-3. In type D-3, there is a complete defect of the central wall and sometimes disruption of the anterior and/or posterior column of the acetabulum. Because the entire weight-bearing area is composed of bone grafts, the use of a Ganz ring or a special technique (a strut screw technique) is required for implantation [4]. Particularly in the case of bone defects in the weight bearing areas, we employ two or three strut screws prior to installation of the reinforcement ring to act as struts for the support ring. Then, the reinforcement ring is installed by compression onto the allograft and the screw heads. The utilization of the reinforcement ring is essential to providing primary fixation of the cup and to prevent mechanical collapse of the allografts until secure incorporation of the allografts (Figs. 2 and 3). A high hip center position installation for the acetabular implant using the KT plate or Bruch-Schneider antiprotrusion cage (Zimmer Inc, Warsaw, IN, USA) is also allowed if the original acetabular installation of the acetabular implant is difficult due to a massive bone deficiency, or if long-term leg shortening or scar formation in soft tissue means that postoperative leg extension would not be possible. For these cases of bone allograft, we used the femoral condyle since cortical bones with quality support and a cancellous nature are useful (Fig. 4).
Fig. 1. We classified the preoperative acetabular bone deficiency using X-ray, CT, and three dimensional CT imaging according to their location and severity into types A through D, according to this classification system. Then, we predicted the shape and amount of the required bone allograft, and the type of implant. Reproduced with permissions of Reference 4, Zimmer Biomet G.K. and KYOCERA Medical Corporation.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
K. Uchiyama et al. / Journal of Orthopaedic Science xxx (2017) 1e8
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Fig. 2. The bone deficiency is the portion surrounded by white lines and arrows (a). In the case of bone defects in the weight bearing areas, we used two to three strut screws prior to installation of the reinforcement ring (three white allows are strut screws) (b). Three white arrows indicate the grafting of cancellous bone chip with fibrin glue (c). The reinforcement ring is installed by compressing it onto the allograft and the strut screw heads (one white allow). The utilization of the reinforcement ring is essential to providing primary fixation of the cup and to prevent mechanical collapse of the allografts until secure incorporation of the allografts (three white allows are grafting of cancellous bone chip) (d). Reproduced with permissions of Reference 4.
Fig. 3. This patient was experiencing a loosening joint after undergoing isoelastic THA 10 years previously (a). After revision surgery using a Ganz ring with strut screws (white allow) (b). Ten years after the revision surgery, we observed favorable remodeling of the allograft and no migration of the ring or the strut screw (white allow) (c).
2.2. Reconstruction of femoral bone deficiency The accepted reconstruction methods of femoral bone deficiency following revision surgeries include impaction bone grafting with polish taper cemented stems [5,6], distal press-fit fixation [7], and the use of a megaprosthesis [8,9] or a segmental cortical
allograft as an allograft prosthesis composite (APC) [10e12]. Impaction allografting is a well-described technique that has some success in patients with proximal femoral bone deficiency [5,6,13]. However, radiographic and histologic examinations have suggested neovascularization of impacted allograft bone in the proximal femur [5]. We classified pre-operative radiological femoral bone
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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Fig. 4. The massive bone deficiency of the acetabulum (a). Grafting the femoral condyle from non-living donor (three white allows), which including highly supportive cortical bone with good quality cancellous bone (b). The grafting of the femoral condyle (three white allows) remained at an appropriate size using an X-ray imaging intensifier (c). The grafting of cancellous bone chips and bone plate for bone deficiency along the acetabular edge (d). The reconstruction of the acetabulum with an allograft using a KT plate (e).
defects by Gustilo's classification [14]. Femoral component bone loosening is divided into four types. Type I is minimal endosteal or inner cortical bone loss. Type II is proximal canal enlargement with cortical thinning and an intact circumferential wall. Type III is a
posteromedial wall defect involving the lesser trochanter, which indicates instability. Type IV is total proximal circumferential loss. For types I, II, and III (Fig. 5), we use conical revision stems with cancellous bone chips encased in fibrin glue for reconstruction of
Fig. 5. Schema of reconstruction of femoral bone deficiency with allograft and stem selection according to the Gustilo classification. Reproduced with permissions Yasusuke Hirasawa, Akio Minami, Yoshiaki Toyama, editors. The State of the Art of Orthopedics for Physicians. Institute of Advanced Medical Technology.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
K. Uchiyama et al. / Journal of Orthopaedic Science xxx (2017) 1e8
the proximal femur (Fig. 6). In type III, we use a strut cortical allograft on the medial side. In Gustilo type IV femoral component loosening, we did not use conical revision stems for distal attachment if there was total proximal circumferential bone deficiency because sufficient primary stability of the distal femur using this stem is difficult to achieve. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft as an allografteprosthesis composite for reconstruction in the presence of circumferential bone loss of the proximal femur according to Gustilo classification type IV (Fig. 7) [15]. The distal interlocking of femoral prosthesis increases torsional stability and axial stability, which may improve biologic fixation. The proximal part of the femoral component is cemented into the allograft for stability, and the distal stem is positioned in the host distal femur without cement to permit compression at the osteotomy site. We think that distal cementing may compromise the integrity of the allograftehost junction. Therefore, we recommend a cementless stem for distal fixation. As a basic requirement for re-THA, we took into consideration that the implant had to be attached securely and directly to the host bone. However, in the case where the distal femur required a stovepipe canal due to osteoporosis, osteolysis, and infection, it was difficult to stably graft bone to the distal femoral cortical bone using a cementless interlocking distal femoral stem. Thus, we determined that a reduction in the distal femoral marrow cavity's diameter, which would accommodate the stem thickness, and a thickening of the cortical bone, which would increase the screw's effect, were necessary. Therefore, we reported two case reports regarding the insertion of cortical strut allografts into the femoral bone canal on
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the medial side, which was followed by the insertion of an interlocking stem. A further cortical strut allograft was inserted into the lateral side of the distal femur. In addition, the distal onlay allograft passed over the allograftehost bone junction. Subsequently, the two strut allografts were secured with interlocking screws to achieve distal stability of the interlocking stem. This procedure resulted in an improvement in the bone stock for the distal femur during re-THA and good clinical progress were recorded [16]. When we performed re-THA using APC, it is important to achieve robust stability between the composite and host bone. Then, we prompted bone union between the junction grafting strut allograft and cancellous bone chip. If the allograftehost bone junction was nonunion in nature, the distal screw would fracture and the stem would subside, so we developed an effective procedure for junction union to loop least autograft with soft tissue around the allograftehost bone junction. Performing a bone allograft to augment femoral bone deficiency has been performed using mainly cadaveric bone allografts obtained from KUBB [17,18]. There is currently little information regarding the histological features of massive allograft bone resorption and incorporation that occur after re-THA. Hamadouche et al. [19] reported the case of one patient who was followed-up for 10 years. During their observations, researchers noticed that the areas of the massive allograft that were in contact with the host bone were partly revascularized, while the portions that were not in contact were mostly resorbed. Therefore, we think that the host femur should be retained to enhance allograft incorporation, and the proximal segmental cortical allograft should be covered by the remnants of the thin proximal part of the host femur.
Fig. 6. Using a trans-trochanteric approach, removal of the implant and granulation tissue results in preservation of thin cortical bone (a). The grafting of cancellous bone chip making bone mil from femoral head allograft. Cancellous bone chips were impacted using a reamer (b, c). The conical stem was then inserted (d).
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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3. Harvesting, processing and storage of bone allografts
Fig. 7. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft as an allografteprosthesis composite for reconstruction in the presence of circumferential bone loss of the proximal femur, according to Gustilo classification type IV.
Harvesting human tissue, including bone, requires providing the donor or family sufficient explanation of the procedures that employ the donated tissue, harvesting methods, and the intended use of the harvested tissue. Providing tissue is a noble act of a public nature performed for society based on the donor's goodwill, and the tissue bank receiving the supply needs to ensure the dignity of the donor and respect the donor's intent and goodwill to society when handling the tissue. When tissue is being harvested, particular attention must be paid to the maintenance of respect for the dead when the donor (living will) or donor's bereaved family provide consent, when the doctor harvests the tissue, and when the harvesting is performed from the deceased. The Kitasato University Hospital Bone Bank (KUBB) was established in 1971 concurrently with the opening of Kitasato University Hospital. At KUBB, clinicians freeze and preserve bone tissue from the femoral head, which is retrieved during operation, and bones from amputated legs. Due to the difficulty in meeting the increasing demand, KUBB began to excise bones from cadaver donors in 1978 after obtaining ‘written informed consent’ from family members of the deceased and following thorough consultations with legal professionals. Since the opening of the bone bank, KUBB has continued basic research on bone allografting [20] and its clinical application, and contributed to the development of bone allografting in Japan. Currently, KUBB runs a 24-h system that handles donors in Kanagawa Prefecture, Tokyo, Chiba Prefecture, and eastern Shizuoka Prefecture, in collaboration with the Japan Organ Transplant Network and the East Japan Tissue Transplant Network. It is preferable to harvest tissue within 12 h after cardiopulmonary function has stopped. The act of harvesting requires that three doctors (made up of six or seven teams) be dispatched along with two tissue transplant coordinators to spend about an hour and a half on tissue harvesting, tissue packaging, reconstruction, and repair. The rate of tissue harvesting and shipping from non-living donors in KUBB from 2007 to 2016 is shown in Figs. 8 and 9. Excised bone and ligament tissue is put in primary cryopreservation in a freezer at 80 C. If it is confirmed not to have bacterial contamination or blood infection, a doctor or trained technician treats the bone and ligament tissue and puts it in storage in cryopreservation. KUBB received assistance in 2008 from the Ministry of Health, Labour, and Welfare's tissue bank facility development project, thereby allowing it to make significant expansions and renovations as well as build a clean processing room within the
Fig. 8. Amount of bones harvested from non-living donors in KUBB from 2007 to 2016.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
K. Uchiyama et al. / Journal of Orthopaedic Science xxx (2017) 1e8
bone bank. This facility is used to remove, as much as possible, the unnecessary tissue that is attached to the harvested bone, such as muscle, periosteum, and cartilage. Then, an ultrasonic irrigation device provided with sterile distilled water that has been set up in the processing room is used for ten hours of heat treatment at 60 C to inactivate viruses that may have been undetectable in blood tests and other screens, thereby better preventing infection in the recipient. Lipid components in the bone marrow can also be removed by ultrasonic irrigation (Fig. 10). To confirm whether contamination has occurred during treatment, all treated bone is swabbed for bacterial culturing before packaging. The tissue is tripled-wrapped in a degassed airtight plastic bag, with the final product bearing a product number (Fig. 11). Each tissue is photographed, radiographed, measured, and weighed, and results are entered into a data sheet along with the results of the bacterial culturing. Secondary cryopreservation is performed, again with a freezer at 80 C, and is thawed immediately prior to use in surgery after a storage period of at least three months following harvesting. At this temperature, storage for at least five years is thought to be possible. For allograft bone transplantation cases and tissue supply cases, KUBB has an attending physician report on the occurrence of infectious diseases and on the condition of the graft bone at six months after the transplantation procedure. This is repeated at one year after the graft is performed to assess the patient's course. A common numbering system is clearly written onto the graft bone being supplied, and a system has been set up to make it possible to ascertain the recipient's condition (traceability) if a problem arises in the follow-up with the graft bone or in the patient receiving the graft. 4. The current state of bone allografting in Japan Between 2007 and 2015, “Cryopreserved allograft bone/ligament tissue from a non-living donor” was approved by Ministry of Health, Labour and Welfare in Japan as a form of advanced medical treatment, with patients being billed for the cost of harvesting, treating, and preserving the allograft tissue. However, the criteria for the approval of advanced medical treatment require that the tissue bank be certified by the Japanese Society of Tissue Transplantation and that shipped tissue is unable to be used at another facility. Moreover, only tissue from non-living donors is allowed to be used for advanced medical treatment. However, with the 2016 revision of medical remuneration, it has become possible to claim 24,370 points (243,700 yen) for
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Fig. 10. Attached superfluous tissue, such as muscle, periosteum, and cartilage, is removed as much as possible from the harvested bone. Then, an ultrasonic irrigation device provided with sterile distilled water that has been set up in the processing room is used for ten hours of heat treatment at 60 C to inactivate viruses that may have escaped notice in blood tests and other screening, thus better ensuring the prevention of infection in the recipient. Ultrasonic irrigation is also used to remove lipid components in bone marrow.
cryopreserved allograft bone and ligament grafts (special) harvested from non-living donors, based on the results of deliberation at advanced medical treatment conferences. However, nowadays, another problem has arisen. As seen from the circumstances of activity at the KUBB, as well, there have been only two or three cases of harvesting from non-living donors per year recently, whereas shipping to other facilities has increased to 20 or more cases. Because there is expected to be a continued increase in the number of facilities that require massive bone allograft, coverage for tissue used at other facilities represents significant progress. Recently, favorable results have been reported from metal augmentation used in total hip arthroplasty [21,22], but bone allograft makes it possible to repair massive bone deficiency, recover bone stock, and improve long-term implant stability. Therefore, allograft bone represents a very useful filling material for treating bone deficiency, and regional bone banks are essential for bone allograft. KUBB is striving to set up a system as a base bank in east Japan that integrates harvesting, treatment, and preservation of allograft bone and ligament tissue, along with shipping, with the
Fig. 9. Number of bones shipped for use at another institute from non-living donors in KUBB from 2007 to 2016.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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Fig. 11. The tissue is tripled-wrapped in a degassed airtight plastic bag, bearing a product number written on it.
hope of expanding fair and just medical treatment that involves tissue transplantation nationwide. Conflict of interest The authors declare that they have no conflict of interest. Acknowledgments I would like to thank emeritus professor Moritoshi Itoman, who offered continuing support and constant encouragement. I would also like to thank Dr. Mitsutoshi Moriya, Dr. Kensuke Fukushima, Dr. Takeaki Yamamoto, and Dr. Yojiro Minegishi for their assistance in revision total hip arthroplasty using bone allografts. I would also like to thank Ms. Midori Kasahara and Mr. Masaki Otani (tissue transplant coordinators of KUBB) for their assistance in harvesting and processing bone allografts. References [1] Pope D, Blankenship S, Jones G, Robinson BS, Maloney WJ, Paprosky WG, Ries MD, Saleh KJ. Maximizing function and outcomes in acetabular reconstruction: segmental bony defects and pelvic discontinuity. Instr Course Lect 2014;63:187e97. [2] Kelley SS. High hip center in revision arthroplasty. J Arthroplasty 1994 Oct;9(5):503e10. [3] Itoman M, Yamamoto M, Yonemoto K, Sekiguchi M, Kai H. Radiological evaluation on allograft reconstruction of the acetabulum combined with supporting device in revision total hip replacement. Nihon Seikeigeka Gakkai Zasshi 1992 Jan;66(1):23e30. [4] Uchiyama K, Takahira N, Fukushima K, Yamamoto T, Moriya M, Itoman M. Radiological evaluation of allograft reconstruction in acetabulum with Ganz reinforcement ring in revision total hip replacement. J Orthop Sci 2010 Nov;15(6):764e71. [5] Lind M, Krarup N, Mikkelsen S, Horlyck E. Exchange impaction allografting for femoral revision hip arthroplasty: results in 87 cases after 3.6 years' followup. J Arthroplasty 2002 Feb;17(2):158e64. [6] Iwase T, Otsuka H, Katayama N, Fujita H. Impaction bone grafting for femoral revision hip arthroplasty with Exeter Universal stem in Japan. Arch Orthop Trauma Surg 2012 Oct;132(10):1487e94. [7] Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year-results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res 1999 Dec;(369):230e42. [8] Parvizi J, Sim FH. Proximal femoral replacements with megaprostheses. Clin Orthop Relat Res 2004 Mar;(420):169e75.
[9] Savvidou OD, Mavrogenis AF, Sakellariou V, Christogiannis I, Vottis C, Christodoulou M, Vlasis K, Papagelopoulos PJ. Salvage of failed total hip arthroplasty with proximal femoral replacement. Orthopedics 2014 Oct;37(10):691e8. [10] Safir O, Kellett CF, Flint M, Backstein D, Gross AE. Revision of the deficient proximal femur with a proximal femoral allograft. Clin Orthop Relat Res 2008;467(1):206e12. [11] Babis GC, Sakellariou VI, O'Connor MI, Hanssen AD, Sim FH. Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year followup study. J Bone Jt Surg Br 2010 Mar;92(3):349e55. [12] Rogers BA, Sternheim A, De Iorio M, Backstein D, Safir O, Gross AE. Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis. J Arthroplasty 2012 Jun;27(6). 829e836.e1. [13] Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Jt Surg Br 2003 Aug;85(6):809e17. [14] Gustilo RB, Pasternak HS. Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop Relat Res 1988 Oct;(235):111e9. [15] Uchiyama K, Moriya M, Yamamoto T, Fukushima K, Takahira N, Itoman M. Revision total hip arthroplasty using an interlocking stem with an allograftprosthesis composite. Acta Orthop Belg 2013 Aug;79(4):398e405. [16] Uchiyama K, Takahira N, Narahara H, Fukushima K, Yamamoto T, Moriya M, Kawamura T, Urabe K, Sakai R, Itoman M, Takaso M. Revision total hip replacement using a cementless interlocking distal femoral stem with allograft-cemented composite and the application of intramedullary and onlay cortical strut allografts: two case reports. J Orthop Sci 2012 May;17(3): 323e7. [17] Komiya K, Nasuno S, Uchiyama K, Takahira N, Kobayashi N, Minehara H, Watanabe S, Itoman M. Status of bone allografting in Japan e nation-wide survey of bone grafting performed from 1995 through 1999. Cell Tissue Bank 2003;4(2e4):217e20. [18] Urabe K, Naruse K, Uchino M, Takaso M, Fujita M, Uchiyama K, Okada T, Kasahara M, Itoman M. The expense for one implantation of a banked bone allograft from a cadaveric donor and the issues affecting current advanced medical treatment in the Japanese orthopaedic field. Cell Tissue Bank 2009 Aug;10(3):259e65. [19] Hamadouche M, Blanchat C, Meunier A, Kerboull L, Kerboull M. Histological findings in a proximal femoral structural allograft ten years following revision total hip arthroplasty: a case report. J Bone Jt Surg Am 2002 Feb;84-A(2): 269e73. [20] Uchiyama K, Ujihira M, Mabuchi K, Takahira N, Komiya K, Itoman M. Development of heating method by microwave for sterilization of bone allografts. J Orthop Sci 2005;10(1):77e83. [21] Pulido L, Rachala SR, Cabanela ME. Cementless acetabular revision: past, present, and future. Revision total hip arthroplasty: the acetabular side using cementless implants. Int Orthop 2011 Feb;35(2):289e98. [22] Whitehouse MR, Masri BA, Duncan CP, Garbuz DS. Continued good results with modular trabecular metal augments for acetabular defects in hip arthroplasty at 7 to 11 years. Clin Orthop Relat Res 2015 Feb;473(2):521e7.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Instructional Lecture
Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan Katsufumi Uchiyama a, *, Gen Inoue a, Naonobu Takahira b, Masashi Takaso a a b
Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 August 2016 Received in revised form 6 January 2017 Accepted 17 January 2017 Available online xxx
Total hip arthroplasty (THA) and hemiarthroplasty have improved hip joint function of patients suffering from hip disease or trauma with excellent clinical results and long-term survivorship. Conversely, there has been an increase in the number of revision surgeries after THA and hemiarthroplasty due to bone deficiency. The reconstruction of deficient bone remains a challenging problem following THA. While performing revision surgery, we have previously classified the preoperative bone deficiency using X-ray, CT and three-dimensional CT imaging according to location and severity of the deficiencies. We then predicted the shape and amount of the required bone allograft and the type of implant. Due to the accepted reconstruction methods of bone deficiency following revision surgeries, it is important to preoperatively assess the site and size of the bone deficiency to be repaired in the revision THA (re-THA). Bone allograft makes it possible to repair massive bone deficiency, recover bone stock, and improve longterm implant stability. Performing bone allograft will require a bone bank for harvesting, treating, and storing bone in Japan. © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Total hip arthroplasty (THA) and hemiarthroplasty have resulted in improvement in hip joint function for patients experiencing femoral neck fracture, osteoarthritis, or avascular necrosis of the femoral head. Furthermore, the number of revision surgeries after THA and hemiarthroplasty with bone deficiency due to prosthesis loosening with massive osteolysis, stress shielding, periprosthetic femoral fracture, or infection has increased. While bone autograft is the best filling material for bone deficiency, harvesting of bone involves invasion into the healthy portions of the body and limits the amount, morphology, and quality of the bone for harvest. Bone allograft is useful for massive bone deficiency that cannot be repaired by bone autografting, but use of bone allograft requires heating to prevent bacterial contamination and the transmission of infectious disease as well as cryopreservation in order to reduce
* Corresponding author. Fax: þ81 42 778 5850. E-mail addresses: [email protected] (K. Uchiyama), [email protected] (G. Inoue), [email protected] (N. Takahira), [email protected] (M. Takaso).
antigenicity. Establishing a bone bank is an essential part of being able to supply safe, high-quality allografts; however, Japan currently has only three bone banks (Tokai regional tissue bank, Kumamoto bone bank, and Kitasato university hospital bone bank) that have been certified by the Japanese Society of Tissue Transplantation. Therefore, it is important to construct a distribution system for bone allografts in Japan. This report addresses the procedure used to salvage bone allografts to reconstruct bone deficiency during revision total hip arthroplasty. We further assess the status of tissue handling, including the harvesting, storage, sterilization, basic study, and shipping of bone allografts. 2. Classification of bone deficiency of revision THA and reconstruction of bone deficiency with bone allografts 2.1. Reconstruction of acetabular bone deficiency The reconstruction of massive acetabular bone defects remains a challenging problem in revision THA [1]. Several methods of acetabular reconstruction have been described, including massive structural allografts, impaction bone grafting, oversized hemispheric cups, and acetabular reconstruction cages. However, none of those methods has been shown to predictably yield favorable
http://dx.doi.org/10.1016/j.jos.2017.01.023 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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results in the setting of massive periacetabular bone loss. We believe that acetabular bone defects should be reconstructed with bone allografting to restore the bone stock, thereby facilitating future revision surgery, particularly in young patients. Additionally, placing the acetabular component in the correct anatomical position decreases the risk of impingement and dislocation [2]. It is important to assess the site and size of the bone deficiency that requires repair in revision THA. We classified preoperative acetabular bone deficiency using X-ray, CT, and three-dimensional CT imaging according to their location and severity into types A through D, according to the classification system [3,4]. We then attempted to predict the shape and amount of the required bone allograft, and the type of implant (Fig. 1). In this classification system, type A bone defects (lateral defects) are subdivided into A-1 (minor defect) and A-2 (major defect). In cases where the center of rotation of the head of the femoral component is more medial than the bone graft, bone defects are classified as A-1, while bone grafting beyond the center of rotation is required for bone defects classified as A-2. A standard hemispherical cup or Müller ring (Zimmer Inc, Warsaw, IN, USA) is used with slightly morselized bone and cancellous bone at rim of the acetabular implant in type A patients. Type B defects (central defects) can be further classified as B-1 (i.e., central defect without penetration of the medial wall) and B-2 (i.e., central defect with penetration). This sub-classification is necessary because B-1 type bone defects can be restored using bone chip grafting, whereas inner-wall penetration in B-2 type bone defects can be better restored by grafting with a bone block. In type B patients, a Ganz reinforcement ring (Zimmer Inc, Warsaw,
IN, USA) is used without a strut screw. A bone defect mainly presenting in the cranial region is classified as type C (cranial type), which is treated using a Ganz ring with strut screw or a KT plate (KYOCERA Medical, Osaka, Japan). In type D bone defects, a craniocentral bone defect retaining the medial wall of the acetabulum is classified as D-1 (without penetration). A bone defect showing minor penetration of the medial wall is classified as D-2, and a bone defect with major penetration is classified as D-3. In type D-3, there is a complete defect of the central wall and sometimes disruption of the anterior and/or posterior column of the acetabulum. Because the entire weight-bearing area is composed of bone grafts, the use of a Ganz ring or a special technique (a strut screw technique) is required for implantation [4]. Particularly in the case of bone defects in the weight bearing areas, we employ two or three strut screws prior to installation of the reinforcement ring to act as struts for the support ring. Then, the reinforcement ring is installed by compression onto the allograft and the screw heads. The utilization of the reinforcement ring is essential to providing primary fixation of the cup and to prevent mechanical collapse of the allografts until secure incorporation of the allografts (Figs. 2 and 3). A high hip center position installation for the acetabular implant using the KT plate or Bruch-Schneider antiprotrusion cage (Zimmer Inc, Warsaw, IN, USA) is also allowed if the original acetabular installation of the acetabular implant is difficult due to a massive bone deficiency, or if long-term leg shortening or scar formation in soft tissue means that postoperative leg extension would not be possible. For these cases of bone allograft, we used the femoral condyle since cortical bones with quality support and a cancellous nature are useful (Fig. 4).
Fig. 1. We classified the preoperative acetabular bone deficiency using X-ray, CT, and three dimensional CT imaging according to their location and severity into types A through D, according to this classification system. Then, we predicted the shape and amount of the required bone allograft, and the type of implant. Reproduced with permissions of Reference 4, Zimmer Biomet G.K. and KYOCERA Medical Corporation.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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Fig. 2. The bone deficiency is the portion surrounded by white lines and arrows (a). In the case of bone defects in the weight bearing areas, we used two to three strut screws prior to installation of the reinforcement ring (three white allows are strut screws) (b). Three white arrows indicate the grafting of cancellous bone chip with fibrin glue (c). The reinforcement ring is installed by compressing it onto the allograft and the strut screw heads (one white allow). The utilization of the reinforcement ring is essential to providing primary fixation of the cup and to prevent mechanical collapse of the allografts until secure incorporation of the allografts (three white allows are grafting of cancellous bone chip) (d). Reproduced with permissions of Reference 4.
Fig. 3. This patient was experiencing a loosening joint after undergoing isoelastic THA 10 years previously (a). After revision surgery using a Ganz ring with strut screws (white allow) (b). Ten years after the revision surgery, we observed favorable remodeling of the allograft and no migration of the ring or the strut screw (white allow) (c).
2.2. Reconstruction of femoral bone deficiency The accepted reconstruction methods of femoral bone deficiency following revision surgeries include impaction bone grafting with polish taper cemented stems [5,6], distal press-fit fixation [7], and the use of a megaprosthesis [8,9] or a segmental cortical
allograft as an allograft prosthesis composite (APC) [10e12]. Impaction allografting is a well-described technique that has some success in patients with proximal femoral bone deficiency [5,6,13]. However, radiographic and histologic examinations have suggested neovascularization of impacted allograft bone in the proximal femur [5]. We classified pre-operative radiological femoral bone
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Fig. 4. The massive bone deficiency of the acetabulum (a). Grafting the femoral condyle from non-living donor (three white allows), which including highly supportive cortical bone with good quality cancellous bone (b). The grafting of the femoral condyle (three white allows) remained at an appropriate size using an X-ray imaging intensifier (c). The grafting of cancellous bone chips and bone plate for bone deficiency along the acetabular edge (d). The reconstruction of the acetabulum with an allograft using a KT plate (e).
defects by Gustilo's classification [14]. Femoral component bone loosening is divided into four types. Type I is minimal endosteal or inner cortical bone loss. Type II is proximal canal enlargement with cortical thinning and an intact circumferential wall. Type III is a
posteromedial wall defect involving the lesser trochanter, which indicates instability. Type IV is total proximal circumferential loss. For types I, II, and III (Fig. 5), we use conical revision stems with cancellous bone chips encased in fibrin glue for reconstruction of
Fig. 5. Schema of reconstruction of femoral bone deficiency with allograft and stem selection according to the Gustilo classification. Reproduced with permissions Yasusuke Hirasawa, Akio Minami, Yoshiaki Toyama, editors. The State of the Art of Orthopedics for Physicians. Institute of Advanced Medical Technology.
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the proximal femur (Fig. 6). In type III, we use a strut cortical allograft on the medial side. In Gustilo type IV femoral component loosening, we did not use conical revision stems for distal attachment if there was total proximal circumferential bone deficiency because sufficient primary stability of the distal femur using this stem is difficult to achieve. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft as an allografteprosthesis composite for reconstruction in the presence of circumferential bone loss of the proximal femur according to Gustilo classification type IV (Fig. 7) [15]. The distal interlocking of femoral prosthesis increases torsional stability and axial stability, which may improve biologic fixation. The proximal part of the femoral component is cemented into the allograft for stability, and the distal stem is positioned in the host distal femur without cement to permit compression at the osteotomy site. We think that distal cementing may compromise the integrity of the allograftehost junction. Therefore, we recommend a cementless stem for distal fixation. As a basic requirement for re-THA, we took into consideration that the implant had to be attached securely and directly to the host bone. However, in the case where the distal femur required a stovepipe canal due to osteoporosis, osteolysis, and infection, it was difficult to stably graft bone to the distal femoral cortical bone using a cementless interlocking distal femoral stem. Thus, we determined that a reduction in the distal femoral marrow cavity's diameter, which would accommodate the stem thickness, and a thickening of the cortical bone, which would increase the screw's effect, were necessary. Therefore, we reported two case reports regarding the insertion of cortical strut allografts into the femoral bone canal on
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the medial side, which was followed by the insertion of an interlocking stem. A further cortical strut allograft was inserted into the lateral side of the distal femur. In addition, the distal onlay allograft passed over the allograftehost bone junction. Subsequently, the two strut allografts were secured with interlocking screws to achieve distal stability of the interlocking stem. This procedure resulted in an improvement in the bone stock for the distal femur during re-THA and good clinical progress were recorded [16]. When we performed re-THA using APC, it is important to achieve robust stability between the composite and host bone. Then, we prompted bone union between the junction grafting strut allograft and cancellous bone chip. If the allograftehost bone junction was nonunion in nature, the distal screw would fracture and the stem would subside, so we developed an effective procedure for junction union to loop least autograft with soft tissue around the allograftehost bone junction. Performing a bone allograft to augment femoral bone deficiency has been performed using mainly cadaveric bone allografts obtained from KUBB [17,18]. There is currently little information regarding the histological features of massive allograft bone resorption and incorporation that occur after re-THA. Hamadouche et al. [19] reported the case of one patient who was followed-up for 10 years. During their observations, researchers noticed that the areas of the massive allograft that were in contact with the host bone were partly revascularized, while the portions that were not in contact were mostly resorbed. Therefore, we think that the host femur should be retained to enhance allograft incorporation, and the proximal segmental cortical allograft should be covered by the remnants of the thin proximal part of the host femur.
Fig. 6. Using a trans-trochanteric approach, removal of the implant and granulation tissue results in preservation of thin cortical bone (a). The grafting of cancellous bone chip making bone mil from femoral head allograft. Cancellous bone chips were impacted using a reamer (b, c). The conical stem was then inserted (d).
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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3. Harvesting, processing and storage of bone allografts
Fig. 7. We have previously performed revision surgery using a cementless interlocking distal femoral stem with segmental cortical allograft as an allografteprosthesis composite for reconstruction in the presence of circumferential bone loss of the proximal femur, according to Gustilo classification type IV.
Harvesting human tissue, including bone, requires providing the donor or family sufficient explanation of the procedures that employ the donated tissue, harvesting methods, and the intended use of the harvested tissue. Providing tissue is a noble act of a public nature performed for society based on the donor's goodwill, and the tissue bank receiving the supply needs to ensure the dignity of the donor and respect the donor's intent and goodwill to society when handling the tissue. When tissue is being harvested, particular attention must be paid to the maintenance of respect for the dead when the donor (living will) or donor's bereaved family provide consent, when the doctor harvests the tissue, and when the harvesting is performed from the deceased. The Kitasato University Hospital Bone Bank (KUBB) was established in 1971 concurrently with the opening of Kitasato University Hospital. At KUBB, clinicians freeze and preserve bone tissue from the femoral head, which is retrieved during operation, and bones from amputated legs. Due to the difficulty in meeting the increasing demand, KUBB began to excise bones from cadaver donors in 1978 after obtaining ‘written informed consent’ from family members of the deceased and following thorough consultations with legal professionals. Since the opening of the bone bank, KUBB has continued basic research on bone allografting [20] and its clinical application, and contributed to the development of bone allografting in Japan. Currently, KUBB runs a 24-h system that handles donors in Kanagawa Prefecture, Tokyo, Chiba Prefecture, and eastern Shizuoka Prefecture, in collaboration with the Japan Organ Transplant Network and the East Japan Tissue Transplant Network. It is preferable to harvest tissue within 12 h after cardiopulmonary function has stopped. The act of harvesting requires that three doctors (made up of six or seven teams) be dispatched along with two tissue transplant coordinators to spend about an hour and a half on tissue harvesting, tissue packaging, reconstruction, and repair. The rate of tissue harvesting and shipping from non-living donors in KUBB from 2007 to 2016 is shown in Figs. 8 and 9. Excised bone and ligament tissue is put in primary cryopreservation in a freezer at 80 C. If it is confirmed not to have bacterial contamination or blood infection, a doctor or trained technician treats the bone and ligament tissue and puts it in storage in cryopreservation. KUBB received assistance in 2008 from the Ministry of Health, Labour, and Welfare's tissue bank facility development project, thereby allowing it to make significant expansions and renovations as well as build a clean processing room within the
Fig. 8. Amount of bones harvested from non-living donors in KUBB from 2007 to 2016.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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bone bank. This facility is used to remove, as much as possible, the unnecessary tissue that is attached to the harvested bone, such as muscle, periosteum, and cartilage. Then, an ultrasonic irrigation device provided with sterile distilled water that has been set up in the processing room is used for ten hours of heat treatment at 60 C to inactivate viruses that may have been undetectable in blood tests and other screens, thereby better preventing infection in the recipient. Lipid components in the bone marrow can also be removed by ultrasonic irrigation (Fig. 10). To confirm whether contamination has occurred during treatment, all treated bone is swabbed for bacterial culturing before packaging. The tissue is tripled-wrapped in a degassed airtight plastic bag, with the final product bearing a product number (Fig. 11). Each tissue is photographed, radiographed, measured, and weighed, and results are entered into a data sheet along with the results of the bacterial culturing. Secondary cryopreservation is performed, again with a freezer at 80 C, and is thawed immediately prior to use in surgery after a storage period of at least three months following harvesting. At this temperature, storage for at least five years is thought to be possible. For allograft bone transplantation cases and tissue supply cases, KUBB has an attending physician report on the occurrence of infectious diseases and on the condition of the graft bone at six months after the transplantation procedure. This is repeated at one year after the graft is performed to assess the patient's course. A common numbering system is clearly written onto the graft bone being supplied, and a system has been set up to make it possible to ascertain the recipient's condition (traceability) if a problem arises in the follow-up with the graft bone or in the patient receiving the graft. 4. The current state of bone allografting in Japan Between 2007 and 2015, “Cryopreserved allograft bone/ligament tissue from a non-living donor” was approved by Ministry of Health, Labour and Welfare in Japan as a form of advanced medical treatment, with patients being billed for the cost of harvesting, treating, and preserving the allograft tissue. However, the criteria for the approval of advanced medical treatment require that the tissue bank be certified by the Japanese Society of Tissue Transplantation and that shipped tissue is unable to be used at another facility. Moreover, only tissue from non-living donors is allowed to be used for advanced medical treatment. However, with the 2016 revision of medical remuneration, it has become possible to claim 24,370 points (243,700 yen) for
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Fig. 10. Attached superfluous tissue, such as muscle, periosteum, and cartilage, is removed as much as possible from the harvested bone. Then, an ultrasonic irrigation device provided with sterile distilled water that has been set up in the processing room is used for ten hours of heat treatment at 60 C to inactivate viruses that may have escaped notice in blood tests and other screening, thus better ensuring the prevention of infection in the recipient. Ultrasonic irrigation is also used to remove lipid components in bone marrow.
cryopreserved allograft bone and ligament grafts (special) harvested from non-living donors, based on the results of deliberation at advanced medical treatment conferences. However, nowadays, another problem has arisen. As seen from the circumstances of activity at the KUBB, as well, there have been only two or three cases of harvesting from non-living donors per year recently, whereas shipping to other facilities has increased to 20 or more cases. Because there is expected to be a continued increase in the number of facilities that require massive bone allograft, coverage for tissue used at other facilities represents significant progress. Recently, favorable results have been reported from metal augmentation used in total hip arthroplasty [21,22], but bone allograft makes it possible to repair massive bone deficiency, recover bone stock, and improve long-term implant stability. Therefore, allograft bone represents a very useful filling material for treating bone deficiency, and regional bone banks are essential for bone allograft. KUBB is striving to set up a system as a base bank in east Japan that integrates harvesting, treatment, and preservation of allograft bone and ligament tissue, along with shipping, with the
Fig. 9. Number of bones shipped for use at another institute from non-living donors in KUBB from 2007 to 2016.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023
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Fig. 11. The tissue is tripled-wrapped in a degassed airtight plastic bag, bearing a product number written on it.
hope of expanding fair and just medical treatment that involves tissue transplantation nationwide. Conflict of interest The authors declare that they have no conflict of interest. Acknowledgments I would like to thank emeritus professor Moritoshi Itoman, who offered continuing support and constant encouragement. I would also like to thank Dr. Mitsutoshi Moriya, Dr. Kensuke Fukushima, Dr. Takeaki Yamamoto, and Dr. Yojiro Minegishi for their assistance in revision total hip arthroplasty using bone allografts. I would also like to thank Ms. Midori Kasahara and Mr. Masaki Otani (tissue transplant coordinators of KUBB) for their assistance in harvesting and processing bone allografts. References [1] Pope D, Blankenship S, Jones G, Robinson BS, Maloney WJ, Paprosky WG, Ries MD, Saleh KJ. Maximizing function and outcomes in acetabular reconstruction: segmental bony defects and pelvic discontinuity. Instr Course Lect 2014;63:187e97. [2] Kelley SS. High hip center in revision arthroplasty. J Arthroplasty 1994 Oct;9(5):503e10. [3] Itoman M, Yamamoto M, Yonemoto K, Sekiguchi M, Kai H. Radiological evaluation on allograft reconstruction of the acetabulum combined with supporting device in revision total hip replacement. Nihon Seikeigeka Gakkai Zasshi 1992 Jan;66(1):23e30. [4] Uchiyama K, Takahira N, Fukushima K, Yamamoto T, Moriya M, Itoman M. Radiological evaluation of allograft reconstruction in acetabulum with Ganz reinforcement ring in revision total hip replacement. J Orthop Sci 2010 Nov;15(6):764e71. [5] Lind M, Krarup N, Mikkelsen S, Horlyck E. Exchange impaction allografting for femoral revision hip arthroplasty: results in 87 cases after 3.6 years' followup. J Arthroplasty 2002 Feb;17(2):158e64. [6] Iwase T, Otsuka H, Katayama N, Fujita H. Impaction bone grafting for femoral revision hip arthroplasty with Exeter Universal stem in Japan. Arch Orthop Trauma Surg 2012 Oct;132(10):1487e94. [7] Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year-results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res 1999 Dec;(369):230e42. [8] Parvizi J, Sim FH. Proximal femoral replacements with megaprostheses. Clin Orthop Relat Res 2004 Mar;(420):169e75.
[9] Savvidou OD, Mavrogenis AF, Sakellariou V, Christogiannis I, Vottis C, Christodoulou M, Vlasis K, Papagelopoulos PJ. Salvage of failed total hip arthroplasty with proximal femoral replacement. Orthopedics 2014 Oct;37(10):691e8. [10] Safir O, Kellett CF, Flint M, Backstein D, Gross AE. Revision of the deficient proximal femur with a proximal femoral allograft. Clin Orthop Relat Res 2008;467(1):206e12. [11] Babis GC, Sakellariou VI, O'Connor MI, Hanssen AD, Sim FH. Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year followup study. J Bone Jt Surg Br 2010 Mar;92(3):349e55. [12] Rogers BA, Sternheim A, De Iorio M, Backstein D, Safir O, Gross AE. Proximal femoral allograft in revision hip surgery with severe femoral bone loss: a systematic review and meta-analysis. J Arthroplasty 2012 Jun;27(6). 829e836.e1. [13] Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction grafting with cement in revision total hip replacement. Evolution of the technique and results. J Bone Jt Surg Br 2003 Aug;85(6):809e17. [14] Gustilo RB, Pasternak HS. Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop Relat Res 1988 Oct;(235):111e9. [15] Uchiyama K, Moriya M, Yamamoto T, Fukushima K, Takahira N, Itoman M. Revision total hip arthroplasty using an interlocking stem with an allograftprosthesis composite. Acta Orthop Belg 2013 Aug;79(4):398e405. [16] Uchiyama K, Takahira N, Narahara H, Fukushima K, Yamamoto T, Moriya M, Kawamura T, Urabe K, Sakai R, Itoman M, Takaso M. Revision total hip replacement using a cementless interlocking distal femoral stem with allograft-cemented composite and the application of intramedullary and onlay cortical strut allografts: two case reports. J Orthop Sci 2012 May;17(3): 323e7. [17] Komiya K, Nasuno S, Uchiyama K, Takahira N, Kobayashi N, Minehara H, Watanabe S, Itoman M. Status of bone allografting in Japan e nation-wide survey of bone grafting performed from 1995 through 1999. Cell Tissue Bank 2003;4(2e4):217e20. [18] Urabe K, Naruse K, Uchino M, Takaso M, Fujita M, Uchiyama K, Okada T, Kasahara M, Itoman M. The expense for one implantation of a banked bone allograft from a cadaveric donor and the issues affecting current advanced medical treatment in the Japanese orthopaedic field. Cell Tissue Bank 2009 Aug;10(3):259e65. [19] Hamadouche M, Blanchat C, Meunier A, Kerboull L, Kerboull M. Histological findings in a proximal femoral structural allograft ten years following revision total hip arthroplasty: a case report. J Bone Jt Surg Am 2002 Feb;84-A(2): 269e73. [20] Uchiyama K, Ujihira M, Mabuchi K, Takahira N, Komiya K, Itoman M. Development of heating method by microwave for sterilization of bone allografts. J Orthop Sci 2005;10(1):77e83. [21] Pulido L, Rachala SR, Cabanela ME. Cementless acetabular revision: past, present, and future. Revision total hip arthroplasty: the acetabular side using cementless implants. Int Orthop 2011 Feb;35(2):289e98. [22] Whitehouse MR, Masri BA, Duncan CP, Garbuz DS. Continued good results with modular trabecular metal augments for acetabular defects in hip arthroplasty at 7 to 11 years. Clin Orthop Relat Res 2015 Feb;473(2):521e7.
Please cite this article in press as: Uchiyama K, et al., Revision total hip arthroplasty e Salvage procedures using bone allografts in Japan, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.023