Bulk Allograft Research Articles

The Use of Locking Plates for Greater Trochanteric Fixation

Stable fixation for healing of the greater trochanter after fracture or osteotomy is difficult to achieve, especially when associated with periprosthetic osteolysis. Wiring techniques are cumbersome and cable grip fixation has an unacceptable rate of non-union, cable fraying, and production/migration of third-body debris. Using 4 case examples, we present a novel and straightforward locking plate technique that we currently use to achieve such fixation. This method also allows placement of bulk allograft that may restore trochanteric bone stock in cases of marked osteolysis. The technique uses implants that are readily available, and can be employed not only in fixation of trochanteric osteotomy but also in trochanteric advancement. At a minimum of 20 months follow-up, healing of the fracture or osteotomy with full abductor function and a significant improvement in hip score was observed in each of the 4 patients. We acknowledge that biomechanical and larger clinical studies are necessary to confirm the success of this technique, but we are pleased with our preliminary findings and continue to use this approach.

(iv) Reconstruction and revision of femoral failure in revision hip arthroplasty

Suitable techniques for femoral reconstruction and revision are dependent on the status of femoral bone stock. The pre-operative planning and operative strategies utilised increase in complexity as the bone stock diminishes. The options range from proximal to distal fixation techniques using cemented or cementless prostheses. Bone stock augmentation in the form of impacted morcellised or structural strut allografts may be required. In the most severe cases bone stock may need to be restored with bulk allograft or restored with a mega-endoprosthesis. A structured reconstruction cascade discussing these options is presented.

Results of Selective Hip Arthroplasty Revision in Isolated Acetabular Failure

Controversy exists over whether to remove well-fixed components at the time of revision of a failed total hip arthroplasty (THA). The purpose of this study was to evaluate the results of selective acetabular revision after acetabular failure in which only the failed component was replaced. Thirty-six isolated acetabular component revisions were performed and prospectively followed for a mean of 4.7 y (range, 2-9.3 y). The components had been in place for a mean of 10.8 y. All femoral components and some metal-backed acetabular shells were well fixed at the time of revision and left in place. Surgery involved cementation of an acetabular liner into a well-fixed acetabular shell in 16 cases, and acetabular revision in 20 cases. Morselized cancellous allograft was used to fill acetabular defects in 27 hips, and proximal femoral defects in 17 hips. Bulk allografts were used to reconstruct the proximal femur in two hips. The mean Harris hip score improved from 57.8 preoperatively to 89.1 at the final follow-up visit. The results were rated excellent in 24 patients, good in nine patients, and fair in three patients. The unrevised femoral components and acetabular shells remained well fixed, and final follow-up radiographs revealed no cases of osteolytic lesion progression around the femoral and acetabular components. Revision of only the failed acetabular component is recommended in cases of isolated acetabular failure, providing excellent results over the medium term, and allowing preservation of bone stock with lower surgical morbidity.

High hip center bipolar hemiarthroplasty for non-reconstructable pelvic discontinuity

A 79-year-old woman with bilateral lower extremity weakness due to cervical myelopathy presented at our department in 2002 after multiple reconstructive procedures in both hips for developmental dysplasia of the hip. In 1993, a bulk allograft in combination with an acetabular cage and a cemented cup were used to treat the left massive acetabular bone loss. The defect was type IVb by the classification of the American Academy of Orthopaedic Surgeons (D’Antonio et al. 1989) and Berry et al. (1999). In 2000, the acetabular construct failed mechani-cally while the existing cemented femoral stem remained well fixed (Figure 1A). Removal of the acetabular hardware was followed by implantation of a whole acetabular allograft. The allograft was stabilized with plates and screws, and a new cemented cup was inserted. 2 years later, allograft fracture and acetabular failure occurred again.In 2002, a high hip center bipolar hemiarthroplasty was per-formed via a standard posterior hip approach. Failed acetabu-lar component and hardware were removed but the femoral stem was left in situ as it was found to be stable. Capsular and periacetabular scar tissues were preserved as much as possible to create a soft tissue cavity to seat the bipolar head into. A 60-mm bipolar femoral head was inserted onto the femoral component to articulate with the periacetabular soft tissues in a high hip center mode. Its position was further augmented with capsular repair around the neck of the prosthesis (capsu-lar noose). A femoral condyle allograft was fixed to the ilium to serve as posterior superior acetabular wall. Postoperatively, the patient was advised to gradually increase her weight bearing using a walker or crutches. No casts or braces were applied. Within 6 months, the bipolar component migrated out of the acetabulum and articulated with the iliac soft tissues (Figure 1B). Although the patient had limb shortening, she had no pain and declined further surgery.The right hip required 7 reconstructive procedures, which led to pelvic discontinuity (type IVb) and resection arthroplasty in 1999 (Figure 1A). In 2000, a re-implantation was performed by using a reinforcement ring with a cemented polyethylene cup and a long cemented femoral prosthesis. 4 years later the was inserted onto the previously implanted and stable femo-ral stem and articulated with the soft tissues adjacent to the lateral ilium (Figure 1B). After surgery, the patient was able to transfer independently and ambulate short distances in her home with a walker.At 3 years postoperatively (right hip) and 5 years postop-eratively (left hip) the patient had no pain, relatively equal leg lengths, and could sit comfortably. Due to complete loss of lower extremity motor function associated with failed spine surgery and cervical myelopathy, the patient was non-ambu-latory. However, the Harris hip score (HHS) of the patient’s left hip had improved from 39 preoperatively to 58 postopera-tively. Similarly, the HHS of the patient’s right hip increased from 14 preoperatively to 58 postoperatively.

The influence of different tibial stem designs in load sharing and stability at the cement–bone interface in revision TKA

Total Knee Arthroplasty (TKA) changes mechanical loading of the knee joint. Bone loss in the tibia is commonly encountered at the time of the revision TKA. Restoration of lost bone support and joint stability are the primary challenges in revision TKA. Normally, these defects are treated with non-living structures like metallic augments or bone grafts (autografts or allografts). Alone, neither of these structures can provide the initial support and stability for revision implants. In the latter, the use of intramedullary stems can provide the necessary load sharing and protect the remaining host bone and graft from excessive stress, increasing component stability. The purpose of this study was to evaluate comparatively load sharing (cortical rim, cancellous bone and stem) and stability at the cement–bone interface under the tibial tray induced by the use of cemented and press-fit tibial component stem extensions. Furthermore the study of the desirable option in cases where the bone defect is cavitary (cancellous bone defect contained by an intact cortical rim) or uncontained bone defect (bone loss involving the supporting cortical rim) was carried out. Because in vitro evaluation of these biomechanical parameters is difficult we used finite element (FE) models to overcome this. The biomechanical results suggest an identical behaviour in case of cavitary defects for both types of stems assessed. In the case of uncontained defect treated with bulk allografts the cemented stem may be a prudent clinical option.

Impaction Grafting Using a Cemented Porous-Coated Modular Acetabular Component

Reconstruction of major acetabular defects continues to challenge surgeons. There are many surgical options for these situations, including oversized hemispherical cups, oblong cups, acetabular cages, bulk allografts, and impaction allografting. We present the case of a modification to the impaction grafting technique for acetabular reconstruction. In our case, a porous-coated modular titanium acetabular component was cemented in place instead of an all-polyethylene acetabular component, which is the standard technique for impaction grafting reconstruction. The use of the modular component allowed a greater number of surgical options at the time of surgery. At 5 years from surgery, the patient has a successful reconstruction and the radiographs continue to look excellent.

Long-Term Results of Anti-Protrusio Cage and Massive Allografts for the Management of Periprosthetic Acetabular Bone Loss

From 1992 to 1995, 71 total hip arthroplasties with extensive acetabular bone loss underwent revision using bulk allografts and Burch-Schneider anti-protrusio cages. Twelve patients died of unrelated causes and 3 were lost to follow-up. Fifty-six hips were available for clinical and radiographic follow-up examination at an average of 11.7 years after surgery. The average final Harris hip score was 75. X-ray signs of incorporation of massive bone graft were observed in 49 hips. Two cases developed deep infection that required resection arthroplasty. Aseptic loosening of the acetabular cage occurred in 5 patients, and 2 of them underwent re-revision. With a total survival rate of 87.5%, anti-protrusio cages and structural allografts compare favorably with other techniques in the long-term reconstructive treatment of extensive loss of acetabular bone stock.

Management of Significant Femoral Bone Loss with Use of Modular Stems

Significant femoral bone loss can be encountered in the multiply revised patient. Deficient proximal bone requires either a bulk allograft or a femoral component that allows stable distal fixation. Extensively coated stems have shown excellent results for many revisions but have shown higher rates of failure among patients with femoral remodeling in retroversion, an enlarged endosteal diameter, or an ectatic canal. A modular tapered stem is an alternative in this subset of patients. A modular tapered implant provides axial and rotational stability through the use of distal splines while the proximal body segments can allow independent adjustment of leg length, offset, and anteversion. We previously reported the 1- to 4-year (average 2 years) results of modular tapered femoral prosthesis in cementless femoral revisions. In the previous study there were 16 patients all with Type IIIB or IV Paprosky femurs. This is a follow-up of that article reporting on 24 patients, all with Type IIIB or IV Paprosky femurs with a follow-up of 2 to 5 years (average 3 years). We revised one component for subsidence, one component was revised for fracture at the modular junction, and one component was revised for sepsis.

Superficial Femoral Artery Injury Resulting From Cerclage Wiring During Revision THA

Vascular injuries around the hip are uncommon with hip arthroplasty. However, given the close proximity of the external iliac and femoral vessels to the hip, iatrogenic injury may occur. We describe a case of superficial femoral artery injury occurring during revision THA using an extended trochanteric osteotomy, bulk allograft, and cerclage wires. We review the available literature on vascular injury in hip arthroplasty and illustrate the great care necessary when placing cerclage wires and the importance of prompt recognition of these potentially devastating complications.

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Introduction: Arthrodesis of the glenohumeral joint for severe pain and disability after failed glenohumeral arthroplasty is extremely difficult. This is a retrospective review of the use of bulk allograft bone to treat this challenging patient population. Methods: Twelve patients with failed shoulder arthroplasty ages 54-78 with deltoid, rotator cuff deficiency, or pain underwent arthrodesis of the shoulder using a proximal humeral or proximal femoral allograft. The allografts were augmented with autogenous iliac crest bone graft in all cases.

Locations for screw fixation beyond the glenoid vault for fixation of glenoid implants into the scapula: An anatomic study

Screw fixation is often required for glenoid implants and glenoid bone grafting, yet no study has evaluated the complex and irregular anatomy of the scapula to determine the best positions for the screws. Current implants rely solely on the bone in the glenoid vault for screw fixation, but in cases with glenoid bone loss, screw fixation may not confer adequate stability. The purpose of this study was to find the best positions for screws that are secured in bone beyond the glenoid vault. Twenty-seven scapulae from the Hamann-Todd osteologic collection underwent a computed tomography scan, and the images were transferred to a custom computer program that allowed 3-dimensional manipulation of the scapular images. Virtual screws were inserted into the scapula through the glenoid fossa, and the starting points and screw lengths were recorded. The coordinates of the starting points were scaled to allow comparisons among the different sizes of scapula. Once the ideal screw position was found, the angle of insertion was altered by 15 degrees in 4 directions, and the resulting screw length was recorded to show the effects of screw insertion error. Three screws could be inserted through the glenoid fossa into bone beyond the glenoid vault. The superior screw had a median length of 29 mm and exited at the junction of the coracoid and the suprascapular notch. The middle screw had a median length of 60 mm and exited at the junction of the spine and the scapular body. The inferior screw had a median length of 75 mm and exited posterior to the tip of the scapula. When the starting positions were constrained by a symmetric implant, the median superior screw length was 19 mm, the median inferior screw length was 61 mm, and the median middle screw length was 55 mm. Screw fixation in bone beyond the glenoid vault can be used for fixation of glenoid implants or glenoid bone grafting. Future studies are required to test the biomechanical stability of this new screw configuration, as well as methods and tools for precise implantation of the screws into the described locations. Once these studies are completed revision total shoulder arthroplasty with severe glenoid bone loss may be treated in 1 stage with screw fixation of a glenoid implant over bulk allograft.

Management of Bone Loss in Revision Total Knee Arthroplasty

Bone deficiencies around the knee can present a substantial challenge during revision total knee arthroplasty. Bone loss occurs from stress shielding, osteolysis, chronic infection, and bone removed during implant extraction. Smaller defects have traditionally been treated with cement filling or allograft bone chips. Larger defects can be reconstructed with bulk allografts or custom prostheses. A hinged prosthesis may be necessary to account for ligamentous insufficiency. In addition to traditional methods of managing bone loss, recent developments include the use of metaphyseal-filling implants made of highly porous metal. These implants can be press-fit into host bone to accommodate large metaphyseal defects. Each revision knee surgery provides unique challenges, requiring proficiency in multiple techniques of bone loss management.

Local control of long bone giant cell tumour using curettage, burring and bone grafting without adjuvant therapy

Giant cell tumour (GCT) is a benign, but aggressive, primary tumour of the bone. The recurrence rate after surgical treatment has been reported to be as high as 50%. Many surgical techniques have been employed in the treatment of this tumour. More aggressive interventions, such as en bloc resection and bulk allograft or prosthetic reconstruction, are generally understood to be associated with lower rates of local recurrence. However, because of lessened morbidity, intralesional techniques have come to be favoured for this condition. In addition to curettage, various adjuvant procedures and packing materials have been advocated in order to control and reconstruct long bone defects secondary to this neoplasm. We report our experience with 40 long bone GCT patients treated with curettage, burring, bone grafting and no adjuvants between 1997 and 2002. There was a local recurrence rate of 32.5%, with most recurrences noted within the first 30 months after surgery. Minor complications were found in 18% of patients. The risk of local recurrence in this study is acceptable (within the range that has been historically reported for curettage and bone grafting). In cases where more resources are available, the addition of adjuvant therapies, as noted in the recent literature, may be beneficial. The results of this study should be considered when designing multicenteric studies in the future.

Structural allografts for bone stock reconstruction in two-stage revision for infected total hip arthroplasty: Good outcome in 16 of 18 patients followed for 5–14 years

Background The use of massive bone allografts in cases of revision of failed total hip arthroplasties (THAs) due to infection is controversial.Patients and methods 18 patients presented with infection at the site of a THA and were treated with a two-stage protocol. In the first stage, the prosthesis was removed together with all necrotic tissues and cement material if present. A custom-made mold of Palacos R cement containing 1 g of gentamicin was then inserted in 17 of the 18 patients. Systemic antibiotics were used during the interval period. In the second stage, the patients had either acetabular or femoral reconstruction using bulk allograft bone.Results Mean follow-up was 9 (5–14) years. 1 patient presented with recurrent infection and underwent a Girdlestone resection arthroplasty as definitive treatment. Another patient had a mechanical failure of the acetabular component, which was revised 10 years after the second stage of the reconstruction. The mean Harris Hip Score improved from 34 points preoperatively to 71 points at the last review. By our definition, 16/18 of the patients had a successful outcome.Interpretation Our results support the use of massive allografts in staged reconstructions of infected THAs complicated by considerable bone loss. ▪

Fresh-Frozen Osteochondral Allograft Reconstruction of a Severely Fractured Talus

Talar fractures constitute <1% of all fractures1 and are associated with a high rate of morbidity due to the limited vascularity of the talus and frequent substantial posttraumatic loss of function. Especially challenging are comminuted talar fractures for which reduction and internal fixation is implausible and a tibiotalar and/or subtalar arthrodesis is performed at the cost of joint mobility and hindfoot anatomy. The use of autologous bone-tissue allografts (from the iliac crest or femoral head) to treat talar neck and body fractures has been reported. However, these allograft procedures have been accompanied by primary fusion of one or more of the seven articular surfaces of the talus, most commonly the talocalcaneal, talonavicular, and talotibial joints, leading to considerable loss of function2-4. The use of whole-bone fresh-frozen allografts in the foot has only been reported for the treatment of bone tumors. Muscolo et al. reported on the use of whole fresh-frozen calcaneal allografts for the treatment of chondrosarcoma and giant-cell tumor of the calcaneus5. We are unaware of any previous reports on the use of bulk allografts as an alternative to subtalar arthrodesis for the treatment of severely comminuted fractures of the talus. In an attempt to minimize loss of function, we reconstructed a severely comminuted talar fracture with use of a portion of a fresh-frozen osteochondral talar allograft. We report our results after twenty-nine months of follow-up. The patient was informed that data concerning this case would be submitted for publication. Afifty-year-old man fell from a height of 16 ft (4.9 m). He complained of pain in the back and in the right ankle. Radiographs demonstrated a comminuted fracture of the posteroinferior aspect of the right talus. The fracture involved the posterior aspect of the talar …

Augments and Allografts in Revision Total Knee Arthroplasty: Usage and Outcome Using One Modular Revision Prosthesis

Sixty-five consecutive Coordinate (DePuy, Warsaw, Ind) revision total knee arthroplasties were eligible for minimum 5-year follow-up. Nine patients died and 2 patients were lost. Therefore, 54 knees (51 patients) had a known outcome. Nine knees failed and required either revision or component removal. Eight additional knees were considered clinical failures. Despite the use of metallic augmentation in 89% of the knees, large structural allografts were required in 48% of the knees. Revisions with bone loss that required bulk allograft failed less often (19.2%) than revisions managed without bulk allografts (42.9%). Of 24 knees originally revised for osteolysis/polyethylene wear, only 1 required rerevision for the same mechanism of failure. Modular augments did not effectively address the bone loss and instability encountered in many instances at revision surgery. Survivorship of this implant was 79.4% ± 13.7% at 8 years.

Femoral Fixation in the Face of Considerable Bone Loss

Considerable femoral bone loss can be encountered in the multiply revised total hip arthroplasty patient. Deficient proximal bone requires either a bulk allograft or a femoral component that allows stable distal fixation. Extensively coated stems have shown excellent results for many revisions but have shown higher rates of failure among patients with femoral remodeling in retroversion, an enlarged endosteal diameter, or an ectatic canal. A modular tapered stem is an alternative in this subset of patients. A modular tapered implant provides axial and rotational stability through the use of distal splines, and the proximal body segments can allow independent adjustment of leg length, offset, and anteversion.

Surgical therapy of pelvis and spine in primary malignant bone tumors

Despite standardization of surgical treatment of primary malignant tumors of the pelvis and spine, prognosis in these centrally located tumors still is inferior compared to those located in the extremities. This fact may be attributed to delayed diagnosis in many cases and the resulting increase in tumor volume as well as to difficulties of resection due to the anatomical situation. The frequency of local recurrence after resection of primary malignant tumors is reported to be between 4 and 41% and the 5-year survival rate below 40%. Whereas the latter has remained almost unchanged during the past 20 years, amputation has been replaced by limb-salvage surgery except for a minimal amount of less than 10%. For reconstruction, biological techniques are increasingly preferred to endoprosthetic replacement or use of bulk allografts because of the high complication rate. Even in the spine wide resections are feasible provided at least one lamina is healthy in order to prepare and save the neural structures without touching the tumor. Compared to the widely used technique of curettage, en bloc resection may provide a significantly better oncologic result with respect to local tumor control. Failure of the dorsoventral stabilization with delayed union is the most frequent complication of these challenging procedures. In order to improve the long-term prognosis of these groups of patients in the future, early diagnosis and immediate admission to a specialized tumor service has to be attempted.

The use of a periosteal replacement membrane for bone graft containment at allograft-host junctions after tumor resection and reconstruction with bulk allograft.

Bone grafting is frequently used to assist in reconstruction of bone defects following limb salvage procedures in tumor surgery. These defects can be large and require the use of bulk allograft and/or significant amounts of particulate graft material. This article reports a clinic's preliminary results with a bone graft containment material that serves as an artificial periosteum. This radiographic review evaluates the material's ability to prevent migration of bone graft and ascertain progressive callus formation. Early results have been encouraging.

The fate of cementless jumbo cups in revision hip arthroplasty

We report 5-year minimum results of cementless over-sized cups used in revision hip arthroplasty, with significant associated bone defects. Forty-three porous-coated jumbo cups were used to treat acetabular defects in revision hip arthroplasty in 42 patients with a mean age of 63 (range, 25–86). Morsellized allograft only was used in 27 hips, and bulk allograft was used in 8 cases. Two patients were lost to follow-up, and 5 died after a mean 7 years' follow-up, with retention of their prostheses. In the remaining 36 cases, the mean follow-up was 10 years (range, 6–14 years). Two acetabular components were revised for aseptic loosening and graft resorption. Two cases were complicated by dislocation. A satisfactory 92% Kaplan Meier shell survival rate was seen at 14 years. Copyright 2003, Elsevier Science (USA). All rights reserved.