Proximal Femoral Deficiency Research Articles

Bone Lengthening for Management of Type 1a Proximal Femoral Deficiency with or without Varus Deformity

Bone Lengthening for Management of Type 1a Proximal Femoral Deficiency with or without Varus Deformity

Freeze Dried Proximal Femoral Allografts in Revision of Femoral Stems

BackgroundFemoral bone deficiency is a challenging problem in revision femoral arthroplasty in younger patients. We evaluated outcomes of revision femoral arthroplasty using a freeze-dried allograft prosthetic composite (APC). MethodsThis was a retrospective review of 16 patients (12 men and 4 women) who had unilateral proximal femoral deficiencies (Paprosky type III B, 13 patients; type IV, 3 patients) revised with freeze-dried APC. Follow-up at mean 7 years included assessment with Merle D'Aubigné score and radiographs. ResultsAt follow-up, the average hip score was improved for pain, function, and range of motion. The 5-year graft survival was 87%, and the estimated median survival was 8.8 years. There were 3 patients who walked without support, 10 patients who walked unlimited distance with a cane, 2 patients who walked with 2 crutches, and 1 patient who walked with a walker. Radiographs showed nonunion at the graft-host junction in 3 hips (19%), but only 1 patient was symptomatic. Asymptomatic trochanteric nonunion was observed in 4 hips (25%). There was moderate graft resorption in 2 patients at 9 years after surgery and mild graft resorption in 1 graft at 7 years. There was subsidence of <2 cm in 2 patients and 3.5 cm in 1 patient. ConclusionThe present study showed acceptable results in treatment of major femoral deficiencies using freeze-dried APC in younger patients. Freeze-dried APC may be a useful for revision femoral arthroplasty.

Hip reconstruction osteotomy by Ilizarov method as a salvage option for abnormal hip joints.

Hip joint instability can be secondary to congenital hip pathologies like developmental dysplasia (DDH) or acquired such as sequel of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, proximal migration of the femur, lower-extremity length discrepancy, abnormal gait, and pain. In this case series of 37 patients coming to our institution between May 2005 and December 2011, we report our results in treatment of unstable hip joint by hip reconstruction osteotomy using the Ilizarov method and apparatus. This includes an acute valgus and extension osteotomy of the proximal femur combined with gradual varus and distraction (if required) for realignment and lengthening at a second, more distal, femoral osteotomy. 18 males and 19 females participated in the study. There were 17 patients with DDH, 12 with sequelae of septic arthritis, 2 with tuberculous arthritis, 4 with posttraumatic arthritis, and 2 with focal proximal femoral deficiency. Outcomes were evaluated by using Harris Hip Scoring system. At the mean follow-up of 37 months, Harris Hip Score had significantly improved in all patients. To conclude, illizarov hip reconstruction can successfully improve Trendelenburg's gait. It supports the pelvis and simultaneously restores knee alignment and corrects lower-extremity length discrepancy (LLD).

A case of Robin sequence, microgastria, radiohumeral synostosis, femoral deficiency, and other unusual findings: A newly recognized syndrome?

In this report, we describe an 8-year-old male with Robin sequence, bilateral radiohumeral synostosis, microgastria, cryptorchidism, dislocated hips, proximal femoral deficiency, and an autism spectrum disorder. This combination of findings has not been previously reported. Features of particular interest are the radiohumeral synostosis and microgastria, both of which are rare defects, and to our knowledge, have not been reported to occur together. We propose that the patient has a newly recognized syndrome consisting of the aforementioned features, the etiology of which is unknown.

Foot and Ankle Function after Tibial Overlengthening

Lengthening the tibia more than 25% of its original length can be indicated for proximal femoral deficiency, poliomyelitis, or femoral infected nonunion. Such lengthening of the tibia can adversely affect the ankle or foot shape and function. The present study aimed to assess the effect of tibial lengthening of more than 25% of its original length on the foot and ankle shape and function compared with the preoperative condition. This was a retrospective study of 13 children with severe proximal focal femoral deficiency, Aitken classification type D, who had undergone limb lengthening from June 2000 to June 2008 using Ilizarov external fixators. The techniques used in tibial lengthening included lengthening without intramedullary rodding and lengthening over a nail. The foot assessment was done preoperatively, at fixator removal, and then annually for 3 years, documenting the range of motion and deformity of the ankle and subtalar joints and big toe and the navicular height, calcaneal pitch angle, and talo-first metatarsal angle. At fixator removal, all cases showed equinocavovarus deformity, with decreased ankle, subtalar, and big toe motion. The mean American Orthopedic Foot and Ankle Society score was significantly reduced. During follow-up, the range of motion, foot deformity, and American Orthopedic Foot and Ankle Society score improved, reaching nearly to the preoperative condition by 2 years of follow-up. The results of our study have shown that tibial overlengthening has an adverse effect on foot and ankle function. This effect was reversible in the patients included in the present study. Lengthening of more than 25% can be safely done after careful discussion with the patients and their families about the probable effects of lengthening on foot and ankle function.

Primary versus secondary calcar replacement hip arthoplasty for treatment of unstable trochanteric fractures

Background Harris and Allen had modified and described a calcar replacement femoral component, which is necessary for the conventional femoral components, as a part of total hip replacement to address many problems related to proximal femoral deficiency. The aim of this study was to compare the clinical and radiological outcomes of a primary salvage calcar replacement hip arthroplasty with secondary salvage calcar replacement hip arthroplasty for treatment of new (group 1, prospective) or failed osteosynthesis or end prosthesis treatment (group 2, retrospective) of unstable trochanteric fractures. Patients and methods Fifteen patients were included in each group, with a mean age of 67.3 years for group 1 patients and 65.8 years for group 2 patients. The female-to-male ratio was 8 : 7 in group 1 and 10 : 5 in group 2. Incidence of preoperative comorbidities was 2.2 per patient in group 1 and 2.0 per patient in group 2. The mean time from the initial unstable trochanteric fracture to the time of calcar replacement hip arthroplasty was 4.2 days and 12.4 months in group 1 and group 2, respectively. The posterolateral approach using the posteriorKocher–Langenbeck proximally and the posterolateral approach distally for the proximal femur without trochanteric osteotomy. All patients were followed up clinically and radiologically, and at the end of the follow-up period (1–3 years) the Merle d’Aubigne and Postel score was used for functional evaluation. Results The mean operative time was 105 and 155 min, the mean amount of blood loss was 550 and 850 ml, and the mean period of hospital stay was 11 and 21 days for group 1 and group 2 patients, respectively. Two patients in group 2 had required postoperative ICU admission. Postoperative complication(s) were reported in one patient (6.6%) in group 1 and in five patients in group 2. Postoperative psychological problems and mortality during the first year were reported in three patients (20%). The Merle d’Aubigne and Postel functional outcome score by the end of the first year was found to be satisfactory (above 14 points) in 100 and 93.3% of patients in group 1 and group 2, respectively. After 3 years of follow-up it was satisfactory in 83.3 and 66.7% of patients in group 1 and group 2, respectively. Conclusion Primary cemented calcar replacement hip arthroplasty for treatment of unstable trochanteric fractures is associated with lesser pain, better walking ability without mortality or psychological problems, and with measurable better overall functional outcomes compared with salvage calcar replacement hip arthroplasty.

Distal locking stem for revision femoral loosening and peri-prosthetic fractures

Revision total hip arthroplasty in the setting of a large proximal femoral deficiency or a peri-prosthetic fracture remains a challenging problem. We describe the development, surgical technique and the use of cementless revision stems with distal inter-locking screws to provide immediate stability of the femoral implant. Results were assessed in a large multicentre French study conducted with the french hip and knee surgery society (SFHG). We retrospectively reviewed 725 revisions using interlocking stems from 14 French orthopaedic departments. Seven different stems were used in this series. In-patient records were retrieved, and in addition to demographic data the indication for revision, the preoperative and postoperative PMA and Harris hip scores were documented. The bone deficiency was classified on the basis of the French National Orthopaedic Meeting (SOFCOT) classification. Intraoperative complications and problems if any were retrieved from operative notes. Clinical status and radiographs at the final follow-up were evaluated, paying special attention to the metaphyseal filling index. Average follow-up was 4.5 years. As for the clinical results, the mean Harris hip score at last follow-up was 81. Therefore, it increased by an average of 31 points. Bone reconstruction was assessed on the cortico-medullary index in the metaphyseal area and at mid-shaft increasing from 36 to 45 and 54 to 63, respectively. Radiologically, 637 implants were stable, and 40 demonstrated subsidence. Forty-eight implants have been revised. We found a significant relation between the metaphyseal filling index, the stability of the stem and the quality of bone reconstruction. Results were analysed with respect to three groups of stems: group 1 was a straight, partially HA-coated implant; group 2 was a curved, fully HA-coated implant; and group 3 was a curved, partially-coated implant. Group 1 showed a significantly higher rate of failure when compared with the others types of implants. Group 2 had better functional results than group 3, which in turn reported better results than group 1. With regard to implant fixation, group 2 had significantly better results. Both groups 2 and 3 induced less thigh pain than group 1. The distal interlocking stem has shown promising results for femoral revisions. The advantages are initial axial and rotational stability and consistent bony in-growth owing to hydroxyapatite coating. Distal locked stems are mainly indicated to treat complex femoral revision with severe bone loss and peri-prosthetic fractures.

Cementless Revision Total Hip Arthroplasty Using Modular Distal Fixation Stem

Purpose: The purpose of this study was to retrospectively evaluate the results of modular distal fixation stem for the proximal femoral deficiency in revision total hip arthroplasty. Materials and Methods: Thirty five patients (36 hips) were followed for more than 24 months after the revision total hip arthroplasty using modular distal fixation stem between December 1998 and May 2002. The preoperative diagnoses included 27 cases of aseptic loosening, 7 cases of septic loosening, and 2 periprosthetic fractures. The femoral deficiencies classified according to Paprosky classification: Type II 3 cases, Type IIIA 14 cases, Type IIIB 8 cases, and Type IV 11 cases. Results: The average Harris hip score improved from 39.5 points to 89.4 points. The average subsidence of the femoral component was 1.3 mm (range, 0-10 mm). All 36 hips had stable fixations, which were 30 cases by bony ingrowth and 6 cases by stable fibrous ingrowth. Postoperative complications included 3 cases of posterior dislocation, 1 case of heterotopic ossification, 1 case of deep vein thrombosis, and 1 case of reactivated infection. . Conclusion: Cementless revision total hip arthroplasty using modular distal fixation stem showed good short-term results in the face of the deficient proximal bony support, and it appears to be a effective surgical option in this difficult revisional total hip cases.

Allograft reconstruction of large proximal femoral defects in revision total hip arthroplasty

Surgical Principles With the increasing frequency of total joint replacement, the orthopaedic surgeon is often confronted with cases of aseptic, time related loosening of total hip arthroplasties. This is compounded by the severe bone loss associated with loosening and the reaction to particular debris [3, 9, 11]. Conventional methods of revision can be difficult and even inadequate for some of these situations [2, 8, 15, 17]. The use of structural allografts for significant proximal femoral deficiencies can restore skeletal architecture and mechanical integrity to these patients. The aim of this technique is to allow the reconstruction of large structural defects with a physiologically compatible material rather than the traditional techniques of custom prosthetic replacement with or without extensive cement augmentation.

Revision total hip arthroplasty: The use of solid allograft

Intract solid allografts was used to augment severe bone loss in 8 acetabula and 15 femora in 22 patients who underwent revision total hip arthroplasty with noncemented implants. The average follow-up period was 4 years. The average time to radiographic union of whole acetabular allografts was 11 months. Superior migration of the allografts occurred in four patients. Varus tilt of the acetabular component within the allografts was noted in three patients. Eleven patients underwent entire proximal femoral allograft reconstruction, and four patients had femoral head allograft reconstruction. Nine patients with entire proximal femoral allografts achieved radiographic union at an average of 13 months and two failed by nonunion. Only one of the four patients with femoral head, allograft reconstruction achieved union. Femoral component subsidence was noted in seven whole proximal femoral allografts (64%). Entire proximal femoral allograft reconstruction was complicated by at least one episode of postoperative dislocation in 6 of 11 procedures. The authors recommend that femoral head allografts should be used with caution to reconstruct proximal femoral deficiencies in which structural, support is required for stability of the implant. Successful use of acetabular allografts requires that the majority of the allograft be contiguous to host bone and not to soft tissue. With entire proximal femoral reconstruction, the tip of the femoral, component should not reside at the host-graft junction. All components should be cemented into allograft bone; and revision surgery should be performed before osteolytic destruction of bone advances to the point where allograft reconstruction is required.

The rotationplasty operation in the treatmenf of osteosarcoma of the distal femur (a case report)

The rotationplasty operation that was applied to proximal femoral deficiency cases before, has recently gained popularity in the t.(eatment of the malignant Iesions of the and the hip as an alternative to amputation and desarticulation procedures. We performed rotationplasty operation for the treatment of a patient with the osteosarcoma of the Ieft distal femur. Safe surgical margins and a functional stumpf with the mobility of the knee were accomplished.

Early diagnosis of proximal femoral deficiency.

A case of proximal femoral deficiency in a fetus, associated with ventriculomegaly and oligohydramnios is described. Vaginal ultrasonographic diagnosis was made in the 14th week of gestation in a 37-year-old asthmatic woman. Ultrasonic follow-up until termination of pregnancy in the 20th week of gestation was performed. The importance of early diagnosis and the possible roles of oligohydramnios and antiasthmatic medications are discussed.

The classification and treatment of proximal femoral deficiencies

After a review of previous classifications the authors suggest that cases of congenital longitudinal deficiency of the femur fall into one of two groups, each with specific features. The treatment alternatives and their indications are discussed in detail and a treatment plan suggested.

Freeze-dried Proximal Femur Allografts in Revision Total Hip Arthroplasty

Failure of cemented total hip arthroplasty can emerge from several causes and may be associated with severe bone loss in the proximal femur with a marked diminution in functional capacity of the limb. This is a preliminary report of 14 patients with revision operations for failed total hip arthroplasty. Freeze-dried allograft bone ws implanted for restoration of extensive bone loss in the proximal for restoration of extensive bone loss in the proximal femur. All 14 patients were operated on to salvage failed cemented total hip arthroplasties. Allografts were employed only for large proximal femoral deficiencies. In these patients the alternatives were either an unstable excision arthroplasty or a femoral deficient prosthesis. After revision, all patients had complete bony union and ambulated with the assistance of a cane with greatly increased function and pain relief. There were no infection. Functionally, the patients have shown marked improvement. At this time there is no radiologic evidence of resorption of the graft. The use of bone allografts in this procedure has been encouraging to date; however, the follow-up period has been only 16-30 months. the success or failure of this procedure will be determined in time.

Rotationplasty of the lower limb for congenital defects of the femur.

The operative technique for combined fusion of the knee and rotationplasty of the limb in the management of congenital deficiency of the femur is presented. The technique described allows earlier definitive prosthetic fitting of a child with proximal femoral deficiency; it has reduced the number of operative procedures needed to obtain the optimal function from that deficient limb; and it has enabled these procedures to be performed at an earlier age. The technique differs from those previously described and represents a significant improvement in management of the patient with femoral deficiency.