DOI: 10.5301/hipint.5000094
Hip Int 2014; 24 ( 2): 210-212
TECHNICAL NOTE
Impaction bone grafting and cemented stem revision in periprosthetic hip fractures: a novel surgical technique Paul M. Dearden, Peter P. Bobak, Peter V. Giannoudis Department of Orthopaedic and Trauma Surgery, Leeds General Infirmary, Leeds, Yorkshire - UK
With an ageing population, and increasing longevity of hip arthroplasty prostheses, the incidence of periprosthetic femoral fractures is rising. We present a simple and easily reproducible technique for reduction of any periprosthetic fracture that requires bone graft augmentation. This method facilitates impaction bone grafting to reconstitute lost bone stock and revision using a cemented implant. Keywords: Revision, Periprosthetic, Hip, Vancouver B3, Impaction, Cement Accepted: July 23, 2013
INTRODUCTION As the population ages, periprosthetic proximal femoral fractures are becoming increasingly common (1). Rates of periprosthetic fracture 10 years post primary and revision total hip replacement are seen to be 1.7% and 6.2% respectively (2). The elderly population is at increased risk and present a specific challenge due to issues of osteopaenia and osteoporosis (3). The complex issues that arise in such a fracture require the surgeon to be skilled in both trauma and revision arthroplasty surgical techniques (3). The classification of periprosthetic femoral fractures should allow the surgeon to choose the most appropriate reconstructive procedure based upon features of the injury. The Vancouver classification has gained acceptance as it allows the surgeon to make informed decisions regarding the type of fixation required, based upon fracture configuration, stability of implant and quality of bone stock (4). Consideration should be given to symptoms of prosthetic loosening prior to the time of periprosthetic fracture. Symptoms of pain or instability prior to fracture may suggest occult loosening to that point unnoticed. Patients with 210
such symptoms of ‘unhappy hips’ generally require revision of the femoral or acetabular component at the time of fracture fixation (5). When periprosthetic femoral fracture occurs with evidence of loose femoral component, the goals of treatment are: to achieve anatomical alignment and length, a stable prosthesis, early mobilisation, early union and preservation of bone stock. In such cases most authors recommend revision with a long-stem femoral component which must bypass the fracture site and enter the distal femur to a length equal to twice the diameter of the femoral shaft (1, 5-7). We present a novel technique utilising simple, readily available equipment, to achieve anatomical reduction of complex periprosthetic fractures. This technique allows for impaction bone grafting and pressurised cementing of revision prosthesis.
PROCEDURE Preoperative standardised radiographs with calibration markers are essential to allow for templating of revision prosthesis. Fresh frozen bone allograft should be available
© 2013 Wichtig Editore - ISSN 1120-7000
Dearden et al
for femoral impaction grafting. Prior to the patient entering the theatre, the allograft bone can be prepared and milled to produce fine chips suitable for impaction grafting. The patient is anaesthetised. Prophylactic antibiotics can be administered after tissue biopsies have been taken in cases where there is suspicion of infection. Due to the increased blood loss that can be anticipated in revision arthroplasty with associated fracture, our protocol is for preoperative tranexamic acid (8) given in the anaesthetic room. The patient is positioned supine and a lateral incision is utilised centred over the femur and greater trochanter. The presence of previous scars is assessed preoperatively and if these are too anterior or posterior, then a new incision is utilised. Our preferred exposure is by trochanteric osteotomy to expose and remove the prosthesis and to allow careful removal of any residual loose cement from the femoral canal. This approach also allows assessment of the proximal femoral bone stock. Tissues biopsies should be taken to exclude the presence of low-grade infection. The exposure of the proximal femur is the same as for any revision surgery for periprosthetic fracture with scar and fibrous tissue being released sufficiently to expose the fracture site without devitalising the fragments. Care is taken to protect the linear aspera and its related feeding blood vessels. A long Charnley curette is used for intramedullary splinting of the femur, working as a skewer to hold all the fragments of femur together in alignment. A 60 ml bladder syringe is prepared by removing both ends with an oscillating saw to create an open ended cylinder. This cylinder is then cut lengthways using heavy scissors to allow it to be opened but so that it still retains its shape. Final reduction is achieved using the syringe carefully wrapped around the exposed fracture site and adjusted to allow complete enclosure of the fracture fragments. This provides a very good reduction of the fracture and this should be secured in place with several 1.2 mm circlage wires. Containment of all pieces is accomplished and a stable mechanical environment for impaction grafting has been created. The femoral canal is now stable and constrained to receive bone graft which can be firmly impacted (Figs. 1a and b). Depending on the fracture configuration more than one syringe can be used. The prosthesis is cemented in place and the bladder syringe can be removed along with the circlage wires. We use commercially available bone cement with a
Fig. 1 - a) Bone plastic femoral model simulating a B3 fracture; b) illustration of wrapping of the syringe around the fracture site secured in place with circlage wires enclosing the fracture fragments.
combination of clindamycin and gentamicin which has prolonged period of antibiotic delivery to local soft tissues and increased activity in preventing biofilm formation than gentamicin alone (9); an important consideration in revision surgery. At this stage, any extruded cement can be removed and the trochanteric osteotomy wired back into place. The prosthesis can now be reduced (Figs. 2a and b).
DISCUSSION In our experience, this technique facilitates reduction, induces a closed chamber, biologically and mechanically favourable for impaction bone grafting and allows utilisation
© 2013 Wichtig Editore - ISSN 1120-7000
211
Impaction grafting and cemented revision in periprosthetic hip fractures
of the whole length of the comminuted femur for fixation that otherwise would have just been bypassed with long stems. It also allows for cementing of a long stem revision prosthesis and a stable hip joint to enable early mobilisation. Moreover, in cases which may require further revision surgery in the future, the remodelling of the fracture site and reconstitution of bone stock will allow for the use of standard length of stems. Indeed, the radiographic evidence of integration of bone graft and replenished bone stock is rather unique. Thus far we have had no cases of re-fracture, implant failure or dislocation following revision surgery in a series of eight patients. We believe that this technique should be added in the surgeons’ armamentarium and be considered for the management of difficult periprosthetic fracture cases. Financial Support: No financial support received.
Conflict of Interest: No conflict of interest.
Fig. 2 - a) Preoperative right hip AP radiograph with fracture; b) postoperative right hip AP radiograph following the application of the above described technique; c) follow-up right hip AP radiographs at 18 months post surgery.
Address for correspondence: Mr Paul Dearden 50 Allerton Grange Rise Leeds Yorkshire, LS17 6LH, UK [email protected]
REFERENCES
5.
1. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003;34(2):95-105. 2. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96-101. 3. Tsiridis E, Spence G, Gamie Z, El Masry MA, Giannoudis PV. Grafting for periprosthetic femoral fractures: strut, impaction or femoral replacement. Injury. 2007;38(6):688-97. 4. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty. 2000;15(1): 59-62.
212
6.
7.
8.
9.
Ninan TM, Costa ML, Krikler SJ. Classification of femoral periprosthetic fractures. Injury. 2007;38(6):661-8. Ogawa H, Ito Y, Takigami I, Shimizu K. Revision total hip arthroplasty for a Vancouver type B3 periprosthetic fracture using an allograft-cemented stem composite by the telescoping technique. J Arthroplasty. 2011;26(4):e25-8. Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral allografting and cemented revision for periprosthetic femoral fractures. J Bone Joint Surg Br. 2004;86(8):1124-32. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011;93(1):39-46. Ensing GT, van Horn JR, van der Mei HC, Busscher HJ, Neut D. Copal bone cement is more effective in preventing biofilm formation than Palacos R-G. Clin Orthop Relat Res. 2008;466(6):1492-8.
© 2013 Wichtig Editore - ISSN 1120-7000
Copyright of Hip International is the property of Wichtig Editore and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Hip Int 2014; 24 ( 2): 210-212
TECHNICAL NOTE
Impaction bone grafting and cemented stem revision in periprosthetic hip fractures: a novel surgical technique Paul M. Dearden, Peter P. Bobak, Peter V. Giannoudis Department of Orthopaedic and Trauma Surgery, Leeds General Infirmary, Leeds, Yorkshire - UK
With an ageing population, and increasing longevity of hip arthroplasty prostheses, the incidence of periprosthetic femoral fractures is rising. We present a simple and easily reproducible technique for reduction of any periprosthetic fracture that requires bone graft augmentation. This method facilitates impaction bone grafting to reconstitute lost bone stock and revision using a cemented implant. Keywords: Revision, Periprosthetic, Hip, Vancouver B3, Impaction, Cement Accepted: July 23, 2013
INTRODUCTION As the population ages, periprosthetic proximal femoral fractures are becoming increasingly common (1). Rates of periprosthetic fracture 10 years post primary and revision total hip replacement are seen to be 1.7% and 6.2% respectively (2). The elderly population is at increased risk and present a specific challenge due to issues of osteopaenia and osteoporosis (3). The complex issues that arise in such a fracture require the surgeon to be skilled in both trauma and revision arthroplasty surgical techniques (3). The classification of periprosthetic femoral fractures should allow the surgeon to choose the most appropriate reconstructive procedure based upon features of the injury. The Vancouver classification has gained acceptance as it allows the surgeon to make informed decisions regarding the type of fixation required, based upon fracture configuration, stability of implant and quality of bone stock (4). Consideration should be given to symptoms of prosthetic loosening prior to the time of periprosthetic fracture. Symptoms of pain or instability prior to fracture may suggest occult loosening to that point unnoticed. Patients with 210
such symptoms of ‘unhappy hips’ generally require revision of the femoral or acetabular component at the time of fracture fixation (5). When periprosthetic femoral fracture occurs with evidence of loose femoral component, the goals of treatment are: to achieve anatomical alignment and length, a stable prosthesis, early mobilisation, early union and preservation of bone stock. In such cases most authors recommend revision with a long-stem femoral component which must bypass the fracture site and enter the distal femur to a length equal to twice the diameter of the femoral shaft (1, 5-7). We present a novel technique utilising simple, readily available equipment, to achieve anatomical reduction of complex periprosthetic fractures. This technique allows for impaction bone grafting and pressurised cementing of revision prosthesis.
PROCEDURE Preoperative standardised radiographs with calibration markers are essential to allow for templating of revision prosthesis. Fresh frozen bone allograft should be available
© 2013 Wichtig Editore - ISSN 1120-7000
Dearden et al
for femoral impaction grafting. Prior to the patient entering the theatre, the allograft bone can be prepared and milled to produce fine chips suitable for impaction grafting. The patient is anaesthetised. Prophylactic antibiotics can be administered after tissue biopsies have been taken in cases where there is suspicion of infection. Due to the increased blood loss that can be anticipated in revision arthroplasty with associated fracture, our protocol is for preoperative tranexamic acid (8) given in the anaesthetic room. The patient is positioned supine and a lateral incision is utilised centred over the femur and greater trochanter. The presence of previous scars is assessed preoperatively and if these are too anterior or posterior, then a new incision is utilised. Our preferred exposure is by trochanteric osteotomy to expose and remove the prosthesis and to allow careful removal of any residual loose cement from the femoral canal. This approach also allows assessment of the proximal femoral bone stock. Tissues biopsies should be taken to exclude the presence of low-grade infection. The exposure of the proximal femur is the same as for any revision surgery for periprosthetic fracture with scar and fibrous tissue being released sufficiently to expose the fracture site without devitalising the fragments. Care is taken to protect the linear aspera and its related feeding blood vessels. A long Charnley curette is used for intramedullary splinting of the femur, working as a skewer to hold all the fragments of femur together in alignment. A 60 ml bladder syringe is prepared by removing both ends with an oscillating saw to create an open ended cylinder. This cylinder is then cut lengthways using heavy scissors to allow it to be opened but so that it still retains its shape. Final reduction is achieved using the syringe carefully wrapped around the exposed fracture site and adjusted to allow complete enclosure of the fracture fragments. This provides a very good reduction of the fracture and this should be secured in place with several 1.2 mm circlage wires. Containment of all pieces is accomplished and a stable mechanical environment for impaction grafting has been created. The femoral canal is now stable and constrained to receive bone graft which can be firmly impacted (Figs. 1a and b). Depending on the fracture configuration more than one syringe can be used. The prosthesis is cemented in place and the bladder syringe can be removed along with the circlage wires. We use commercially available bone cement with a
Fig. 1 - a) Bone plastic femoral model simulating a B3 fracture; b) illustration of wrapping of the syringe around the fracture site secured in place with circlage wires enclosing the fracture fragments.
combination of clindamycin and gentamicin which has prolonged period of antibiotic delivery to local soft tissues and increased activity in preventing biofilm formation than gentamicin alone (9); an important consideration in revision surgery. At this stage, any extruded cement can be removed and the trochanteric osteotomy wired back into place. The prosthesis can now be reduced (Figs. 2a and b).
DISCUSSION In our experience, this technique facilitates reduction, induces a closed chamber, biologically and mechanically favourable for impaction bone grafting and allows utilisation
© 2013 Wichtig Editore - ISSN 1120-7000
211
Impaction grafting and cemented revision in periprosthetic hip fractures
of the whole length of the comminuted femur for fixation that otherwise would have just been bypassed with long stems. It also allows for cementing of a long stem revision prosthesis and a stable hip joint to enable early mobilisation. Moreover, in cases which may require further revision surgery in the future, the remodelling of the fracture site and reconstitution of bone stock will allow for the use of standard length of stems. Indeed, the radiographic evidence of integration of bone graft and replenished bone stock is rather unique. Thus far we have had no cases of re-fracture, implant failure or dislocation following revision surgery in a series of eight patients. We believe that this technique should be added in the surgeons’ armamentarium and be considered for the management of difficult periprosthetic fracture cases. Financial Support: No financial support received.
Conflict of Interest: No conflict of interest.
Fig. 2 - a) Preoperative right hip AP radiograph with fracture; b) postoperative right hip AP radiograph following the application of the above described technique; c) follow-up right hip AP radiographs at 18 months post surgery.
Address for correspondence: Mr Paul Dearden 50 Allerton Grange Rise Leeds Yorkshire, LS17 6LH, UK [email protected]
REFERENCES
5.
1. Tsiridis E, Haddad FS, Gie GA. The management of periprosthetic femoral fractures around hip replacements. Injury. 2003;34(2):95-105. 2. Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br. 2011;93(1):96-101. 3. Tsiridis E, Spence G, Gamie Z, El Masry MA, Giannoudis PV. Grafting for periprosthetic femoral fractures: strut, impaction or femoral replacement. Injury. 2007;38(6):688-97. 4. Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and validity of the Vancouver classification of femoral fractures after hip replacement. J Arthroplasty. 2000;15(1): 59-62.
212
6.
7.
8.
9.
Ninan TM, Costa ML, Krikler SJ. Classification of femoral periprosthetic fractures. Injury. 2007;38(6):661-8. Ogawa H, Ito Y, Takigami I, Shimizu K. Revision total hip arthroplasty for a Vancouver type B3 periprosthetic fracture using an allograft-cemented stem composite by the telescoping technique. J Arthroplasty. 2011;26(4):e25-8. Tsiridis E, Narvani AA, Haddad FS, Timperley JA, Gie GA. Impaction femoral allografting and cemented revision for periprosthetic femoral fractures. J Bone Joint Surg Br. 2004;86(8):1124-32. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011;93(1):39-46. Ensing GT, van Horn JR, van der Mei HC, Busscher HJ, Neut D. Copal bone cement is more effective in preventing biofilm formation than Palacos R-G. Clin Orthop Relat Res. 2008;466(6):1492-8.
© 2013 Wichtig Editore - ISSN 1120-7000
Copyright of Hip International is the property of Wichtig Editore and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
