Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature

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1 Page 1 of 5 Trauma & Orthopaedics Long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty: A case report and review of the literature GJ Macpherson 1 *, T Gotterbarm 2, PR Aldinger 3, H Mau 4, SJ Breusch 1 Abstract Introduction The management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient s bone. This case report discusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty. We present the operative technique and long-term fate of a bivalved femoral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement. Conclusion The use of femoral allograft for augmenting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case * Corresponding author gavin.macpherson@nhs.net 1 Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK 2 Stiftung Orthopädische Universitätsklinik, Schlierbacher Landstraße 200a, Heidelberg, Germany 3 Orthopädischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D Stuttgart, Germany 4 Endoklinik Hamburg, Holstenstr. 2, Hamburg, Germany represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treatment of long-bone periprosthetic fractures with poor bone stock. Introduction Data from joint registries indicate an increase in the number of primary and revision knee arthroplasties being performed each year internationally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and Periprosthetic supracondylar femoral fractures can occur intraoperatively and postoperatively, with an overall incidence of % above primary total knee arthroplasties (TKAs) 2 7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38% 3,6 8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixation 4,5,9. Periprosthetic fractures are more common in the elderly population and in females 7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock 3,9 11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction of locked plate technology has revolutionized surgery in the presence of osteoporotic bone 12, the use of a combination of cortical femoral allograft and compression plate 13 or a bivalved total femoral allograft 5,14 may be indicated when a periprosthetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminution. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group. In this case report, we aim to provide further evidence that a bivalved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the patient s bone stock. This technique can provide a reliable long-term solution in this complex fracture group. One month after primary TKA for valgus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-presented with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with femoral head structural allograft. Three months after discharge, she fell and sustained a spiral periprosthetic fracture around the femoral stem (Figure 1).

2 Page 2 of 5 Figure 1: Spiral periprosthetic fracture around an uncemented stemmed revision total knee arthroplasty. Figure 2: Bivalved femoral cortical allograft. Note notches prepared with a high-speed burr. After graft placement, grooves were burred to accommodate the cerclage wires. Discussion The use of bivalved total femoral allograft in the treatment of femoral periprosthetic fractures is not a new technique and has been widely reported following fractures around hip arthroplasty implants Wang et al. in 2002 recommended the use of a combination of compression plate and cortical strut allograft. They reported a 100% union rate but did have one case of osteomyelitis and one malunion after a maximum follow-up of 68 months13. When bivalved total femoral allografting is compared with locked plate fixation, the use of a cortical allograft and a Figure 3: Intraoperative image after tightening of all but one cerclage wires. Note one of two temporary hose clamps that were removed prior to wound closure. locked plate is stiffer than a locked plate alone but is not as stiff as using two locked plates positioned orthogonally19. The similar modulus of elasticity between the cortical allograft and the host bone reduces the effect of stress shielding20. The use of cortical allograft has the potential Due to the poor bone stock, it was decided to treat the fracture with a total femoral allograft. The donor femur was bivalved and prepared/ shaped with high-speed burrs15 to fit the host femur (Figure 2). After primary fracture reduction with two lag screws and cerclages, the allografts were placed medially and laterally, leaving the vasculature along the linea aspera intact. The allografts were temporarily held around the reduced femur with sterilized hose clamps whilst cerclage wires were sequentially tightened in grooves that had been burred on the outer surface of the allograft to stop the cerclage sliding (Figure 3). After partial weight bearing for 6 weeks, the patient was walking unaided at 3 months having achieved full knee extension and 85 flexion. Radiographic allograft integration proximally and distally was observed after 2 years. Four years postoperatively, she re-presented with an ipsilateral femoral neck fracture and underwent an uncomplicated cemented total hip replacement (THR) via a transgluteal approach. Intraoperatively, the proximal allograft docking revealed a smooth continues structure of allograft merging into the host femur. The latest radiographs were taken at 8 and 10 years (Figures 4 and 5).

3 Page 3 of 5 Figure 4: (a) and (b): Follow-up radiographs 8 years following bivalved total femoral allograft. Note previous allograft augmented lateral femoral condyle fixed with two cancellous screws. Distal and proximal allograft incorporation and remodelling is evident. to add to the bone stock if the graft incorporates into the host bone 15 and is therefore particularly useful in this patient population who are known to be commonly affected by osteoporosis 21,22. Fracture union rates of % have been reported with the use of cortical allografts with or without plate fixation for femoral periprosthetic fractures 13,16,23,24, and the addition of allograft may enhance the bony union by stimulating the fracture to heal 25. Cortical allografts allow for customization of the fixation without the expense of having a customized implant manufactured. Shaping the graft to complement the host femur adds to the complexity of the surgery and may make the procedure more demanding than either traditional internal fixation methods or the use of an endoprosthesis. The increased complexity of the surgery demands more extensive soft-tissue dissection and periosteal stripping 26, which may account for a high rate of complications, reported as high as 17% 27 with deep infection occurring at a rate of 4 13% The large mass of dead bone may increase the deep infection rate as the devitalized bone allows proliferation of bacteria leading to infection. Disease transmission is possible with the use of allograft, but contemporary bone bank protocols have reduced this risk The process of incorporation of a strut has been described as going through a number of definable stages (creeping substitution) 35. Complete reabsorption is rarely seen in practice; however the stages that precede this reabsorption have been observed in this case and include round off, scalloping, bridging and cancellization 35. The most recent radiological examination of this patient demonstrated cancellization, but not reabsorption, and this indicates revascularization of the cortical graft 35, which was evident at THR implantation. In this case of rheumatoid arthritis, we were confronted with extremely poor stock in a patient who had previously sustained multiple osteoporotic fractures including distal radius and lumbar vertebrae. The initial lateral condyle sinter fracture had occurred after a simple stumble, hence meeting the criteria for a pathological fracture secondary to osteoporosis. At revision of the femoral component, an allograft femoral head was used to correct the recurrent valgus deformity and restore deficient lateral condyle bone stock. At the time, it was noted that the cancellous bone was so weak that it could be indented by digital pressure. Therefore, when the patient re-presented with the second, now diaphyseal periprosthetic fracture, the decision was made to treat the fracture with a total bivalved allograft to improve bone stock, as we did not trust internal fixation devices to provide reliable stability to allow mobilization of her TKA, which would have been at significant risk of stiffness. Conclusion To our knowledge, this case represents the longest (11-year) follow-up of a bivalved total femoral allograft above a stemmed revision TKA published. The radiographs and intraoperative findings during hip replacement have confirmed bony incorporation. In this particular case, the absence of the potential alternative of a locking plate with multiple screws crossing the canal has allowed straight forward implantation of a THA, which otherwise would have not been the case. In our opinion, bivalved total femoral allograft should be considered for periprosthetic fractures above TKAs where there is reduced bone stock and/or fracture comminution. The potential advantages of cortical allograft increased bone stock, reduced stress shielding, acceptable rates of union and customization of the graft must be weighted against the

4 Page 4 of 5 Figure 5: Routine 10-year follow-up radiograph of the pelvis. Note bony incorporation of allograft proximally. potential disadvantages increased complexity of surgery, risk of infection and disease transmission. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations list THA, total hip replacement; TKA, total knee arthroplasty References 1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to J Bone Joint Surg Am Apr;89(4): Ritter MA, Faris PM, Keating EM. Anterior femoral notching and ipsilateral supracondylar femur fracture in total knee arthroplasty. J Arthroplasty. 1988;3(2): Merkel KD, Johnson EW. Supracondylar fracture of the femur after total knee arthroplasty. J Bone Joint Surg Am Jan;68(1): Figgie MP, Goldberg VM, Figgie HE, Sobel M. The results of treatment of supracondylar fracture above total knee arthroplasty. J Arthroplasty Sep; 5(3): Sisto DJ, Lachiewicz PF, Insall JN. Treatment of supracondylar fractures following prosthetic arthroplasty of the knee. Clin Orthop Relat Res Jun; 196: Meek R, Norwood T, Smith R, Brenkel I, Howie C. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br Jan;93(1): Berry DJ. Epidemiology: hip and knee. Orthop Clin North Am Apr;30(2): Inglis A, Walker P. Revision of failed knee replacements using fixed- axis hinges. J Bone Joint Surg Br Sep; 73(5): Culp R, Schmidt R, Hanks G, Mak A, Esterhai J, Heppenstall RB. Supracondylar fracture of the femur following prosthetic knee arthroplasty. Clin Orthop Relat Res Sep;222: Cain PR, Rubash HE, Wissinger HA, McClain EJ. Periprosthetic femoral fractures following total knee arthroplasty. Clin Orthop Relat Res Jul;208: Johnston AT, Tsiridis E, Eyres KS, Toms AD. Periprosthetic fractures in the distal femur following total knee replacement: A review and guide to management. Knee Jun;19(3): Greiwe RM, Archdeacon MT. Locking plate technology: current concepts. J Knee Surg Jan;20(1): Wang J-W, Wang C-J. Supracondylar fractures of the femur above total knee arthroplasties with cortical allograft struts. J Arthroplasty Apr;17(3): Chandler HP, Penenberg BL. Bone stock deficiency in total hip replacement: Classification and management. Slack Inc; Chandler HP, Tigges RG. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons The role of allografts in the treatment of periprosthetic femoral fractures. J Bone Joint Surg Am. J Bone Joint Surg.1997 Sep; 79(9): Emerson RH, Malinin TI, Cuellar AD, Head WC, Peters PC. Cortical strut allografts in the reconstruction of the femur in revision total hip arthroplasty. A basic science and clinical study. Clin Orthop Relat Res Dec;(285): Haddad FS, Garbuz DS, Masri BA, Duncan CP. Structural proximal femoral allografts for failed total hip replacements: a minimum review of five years. J Bone Joint Surg Br Aug;82(6): Head WC, Malinin TI. Results of onlay allografts. Clin Orthop Relat Res Feb;(371): Choi JK, Gardner TR, Yoon E, Morrison TA, Macaulay WB, Geller JA. The effect of fixation technique on the stiffness of comminuted Vancouver B1 periprosthetic femur fractures. J Arthroplasty Sep;25(6 Suppl.): Mihalko WM, Beaudoin AJ, Cardea JA, Krause WR. Finite-element modelling of femoral shaft fracture fixation techniques post total hip arthroplasty. J Biomech May;25(5):

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