1. FEMORAL RECONSTRUCTION WITH ALLOGRAFTS M. Kerboull

2. Revision with a cemented prosthesis Femoral restoration with allografts Standard femoral component Perfectly suitable to a sound cemented fixation

3. MAIN SPECIFICATIONS FOR A SOUND CEMENTED PROSTHESIS A polished stem (Ra 0.04  m) ( < 0.1  m ) with a rectangular cross section A tapered shape with a taper angle of 5° Cement and bone subjected only to pressure stresses No shear stresses at the cement bone interface

4. Endomedullary reconstruction with impacted cancellous graft Cortical reinforcement with strut grafts Replacement of a destroyed proximal femur with massive allograft Endomedullary reconstruction with a massive femoral graft 4 TECHNIQUES

5. ENDOMEDULLARY FEMORAL RECONSTRUCTION WITH MASSIVE FEMORAL ALLOGRAFT « Double sheath technique »

6. INDICATIONS This technique has been used -since 1988 - concurrently with the « impaction grafting » - preferred in cases of severe femoral structural defects - more logical to repair cortical defects with cortical grafts

7. ITS MAIN INDICATION IS EXTENSIVE OSTEOLYSIS DUE TO AGGRESSIVE GRANULOMATOSIS THAT HAS THINNED DOWN CORTICES WIDENING THE MEDULLARY CANAL AND LOOSENING THE FEMORAL COMPONENT

8. PRINCIPLES OF THE SURGICAL TECHNIQUE To repair the femoral cortex where it is destroyed, inside the medullary canal, by lining it with a femoral cortical graft

9. A.After prosthesis and cement removal, reaming and cleaning the medullary canal B. A massive proximal femoral allograft is introduced through the cervical orifice

10. A.The graft has to be carrefully shaped so that it excactly and tightly fits the medullary canal all over the extent of the pathologic area without splitting thin cortices B.Section of the greater trochanter of the graft at the level of the trochanteric osteotomy - obturation of the medullary canal of the graft and host bone by impacted cancellous bone - lining of proximal graft with a strut fragment C.Then a standard femoral component can be cemented into the graft The femoral component is a sheath for the prosthesis and the widened proximal part of the femur a sheath for the graft. This technique requires a bone bank well supplied with proximal femoral allografts. This is relatively rare, and the main limitation of the procedure is the difficulty finding a suitable graft.

11. Some examples to illustrate this technique

12. DUR. 06.96 04.95 Loosening of a rough titanium stemBone restoration with a massive graft

13. ALB. 09.98 10.98 Loosening of the matte stem with femoral osteolysis Bone reconstruction

14. BEA. 03.97 05.98 A big matte stem Femoral restoration 1 y. PO

15. De.G.R. 09.97 11.97 Another case of femoral loosening with osteolysis Double sheath technique 2 months. PO

16. GAR. 09.9912.99 Cement bone loosening of a big matte titanium stem Bone restoration with Massive intra medullary allograft 3 months PO

17. ROB. 06.91 09.93 Major destruction of femoral cortices Bone restoration with massive graft and strut graft

18. ROB. 09.98 Same case. 7 y. PO AP view Lateral view

19. Extremely severe cortical bone loss 03.98 10.99 03.03 Double sheath technique Using a 250 mm stem and a long graft X-rays 5 y. PO

20. BEG. 03.98 Lateral diaphysal cortical defect Restoration with massive graft and a 200 mm stem

21. BEG. (2 y. PO) 07.00 At 2 y. PO excellent bone union between graft and host bone

22. BEG. 03.98 07.00 12.02 Same caseAP radiograph 5 y. PO

23. 2007 9 years PO AP view Excellent function

24. 09.88 GRO. 07.88 Loosening of the femoral component Reconstruction with massive intra medullary graft

25. GRO. 1 m. PO 2 y. PO Radiological bone union between the graft on host femoral cortices has been regularly obtained within a year after surgery. Demarcation between graft on host bone visible in the immediate postoperative time has progressively diasappeared, the gap being filled with new bone.

26. GRO. 03.99 Same case 11 y. PO. We can hardly distinguish the graft from the host bone

27. JAN. 03.91 02.98 Another case, radiological result at 7 y. PO

28. JAN. 07.02 And at 11 y. PO

29. TRA. 05.88 02.89 The first case operated on in 1988 with the double sheath technique

30. TRA. 01.99 (10 y. PO)02.02 (13 y. PO)

31. 2010 X-rays 22 y. PO

32. MATERIAL 17 WOMEN 9 MEN Average age 67 y. (53 to 83) Operated on from 1988 to 2000 27 femoral reconstructions associated with 24 acetabular reconstructions CHARNLEY-KERBOULL PROSTHESIS 22 Standard 5 Long stem (200 to 250 mm)

33. MATERIAL PRIMARY DIAGNOSIS 25 coxarthrosis 16 primary 9 secondary 1 osteonecrosis 1 rheumatoid arthritis

34. MATERIAL PREVIOUS FAILURE OF THR Average 2,1 (1 to 8) LOOSENINGS : - Femoral27 (mechanical 24, septic 3) - Acetabular24 (mechanical 21, septic 3)

35. FEMORAL DEFICIENCIES SOFCOT TYPE III17 TYPE IV10 AAOS TYPE III27 Level II 9 Level III18 CLASSIFICATION

36. FOLLOW-UP Physical and radiological examination at 6 w., 3 m., 1 y. and then every one or two years. AVERAGE FOLLOW-UP 9 y. (3 to 22 y.) LOST0 DECEASED4 (5 hips) between 2 and 6 y. PO

37. COMPLICATIONS 3 NON UNION OF THE GREATER TROCHANTER 2 revised, 1united 1LATE DISLOCATION 1FEMORAL FRACTURE (at 2 y.) united after plating 1FATIGUE FRACTURE OF THE FEMUR (1 y. PO) spontaneously united

38. BER. 02.97 10.97 (8 m. PO)

39. BER. (11 m. PO) 01.98

40. BER. 11.98 03.03 This fracture spontaneously unitedX-rays 6 y. PO

41. CLINICAL RESULTS (d’Aubigné score) PAIN35.9 MOTION5.25.8 STABILITY AND WALKING3.4 5.6 GLOBAL FUNCTION 11.6 17.4 EXCELLENT(18)18 VERY GOOD(17) 5 GOOD(16) 1 FAIR (15) 2 POOR (14) 1  23

42. RADIOLOGICAL RESULTS SUCCESSES25 Graft host-bone union No loosening No resorption of the graft No subsidence of the graft POTENTIAL FAILURE 1 Partial resorption of the graft No loosening ACTUAL FAILURE 1 Partial resorption of the graft Femoral loosening Not revised

43. LOZ. 06.90 03.91 Reccurent loosening due to chronic infection. Femoral reconstruction with massive intra medullary graft Early (9 months) resorption of the graft and loosening of the stem

44. LOZ. 05.94 (4 y. PO) 11.97 (7 y. PO) He couldn’t be reoperated on because of poor cardiovascular conditions

45. Despite this failure, this reconstruction procedure seems to be valuable and reliable enough to allow us to extend this short series.