1. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - The Role of Allografts in the Treatment of Periprosthetic Femoral Fractures*† by HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am Volume 79(9):1422-32 September 1, 1997 ©1997 by The Journal of Bone and Joint Surgery, Inc.

2. Figs. 1-A through 5-D: Illustrations of the technique for treatment of a proximal femoral fracture. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

3. Fig. 1-B: An open reduction of the fracture is performed, and the fracture is temporarily held with cerclage wires or cables. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

4. Fig. 2: The allograft femoral (or tibial) shaft is split into two equal parts. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

5. Fig. 3 The inside surface of the graft is machined with a high-speed burr to conform to the outside of the host femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

6. Fig. 4 The two grafts are placed medial and lateral to the linea aspera, without disrupting it, in an effort to preserve its blood supply to the host bone. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

7. Fig. 5-A: Hose clamps are used to compress the struts to the host bone initially. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

8. Fig. 5-B: A bone hook with a hole in the tip is used to pass double number-16 wires around the struts. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

9. Fig. 5-C: The wires are tightened and twisted with a Harris wire-tightener (Johnson and Johnson, Raynham, Massachusetts). HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

10. Fig. 5-D: When the wires are secure, the hose clamps are removed and bone graft is added to the site of the fracture. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

11. Figs. 6-A through 6-E: An eighty-year-old woman who had a total hip replacement on the right for post-traumatic osteoarthrosis following a fracture of the femoral neck. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

12. Fig. 6-B: Radiographs made after the patient fell, six months after the total hip replacement, and sustained a Johansson type-II fracture25 distal to a well cemented femoral stem. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

13. Figs. 6-C and 6-D: Radiographs demonstrating a healed fracture, with the struts beginning to unite with the host bone, four months after an open reduction and internal fixation with onlay femoral allograft struts secured with Dall-Miles cables (Howmedica, R... HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

14. Fig. 6-D: Radiographs demonstrating a healed fracture, with the struts beginning to unite with the host bone, four months after an open reduction and internal fixation with onlay femoral allograft struts secured with Dall-Miles cables (Howmedica, Rutherford... HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

15. Fig. 6-E: Radiograph made one year and seven months postoperatively. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

16. Figs. 7-A through 7-F: A fifty-eight-year-old woman who had a customized long-stem hinged total knee prosthesis. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

17. Fig. 7-B: Radiographs made after the patient sustained a proximal femoral fracture proximal to the tip of a well fixed femoral stem. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

18. Fig. 7-C: Illustration demonstrating how an allograft tibia was split into two equal pieces and was secured to the femur with number-16 stainless-steel wires. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

19. Fig. 7-D: Radiograph, made three months postoperatively, demonstrating union, which was evident clinically as well. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

20. Figs. 7-E and 7-F: Radiographs, made four years and nine months postoperatively, showing union of the grafts with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

21. Fig. 7-F: Radiographs, made four years and nine months postoperatively, showing union of the grafts with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

22. Fig. 8 Illustrations demonstrating how supracondylar fractures can be fixed with a lateral blade- plate and a medial allograft strut. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

23. Fig. 9 Illustrations demonstrating how supracondylar fractures can be fixed with a lateral blade- plate and a medial allograft strut. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

24. Figs. 10-A through 10-F: A seventy-six-year-old woman who had a total hip replacement on the right for degenerative arthritis. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

25. Fig. 10-B: Radiograph made three months after open reduction and fixation with a supracondylar plate. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

26. Fig. 10-C: Radiograph, made five months postoperatively, showing a fracture of the plate. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

27. Fig. 10-D: Radiograph made five weeks after a repeat open reduction and fixation with a medial femoral allograft strut and a new supracondylar plate. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

28. Figs. 10-E and 10-F: Radiographs, made one year and nine months after the repeat operation, showing that the fracture had healed and the medial strut had united with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

29. Fig. 10-F: Radiographs, made one year and nine months after the repeat operation, showing that the fracture had healed and the medial strut had united with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

30. Fig. 11: Illustration demonstrating how comminuted, very distal fractures can be stabilized with a distal allograft strut and a condylar plate. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

31. Fig. 12: Illustration demonstrating how screws have little fixation in the weak host bone but good fixation in the graft. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

32. Figs. 13-A through 13-F: An eighty-year-old woman who had a well functioning total knee replacement. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

33. Fig. 13-B: Radiographs made after the patient fell, seven years after the knee replacement, and sustained a comminuted supracondylar fracture. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

34. Fig. 13-C: Radiograph made one month after an open reduction and fixation with a lateral tibial buttress plate medially and an allograft strut laterally. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

35. Fig. 13-D: Radiograph, made eleven weeks postoperatively, showing that the reduction has been maintained. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

36. Figs. 13-E and 13-F: Radiographs, made at eight months, showing that the fracture had united and the graft had united with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.

37. Fig. 13-F: Radiographs, made at eight months, showing that the fracture had united and the graft had united with the femur. HUGH P. CHANDLER, and RUSSELL G. TIGGES J Bone Joint Surg Am 1997;79:1422-32 ©1997 by The Journal of Bone and Joint Surgery, Inc.