228
THE JOURNAL OF BONE AND JOINT SURGERY
CASE REPORT
Viability of impacted bone allografts under metal mesh at the calcar in revision surgery of the hip
M. Buttaro, G. S. Araujo, E. S. Araujo, F. Comba, F. Piccaluga
画蛇添足翻译From the Italian Hospital of Buenos Aires, Buenos Aires, Argentina
M. Buttaro, MD, Orthopaedic Surgeon
G. S. Araujo, MD, Orthopaedic Resident
F . Comba, MD, Orthopaedic Surgeon
pet是什么意思
F . Piccaluga, MD, Hip Surgery Unit Chief, Orthopaedic Surgeon.
The Hip Surgery Unit. Institute of Orthopaedics, “Carlos E. Ottolenghi” Italian Hospital of Buenos Aires, Potosi 4215 (C1199ACK), Buenos Aires, Argentina.
E. S. Araujo, MD, Professor of Orthopaedic Pathology Bone Pathology Laboratory, Paraguay 2301 (C1425), Buenos Aires, Argentina.
Correspondence should be nt to Dr M. Buttaro; e-mail:
martin.buttaro@hospitalitaliano.
org.ar
of Bone and Joint Surgery doi:10.1302/0301-620X.90B2.
19921 $2.00
2008;90-B:228-31.
uplinkReceived 10 July 2007; Accepted after revision 14 September 2007
Metal meshes are ud in revision surgery of the hip to contain impacted bone grafts in cas with cortical or calcar defects in order to provide rotational stability to the stem. However, the viability of bone allografts under the metal meshes has been uncertain. We describe the histological appearances of biopsies obtained from impacted bone allografts to the calcar contained by a metal mesh in two femoral reconstructions which needed further surgery at 24 and 33 months after the revision procedure.
A line of osteoid and viable new bone was obrved on the surface of necrotic
trabeculae. Active bone marrow between the trabeculae showed necrotic areas in some medullary spaces with reparative fibrous tissue and isolated reactive lymphocytes. This is interpreted as reparative changes after revascularisation of the cancellous allografts.The pathological findings are similar to tho reported in allografts contained by
cortical host bone and support the hypothesis that incorporation of morcellid bone under metal meshes is not affected by the devices.
Impaction allografting is a reconstructive sur-gical option in femoral revision surgery, with excellent clinical and radiological results at medium-term follow-up. 1-4 Cadaver specimens and bone biopsies have shown incorporation of bone and allograft trabeculation. 5 In the prence of defects in the cortex or calcar ,metal meshes have been recommended to con-tain the grafts in order to provide rotational stability to the stem. 2,6-8 Although the clinical and radiological results have been promising,the viability of allografts under the meshes has been doubtful. Furthermore, in an experimen-tal study, incorporation of the graft under the meshes has been questionable. 9
Our hypothesis was that incorporation of morcellid bone under metal meshes is not affected by the devices. We describe the his-tological obrvations on biopsies from impacted bone allograft contained by a calcar metal mesh in two femoral reconstructions which needed further surgery. Ca one. A 78-year-old man was treated had been undertaken a year earlier. His medi-acetabular and femoral reconstructions with impacted bone allografts and a cemented C-Stem (De Puy, Warsaw, Indiana) were per-formed. The femur had an Endoklinik grade 3defect of 30 mm in the calcar . 10 A 35 mm wide hemicircumferential metal mesh was trimmed to cover the femoral defect. It was 3.8 mm thick, with 3 mm 2 perforations, and was fixed to the proximal femur with two Ortron 90 (De Puy) cerclage wires. Three femoral heads from our bone bank were ud to reconstruct the femur. T
hey had not been irradiated. They were morcellid manually into pieces of 0.4 cm to 0.6 cm in size and mixed for 15 minutes with 1000 mg of powdered vancomycin (Lilly, Indianapolis, Indiana) per femoral head. 11 Impaction grafting was carried out as described by Gie et al. 6
The graft was packed by specific instrumentation (Primary Impaction Grafting Instruments; De Puy Int.,Leeds, United Kingdom).
Two years after this revision, the patient pre-nted with pain in the groin and radiographs showing superolateral migration of the ace-tabular component with rupture of the mesh at the rim (Fig. 1). The stem, cement and allograft were clinically and radiologically stable. The acetabular component was revid using a reconstruction ring (Graft Augumen-tation Prosthesis (GAP); Stryker Howmedica Osteonics, Rutherford, New Jery) with impacted allografts and a cemented acetabu-lar component. The patient’s connt was obtained for biopsy specimens from the
VIABILITY OF IMPACTED BONE ALLOGRAFTS UNDER METAL MESH AT THE CALCAR IN REVISION SURGERY OF THE HIP
229
VOL. 90-B, No. 2, FEBRUARY 2008
reconstructed femur. Six specimens were taken from the calcar zone through the fenestrations of the metal mesh using a 4 mm Jamshidi needle.
Ca two. A one-stage aptic acetabular and femoral recon-struction with vancomycin-supplemented impacted bone allografts and a plain cemented Charnley stem (Fico, Buenos Aires, Argentina) was carried out in a 35-year-old woman in
April, 2004. She had received a primary cemented THR in 1996 becau of developmental dysplasia. She was otherwi well.
Two morcellid femoral heads with vancomycin and a 40 mm wide metal mesh with the same characteristics as in ca 1 were ud to reconstruct an Endoklinik grade 3 fem-oral defect of 35 mm at the calcar . 10
Impaction grafting was
Fig. 1
Anteroposterior radiograph showing acetabular migration in ca 1, two years after two-staged reimplanta-tion with impacted bone allografts and metal meshes in the acetabular
rim and femoral calcar.
Fig. 3
Histological slides of ca 1 showing necrotic lamellar bone trabeculae (*)with new surface aposition (black arrows). The bone marrow is necrotic with fibrosis (F) and reactive inflammatory infiltration (I) in areas of repair (haematoxylin and eosin ×
50).
Fig. 2
Anteroposterior radiograph show-ing a displaced peri-prosthetic frac-ture at the tip of the stem in ca 2. A metal mesh containing impacted bone allografts was ud to recon-
struct the calcar 33 months earlier.
webuiFig. 4
darling什么意思
Histological slides showing viable new bone apposition (black arrows)and newly remodelled bone (RB) over a necrotic allograft trabecula (hae-matoxylin and eosin × 150).
230
M. BUTTARO, G. S. ARAUJO, E. S. ARAUJO, F. COMBA, F . PICCALUGAearthcam
THE JOURNAL OF BONE AND JOINT SURGERY
performed using specific instrumentation (Primary Impac-tion Grafting Instruments; De Puy Int).
At 33 months after this revision, she fell and sustained a Vancouver type B1 displaced peri-prosthetic fracture (Fig. 2). 12 At operation, with her prior connt, six biopsy specimens were taken from the calcar reconstruction with a 4 mm Jamshidi needle through the metal mesh fenestrations by the same surgeon (MB) who had performed the previous revision procedure.
Pathological findings
The six samples from each patient showed the abnce of nuclei in the lacunae, corresponding to necrosis of the lamellar trabeculae. A line of osteoid and viable new appo-sition of bone was en on the surface of the necrotic tra-beculae. Active bone marrow lay between them and showed necrotic areas in some medullary spaces with repar-ative fibrous tissue and isolated reactive lymphocytes in others (Figs 3 and 4). This appearance is similar to that which occurs after revascula
risation of cancellous allografts.
Discussion
The histological appearances of the biopsy specimens support the view that metal meshes do not affect viability of the bone grafts. With gmental defects, the combination of impacted bone allografts and meshes is associated with a favourable outcome. 2,6 Meshes conform to the remaining bone and allow cancellous grafts to be in contact with the surrounding soft tissue. 7,8,13 The fenestrated nature of the devices ensures retention of the graft at the defect and pro-vides a favourable scaffold for bony restoration. However ,there have been reports of poor incorporation of bone grafts in tibial defects contained by metal meshes and impacted allografts in rabbits. 9 As the animals were not weight-bearing and considering this as a factor which might influence graft incorporation, we considered that the find-ings could be different in a clinical situation. 14 Further-more, recent experimental reports recommend the u of an open wire mesh for reconstruction of gmental femoral defects in combination with impaction grafting to allow for optimal revascularisation in an area of impaired vascular-ity. 7step by step
Becau our examinations were limited to biopsy speci-mens and did not include post-mortem studi
es, we could not demonstrate histologically the three zones described by previous authors. 5,15 However, we obrved necrotic osous trabeculae, fibrosis and occasional lymphocytes,which are findings consistent with remodelling of bone graft and new bone formation. 16,17 The viability and sub-quent incorporation of the allograft is not judged easily from radiographs and is practically impossible when it is contained by a metal mesh.
Our allografts included vancomycin as a prophylactic agent as there is a significant increa in the prevalence of methicillin-resistant Staphylococcus aureus (M RSA) in
most countries, including ours, rising to 40% to 50% in some cas. 18 Vancomycin has been shown not to affect incorporation of bone allograft. 19,20
Our findings were en in femurs reconstructed with two different designs of femoral component. The first was a tri-ple taper polished cemented femoral component similar to the Exeter stem (Stryker Howmedica Osteonics, Allendale,New Jery) which gives excellent medium-term results when using the impacted bone allograft technique. 4 The cond was a Charnley-type femoral component which has also been shown to give very favourable results. 1圣诞老人英语怎么说
Although we obrved viable trabecular bone in our specimens, additional biopsies and post-mortem
retrieval of femurs reconstructed with this technique are needed to confirm our findings.
Our obrvations encourage the u of metal meshes com-bined with impacted morcellid bone allograft to recon-struct femoral deficiencies after failure of femoral implants.
No benefits in any form have been received or will be received from a commer-ical party related directly or indirectly to the subject of this article.
References
1.Piccaluga F, González Della Valle A, Encinas Fernández JC, Pusso R. Revision of the femoral prosthesis with impaction allografting and a Charnley stem: a 2- to 12-year follow up. J Bone Joint Surg [Br] 2002;84-B:544-9.
2.Schreurs BW, Arts JJ, Verdonschot N, et al. Femoral component revision with u of impaction bone-grafting and a cemented polished stem: surgical technique. J Bone Joint Surg [Am] 2006;88-A(Suppl 1):259-74.
3.Oakes DA, Cabanela ME. Impaction bone grafting for revision hip arthroplasty:biology and clinical applications. J Am Acad Orthop Surg 2006;14:620-8.
4.Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction grafting with cement in revision total hip replacement: evolution of the techniques and results. J Bone Joint Surg [Br] 2003;85-B:809-17.
5.Linder L. Cancellous impaction grafting in the human femur: histological and radio-graphic obrvations in 6 autopsy femurs and 8 biopsies. Acta Orthop Scand 2000;71:543-52.
6.Gie GA, Linder L, Ling RSM, et al. Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg [Br] 1993;75-B:14-21.
7.Bolder SB, Schreurs BW, Verdonschot N, Ling RS, Slooff TJ. The initial stability of an exeter femoral stem after impaction bone grafting in combination with gmen-tal defect reconstruction. J Arthroplasty 2004;19:598-604.
8.Bolder SB, Schreurs BW, Verdonschot N, Veth RP, Buma P. Wire mesh allows more revascularization than a strut in impaction bone grafting: an animal study in goats. Clin Orthop 2004;423:280-6.
9.Roidis N, Karachalios T, Khaldi L, Stamos K, Lyritis GP. The role of stainless steel wire mesh and
cement in bone allograft incorporation in impaction grafting technique: an experimental study in rabbits. J Arthroplasty 2003;18:484-93.
10.Engelbrecht E, Heinert K. Klassification und Behandlungsrichtilien von Knochen-subsanzverlusten bei Revisions-operationen am Huftgelenk mittelfrsige Ergebnis. Primare und Revisionsalloarthroplastik . Hrsg-Endo-Klinik, Hamburg: Springer-Verlag,1987:189-201 (in German).
11.Buttaro MA, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty: two-stage revision results. J Bone Joint Surg [Br] 2005;87-B:314-19.
12.Duncan CP, Masri BA. Fractures of the femur after hip replacement. Instr Cour Lect 1995;44:293-304.
13.Lindy RW, Gugala Z, Milne E, et al. The efficacy of cylindrical titanium mesh cage for the reconstruction of a critical-sized canine gmental femoral diaphyal defect. J Orthop Res 2006;24:1438-53.
airpollution14.Schreurs BW, Slooff TJ, Buma P, Verdonschot N. Basic science of bone impac-tion grafting. Instr Cour Lect 2001;50:211-20.
15.Ling RS, Timperley AJ, Linder L. Histology of cancellous impaction grafting in the femur: a ca report. J Bone Joint Surg [Br] 1993;75-B:693-6.
16.Nelisn RG, Bauer TW, Weidenhielm LR, LeGolvan DP, Mikhail WE. Revision hip arthroplasty with the u of cement and impaction grafting: histological analysis of four cas. J Bone Joint Surg [Am]
1995;77-A:412-22.
VIABILITY OF IMPACTED BONE ALLOGRAFTS UNDER METAL MESH AT THE CALCAR IN REVISION SURGERY OF THE HIP
asonal231
VOL. 90-B, No. 2, FEBRUARY 2008
17.Muscolo DL, Caletti E, Schajowicz F, Araujo ES, Makino A. Tissue-typing in human massive allografts of frozen bone. J Bone Joint Surg [Am] 1987;69-A:583-95. 18.Giannoudis PV, Parker J, Wilcox MH. Methicillin-resistant Staphylococcus aureus in trauma and orthopaedic practice. J Bone Joint Surg [Br] 2005;87-B:749-54.
19.Buttaro MA, Gonzalez Della Valle AM, Pineiro L, et al. Incorporation of vanco-mycin-supplemented bone incorporation of vancomycin-supplemented bone allo-grafts: radiographical, histopathological and immunohistochemical study in pigs. Acta Orthop Scand 2003;74:505-13.
20.Buttaro MA, Morandi A, Rivello GH, Piccaluga F. Histology of vancomycin-sup-plemented impacted bone allografts in revision total hip arthroplasty. J Bone Joint Surg [Br]
2005;87-B:1684-7.
