Judas, F

Lucas, F

Marques, A

Maximino, L

Repositório Institucional dos Hospitais da Universidade de Coimbra

ÓRGÃO OFICIAL dA SOCIEdAdE PORTUGUESA dE REUMATOLOGIA14CASO CLÍNICO1. Orthopaedic Surgeon/ Chief of Service, Professor of the Facultyof Medicine, University Clinic of Orthopaedics, Coimbra UniversityHospitals, Faculty of Medicine, University of Coimbra. 2. Orthopaedic Resident, University Clinic of Orthopaedics, Coimbra University Hospitals.3. Orthopaedic Surgeon/ Graduated Assistant, University Clinic of Orthopaedics, Coimbra University Hospitals.creased fluid pressure and implant motion may play arole, the final pathway seems to be related to the hostresponse to the wear particles generated by the diffe rentfriction systems of the prostheses: polyethylene-on--metal, metal-on-metal, polyethylene-on-ceramic, andceramic-on-ceramic bearing surfaces1,2,3.The cellular response to particulate debris, a foreignbody reaction, can produce periprosthetic osteolysisthat leads to bone loss and consequently to asepticloose ning of the hip prostheses. Polyethylene particlesseem to be the major culprit1,3.Aseptic loosening remains a dominant cause for im-plant failure requiring revision. Revision hip surgerywith extensive bone loss is never an easy prospect forthe patient or surgeon. It is technically challenging, in-volves higher costs, and often lower success rates.Particles of polyethylene and other debris are dis-pensed through the joint fluid. Fluid flows accordingto pressure gradients, and any area of bone accessed byjoint fluid is a potential site for deposition of wear de-bris. Schmalzried, Jasty and Harris described “the ef-fective joint space” where debris and fluids migratearound the components of the prostheses and causebone lysis out of the joint space. This concept explainsthe development of osteolysis at the tip of a well-fixedfemoral component, or over the dome of an acetabularcomponent with holes in the metal backing2,3.Pelvic and femoral osteolysis are generally progres-sive processes of particle-induced bone loss. The pat-tern of lysis depends on the implant design. Many pa-tients with osteolytic lesions remain asymptomatic un-til catastrophic failure occurs from dislocation orperiprosthetic fracture. Once the osteolysis is detected,more frequent follow-up is advisable. Radiographsshould be made at 3- to 6-month intervals rather thanyearly4,5,6.The purpose of this paper is to report an unusualcase of a patient with a stable total revision hip pros-Rapid progression of a severe femoral bone loss in a stable revision hip prosthesis: causes and managementFernando Judas1, Alexandre Marques2, Luís Maximino3, Francisco Lucas3AbstrActWe report a case of a severe bone loss of the proximalfe mur with a rapid progression, in a 72-year-old malepatient with a stable total revision hip prosthesis. Thepa tient had a persistent mechanical thigh pain. Theblood laboratory values were normal. Infection diseaseand osteolytic bone tumor were excluded.A surgical procedure was performed. The nativebone of the proximal femur was resorbed and replacedby a dense fibrous tissue with some sclerotic bone frag-ments. A large amount of a brownish fluid and a red--brown and friable tissue were found in the pseudo-joint cavity. The proximal femur was reconstructed using a large amount of cryopreserved cancellous boneallograft, with retention of the femoral prosthesis. The mechanism of the bone lesion can be related notonly to the host response to the wear particles, butmainly to the fluid pressure in the effective joint space.Femoral progressive osteolysis in a stable hip pros-thesis is an indication for surgery in useful time, beforeadverse bone remodeling can begin and lead to majorbone loss.Keywords: Severe femoral bone loss; Osteolysis; Revi-sion hip prosthesis.IntroductIonBone loss has been reported in association with eitherloose or well-fixed total hip prostheses. Although in-ACTA REUMATOL PORT. 2012;37:14-18ÓRGÃO OFICIAL dA SOCIEdAdE PORTUGUESA dE REUMATOLOGIA15FEMORAL BONE LOSS IN REVISION HIP PROSTHESISthesis who had a rapid and severe bone resorption ofthe proximal femur, like an osteolytic bone tumor. Wesuggest a possible explanation for the development ofthe impressive bone loss and we describe the surgicaltechnique used for femur reconstruction.cAsE rEportA 72-year-old man was submitted in January 2006 toa total revision hip arthroplasty in the right side due toaseptic loosening of a primary cementless prosthesisCLS®, with 11-years follow-up. The aetiology of theprimary prosthesis was a degenerative arthritis of thehip. In the revision surgery, an acetabular metallic support ring with a cemented polyethylene cup and arevision conical stem were implanted. The pelvic andfemoral bone loss were reconstructed with morselizedcancellous bone allograft (Fig. 1a). No complicationswere reported in the first three years of the postopera -tive course.A dislocation of the revision prosthesis occurred inMay 2009 by indirect traumatism. The dislocation wasreduced under general anesthesia and signs of osteo -lysis in the proximal femur were detected. The patientreturned to his normal activity after 15 days.In August 2010 the radiographic studies showed anaggravation of the femoral osteolysis in the stage II, ac-cording to the HUC Classification System6. Neverthe-less the femoral stem was stable by the excellent fixa-tion of the distal part and the acetabular component re-mained well-fixed (Fig.1b). The patient had a thighpain, that was aggravated by weight-bearing and re-lieved by analgesics (metamizole) and resting. The pa-tient walked with support aids, two forearm crutches,and was medicated with warfarin to control atrial fi -brillation. Due to the constant mechanical pain and weakness,he visited our Department five months later. Plain ra-diographs revealed a severe expansive osteolytic lesionof the proximal femur. The bone was almost entirelyresorbed (Fig. 2) and a surgical intervention was per-formed. The blood laboratory values were normal. The hip was exposed through a standard posteriorapproach. The proximal femur bone was replaced bya pseudojoint cavity composed by a dense fibrous tis-sue with some sclerotic bone fragments. A capsulardistension was detected. When the pseudojoint cavi-ty was incised, a large amount of a brownish fluid (400 cc) escaped under great pressure (Fig. 3). The inner surfaces of the pseudojoint cavity and theFIGurE 1. Periprosthetic osteolysis. a) Radiograph of a revision hip prosthesis at 1-year follow-up. The prosthesis wasstable with absence of periprosthetic osteolysis. b) At 4-yearsfollow-up the radiograph revealed moderate proximal femoralosteolysis, stage II according to the HUC Classification SystemA bFIGurE 2. Five months later, painful and severe expansive osteolytic lesion of the proximal femur. The bone was almostentirely resorbed. The acetabular and femoral components remained mechanically stableÓRGÃO OFICIAL dA SOCIEdAdE PORTUGUESA dE REUMATOLOGIA16FERNANdO JudAS E cOLjoint space were cleaned of a red-brown, uniform andfriable tissue. At macroscopic examination it seemedlike a chronic connective granulation tissue possiblyderived from hematoma resorption, with no evidenceof acute inflammation. The histopathologic examina-tion of the specimens revealed fibrous and necroticmaterial, including some segments of granulation tis-sue with an exuberant angiomatous component.The proximal femur was reconstructed using a largeamount of cryopreserved cancellous bone allograft(300 cc) from HUC Tissue Bank, with retention of the femoral prosthesis. The morselized bone was im-pacted to fill the space of the pseudojoint cavity aroundthe femoral implant (Figs. 4a and 4b).Final culture results of fluid and soft-tissue speci-mens obtained at the time of surgery were negative forinfection. No complications were reported in the postopera-tive course. Immediately after surgery, the patient wasmobilized with protected weight-bearing. Three weeksafter surgery, the mechanical tight pain disappeared. At7-months follow-up, the patient was clinically able towalk without external support; had a Trendelenburgsign and reported no groin or thigh pain. He was verypleased with the surgery result.dIscussIon The current clinical case illustrates a rare example ofan extensive and aggressive osteolysis of the proximalfemur. Investigations have indicated that the cellularresponse to wear particles is central to the develop-ment of osteolysis in total hip arthroplasties. Mechani -cal factors were also responsible for osteolysis.Whether the initiating factor is biologic or mechanicalis a subject of debate2,3.In the current case, four years after the revision hipsurgery plain radiographs showed a moderate osteoly -sis of the proximal femur. The primary factor in thisins tance seems to have been the biological reaction tothe wear particles of polyethylene, cement and metal,either alone or in concert.However, an unusual progression of the lytic boneloss was detected during a short period of five monthsthat led to the femoral bone resorption. In this situa-tion, it is vital to exclude the presence of infection orbone tumor, because periprosthetic osteolysis is usual -ly a progressive and slow process that also leads to aprogressive bone stock loss.Infection must be suspected whenever resorptionof bone is considerable, the endosteal surface of thebone is scalloped, periosteal elevation is present, andthe erythrocyte sedimentation rate or C-reactive pro-tein level are high. The clinical and laboratory studieseliminated an infection process in this clinical case,and the final culture results of fluid and soft-tissuespecimens obtained at the time of surgery were nega-tive for infection.Although the incidence of malignant tumors in pa-tients undergoing total hip arthroplasties is known tobe lower than in the general population, there are seve -ral reports on the development of malignant tumors atFIGurE 4. Management of the expansive bone loss. a) The proximal femur was reconstructed using cryopreserved cancellous bone allograft (HUC Tissue Bank), the prosthesiswas not replaced b) Radiograph at 7 months of the postoperative period showing the process of the allograft bone incorporationAFIGurE 3. Intraoperative photograph showing a large amountof a brownish fluid under great pressure (400 cc) in the pseudojoint cavity and in the joint spacebÓRGÃO OFICIAL dA SOCIEdAdE PORTUGUESA dE REUMATOLOGIA17FEMORAL BONE LOSS IN REVISION HIP PROSTHESISthe site of total hip arthroplasties. Malignant fibroushistiocytoma at the site of an endoprosthesis of the hipconstitutes a distinct rarity, and has been attributed tothe implants or to their alloy constituents7. Thehistopathologic examination of the specimen from thesurgical operation revealed fibrous and necrotic mate-rial and the absence of malignant lesions.A mechanical instability of the femoral componentmay originate expansive bone loss8, nevertheless wecan also eliminate this mechanism because in the cur-rent case the stem was stable.We believe that the continued expansion of the os-teolysis during a short time of five months can be main-ly secondary to an intense fluid pressure, supported bya failure of venous and lymphatic drainage. In fact, alarge volume of articular fluid under a high pressurewas found in the pseudojoint cavity and in the jointspace at the time of surgery. No granulomatous mem-branes suggestive of a biological reaction to wear par-ticles were detected in periprosthetic tissues. Osteo -lysis can also occur in the absence of wear particles byfluid pressure in the effective joint space9.Van der Vis and Aspenberg showed that fluctuatingpressure applied to bone can result in the death of os-teocytes near the implant and subsequent bone re-sorption. Thus, there is evidence that fluid pressureand ensuing flow could be a main cause of not onlypain, but also osteolysis10,11. It is also true that bone ero-sion by aneurisms can be caused by constant mecha -nical pressure, analogous to what happens betweenperiprosthetic osteolytics lesions and arthrosis cysts.The exact pathogenesis of the granulation tissue withexuberant angiomatous component present in thepseudojoint cavity and in the joint space is unclear.One hypothesis is the possibility that a hemorrhagicprocess may have contributed to its origin and also tothe fluid pressure. This may be related to the fact thatthe patient was under oral anticoagulant therapy (war-farin) to control atrial fibrillation, and he had also des -cribed a constant and mechanical thigh pain during thepreoperative time. Severe bone loss of the proximal femur secondary tomajor osteolysis is a difficult situation to deal with, of-fering no ideal treatment option. The possible optionsinclude the implantation of a composite allograft/stemprosthesis, a modular type megaprosthesis, a custom-made megaprosthesis, the use of massive or corticalstrut bone allografts, and impaction cancellous boneallografting12, 13, 14, 15, 16.In the current case the replacement of the femoral re-vision prosthesis by a new femoral implant was not anacceptable option, because the stem was mechanicallystable. The proximal femur reconstruction with bone allo-grafting seemed preferable because it is an attractivetechnique since it restores the bone stock around theimplant17, 18, and it can be done without surgical dislo-cation of the stem. We used cancellous bone allografts.The morselized bone was impacted and filled the spacebetween the femoral stem and the inner surfaces of thepseudojoint cavity.Cryopreserved cancellous bone allografts showedclinical efficacy for the reconstruction of bone defects19.The validity of the impaction allografting technique hasbeen demonstrated previously by histological and me-chanical criteria. Histologically, grafted bone chips wereshown to be replaced by host bone in human retrievalstudies and animal experiments 21. Femoral progressive osteolysis in a stable hip pros-thesis even in the absence of symptoms is clear indica-tion for surgery, before adverse bone remodeling maybegin and lead to major bone loss. If allowed toprogress, femoral reconstruction becomes more com-plex or impossible.corrEpondEncE toFernando JudasUniversity Clinic of Orthopaedics, Coimbra University Hospitals, Praceta Prof. Mota Pinto, Bloco de Celas 3000 Coimbra, Portugal E-mail: fernandojudas@gmail.comrEFErEncEs1. Canales V, Panisello JJ, Herrera A, Sola A, Mateo JJ, Caballero MJ.Extensive osteolysis caused by polyethylene particle migrationin an anatomical hydroxyapatite-coated hip prosthesis: 10 years’follow-up. Arthroplasty 2010; 25(7):1115-1124.2. Harris WH. The problem is osteolysis. Clin Orthop 1995;311:46.3. Archibeck MJ, Jacobs JJ, Roebuck KA, Glant TT. The basic scien-ce of periprosthetic osteolysis. Instr Course Lect 2001;50:185--195.4. Harris WH, McCarthy Jr JC, O’Neill DA. Femoral componentloosening using contemporary techniques of femoral cement fi-xation. J Bone Joint Surg 1982; 64A:1063.5. Maloney WJ, Woolson ST. Increasing incidence of femoral os-teolysis in association with uncemented Harris-Galante totalhip arthroplasty: a follow-up report. J Arthroplasty 1996;11:130.6. Proença A, Judas F, Cabral R, Canha N. Revision surgery of hipprosthesis. Osteolysis reconstruction with bone allografts. 1996Orthopaedics Department of Coimbra University Hospitals.7. Schuh A, Zeiler G, Holzwarth U, Aigner T. Malignant fibroushistiocytoma at the site of a total hip arthroplasty. Clin OrthopÓRGÃO OFICIAL dA SOCIEdAdE PORTUGUESA dE REUMATOLOGIA18FERNANdO JudAS E cOL2004; 425:218-222.8. Kalhor M, Notzli HP, Stover MD, Ganz G. Extreme ectasia ofthe femoral diaphysis secondary to loosening of a long Wagnerstem: a case report. J Bone Joint Surg Am 2004; Volume 86--A(3):590-594.9. Manley MT, D’Antonio JA, Capello WN, Edidin AA. Osteolysis:a disease of access to fixation interfaces. Clin Orthop2002;405:129-137.10. Aspenberg P, Van der Vis H. Migration, particles, and fluid pres-sure. A discussion of causes of prosthetic loosening. Clin Or -thop. 1998;352:75-80.11. Van der Vis HM, Aspenberg P, Marti RK, Tigchelaar W, VanNoorden CJ. Fluid pressure causes bone resorption in a rabbitmodel of prosthetic loosening. Clin Orthop. 1998;350:201--208.12. Bertani A, Helix M, Louis ML, Rochwerger A, Curvale G. Totalhip arthroplasty in severe segmental femoral bone loss situa-tions: use of a reconstruction modular stem design. (JVC IX).Retrospective study of 23 cases. Orthop Traumatol Surg Res2009; 95(7):491-497.13. Head WC, Malinin TI, Mallory TH, Emerson RH Jr. Onlay cor-tical allografting for the femur. Orthop Clin North Am1998;29:307-312.14. Gross AE, Hutchison CR, Alexeeff M, Mahomed N, Leitch K,Morsi E. Proximal femoral allografts for reconstruction of bonestock in revision arthroplasty of the hip. Clin Orthop1995;319:151-158.15. Zmolek JC, Dorr LD. Revision total hip arthroplasty. The use ofsolid allograft. J Arthroplasty 1993;8:361-370.16. Argenson JN, Gravier R. Femoral revision with impacted mas-sive or morselized graft. Rev Chir Orthop Reparatrice ApparMot 2000;86:46-47.17. Slooff TJJH, Schreurs BW, Gardeniers JWM: Revision total hiparthroplasty with impacted cancellous allografts and cement.2001; In Pipino F (ed): Bone Cement and Cemented Fixationof Implants 40 Years of Clinical Practice and Prospective for thefuture; 2001; pp 163.18. Gie GA, Ling RSM: Contained, morsellised, impacted allograftin revision total hip arthroplasty, the femoral side. 1998 Ort-hopaedics Today; 1:18. 19. Judas F. Contribution to the study of Morselized Bone Allograftsand Biomaterials. PhD Thesis. 2002, Coimbra University.20. Judas F, Figueiredo MH, Cabrita AM, Proença A: Incorporationof impacted morselized bone allografts in rabbits. TransplantProc 2005, 37(6):2802-2804.21. Williams Amy, Szabo RM. Bone transplantation. Orthopaedics2004; Vol 27, Nº 5:488-495.

Rapid progression of a severe femoral bone loss in a stable revision hip prosthesis: causes and management

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Rapid progression of a severe femoral bone loss in a stable revision hip prosthesis: causes and management

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