Role of impaction bone grafting of allografts in the management of benign lesions of the proximal femur

Abstract

Purpose of study: The use of allografts to reconstruct benign lesions of the proximal femur after curettage has seldom been reported. We report our experience of impaction bone grafting of only allografts combined with osteosynthesis to manage benign lesions involving the proximal femur.

Materials and methods: Between 2013 and 2019, 35 patients of a mean age of 23.8 years (14-41) who had a biopsy proven benign pathology and a median pre-operative Mirels' score of 9 (8-11) were managed using extended curettage, impaction bone grafting of allografts combined with osteosynthesis through a lateral approach. Radiographs were assessed to see for any recurrence at follow-ups, and functional outcomes were assessed using Musculoskeletal Tumour Society (MSTS) score and Harris hip score (HHS).

Results: At a mean follow-up was 41.5 months (23-80), patients demonstrated favorable functional outcomes with a mean MSTS of 28.3 (18-30) and a mean HHS of 94.3 (66-100) at the last follow-up. Two cases (GCT = 1; fibrous dysplasia = 1) had a recurrence of disease. Allografts demonstrated a particular integration pattern on radiographs that involved an intermediate period of lucency followed by consolidation and integration with the parent bone.

Conclusion: Impaction grafting of allografts in benign lesions of the proximal femur allows adequate bony consolidation of the cavity after extended curettage and can be effectively used as a permanent solution to manage such lesions in most cases. The intermediate period of lucency seen on radiographs must not be confused for recurrence, and patients must be followed up continuously.

Study design: Retrospective Case Series.

Level of evidence: Level IV.

Keywords: Allografts; Benign lesion; Impaction bone grafting; Proximal femur.

Fig. 1

Lytic lesion of the femoral neck with a Mirel's score of 10 at presentation (a). Extended curettage using high-speed burr (b) followed by impaction bone grafting (c, d) of morselized allografts followed by DHS fixation (e). Radiograph taken at 3-year follow-up showing good consolidation of the cavity (f).

Fig. 2

Fibrous dysplasia involving proximal femur in a 17-year-old female (a). Post-operative radiograph showing impacted allografts (b) and complete incorporation in the radiograph taken at 30 months post-surgery (c). Patient demonstrated an MSTS score of 95 and HHS of 27 at last follow-up.

Fig. 3

Lytic lesion of the femoral neck in a 24-year-old female (a) managed with IBG of allografts (b) and DHS fixation (c). Post-operative radiograph at 6 months (d) demonstrated lucency in the region of impacted allografts which resolved and showed incorporation at subsequent follow-up at 12 months (e). The histological samples corresponded with chondromyxoid fibroma.

Fig. 4

Lytic lesion diagnosed as Chondroblastoma (a). Due to the wide diameter of the neck, an additional fibular allograft strut was combined along with allografts and implant during surgery. Good consolidation of the cavity and incorporation of the allograft with the parent bone seen at 2 years follow-up (b).

Fig. 5

Simple bone cyst in a 19-year-old female who presented with a Mirel's score at 9 during presentation (a, b). Following management with IBG of allografts, she went on to have a favorable outcome showing good incorporation into parent bone (c, d). Two years post-surgery, she had symptoms related to implant irritation (e). Following implant removal, she remained asymptomatic (f) at the latest follow-up.

Fig. 6

Complications: GCT in a 24-year-old female had a recurrence following surgery (a). Due to an increase in the size of the lesion leading to the destruction of the femoral head (b) and an increase in symptoms, we suspected recurrence. Biopsy confirmed recurrence of GCT. To harden the lesion and aid in dissection, two doses of Denosumab were administered. We did revision surgery involving extended curettage and joint replacement (c). Recurrence of FD in a 19-year-old male seen on radiograph during follow-up (d) was managed conservatively as the patient was asymptomatic. Regular follow-up radiographs did not show any increase in the size of the lesion.