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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 98-109

Acquired long bone defects classifications: Literature review (Part II – long bone defects around the joint)


1 Department of Orthopaedic Trauma, Moscow City Clinical Hospital #13, 1/1 Velozavodskaya str., Moscow, Russian Federation
2 Department of Military Traumatology and Orthopedics, S.M. Kirov Military Medical Academy, 13 Botkinskaya str., Saint Petersburg, Russian Federation
3 Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, USA
4 Department of Traumatology and Orthopedics, Vreden National Medical Research Center of Traumatology and Orthopedics, 8 Akademik Baykov str.; Chair of Traumatology and Orthopedics, Saint Petersburg State Pediatric Medical University, 2 Litovskaya str., Saint Petersburg, Russian Federation

Date of Submission20-Sep-2021
Date of Decision11-Oct-2021
Date of Acceptance18-Nov-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Anton A Semenistyy
Inozemcev Moscow City Clinical Hospital, Fortunatovskaya Street 1, Moscow 105187
Russian Federation
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_28_21

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  Abstract 


Introduction: In recent years, multiple classifications of long bone defects around the joint (LBDAJ) have been proposed. However, there is no universal clinical classification of LBDAJ to date. Through comprehensive literature review, we aim to identify the criteria that may be used to develop a future universal classification of LBDAJ. Materials and Methods: We performed a comprehensive review of the literature to identify all articles describing classification systems of LBDAJ in both native and prosthetic joints. Two reviewers searched the following electronic databases independently: The Cochrane Bone, Joint and Muscle Trauma Group, MEDLINE, and eLibrary. Studies investigating bone defects around the joint reporting a classification or any criteria to classify bone defects were included in this review. All studies not related to bone articular surfaces were excluded. Results: A total of 15 classifications for LBDAJ in the preserved joint were. Most systems considered the size of bone defect as a key criterion for clinical decision-making. A total of 31 classifications for periprosthetic bone defects related to hip, knee and shoulder arthroplasty were identified. The following criteria were used by different authors to classify periprosthetic bone defects: Location (n = 22), size (n = 20), containment (n = 9), discontinuity (n = 6), shape or geometrical characteristics of the defect (n = 4), fracture (n = 2), and deformity. Conclusion: Despite the large variety of the existing classifications of bone defects around the joint, there is no classification that could be considered universal. For the development of a future universal classification, defect location, size, and containment are likely to be the main factors to consider as important.

Keywords: Articular defect, bone defect, bone loss, classification, meta-epiphyseal defect, osteochondral defect, periprosthetic defect


How to cite this article:
Semenistyy AA, Komarov AV, Sheridan GA, Rozbruch S R, Solomin LN. Acquired long bone defects classifications: Literature review (Part II – long bone defects around the joint). J Limb Lengthen Reconstr 2021;7:98-109

How to cite this URL:
Semenistyy AA, Komarov AV, Sheridan GA, Rozbruch S R, Solomin LN. Acquired long bone defects classifications: Literature review (Part II – long bone defects around the joint). J Limb Lengthen Reconstr [serial online] 2021 [cited 2022 May 20];7:98-109. Available from: https://www.jlimblengthrecon.org/text.asp?2021/7/2/98/334374




  Introduction Top


Bone defects around the joint have different causes, such as high-velocity trauma, infection, neoplasms, failed surgical interventions, avascular bone necrosis and various joint destructing diseases.[1],[2],[3],[4],[5],[6] The management of patients suffering from long bone defects around the joint (LBDAJ) often requires a complex staged surgical reconstruction and long-term rehabilitation with no guarantee of a positive outcome.[5],[7]

In surgical practice, classifications are intended to evaluate a condition, determine the most appropriate treatment tactic and allow surgeons to predict and compare their outcomes.[8] In recent years, multiple classifications of bone defects around the joint have been proposed. However, to the best of our knowledge, there is no universal clinical classification of LBDAJ.

Through performing a comprehensive literature review, we aim to identify the criteria that may be used to develop a future universal classification of LBDAJ, which will allow for the evaluation of a bone defect, determination of the most effective treatment strategy, and the prediction and comparison of outcomes.[9],[10]


  Materials and Methods Top


We performed a comprehensive review of the literature to identify all articles describing classification systems of bone defects around the joint in both native and prosthetic joints.

Eligibility criteria

Articles written in English, German, French, or Russian dealing with classifications or treatment protocols of LBDAJ were eligible for inclusion. Studies investigating bone defects around the joint reporting a classification or any criteria used by authors to divide the bone defects into different groups were included in this review. All studies not related to bone articular surfaces were excluded. Studies related to congenital bone deficiencies were also excluded.

This systematic review was registered through PROSPERO – International prospective register of systematic reviews (Registration number CRD42020195771). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist was adhered to [Figure 1].
Figure 1: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow 2009 diagram which illustrates the number of studies that have been identified, included, and excluded as well as the reason for exclusion

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Search

Two reviewers searched the following electronic databases independently: The Cochrane Bone, Joint and Muscle Trauma Group, MEDLINE, eLibrary. An additional manual search was performed through relevant literature including book chapters and dissertations related to the topic. The reference lists of eligible articles were screened to identify any additional relevant literature. The primary search was performed on Medline through PubMed using the following strategy: (osteochondral defect [Title/Abstract] OR articular[Title/Abstract] OR periarticular[Title/Abstract] OR metaphyseal[Title/Abstract] OR epiphyseal[Title/Abstract] OR metaepiphyseal[Title/Abstract] OR joint[Title/Abstract] OR periprosthetic[Title/Abstract] OR arthroplasty[Title/Abstract] OR replacement[Title/Abstract]) AND (bone defect[Title] OR bone loss[Title] OR bone defects[Title] OR defect[Title] OR defects[Title]) AND (classification[Title/Abstract] OR treatment[Title/Abstract] OR management[Title/Abstract] OR classifications[Title/Abstract]) NOT glenoid[title] NOT acetabular[title] NOT talar[title] NOT talus[title] NOT acetabulum[title] NOT cartilage[title] NOT foot[title] NOT hand[title] NOT periodontal[title/abstract]. This search was carried out on July 1, 2020.


  Results Top


Classifications of bone defects around the preserved joint

A total of 15 classifications were identified in the literature and underwent analysis [Table 1]. Initial attempts to classify the meta-epiphyseal bone defects were made in the mid-1980s in conjunction with an increased performance of arthroplasty surgery.[25],[26],[27],[28],[29] This period is also associated with the worldwide popularisation of Ilizarov's transosseous osteosynthesis.[3],[13] The unsolved problem of the unstable shoulder gave rise to the development of multiple Hills-Sachs lesion classifications at this time also.[12],[14] Outerbridge was the first to describe osteochondral defects of patella, based on the depth of the lesion.[11] This principle was adopted from other authors who described classifications of osteochondral lesions in long bones.[15],[19]
Table 1: Classifications of periarticular bone defects

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Extra-articular and intra-articular meta-epiphyseal bone defects have fundamental differences in treatment approaches and this also explains the wide variation in the current classifications.[30] For intra-articular bone defects, most authors consider the size and location of articular injury to be the main factor of relevance. These criteria are usually the basis for making clinical decisions,[11],[15],[16],[19],[21],[24]

Catagni et al. coined the term “non-union with bone loss” in 1986 in their classification of pseudoarthroses to emphasize the differences in the treatment of nonunions with or without shortening with no contact between bone fragments.[13] Zappatera et al. introduced the treatment outcomes for upper extremity bone defects using the Masquelet technique. In their review, bone defects around the joint were divided into meta-diaphyseal, metaphyseal and meta-epiphyseal. To describe the type of bone defect the authors used the Catagni classification.[12],[20],[31]

Bone substitutes and special techniques (e.g., reamer-irrigator-aspirator bone harvesting) increase the potential volume of bone defects which may be reconstructed with bone grafting. Therefore, the size of bone defect expressed as a volume in cm3, became an important criterion in some classifications of peri-articular bone defects.[22],[23]

The universal classification of long bones defects proposed in 2016 by Solomin et al. is based on the Müller AO Classification principles (alphanumeric designation of pathology from simple to complex, from general to specific).[8],[21] According to this classification, long bone defects are divided into four types based on the complexity of the pathology: A, B, C, and D. Each type is subdivided into groups and subgroups. The extra-articular defects are listed as type A2 (limited metaphyseal). Intra-articular defects are listed as types A3 (limited epiphyseal) and type D (complete articular). The latter two belong to the group referred to as “bone defects around the joint.”

Another classification proposed by Solomin et al. is a clinical classification of bone defects around the knee with contraindications to arthroplasty. This classification describes epiphyseal, metaphyseal, and diaphyseal bone defects of the distal femur and proximal tibia and serves to choose the optimal reconstruction algorithm in performing a knee arthrodesis.[24]

The following aetiologies were used to design the various classification systems: Posttraumatic,[4],[11],[12],[13],[14],[16],[17],[18],[19],[20],[21],[22],[23],[24] infectious,[4],[13],[20],[22],[23],[24] iatrogenic,[12],[13],[22],[24] those associated with degenerative and inflammatory joint diseases.[11],[15] Some classifications were universal for all segments[4],[15],[16],[20],[21],[22],[23] and others were specific to the shoulder,[12],[14],[17],[18] knee[11],[24] and ankle.[11],[19] There were many classifications developed for a particular treatment method. These included distraction osteogenesis with external fixator,[4],[11],[22],[24] open reduction and internal fixation,[4],[11],[22],[23] arthroscopy[14],[15],[16] and bone grafting.[20]

[Table 2] describes classifications based on the etiology of the defect. Most authors consider the size of bone defect as a key criterion for clinical decision-making. The size may be expressed in relative terms (histological depth or % of articular surface involved), or in absolute values (cm3, mm3, cm2, and cm). The bone defect size may be measured on X-ray, computed tomography, magnetic resonance imaging or arthroscopy.
Table 2: Classifications of long bone defects around the joint by aetiology of defect

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According to our conducted analysis, most classifications for periarticular bone defects are developed to guide treatment and therefore may be considered as clinical classifications.[4],[11],[12],[13],[14],[15],[16],[17],[18],[20],[21],[22],[23]

Classifications of periprosthetic bone defects

A total of 31 classifications for periprosthetic bone defects related to hip, knee and shoulder arthroplasty were identified in the literature and underwent analysis [Table 3].[25],[26],[27],[28],[29],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61] We could not identify any classification of bone defects related to elbow, wrist, or ankle arthroplasty.
Table 3: Classifications of periprosthetic bone defects

Click here to view


Of 31 classifications, 14 were developed for hip,[25],[26],[27],[28],[29],[32],[33],[34],[35],[36],[37],[38],[39],[40] 14 for the knee[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58] and 3 for shoulder arthroplasty.[56],[57],[58],[59],[60],[61] In contrast to classifications of bone defects around preserved joints, most classifications of periprosthetic bone defects were developed for both articulating bones.[27],[28],[32],[33],[37],[38],[40],[41],[42],[43],[44],[45],[46],[47],[50],[51],[52],[53],[55],[56],[57],[58],[60] We found that all classifications of periprosthetic knee defects could be applied to both the femur and the tibia. In contrast, the classifications of hip and shoulder periprosthetic bone defects were always different for each of the two articulating bones, and so this required a specific classification for each bone. Therefore, all eiht double classifications of the hip and shoulder periprosthetic bone defects were actually 16 single classifications.[27],[28],[32],[33],[34],[38],[40],[60]

The following criteria were used by different authors to classify periprosthetic bone defects: Location (n = 22), size (n = 20), containment (n = 9), discontinuity (n = 6), shape or geometrical characteristics of the defect (n = 4), fracture (n = 2), and deformity (n = 1) [Table 3].

Location

Location was the most popular criterion (22/31). In the classification of periprosthetic proximal femur defects, Paprosky et al. used the terms “metaphyseal” and “diaphyseal” to describe the location.[32] A similar approach was used by many other authors.[25],[29],[33],[34],[35],[37],[42],[47],[56],[60],[61] Medial-lateral, anterior-posterior, central/peripheral were other terms used in periprosthetic bone defect classifications.[26],[48],[49]

Some authors suggested the use of anatomical landmarks to describe the location: Chandler et al. describe the involvement of the femoral neck, calcar and greater trochanter as an important factor in making clinical decisions.[37] Casella et al. observed the integrity of the calcar, lateral wall, and any bone defect involvement of the femoral diaphysis in the evaluation of bone defects resulting from conservative arthroplasty (resurfacing hip, neck retaining implants, and metaphyseal bone preserving stems).[39] In knee arthroplasty, authors describe the defect location relative to the femoral or tibial condyles.[42],[54],[56] The involvement of the deltoid insertion site and calcar are important factors to assess in revision shoulder arthroplasty.[60],[61]

Size

The next factor, playing an important role in bone defect evaluation is the size (20/31). Many authors use subjective terms to describe bone defects: Minimal-extensive,[32] minimal-significant,[35] intact-damaged-deficient[42],[56] without any reference to absolute values. Other authors use these similar terms in combination with absolute values. When classifying femoral defects in knee arthroplasty, Rand et al. use the terms minimal, moderate, extensive, and massive, specifying that “minimal” is <5 mm deep with <50% condylar involvement. “Moderate” is 5–10 mm in depth with 50%–70% condylar involvement. “Extensive” is over 10 mm in depth with 70%–90% condylar involvement, and “Massive” is when condylar involvement is >90%.[49] Other similar ways of representing bone defects have been noted in other classifications.[26],[51],[52],[53]

According to the classification by Saleh et al., it is important to divide the periprosthetic hip bone defects with circumferential bone loss into those more and <5 cm in length.[38] Gustilo et al. proposed an assessment of the percentage of cortical thinning to describe the bone loss in hip arthroplasty.[28] A similar approach is used in the PHAROS Classification System developed for shoulder arthroplasty.[61] There are classifications describing the size of bone defects in cubic centimeters.[54] There are also classifications describing the radiological features reflecting the size of bone defects also.[51]

Containment, shape, and geometrical characteristics

Containment is the next criterion that is used by many authors to evaluate periprosthetic bone defects (9/31). “A contained defect has an intact cortical rim, whereas an uncontained defect has segmental bone loss with no remaining cortex.”[62] This term was introduced by Stockley et al. in 1992 to classify defects in total knee arthroplasty and was further used by many other authors.[35],[38],[41],[47],[52],[53],[54] In comparison to others, this criterion is more universal and interpreted similarly by all authors as “contained” or “uncontained”. The most frequently used terms describing defect containment in hip and knee arthroplasty are: “segmental, cavitatory, and combined.”[27],[50],[56] Some authors describe the shape and other geometrical features of bone defects in their classification (4/31).

Discontinuity, fracture, and deformity

Discontinuity is the term used in six classifications to describe the most severe bone defects with complete separation of the prosthesis from the bone.[27],[32],[37],[38],[50],[56] Moreover, some authors suggest that one takes into account the presence of fracture and deformity in periprosthetic bone defect classifications.[27],[37],[38] 'Stability' and 'bone-prosthesis contact' are used only in four classifications, including the AORI, which is the most widely used classification of periprosthetic bone defects of the knee.[26],[36],[40],[42]

The two most popular criteria (location and size) are presented in [Table 4]. As seen in the presented analysis, many classifications are descriptive and do not guide clinical decision-making. Three of 31 classifications were not included in this analysis, as they do not consider any of the aforementioned criteria.[27],[36],[41] Half (14/28) consider both the location and size criteria, and 10/14 are clinically oriented.[28],[32],[33],[34],[35],[38],[39],[42],[52],[53],[56],[57],[59],[61]
Table 4: Classifications of periprosthetic bone defects by most popular criteria (location and size)

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  Discussion Top


The significant differences in classification approach described in this review underline the importance of LBDAJ under two headings: 1-periarticular defects around the preserved joint and 2– periprosthetic LBDAJ.

According to modern approaches, the following goals are set in the treatment of periarticular bone defects: 1 – to preserve or restore the joint anatomy and function by means of complete reconstruction, 2 – mechanical support of the affected articular surface, 3 – restoration of bone stock to accommodate prosthesis placement, and 4 – healing of the defect itself.[30] The conducted analysis has shown that intra-articular bone defects can be divided into both reconstructable and nonreconstructable defects. In the treatment of reconstructable defects, the main goal is to restore and preserve the joint function. In nonreconstructable defects, the treatment of choice is usually arthroplasty or arthrodesis, with the following goals: 1 – restoration of joint function by means of arthroplasty and 2 – relief of pain and restoration of stability of the extremity with arthrodesis. In some cases, amputation may be the best option.[63],[64]

The classifications designed for periprosthetic defects, by definition, differ significantly from classifications of bone defects around the preserved joint. The periprosthetic LBDAJ classifications help to predict how the bone defect may affect endoprosthesis stability, to select the most appropriate revision implant and to predict outcomes.[42] These classifications are usually designed for both articulating bones separately. This approach is similar to the one used for the AO universal classification of periprosthetic fractures and could be used for the development of a universal classification of periprosthetic bone defects.[63]

Solomin et al. proposed the classification of bone defects around the knee.[24] In contrast to the previously described classifications, it considers the “knee joint” as a single unit, similar to existing classifications of periprosthetic defects.[41],[42],[47],[50],[51],[52],[53],[55],[56],[57],[58] The authors define epiphyseal, metaphyseal, and diaphyseal defects of both the distal femur and the proximal tibia. This classification was developed to determine the algorithm for reconstruction in patients with contraindications for arthroplasty.

Despite significant differences in the described group of classifications, it is important to underline their similarities. The location and size of bone defects are considered to be the most pertinent criteria by most authors of bone defects in both periprosthetic and preserved joint classifications. It is evident that the concept of 'containment' is the most universal and unambiguous criterion, which allows for the accurate evaluation of endoprosthesis stability. Although no single comprehensive approach to classifying periarticular bone defects exists as of yet, we have identified the most important criteria that would likely need to be involved in the development of such a classification. The defect location, size, and containment would be the most important criteria to include in this classification system if it were to be designed in future studies.


  Conclusion Top


Despite the large variety of the existing classifications of bone defects around the joint, there is no classification that could be considered universal. This review has shown that classifications of periprosthetic and preserved joint bone defects should be analyzed separately. For the development of a future universal classification, defect location, size, and containment are likely to be the main factors to consider as important.

Highlights:

  • Despite the large variety of existing classifications for LBDAJ, there is no classification that could be considered universal
  • Classifications of LBDAJ should be specific for either prosthetic joints or preserved joints, as the goals of management are different in both settings
  • We have identified the most important criteria that would likely need to be involved in the development of such a universal classification
  • Defect location, size and containment would be the most important criteria to include in future universal classification development.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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