Aseptic loosening is uncommon with uncemented proximal tibia tumor prostheses

The long-term risks of infection and amputation with limb salvage surgery using endoprostheses

Endoprostheses are now an established technique to reconstruct defects following bone tumour resection. The long-term durability of the reconstruction is excellent, with limb salvage being maintained in the long-term in 91% of patients at 20 years from surgery. The main reasons for secondary amputation were locally recurrent disease and deep periprosthetic infection. Infection remains one of the biggest threats to early failure of reconstructions with endoprostheses. Most series of reconstructions show a periprosthetic infection rate of approximately 10%. Infection most frequently occurs within 12 months from the last surgical procedure; however, the risk of infection is life-long. The commonest pathogenic organism is coagulase-negative Staphylococcus. The most effective treatment for deep infection is two-stage revision, with local treatments having little chance of curing deep infection. Research is on-going into surface treatments with silver and other materials to help to reduce the infection rates.

Endoprosthetic replacement for primary tumours around the knee: experience from Peking University

In developing countries locally-made low-cost prostheses are mainly used in limb-salvage surgery to alleviate the economic burden. We retrospectively collected data on 104 patients treated by limb-salvage surgery between July 1997 and July 2005. We used a locally-designed and fabricated stainless-steel endoprosthesis in each case. Oncological and functional outcomes were evaluated at a mean follow-up of 47 months (12 to 118). A total of 73 patients (70.2%) were free from disease, nine (8.7%) were alive with disease, 19 (18.2%) had died from their disease and three (2.9%) from unrelated causes. According to the Musculoskeletal Tumor Society scoring system, the mean functional score was 76.3% (SD 17.8). The five-year survival for the implant was 70.5%. There were nine cases (8.7%) of infection, seven early and two late, seven (6.7%) of breakage of the prosthesis, three (2.9%) of aseptic loosening and two (1.9%) of failure of the polyethylene bushing. Multivariate analysis showed that a proximal tibial prosthesis and a resection length of 14 cm or more were significant negative prognostic factors. Our survival rates and Musculoskeletal Tumor Society functional scores are similar to those reported in the literature. Although longer follow-up is needed to confirm our results, we believe that a low-cost custom-made endoprosthesis is a cost-effective and reliable reconstructive option for limb salvage in developing countries.

Implant design and resection length affect cemented endoprosthesis survival in proximal tibial reconstruction

Endoprosthetic reconstruction of the proximal tibia continues to pose many challenges. A retrospective analysis of 44 consecutive patients who underwent cemented proximal tibial replacement were included to investigate if patient age, surgical stage, type of implant, stem diameter, or resection length could be associated with implant failure. Fifteen patients (34%) suffered prosthetic failure, 7 due to infection. Prosthetic-related complications occurred in 13 patients (30%). Custom design prosthesis and longer length of resection were significantly associated with prosthesis survival in a Cox regression analysis (P = .001, hazard ratio = 8.747 and P = .044, hazard ratio = 1.217, respectively). Cemented proximal tibial replacement offers a functional knee, but reducing risk of complications still remains challenging. Prosthetic design and length of resection affect overall cemented endoprosthesis survival.

The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the proximal tibia following resection of a tumour. Survival of the implant and 'servicing' procedures have been documented using a prospective database. A total of 194 patients underwent a proximal tibial replacement, with 95 having a fixed-hinge design and 99 a rotating-hinge with a hydroxyapatite collar; their median age was 21.5 years (10 to 74). At a mean follow-up of 14.7 years (5 to 29), 115 patients remain alive. The risk of revision for any reason in the fixed-hinge group was 32% at five years, 61% at ten years and 75% at 15 and 20 years, and in the rotating-hinge group 12% at five years, 25% at ten years and 30% at 15 years. Aseptic loosening was the most common reason for revision in the fixed-hinge knees, fracture of the implant in the early design of rotating hinges and infection in the current version. The risk of revision for aseptic loosening in the fixed-hinge knees was 46% at ten years. This was reduced to 3% in the rotating-hinge knee with a hydroxyapatite collar. The cemented, rotating hinge design currently offers the best chance of long-term survival of the prosthesis.

Pasteurized autograft-prosthesis composite for reconstruction of proximal tibia in 13 sarcoma patients

BACKGROUND

The purpose of this study is to ascertain the survival of the pasteurized autograft-prosthesis composite and functional outcome of this procedure, and to evaluate the complications including nonunion, infection, loosening, bony resorption, and fracture.

METHODS

We retrospectively reviewed 13 proximal tibial sarcoma patients who underwent tibia reconstructions with using a pasteurized autograft-prosthesis between 1993 and 2003.

RESULTS

Four patients underwent removal of the composite with a minimum follow-up of 11 months (average: 43 months, range: 11-75 months). The survival rate of the 13 composites, as calculated by the Kaplan-Meier method, was 76.9% at 5 years. The primary cause of removing the composite was infection in three patients and loosening in one patient. The average MSTS functional score of 11 patients was 23.6 +/- 3.3 (79%). Nonunion was identified in four patients, while infection developed in three patients. Loosening of the stem and resorption of the pasteurized bone was detected in one case each. No patient developed fracture of autograft.

CONCLUSIONS

Our data suggest that the pasteurized autograft-prosthesis has comparable functional outcome and complication rates as other methods, such as endoprosthesis and allograft-prosthetic composite and it offers a reconstructive option for surgeons who do not have access to large allograft banks.

Pasteurized autograft-prosthesis composite for distal femoral osteosarcoma

BACKGROUND

We examined the survivorship and functional outcome of the pasteurized autograft-prosthesis composite for distal femoral osteosarcoma. We also evaluated complications including nonunion, loosening, bony resorption, infection, and fracture.

METHODS

We retrospectively reviewed 15 distal femoral osteosarcoma patients who underwent reconstructions using pasteurized autograft-prosthesis composite between 1993 and 2003.

RESULTS

No patient required graft removal during a minimum follow-up of 35 months (average 56 months; range 35-78 months). The average Musculoskeletal Tumor Society System (MTSS) functional score was 86%. Nonunion developed in five patients, and three of them subsequently showed loosening of the stem. No patient experienced infection or fracture.

CONCLUSIONS

Our data suggest that the pasteurized autograft-prosthesis composite could be an easily accessible alternative for the reconstruction of large skeletal defects in the distal femur because of the satisfactory functional outcome with a low rate of ultimate failure and complications in this study.