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Su MW, Groot OQ, Werenski JO, Sodhi A, Merchan N, Anderson ME, Heincelman C, Chang CY, Lozano-Calderon SA. Cemented and Press-fit Femoral Stems for the Management of Oncologic Femoral Tumors. J Am Acad Orthop Surg 2024:00124635-990000000-00994. [PMID: 38773833 DOI: 10.5435/jaaos-d-23-01043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/17/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Stem fixation in reconstruction after resection of femoral tumors is debated. Cemented stems offer immediate stability but risk aseptic loosening, while press-fit stems allow bone ingrowth but risk stress shielding and subsidence. Our retrospective review aimed to determine implant failure rates and their associated factors, as well as the rates of infection, debridement, and mortality for both fixation groups (cemented or press-fit stems) used in patients undergoing resection of femoral tumor disease and subsequent arthroplasty. METHODS We retrospectively studied 252 patients who underwent resection of femoral tumors and subsequent arthroplasty using cemented (n = 173; 69%) or press-fit (noncemented) (n = 79; 31%) stems between 1999 and 2020. Implant failure was the primary outcome, with secondary outcomes including rates of implant infection, debridement, and mortality. Multivariable regression was done to assess risk factors for implant failures. RESULTS The study found implant failure rates of 11% and 18% for cemented stems and press-fit stems, respectively. Lower stem to diaphyseal ratios (P = 0.024) and younger patients (P = 0.008) were associated with a higher risk of implant failure in cemented stems. The infection rates were 14% and 10% for cemented and press-fit stems, respectively. Debridement rates were 16% and 13% for cemented and press-fit stems, respectively, while the 1-year mortality rate was 16% for cemented stems and 1.5% for press-fit stems. CONCLUSIONS This study is the largest of its kind, providing patient characteristics and outcomes in both cemented and press-fit stems in the setting of reconstruction for femoral tumors. Both methods can be effective, with outcomes dependent on patient-specific factors, such as life expectancy, activity level, and body habitus, as well as proper implant fit. Additional studies of both implants and longer follow-up are required to elucidate the optimal fixation method for each individual patient. LEVEL OF EVIDENCE Level III, retrospective noncomparative study.
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Affiliation(s)
- Marie W Su
- From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Musculoskeletal Oncology Service, Harvard Medical School, Boston, MA (Su, Groot, Werenski, Sodhi, Merchan, and Lozano-Calderon), Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Merchan, Anderson, Heincelman, Chang), Department of Orthopaedic Surgery, Musculoskeletal Oncology Service (Dr. Merchan, Dr. Anderson, Dr. Heincelman), Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Merchan, Dr. Anderson, Dr. Heincelman)
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2
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Atherley O'Meally A, Cosentino M, Aiba H, Aso A, Solou K, Rizzi G, Bordini B, Donati DM, Errani C. Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1581-1595. [PMID: 38363346 DOI: 10.1007/s00590-024-03846-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections. METHODS We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases. RESULTS We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively. CONCLUSION Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.
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Affiliation(s)
- Ahmed Atherley O'Meally
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopaedic Surgery, Complejo Hospitalario Metropolitano CSS, Panama, Panama
| | - Monica Cosentino
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Hisaki Aiba
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Ayano Aso
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Konstantina Solou
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- University of Patras, Patras, Greece
| | - Giovanni Rizzi
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Maria Donati
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
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Scoccianti G, Innocenti M, Scanferla R, Scolari F, Muratori F, Ungar A, Rostagno C, Campanacci DA. Survival and Results after Resection and Reconstruction with Megaprosthesis at the Hip in Octogenarians. J Clin Med 2023; 12:7740. [PMID: 38137808 PMCID: PMC10743573 DOI: 10.3390/jcm12247740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Few data are available about results after procedures of resection and megaprosthesis at the hip in very elderly patients. The aim of our study was to ascertain survival and complications in patients aged 80 or older undergoing these major orthopedic procedures. A consecutive series of 27 procedures in 26 patients aged 80-93 years was evaluated. In total, 15 procedures were performed due to oncological diseases, 6 were performed following joint arthroplasty failures or periprosthetic fractures, and 6 were performed after trauma or trauma sequelae. Survival of the patients ranged from 0 to 122 months. Overall survival was 56% at 3 years, 24% at 5 years, and 16% at 8 years. An early postoperative death during the first 3 months occurred in five patients (18.5%). The only preoperative parameter negatively affecting survival was preoperative hemoglobin lower than 11 g/dL. Local complications were similar to reported rates in all-age patients' series. In our experience, resection and megaprosthetic reconstruction can also be a valid choice in very elderly patients, with 56% of patients living more than two years from surgery and 24% more than five. Nevertheless, early postoperative deaths are frequent. A multidisciplinary evaluation of frailty of the patient must be accomplished, and patients and relatives must be informed about the risks of the procedure.
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Affiliation(s)
- Guido Scoccianti
- Department of Orthopaedic Oncology, Careggi University Hospital, 50134 Firenze, Italy; (R.S.); (F.M.); (D.A.C.)
| | - Matteo Innocenti
- Orthopaedic Clinic, Careggi University Hospital, 50134 Firenze, Italy;
| | - Roberto Scanferla
- Department of Orthopaedic Oncology, Careggi University Hospital, 50134 Firenze, Italy; (R.S.); (F.M.); (D.A.C.)
| | - Federico Scolari
- Department of Health Sciences, University of Florence, 50121 Florence, Italy;
| | - Francesco Muratori
- Department of Orthopaedic Oncology, Careggi University Hospital, 50134 Firenze, Italy; (R.S.); (F.M.); (D.A.C.)
| | - Andrea Ungar
- Department of Internal and Geriatric Medicine, Careggi University Hospital, 50134 Firenze, Italy;
| | - Carlo Rostagno
- Department of Internal and Postoperative Medicine, Careggi University Hospital, 50134 Firenze, Italy;
| | - Domenico Andrea Campanacci
- Department of Orthopaedic Oncology, Careggi University Hospital, 50134 Firenze, Italy; (R.S.); (F.M.); (D.A.C.)
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Trikha R, Greig DE, Olson TE, Kendal JK, Geiger EJ, Wessel LE, Eckardt JJ, Bernthal NM. Proximal Femur Replacements for an Oncologic Indication Offer a Durable Endoprosthetic Reconstruction Option: A 40-year Experience. Clin Orthop Relat Res 2023; 481:2236-2243. [PMID: 37458708 PMCID: PMC10566928 DOI: 10.1097/corr.0000000000002765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/22/2023] [Accepted: 06/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Proximal femur replacements (PFRs) are an effective surgical option to treat primary and metastatic tumors causing large bony defects in the proximal femur. Given the relative rarity of these indications, current studies on PFR for oncologic indications are generally limited by patient volume or relatively short-term follow-up. Because recent advances in systemic therapy have improved the prognosis of patients who undergo limb salvage surgery for musculoskeletal tumors, data on the long-term durability of endoprosthetic reconstructions have become increasingly important. QUESTIONS/PURPOSES (1) How does the long-term survival of cemented bipolar PFRs compare with patient survival in patients who underwent PFR for benign, aggressive, and metastatic tumors? (2) What are common reasons for revisions of primary PFRs? (3) Which factors are associated with survival of primary PFRs? (4) What is the survivorship free from conversion of bipolar PFRs to THA? METHODS Between January 1, 1980, and December 31, 2020, we treated 812 patients with an endoprosthetic reconstruction for an oncologic indication. All patients who underwent a primary PFR for an oncologic indication were included in this study. The study cohort consisted of 122 patients receiving a primary PFR. Eighteen patients did not reach a censored endpoint such as death, revision, or amputation within 2 years. Thirty-three patients died within 2 years of their surgery. Of the 122 patients with primary PFRs, 39 did not reach a censored endpoint and have not been seen within the past 5 years. However, the mean follow-up time for these patients was longer than 10 years. The Social Security Death Index was queried to identify any patients who may have died but might not have been captured by our database To allow for adequate follow-up, endoprosthetic reconstructions performed after December 31, 2020 were excluded. The mean age at the time of the index surgery was 48 ± 22 years. The mean follow-up time of surviving patients was 7 ± 8 years. All PFRs were performed using a bipolar hemiarthroplasty with a cemented stem, and all implants were considered comparable. Demographic, oncologic, procedural, and outcome data including prosthesis survival, patient survival, complication rates, and rates of conversion to THA were analyzed. Patient, prosthesis, and limb salvage survival rates were generated, with implant revision as the endpoint and death as a competing risk. Statistical significance was defined as p < 0.05. RESULTS Generally, patients with benign or low-grade (Stage I) disease outlived their implants (100% patient survival through 30 years; p = 0.02), whereas the opposite was true in patients with high-grade, localized Stage II disease (64% patient survival at 5 years [95% CI 49% to 76%]; p = 0.001) or widespread Stage III metastatic disease (6.2% patient survival at 5 years [95% CI 0.5% to 24%]; p < 0.001). Primary PFR implant survival at 5, 10, 20, and 30 years was 97% (95% CI 90% to 99%), 81% (95% CI 67% to 90%), 69% (95% CI 46% to 84%), and 51% (95% CI 24% to 73%), respectively. Eight percent (10 of 122) of primary PFRs were revised for any reason. The most common causes of revision were aseptic loosening (3% [four of 122]), infection (3% [three of 122]), breakage of the implant (2% [two of 122]), and tumor progression (1% [one of 122]). Follow-up time was the only factor that was associated with revision of primary PFRs. Neither segment length nor stem length were associated with revision of primary. Six percent (seven of 122) of PFRs were converted to THA at a mean 15 ± 8 years from the index procedure. Survivorship free from conversion to THA (accounting for death as a competing risk) was 94% (95% CI 85% to 99%), 86% (95% CI 68% to 94%). and 77% (95% CI 51% to 91%) at 10, 20, and 30 years, respectively. CONCLUSION Cemented bipolar PFRs for an oncologic indication are a relatively durable reconstruction technique. Given the relative longevity and efficacy of PFRs demonstrated in our study, especially in patients with high-grade or metastatic disease where implant survival until all-cause revision was longer than patient survival, surgeons should continue to seriously consider PFRs in appropriate patients. The relative rarity of these reconstructions limits the number of patients in this study as well as in current research; thus, further multi-institutional collaborations are needed to provide the most accurate prognostic data for our patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Rishi Trikha
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Danielle E. Greig
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas E. Olson
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Joseph K. Kendal
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Erik J. Geiger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren E. Wessel
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey J. Eckardt
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery at the University of California, Los Angeles, Los Angeles, CA, USA
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Housset V, Anract P, Babinet A, Auberger G, Biau D. Proximal femur versus acetabular extra-articular resection of the hip joint for primary malignant bone tumors: a retrospective comparative review of 33 cases. World J Surg Oncol 2022; 20:168. [PMID: 35643461 PMCID: PMC9145149 DOI: 10.1186/s12957-022-02642-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Extra-articular resection (EAR) of the hip joint is prone to significant complications and morbidity. Thus, this study evaluates the cumulative incidences and main reasons of reoperation following EAR of primary malignant bone tumors (PMBT) of the hip to determine whether the outcomes are different between EAR of the pelvis and that of the proximal femur. Patients and methods Thirty-three patients presented with a PMBT of the proximal femur or pelvis were included in this study. Among all PMBTs, 58% originated from the pelvis and 42% were from the proximal femur. Twenty patients had chondrosarcomas (61%), 10 had osteosarcomas (30%), and 3 had sarcomas of another histological subtype (9%). Results The mean follow-up was of 76 months (range: 24–220 months). The cumulative probabilities of revision for any reason were 52% (95% confidence interval [CI] 30–70%) 5 years after surgery. The 5-year cumulative probabilities of revision were 13% (95% CI 4–27%), 24% (95% CI 10–42%), and 34% (95% CI 14–56%) for mechanical, infectious, and tumoral reasons, respectively. The 5-year cumulative probabilities of revision for any reason were 78% (95% CI 37–94%) and 14% (95% CI 2–38%) for the pelvis and proximal femur, respectively (p = 0.004). Posterior column preservation was significantly associated with more mechanical complications even after adjusting for the resection site (p = 0.043). Conclusion Half of patients undergoing EAR of the hip joint for PMBT of the proximal femur or acetabulum will require another operation. EAR of the pelvis is associated with significantly worse outcome than EAR of the proximal femur.
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Wu C, Zeng B, Deng J, Shen D, Wang X, Tan L, Liu X, Qiu G. Custom design and biomechanical clinical trials of 3D-printed polyether ether ketone femoral shaft prosthesis. J Biomed Mater Res B Appl Biomater 2022; 110:2006-2014. [PMID: 35297154 DOI: 10.1002/jbm.b.35055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 02/10/2022] [Accepted: 03/03/2022] [Indexed: 01/18/2023]
Abstract
During the surgical resection and reconstruction of a pathological femoral fracture, the removal of the femoral tumor leaves a large bone defect. Thus, it is necessary to reconstruct the defect and perform internal fixation. Polyether ether ketone (PEEK) has been widely used in spinal fusion and cranioplasty given its excellent biomechanical properties, biocompatibility, and stability. The typical design method of femoral prosthesis is based on the contralateral mirror image model (M-model), and we propose a novel method for designing femoral prosthesis, which is based on the cross section and centerline of the mirrored femur (C-model). In this study, the femoral shaft prostheses based on two models were manufactured using fused deposition modeling technology, and we use mechanical test and finite element analysis (FEA) to reveal the differences in mechanical properties of the two models. The mechanical results showed that the maximum loading force and yield strength were increased by 3% and 6% in the C-model prosthesis compared with the M-model prosthesis, respectively. In FEA, the results indicate that the C-model prosthesis could reduce the stress concentration by 5.4%-10.9% compared to the M-model prosthesis. Finally, the 3D-printed PEEK femoral shaft prosthesis based on C-model was implanted, no early complications occurred. Postoperative radiological examination indicated that the prosthesis and the femoral osteotomy end were closely matched and fixed well.
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Affiliation(s)
- Chao Wu
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China.,Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Baifang Zeng
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China.,Department of Orthopedics, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiayan Deng
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Danwei Shen
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
| | - Xiangyu Wang
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Lun Tan
- Department of Orthopedics, Zigong Fourth People's Hospital, Zigong, China
| | - Xin Liu
- Health Management Center, Zigong Fourth People's Hospital, Zigong, China
| | - Guigang Qiu
- Digital Medical Center, Zigong Fourth People's Hospital, Zigong, China
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Theil C, Schwarze J, Gosheger G, Moellenbeck B, Schneider KN, Deventer N, Klingebiel S, Grammatopoulos G, Boettner F, Schmidt-Braekling T. Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection. Cancers (Basel) 2022; 14:cancers14020351. [PMID: 35053514 PMCID: PMC8773828 DOI: 10.3390/cancers14020351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection. Abstract Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.
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Affiliation(s)
- Christoph Theil
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Jan Schwarze
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Georg Gosheger
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Burkhard Moellenbeck
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Kristian Nikolaus Schneider
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Niklas Deventer
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Sebastian Klingebiel
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA;
| | - Tom Schmidt-Braekling
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
- Correspondence:
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8
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Lex JR, Evans S, Parry MC, Jeys L, Stevenson JD. Acetabular complications are the most common cause for revision surgery following proximal femoral endoprosthetic replacement : what is the best bearing option in the primary and revision setting? Bone Joint J 2021; 103-B:1633-1640. [PMID: 34587800 DOI: 10.1302/0301-620x.103b10.bjj-2020-2480.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs. METHODS This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%). RESULTS At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%). CONCLUSION Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633-1640.
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Affiliation(s)
- Johnathan Robert Lex
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK.,Division of Orthopaedic Surgery, University of Toronto Temerty Faculty of Medicine, Toronto, Canada
| | - Scott Evans
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK
| | - Michael C Parry
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK.,Aston University Medical School, Aston University, Birmingham, UK
| | - Lee Jeys
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK.,Faculty of Health Sciences, Aston University, Birmingham, UK
| | - Jonathan D Stevenson
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK.,Aston University Medical School, Aston University, Birmingham, UK
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9
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Chen KL, Chen CM, Chen CF, Cheng YC, Lin YK, Tsai SW, Chen TH, Wu PK, Chen WM. Comparable outcomes of recycled autografts and allografts for reconstructions in patients with high-grade osteosarcoma. INTERNATIONAL ORTHOPAEDICS 2021; 45:2973-2981. [PMID: 34414485 DOI: 10.1007/s00264-021-05161-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This retrospective, single-centre study compares the clinical and radiographic outcomes of limb reconstruction using recycled autografts to that using allografts. METHODS Patients with histopathologically verified high-grade osteosarcoma treated with wide bone resection and limb reconstruction using allografts or recycled autografts from January 1998 through December 2012 were retrospectively screened for enrolment eligibility. The final study cohort included 255 patients (allograft, 91; recycled autograft, 164). Data regarding post-operative complications, salvage treatment, and graft survival were collected. A modified International Society of Limb Salvage classification system was used to evaluate the radiographic findings. RESULTS The time to graft-host union did not differ significantly between the two graft types. Patients receiving recycled autografts had fewer complications compared than did those receiving allografts (recycled autografts vs. allograft: structural failure, 4.3 vs. 13.2%; late infection, 2.4 vs. 7.7%; all p < 0.05). Complications occurred most frequently during the first three years after surgery, and the majority were manageable. The five year limb survival rate did not differ significantly between the two graft types (91.3 vs. 94.0%; p = 0.752). No local oncological recurrence was observed within the recycled autografts. CONCLUSION Recycled autografts and allografts are feasible options for biological limb reconstructions in terms of complications and graft survival after wide resection of osteosarcoma.
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Affiliation(s)
- Kuan-Lin Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC
| | - Chao-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC
| | - Yu-Chi Cheng
- Department of Radiology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC
| | - Yu-Kuan Lin
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC.,Institute of Biomedical Engineering, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan (ROC)
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC.,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC
| | - Tain-Hsiung Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC. .,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC. .,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC. .,Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC.
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Department of Orthopaedics, Therapeutical and Research Center of Musculoskeletal Tumor, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 112, Taiwan ROC.,Orthopaedic Department School of Medicine, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei City, 112, Taiwan ROC
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10
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Christ AB, Fujiwara T, Fabbri N, Healey JH. Compliant Compression Reconstruction of the Proximal Femur Is Durable Despite Minimal Bone Formation in the Compression Segment. Clin Orthop Relat Res 2021; 479:1577-1585. [PMID: 33595932 PMCID: PMC8208447 DOI: 10.1097/corr.0000000000001663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Compliant compression fixation was developed to promote permanent bone-prosthesis osteointegration while preserving bone stock in patients needing endoprosthetic reconstructions. This has demonstrated durability in the distal femur, with reliable cortical hypertrophy adjacent to the implant. However, the extent of bone formation and prosthetic survivorship of proximal femoral replacements with compliant compression fixation has not been established. QUESTIONS/PURPOSES (1) How much bone formation occurs across the compression segment in patients treated with a proximal femoral replacement implant using compliant compression fixation? (2) What were the Musculoskeletal Tumor Society (MSTS) scores at minimum 24-month follow-up of patients who received this reconstruction? (3) What is the implant survivorship free from implant removal or revision for any reason at final follow-up? METHODS From 2006 to 2018, we performed 213 proximal femoral replacements in patients with oncologic conditions of the proximal femur where the trochanters could not be preserved. Of these, 6% (12 of 213) were performed with an implant that used compliant compression fixation. We used this device in primary oncologic reconstructions in patients younger than 65 years of age without metastases who had nonirradiated bone with the requisite ≥ 2.5 mm of cortical thickness in the hope that it would provide more durable fixation and bone stock preservation than conventional reconstructions. All patients were followed for longer than 2 years except one who died in that interval. Median (range) follow-up was 6 years (2 to 10 years). Seven patients received diagnosis-specific chemotherapy in a consistent manner based on Children's Oncology Group chemotherapy protocols. Using the NIH-developed ImageJ open-access software, we measured the area of bone under compression on 3-, 6-, 9-, 12-, 18-, and 24-month radiographs and the length of the traction bar potential-compression distance, reconciling independent measures from two investigators using the identical method as published for the distal femur with compression fixation. The duration of prosthesis retention was evaluated using a competing risk analysis for the 11 surviving patients. RESULTS Bone hypertrophy in the compression segment was scant. At the final analysis, cortical bone formation was a median (range) of 4 (-7 to 14) above baseline. The median (range) MSTS score was 27 (19 to 30). One implant failed after trauma, and the patient underwent revision of the implant. CONCLUSION Despite scant bone formation across the compression segment and drastically less formation than reported for distal femoral replacements, compliant compression fixation of the proximal femur demonstrated good survivorship in patients 65 years or younger with localized sarcoma and nonirradiated, adequate bone stock in this small, retrospective series. Patients achieved good functional outcomes at final follow-up. The potential benefit of this reconstruction method should be weighed against the initial period of limited weightbearing and the life expectancy of the patient. LEVEL OF EVIDENCE Level IV, cohort study.
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Affiliation(s)
- Alexander B. Christ
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, affiliated with Weill Medical College of Cornell University, New York, NY, USA
| | - Tomohiro Fujiwara
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, affiliated with Weill Medical College of Cornell University, New York, NY, USA
| | - Nicola Fabbri
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, affiliated with Weill Medical College of Cornell University, New York, NY, USA
| | - John H. Healey
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, affiliated with Weill Medical College of Cornell University, New York, NY, USA
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11
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Gautam D, Arora N, Gupta S, George J, Malhotra R. Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies. Curr Rev Musculoskelet Med 2021; 14:255-270. [PMID: 33864628 PMCID: PMC8137768 DOI: 10.1007/s12178-021-09707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality. RECENT FINDINGS The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence. LEVEL OF EVIDENCE (CEBM) 2a.
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Affiliation(s)
- Deepak Gautam
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Nitish Arora
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Saurabh Gupta
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Jaiben George
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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12
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Mei J, Pang L, Jiang Z. Strategies for managing the destruction of calcar femorale. BMC Musculoskelet Disord 2021; 22:460. [PMID: 34011332 PMCID: PMC8136139 DOI: 10.1186/s12891-021-04324-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 05/05/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The calcar femorale was identified long ago. However, our current understanding of the calcar is insufficient, and its related concepts are sometimes confused. The calcar femoral is an important anatomical structure of the proximal femur, and its function can be overlooked. In trauma, tumors, or other diseases, the calcar femorale can be destroyed or changed pathologically. As a result, the mechanical structure of the proximal femur becomes destroyed, causing pathological fractures. How to address the destruction of the calcar femorale or the damage to the calcar femorale is discussed in this article. MAIN TEXT Destruction of the calcar femorale is accompanied by many conditions, including trauma, tumors, and other diseases. The types of hip fractures caused by trauma include femoral neck fractures and intertrochanteric fractures. Dynamic hip screws, proximal femoral nail anti-rotation, and multiple parallel cannulate pins can be used in different conditions. When metastatic and primary bone tumors involve the calcar femorale, endoprostheses are widely used. Other diseases, such as fibrous dysplasia and aneurysmal bone cyst are treated differently. CONCLUSIONS The calcar femorale can redistribute stresses and the destruction of the calcar femorale can lead to an increase in posterior medial stress. Many factors need to be considered when deciding whether to reconstruct the calcar femorale. Effective treatment strategies for managing the destruction of calcar femorale will need first establishing the precise mechanism of the destruction of the calcar and then designing therapies towards these mechanisms. Further investigation to the calcar needs to be carried out.
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Affiliation(s)
- Jin Mei
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072 Sichuan Province China
| | - Lili Pang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072 Sichuan Province China
| | - Zhongchao Jiang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072 Sichuan Province China
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13
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Gusho CA, Clayton B, Mehta N, Colman MW, Gitelis S, Blank AT. Survival and outcomes of modular endoprosthetic reconstruction of the proximal femur for primary and non-primary bone tumors: Single institutional results. J Orthop 2021; 25:145-150. [PMID: 34025058 DOI: 10.1016/j.jor.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/02/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose This study assessed implant survival and dislocation following proximal femur tumor endoprosthetic replacement. Methods Thirty-eight procedures were performed between 2005 and 2019. The cumulative incidence of implant revision was calculated with death as a competing risk. Results The majority of endoprostheses were bipolar hemiarthroplasty (n = 33, 86.8%). The cumulative incidence of revision was 14.6% (95% CI, 3.2%-34.1%) at five years. Dislocation occurred in 7.9% (n = 3) of hips at a mean (SD) 44 ± 35.2 days. Conclusions Proximal femur tumor endoprosthetic replacement is a durable option that tends to outlive patients. Strict postoperative bracing may lower dislocation rates. Level of evidence III. Retrospective Study.
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Affiliation(s)
- Charles A Gusho
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Bishir Clayton
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nabil Mehta
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew W Colman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Steven Gitelis
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alan T Blank
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
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14
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Groundland J, Brown J, Jones K, Randall RL. Is osseous reattachment of the greater trochanter necessary compared to soft-tissue-only abductor repair in proximal femoral megaprosthesis reconstruction? J Surg Oncol 2021; 124:115-123. [PMID: 33765357 DOI: 10.1002/jso.26477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND One of the challenges to surgical reconstruction following oncologic proximal femur resection is reliable re-establishment of the abductor mechanism. Surgical and functional outcomes following re-approximation of the abductor mechanism to a metallic endoprosthetic after tumor resection of the proximal femur have not been well established in the literature. METHODS A retrospective review was performed, inclusive of patients who received a proximal femur replacement with a metallic endoprosthesis following tumor resection. Patients were divided into two groups: (1) those that received an abductor repair involving a trochanteric osteotomy and osseous fixation of the greater trochanter/abductor mechanism to the endoprosthesis, and (2) those that did not have a trochanteric osteotomy and therefore had an abductor repair consisting of only soft tissue reattachment to the endoprosthesis. The two groups were assessed for demographic characteristics, diagnosis, surgical outcomes including rates of complication and failure, radiographic evidence of trochanteric failure, and functional outcomes. Descriptive statistics, comparative statistics, and logistic regression analyses were performed to discern differences between the two study groups. RESULTS Fifty-three patients were included in the analysis, 29 had abductor reconstructions involving reattachment of the greater trochanter to the metallic endoprosthesis and 24 had soft tissue reconstruction of the abductor mechanism without bony fixation. There were no differences between the two groups for demographic data, cancer diagnosis, follow up, or survivorship. Radiographic evidence of trochanteric dissociation from the endoprosthesis was observed in 45% of osteotomy cases. Only 10% of patients in the trochanter osteotomy group and 38% of the soft tissue only group were able to resume a normal, non-Trendelenburg gait at final postoperative visit (p = .024). Need for an assistive ambulatory device was seen in 83% and 67% of the osteotomy and soft-tissue-only patients, respectively (p = .21). CONCLUSION Re-establishing the abductor mechanism following proximal femur oncologic resection remains a challenge to orthopedic oncologists. Even when possible, salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function in this series, when compared to a similar cohort that received a soft-tissue-only abductor repair. Abductor mechanism reconstruction with a greater trochanteric osteotomy and subsequent fixation to the proximal femur endoprosthesis had a high rate of radiographic failure. Additionally, reattachment of the greater trochanter to the proximal femur endoprosthesis demonstrated no improvement in Trendelenburg gait or reliance on an assistive ambulatory device when compared to a soft-tissue-only abductor repair.
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Affiliation(s)
- John Groundland
- Sarcoma Service, Department of Orthopedics, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey Brown
- Department of Orthopedics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kevin Jones
- Sarcoma Service, Department of Orthopedics, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - R Lor Randall
- Department of Orthopedic Surgery, UC Davis Medical Center, University of California, Sacramento, California, USA
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15
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Techniques and outcomes of hip abductor reconstruction following tumor resection in adults. Orthop Traumatol Surg Res 2021; 107:102765. [PMID: 33321236 DOI: 10.1016/j.otsr.2020.102765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 05/25/2020] [Indexed: 02/03/2023]
Abstract
The function of the abductor mechanism (AM) of the hip can be disturbed, or even compromised, following tumor resection in the hip area. The consequences are instability (limping, dislocation), pain and altered walking ability. Several reconstruction techniques can be used for the same AM sacrifice. After defining the AM, this lecture will discuss the best technique for a given type of bone and muscle resection. These reconstruction techniques depend on exactly where the AM was sacrificed. For zone 1 resections of the ilium and/or iliac gluteal insertions, reconstruction is often optional. When muscle from the AM is resected, especially when the gluteal tendon is detached from its trochanteric insertion, isolated reconstruction can be done or reconstruction in combination with a tendon allograft or an allograft and/or tendon transfer from the surrounding area. This sacrifice, whether followed by reconstruction or not, in most cases leads to a good functional outcome, except when a complete musculotendinous unit or the superior gluteal nerve is sacrificed. Isolated resection of the greater trochanter is rare; however, this completely disrupts the continuity of the AM and justifies reconstruction, often using a bone-tendon allograft. Proximal femur resection is the most common scenario. The extent of the trochanteric resection and the gluteal tendon attachments drives the type of prosthesis used. The two most used techniques consist in an allograft sleeve over a long cemented femoral stem (allograft prosthesis composite - APC) or a modular proximal femoral endoprosthesis (megaprosthesis) with a specific AM fixation system (small plate or wire cerclage, resorbable or metal wire, synthetic reattachment tube). These two techniques yield nearly identical long-term functional outcomes with complications specific to each: osteolysis and fracture for APC, failure of tendon reattachment for megaprosthesis. Beyond these technical considerations, one must consider the poor availability of massive bone allografts. This is a highly relevant issue in France, and partially explains the shift to reconstruction with a megaprosthesis. Lastly, we will look at the different clinical and diagnostic tests used to evaluate the function of the AM in an oncology context and the outcomes of the various types of reconstruction.
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16
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Liu C, Min L, Zhou Y, Luo Y, Tang F, Lu M, Duan H, Zhang W, Yu X, Tu C. Long-term results of uncemented allograft prosthesis composite reconstruction for the tumor in proximal femur: a minimum follow-up of sixty-five months. BMC Musculoskelet Disord 2021; 22:128. [PMID: 33522918 PMCID: PMC7849157 DOI: 10.1186/s12891-021-03991-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 01/19/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Uncemented allograft prosthesis composite (APC) has been applied for tumorous bone defect reconstruction in the proximal femur. However, the long-term results are rarely reported. This study aimed to evaluate long-term outcomes of uncemented APC. METHODS Eighteen patients who received uncemented APC reconstruction in the proximal femur after tumor resections were retrospectively reviewed. RESULTS The average resection length was 110 mm (80-154) and the average follow-up was 106.7 months (65-141). Bone union achieved in all patients with an average duration of 7.6 months (5-10). The average HHS, MSTS score and gluteus medius strength at one-year follow-up were 88.0 (80-94), 25.2 (22-28) and 4 (3-5), respectively. While at the last follow-up, the HHS, MSTS score and gluteus medius strength were 83.0 (48-100), 24.0 (10-30) and 4 (2-5), respectively. Five intraoperative fractures were fixed with cerclage wires. Two postoperative periprosthetic and prosthetic fractures received a revision. Three local recurrent patients received a secondary surgery. One of these three lung metastatic patients underwent lung metastatic tumor resection. Another two patients were diagnosed with both bone and lung metastases, only one of them underwent amputation. Two greater trochanteric fractures received no treatment. There were10 severe, 3 moderate and 5 mild allograft resorptions without treatment. CONCLUSION Uncemented APC is a reliable reconstruction for neoplastic bone defect of the proximal femur, especially for the young patient who expected long-life expectancy and good function. Though allograft resorption and trochanteric fracture are the common complications, they seem no effect on the function.
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Affiliation(s)
- Cai Liu
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Li Min
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Yong Zhou
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Yi Luo
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Fan Tang
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Minxun Lu
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Hong Duan
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Wenli Zhang
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Xinzhu Yu
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China
| | - Chongqi Tu
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Guoxue Road 37#, Chengdu, 610041, China.
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"Purse-String" Capsular Closure for Decreasing Dislocation Rates in Proximal Femur Replacements. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00086. [PMID: 33986206 PMCID: PMC7665252 DOI: 10.5435/jaaosglobal-d-20-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
Hip joint dislocation is the most common complication after a proximal femur replacement. As the utilization of proximal femur replacements continues to increase, it becomes imperative for surgeons to find the optimal method to decrease postoperative dislocation and its sequelae. These cases often involve extensive soft-tissue deficits that require reconstruction to provide postoperative strength and stability. Patients report good functional outcomes; however, dislocation remains a concern. Although “described” previously in the literature, the authors illustrate the “purse-string” hip joint capsular closure technique to help other surgeons understand it and apply to their practice as deemed necessary. We also present the senior author's results with using a modified version of the “purse-string” hip joint capsular closure technique.
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18
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Hakozaki M, Kawakami R, Sasaki N, Toshiki N, Kaneuchi Y, Yamada H, Konno S. Salvage Reconstruction With the Masquelet Technique Following Wide Resection for Chondrosarcoma of the Proximal Femoral Metaphysis: A Case Report. In Vivo 2020; 34:3495-3501. [PMID: 33144459 DOI: 10.21873/invivo.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bone reconstruction following a wide resection for a malignant musculoskeletal tumor remains challenging, especially for an intercalary defect following the resection of a metaphyseal lesion. CASE REPORT Here, we describe a surgical procedure using the Masquelet technique for the biological reconstruction of a huge subtrochanteric bone defect following failed pasteurized autologous bone grafting for a conventional chondrosarcoma of the proximal femoral metaphysis with a subtrochanteric pathological fracture. The patient, a 43-year-old Japanese male, was able to walk without a cane or a brace at 15 months after the final operation (International Society of Limb Salvage score, 86.7%). CONCLUSION This procedure should be considered as one of the reconstruction options following the wide resection of malignant bone tumors located in the metaphysis.
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Affiliation(s)
- Michiyuki Hakozaki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan .,Higashi-Shirakawa Orthopaedic Academy, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Ryoichi Kawakami
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Traumatology and Reconstructive Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Kawakami Orthopaedic Clinic, Fukushima, Japan
| | - Nobuyuki Sasaki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Narihiro Toshiki
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoichi Kaneuchi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Yamada
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Musculoskeletal and Bone Metabolism, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shinichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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19
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Nooh A, Alaseem A, Epure LM, Ricard MA, Goulding K, Turcotte RE. Radiographic, Functional, and Oncologic Outcomes of Cemented Modular Proximal Femur Replacement Using the "French Paradox" Technique. J Arthroplasty 2020; 35:2567-2572. [PMID: 32418744 DOI: 10.1016/j.arth.2020.04.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Endoprostheses are frequently used in the management of tumors involving the proximal femur. Aseptic loosening is a common complication that has been linked to the cementing technique. The "French paradox" is well-known cementing technique in the arthroplasty literature. No previous reports have assessed loosening in proximal femur replacements using this technique. We examined rates of femoral stem aseptic loosening in proximal femur replacements, functional outcomes, complications, and oncologic outcomes. METHODS We conducted a retrospective review of 47 patients who underwent proximal femur replacement between 2000 and 2019. Two reviewers evaluated preoperative and postoperative radiographs using the International Society of Limb Salvage scoring system and Barrack criteria for stem loosening. The acetabulum was evaluated according to the criteria of Baker et al. Functional outcomes were assessed using Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score. The mean follow-up was 44 months. RESULTS The mean International Society of Limb Salvage scores for the 2 reviewers were 86% ± 6% and 84% ± 6%. The first reviewer graded femoral stem loosening as "possibly loose" in 2 patients, one of whom was graded as possibly loose by the second reviewer. The 2 reviewers found no acetabular erosion in 16 (70%) and 15 (65.4%) patients, respectively. The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score at last follow-up were 61% and 72%, respectively. Twenty complications occurred in 13 patients, and 5 patients experienced local recurrence. CONCLUSION Despite complications, we showed favorable femoral component survival rates. Cementing the proximal femur prosthesis with tight canal fit and thin cement mantle is a viable option for the short and medium term. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anas Nooh
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Abdulrahman Alaseem
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Laura M Epure
- Department of Orthopaedic Surgery, SMBD-Jewish General Hospital, McGill University, Montreal, Canada
| | - Marc-Antoine Ricard
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Krista Goulding
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert E Turcotte
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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20
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Atalay İB, Yapar A, Ulucakoy C, Duman EM, Toğral G, Ozturk R, Güngör BŞ. The Effectiveness of Tranexamic Acid in Patients With Proximal Femoral Tumor Resection Prosthesis. Cureus 2020; 12:e10105. [PMID: 33014639 PMCID: PMC7526757 DOI: 10.7759/cureus.10105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim: The aim of this study is to evaluate the risk of thromboembolic events and amount of postoperative blood loss and transfusion in patients who received preoperative tranexamic acid (TXA) administration in proximal femoral resection and endoprosthesis of proximal femur malignant lesion. Methods: In this study, the data of 46 patients who underwent extensive resection and proximal femoral tumor prosthesis for proximal femoral bone malignancies were retrospectively reviewed. Patients were divided into two groups according to preoperative 15 mg/kg bolus intravenous administration of TXA. These patients were compared in terms of postoperative blood loss, postoperative bleeding, and transfusion requirements. Results: There were 46 patients (18 female, 28 male) with a mean age of 60.7±14.7 (19-89) years. Fifteen patients (32.6%) were treated with iv TXA. In the TXA group (46.7%), there was a statistically significant decrease in the need for transfusion compared to the patient group (93.5%) without TXA (p=0.001). Postoperative 24th hour, 48th hour,and total drainage blood loss values were found to be significantly lower in the TXA group (p=0.047, p=0.015, and p=0.019, respectively). There was no thromboembolic event observed. Conclusion: Because of proximal femoral malignancy, extensive tumor resection and preoperative bolus 15 mg/kg TXA administration in proximal femoral prosthesis surgery significantly decreased the amount of postoperative bleeding and transfusion requirement without increasing the risk of thromboembolic event. Level of Evidence: Level III - retrospective comparative study.
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Affiliation(s)
- İsmail Burak Atalay
- Orthopedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Aliekber Yapar
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Coskun Ulucakoy
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Emek Mert Duman
- Orthopedics and Traumatology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Güray Toğral
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Recep Ozturk
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
| | - Bedii Şafak Güngör
- Orthopedics, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, TUR
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21
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Jamshidi K, Mirkazemi M, Gharedaghi M, Izanloo A, Mohammadpour M, Pisoudeh K, Bagherifard A, Mirzaei A. Bipolar hemiarthroplasty versus total hip arthroplasty in allograft-prosthesis composite reconstruction of the proximal femur following primary bone tumour resection. Bone Joint J 2020; 102-B:524-529. [PMID: 32228068 DOI: 10.1302/0301-620x.102b4.bjj-2019-0925.r2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods. METHODS In a retrospective study, 57 patients who underwent APC reconstruction of proximal femur following the primary tumour resection, either using BHA (29) or THA (28), were included. Functional outcome was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and Harris Hip Score (HHS). Postoperative complications of the two techniques were also compared. RESULTS The mean follow-up of the patients was 8.3 years (standard deviation (SD) 5.5) in the BHA and 6.9 years (SD 4.7) in the THA group. The mean HHS was 65 (SD 16.6) in the BHA group and 88 (SD 11.9) in the THA group (p = 0.036). The mean MSTS score of the patients was 73.3% (SD 16.1%) in the BHA and 86.7% (SD 12.2%) in the THA group (p = 0.041). Limping was recorded in 19 patients (65.5%) of the BHA group and five patients (17.8%) of the THA group (p < 0.001). Dislocation occurred in three patients (10.3%) of the BHA group and two patients (7.1%) of the THA group. CONCLUSION While the dislocation rate was not higher in THA than with BHA, the functional outcome was significantly superior. Based on our results, we recommend THA in APC reconstruction of the proximal femur. Cite this article: Bone Joint J 2020;102-B(4):524-529.
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Affiliation(s)
- Khodamorad Jamshidi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Mirkazemi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Gharedaghi
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azra Izanloo
- Razavi Cancer Research Center, Razavi Hospital, Imam Reza International University, Mashhad, Iran
| | - Mehdi Mohammadpour
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Karim Pisoudeh
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Bagherifard
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Mirzaei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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22
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Limb Salvage and Reconstruction Options in Osteosarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1257:13-29. [PMID: 32483727 DOI: 10.1007/978-3-030-43032-0_2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in chemotherapy, sophisticated imaging, and surgical techniques over the last few decades have allowed limb-salvage surgery (LSS) to become the preferred surgical treatment for bone sarcomas of the extremities. The goal of LLS is to maximize limb functionality to allow for the maintenance of quality of life without compromising overall survival and tumor local recurrence rates. Today, limb-salvage procedures are performed on 80-95% of patients with extremity osteosarcoma, and the 5-year survival rate in extremity osteosarcoma patients is now 60-75%.This chapter will focus on LSS for extremity osteosarcoma. Common types of surgical reconstruction techniques including endoprostheses, intercalary or osteoarticular allografts, vascularized fibular autografts, and allograft prosthetic composites (APC), and their complications such as infection, local recurrence, graft fracture, implant failure, and nonunion will be discussed in detail. Anatomic locations of lesions discussed include the proximal femur, distal femur, proximal tibia, distal tibia, proximal humerus, distal humerus, and forearm bones.
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23
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CORR Insights®: Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review. Clin Orthop Relat Res 2019; 477:903-904. [PMID: 30844828 PMCID: PMC6437366 DOI: 10.1097/corr.0000000000000685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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