Total hip replacement for proximal femoral tumours: our midterm results

Dual Mobility for Oncological Hip Reconstruction: Significantly Reduced Dislocation Rates at 5 years

BACKGROUND

Although dual mobility total hip arthroplasty has become increasingly common in recent years, limited remains known on dual mobility in surgical oncology. This university-based investigation compared dislocation and revision rates of DMs, conventional total hip arthroplasty (THA), and hemiarthroplasties (HAs) for oncological hip reconstruction.

METHODS

An institutional tumor registry was used to identify 221 patients undergoing 45 DMs, 67 conventional THAs, and 109 HAs, performed for 17 primary hip tumors and 204 hip metastases between 2010 and 2020. The median age at surgery was 65 years, and 52% were female. The mean follow-up was 2.5 years. Kaplan-Meier survivorship curves and log-rank tests were done to compare dislocation and revision rates among all 221 patients, after a one-to-one propensity match, based on age, sex, tumor type (metastasis, primary tumor), and tumor localization (femur, acetabulum).

RESULTS

The 5-year survivorship free of dislocation was 98% in DMs, 66% in conventional THAs ( P = 0.03; all P values compared with DMs), and 97% among HAs ( P = 0.48). The 5-year survivorship free of revision was 69% in DMs, 62% in conventional THAs ( P = 0.68), and 92% in HAs ( P = 0.06). After propensity matching, the 5-year survivorship free of dislocation was 42% in 45 conventional THAs ( P = 0.027; compared with all 45 DMs) and 89% in 16 matched HAs ( P = 0.19; compared with 16 DMs with femoral involvement only). The 5-year survivorship free of revision was 40% in matched conventional THAs ( P = 0.91) and 100% in matched HAs ( P = 0.19).

CONCLUSIONS

DMs showed markedly lower rates of dislocation than conventional THAs, with overall revision rates remaining comparable among different designs. DMs should be considered the option of choice for oncological hip reconstruction if compared with conventional THAs. HAs are a feasible alternative when encountering femoral disease involvement only.

LEVEL OF EVIDENCE

III.

Dislocation rate after hip arthroplasty due to metastatic bone disease: a retrospective cohort study evaluating the postoperative dislocation risk across different articulating solutions

BACKGROUND AND PURPOSE

Joint stability after hip replacement (HR) in patients with metastatic bone disease (MBD) is of special importance. Dislocation is the second leading cause of implant revision in HR, while survival after MBD surgery is poor with an expected 1-year survival of around 40%. As few studies have investigated the dislocation risk across different articulation solutions in MBD, we conducted a retrospective study on primary HR for patients with MBD treated in our department.

PATIENTS AND METHODS

The primary outcome is the 1-year cumulative incidence of dislocation. We included patients with MBD who received HR at our department in 2003-2019. We excluded patients with partial pelvic reconstruction, total femoral replacement, and revision surgery. We assessed the incidence of dislocation with competing risk analysis with death and implant removal as competing risks.

RESULTS

We included 471 patients. Median follow-up was 6.5 months. The patients received 248 regular total hip arthroplasties (THAs), 117 hemiarthroplasties, 70 constrained liners, and 36 dual mobility liners. Major bone resection (MBR), defined as resection below the lesser trochanter, was performed in 63%. The overall 1-year cumulative incidence of dislocation was 6.2% (95% CI 4.0-8.3). Dislocation stratified by articulating surface was 6.9% (CI 3.7-10) for regular THA, 6.8% (CI 2.3-11) for hemiarthroplasty, 2.9% (CI 0.0-6.8) for constrained liner, and 5.6% (CI 0.0-13) for dual mobility liners. There was no significant difference between patients with and without MBR (p = 0.5).

CONCLUSION

The 1-year cumulative incidence of dislocation is 6.2% in patients with MBD. Further studies are needed to determine any real benefits of specific articulations on the risk of postoperative dislocation in patients with MBD.

Bipolar hemiarthroplasty versus total hip arthroplasty in allograft-prosthesis composite reconstruction of the proximal femur following primary bone tumour resection

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.

Dual mobility acetabular cups for total hip arthroplasty: advantages and drawbacks

INTRODUCTION

The dual mobility cup (DMC) concept was proposed by Professor Gilles Bousquet in 1974. Its' aims were to prevent postoperative dislocation, restore the physiological range of motion of the hip, and reduce the stresses at the interface. Since it was created, this design has been modified multiple times to reduce the complication rate, improve implant survival, and expand the indications.

AREAS COVERED

The objective of this review is to discuss the advantages and disadvantages of this implant based on its 40-year history and also to propose a range of indications based on published results. This will provide surgeons with a complete overview of DMC.

EXPERT COMMENTARY

Published studies on DMC confirm the low dislocation rate. Improvements made to DMC overtime have greatly reduced the complications related to wear, such as aseptic loosening and intraprosthetic dislocation (IPD). According to the literature, the indications have expanded and are no longer limited to revision surgery only. Long-term studies are needed before we can draw formal conclusions and consolidate these promising results.

Lower limb reconstruction in tumor patients using modular silver-coated megaprostheses with regard to perimegaprosthetic joint infection: a case series, including 100 patients and review of the literature

PURPOSE AND OBJECTIVE

Bone resection regarding adequate surgical margins is the treatment of choice for malignant bone tumors. In the case of metastasis-related complications, so-called skeletal-related events, it is highly important to achieve pain relief and a stable joint situation to re-mobilize the patients immediately following surgery. To bridge the often large osseous defect zones after tumor resection, both cemented and uncemented modular endoprosthetic systems are widely used. Patients undergoing tumor-related endoprosthetic orthopedic surgery are facing high risk for developing a periprosthetic joint infection (PJI). The immunocompromised condition due to anti-neoplastic treatment and long operation time with large exposure of tissue contributes to a high risk of infection.

METHODS

The authors present a case series of 100 patients (31% primary bone tumor and 69% metastasis-related surgery) undergoing tumor-related lower limb salvage surgery with special regard to periprosthetic joint infection and the management of this "difficult to treat" situation. Furthermore, a review of the current literature regarding infection following bone tumor resection and endoprosthetic reconstruction is performed and discussed.

RESULTS

The median follow-up was 24 months (range 12-108 months). Ten patients (10%) suffered from a periprosthetic joint infection. We recorded six acute infections (type I) <4 weeks after surgery, one infection >4 weeks after surgery (type II), and three late infections (type III). According to the definition of Laffer et al., three of our patients (30%) are probably free of infection, one patient died of PJI-associated sepsis, and five patients were free of infection, but without restoration of the affected joint.

CONCLUSION

In conclusion, our own results show that perimegaprosthetic joint infection among silver-coated implants, in patients undergoing tumor-related surgery of the lower limb, is lower compared to non-silver-coated implants. Due to heterogeneity of patients and potential treatment options, the treatment regime should be tailored for the patients' individual situation.

The evolution of outcomes and indications for the dual-mobility cup: a systematic review

PURPOSE

Instability following total hip arthroplasty remains a common and disabling complication. The dual mobility cup (DMC) allows a reduction in the dislocation rate. An increasing number of studies have been undertaken to better understand DMC long term outcomes and complications. The goal of this systematic review was to clarify its different uses and outcomes according to the indications.

METHODS

A comprehensive literature review was performed using the keywords 'dual mobility' and 'tripolar cup' with no limit regarding the year of publication. One hundred seventy six publications were identified.

RESULTS

Current literature shows that "contemporary" dual mobility cup are a significant indication to manage instability following primary and revision hip arthroplasty. Survivorship at midterm is comparable to other articulations for primary THA, but is more difficult to evaluate in revision. Intra-prosthetic dislocation, wear, and loosening are now uncommon with new generations of DMC.

CONCLUSIONS

Compared to previous generations of DMC, the current "contemporary" DMC presents a significant improvement. Current literature reveals a tendency to increase the indications but further studies with long term follow up remain important to consolidate these findings.

Outcome after fixation of metastatic proximal femoral fractures: A systematic review of 40 studies

Endoprosthetic reconstruction, intramedullary nailing, and open reduction internal fixation (ORIF) are the most commonly practiced surgical strategies for treatment of metastatic proximal femoral fractures. This review describes functional outcome, local, and systemic complications. All three surgical strategies result in reasonable function on average; however, wide ranges indicate that both poor and good functional levels are obtained. We found that the overall reoperation rate was comparable for endoprosthesis and intramedullary nailing, but was higher for ORIF. J. Surg. Oncol. 2016;114:507-519. © 2016 Wiley Periodicals, Inc.

Implant longevity, complications and functional outcome following proximal femoral arthroplasty for musculoskeletal tumors: a systematic review

A systematic review of the literature was undertaken to evaluate the outcomes and complications following proximal femoral arthroplasty for primary or metastatic tumors affecting the proximal femur. Six hundred sixty-eight patients were available for review. The length of resection ranged from 92 to 212 mm. Limb salvage rate reached over 90%. At 5 years the implant survival rate was 84% and at 10 years, it was 70%. The overall revision rate was 11.1%. Prevalence of venous thrombo-embolic (VTE) events was 8.5%, dislocation rate was 5.8%, infection was 5.2%, local tumor reoccurrence was 4.7%, perioperative mortality was 1.5%, and periprosthetic fracture was 0.6%. Where it was provided the Musculoskeletal Tumour Score was 70.8%. The implants tend to outlive patients with metastatic disease and high-grade localized disease, providing them with a relatively pain-free limb with good mobility and quality of life.

A long femoral stem is not always required in hip arthroplasty for patients with proximal femur metastases

BACKGROUND

During hip arthroplasties for treating proximal femur metastases, a long femoral stem frequently is used, presumably protecting the entire femur against progression of the existing lesions or development of new lesions. However, it is unclear whether a long stem is really required.

QUESTIONS/PURPOSES

We therefore determined in patients with proximal femur metastases (1) the reoperation rate related to different stem lengths after hip arthroplasty, (2) the risk of tumor progression in the same femur (the progression of preexisting lesions and the development of new distal femur lesions), and (3) complications.

METHODS

We retrospectively reviewed 203 patients (206 femurs) with proximal femur metastases treated with hip arthroplasty. These femurs were divided into three groups based on femoral stem length: short stem (SS), 12 to 14 cm; medium stem (MS), 20 to 24 cm; and long stem (LS), 25 to 35 cm. We reviewed reoperations, disease progression in the same femur, and complications. Minimum followup was 2 days (median, 487 days; range, 2-4853 days), with most patients followed to their death.

RESULTS

Only three femurs were revised owing to tumor progression, with no difference among the SS, MS, and LS groups. Two SS prostheses were revised for nononcologic reasons. Tumor progression in the same femur was uncommon during the patient's survival, with 11 femurs showing progression of the proximal lesion and five femurs showing new distal lesions. The complication rate was higher in the LS group (28%) than the combined rate in the MS and SS groups (16%), especially acute cardiopulmonary complications (18% versus 7.5%).

CONCLUSIONS

Reoperation after hip arthroplasty for proximal femur metastases is uncommon and not correlated with femoral stem length. Considering the high complication rate associated with a LS hip prosthesis, we do not believe its routine use is justified.

Pathological fracture of the proximal femur in osteosarcoma: need for early radical surgery?

Seventeen patients underwent treatment for a pathological fracture of the proximal femur due to osteosarcoma. Their age range was from 9 to 84 (mean age 42) with nine patients under the age of 40 and eight above the age of 40. Twelve patients had a fracture at diagnosis and five developed a fracture after the diagnosis. Seven patients had metastatic disease at diagnosis. Five patients were referred after internal fixation of the fracture prior to diagnosis. Chemotherapy was used when appropriate and eight patients then underwent limb salvage surgery, six had an amputation, and three had palliative treatment. The estimated five-year survival was 14%. These results are significantly worse than expected, and it proved impossible to identify any group who fared well. The high incidence of metastases both at diagnosis and subsequently suggests this group of patients are at very high risk. Review of multicentre data may suggest an optimum treatment for this patient group.

Infection following Bone Tumor Resection and Reconstruction with Tumoral Prostheses: A Literature Review

Bone resection is the choice treatment of malignant bone tumors. Tumor prosthesis is one of the most common solutions of reconstruction following resection of bone tumor located to the metaphysis of long bones. Periprosthetic infections are a frequent complication of limb-salvage surgery which is largely due to prolonged and repeated surgeries, as well as to the immunocompromised condition of these patients due to neoplastic treatment. Furthermore, the large exposure of tissues during this type of surgery and the dissection across vascular distributions also contributes to the high risk of infection. The authors reviewed the literature discussing the incidence of infections of tumor prosthesis implanted following resection of bone tumors, taking into account the different sites of implantation. In the English literature, the highest risk of infection which led to limb amputation was observed after proximal tibia resection and this difference was considered to be due to the poor condition of soft tissue and also after pelvic resection due to huge dead space after sarcoma resection not filled by implant. Independent of the location, the management of infected prosthesis is similar. That is, after one or more attempts at debridement and antibiotic therapy, it consists of implant removal and insertion of a new implant in a one- or two-stage procedure, with a decreased risk of failure with the two-stage procedure.

Dual mobility design use in preventing total hip replacement dislocation following tumor resection

INTRODUCTION

Total hip replacement (THR) following hip tumor resection incurs a high risk of dislocation. We assessed the incidence of dislocation associated with use of a dual mobility cup,and the functional results achieved.

HYPOTHESIS

Use of a dual mobility cup would reduce the risk of THR instability following hip tumor resection.

MATERIAL AND METHODS

We analyzed dislocation rates in a retrospective series of 71 dual mobility cup THRs implanted following the resection of a tumor hip condition: 33 primary bone tumors and 38 bone metastases. The presenting pathology was diagnosed anatomically, and surgery classified in terms of adopted abductor system strategy. Functional results were assessed in terms of pain (analgesia on the World Health Organisation [WHO] scale), assisted walking and Musculoskeletal Tumor Society (MSTS) score.

RESULTS

An overall rate of 9.8% dislocation was observed, taking into account all etiologies and contexts together. More precisely, this rate resulted from a compound figure of 5.2% in bone metastasis and 15% in primitive bone tumor. Dislocation risk depended lesson etiology than on the surgical management of the abductor system, being 3.5% in the case of abductor conservation, 9.5% in the case of abductor sectioning/reinsertion, and 18%in case of gluteus medius muscle or nerve resection. Functional improvement was consistently observed, especially in bone metastasis. At the maximal follow-up, 32 patients were not using analgesics, six were taking WHO class III analgesics, 10 class II and 23 class I. Mean MSTS score was 68.1% +/- 23.5% in bone metastasis and 59.6% +/- 17.5% in primary bone tumor.Fourteen patients could walk without assistance, 33 with a single cane, 15 with two canes and eight with a walker; one patient had not been able to resume walking.

DISCUSSION

In these indications, dual mobility cups use lead to lower dislocation rates than those reported in the literature. It proved especially effective in the case of bone metastasis and consolidation surgery. In the case of primary bone tumor, it failed to prevent dislocation following acetabular resection, especially when involving the abductor muscles and/or abductor innervation, although it provided lower dislocation rates, comparable to those experienced with other techniques, when applied to limited resection.

LEVEL OF EVIDENCE

IV. Retrospective therapeutic study.