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Li H, Zhang X, Li X, Shen J, Yin J, Zou C, Xie X, Huang G, Lin T. The survival and complication profiles of the Compress® Endoprosthesis: A systematic review and meta-analysis. J Bone Oncol 2024; 47:100623. [PMID: 39157743 PMCID: PMC11327388 DOI: 10.1016/j.jbo.2024.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/20/2024] Open
Abstract
Background/purpose This study aimed to summarize the survival and complication profiles of the compress® endoprosthesis (CPS) through a systematic review and meta-analysis. Methods Online databases (PubMed, EMBASE and Web of Science) were searched from inception to November 2023. Trials were included that involved the use of CPS for endoprosthetic replacement in patients with massive segmental bone defects. Patients' clinical characteristics and demographic data were extracted using a standardized form. The methodological quality of included 13 non-comparative studies was assessed on basis of the Methodological Index for Non-Randomized Studies (MINORS). All the available Kaplan-Meier curves in the included studies were digitized and combined using Engauge-Digitizer software and the R Project for Statistical Computing. Results The meta-analysis of thirteen included studies indicated: the all-cause failure rates of CPS were 26.3 % after surgery, in which the occurrence rates of aseptic loosening were 5.8 %. And the incidences of other complications were as follows: soft tissue failure (1.8 %), structure failure (8.2 %), infection (9.5 %), tumor progression (1.1 %). The 1-, 4-, and 8-year overall survival rates for all-cause failure with 95 % CI were 89 % (86 %-92 %), 75 % (71 %-79 %) and 65 % (60 %-70 %), respectively. The estimated mean survival time of all-cause failure was 145 months (95 % CI, 127-148 months), and the estimated median survival time of all-cause failure was 187 months (95 % CI, 135-198 months). The 1-, 4-, and 8-year overall survival rates of aseptic loosening with 95 % CI were 96 % (94 %-98 %), 91 % (87 %-95 %) and 88 % (83 %-93 %), respectively. The estimated mean survival time of aseptic loosening was 148 months (95 % CI, 137-153 months). Conclusion CPS's innovative spring system promotes bone ingrowth by providing immediate and high-compression fixation, thereby reducing the risk of aseptic loosening caused by stress shielding and particle-induced osteolysis. CPS requires less residual bone mass for reconstructing massive segmental bone defects and facilitates easier revision due to its non-cemented fixation. In addition, the survival rate, estimated mean survival time, and complication rates of CPS are not inferior to those of common endoprosthesis.
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Affiliation(s)
- Haolong Li
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Xinxin Zhang
- Department of Urology and Andrology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Xinyu Li
- Department of Urology and Andrology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Jingnan Shen
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Junqiang Yin
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Changye Zou
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Xianbiao Xie
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Gang Huang
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
| | - Tiao Lin
- Department of Musculoskeletal Oncology, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan 2 Road, Guangzhou 510080, China
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Rennie C, Rodriguez M, Futch KN, Krasney LC. Complications Following Osseointegrated Transfemoral and Transtibial Implants: A Systematic Review. Cureus 2024; 16:e57045. [PMID: 38681289 PMCID: PMC11046368 DOI: 10.7759/cureus.57045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Lower limb amputation is a common orthopedic surgery in the United States and can be performed either above or below the knee. Prosthetics are typically externally fitted to the patient's residual stump; however, osseointegrated implants offer a potential alternative to this process. Transcutaneous limb osseointegration involves the intramedullary anchoring of an implant that can later attach to a prosthetic via a stoma in the residual limb. There are proposed benefits to this, including decreased skin and soft tissue complications as well as an increased sense of stability. As this is a relatively new procedure, the complications and efficacy are not well supported by the literature at this time. The primary aim of this analysis was to synthesize the currently available data on transfemoral and transtibial osseointegration in order to improve our understanding of the potential complications of the procedure. A literature search was performed in the following databases: Biomedical Reference Collection, CINAHL, Cochrane Library, and PubMed/MEDLINE. Articles were screened by three independent reviewers for studies written or available in English, study design, and study outcomes, including complications. No filter was applied for publication date, publication national origin, or sample size. A total of 20 articles were selected for the final qualitative analysis. This review demonstrates an overall low or non-inferior rate of both minor and severe complications in transtibial and transfemoral osseointegration. This procedure should be considered as an option during preoperative planning in the context of above-the-knee and below-the-knee amputations. However, continued studies with larger sample sizes and extended postoperative follow-up are necessary for a greater strength of recommendation.
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Affiliation(s)
- Christopher Rennie
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Melissa Rodriguez
- Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Harrogate, USA
| | - Katerina N Futch
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Leighann C Krasney
- Orthopaedic Surgery, California Pacific Orthopaedics, San Francisco, USA
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Parlee L, Kagan R, Doung YC, Hayden JB, Gundle KR. Compressive osseointegration for endoprosthetic reconstruction. Orthop Rev (Pavia) 2020; 12:8646. [PMID: 33312488 PMCID: PMC7726822 DOI: 10.4081/or.2020.8646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/20/2020] [Indexed: 02/02/2023] Open
Abstract
This review summarizes the biomechanical concepts, clinical outcomes and limitations of compressive osseointegration fixation for endoprosthetic reconstruction. Compressive osseointe - gration establishes stable fixation and integration through a novel mechanism; a Belleville washer system within the spindle applies 400-800 PSI force at the boneimplant interface. Compressive osseointegration can be used whenever standard endoprosthetic reconstruction is indicated. However, its mode of fixation allows for a shorter spindle that is less limited by the length of remaining cortical bone. Most often compressive osseointegration is used in the distal femur, proximal femur, proximal tibia, and humerus but these devices have been customized for use in less traditional locations. Aseptic mechanical failure occurs earlier than with standard endoprosthetic reconstruction, most often within the first two years. Compressive osseointegration has repeatedly been proven to be non-inferior to standard endoprosthetic reconstruction in terms of aseptic mechanical failure. No demographic, device specific, oncologic variables have been found to be associated with increased risk of aseptic mechanical failure. While multiple radiographic parameters are used to assess for aseptic mechanical failure, no suitable method of evaluation exists. The underlying pathology associated with aseptic mechanical failure demonstrates avascular bone necrosis. This is in comparison to the bone hypertrophy and ingrowth at the boneprosthetic interface that seals the endosteal canal, preventing aseptic loosening.
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Affiliation(s)
- Lindsay Parlee
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University
| | - Ryland Kagan
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University
| | - Yee-Cheen Doung
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University
| | - James B Hayden
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University
| | - Kenneth R Gundle
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University.,Operative Care Division, Portland VA Medical Center, OR, USA
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Li Y, Sun Y, Shan HC, Niu XH. Comparative Analysis of Early Follow-up of Biologic Fixation and Cemented Stem Fixation for Femoral Tumor Prosthesis. Orthop Surg 2020; 11:451-459. [PMID: 31243921 PMCID: PMC6595119 DOI: 10.1111/os.12483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 08/04/2018] [Accepted: 08/24/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare the safety and efficacy between biologic fixation and traditional cement stems for the fixation of distal femoral prostheses for reconstruction following tumor resection. METHODS Retrospective analysis was performed of patients who received a first distal femoral tumor prosthesis, with a rotating hinge, in the Department of Orthopaedic Oncology of Beijing Jishuitan Hospital between October 2011 and January 2016. Two hundred and sixty eligible cases were enrolled, with a cemented fixation used in 199 of these cases and a biologic fixation in 61 cases. Survival rates and survival time of prostheses were analyzed, with prosthetic failure considered as the endpoint event for survival time of the prosthesis. Kaplan-Meier survival curve and the log-rank test were used to compare survival rates between the two types of fixation methods, and factors that may affect the survival rate of prosthesis were evaluated. RESULTS Of the 260 cases forming our study group, 138 were males and 122 females, with 102 males and 97 females in the cemented fixation group (mean age, 25.8 years; range, 8-72 years) and 36 males and 25 females in the biologic fixation group (mean age, 25.5 years; range, 12-59 years). Osteosarcoma was the most common type of tumor (188 cases, 72.3%), of which 145 cases (72.9%) were in the cemented and 45 cases (72.1%) in the biologic fixation group. Among the 260 cases enrolled into the study group, 13 patients were lost to follow-up. The average duration of follow-up for the remaining 247 cases was 28.8 months (median, 28.8 months; range, 4-61 months). The 3-year overall survival rate of prostheses was 87.2% for the biologic fixation group and 80.4% in the cemented fixation group (P = 0.389). The 3-year mechanical survival rate (excluding cases of infection and oncologic progression) was 100% for the biologic fixation and 97.6% for the cemented fixation group (P = 0.468). Complications were identified in 21 cases: 3 cases (5%) in the biologic and 18 cases (9.6%) in the cemented fixation group (P = 0.264). Two revisions were required in the cemented fixation group, but no revision was required in the biologic fixation group. A total of 10 patients required amputation after prosthesis implantation. Of these, 7 cases (4 cement and 3 biologic) were due to tumor recurrence; 3 cases were due to infection, with all cases occurring in the cement fixation group. CONCLUSION The current study provides a baseline reference for future mid-term to long-term follow-up, laying the foundation for further studies and comparison of the incidence of aseptic loosening of both types of prosthesis.
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Affiliation(s)
- Yuan Li
- Department of Orthopaedic Oncology Surgery, Beijing Ji Shui Tan Hospital, Peking University, Beijing, China
| | - Yang Sun
- Department of Orthopaedic Oncology Surgery, Beijing Ji Shui Tan Hospital, Peking University, Beijing, China
| | - Hua-Chao Shan
- Department of Orthopaedic Oncology Surgery, Beijing Ji Shui Tan Hospital, Peking University, Beijing, China
| | - Xiao-Hui Niu
- Department of Orthopaedic Oncology Surgery, Beijing Ji Shui Tan Hospital, Peking University, Beijing, China
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Abstract
Osseointegration is a surgical approach that permitted the direct attachment of an external prosthesis to the skeleton in some select patients with amputation, who had failed to tolerate conventional sockets, thereby obviating related issues such as discomfort, skin breakdown, and poor fit. In this specific population, osseointegration offers the potential for enhanced biomechanical advantage and rehabilitative potential. Multiple percutaneous implant systems exist for clinical use internationally, each attempting to create a stable bone-implant interface while avoiding complications such as infection and loosening. Prospective clinical trials are now underway in the United States. This article will review the history and biology of osseointegration, indications and contraindications for use of currently available implant systems, and reported outcomes. Future directions of orthopaedic osseointegration technology, including electronic systems capable of biomimetic bidirectional volitional motor control of, and sensory/proprioceptive feedback from, external prosthetic devices, will also be discussed.
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Summers SH, Zachwieja EC, Butler AJ, Mohile NV, Pretell-Mazzini J. Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature. JBJS Rev 2019; 7:e1. [PMID: 31268862 DOI: 10.2106/jbjs.rvw.18.00146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. METHODS A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. RESULTS A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). CONCLUSIONS Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Spencer H Summers
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida
| | - Erik C Zachwieja
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida
| | - Alexander J Butler
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida
| | - Neil V Mohile
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida.,Musculoskeletal Oncology Division, Department of Orthopedics, University of Miami, Miami, Florida
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A Quantitative Approach for the Bone-implant Osseointegration Assessment Based on Ultrasonic Elastic Guided Waves. SENSORS 2019; 19:s19030454. [PMID: 30678295 PMCID: PMC6387175 DOI: 10.3390/s19030454] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 12/20/2022]
Abstract
Quantitative and reliable monitoring of osseointegration will help further evaluate the integrity of the orthopaedic construct to promote novel prosthesis design and allow early mobilisation. Quantitative assessment of the degree or the lack of osseointegration is important for the clinical management with the introduction of prosthetic implants to amputees. Acousto-ultrasonic wave propagation has been used in structural health monitoring as well as human health monitoring but so far has not extended to osseointegrated implants or prostheses. This paper presents an ultrasonic guided wave approach to assess the osseointegration of a novel implant. This study explores the potential of integrating structural health monitoring concepts into a new osseointegrated implant. The aim is to demonstrate the extension of acousto-ultrasonic techniques, which have been widely reported for the structural health monitoring of engineering structures, to assess the state of osseointegration of a bone and implant. To illustrate this potential, this paper will report on the experimental findings which investigated the unification of an aluminium implant and bone-like geometry surrogate. The core of the test specimen is filled with silicone and wrapped with plasticine to simulate the highly damped cancellous bone and soft tissue, respectively. To simulate the osseointegration process, a 2-h adhesive epoxy is used to bond the surrogate implant and a bone-like structure. A series of piezoelectric elements are bonded onto the surrogate implant to serve as actuators and sensors. The actuating piezoelectric element on an extramedullary strut is excited with a 1 MHz pulse signal. The reception of the ultrasonic wave by the sensing elements located on the adjacent and furthest struts is used to assess the integration of this implant to the parent bone structure. The study shows an Osseointegration Index can be formulated by using engineering and acousto-ultrasonic methods to measure the unification of a bone and implant. This also highlights a potential quantitative evaluation technique regardless of bone-implant geometry and soft tissue damping.
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Haijie L, Dasen L, Tao J, Yi Y, Xiaodong T, Wei G. Implant Survival and Complication Profiles of Endoprostheses for Treating Tumor Around the Knee in Adults: A Systematic Review of the Literature Over the Past 30 Years. J Arthroplasty 2018; 33:1275-1287.e3. [PMID: 29191444 DOI: 10.1016/j.arth.2017.10.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/09/2017] [Accepted: 10/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Endoprosthetic replacement has become the mainstream method of reconstruction after tumor resection around the knee for decades, but there is a lack of comprehensive review evaluating the implant outcomes. We performed a systematic review to analyze the implant survival and complication profiles of distal femoral replacement (DFR) and proximal tibial replacement (PTR) in adults, and to evaluate the effects of different fixation methods and hinge mechanisms. METHODS A systematic review of 40 studies with 4748 DFR cases and 1713 PTR cases was performed after searching the PubMed and EMBASE databases. Results of the implant longevity, complications, and other relevant data were extracted, recategorized, and analyzed. An additional review of 227 cases of Compress DFR from 6 studies was also performed. RESULTS The mean 5-, 10-, 15-, and 20-year implant survival rates of DFR were 78.3%, 70.1%, 61.6%, and 38.3%, slightly higher than those of PTR (75%, 60%, 55.3%, and 25.1%). Aseptic loosening (8.8%) and infection (8.5%) were the most devastating complications in DFR, while in PTR it was infection (16.8%). Cemented or cementless fixation did not significantly affect implant survival or aseptic loosening rate. Rotating-hinge mechanism might improve long-term implant survival and reduce bushing wear, but not necessarily prevented aseptic loosening. The series Kotz modular femur and tibia replacement system/Howmedica modular replacement system/global modular replacement system was one of the most durable implants. The Compress DFR showed no superiority in implant survival and complication profiles over other brands of endoprostheses. CONCLUSION Short-term to mid-term implant survival of adult tumor endoprostheses around the knee is acceptable but long-term outcome remains unsatisfactory. Efforts should be made in reducing loosening and infection.
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Affiliation(s)
- Liang Haijie
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
| | - Li Dasen
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
| | - Ji Tao
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
| | - Yang Yi
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
| | - Tang Xiaodong
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
| | - Guo Wei
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Beijing, People's Republic of China
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Kagan R, Adams J, Schulman C, Laursen R, Espana K, Yoo J, Doung YC, Hayden J. What Factors Are Associated With Failure of Compressive Osseointegration Fixation? Clin Orthop Relat Res 2017; 475:698-704. [PMID: 26926774 PMCID: PMC5289163 DOI: 10.1007/s11999-016-4764-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Compressive osseointegration is as an alternative to traditional intramedullary fixation. Two- to 10-year survivorship and modes of failure have been reported; however, as a result of relatively small numbers, these studies are limited in their ability to identify risk factors for failure. QUESTIONS/PURPOSES (1) What is survivorship free from aseptic mechanical and survivorship free from overall failure of compressive osseointegration fixation? (2) What patient factors (age, sex, body mass index [BMI], anatomic location of reconstruction, indication for reconstruction, radiation, chemotherapy) are associated with increased risk of failure? METHODS Between 2006 and 2014, surgeons at one center treated 116 patients with 137 Compress® implants for lower extremity oncologic reconstructions, revision arthroplasty, and fracture nonunion or malunion. One hundred sixteen implants were available for review with a minimum of 2-year followup (mean, 4 years; range, 2-9 years). Kaplan-Meier survival plots were produced to examine survivorship and Cox regression modeling was used to generate hazard ratios (HRs) for potential risk factors for failure. Patient factors (age, sex, BMI, anatomic location of reconstruction, indication for reconstruction, radiation, chemotherapy) were obtained from chart review and an institutional database. RESULTS Survivorship free from aseptic mechanical failure was 95% (95% confidence interval [CI], 91%-99%) at 18 months and 93% (95% CI, 86%-99%) at 4 years. Survivorship free from overall failure was 82% (95% CI, 75%-89%) at 18 months and 75% (95% CI, 66%-84%) at 4 years. Risk of overall failure was increased with reconstruction of the proximal tibia (HR, 4.42; 95% CI 0.98-19.9) and distal femur (HR, 1.74; 95% CI, 0.50-6.09) compared to the proximal femur (HR, 1; referent; p = 0.049). Risk of aseptic mechanical failure was increased with reconstruction of the proximal tibia (HR, 1; referent) and distal femur (HR, 0.37; 95% CI, 0.08-1.77) compared with the proximal femur (HR, 0, p = 0.048). Radiation was associated with increased risk of overall failure (HR, 3.85; 95% CI, 1.84-8.02; p < 0.003), but not aseptic mechanical failure. Age, sex, BMI, chemotherapy, and surgical indication were not associated with increased risk of aseptic or overall failure. CONCLUSIONS This study questions the use of age as a contraindication for the use of this technology and suggests this technology may be considered in proximal femoral reconstruction and for patients with indications other than primary oncologic reconstructions. Future research should establish long-term survivorship data to compare this approach with conventional intramedullary stems and to evaluate the potential benefits of preventing stress shielding and preserving bone stock in revision situations. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ryland Kagan
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Jacob Adams
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Caroline Schulman
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Rachel Laursen
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Karina Espana
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Jung Yoo
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - Yee-Cheen Doung
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
| | - James Hayden
- 0000 0000 9758 5690grid.5288.7Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code OP-31, Portland, OR 97239 USA
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Goldman LH, Morse LJ, O’Donnell RJ, Wustrack RL. How Often Does Spindle Failure Occur in Compressive Osseointegration Endoprostheses for Oncologic Reconstruction? Clin Orthop Relat Res 2016; 474:1714-23. [PMID: 27106130 PMCID: PMC4887378 DOI: 10.1007/s11999-016-4839-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 04/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Compressive osseointegration is a promising modality for limb salvage in distal femoral oncologic tumors. However, few studies have explored short-term survival rates in a large patient cohort of distal femur compressive endoprostheses or highlighted the risk factors for spindle failures. QUESTIONS/PURPOSES We asked: (1) What is the frequency of compressive osseointegration spindle failure in distal femoral reconstructions? (2) What are the characteristics of rotational failure cases with distal femur compressive osseointegration endoprostheses? (3) What are the risk factors for mechanical and rotational failure of distal femur compressive osseointegration implantation? (4) What are other modalities of failure or causes of revision surgery, which affect patients undergoing distal femur compressive osseointegration implantation for oncologic reconstruction? METHODS Between 1996 and 2013, 127 distal femoral reconstructions with the Compress(®) prosthesis were performed in 121 patients. During that time, 116 Compress(®) prostheses were implanted for aggressive primary tumors of the distal femur and/or failure of previous oncologic reconstruction. This approach represented approximately 91% of the distal femoral reconstructions performed during that time. Of the patients with prostheses implanted, four patients (four of 116, 3%) had died, and 37 (37 of 116, 32%) were lost to followup before 24 months. The median followup was 84 months (range, 24-198 months), and 71 patients (66% of all patients) were seen within the last 3 years. A retrospective chart review was performed to determine failure modality as defined by radiographs, clinical history, and intraoperative findings. Risk factors including age, sex, BMI, resection length, and perioperative chemotherapy were analyzed to determine effect on spindle and rotational failure rates. Survival analysis was determined using the Kaplan-Meier estimator. Differences in survival between groups were analyzed using the log rank test. Risk factors were determined using Cox proportional hazard modeling. RESULTS Spindle survival at 5 and 10 years was 91% (95% CI, 82%-95%). Survival rates from rotational failure at 5 and 10 years were 92% (95% CI, 83%-96%); the majority of failures occurred within the first 2 years postoperatively and were the result of a twisting mechanism of injury. With the numbers available, none of the potential risk factors examined were associated with mechanical failure. The 5-year and 10-year all-cause revision-free survival rates were 57% (95% CI, 44%-67%) and 50% (95% CI, 36%-61%), respectively. CONCLUSIONS Distal femur compressive osseointegration is a viable method for endoprosthetic reconstruction. Rotational failure is rare with the majority occurring early. No variables were found to correlate with increased risk of mechanical failure. More research is needed to evaluate methods of preventing mechanical and rotational failures in addition to other common causes of revision such as infection in these massive endoprosthetic reconstructions. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Lauren H. Goldman
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA USA ,Department of Radiology, Montefiore Medical Center, 111 E 210th Street, Bronx, NY 10467 USA
| | - Lee J. Morse
- Oakland Medical Center, Kaiser Permanente, Oakland, CA USA
| | - Richard J. O’Donnell
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA USA
| | - Rosanna L. Wustrack
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA USA
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11
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Total femoral and proximal tibial compressive osseointegration. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Khemka A, Frossard L, Lord SJ, Bosley B, Al Muderis M. Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases. Acta Orthop 2015; 86:740-4. [PMID: 26145721 PMCID: PMC4750776 DOI: 10.3109/17453674.2015.1068635] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment. PATIENTS AND METHODS We retrospectively reviewed all 4 cases (aged 38-77 years) of transtibial amputations managed with osseointegration and TKR in 2012-2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1-3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test. RESULTS There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29-52 and a 6-minute walk test improvement range of 37-84 meters. INTERPRETATION It is possible to combine TKR with osseointegrated implants.
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Monument MJ, Lerman DM, Randall RL. Novel applications of osseointegration in orthopedic limb salvage surgery. Orthop Clin North Am 2015; 46:77-87. [PMID: 25435037 DOI: 10.1016/j.ocl.2014.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osseointegration is a biologic process vital to modern endoprosthetic fixation in orthopedic surgery. Numerous engineering advancements have improved the utilization of this technology in orthopedics; however, issues such as stress shielding, aseptic loosening, and bone loss remain an ongoing challenge. These host responses are especially problematic in limb salvage surgery. Novel applications of osseointegration have been developed to address some of these fixation issues with massive tumor endoprostheses. This articles reviews osseointegration and emerging novel applications of this technology in limb salvage surgery and future prosthetics for amputees.
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Affiliation(s)
- Michael J Monument
- Sarcoma Services, Department of Orthopaedic Surgery, Huntsman Cancer Institute, Primary Children's Medical Center, University of Utah, 2000 Circle of Hope, Room 4260, Salt Lake City, UT 84112, USA
| | - Daniel M Lerman
- Sarcoma Services, Department of Orthopaedic Surgery, Huntsman Cancer Institute, Primary Children's Medical Center, University of Utah, 2000 Circle of Hope, Room 4260, Salt Lake City, UT 84112, USA
| | - R Lor Randall
- Sarcoma Services, Department of Orthopaedic Surgery, Huntsman Cancer Institute, Primary Children's Medical Center, University of Utah, 2000 Circle of Hope, Room 4260, Salt Lake City, UT 84112, USA.
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Calvert GT, Cummings JE, Bowles AJ, Jones KB, Wurtz LD, Randall RL. A dual-center review of compressive osseointegration for fixation of massive endoprosthetics: 2- to 9-year followup. Clin Orthop Relat Res 2014; 472:822-9. [PMID: 23467985 PMCID: PMC3916600 DOI: 10.1007/s11999-013-2885-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Aseptic failure of massive endoprostheses used in the reconstruction of major skeletal defects remains a major clinical problem. Fixation using compressive osseointegration was developed as an alternative to cemented and traditional press-fit fixation in an effort to decrease aseptic failure rates. QUESTIONS/PURPOSES The purpose of this study was to answer the following questions: (1) What is the survivorship of this technique at minimum 2-year followup? (2) Were patient demographic variables (age, sex) or anatomic location associated with implant failure? (3) Were there any prosthesis-related variables (eg, spindle size) associated with failure? (4) Was there a discernible learning curve associated with the use of the new device as defined by a difference in failure rate early in the series versus later on? METHODS The first 50 cases using compressive osseointegration fixation from two tertiary referral centers were retrospectively studied. Rates of component removal for any reason and for aseptic failure were calculated. Demographic, surgical, and oncologic factors were analyzed using regression analysis to assess for association with implant failure. Minimum followup was 2 years with a mean of 66 months. Median age at the time of surgery was 14.5 years. RESULTS A total of 15 (30%) implants were removed for any reason. Of these revisions, seven (14%) were the result of aseptic failure. Five of the seven aseptic failures occurred at less than 1 year (average, 8.3 months), and none occurred beyond 17 months. With the limited numbers available, no demographic, surgical, or prosthesis-related factors correlated with failure. CONCLUSIONS Most aseptic failures of compressive osseointegration occurred early. Longer followup is needed to determine if this technique is superior to other forms of fixation.
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Affiliation(s)
- George T Calvert
- Division of Orthopaedic Surgery, Department of Surgery, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA, 91010, USA,
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Abstract
BACKGROUND Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown. QUESTIONS/PURPOSES We therefore determined the survival of the Compress prosthesis (Biomet Inc, Warsaw, IN, USA) at 5 and 10 actuarial years and identified the failure modes for this form of prosthetic fixation. METHODS We retrospectively reviewed clinical and radiographic records for all 82 patients who underwent Compress knee arthroplasty from 1998 to 2008, as well as one patient who received the device elsewhere but was followed at our institution. Prosthesis survivorship and modes of failure were determined. Followup was for a minimum of 12 months or until implant removal (median, 43 months; range, 6-131 months); 28 patients were followed for more than 5 years. RESULTS We found a survivorship of 85% at 5 years and 80% at 10 years. Eight patients required prosthetic revision after interface failure due to aseptic loosening alone (n = 3) or aseptic loosening with periprosthetic fracture (n = 5). Additionally, five periprosthetic bone failures occurred that did not require revision: three patients had periprosthetic bone failure without fixation compromise and two exhibited irregular prosthetic osteointegration patterns with concomitant fracture due to mechanical insufficiency. CONCLUSIONS Compress prosthetic fixation after distal femoral tumor resection exhibits long-term survivorship. Implant failure was associated with patient nonadherence to the recommended weightbearing proscription or with bone necrosis and fracture. We conclude this is the most durable FDA-approved fixation method for distal femoral megaprostheses. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Pedtke AC, Wustrack RL, Fang AS, Grimer RJ, O’Donnell RJ. Aseptic failure: how does the Compress(®) implant compare to cemented stems? Clin Orthop Relat Res 2012; 470:735-42. [PMID: 22045069 PMCID: PMC3270164 DOI: 10.1007/s11999-011-2159-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Failure of endoprosthetic reconstruction with conventional stems due to aseptic loosening remains a challenge for maintenance of limb integrity and function. The Compress(®) implant (Biomet Inc, Warsaw, IN, USA) attempts to avoid aseptic failure by means of a unique technologic innovation. Though the existing literature suggests survivorship of Compress(®) and stemmed implants is similar in the short term, studies are limited by population size and followup duration. QUESTIONS/PURPOSES We therefore compared (1) the rate of aseptic failure between Compress(®) and cemented intramedullary stems and (2) evaluated the overall intermediate-term implant survivorship. METHODS We reviewed 26 patients with Compress(®) implants and 26 matched patients with cemented intramedullary stems. The patients were operated on over a 3-year period. Analysis focused on factors related to implant survival, including age, sex, diagnosis, infection, aseptic loosening, local recurrence, and fracture. Minimum followup was 0.32 years (average, 6.2 years; range, 0.32-9.2 years). RESULTS Aseptic failure occurred in one (3.8%) patient with a Compress(®) implant and three (11.5%) patients with cemented intramedullary stems. The 5-year implant survival rate was 83.5% in the Compress(®) group and 66.6% in the cemented intramedullary stem group. CONCLUSIONS The Compress(®) implant continues to be a reliable option for distal femoral limb salvage surgery. Data regarding aseptic failure is encouraging, with equivalent survivorship against cemented endoprosthetic replacement at intermediate-term followup. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew C. Pedtke
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA USA
| | - Rosanna L. Wustrack
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA USA
| | - Andrew S. Fang
- Department of Orthopedic Surgery, The Permanente Medical Group, South San Francisco, CA USA
| | | | - Richard J. O’Donnell
- Orthopaedic Oncology Service, UCSF Helen Diller Family Comprehensive Cancer Center, 1600 Divisadero Street, 4th Floor, San Francisco, CA 94115-1939 USA
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Palumbo BT, Henderson ER, Groundland JS, Cheong D, Pala E, Letson GD, Ruggieri P. Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques. Cancer Control 2011; 18:160-70. [PMID: 21666578 DOI: 10.1177/107327481101800303] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients. METHODS The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management. RESULTS Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies. CONCLUSIONS Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena.
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Affiliation(s)
- Brian T Palumbo
- Department of Orthopaedic Surgery, University of South Florida, Tampa 33620, USA.
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Foo LSS, Hardes J, Henrichs M, Ahrens H, Gosheger G, Streitbürger A. Surgical difficulties encountered with use of modular endoprosthesis for limb preserving salvage of failed allograft reconstruction after malignant tumor resection. J Arthroplasty 2011; 26:744-50. [PMID: 20692805 DOI: 10.1016/j.arth.2010.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 06/18/2010] [Indexed: 02/01/2023] Open
Abstract
We reviewed outcomes and discussed surgical difficulties encountered in 10 patients who had modular endoprosthesis for limb preserving salvage of failed allograft reconstruction after malignant tumor resection. Mean allograft survival time before failure was 127.4 months (range, 14-264 months). Mean length of follow-up since endoprosthesis revision surgery was 62.8 months (range, 16-132 months). There was one endoprosthesis failure, resulting in a mean endoprosthesis survival time of 56.9 months (range, 16-132). Complications included arterial laceration, nerve injury, periprosthetic crack fracture, aseptic loosening, and infection. Modular endoprosthesis remain a viable option that should be considered in any limb preserving salvage of failed allograft reconstructions. However, altered anatomy, poor/short remnant host bone, periprosthetic fractures, inadequate soft tissue coverage and infection remain important difficulties encountered.
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Affiliation(s)
- Leon S S Foo
- Klinik und Poliklinik für Allgemeine Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Münster, Germany
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