Outcome after disarticulation of the hip for sarcomas

Limb Salvage and Pelvic Reconstruction With Endoprosthesis After Pelvic Tumor Resection: A Narrative Review

Periacetabular defects following tumor resection present formidable challenges in reconstruction and continue to pose clinical difficulties. Historically, treatment approaches leaned towards hindquarter amputation; however, due to associated morbidities and functional limitations, limb-sparing procedures gained prominence in the 1980s. Nevertheless, the intricacies of pelvic anatomy and the imperative of achieving wide surgical margins while preserving essential structures make pelvic tumor resection and subsequent reconstruction inherently complex. Various reconstruction modalities have been explored, including non-vascularized fibular grafts and prosthetic implants. Among these options, the LUMiC® endoprosthesis stands out as a promising solution for pelvic reconstruction post-tumor resection. Characterized by a modular design featuring a hydroxyapatite-coated stem and acetabular cup, this device has shown favorable implant survival rates in studies, despite encountering complications primarily associated with soft tissue failure, dislocation, and infection. Notably, the incidence of complications varies across studies. The Henderson classification system delineates these complications, encompassing soft tissue issues, aseptic loosening, periprosthetic fractures, infections, and tumor recurrence. Despite the encouraging functional outcomes associated with the LUMiC® endoprosthesis, it is not immune to limitations. Concerns persist regarding complications such as dislocation and infection, underscoring the imperative for further research to evaluate the long-term durability and reliability of this reconstructive approach. Moreover, advancements in surgical techniques, perioperative management, and the advent of navigation-assisted procedures hold promise for enhancing outcomes and mitigating complication rates in pelvic reconstruction surgeries.

Damage control hip disarticulation: two-stage operation with index creation of a large medial flap for the septic hip

Background

Although rarely performed, hip disarticulation (HD) is usually used for the patient with a non-viable leg who is also in extremis. HD was first used for trauma and infection; however, the technique was perfected during the age of hindquarter amputation for osteosarcomas. The operation performed by most surgeons today is still based on the oncological principles of high vessel control and ligation. When this approach has been used in the overwhelmingly infected or mangled extremity, it has resulted in high mortality rates. During the last 20 years, the concept of damage control operation has been embraced by emergency surgeons in all fields. We sought to extrapolate this concept and to apply it to the non-viable lower extremity.

Methods

We describe a new concept of damage control HD, review the technique and discuss our consecutive series of nine patients who underwent the procedure for trauma or necrotizing infection without flap dehiscence or mortality.

Results

All patients survived to hospital discharge. At time of discharge or at follow-up, six of the nine patients were able to transfer to a wheelchair.

Discussion

Proper disarticulations for infection need to address these two operative and postoperative issues: damage control debridement with creation of sufficient flap size and thorough postoperative wound care.Level IV.

Rotational Tibio-Pelvic Constrained Hip Arthroplasty: A Surgical Technique: A Case Report

CASE

A 25-year-old man presented with chronic bone and soft tissue infection of the right thigh following resection and radiation of epithelioid sarcoma. Multiple revisions and debridement procedures had failed to control the infection and left him unable to ambulate. We describe a modified Van Nes rotationplasty using a constrained, prosthetic hip between the tibia and pelvis following femur resection. With 18 months of follow-up, the patient was able to walk with a prosthetic device without evidence of recurrent infection.

CONCLUSIONS

We report this rotationplasty as a potential approach to avoid hip disarticulation in cases requiring extensive debridement for incurable infection.

A case of an elderly hip disarticulation amputee with rheumatoid arthritis who regained the ability to walk using a hip prosthesis

[Purpose] We report a case of an elderly patient with rheumatoid arthritis who underwent hip disarticulation because of necrotizing fasciitis and regained the ability to walk independently with a prosthetic limb. [Participant and Methods] A 61-year-old female patient underwent right hip disarticulation due to severe necrotizing fasciitis of the right lower limb. Her chief complaint was that she was not able to walk inside her house or outdoors to perform instrumental activities of daily living. We applied a Canadian-type hip disarticulation prosthesis to the stump. The patient received in-hospital physical therapy, occupational therapy, and clinical psychology counselling for 145 days. As her hands and fingers were weakened by rheumatism, we made several modifications to the prosthesis to enable the patient to attach and detach it independently. [Results] The patient was able to use the prosthesis to walk continuously for 45 m, perform various housework duties, drive a car, and go out, thus accomplishing the desired daily activities. [Conclusion] Our patient, an elderly hip disarticulation amputee with rheumatoid arthritis, was able to walk independently using a prosthetic limb. The application of prosthetic limbs may be appropriate even for hip disarticulation amputees with comorbidities that make it difficult to acquire a prosthetic gait.

[Endoprostheses for stump formation after hip disarticulation]

BACKGROUND

Hip disarticulation is a psychologically and physically demanding procedure. However, it remains a therapeutical option whenever limb salvage proves impossible due to sarcoma, severe implant-associated infections or trauma. The stump lengthening procedure (SLP) is a surgical technique that allows partial salvage of the thigh through endoprosthetic proximal femur replacement after hip disarticulation, depending on the amount of viable soft tissue coverage. This leads to a more appealing visual appearance, facilitates prosthetic fitting and significantly improves limb function.

OBJECTIVES

Description of indications for SLP, surgical technique, presentation of clinical and functional outcomes.

METHODS

Review of applying literature and presentation of outcomes of our own SLP collective.

RESULTS

The risk of local recurrence does not increase after SLP compared to hip disarticulation. While the majority of patients can be fitted with an exoprosthesis, a walking aid is usually necessary for ambulation. Exoprostheses are usually worn throughout the entire day, and patients manage distances of a mean of 2000 metres, even if reconstruction lengths are less than 10 cm. Patients aged 50 years or older tend to wear their exoprosthesis for shorter periods of daywear and achieve significantly poorer functional scores. Postoperative complications are common at a rate of 52%. Periprosthetic infection (21%) and soft tissue perforation of the implant with subsequent implant-associated infection (14%) were the most severe complications observed.

CONCLUSIONS

The stump lengthening procedure poses a feasible alternative to classic hip disarticulation in patients with multiple prior operations and/or advanced stages of disease. It leads to satisfactory cosmetic and functional results without jeopardizing local tumor control. Stump perforation presents as the most common complication. Apart from improving the ability to sit down comfortably, both patients treated with a curative and palliative intent manage to ambulate using exoprostheses. With increasing age at the time of operation, walking aids are necessary for ambulation.

Hip disarticulation - case series analysis and literature review

Objective

To present a retrospective study of 16 patients submitted to hip disarticulation.

Methods

During the period of 16 years, 16 patients who underwent hip disarticulation were identified. All of them were studied based on clinical records regarding the gender, age at surgery, disarticulation cause, postoperative complications, mortality rates and functional status after hip disarticulation.

Results

Hip disarticulation was performed electively in most cases and urgently in only three cases. The indications had the following origins: infection (n = 6), tumor (n = 6), trauma (n = 3), and ischemia (n = 2). The mean post-surgery survival was 200.5 days. The survival rates were 6875% after six months, 5625% after one year, and 50% after three years. The mortality rates were higher in disarticulations with traumatic (66.7%) and tumoral (60%) causes. Regarding the eight patients who survived, half of them ambulate with crutches and without prosthesis, 25% walk with limb prosthesis, and 25% are bedridden. Complications and mortality were higher in the cases of urgent surgery, and in those with traumatic and tumoral causes.

Conclusion

Hip disarticulation is a major ablative surgery with obvious implications for limb functionality, as well as high rates of complications and mortality. However, when performed at the correct time and with proper indication, this procedure can be life-saving and can ensure the return to the home environment with a certain degree of quality of life.

Stump lengthening procedure with modular endoprostheses - the better alternative to disarticulations of the hip joint?

We report outcomes of 28 patients after stump-lengthening procedures (SLPs) with modular tumor endoprostheses following high-thigh amputation and hip disarticulation over 11years. Mean follow up was 41.3months (range 7.4 to 133.6months). Mean Musculoskeletal Tumour Society Score was 56% (n=11); ten out of eleven patients alive used an exoprosthesis regularly. Complications occurred in 15 patients with infection being most common. In 2 cases, the prostheses had to be explanted. Our data suggest that SLP facilitates post-operative rehabilitation and prosthesis usage. Modular endoprostheses for stump-lengthening allow optimization of remnant soft-tissue envelope, reducing the risk of stump perforation.

Custom-made endoprostheses for the femoral amputation stump: an alternative to hip disarticulation in tumour surgery

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.

Necrotizing fasciitis and sepsis caused by Aeromonas hydrophila after crush injury of the lower extremity

BACKGROUND

Aeromonas hydrophila is a motile gram-negative bacillus found in water sources that typically causes minor skin infections or gastroenteritis in humans. There are sporadic reports of cases of sepsis or necrotizing fasciitis caused by A. hydrophila but no other cases of severe infection secondary to trauma. The mortality rate of septic shock caused by A. hydrophila approaches 100%.

METHODS

Case report and review of pertinent literature.

RESULTS AND CONCLUSIONS

A patient recently seen at our institution illustrates the features of necrotizing fasciitis and sepsis caused by A. hydrophila after an open femur fracture. We describe the aggressive multi-modality treatment necessary to maximize the likelihood of survival.

The effect of neutron radiation on conventional and highly cross-linked ultrahigh-molecular-weight polyethylene wear

The effects of a sarcoma therapy dose level neutron radiation on oxidation and wear were compared between conventional (N2\Vac, Stryker Orthopedics, Mahwah, NJ) and highly cross-linked (Crossfire, Stryker Orthopedics) ultrahigh-molecular-weight polyethylene acetabular liners. Liners were exposed to 15 Gy, a typical sarcoma treatment dose. Wear testing was conducted on a hip simulator. Transvinylene and oxidation indices were measured to determine if significant radiolytic reactions and oxidation occurred after the neutron beam exposure. The neutron bombardment produced further oxidation in both N2\Vac and Crossfire liners. Surprisingly, neutron radiation caused 62% increase in wear for N2\Vac but 0% change for the Crossfire acetabular liners. This study suggested that when joint implants are exposed to neutron beam radiation therapy, the conventional polyethylene liner is at risk for rapid wear.