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Lari A, Esmaeil A, AlSalem Y, Alabbad F, Shahin M, Aoude A. Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis. JBJS Rev 2024; 12:01874474-202407000-00001. [PMID: 38968379 PMCID: PMC11221795 DOI: 10.2106/jbjs.rvw.24.00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
BACKGROUND Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication. METHODS This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models. RESULTS A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery. CONCLUSION TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ali Lari
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait
| | - Ali Esmaeil
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait
| | - Yousef AlSalem
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait
| | - Fahad Alabbad
- Department of Orthopedic Surgery, AlRazi National Orthopedic Hospital, Kuwait
| | - Maged Shahin
- Department of Orthopedic Surgery, AlFarwaniya Hospital, Kuwait
| | - Ahmed Aoude
- McGill University Health Centre, Montreal, Quebec, Canada
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Gonzalez MR, Inchaustegui ML, Layme J, Ruiz-Arellanos K, Larios F, Pretell-Mazzini J. Postoperative Outcomes of Total Femur Replacement in Oncologic and Nononcologic Patients: A Systematic Review of the Literature. J Arthroplasty 2024; 39:1624-1631.e2. [PMID: 38061400 DOI: 10.1016/j.arth.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients. METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated. RESULTS Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001). CONCLUSIONS Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria L Inchaustegui
- Department of Orthopaedics and Traumatology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Josue Layme
- Department of Orthopaedics and Traumatology, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Kim Ruiz-Arellanos
- Department of Orthopaedics and Traumatology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Felipe Larios
- Department of Orthopaedics and Traumatology, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Juan Pretell-Mazzini
- Division of Orthopedic Oncology, Miami Cancer Institute, Baptist Health System South Florida, Plantation, Florida
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Mori T, Kobayashi E, Sato Y, Takenaka S, Endo M, Nakamura T, Morii T, Yoshida Y, Ueda T, Kawano H, Kawai A. What Are the Complication Rates and Factors Associated With Total Femur Replacement After Tumor Resection? Findings From the Japanese Musculoskeletal Oncology Group. Clin Orthop Relat Res 2024; 482:702-712. [PMID: 37796200 PMCID: PMC10937000 DOI: 10.1097/corr.0000000000002874] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Patients undergoing massive tumor resection and total femur replacement (TFR) face a substantial risk of hip dislocation and infection, often resulting in multiple implant revisions or hip disarticulation. These complications can impact their independence and prognosis. Additionally, their shorter life expectancy is influenced by challenges in achieving local radical resection and controlling metastases. Identifying suitable candidates for TFR is vital, necessitating investigations into dislocation, infection, implant failure rates, local recurrence, overall survival, and associated factors. QUESTIONS/PURPOSES (1) What is the postsurgical complication (hip dislocation and infection) rate and factors associated with postsurgical complications in patients who underwent TFR after tumor resection? (2) What is the local recurrence rate, implant failure rate, overall survival rate, and factors associated with local recurrence and implant failure? METHODS We retrospectively evaluated 42 patients (median [range] age 47 years [10 to 79 years]) who underwent TFR and tumor resection at the time of the same surgical procedure between 1990 and 2020 at 12 registered institutions that specialized in tumor treatment in Japan. A total of 55% (23) of the patients were men, and 79% (33) had bone sarcoma. The median (range) follow-up period was 36.5 months (2 to 327 months). Of the 42 patients, 12% (5) were lost to follow-up before 2 years without meeting a study endpoint (postsurgical complications, revision, or amputation), and another 19% (8) died before 2 years with implants intact, leaving 69% (29) of the original group who had either follow-up of at least 2 years or met a study endpoint before the minimum surveillance duration. Another 10% (4) had a minimum of 2 years of follow-up but had not been seen in the past 5 years. Infection was defined as deep-seated infection involving soft tissues, bones, joints, and the area around the implant. We did not consider superficial infections. Implant failure was defined when a patient underwent reimplantation or amputation. The complication and implant failure rates were assessed by the cumulative incidence function method, considering competing events. The Kaplan-Meier method was used to estimate the overall survival rate. RESULTS The 1-month, 6-month, 1-year, and 2-year dislocation rates were 5%, 12%, 14%, and 14%, respectively. The 1-month, 6-month, 1-year, and 2-year infection rates were 5%, 7%, 10%, and 15%, respectively. Multivariable analyses for hip dislocation and infection revealed that resection of the abductor muscles and large tumor size were positively associated with hip dislocation. The 6-month, 1-year, and 2-year local recurrence rates were 5%, 15%, and 15%, respectively. The 6-month, 1-year, 2-year, and 5-year implant failure rates were 5% (95% confidence interval 1% to 15%), 7% (95% CI 2% to 18%), 16% (95% CI 6% to 29%), and 16% (95% CI 6% to 29%), respectively. Multivariable analyses of local recurrence and implant failure that led to reimplantation or amputation revealed that a positive surgical margin was positively associated with local recurrence. The 1-year, 2-year, and 5-year overall patient survival rates were 95% (95% CI 87% to 102%), 77% (95% CI 64% to 91%), and 64% (95% CI 48% to 81%), respectively. CONCLUSION Hip dislocation, infection, and local recurrence were frequently observed in patients who received massive tumor resection and TFR in our study, eventually leading to reimplantation or amputation. Preserving the abductor muscles and resecting the tumor with a wide margin can prevent postoperative dislocation and local recurrence. Future research should focus on patient selection criteria, prevention of hip dislocation, and innovative treatments. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Tomoaki Mori
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Kobayashi
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Takenaka
- Musculoskeletal Oncology Service, Osaka International Cancer Institute, Osaka, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Kyushu University, Fukuoka, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeshi Morii
- Department of Orthopaedic Surgery, Kyorin University, Tokyo, Japan
| | - Yukihiro Yoshida
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takafumi Ueda
- Department of Orthopaedic Surgery, National Hospital Organization Osaka, National Hospital, Osaka, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University, Tokyo, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
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Cabrolier J, Ceballos O, Rieloff F, Hardoy F, Tolosa R, Wevar O. Clinical outcomes of total femoral replacement. First Latin American experience. Surg Oncol 2024; 53:102038. [PMID: 38316087 DOI: 10.1016/j.suronc.2024.102038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/28/2023] [Accepted: 01/20/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION The femur is frequently affected by primary and metastatic bone tumors. In cases with substantial bone loss, Total Femur Replacement (TFR) remains the only viable limb preservation option. This study investigates the clinical outcomes of TFR patients in a Latin American setting, with a minimum 3-year follow-up. METHODS Retrospective review identifying cases of TFR at a single center from 2009 to 2020. Patients who had TFR either due to oncological indications or complications arising from oncology-related surgeries were included. Data on the indications for surgery and post-operative complications were recorded. To assess functional status, the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS) were used. RESULTS Fourteen patients met the inclusion criteria. Diagnoses included eight osteosarcomas, four chondrosarcomas, one Ewing sarcoma, and one giant cell tumor. Ten patients had undergone prior surgeries. Indication for TFR was a complication of a previous surgery in 78.6 % of cases. Post-TFR complications were experienced by 35.7 % of patients, requiring further surgeries. At the 3-year mark, average MSTS and TESS scores were 67.4 % and 70.8 %, respectively. CONCLUSION Total femur replacement serves as a valuable limb salvage solution for patients with significant femoral defects in oncological scenarios, however, there is a significant risk of complications. Given its potential benefits, it is essential for developing countries to consider incorporating TFR into their healthcare systems.
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Affiliation(s)
- Jorge Cabrolier
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martin 771, 8340220, Santiago, Región Metropolitana, Chile; Clinica Alemana - Universidad Del Desarrollo, Av Vitacura 5951, 7640745, Vitacura, Region Metropolitana, Chile.
| | - Oscar Ceballos
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martin 771, 8340220, Santiago, Región Metropolitana, Chile; Clínica Santa Maria, Bellavista 0415, 7520349, Providencia, Región Metropolitana, Chile.
| | - Fabiola Rieloff
- Hospital Santa Cruz, Federico Errazuriz 920, 3130671, Santa Cruz, O'Higgins, Chile.
| | - Francisco Hardoy
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martin 771, 8340220, Santiago, Región Metropolitana, Chile; Clínica Davila, Avenida Recoleta 464, Recoleta, Región Metropolitana, Chile.
| | - Ricardo Tolosa
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martin 771, 8340220, Santiago, Región Metropolitana, Chile; Clínica Davila, Avenida Recoleta 464, Recoleta, Región Metropolitana, Chile.
| | - Orlando Wevar
- Instituto Traumatológico Dr. Teodoro Gebauer, San Martin 771, 8340220, Santiago, Región Metropolitana, Chile; Clínica Santa Maria, Bellavista 0415, 7520349, Providencia, Región Metropolitana, Chile.
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Rowell PD, Ferguson PC, Tsoi KM, Nevin JL, Novak R, Griffin AM, Wunder JS. Endoprosthetic reconstruction for lower extremity soft tissue sarcomas with bone involvement. J Surg Oncol 2023; 128:660-666. [PMID: 37144623 DOI: 10.1002/jso.27300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/24/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Bone resection and endoprosthetic reconstruction (EPR) in the setting of soft tissue sarcoma (STS) management is rare and incurs unique challenges. We aim to report on the surgical and oncological outcomes of this relatively previously undocumented cohort. METHODS This is a single-center retrospective review of prospectively collected data for patients who required EPRs following resection of STSs of the lower extremity. Following inclusion criteria, we assessed 29 cases of EPR for primary STS of the lower limb. RESULTS The mean age was 54 years (range 18-84). Of the 29 patients, there were 6 total femur, 11 proximal femur, 4 intercalary, and 8 distal femur EPRs. Fourteen of 29 patients (48%) underwent re-operations for surgical complications, with 9 relating to infection (31%). When a matched cohort analysis was performed comparing our cohort to STSs that did not necessitate EPR, a reduced rate of overall survival and metastasis-free survival was found in those requiring EPR. CONCLUSION This series identifies a high rate of complication from EPRs performed for STS. Patients should be cautioned about the high rate of infection, surgical complications, and lower overall survival in this setting.
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Affiliation(s)
- P D Rowell
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - P C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - K M Tsoi
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - J L Nevin
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - R Novak
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - A M Griffin
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - J S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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Wahyudi M, Alaztha Z. Chondrosarcoma arising in monostotic fibrous dysplasia treated with total femur resection and megaprothesis: A case report. Int J Surg Case Rep 2021; 85:106194. [PMID: 34293652 PMCID: PMC8319740 DOI: 10.1016/j.ijscr.2021.106194] [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: 05/01/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Fibrous dysplasia is tumor like lesions of bone which develop as substitution of bone by an expansion of fibrous connective tissue mixed with hard trabeculae. Chondrosarcomas is one of common malignant primary bone tumor derived from heterogenous group of neoplasm producing chondroid matrix. Chondrosarcoma arising in fibrous dysplasia, especially in monostotic fibrous dysplasia is a very rare case. CASE REPORT A 54-year-old male presented with chief complaint of pain on left thigh. Patient with history of pathological fracture on left femoral diaphysis 3 years ago due to fibrous dysplasia and had underwent curettage, open reduction, and internal fixation at other hospital. Plain radiography revealed expansive lytic lesion, interrupted periosteal reaction with plate and screw attached to the lesion, and soft tissue mass. MRI T2FS sequence showed hyperintense mass extending from subtrochanteric to distal of left femoral diaphysis. Histopathological result from biopsy suggested chondrosarcoma. CONCLUSIONS Malignant transformation of monostotic type was less frequently compared to polyostotic type. Among all malignant transformation cases, alteration to chondrosarcoma was more scarce than other malignancy such as osteosarcoma and fibrosarcoma. Wide surgical margin and reconstruction in chondrosarcoma provide good local control and functional outcome.
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Affiliation(s)
- Muhammad Wahyudi
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Indonesia
| | - Ziad Alaztha
- Department of Orthopaedic and Traumatology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Indonesia.
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