1
|
Minami N, Tsukamoto S, Shimizu T, Honoki K, Hasegawa H, Masunaga T, Kido A, Errani C, Mavrogenis AF, Tanaka Y. Coverage of lateral soft tissue defects with sartorius muscle flap after distal femoral replacement for malignant bone tumors. SICOT J 2024; 10:27. [PMID: 39137795 PMCID: PMC11323838 DOI: 10.1051/sicotj/2024025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/02/2024] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION To prevent infection after limb-sparing surgery for primary malignant bone tumors, it is important to cover the megaprosthesis with muscle tissue that has sufficient blood flow. Coverage with a lateral gastrocnemius flap has been reported in cases of distal femoral replacement in which the vastus lateralis and vastus intermedius muscles have been resected; however, the risk of peroneal nerve palsy is reportedly high because the muscle flap passes near the peroneal head. This study was performed to examine the postoperative outcomes of patients with primary malignant bone tumors of the distal femur who underwent wide resection (including the vastus lateralis and vastus intermedius muscles) followed by reconstruction with a megaprosthesis and coverage of the lateral side of the prosthesis with a sartorius muscle flap. METHODS We retrospectively analyzed three patients who underwent reconstruction with a megaprosthesis after wide resection of a primary malignant bone tumor of the distal femur involving the vastus lateralis and vastus intermedius muscles and reconstruction of the soft tissue defect on the lateral side of the prosthesis with a sartorius muscle flap. RESULTS The average defect size was 6 × 13 cm, the average time required for a sartorius muscle flap was 100 min, and the average implant coverage was 93%. The average postoperative follow-up period was 35 months, during which no postoperative complications such as infection, skin necrosis, or nerve palsy occurred. DISCUSSION The distally based sartorius muscle flap is easy to elevate in the supine position, has minimal functional loss after harvesting, and has minimal risk of nerve palsy. It can be advocated as the first option for coverage of soft tissue defects lateral to distal femoral replacement.
Collapse
Affiliation(s)
- Naoki Minami
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Takamasa Shimizu
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Hideo Hasegawa
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Tomoya Masunaga
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, Nara, Japan
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Rizzoli Institute, Bologna, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara City, Nara 634-8521, Japan
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Shiraishi S, Fujiwara T, Nabeshima A, Iida K, Endo M, Matsumoto Y, Oda Y, Nakashima Y. Geriatric nutritional risk index as a predictor for surgical site infection in malignant musculoskeletal tumours of the trunk. Jpn J Clin Oncol 2024:hyae095. [PMID: 39037963 DOI: 10.1093/jjco/hyae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/12/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Surgical site infection (SSI) is common in surgery for malignant musculoskeletal tumours, specifically those arising from the trunk. In this study, we investigated the risk factors for SSI after resection of musculoskeletal tumours of the trunk. METHODS This retrospective observational study included 125 patients (72 males, 53 females) with musculoskeletal tumours of the trunk in our hospital from 1 April 2008 to 31 August 2023. The incidence of SSI and its risk factors were investigated. RESULTS SSI was observed in 26% (32/125), and the median time to SSI was 22 days. On multivariate analysis, the following were identified as risk factors for SSI: tumours arising caudal to Jacoby's line (hazard ratio [HR] 4.04; P = .0107), soft tissue reconstruction (HR 3.43; P = .0131), and low Geriatric Nutritional Risk Index (GNRI) (HR 0.96; P = .0304). Patients were classified into two risk categories based on GNRI scores: the risk group (GNRI ≤98) and no risk group (>98). The risk group showed a significantly lower overall noninfection survival rate (P = .023). CONCLUSION Tumours arising caudal to Jacoby line, soft tissue reconstruction, and lower GNRI were risk factors for SSI. Preoperative and postoperative nutritional interventions should be considered to improve GNRI.
Collapse
Affiliation(s)
- Sakura Shiraishi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
4
|
Bozzo A, Aysola V, Yeung CM, Healey JH, Prince DE. Distraction Osteogenesis Reconstruction Following Resection of Bone Sarcomas: Surgical, Functional, and Oncological Outcomes from a Prospective Trial Analysis. J Bone Joint Surg Am 2024; 106:1205-1211. [PMID: 38728434 DOI: 10.2106/jbjs.23.00707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND While sustainable long-term function has been established for biological reconstruction with distraction osteogenesis (DO) following osseous resections, there is a paucity of published data informing surgeons and patients on important milestones in the reconstructive process. The objectives of this study were to determine when to expect complete bone healing and full weight-bearing as well as to quantify the influence of chemotherapy on the osseous regeneration process. METHODS Prospectively, pathological and clinical data were collected for 30 consecutive patients who underwent primary or secondary DO-based reconstruction following osseous resection from 2018 to 2021. Serial radiographs indicated the times to cortex formation and full union. An unpaired t test was used to compare the time required for full bone remodeling of segments transported with and without concurrent chemotherapy. RESULTS The average resection length was 13.6 cm (range, 4 to 22 cm). Patients underwent an average of 6.1 procedures (range, 1 to 14 procedures). Half (50%) of all procedures were planned, while half were unplanned procedures. All patients achieved full, independent weight-bearing at a median of 12 months (interquartile range [IQR], 9 to 16 months). For the 34 segments transported concurrently with chemotherapy, the mean bone healing index (BHI) was 2.3 ± 0.7, and the mean BHI was 1.2 ± 0.4 for the 25 segments without chemotherapy at any point during their transport (p < 0.0001). CONCLUSIONS All 30 patients achieved full bone healing and independent weight-bearing at a median of 1 year postoperatively and continued to show functional improvement afterward. Surgeons and patients can expect bone healing to be nearly twice as fast for segments transported after completion of systemic chemotherapy compared with segments transported concurrently with adjuvant chemotherapy. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Anthony Bozzo
- Orthopaedic Service of the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Orthopedic Oncology, McGill University, Montreal, Canada
| | - Varun Aysola
- Orthopaedic Service of the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Caleb M Yeung
- Orthopaedic Service of the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John H Healey
- Orthopaedic Service of the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel E Prince
- Orthopaedic Service of the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
5
|
Gonzalez MR, Acosta JI, Clunk MJ, Bedi ADS, Karczewski D, Newman ET, Raskin KA, Lozano-Calderon SA. Debridement, Antibiotics, and Implant Retention (DAIR) Plus Offers Similar Periprosthetic Joint Infection Treatment Success Rates to Two-Stage Revision in Oncologic Megaprosthesis. J Arthroplasty 2024; 39:1820-1827. [PMID: 38224789 DOI: 10.1016/j.arth.2024.01.021] [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: 09/25/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Prosthetic joint infections (PJIs) after megaprosthesis implantation are associated with high rates of treatment failure and amputation. Our study analyzed PJI treatment success rates by surgical strategy and assessed risks of reinfection and amputation. METHODS We retrospectively analyzed the outcomes of patients diagnosed with PJI after undergoing megaprosthesis implantation for oncologic indications. The 2011 Musculoskeletal Infection Society criteria were used to define PJI. Reinfection, reoperation, and amputation for PJI recurrence were assessed. A total of 67 patients with megaprosthesis PJIs were included. There were fourteen patients who were treated with debridement, antibiotics, and implant retention (DAIR), 31 with DAIR plus (DAIR with modular component exchange and stem retention), and 21 with two-stage revisions. Kaplan-Meier estimates were used for survival analyses and Cox proportional hazards for risk factor analyses. RESULTS The two-year reinfection-free survival was 25% for DAIR and 60% for DAIR plus or two-stage revision (P = .049). The five-year amputation-free survival was 84% for DAIR plus or two-stage revision, and 48% for DAIR (P = .13). Reinfection-free, reoperation-free, and amputation-free survival were similar between DAIR plus and two-stage revision at the 2- and 5-year marks. Body mass index ≥30 (hazard ratio [HR] = 2.65) and chronic kidney disease (HR = 11.53) were risk factors for reinfection. Treatment with DAIR plus or two-stage revision (HR = 0.44) was a protective factor against reinfection. CONCLUSIONS A DAIR was associated with high rates of treatment failure and higher amputation rates than DAIR plus or 2-stage surgery. A DAIR plus was not inferior to 2-stage revision clearing a PJI and might be performed in patients who cannot withstand two-stage revision surgery.
Collapse
Affiliation(s)
- Marcos R Gonzalez
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | - José I Acosta
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts; School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico; Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marilee J Clunk
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Angad D S Bedi
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | - Daniel Karczewski
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | - Erik T Newman
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | - Kevin A Raskin
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderon
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital Boston/Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Cianni L, Taccari F, Bocchi MB, Micheli G, Sangiorgi F, Ziranu A, Fantoni M, Maccauro G, Vitiello R. Characteristics and Epidemiology of Megaprostheses Infections: A Systematic Review. Healthcare (Basel) 2024; 12:1283. [PMID: 38998818 PMCID: PMC11241048 DOI: 10.3390/healthcare12131283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/18/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants' infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors. METHODS We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons. RESULTS The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively. CONCLUSIONS The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management.
Collapse
Affiliation(s)
- Luigi Cianni
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Taccari
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Beatrice Bocchi
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Micheli
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavio Sangiorgi
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Ziranu
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Ospedale Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giulio Maccauro
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
7
|
Papalia GF, Ariyaratne S, Sison J, Morris G, Vaiyapuri S, Kurisunkal V, Botchu R. An unusual cystic presentation of pelvic skeletal Ewing sarcoma: a case series. Skeletal Radiol 2024:10.1007/s00256-024-04660-0. [PMID: 38625623 DOI: 10.1007/s00256-024-04660-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/17/2024]
Abstract
Ewing sarcoma (ES) is the second most common primary malignant bone tumour in children and adolescents. About 14.5% of primary malignancies develop in pelvic bones, where they typically have worse prognoses than extremity or acral sarcomas. It usually presents with aggressive features on radiology scans, but may also present with different radiological characteristics. In this series, we describe rare appearances of pelvic skeletal Ewing sarcoma, with large extraosseous cystic component on imaging, defined by the presence of fluid-filled spaces in the extraosseous tumour lesion, which distinguishes it from the solid nature of conventional ES. We report 3 cases of cystic presentation of ES, with imaging features supporting diagnosis of a primary malignant bone tumour arising from the superior pubic ramus with associated massive intrapelvic solid and cystic mass. CT-guided biopsy provided diagnosis of ES, with large intrapelvic soft tissue and cystic component. These patients underwent neo-adjuvant chemotherapy and proton beam therapy with significant reduction in size of the solid components, while the cystic components remained relatively unchanged. Two patients underwent surgical resection of the tumour (navigated P3 internal hemipelvectomy and hemipelvis P2/P3 resection, respectively), and one patient died while on treatment. In both who underwent surgery, histology showed ES with margins clear and more than 99% of treatment-induced necrosis. To the authors' knowledge, this unusual presentation of pelvic ES is described for the first time in the literature as a case series, with particular reference to atypical extraosseous cystic changes, along with the clinical and radiological characteristics, and their treatment.
Collapse
Affiliation(s)
- Giuseppe Francesco Papalia
- Department of Orthopedic Oncology, Royal Orthopedic Hospital, Birmingham, UK.
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128, Roma, Italy.
| | - Sisith Ariyaratne
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| | - Jerome Sison
- Department of Orthopedic Oncology, Royal Orthopedic Hospital, Birmingham, UK
| | - Guy Morris
- Department of Orthopedic Oncology, Royal Orthopedic Hospital, Birmingham, UK
| | | | - Vineet Kurisunkal
- Department of Orthopedic Oncology, Royal Orthopedic Hospital, Birmingham, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| |
Collapse
|
8
|
Hameed D, Dubin JA, Deter C, Bains SS, Chen Z, Salib CG, Moore MC, Wallace MT, Aboulafia AJ. Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications. J Orthop 2024; 50:135-138. [PMID: 38283873 PMCID: PMC10809001 DOI: 10.1016/j.jor.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/16/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
Background Distal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Methods All patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). Results Revision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1-57.8). Conclusion The use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.
Collapse
Affiliation(s)
- Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Carly Deter
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Zhongming Chen
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Christopher G. Salib
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Mallory C. Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Matthew T. Wallace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Albert J. Aboulafia
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| |
Collapse
|
9
|
Stevenson J, Siddiqi MA, Sheehy V, Kendrick B, Whitwell D, Taylor A, Blunn G, Mohammad HR, Kamath AF, Thoma S. Early radiological outcomes of a fully porous bridging collar in lower-limb endoprosthetic reconstructions: a case-matched retrospective series to assess osseointegration. ARTHROPLASTY 2024; 6:17. [PMID: 38429812 PMCID: PMC10908216 DOI: 10.1186/s42836-023-00230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/26/2023] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Limb-salvage surgery involving the utilization of endoprosthetic replacements is commonly employed following segmental bone resection for primary and secondary bone tumors. This study aimed to evaluate whether a fully porous bridging collar promotes early osseous integration in endoprosthetic replacements. METHODS We undertook a retrospective review of all lower-limb endoprostheses utilizing a fully porous endosteal bridging collar design. We matched this cohort with a conventional extra-osteal non-porous fully hydroxyapatite-coated grooved collar cohort according to surgical indication, implant type, resection length, age, and follow-up time. At 6, 12, and 24 months post-implantation, radiographs were assessed for the number of cortices with or without osseointegration on orthogonal radiographs. Each radiograph was scored on a scale of -4 to + 4 for the number of cortices bridging the ongrowth between the bone and the collar of the prosthesis. Implant survival was estimated using the Kaplan-Meier method, and the mean number of osseointegrated cortices at each time point between the collar designs was compared using a paired t-test. RESULTS Ninety patients were retrospectively identified and analyzed. After exclusion, 40 patients with porous bridging collars matched with 40 patients with conventional extra-osteal non-porous collars were included in the study (n = 80). The mean age was 63.4 years (range 16-91 years); there were 37 males and 43 females. The groups showed no difference in implant survival (P = 0.54). The mean number of cortices with radiographic ongrowth for the porous bridging collar and non-porous collar groups was 2.1 and 0.3, respectively, at 6-month (P < 0.0001), 2.4 and 0.5, respectively, at 12-month (P = 0.044), and 3.2 and -0.2, respectively, at 24-month (P = 0.18) radiological follow-up. CONCLUSION These findings indicate that fully porous bridging collars increased the number of cortices, with evidence of bone ongrowth between 6 and 24 months post-implantation. By contrast, extra-osteal collars exhibited reduced evidence of ongrowth between 6 and 24 months post-implantation. In the medium term, the use of a fully porous bridging collar may translate to a reduced incidence of aseptic loosening.
Collapse
Affiliation(s)
- Jonathan Stevenson
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
- Aston University Medical School, Aston University, Birmingham, B4 7ET, UK.
| | - M Ather Siddiqi
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Windmill Road, Oxford, OX3 7LD, UK
| | - Vicky Sheehy
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Windmill Road, Oxford, OX3 7LD, UK
| | - Ben Kendrick
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Windmill Road, Oxford, OX3 7LD, UK
| | - Duncan Whitwell
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Windmill Road, Oxford, OX3 7LD, UK
| | - Adrian Taylor
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Windmill Road, Oxford, OX3 7LD, UK
| | - Gordon Blunn
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, St. Michaels Building, White Swan Road, Portsmouth, PO1 2DT, UK
| | - Hasan R Mohammad
- Bart's Bone Joint Health, Bart's and the London School of Medicine and Dentistry, Blizard Institute, 4 Newark St., London, E1 2AT, UK
| | - Atul F Kamath
- Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, 9500 Euclid Avenue A40, Cleveland, OH, 44195, USA
| | - Sofia Thoma
- Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| |
Collapse
|
10
|
El Alaoui O, Jelti O, Lachkar A, Najib A, Yacoubi H. Megaprosthesis Total Knee Replacement Following Resection of Extensive Osteoblastic Osteosarcoma in the Distal Femur: A Case Report. Cureus 2024; 16:e56971. [PMID: 38665714 PMCID: PMC11045034 DOI: 10.7759/cureus.56971] [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] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Osteosarcoma is the most common type of primary bone cancer, which usually appears in the distal femur. The diagnosis of this condition typically involves advanced imaging and tissue biopsy, as well as taking into account characteristic clinical and radiographic indicators. The treatment approach for distal femoral osteosarcoma is multidisciplinary and involves initial chemotherapy, followed by limb-sparing surgery, reconstruction of bone and soft tissue, and subsequent adjuvant chemotherapy. We present a case study of a 25-year-old male admitted with a blastic lesion in the distal femur, confirmed via open biopsy to be osteoblastic osteosarcoma. Further evaluation revealed multiple pulmonary nodular lesions, managed with chemotherapy. After four months, regression of the lesion was observed. Due to malignant clinical and imaging features, excision of the lesion and subsequent reconstruction were performed, utilizing a custom-made total knee arthroplasty. The excision encompassed the removal of the distal 14 cm of the femur, with histological examination confirming central osteoblastic osteosarcoma. Satisfactory outcomes were observed during a one-year follow-up, indicating promising results. Vigilance is crucial, especially in young patients with surface-type bone tumors, as this neoplasm requires consideration.
Collapse
Affiliation(s)
- Oussama El Alaoui
- Orthopedics and Traumatology, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University of Oujda - CHU Mohammed VI Oujda, Oujda, MAR
| | - Ousama Jelti
- Orthopedics, Traumatology and Orthopedic, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Adnane Lachkar
- Orthopedic Trauma, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University of Oujda, Oujda, MAR
| | - Abdeljaouad Najib
- Traumatology, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Hicham Yacoubi
- Orthopedic Trauma, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University of Oujda, Oujda, MAR
| |
Collapse
|
11
|
Ng YH, Chai YC, Mazli N, Jaafar NF, Ibrahim S. Outcome of Endoprosthesis used in Limb Salvage Surgery in a Malaysian Orthopaedic Oncology Centre. Malays Orthop J 2024; 18:60-65. [PMID: 38638655 PMCID: PMC11023336 DOI: 10.5704/moj.2403.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/14/2023] [Indexed: 04/20/2024] Open
Abstract
Introduction To describe the duration of survival among bone tumour patients with endoprosthesis reconstruction and to determine frequency of implant failure, revision of surgery, and amputation after endoprosthesis reconstruction. Materials and methods A retrospective cross-sectional review of all patients with either primary bone tumour or secondary bone metastases treated with en bloc resection and endoprosthesis reconstruction from January 2008 to December 2020. Results A total of 35 failures were recorded among the 27 (48.2%) patients with endoprostheses. Some of the patients suffered from one to three types of modes of failure on different timelines during the course of the disease. Up to eight patients suffered from more than one type of failure throughout the course of the disease. Out of all modes of failure, local recurrence (type 5 failure) was the most common, accounting for 25.0% of all failure cases. Four patients (7.1%) eventually underwent amputation, which were either due to infection (2 patients) or disease progression causing local recurrence (2 patients). Conclusion The overall result of endoprosthesis reconstruction performed in our centre was compatible with other centres around the world. Moreover, limb salvage surgery should be performed carefully in a selected patient group to maximise the benefits of surgery.
Collapse
Affiliation(s)
- Y H Ng
- Department of Orthopaedic, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - Y C Chai
- General Psychiatry Division, Hospital Permai Johor Bahru, Johor Bahru, Malaysia
| | - N Mazli
- Department of Orthopaedics and Traumatology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - N F Jaafar
- Department of Orthopaedic, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - S Ibrahim
- Department of Orthopaedic, Hospital Sultan Ismail, Johor Bahru, Malaysia
| |
Collapse
|
12
|
Trikha R, Greig D, Sekimura T, Geiger EJ, Wessel L, Eckardt JJ, Bernthal NM. The microbial profile of infected endoprosthetic reconstructions after wide excision for patients with musculoskeletal tumors: A call for pathogen-based practices. J Surg Oncol 2023; 128:1437-1445. [PMID: 37610049 DOI: 10.1002/jso.27428] [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: 05/07/2023] [Revised: 07/25/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Periprosthetic infection is a devastating complication following endoprosthetic reconstruction. This study utilized a large database of endoprostheses to describe the incidence, risk factors, and microbial profile of such infections to better catalogue and understand these catastrophic events. METHODS A retrospective review of endoprosthetic reconstructions for an oncologic indication from January 1, 1981 to December 31, 2020 was performed. Demographic, oncologic, procedural and outcome data was analyzed. Multivariable logistic regression was used to identify potential risk factors for infection with significance defined as p < 0.05. RESULTS Forty four out of 712 (6.2%) reconstructions resulted in infection at a mean time of 39.9 ± 44.5 months. Revision surgery (odds ratio [OR] 6.14, p < 0.001) or having a postoperative wound complication (OR 7.67, p < 0.001) were significantly associated with infection. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly cultured organisms at a rate of 34.1% (15/44) and 22.7% (10/44), respectively. Ten infections resulted in amputation; five due to antimicrobial-resistant infections and three due to polymicrobial infections. CONCLUSION Understanding the microbial profile of patients undergoing endoprosthetic reconstruction is paramount. This study demonstrates a relatively high rate of polymicrobial and antibiotic-resistant infections that portend worse outcomes, thus suggesting that pathogen-specific infectious practices may be warranted. LEVEL OF EVIDENCE Retrospective cohort study, level III.
Collapse
Affiliation(s)
- Rishi Trikha
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Danielle Greig
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Troy Sekimura
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Erik J Geiger
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Lauren Wessel
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Jeffrey J Eckardt
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery at the University of California, Santa Monica, California, USA
| |
Collapse
|
13
|
Welsh C, Hull P, Meckmongkol T, Mumith A, Lovejoy J, Giangarra C, Coathup M. Osseointegration reduces aseptic loosening of primary distal femoral implants in pediatric and adolescent osteosarcoma patients: a retrospective clinical and radiographic study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3585-3596. [PMID: 37246989 DOI: 10.1007/s00590-023-03590-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
AIM The challenge of distal femoral replacement (DFR) longevity remains a priority for orthopaedic oncologists as the overall survival and activity level of young patients with osteosarcoma continues to improve. This study hypothesized that increased extracortical osseointegration at the bone-implant shoulder (i.e., where the metal implant shaft abuts the femur) will improve stress transfer adjacent to the implant, as evidenced by reduced cortical bone loss, radiolucent line progression and implant failure in young patients (< 20 years) following DFR surgery. METHODS Twenty-nine patients of mean age 13.09 ± 0.56 years received a primary DFR. The clinical outcome of 11 CPS®, 10 GMRS®, 5 Stanmore® and 3 Repiphysis® implants was evaluated over a mean follow-up period of 4.25 ± 0.55 years. The osseous response to a bone-implant shoulder composed of either a hydroxyapatite-coated grooved ingrowth collar (Stanmore®), a porous metal coating (GMRS®) or a polished metal surface (Repiphysis®) was quantified radiographically. RESULTS All (100.0%) of the Stanmore® implants, 90.0% of GMRS®, 81.8% of CPS® and 33.3% of the Repiphysis® implants survived. Significantly increased extracortical bone and osseointegration were measured adjacent to the Stanmore® bone-implant shoulder when compared with the GMRS® and Repiphysis® implants (p < 0.0001 in both cases). Significantly decreased cortical loss was identified in the Stanmore® group (p = 0.005, GMRS® and p < 0.0001, Repiphysis®) and at 3 years, the progression of radiolucent lines adjacent to the intramedullarly stem was reduced when compared with the GMRS® and Repiphysis® implants (p = 0.012 and 0.026, respectively). CONCLUSIONS Implants designed to augment osseointegration at the bone-implant shoulder may be critical in reducing short- (≤ 2 years) to mid- (≤ 5 years) term aseptic loosening in this vulnerable DFR patient group. Further longer-term studies are required to confirm these preliminary findings.
Collapse
Affiliation(s)
- Clayton Welsh
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Peyton Hull
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Teerin Meckmongkol
- College of Medicine, University of Central Florida, Orlando, FL, USA
- Department of General Surgery, Nemours Children's Hospital, Orlando, FL, USA
- Department of Internal Medicine, College of Medicine, Biionix (Bionic Materials, Implants & Interfaces) Cluster, University of Central Florida, Orlando, FL, USA
| | - Aadil Mumith
- College of Medicine, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine, College of Medicine, Biionix (Bionic Materials, Implants & Interfaces) Cluster, University of Central Florida, Orlando, FL, USA
- Sunnybrook Holland Orthopaedic Centre, Toronto, Canada
| | - John Lovejoy
- College of Medicine, University of Central Florida, Orlando, FL, USA
- Department of Orthopaedics, Sports Medicine and Physical Medicine and Rehabilitation, Nemours Children's Hospital, Orlando, FL, USA
| | - Charles Giangarra
- Department of Orthopaedic Surgery, Marshall University, Huntington, WV, USA
| | - Melanie Coathup
- College of Medicine, University of Central Florida, Orlando, FL, USA.
- Department of Internal Medicine, College of Medicine, Biionix (Bionic Materials, Implants & Interfaces) Cluster, University of Central Florida, Orlando, FL, USA.
| |
Collapse
|
14
|
Ghanem M, Kalb A, Heyde CE, Roth A. Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities. Sci Rep 2023; 13:17594. [PMID: 37845299 PMCID: PMC10579354 DOI: 10.1038/s41598-023-44992-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 10/14/2023] [Indexed: 10/18/2023] Open
Abstract
In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.
Collapse
Affiliation(s)
- M Ghanem
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig (Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR), Liebigstrasse 20, 04103, Leipzig, Germany.
- Department of Physical Therapy and Rehabilitation, University Hospital Leipzig, Leipzig, Germany.
| | - A Kalb
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig (Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR), Liebigstrasse 20, 04103, Leipzig, Germany
| | - C-E Heyde
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig (Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR), Liebigstrasse 20, 04103, Leipzig, Germany
| | - A Roth
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig (Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR), Liebigstrasse 20, 04103, Leipzig, Germany
| |
Collapse
|
15
|
Cho S, Jeon DG, Cho WH, Song WS, Kim Y. Proximal Femur Salvage in Revision Knee Arthroplasty Due to Oncologic Indications: Long-term Results of Onlay and Overlapping Allograft in Revision Surgeries. Clin Orthop Surg 2023; 15:853-863. [PMID: 37811502 PMCID: PMC10551674 DOI: 10.4055/cios22254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 10/10/2023] Open
Abstract
Background Mechanical failures of tumor endoprosthesis in the distal femur usually require revision surgery. We investigated if the proximal femur host bone can be salvaged by onlay and overlapping allograft in revision surgeries due to aseptic loosening and stem fractures. Methods We retrospectively reviewed 18 patients (7 men and 11 women) with osteosarcoma around the knee. The entire cohort was classified into three subgroups (no bone graft: 6, onlay allograft: 7, and overlapping allograft: 5) according to our treatment strategy. Results The median interval from the initial surgery to the revision was 94.5 months (range, 21-219 months), and the median follow-up period from the revision surgery was 88.0 months (range, 24-179 months). At the last follow-up, 9 of the 18 patients maintained their endoprostheses, and the 5-year prosthesis survival rate was 57.9%. Limb survival was 100%. Five-year prosthesis survival rate was 66.7% in the no bone graft group, 85.7% in the onlay allograft group while 30.0% in the overlapping allograft group. In the no bone graft group and onlay allograft group, 66.7% (4/6) and 57.1% (4/7) maintained their revision prostheses while no prostheses survived in the overlapping allograft group. Recurrent stem loosening was observed in 14.2% (1/7) and 60.0% (3/5) of the onlay allograft and overlapping allograft groups, respectively, despite allograft bone union. The complication rate was 66.7% (12/18) in the entire cohort. The most common type of complication was infection (n = 6), followed by aseptic loosening (n = 4) and mechanical failure (n = 2). Conclusions This study indicates that onlay allograft can be used as a supportive method in revising failed endoprosthesis if the extent of host bone destruction is extensive. However, applying overlapping allograft to secure bone stock showed a high rate of mechanical failures and infection in the long term. Future studies with a larger cohort are necessary to assess the prognostic factors for the higher complication rate in overlapping allograft and the need for overlapping allograft. Surveillance with consideration of the risk of anteromedial osteolysis in allograft and efforts for prevention of periprosthetic infection are essential.
Collapse
Affiliation(s)
- Sanghyun Cho
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Dae-Geun Jeon
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Wan Hyeong Cho
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Won Seok Song
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
| | - Yongsung Kim
- Department of Orthopedic Surgery, Korea Cancer Center Hospital, Seoul, Korea
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
16
|
Laitinen MK, Parry MC, Morris GV, Jeys LM. Pelvic bone sarcomas, prognostic factors, and treatment: A narrative review of the literature. Scand J Surg 2023; 112:206-215. [PMID: 37438963 DOI: 10.1177/14574969231181504] [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] [Indexed: 07/14/2023]
Abstract
Primary sarcomas of bone are rare malignant mesenchymal tumors. The most common bone sarcomas are osteosarcoma, Ewing's sarcoma, and chondrosarcoma. The prognosis has improved over the years, but bone sarcomas are still life-threatening tumors that need a multidisciplinary approach for diagnosis and treatment. Bone sarcomas arising in the pelvis present a unique challenge to orthopedic oncologists due to the absence of natural anatomical barriers, the close proximity of vital neurovascular structures, and the high mechanical demands placed on any pelvic reconstruction following the excision of the tumor. While radiotherapy has an important role especially in Ewing's sarcoma and chemotherapy for both Ewing's sarcoma and osteosarcoma, surgery remains the main choice of treatment for all three entities. While external hemipelvectomy has remained one option, the main aim of surgery is limb salvage. After complete tumor resection, the bone defect needs to be reconstructed. Possibilities to reconstruct the defect include prosthetic or biological reconstruction. The method of reconstruction is dependent on the location of tumor and the surgery required for its removal. The aim of this article is to give an insight into pelvic bone sarcomas, their oncological and surgical outcomes, and the options for treatment based on the authors' experiences.
Collapse
Affiliation(s)
- Minna K Laitinen
- Helsinki University Hospital and University of Helsinki Helsinki Finland Bridge Hospital Haartmaninkatu 4 PL 370 00029 HUS
- The Royal Orthopaedic Hospital, Birmingham, UK
| | - Michael C Parry
- The Royal Orthopaedic Hospital, Birmingham, UK
- The Royal Orthopaedic Hospital, Birmingham, UK
| | - Guy V Morris
- The Royal Orthopaedic Hospital, Birmingham, UK
- The Royal Orthopaedic Hospital, Birmingham, UK
| | - Lee M Jeys
- The Royal Orthopaedic Hospital, Birmingham, UK
| |
Collapse
|
17
|
Emet A, Demirtas Y, Beydemir A, Ayvaz M. Comparison of the Results of Patients Treated With Limb-Sparing Treatment Options in Malignant Bone Tumors: Sharing the Experience of Twelve Bicentric Patients. Cureus 2023; 15:e46270. [PMID: 37790071 PMCID: PMC10544185 DOI: 10.7759/cureus.46270] [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] [Accepted: 09/30/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVES Extremity-sparing surgery should be the main objective if a functional extremity is to be obtained in cases of malignant bone tumors. After extensive resection, numerous techniques have been described to reconstruct bone defects. This study aimed to compare the outcomes of patients who underwent external radiation therapy and liquid nitrogen biological reconstruction at two different facilities. METHODS The study included 12 patients who received biological reconstruction therapy for bone sarcoma and had at least two years of follow-up. Demographic data, pathological diagnosis, presence of systemic metastasis, and recurrence during follow-up were among the information logged. Patients who used liquid nitrogen were placed in group 1, and those who underwent external irradiation were placed in group 2. After being contacted for their final follow-up appointments, the outcomes were compared by recording the Musculoskeletal Tumor Society Score (MSTSS). RESULTS For participants with a mean age of 10.75±3.6 (5-17), the follow-up period was 30.2±16.3 months in total. In contrast to the patients in group 1, who experienced union on average after 7.5±1.2 months, those in group 2 experienced union after 7.6±1.1 months. Patients in group 1 had an MSTSS of 75.5±11.8%, while those in group 2 had a score of 77±4.4. There was no discernible difference between the two groups' union times (p>0.05). There was no statistically significant difference between the two groups' MSTSS (p>0.05). CONCLUSION After tumor resection, extracorporeal radiation therapy and the application of liquid nitrogen are still useful treatment options and neither of them is superior to the other.
Collapse
Affiliation(s)
- Abdulsamet Emet
- Orthopedics and Traumatology, Etlik City Hospital, Ankara, TUR
| | - Yunus Demirtas
- Orthopedics and Traumatology, Yuksek Ihtisas University Medical School, Ankara, TUR
| | | | - Mehmet Ayvaz
- Orthopedics and Traumatology, Hacettepe University, Ankara, TUR
| |
Collapse
|
18
|
Bozzo A, Yeung CM, Van De Sande M, Ghert M, Healey JH. Operative Treatment and Outcomes of Pediatric Patients with an Extremity Bone Tumor: A Secondary Analysis of the PARITY Trial Data. J Bone Joint Surg Am 2023; 105:65-72. [PMID: 37466582 PMCID: PMC11231958 DOI: 10.2106/jbjs.22.01231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Osteosarcoma and Ewing sarcoma are the 2 most common primary bone sarcomas, occurring predominantly in pediatric patients, with the incidence of osteosarcoma correlating with periods of peak bone-growth velocity. Although survival outcomes have plateaued over the past several decades, ongoing treatment advances have improved function, decreased infection rates, and improved other clinical outcomes in patients with bone tumors. Recently, the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial addressed the serious problem of surgical site infection (SSI) and the lack of consensus regarding the appropriate prophylactic postoperative antibiotic regimen. The objective of the present secondary analysis of the PARITY trial was to characterize the modern treatment and surgical and oncologic outcomes of pediatric patients with bone tumors at 1 year postoperatively. METHODS The PARITY trial included patients ≥12 years old with a bone tumor or soft-tissue sarcoma that was invading the femur or tibia, necessitating osseous resection and endoprosthetic reconstruction. This pediatric subanalysis of the PARITY trial data included all PARITY patients ≤18 years old. As in the main PARITY study, patients were randomized to either a 5-day or 1-day course of postoperative antibiotic prophylaxis. The primary outcome measure was the development of an SSI within 1 year, and secondary outcomes included antibiotic-related adverse events, unplanned additional operations, local recurrence, metastasis, and death. RESULTS A total of 151 patients were included. An adjudicated SSI occurred in 27 patients (17.9%). There was no difference in the rate of any SSI between the 5-day and 1-day antibiotic groups (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.4 to 1.9; p = 0.82). Antibiotic-related complications occurred in 13 patients (8.6%), with no difference noted between groups (HR, 0.46; 95% CI, 0.2 to 1.4; p = 0.18). A total of 45 patients (29.8%) required a return to the operating room within the first postoperative year, which corresponded with a 68.8% reoperation-free rate of survival at 1 year when accounting for competing risks. The most common reason for reoperation was infection (29 of 45; 64.4%). A total of 7 patients (4.6%) required subsequent amputation of the operative extremity, and an additional 6 patients (4.0%) required implant revision within 12 months. A total of 36 patients (23.8%) developed metastases, and 6 patients (4.0%) developed a local recurrence during the first postoperative year. A total of 11 patients (7.3%) died during the study period. There were no significant differences in oncologic outcomes between the 5-day and 1-day antibiotic groups (HR, 0.97; 95% CI, 0.5-1.8; p = 0.92). CONCLUSIONS There were no significant differences in surgical or oncologic outcomes between pediatric patients who underwent a 1-day versus 5-day antibiotic regimen following endoprosthetic reconstruction in the PARITY trial. Surgeons should be aware of and counsel patients and caregivers regarding the 30% rate of reoperation and the risks of infection (17.9%), death (7.3%), amputation (4.6%), and implant revision (4%) within the first postoperative year. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Anthony Bozzo
- Division of Musculoskeletal Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Caleb M. Yeung
- Division of Musculoskeletal Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Michiel Van De Sande
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - John H. Healey
- Division of Musculoskeletal Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| |
Collapse
|
19
|
Fraterrigo G, Schileo E, Simpson D, Stevenson J, Kendrick B, Taddei F. Does a novel bridging collar in endoprosthetic replacement optimise the mechanical environment for osseointegration? A finite element study. Front Bioeng Biotechnol 2023; 11:1120430. [PMID: 37342508 PMCID: PMC10277679 DOI: 10.3389/fbioe.2023.1120430] [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: 12/09/2022] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
Introduction: Limb-salvage surgery using endoprosthetic replacements (EPRs) is frequently used to reconstruct segmental bone defects, but the reconstruction longevity is still a major concern. In EPRs, the stem-collar junction is the most critical region for bone resorption. We hypothesised that an in-lay collar would be more likely to promote bone ongrowth in Proximal Femur Reconstruction (PFR), and we tested this hypothesis through validated Finite Element (FE) analyses simulating the maximum load during walking. Methods: We simulated three different femur reconstruction lengths (proximal, mid-diaphyseal, and distal). For each reconstruction length one in-lay and one traditional on-lay collar model was built and compared. All reconstructions were virtually implanted in a population-average femur. Personalised Finite Element models were built from Computed Tomography for the intact case and for all reconstruction cases, including contact interfaces where appropriate. We compared the mechanical environment in the in-lay and on-lay collar configurations, through metrics of reconstruction safety, osseointegration potential, and risk of long-term bone resorption due to stress-shielding. Results: In all models, differences with respect to intact conditions were localized at the inner bone-implant interface, being more marked in the collar-bone interface. In proximal and mid-diaphyseal reconstructions, the in-lay configuration doubled the area in contact at the bone-collar interface with respect to the on-lay configuration, showed less critical values and trends of contact micromotions, and consistently showed higher (roughly double) volume percentages of predicted bone apposition and reduced (up to one-third) percentages of predicted bone resorption. In the most distal reconstruction, results for the in-lay and on-lay configurations were generally similar and showed overall less favourable maps of the bone remodelling tendency. Discussion: In summary, the models corroborate the hypothesis that an in-lay collar, by realising a more uniform load transfer into the bone with a more physiological pattern, creates an advantageous mechanical environment at the bone-collar interface, compared to an on-lay design. Therefore, it could significantly increase the survivorship of endo-prosthetic replacements.
Collapse
Affiliation(s)
- Giulia Fraterrigo
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Bioingegneria Computazionale, Bologna, Italy
| | - Enrico Schileo
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Bioingegneria Computazionale, Bologna, Italy
| | | | - Jonathan Stevenson
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Aston University Medical School, Aston University, Birmingham, United Kingdom
| | - Ben Kendrick
- Nuffield Orthopaedic Centre, Oxford University Hospitals Trust, Oxford, United Kingdom
- Nuffield Department of Orthopaedics, Rheumatology and Musculo-skeletal Science, University of Oxford, Oxford, England
| | - Fulvia Taddei
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Bioingegneria Computazionale, Bologna, Italy
| |
Collapse
|
20
|
Şirin E, Sofulu Ö, Baysal Ö, Akgülle AH, Erol B. Staged Management of Infection with Adjustable Spacers After Megaprosthesis Implantation in Primary Sarcoma Patients. Indian J Orthop 2023; 57:938-947. [PMID: 37214371 PMCID: PMC10192496 DOI: 10.1007/s43465-023-00876-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/16/2023] [Indexed: 05/24/2023]
Abstract
Background While periprosthetic joint infection has always been a significant concern for orthopaedic surgeons, the rate of infection is five to ten times higher after tumor prosthesis implantation. With the growing use of mega-implants, the number of these infections has also increased. We aimed to investigate the results of our patients with a primary malignant musculoskeletal tumor, who underwent two-stage revision surgery for an infected mega-prosthesis. We also presented the emerging complicatons and required soft tissue reconstruction procedures. Methods The study included 32 primary bone and soft tissue sarcoma patients who underwent a two-stage revision procedure for infection. After a rigorous bone and soft tissue debridement procedure at the first stage, antibiotic-loaded bone cement was wrapped around a cloverleaf type intramedullary nail and inserted into the forming gap. After a minimum of 6 weeks of antibiotic therapy, depending on patients' clinical signs and serum infection markers, the reimplantation stage was undertaken. Results The mean oncologic follow-up period was 28 months (range 5-96 months). During this period, 11 patients died because of non-infection related causes, 12 patients were alive with their disease, whereas 9 patients were totally free of their oncologic condition. The infection was eradicated in all survivors except one patient, where a high-level transfemoral amputation became necessary. Conclusion Periprosthetic infection after tumor proshesis implantation in cancer patients can be managed with same principles as conventional arthroplaty procedures, taking care that they are immunocompromised and vulnerable patients and their bone stock loss is significant which makes surgical options more challenging.
Collapse
Affiliation(s)
- Evrim Şirin
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ömer Sofulu
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Özgür Baysal
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Hamdi Akgülle
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Bülent Erol
- Department of Orthopaedic Surgery and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
21
|
Pilavaki P, Gahanbani Ardakani A, Gikas P, Constantinidou A. Osteosarcoma: Current Concepts and Evolutions in Management Principles. J Clin Med 2023; 12:jcm12082785. [PMID: 37109122 PMCID: PMC10143544 DOI: 10.3390/jcm12082785] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/08/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Osteosarcoma is a rare malignancy arising from mesenchymal tissue, and represents the most common bone sarcoma. The management of osteosarcoma is challenging, and requires a multidisciplinary approach. In daily clinical practice, surgery, radiotherapy, and conventional chemotherapy constitute the therapeutic armamentarium against the disease. However, a significant number of patients with initially localized osteosarcoma will experience local or distant recurrence, and the prognosis for metastatic disease remains dismal. There is a pressing need to identify novel therapeutic strategies to better manage osteosarcoma and improve survival outcomes. In this study, we present recent advances in the therapeutic management of osteosarcoma, including surgical and medical advances. The role of immunotherapy (immune checkpoint inhibitors, adoptive cellular therapy, cancer vaccines) and other targeted therapies including tyrosine kinase inhibitors is discussed; however, additional studies are required to delineate their roles in clinical practice.
Collapse
Affiliation(s)
- Pampina Pilavaki
- Medical School, University of Cyprus, Nicosia 1678, Cyprus
- Medical Oncology, Bank of Cyprus Oncology Center, Nicosia 2006, Cyprus
| | | | - Panagiotis Gikas
- Department of Orthopaedics, Cleveland Clinic London, London SW1X 7HY, UK
| | - Anastasia Constantinidou
- Medical School, University of Cyprus, Nicosia 1678, Cyprus
- Medical Oncology, Bank of Cyprus Oncology Center, Nicosia 2006, Cyprus
- Cyprus Cancer Research Institute, Nicosia 2109, Cyprus
| |
Collapse
|
22
|
Geiger EJ, Arnold MT, Hart CM, Greig D, Trikha R, Sekimura T, Eckardt JJ, Bernthal NM. What Is the Long-term Survivorship of Primary and Revision Cemented Distal Femoral Replacements for Limb Salvage of Patients With Sarcoma? Clin Orthop Relat Res 2023; 481:460-471. [PMID: 35943730 PMCID: PMC9928619 DOI: 10.1097/corr.0000000000002333] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/30/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cemented endoprosthetic reconstruction after resection of primary bone sarcomas has been in common use for decades. Although multiple studies have reported the survivorship of primary endoprostheses, implant survivorship after revision surgery is less well established. Given that earlier advances in systemic therapy improved survival of patients with sarcoma, the usage of revision endoprostheses can be expected to increase and, as such, understanding revision implant survivorship will help to inform patient and surgeon expectations. Additionally, as new implants are developed that allow alternative reconstruction options, a normative dataset establishing accurate expectations for revision cemented endoprostheses is a critical benchmark by which to measure progress. QUESTIONS/PURPOSES (1) What is the implant survivorship free of all-cause revision for primary and revision cemented distal femoral replacements (DFRs) used in the treatment of malignant or benign tumors? (2) What are the most common indications for revision of primary and revision DFRs in an oncology population with mean follow-up of more than 10 years? (3) How does the indication for revision of a primary DFR affect the subsequent risk for and type of revision DFR complication? (4) What patient, tumor, or implant characteristics are associated with improved survivorship free of revision in cemented DFRs used in patients treated initially for primary malignant or benign tumors? METHODS This was a retrospective, comparative study using our institution's longitudinally-maintained database of 806 cemented endoprostheses starting in 1980 and assessed through December 31, 2018. In all, 365 DFRs were inserted during this time, but 14% (51 of 365) were placed for nonprimary bone tumors and 1% (5 of 365) were cementless reconstructions, leaving 309 cemented DFRs. Seventy-one percent (218 of 309) were primary implants and 29 percent (91 of 309) were revision implants (used to revise a prior DFR in all patients). During this time period, our strong bias was to use cemented stems and, thus, nearly all of our patients had cemented stems. Six percent (13 of 218) of primary DFRs were implanted more than 2 years before the study end; however, they lacked 2 years of follow-up data and, thus, were considered lost to follow-up, leaving 205 implants in the primary DFR analysis group. Only the first revision after primary DFR revision surgery was included in the revision cohort analysis. Thirty-two percent (29 of 91) of revision DFRs were second or more revision patients and were excluded, leaving 62 implants in the revision analysis group. Most patients in both groups were men (57% [117 of 205] for primary and 71% [44 of 62] for revision) who had been diagnosed with osteosarcoma (75% [153 of 205] and 73% [45 of 62] for primary and revision, respectively). The primary cohort had mean age of 26 ± 16 years with a mean follow-up of 136 ± 122 months, and the revision cohort had mean age of 31 ± 13 years (p = 0.02) with 141 ± 101 months of follow-up. Study endpoints included all-cause implant revision and cause-specific revision for soft tissue complications, aseptic loosening, structural complications (defined as periprosthetic or implant fracture), infection, or tumor progression. Planned surgery for implant lengthening procedures was excluded. Implant survivorship free from all-cause revision was calculated using a competing risk (cumulative incidence) estimator with death as a competing risk. A log-rank test using chi-square analysis was used to evaluate the differences in implant survivorship between primary DFRs and first revisions. The cause-specific incidences of implant revision were tabulated for primary and revision DFRs. Cox regression analysis investigated the odds of subsequent all-cause revision surgery for revision cemented DFRs based on the primary implant complication. A binary logistic regression analysis using age, gender, indication for revision, tumor type, infection, perioperative chemotherapy, and radiation was performed to identify factors associated with a second DFR reoperation. Relative effect sizes are reported as ORs. RESULTS The revision DFR cohort had a shorter mean survival to all-cause revision than the primary cohort (mean 10 years [95% CI 7 to 12] versus 18 years [95% CI 15 to 20]; p < 0.001). The most common complications necessitating revision for revision implants were periprosthetic or implant fracture in 37% (23 of 62) and aseptic loosening in 15% (9 of 62), and the type of primary implant complication was not associated with risk of subsequent all-cause revision surgery for revision implants. Stem diameter less than 15 mm was associated with repeat all-cause revision in cemented revision DFRs after controlling for resection length, stem length, implant fabrication (custom or modular), and presence of a porous collar (OR 4 [95% CI 1 to 17]; p = 0.03). No other parameters that we explored, including patient age, gender, chemoradiation history, or primary tumor diagnosis, were associated with repeat revision surgery. CONCLUSION Understanding modifiable factors that can improve revision DFR survival is critical to achieving long-term limb salvage for patients with tumors around the knee. Our data suggest that utilizing implants with the largest possible stems-or at a minimum increasing the stem size over the primary implant-is important to revision cemented DFR survivorship and is an important part of our revision practice. Improving revision implants' resistance to aseptic loosening through designs that resist torsion (a common mode of cemented fixation failure)-such as with the use of custom cross-pin fabrication-may be one method to improve survivorship. Another will be improved implant metallurgy that is resistant to fatigue fracture. Next steps may include understanding the optimal ratio of femoral diaphyseal width to implant diameter in patients where anatomic constraints preclude the insertion of cemented stems 15 mm or more in diameter. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
Affiliation(s)
- Erik J. Geiger
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Michael T. Arnold
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Christopher M. Hart
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Danielle Greig
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Rishi Trikha
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Troy Sekimura
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Jeffrey J. Eckardt
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
23
|
Tsantes AG, Altsitzioglou P, Papadopoulos DV, Lorenzo D, Romanò CL, Benzakour T, Tsukamoto S, Errani C, Angelini A, Mavrogenis AF. Infections of Tumor Prostheses: An Updated Review on Risk Factors, Microbiology, Diagnosis, and Treatment Strategies. BIOLOGY 2023; 12:biology12020314. [PMID: 36829589 PMCID: PMC9953401 DOI: 10.3390/biology12020314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
Several causes contribute to the high infection rate in tumor prostheses, including extensive tissue dissection and patients' immunosuppression due to the neoplastic disease. Most of these infections develop within the first 2 years following surgery with 70% of them occurring during the first year, while they are often associated with a low pathogen burden. The pathogenesis of infections in tumor prostheses is linked to bacteria developing in biofilms. Approximately half of them are caused by Staphylococcus spp., followed by Streptococcus spp., Enterococcus spp., and Enterobacteriaceae spp., while multiple pathogens may be isolated in up to 25% of the cases, with coagulase-negative Staphylococci (CoNS) and Enterococccus spp. being the most frequent pair. Although early detection and timely management are essential for complete resolution of these challenging infections, prompt diagnosis is problematic due to the highly varying clinical symptoms and the lack of specific preoperative and intraoperative diagnostic tests. Surgical management with one- or two-stage revision surgery is the mainstay for successful eradication of these infections. The recent advances in laboratory diagnostics and the development of biofilm-resistant prostheses over the past years have been areas of great interest, as research is now focused on prevention strategies. The aim of this study is to review and consolidate the current knowledge regarding the epidemiology, risk factors, microbiology, and diagnosis of infections of tumor prostheses, and to review the current concepts for their treatment and outcomes.
Collapse
Affiliation(s)
- Andreas G. Tsantes
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Pavlos Altsitzioglou
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitrios V. Papadopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 14233 Athens, Greece
| | - Drago Lorenzo
- Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
| | | | | | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Andrea Angelini
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35122 Padova, Italy
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-210-6542800
| |
Collapse
|
24
|
Tsukamoto S, Mavrogenis AF, Masunaga T, Kido A, Honoki K, Tanaka Y, Fujii H, Tanaka Y, Errani C. Megaprosthetic reconstruction of the distal femur with a short residual proximal femur following bone tumor resection: a systematic review. J Orthop Surg Res 2023; 18:68. [PMID: 36707881 PMCID: PMC9881341 DOI: 10.1186/s13018-023-03553-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To investigate the risk of postoperative function and complications associated with reconstruction methods in patients with short residual proximal femurs (< 12 cm) after resection of distal femoral bone tumors, we performed a systematic review of studies reporting postoperative function and complications in these patients. METHODS Of the 236 studies identified by systematic searches using the Medline, Embase, and Cochrane Central Register of Controlled Trials databases, eight were included (none were randomized controlled trials). In these studies, 106 (68.4%), 12 (7.7%), and 37 (23.9%) patients underwent reconstruction with custom-made megaprostheses with extracortical plates or cross-pins, allograft prosthetic composite (APC), and Compress® compliant pre-stress (CPS) implants, respectively. RESULTS Aseptic loosening occurred slightly more frequently in the APC group than in the other reconstruction methods (APC group, 21%; custom-made megaprosthesis group, 0-17%; CPS implant group, 14%). No differences were noted in the frequencies of implant breakage, fractures, or infections between the three reconstruction methods. Mechanical survival, where endpoint was set as implant removal for any reason, was 80% at seven years in the APC group, 70-77% at 10 years in the custom-made megaprosthesis group, and 68% at nine years in the CPS implant group. Therefore, there appeared to be no difference among the three reconstruction methods with respect to mechanical survival. CONCLUSIONS During megaprosthetic reconstruction of the distal femur with a short residual proximal femur after bone tumor resection, similar results were obtained using custom-made megaprostheses, APCs, and CPS implants.
Collapse
Affiliation(s)
- Shinji Tsukamoto
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Andreas F. Mavrogenis
- grid.5216.00000 0001 2155 0800First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Tomoya Masunaga
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Akira Kido
- grid.410814.80000 0004 0372 782XDepartment of Rehabilitation Medicine, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Kanya Honoki
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Yuu Tanaka
- Department of Rehabilitation Medicine, Wakayama Professional University of Rehabilitation, 3-1, Minamoto-Cho, Wakayama-City, Wakayama 640-8222 Japan
| | - Hiromasa Fujii
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Yasuhito Tanaka
- grid.410814.80000 0004 0372 782XDepartment of Orthopaedic Surgery, Nara Medical University, 840, Shijo-Cho, Kashihara-City, Nara 634-8521 Japan
| | - Costantino Errani
- grid.419038.70000 0001 2154 6641Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy
| |
Collapse
|
25
|
Early radiographic osseointegration of a novel highly porous 3D-printed titanium collar for megaprostheses compared to a previous generation smooth HA-coated collar. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04760-3. [PMID: 36598605 PMCID: PMC10374805 DOI: 10.1007/s00402-022-04760-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Extracortical osseointegration at the collar-bone interface of megaprostheses is associated with improved implant stability, lower rates of stem fracture and loosening. The use of hydroxy-apatite (HA-) coated collars showed mixed results in previously published reports. A novel collar system has recently become available utilizing additive manufacturing technology to create a highly porous titanium collar with a calcium-phosphate coated surface. The aim of this study was to evaluate our early experience with this novel collar and compare it to the previously used HA-coated model. METHODS Twenty patients who underwent megaprostheses implantation utilizing the novel collar system were case matched to 20 patients who had previously undergone a HA-coated collar. A minimum radiological follow-up of three months was available in all included patients. Osseointegration was evaluated using postoperative plain radiographs in two planes based on a previously published semi-quantitative score. RESULTS Compared to the HA-coated collar the use of the novel highly porous collar was associated with a higher proportion of cases demonstrating osseointegration at the bone-collar interface (80% vs. 65%). Application of the highly porous collar led to a significantly shortened time to reach the final ongrowth score (173 ± 89 days vs. 299 ± 165 days, p < 0.05). At one year follow-up, 90% of the novel collars had reached their final osseoingration grade compared to 50% in the HA-coated collar group (p < 0.001). Radiological osseointegration was seen in 71% for highly porous collars where the indication was revision arthroplasty, compared to 27% in reported in the literature. CONCLUSION These results indicate more reliable and accelerated osseointegration at the bone-collar interface of a novel highly porous collar system compared to a previously used HA-coated collar. Further studies are warranted to confirm these findings.
Collapse
|
26
|
Gibbons JAB, Kahlenberg CA, Jannat-Khah DP, Christ AB, Goodman SM, Sculco PK, Figgie MP, Mehta BY. Tumors Constitute a Majority of Total Knee Arthroplasty in Patients <21 Years Old: A United States Nationwide Analysis. J Arthroplasty 2022; 38:836-842. [PMID: 36481288 DOI: 10.1016/j.arth.2022.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is rarely performed in patients under 21 years old, but the frequency of utilization of TKA in this population in the United States is not known. The purpose of this study was to evaluate trends in the use of TKA in patients <21 in the United States. Additionally, we aimed to determine the characteristics of these patients and the hospitals in which this procedure is performed. METHODS We retrospectively reviewed the Kids' Inpatient Database, a national weighted sample of all inpatient hospital admissions in the United States in patients <21 years of age. We used International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes to identify patients undergoing TKA from 2000 to 2019 and determine a primary diagnosis. Descriptive statistics were calculated using the appropriate sample weights. RESULTS The total weighted number of TKAs performed in patients <21 years from 2000 to 2019 was 1,535. There were 70.9% of TKAs performed for a primary diagnosis of tumor, and the use of TKA for malignant tumors has increased. In contrast, the use of TKA for inflammatory arthritis/juvenile idiopathic arthritis decreased significantly over the study period. The majority of TKAs were performed in urban teaching hospitals with a large bed size. CONCLUSION Approximately 1,535 TKAs have been performed in patients <21 years from 2000 to 2019 in the United States. The majority of these procedures were performed for reconstruction after resection of a malignant tumor. The rate of TKA for inflammatory arthritis/juvenile idiopathic arthritis has decreased over the past two decades.
Collapse
Affiliation(s)
| | | | - Deanna P Jannat-Khah
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| | - Alexander B Christ
- Keck Hospital of the University of Southern California, Los Angeles, California
| | - Susan M Goodman
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| | - Peter K Sculco
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| | - Mark P Figgie
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| | - Bella Y Mehta
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| |
Collapse
|
27
|
[Application of three-dimensional printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1374-1380. [PMID: 36382455 PMCID: PMC9681585 DOI: 10.7507/1002-1892.202206058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate the clinical application and effectiveness of three-dimensional (3D) printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors. METHODS The clinical data of 10 adolescent patients with femoral primary malignant tumor who met the selection criteria and underwent limb salvage surgery with 3D printed customized prosthesis with preserved epiphysis and articular surface between January 2020 and October 2021 were retrospectively analyzed. There were 6 males and 4 females with an average age of 12.5 years ranging from 7 to 18 years. There were 8 cases of osteosarcoma and 2 cases of Ewing's sarcoma. Enneking stage was Ⅱb. The length of the lesions ranged from 76 to 240 mm, with an average of 138.0 mm. The length of osteotomy (i. e. length of customized prosthesis) ranged from 130 to 275 mm, with an average of 198.5 mm; the distance between distal osteotomy end and epiphyseal line ranged from 0 to 15 mm, with an average of 8.8 mm; the bone defect after osteotomy accounted for 37.36% to 79.02% of the total length of the lesion bone, with a mean of 49.43%. The operation time, intraoperative blood loss, complications, tumor outcome (refered to RESIST1.1 solid tumor efficacy evaluation criteria), and limb length discrepancy were recorded. The Musculoskeletal Cancer Society (MSTS) 93 score was used to evaluate the function at 6 months after operation, and visual analogue scale (VAS) score was used to evaluate the pain before and after operation. RESULTS The operation was successfully performed in all the 10 patients, and the postoperative pathological results were consistent with the preoperative pathological results. The operation time was 165-440 minutes, with an average of 263 minutes; and the intraoperative blood loss was 100-800 mL, with an average of 350 mL. All patients were followed up 7-26 months, with an average of 11.8 months. No tumor was found on the osteotomy surface; the customized prosthesis were firmly installed and closely matched with the retained articular surface. The tumor outcome of neoadjuvant chemotherapy was stable in 4 cases and partial remission in 6 cases. No local recurrence or distant metastasis was found in 9 cases after postoperative adjuvant chemotherapy; pulmonary metastasis was found in 1 case at 12 months after operation. Two patients had local incision fat liquefaction, superficial infection, and delayed healing at 14 days after operation; 1 patient had local bone absorption at the contact surface of the prosthesis, and the screw and prosthesis did not loosen at 7 months after operation; the other patients had good incision healing, with no infection, prosthesis loosening, fracture, or other complications. At 6 months after operation, the MSTS93 score was 19-28, with an average of 24.1; 8 cases were excellent and 2 cases were good. The VAS score was 0.9±1.0, which significantly improved when compared with before operation (5.9±1.0) ( t=23.717, P<0.001). The height of the patients increased by 1-12 cm, with an average of 4.6 cm. At last follow-up, 4 patients had limb length discrepancy, with a length difference of 1 cm in 2 cases and 2 cm in 2 cases. CONCLUSION The application of 3D printed customized prosthesis in the resection and reconstruction of adolescents femoral primary malignant tumors can achieve the purpose of preserving epiphysis and articular surface, and obtain good effectiveness.
Collapse
|
28
|
Moses Li ML, Wong KC, Chiu WK, Kumta SM. Intermediate-term results and risk factors analysis of tumor endoprosthesis in paediatric patients after the resection of lower extremity bone sarcoma. J Orthop Surg (Hong Kong) 2022; 30:10225536221132403. [PMID: 36207771 DOI: 10.1177/10225536221132403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Mechanical failure of the endoprostheses is a concern in paediatric patients with primary bone sarcoma. Their long-term results are variable in the Asian population, thus we aim to investigate the outcome by assessing the mechanical failure, its risk factors and the functional results. METHODS We retrospectively reviewed 38 paediatric patients (mean 13.29, range 6-18) with primary bone sarcoma of lower extremity undergone chemotherapy and limb salvage surgery with tumor endoprosthesis between 2003 and 2016. All hospital notes were reviewed for any type of failures. Risk factors for implant loosening like stem size, remaining bone length, stem length, extracortical bone bridge ingrowth (EBBI), the ratio of resected bone length to whole bone length, bone stem ratio and custom-made versus modular were analyzed. The limb function was recorded by Musculoskeletal Tumor Society (MSTS) score. Median follow-up time was 7.42 years (3.0-15.4 years) and minimum follow-up for surviving patients was 2 years. RESULTS Endoprosthesis survivorship, according to Kaplan Meier was 94.7%, 85.4% and 66.2% at 2, 5 and 10 years respectively. Type II failure occurred in three patients (7.9%). Type III failure occurred in four patients (10.5%). Type IV failure occured in two patients (5.2%). Only EBBI independently predicted implant loosening (p = .007). Risk factors like stem size, remaining bone length, stem length, the ratio of resected bone length to whole bone length and custom-made versus modular were not associated with increase in implant loosening (p > .05). The mean stem size was 9.41 mm in asymptomatic group, comparable with 9.22 mm in the failure group (p = .79). The MSTS score was 29.62. CONCLUSIONS Our data suggests that paediatric Chinese patients with small body built had good and excellent mid-term results in implant survival and limb function respectively. EBBI is important in preventing loosening in tumor endoprosthesis. In contrast to the reported higher failure risk with stem size <12 mm, we found no increased loosening rate with smaller stem size endoprosthesis. LEVEL OF EVIDENCE Class III.
Collapse
Affiliation(s)
- Man Lung Moses Li
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
| | - Kwok Chuen Wong
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
| | - Wang Kei Chiu
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
| | | |
Collapse
|
29
|
Dorovskikh SI, Vikulova ES, Sergeevichev DS, Guselnikova TY, Zheravin AA, Nasimov DA, Vasilieva MB, Chepeleva EV, Saprykin AI, Basova TV, Morozova NB. Biological Studies of New Implant Materials Based on Carbon and Polymer Carriers with Film Heterostructures Containing Noble Metals. Biomedicines 2022; 10:biomedicines10092230. [PMID: 36140329 PMCID: PMC9496383 DOI: 10.3390/biomedicines10092230] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022] Open
Abstract
This paper presents pioneering results on the evaluation of noble metal film hetero-structures to improve some functional characteristics of carbon-based implant materials: carbon-composite material (CCM) and carbon-fiber-reinforced polyetheretherketone (CFR-PEEK). Metal-organic chemical vapor deposition (MOCVD) was successfully applied to the deposition of Ir, Pt, and PtIr films on these carriers. A noble metal layer as thin as 1 µm provided clear X-ray imaging of 1−2.5 mm thick CFR-PEEK samples. The coated and pristine CCM and CFR-PEEK samples were further surface-modified with Au and Ag nanoparticles (NPs) through MOCVD and physical vapor deposition (PVD) processes, respectively. The composition and microstructural features, the NPs sizes, and surface concentrations were determined. In vitro biological studies included tests for cytotoxicity and antibacterial properties. A series of samples were selected for subcutaneous implantation in rats (up to 3 months) and histological studies. The bimetallic PtIr-based heterostructures showed no cytotoxicity in vitro, but were less biocompatible due to a dense two-layered fibrous capsule. AuNP heterostructures on CFR-PEEK promoted cell proliferation in vitro and exhibited a strong inhibition of bacterial growth (p < 0.05) and high in vitro biocompatibility, especially Au/Ir structures. AgNP heterostructures showed a more pronounced antibacterial effect, while their in vivo biocompatibility was better than that of the pristine CFR-PEEK, but worse than that of AuNP heterostructures.
Collapse
Affiliation(s)
- Svetlana I. Dorovskikh
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - Evgeniia S. Vikulova
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - David S. Sergeevichev
- «E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Tatiana Ya. Guselnikova
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - Alexander A. Zheravin
- «E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Dmitriy A. Nasimov
- Rzhanov Institute of Semiconductor Physics SB RAS, 13 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - Maria B. Vasilieva
- «E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Str., 630055 Novosibirsk, Russia
- Zelman Institute for the Medicine and Psychology, Novosibirsk State University, 1, Pirogov Str., 630090 Novosibirsk, Russia
| | - Elena V. Chepeleva
- «E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, 15 Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Anatoly I. Saprykin
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - Tamara V. Basova
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
| | - Natalya B. Morozova
- Nikolaev Institute of Inorganic Chemistry Siberian Branch of the Russian Academy of Sciences SB RAS, 3 Lavrentiev Ave., 630090 Novosibirsk, Russia
- Correspondence: ; Tel.: +7-3833309556
| |
Collapse
|
30
|
Are Postoperative Infections in the First 12 Months after Wide Resection and Megaprosthetic Replacement Associated with the Survival of Osteosarcoma Patients? Results of a Multicenter Study. Cancers (Basel) 2022; 14:cancers14112682. [PMID: 35681660 PMCID: PMC9179350 DOI: 10.3390/cancers14112682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Postoperative infection is one of the gravest complications in patients following megaprosthetic replacement due to primary malignant bone tumors. On the other hand, several studies have also suggested that patients with a variety of different cancers may have a better chance of survival following the development of an infection, possibly as a result of the immune and inflammatory host responses to infection. Our retrospective analysis of 437 extremity osteosarcoma patients found that patients with a poor response to neoadjuvant chemotherapy and an infection in the first 12 months after primary tumor surgery had a better chance of survival compared to patients without infections. If this finding can be validated in a different patient cohort, it would suggest that the efficacy of novel immunomodulatory treatments in osteosarcoma patients should be evaluated and reported separately for patients with a good and a poor response to preoperative chemotherapy, as the latter might benefit more from such treatments. Abstract Recent retrospective studies suggested that early postoperative infections might be associated with a survival benefit for extremity osteosarcoma patients, but the reported results have been conflicting. The files of 437 patients with a newly diagnosed, high-grade osteosarcoma of the extremities treated at 5 referral centers in Germany and Austria between 1989 and 2016 were retrospectively evaluated. All patients underwent multi-agent chemotherapy and limb-sparing tumor excision, followed by endoprothetic replacement. We used the Kaplan–Meier method to calculate survival curves, which we compared with the log-rank test. With a median follow-up of 100 months (interquartile range, 49–155 months), local recurrence (LR) probability, event-free survival (EFS), and disease-specific survival (DSS) after 5 years in this selected patient cohort amounted to 5%, 67%, and 79%, respectively, and 46 patients (10.5%) developed an early postoperative infection. We found no significant differences in LR, EFS, or DSS between patients with and without early infections, and there were no differences in known prognostic factors between the two groups. However, in subgroup analyses patients with a poor response to neoadjuvant chemotherapy and an early infection had a better DSS compared to patients without early infections (93% vs. 62% after 5 years, p = 0.044). Provided that our findings can be validated in separate patient cohorts, we believe that patient outcome after adjuvant immunomodulatory treatments in osteosarcoma patients should be evaluated and reported separately for good and poor responders to neoadjuvant chemotherapy in future studies.
Collapse
|
31
|
Megaprosthesis for Metastatic Bone Disease—A Comparative Analysis. Curr Oncol 2022; 29:3460-3471. [PMID: 35621669 PMCID: PMC9139992 DOI: 10.3390/curroncol29050279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/25/2022] [Accepted: 05/06/2022] [Indexed: 01/14/2023] Open
Abstract
Background: Megaprosthetic reconstruction is sometimes indicated in advanced metastatic bone disease (MBD) of the appendicular skeleton with large degrees of bone loss or need for oncological segmental resection. Outcome after megaprosthetic reconstruction was studied in the setting of primary bone sarcoma with high levels of complications, but it is not known if this applies to MBD. Method: We performed a comparative analysis of complications and revision surgery for MBD and bone sarcoma surgery in an institutional cohort from 2005–2019. Presented are the descriptive data of the cohort, with Kaplan–Meier (K–M) rates of revision at 1, 2 and 5 years together with a competing risk analysis by indication type. Results: Rates of revision surgery are significantly lower for MBD (8% at 1 year, 12% at 2 years), in the intermediate term, compared to that of sarcoma (18% at 1 year, 24% at 2 years) (p = 0.04). At 5 years this is not significant by K–M analysis (25% for MBD, and 33% for sarcoma), but remains significant in a competing risk model (8% for MBD, and 20% for sarcoma) (p = 0.03), accounting for death as a competing event. Conclusion: Rates of revision surgery after megaprosthetic reconstruction of MBD are significantly lower than that for primary bone sarcoma in this cohort.
Collapse
|
32
|
Li ZM, Yu XC, Zheng K. Radiographic Assessment of Aseptic Loosening of Tumor-Type Knee Prosthesis in Distal Femur. Orthop Surg 2022; 14:1143-1151. [PMID: 35524629 PMCID: PMC9163797 DOI: 10.1111/os.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/09/2022] [Accepted: 04/09/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To measure the full-length anteroposterior and lateral radiographs of lower limbs after the resection of a tumor in the distal femur and tumor-type knee prosthesis replacement and to analyze the factors leading to aseptic loosening of the prosthesis. METHODS A total of 26 cases of tumor-type knee prosthesis replacement or revision due to the distal femoral tumor at our hospital from January 2007 to December 2019 were retrospectively analyzed. The patients were divided into the loosening and unloosening groups depending on whether aseptic loosening occurred after surgery. Full-length anteroposterior and lateral radiographs of lower limbs were used to measure bone resection length, length of prosthesis, distance of proximal apex of the medullary stem of the femoral prosthesis from the maximum arc of the anterior femoral arch, diameter of the medullary stem, etc. Data were analyzed, and the risk factors for aseptic loosening of the prosthesis were explored. RESULTS The ratio of the prosthetic length to the femoral length (63.72 ± 5.21) and the ratio of the femoral medullary stem diameter to the femoral diameter (26.03 ± 8.45) were smaller in the loosening group than in the unloosening group. The difference was statistically significant (p < 0.05). The distance between the apex of the medullary stem and the maximum arc of the anterior femoral arch was significantly shorter in the loosening group (3.47 ± 2.96) than in the unloosening group, and the difference was statistically significant (p < 0.05). The measurement of the lower limb alignment showed significant differences between the loosening and unloosening groups in terms of HKAA, mLDFA, and distance between the lower limb alignment and the center of the knee joint (p < 0.05). The logistic regression analysis showed that less than 30% ratio between the medullary stem diameter and the femoral diameter, less than 3 cm distance between the apex of the medullary stem and the maximum curvature of the anterior arch of the femur, distance between the lower limb alignment and the center of the knee joint, and presence of varus knee and valgus knee after the surgery were the risk factors for aseptic loosening of the prosthesis. CONCLUSIONS The diameter of the femoral medullary stem of the prosthesis, the apex position of the prosthetic stem, and the lower limb alignment are the risk factors for aseptic loosening of the prosthesis.
Collapse
Affiliation(s)
- Zi-Ming Li
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiu-Chun Yu
- Department of Orthopaedics, The 960th Hospital of the PLA, Jinan, China
| | - Kai Zheng
- Department of Orthopaedics, The 960th Hospital of the PLA, Jinan, China
| |
Collapse
|
33
|
Martin JR, Auran RL, Duran MD, de Comas AM, Jacofsky DJ. Management of Primary Aggressive Tumors of the Knee. J Knee Surg 2022; 35:585-596. [PMID: 35181876 DOI: 10.1055/s-0042-1743221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary bone sarcomas and aggressive benign bone tumors are relatively rare. It is essential to recognize features that are concerning for these aggressive tumors based on a patient's history, physical exam, and radiographs. Physicians and other health care providers should have a high suspicion for these tumors and promptly refer these patients to orthopaedic oncologists. A multidisciplinary, team-based approach is required to obtain an accurate diagnosis and provide comprehensive care. This review discussed the appropriate work-up, biopsy principles, relevant peri-operative medical management, and surgical treatment options for patients with aggressive primary bone tumors around the knee. Primary bone sarcomas (osteosarcoma and chondrosarcoma) and aggressive benign bone tumors (giant cell tumor, chondroblastoma, and chondromyxoid fibroma) that have a predilection to the distal femur and proximal tibia are the focus of this review.
Collapse
Affiliation(s)
- John R Martin
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Richard L Auran
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Michael D Duran
- The Center for Orthopedic Research and Eduction (CORE) Institute, Phoenix, Arizona
| | - Amalia M de Comas
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona.,The Center for Orthopedic Research and Eduction (CORE) Institute, Phoenix, Arizona
| | - David J Jacofsky
- The Center for Orthopedic Research and Eduction (CORE) Institute, Phoenix, Arizona
| |
Collapse
|
34
|
Asokan A, Ibrahim MS, Thompson JW, Haddad FS. Debridement, antibiotics, and implant retention in non-oncological femoral megaprosthesis infections: minimum 5 year follow-up. J Exp Orthop 2022; 9:32. [PMID: 35403987 PMCID: PMC9001793 DOI: 10.1186/s40634-022-00469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/17/2022] [Indexed: 08/27/2024] Open
Abstract
PURPOSE Megaprostheses are increasingly utilised outside of the oncological setting, and remain at significant risk of periprosthetic joint infection (PJI). Debridement, antibiotic, and implant retention (DAIR) is an established treatment for PJI, however its use in non-oncological patients with femoral megaprostheses has not been widely reported. There are significant differences in patient physiology, treatment goals, and associated risks between these patient cohorts. METHODS We identified 14 patients who underwent DAIR for a PJI of their femoral megaprostheses, between 2000 and 2014, whom had their index procedure secondary to non-oncological indications. Patients were managed as part of a multidisciplinary team, with our standardised surgical technique including exchange of all mobile parts, and subsequent antibiotic therapy for a minimum of 3 months. Patients were followed up for a minimum of 5 years. RESULTS Patients included six proximal femoral replacements, five distal femoral replacements, and three total femoral replacements. No patients were lost to follow-up. There were six males and eight females, with a mean age of 67.2 years, and mean ASA of 2.3. Nine patients (64.3%) successfully cleared their infection following DAIR at a minimum of 5 year follow-up. Five patients (35.7%) required further revision surgery, with four patients cleared of infection. No patients who underwent DAIR alone suffered complications as a result of the procedure. CONCLUSIONS The use of DAIR in these complex patients can lead to successful outcomes, but the risk of further revision remains high. The success rate (64.3%) remains on par with other studies evaluating DAIR in megaprostheses and in primary arthroplasty. This study indicates judicious use of DAIR can be an appropriate part of the treatment algorithm. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- A Asokan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.
| | - M S Ibrahim
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - J W Thompson
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - F S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| |
Collapse
|
35
|
Zan P, Wang H, Cai Z, Shen J, Sun W. Revision surgeries for tumor endoprostheses around the knee joint: a mid-long-term follow-up of 20 cases. World J Surg Oncol 2022; 20:76. [PMID: 35272693 PMCID: PMC8908670 DOI: 10.1186/s12957-022-02542-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/27/2022] [Indexed: 11/28/2022] Open
Abstract
Background Tumor endoprostheses of the knee joint after limb salvage surgery is associated with high rates of complications, which has introduced great challenges to a delayed revision surgery. The aim of the study was to summarize the failures, functional outcomes and prosthetic survival in revision tumor endoprostheses of the knee joint. Methods The clinical data of 20 patients with malignant tumors who received prosthetic revisions after limb salvage surgery from January, 2000 until January, 2018 were retrospectively reviewed. The cohort was constituted of 11 male and 9 female patients with a mean age of 34.1 years (range, 16 to 66 years). Infection cases received two-stage revisions after removing prostheses initially, while all other cases received one-stage revisions. Revision reasons and complications were well documented and analyzed. Results All patients received complete follow-up with a mean time of 64.7 months (range, 27 to 155 months). A total of 6 (6/20, 30.0%) patients experienced a second complication after revision surgery, of whom, one patient with deep infection experienced repeated infections after prosthetic revision and received amputation surgery; one patient revised of prosthetic fracture experienced an infection and received a second-stage infection revision; one case revised of prosthetic loosening had deep infection receiving anti-infective therapy with prostheses still in position; one case having wound complication healed after receiving two times of debridement surgery; one MBGCT patient experienced a second aseptic loosening 6 years after the initial loosening thus undergoing a second revision; a recurrent osteosarcoma patient died of pulmonary metastasis 3 years after revision surgery. Kaplan-Meier survival curve indicated a 5-year survival rate of initial prostheses was 75%. The Musculoskeletal Tumor Society (MSTS-93) score [20.9 (range, 15 to 27 scores)] at 1 year after revision surgeries was significantly improved (p < 0.001) when compared with the score [17.2 (range, 13 to 21 scores)] before revisions. Conclusion Prosthetic mechanical problems, aseptic loosening and infections were primary reasons for revisions after tumor endoprostheses of the knee joint. Although revision surgeries were complicated while still associated with high risk of failure, which remains the remedy strategy for limb salvage and functional recovery in those patients.
Collapse
Affiliation(s)
- Pengfei Zan
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, China
| | - Hongsheng Wang
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, China
| | - Zhengdong Cai
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, China
| | - Jiakang Shen
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, China.
| | - Wei Sun
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100 Haining Road, Hongkou District, Shanghai, China.
| |
Collapse
|
36
|
Piscopo A, Pola E, Fusini F, Cipolloni V, Piscopo D, Colò G, Zanchini F. Revision arthroplasty with megaprosthesis after Girdlestone procedure for periprosthetic joint infection as an option in massive acetabular and femoral bone defects. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021531. [PMID: 35604274 PMCID: PMC9437688 DOI: 10.23750/abm.v92is3.12160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/19/2021] [Indexed: 11/30/2022]
Abstract
Background and aim: To evaluate the clinical outcomes of patients treated with Girdlestone procedure (GP) or excision arthroplasty (EA) for periprosthetic infection with massive bone defects and undergoing revision arthroplasty. Methods: All patients treated with EA or GP for hip periprosthetic infection between 2014 and 2017 and sustaining revision arthroplasty (RA) were included in the study. Patients with less than 24 months of follow-up or less than 12 months between GP or EA and RA were excluded. Any sign of implant mobilization or periprosthetic fracture was assessed through X-ray. Patients were evaluated with D’aubigne-Postel hip score before RA and at the last follow-up. Mann-Whitney U test was used to assess differences between pre-RA surgery and last follow-up. P value was set as <0.05. Results: Twelve patients meet the inclusion criteria (mean follow-up 58+/-9.72 months). No radiographic sign of implant mobilization or periprosthetic fracture was reported. A significant difference was found for each parameter of the D’Aubigne-Postel score (p < 0.0001); none of the patients reached more than fair results in the absolute hip score. The difference between pre and post-operative global status showed a fair improvement. A significant difference was found for leg length discrepancy between pre and post RA (p<0.0001). Conclusions: Conversion from EA or GP to RA in patients suffering from massive acetabular and femur defects is challenging; conversion procedure is able to reduce patients’ disability and to improve walking ability. (www.actabiomedica.it)
Collapse
Affiliation(s)
| | - Enrico Pola
- Clinical Orthopaedics, University of Campania "Luigi Vanvitelli", via L. de Crecchio 4, Naples, Italy.
| | - Federico Fusini
- Department of Orthopaedic and Traumatology, Orthopaedic and Trauma Center, University of Turin, via Zuretti 29, 10121, Turin.
| | - Valerio Cipolloni
- Spine Division, Department of Orthopaedics and Traumatology, A. Gemelli University Hospital, Catholic University of Rome, Italy.
| | - Davide Piscopo
- Clinical Orthopaedics, University of Campania "Luigi Vanvitelli", via L. de Crecchio 4, Naples, Italy.
| | - Gabriele Colò
- Department of Orthopaedics and Traumatology, Regional Center for Joint Arthroplasty, ASO Alessandria, AA Antonio e Biagio e Cesare Arrigo, Alessandria, Italy..
| | - Fabio Zanchini
- Clinical Orthopaedics, University of Campania "Luigi Vanvitelli", via L. de Crecchio 4, Naples, Italy.
| |
Collapse
|
37
|
Theil C, Schwarze J, Gosheger G, Moellenbeck B, Schneider KN, Deventer N, Klingebiel S, Grammatopoulos G, Boettner F, Schmidt-Braekling T. Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection. Cancers (Basel) 2022; 14:cancers14020351. [PMID: 35053514 PMCID: PMC8773828 DOI: 10.3390/cancers14020351] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection. Abstract Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.
Collapse
Affiliation(s)
- Christoph Theil
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Jan Schwarze
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Georg Gosheger
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Burkhard Moellenbeck
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Kristian Nikolaus Schneider
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Niklas Deventer
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Sebastian Klingebiel
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA;
| | - Tom Schmidt-Braekling
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
- Correspondence:
| |
Collapse
|
38
|
Dang J, Fu J, Liu D, Zhang Z, Mi Z, Cheng D, Liu X, Zhang Y, Zhu D, Wang L, Shi Y, Fan H. Clinical application of 3D-printed patient-specific guide plate combined with computer navigation in acetabular reconstruction following resection of periacetabular tumors. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:76. [PMID: 35282055 PMCID: PMC8848447 DOI: 10.21037/atm-21-7013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/13/2022] [Indexed: 11/24/2022]
Abstract
Background The precise acetabular reconstruction has historically been a challenging procedure. 3D-printed patient-specific guide (PSG) and computer navigation (CN) technologies have been used to assist acetabular component positioning and pelvic reconstruction. This precise reconstruction approach may translate into clinical benefit. Methods The clinical data of 84 patients who underwent periacetabular malignant tumor resection and screw-rod-acetabular cage system reconstruction in our center from January 2013 to December 2020 were retrospectively analyzed. Patients were divided into four groups: free hand (FH) group, PSG group, CN group, and PSG combined with computer navigation (PSG + CN) group. The operation time, intraoperative blood loss, and number of fluoroscopy views were recorded. The oncological prognosis, radiographic measurements of the acetabulum, limb function data, and postoperative complications were compared among groups. And finally, we evaluated the risk factors for mechanical failure of the prosthesis. Results The postoperative X-ray and computed tomography (CT) scan revealed that the vertical offset discrepancy (VOD) between affected side and contralateral side was 8.4±1.9, 5.9±2.2, 4.1±1.3, and 2.4±1.2 mm in each groups; the horizontal offset discrepancy (HOD) was 9.0±1.9, 6.1±2.2, 3.2±1.3, and 2.1±1.2 mm, correspondingly; the abduction angle discrepancy (ABAD) was 8.6°±1.8°, 5.6°±2.0°, 2.5°±1.3°, and 1.8°±0.9°, respectively; the anteversion angle discrepancy (ANAD) was 5.9°±1.6°, 3.6°±1.7°, 2.9°±1.6°, and 1.9°±0.9°, correspondingly. Statistical results show that the PSG + CN group was superior to the FH group and the PSG group in terms of acetabular position and limb function (P<0.05). Body mass index (P=0.040) and resection type (P=0.042) were found to be the high-risk factors for mechanical failure of the prosthesis. Conclusions PSG + CN has potential advantages in improving the accuracy and safety of acetabular positioning and reconstruction.
Collapse
Affiliation(s)
- Jingyi Dang
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jun Fu
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Dong Liu
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhao Zhang
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhenzhou Mi
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Debin Cheng
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xincheng Liu
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yushen Zhang
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Dongze Zhu
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Wang
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yubo Shi
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hongbin Fan
- Department of Orthopedic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| |
Collapse
|
39
|
Ashford R, Aujla RS. Bone and Soft Tissue Tumours. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
40
|
Houdek MT, Wagner ER, Rose PS, Barlow JD, Elhassan BT, Sanchez-Sotelo J. Allograft prosthetic composite reconstruction using a reverse total shoulder arthroplasty for failed oncologic proximal humerus reconstruction. J Surg Oncol 2021; 125:775-781. [PMID: 34913481 DOI: 10.1002/jso.26772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Endoprosthetic or allograft reconstruction are the preferred reconstruction techniques for proximal humeral bone tumors. Failure of these reconstructions may occur, but historically revision is performed rarely due to the lack of reliable options. Reverse shoulder arthroplasty with an allograft prosthetic composite (rAPC) may provide a revision option. The purpose of the current study was to evaluate our institutional outcome of these procedures. METHODS Eleven (6 male, 5 female) patients (mean age 51 ± 17 years) underwent revision of a failed oncologic reconstruction of the proximal humerus utilizing a rAPC. The most common indication for revision was subluxation (n = 6) and the most common previous implant was an endoprosthesis (n = 5). RESULTS Revision resulted in improvements in shoulder elevation (39° vs. 62°, p = 0.02), external rotation (13° vs. 25°, p = 0.04), American Shoulder and Elbow Surgeons score (39 vs. 58, p = 0.004) and Musculoskeletal Tumor Society Scores (51% vs 69%, p = 0.002). There were 2 re-revision procedures performed. One for an allograft fracture and one for allograft resorption and loosening. CONCLUSIONS Revision with a rAPC can effectively restore patient function. Due to the complexity of the cases, we advocate for these procedures to be performed by subspecialty upper extremity surgeons trained in complex revision shoulder arthroplasty.
Collapse
Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric R Wagner
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bassem T Elhassan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
41
|
Fujiwara T, Tsuda Y, Stevenson J, Parry M, Jeys L. Extra-articular resection of the hip joint for pelvic sarcomas: Are there any oncological and functional risks compared with intra-articular resection? J Bone Oncol 2021; 31:100401. [PMID: 34815929 PMCID: PMC8592885 DOI: 10.1016/j.jbo.2021.100401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While extra-articular resection (EAR) of the knee and shoulder joint is associated with poorer clinical outcomes, the oncological and functional risks of EAR of the hip joint are unknown. We aimed to compare these risks between EAR of the hip joint and intra-articular resection (IAR). METHODS We conducted a comparative study of 75 patients who underwent en-bloc tumour resection and limb-salvage reconstruction for bone sarcomas of the peri-acetabulum between 1996 and 2016. We divided patients into two groups for analyses; EAR (n = 21) and IAR (n = 54). RESULTS There was no statistical difference in oncological outcomes; the 5-year cumulative incidence of disease-specific death was 34% and 35% in the EAR and IAR groups, respectively (p = 0.943), and the 5-year cumulative incidence of LR was 26% and 34%, respectively (p = 0.482). The most common complications were dislocation (28%) and deep infection (28%); there was equally no difference between the groups. The mean Musculoskeletal Tumour Society score was 66% and 65% in the EAR and IAR groups, respectively (p = 0.795), and were significantly lower in patients with deep infection (52% vs. 69%; p = 0.013). In a sub-analysis on the outcomes in patients who underwent PI-uninvolved PII-resection for chondrosarcoma, no major differences in oncologic and functional outcomes were confirmed. CONCLUSION Patients undergoing EAR and limb-salvage reconstructions of the hip joint have undistinguishable oncological, clinical and functional outcomes compared to those undergoing IAR and reconstructions. If preoperative imaging suggests articular tumour involvement, there appears to be no detrimental effect of undertaking EAR to optimise local control.
Collapse
Affiliation(s)
- Tomohiro Fujiwara
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yusuke Tsuda
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan Stevenson
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Michael Parry
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Lee Jeys
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom
| |
Collapse
|
42
|
Labott JR, Brinkmann EJ, Hevesi M, Couch CG, Rose PS, Houdek MT. The ACS-NSQIP surgical risk calculator is a poor predictor of postoperative complications in patients undergoing oncologic distal femoral replacement. Knee 2021; 33:17-23. [PMID: 34536764 DOI: 10.1016/j.knee.2021.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 08/31/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal femur replacement (DFR) has become a preferred reconstruction for tumors involving the femur but is associated with known complications. The ACS-NSQIP surgical risk calculator is an online tool developed to estimate postoperative complications in the first 30-days, however, has not been used in patients undergoing DFR. The purpose of this study was determining the utility of the ACS-NSQIP calculator to predict postoperative complications. METHODS 56 (30 male, 26 female) patients who underwent DFR were analyzed using the CPT codes: 27,365 (Under Excision Procedures on the Femur and Knee Joint), 27,447 (Arthroplasty, knee, condyle and plateau), 27,486 (Revision of total knee arthroplasty, with or without allograft), 27,487 (Revision of total knee arthroplasty, with or without allograft) and 27,488 (Repair, Revision, and/or Reconstruction Procedures on the Femur [Thigh Region] and Knee Joint). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 30 (54%) of patients. The predicted risk of complications based off the CPT codes were: 27,356 (14%); 27,447 (5%); 27,486 (7%); 27,487 (8%) and 27,488 (12%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (27356, AUC 0.54); (27447, AUC 0.45); (27486, AUC 0.45); (27487, AUC 0.46); (27488, AUC 0.46). CONCLUSIONS Distal femur arthroplasty performed in the setting of oncologic orthopedics is a complex procedure in a "high risk" surgical group. The ACS-NSQIP does not adequately predict the incidence of complications in these patients and cannot be reliably used in the shared decision-making process.
Collapse
Affiliation(s)
- Joshua R Labott
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Elyse J Brinkmann
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Mario Hevesi
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Cory G Couch
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Peter S Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Matthew T Houdek
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States.
| |
Collapse
|
43
|
Wei X, Tang Z, Wu H, Zuo X, Dong H, Tan L, Wang W, Liu Y, Wu Z, Shi L, Wang N, Li X, Xiao X, Guo Z. Biofunctional magnesium-coated Ti6Al4V scaffolds promote autophagy-dependent apoptosis in osteosarcoma by activating the AMPK/mTOR/ULK1 signaling pathway. Mater Today Bio 2021; 12:100147. [PMID: 34704011 PMCID: PMC8523865 DOI: 10.1016/j.mtbio.2021.100147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
The recurrence of osteosarcoma (OS) after reconstruction using Ti6Al4V prostheses remains a major problem in the surgical treatment of OS. Modification of the surfaces of Ti6Al4V prostheses with antitumor functions is an important strategy for improving therapeutic outcomes. Magnesium (Mg) coating has been shown to be multifunctional: it exhibits osteogenic and angiogenic properties and the potential to inhibit OS. In this study, we determined the proper concentration of released Mg2+ with respect to OS inhibition and biosafety and evaluated the anti-OS effects of Mg-coated Ti6Al4V scaffolds. We found that the release of Mg2+ during short-term and long-term degradation could significantly inhibit the proliferation and migration of HOS and 143B cells. Increased cell apoptosis and excessive autophagy were also observed, and further evidence of AMPK/mTOR/ULK1 signaling pathway activation was obtained both in vitro and in vivo, which suggested that the biofunctional scaffolds induce OS inhibition. Our study demonstrates the ability of an Mg coating to inhibit OS and may contribute to the further application of Mg-coated Ti6Al4V prostheses. Multifunctional Mg coating is considerable surface modification for Ti6Al4V prostheses. Mg2+ releasing by the scaffolds could significantly inhibit the proliferation and migration of OS cells. The biofunctional scaffolds could inhibit OS by activating autophagy-dependent apoptosis. The AMPK/mTOR/ULK-1 pathway was involved in autophagy-depended apoptosis induced by the scaffolds.
Collapse
Affiliation(s)
- X Wei
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - Z Tang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - H Wu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - X Zuo
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - H Dong
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - L Tan
- Institute of Metal Research, Chinese Academy of Science, Shenyang, 110016, PR China
| | - W Wang
- Department of Immunology, State Key Laboratory of Cancer Biology, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - Y Liu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - Z Wu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - L Shi
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - N Wang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - X Li
- Department of Orthopaedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| | - X Xiao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, PR China
| | - Z Guo
- Department of Orthopaedics, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710038, PR China
| |
Collapse
|
44
|
Alexander W, Overland J, Thomason P, O'Sullivan M, Donnan L, Coombs C. Pedicled fibular transfer for biologic knee extensor tendon reinsertion following proximal tibial resection in pediatric osteosarcoma: Long-term outcomes. Microsurgery 2021; 41:753-761. [PMID: 34435382 DOI: 10.1002/micr.30802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 06/09/2021] [Accepted: 08/19/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Proximal tibial sarcoma resections result in a reconstructive challenge, necessitating joint and extensor mechanism reconstruction. The gait and functional outcomes for children reconstructed with a combination of megaprosthesis and pedicled fibular flap for extensor mechanism reconstruction, are presented. METHODS Four patients, aged 11-18 years old, were available for comprehensive analysis. The proximal tibial osteosarcoma was resected, and the reconstructive technique involved a megaprosthesis for the knee joint, used in combination with a pedicled fibula flap as a biologic structure for reinsertion of the knee extensor mechanism. Outcomes were measured with three-dimensional gait analysis and patient questionnaires. RESULTS Minor postoperative wound issues occurred in some patients, requiring debridement with skin grafting. One patient fractured their transferred fibula, requiring fixation. The follow up period ranged from 1.7 to 24 years postoperatively. The longevity and quality of reconstructions were strong, measured by both objective and patient-reported outcomes. All patients reported independent walking >500 m in the Functional Mobility Scale and rated their walking as a nine or 10 (out of 10) on the Functional Assessment Questionnaire. Knee society scoring revealed overall satisfaction rate of 75-80%. No patients required gait aids. The gait profile analysis revealed effective gait patterns, with patterns deviating 5.4-7° from "typical gait." Deviations >6.5° are considered abnormal. CONCLUSION The long-term results of combining a megaprosthesis with a pedicled fibula flap for extensor reinsertion, revealed a high level of independent function. The patients performed well, without the need for aids, and gait study evidence of minimal gait deviations.
Collapse
Affiliation(s)
- Will Alexander
- Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia
| | | | - Pamela Thomason
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Melbourne, Australia
| | - Mark O'Sullivan
- Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Leo Donnan
- Department of Orthopaedic Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Christopher Coombs
- Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia
| |
Collapse
|
45
|
Hindiskere S, Staals E, Donati DM, Manfrini M. What Is the Survival of the Telescope Allograft Technique to Augment a Short Proximal Femur Segment in Children After Resection and Distal Femur Endoprosthesis Reconstruction for a Bone Sarcoma? Clin Orthop Relat Res 2021; 479:1780-1790. [PMID: 33635286 PMCID: PMC8277267 DOI: 10.1097/corr.0000000000001686] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/29/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large, malignant bone tumors and revision limb salvage procedures often result in the resection of extensive lengths of the involved bone segment, leaving a residual segment of bone that may be too short to support a standard intramedullary stem for endoprosthetic reconstruction. Telescope allografting, in which an allograft is used to augment the remaining bone segment by telescoping it into the residual bone segment, was described for situations in which residual bone stock is insufficient after tumor resection or prosthetic revision. Apart from one study that first described the procedure [15], there are no other studies reporting the outcome of this telescopic concept for restoring bone stock. QUESTIONS/PURPOSES For patients younger than 18 years who underwent the telescopic allograft technique to augment a short segment of the proximal femur after resection of bone sarcomas who also underwent endoprosthesis reconstruction of the distal femur, we asked: (1) What is the survivorship free from removal of the telescopic allograft and the endoprosthetic stem at 7 years after surgery? (2) What proportion of these reconstructions will heal to the host bone without delayed union or nonunion? (3) What is the functional outcome based on the Musculoskeletal Tumor Society (MSTS) score? METHODS We retrospectively studied our institutional database and identified 127 patients younger than 18 years who underwent surgery for a primary malignant bone tumor of the distal femur between December 2008 and October 2018. After excluding 16 patients undergoing amputation and rotationplasty and 57 patients undergoing recycled autograft/allograft reconstruction, 54 patients who underwent primary or revision distal femur endoprosthesis reconstruction were identified. Among these patients, we considered 15 patients who underwent telescopic allograft augmentation of the femur for analysis. One patient was lost to follow-up before 2 years but was not known to have died, leaving 14 for analysis at a median (range) 49 months (24 to 136 months) of follow-up. The indications for telescopic allograft augmentation of the femur in our institution were a proximal femur length of less than 120 mm after resection or resection of more than two-thirds of the total length of the femur. Ten of 14 patients underwent telescopic allograft augmentation as a revision procedure (distal femur resorption in five patients, endoprosthesis stem loosening in three patients, implant fracture in one patient, and infection in one patient), and the remaining four patients underwent telescopic allograft augmentation as a primary limb salvage procedure for large malignant bone tumors of the distal femur. The histologic diagnosis in all patients was osteosarcoma. At the time of telescopic allograft augmentation and reconstruction, the median age of the patients was 14 years (7 to 18 years). The size and the type of bone allograft to be used (femoral shaft or proximal femur) was planned before surgery, with consideration of the extent of resection, level of osteotomy, diameter of the host bone at the osteotomy site, and approximate diameter of the endoprosthesis stem to be used. The segment of the cylindrical allograft used for telescoping was thoroughly washed, prepared, and impacted onto the native femur to achieve telescoping and overlap. Serial digital radiographs were performed once a month for the first 6 months after the procedure, every 2 months until 1 year, and then every 6 months thereafter. Two surgeons in the department (at least one of which was involved in the surgery) retrieved and reviewed clinical notes and radiographs to determine the status of the telescopic allograft and endoprosthesis stem. We defined delayed union as radiological union at the osteotomy site more than 6 months after the procedure without additional surgery; we defined nonunion as no radiological evidence of callus formation at the osteotomy site 9 months after the procedure, necessitating additional surgery. The reviewers did not disagree about the definition of healing time. None of the patients missed radiographic follow-up. Kaplan-Meier survivorship free from removal of telescopic allograft and the endoprosthesis stem at 7 years after surgery was estimated. Patient function was assessed using the 1993 version of the MSTS [9], as determined by chart review of the institutional database performed by one of the surgeons from the department. RESULTS The survivorship free from removal of the telescopic allograft and endoprosthesis stem at 7 years after surgery was 80% (95% confidence interval 22% to 96%). The allograft united with the host bone in 100% (14 of 14) of the patients. Though 21% (3 of 14) had delayed union, no nonunions were seen. The median (range) MSTS score at the final follow-up interval was 27 (22 to 30). CONCLUSION Although this is a small group of patients, we believe that allograft segments help augment short bone stock of the proximal femur after long-segment resections, and the telescopic technique seems to be associated with a low proportion of nonunion or delayed union, which is one of the most common complications of allografts. Maintaining an adequate length of the proximal femur is important in preserving the hip, and this technique may be especially useful for young individuals who may undergo repeated revision procedures. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
Affiliation(s)
- Suraj Hindiskere
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
| | - Eric Staals
- Department of Orthopaedic Oncology, Rizzoli Institute, Bologna, Italy
| | | | - Marco Manfrini
- Department of Orthopaedic Oncology, Rizzoli Institute, Bologna, Italy
| |
Collapse
|
46
|
Wong KC, Sze LKY, Kumta SM. Complex joint-preserving bone tumor resection and reconstruction using computer navigation and 3D-printed patient-specific guides: A technical note of three cases. J Orthop Translat 2021; 29:152-162. [PMID: 34249613 PMCID: PMC8241897 DOI: 10.1016/j.jot.2021.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 02/07/2023] Open
Abstract
In selected extremity bone sarcomas, joint-preserving surgery retains the natural joints and nearby ligaments with a better function than in traditional joint-sacrificing surgery. Geometric multiplanar osteotomies around bone sarcomas were reported with the advantage of preserving more host bone. However, the complex surgical planning translation to the operating room is challenging. Using both Computer Navigation and Patient-Specific Guide may combine each technique's key advantage in assisting complex bone tumor resections. Computer Navigation provides the visual image feedback of the pathological information and validates the correct placement of Patient-Specific Guide that enables accurate, guided bone resections. We first described the digital workflow and the use of both computer navigation and patient-specific guides (NAVIG) to assist the multiplanar osteotomies in three extremity bone sarcoma patients who underwent joint-preserving bone tumor resections and reconstruction with patient-specific implants. The NAVIG technique verified the correct placement of patient-specific guides that enabled precise osteotomies and well-fitted patient-specific implants. The mean maximum deviation errors of the nine achieved bone resections were 1.64 ± 0.35 mm (95% CI 1.29 to 1.99). The histological examination of the tumor specimens showed negative resection margin. At the mean follow-up of 55 months (40–67), no local recurrence was noted. There was no implant loosening that needed revision. The mean MSTS score was 29 (28–30) out of 30 with the mean knee flexion of 140° (130°–150°). The excellent surgical accuracy and limb function suggested that the NAVIG technique might replicate the surgical planning of complex bone sarcoma resections by combining the strength of both Computer Navigation and Patient-Specific Guide. The patient-specific approach may translate into clinical benefits. The translational potential of this article: The newly described technique enhances surgeons’ capability in performing complex joint-preserving surgery in bone sarcoma that is difficult to be achieved by the traditional method. The high precision and accuracy may translate into superior clinical outcomes.
Collapse
Affiliation(s)
- Kwok Chuen Wong
- Orthopaedic Oncology, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Louis Kwan Yik Sze
- Orthopaedic Oncology, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shekhar Madhukar Kumta
- Orthopaedic Oncology, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
47
|
Davies B, Kaila R, Andritsos L, Gray Stephens C, Blunn GW, Gerrand C, Gikas P, Johnston A. Osteointegration of hydroxyapatite-coated collars in cemented massive endoprostheses following revision surgery. Bone Jt Open 2021; 2:371-379. [PMID: 34134510 PMCID: PMC8244796 DOI: 10.1302/2633-1462.26.bjo-2021-0017.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery. Methods Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months. Results In all, 39 patients underwent radiological review at mean 43.5 months; 22/39 (56.4%) showed no osseointegration to the collar. Revision endoprostheses for aseptic loosening were less likely to show osseointegration compared with other indications for revision. Oncological cases with previous or current infection were more likely to show osseointegration to ≥ 1 collar side than those without evidence of prior infection. Conclusion This seven-year review identified osseointegration of HA-coated collars after revision surgery is less likely (43.6%, 17/39) than after primary surgery. Young patients who undergo revision surgery following initial oncological indication may benefit the most from this collar design. Use in revision oncological cases with a history of infection may be beneficial. HA-coated collars showed limited benefit for patients undergoing revision for failed arthroplasty with history of infection. Cite this article: Bone Jt Open 2021;2(6):371–379.
Collapse
Affiliation(s)
- Benjamin Davies
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Rajiv Kaila
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | | | | | - Gordon W Blunn
- University of Portsmouth School of Pharmacy and Biomedical Sciences, Portsmouth, UK
| | - Craig Gerrand
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | | | - Andrew Johnston
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| |
Collapse
|
48
|
Long-term outcomes and improved risk of revision following tumor endoprosthetic replacement of the distal femur: Single institutional results. J Orthop 2021; 25:259-264. [PMID: 34177190 DOI: 10.1016/j.jor.2021.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/16/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose This study assessed revision characteristics following distal femur tumor endoprosthetic replacement. Methods Fifty-seven procedures were performed between 2005 and 2019. The cumulative incidence of implant revision was calculated with death as a competing risk. Results The all-cause revision rate was 21.1% (n = 12) at a mean 65.3 ± 47.3 months. Competing risk analysis revealed a cumulative revision incidence of 12.0% (95% CI, 3.6-25.9%) at five years and 36.5% (95% CI, 12.8-61.0%) at ten years. Conclusions We provide an accurate assessment of revision risk which is slightly lower than historical controls, with identification of failure modes to reliably inform patient expectations. Level of evidence III. Retrospective Study.
Collapse
|
49
|
3D-Printed Connector for Revision Limb Salvage Surgery in Long Bones Previously Using Customized Implants. METALS 2021. [DOI: 10.3390/met11050707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In orthopedic oncology, revisional surgery due to mechanical failure or local recurrence is not uncommon following limb salvage surgery using an endoprosthesis. However, due to the lack of clinical experience in limb salvage surgery using 3D-printed custom-made implants, there have been no reports of revision limb salvage surgery using a 3D-printed implant. Herein, we present two cases of representative revision limb salvage surgeries that utilized another 3D-printed custom-made implant while retaining the previous 3D-printed custom-made implant. A 3D-printed connector implant was used to connect the previous 3D-printed implant to the proximal ulna of a 40-year-old man and to the femur of a 69-year-old woman. The connector bodies for the two junctions of the previous implant and the remaining host bone were designed for the most functional position or angle by twisting or tilting. Using the previous 3D-printed implant as a taper, the 3D-printed connector was used to encase the outside of the previous implant. The gap between the previous implant and the new one was subsequently filled with bone cement. For both the upper and lower extremities, the 3D-printed connector showed stable reconstruction and excellent functional outcomes (Musculoskeletal Tumor Society scores of 87% and 100%, respectively) in the short-term follow-up. To retain the previous 3D-printed implant during revision limb salvage surgery, an additional 3D-printed implant may be a feasible surgical option.
Collapse
|
50
|
Kito M, Okamoto M, Aoki K, Tanaka A, Komatsu Y, Suzuki S, Takazawa A, Yoshimura Y, Takahashi J. Distal femoral impaction bone grafting in revision for tumor endoprosthesis. Knee 2021; 29:42-48. [PMID: 33548830 DOI: 10.1016/j.knee.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/26/2020] [Accepted: 01/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reconstruction using tumor endoprosthesis has been widely used in cases with large bone defects caused by bone and soft tissue tumor resection of the distal femur which extend into the knee joint. However, reconstruction failure can lead to major problems in the long term. We have been performing impaction bone grafting with allogeneic cancellous bone during revision surgery for tumor endoprosthesis of the distal femur to compensate for the thinness and fragility of the remaining femur. The aim of this study is to examine the surgical method, problems, and clinical outcomes of revision surgery with impaction bone grafting. METHODS Three patients who underwent revision surgery for tumor endoprosthesis using impaction bone grafting at our institution with more than 2 years of follow-up were included. RESULTS Union between the graft and host bone were achieved in all cases. The mean time to radiographic union was 1.0 year (0.6-1.5 years). Although intraoperative penetration to the anterior cortex of the distal femur occurred in 2 cases, there were no postoperative fractures. There were no failures of tumor endoprosthesis at final observation. CONCLUSION Good short-term results were observed in 3 patients who underwent revision tumor endoprosthesis with impaction bone grafting following a bone and soft tissue tumor resection of the distal femur. The method was considered to be a useful treatment option. Impaction bone grafting is an established surgical option that can be applied to revision surgery for tumor endoprosthesis.
Collapse
Affiliation(s)
- Munehisa Kito
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Masanori Okamoto
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan.
| | - Kaoru Aoki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Atsushi Tanaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Yukiko Komatsu
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Shuichiro Suzuki
- Department of Orthopaedic Surgery, Matsumoto Medical Center, 2-20-30 Muraimachi Minami, Matsumoto, Nagano 399-8701, Japan
| | - Akira Takazawa
- Department of Orthopaedic Surgery, Shinshu Ueda Medical Center, 1-27-21 Midorigaoka, Ueda, Nagano 386-8610, Japan
| | - Yasuo Yoshimura
- Department of Orthopaedic Surgery, Shinshu Ueda Medical Center, 1-27-21 Midorigaoka, Ueda, Nagano 386-8610, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| |
Collapse
|