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Atherley O’Meally A, Rizzi G, Cosentino M, Aiba H, Aso A, Solou K, Campanacci L, Zuccheri F, Bordini B, Donati DM, Errani C. What Are the Complications, Reconstruction Survival, and Functional Outcomes of Modular Prosthesis and Allograft-prosthesis Composite for Proximal Femur Reconstruction in Children With Primary Bone Tumors? Clin Orthop Relat Res 2025; 483:455-469. [PMID: 39235267 PMCID: PMC11827998 DOI: 10.1097/corr.0000000000003245] [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] [Received: 02/22/2024] [Accepted: 08/13/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Proximal femur reconstruction after bone tumor resection in children is a demanding surgery for orthopaedic oncologists because of the small bone size and possible limb-length discrepancy at the end of skeletal growth owing to physis loss. The most commonly used reconstruction types used for the proximal femur are modular prostheses and allograft-prosthesis composites. To our knowledge, there are no previous studies comparing the outcomes after modular prosthesis and allograft-prosthesis composite reconstruction of the proximal femur in children with primary bone tumors. QUESTIONS/PURPOSES (1) What was the cumulative incidence of reoperation for any reason after allograft-prosthesis composite and modular prosthesis reconstructions of the proximal femur in children with primary bone tumors? (2) What was the cumulative incidence of reconstruction removal or revision arthroplasty in those two treatment groups? (3) What complications occurred in those two treatment groups that were managed without further surgery or with surgery without reconstruction removal? METHODS Between 2000 and 2021, 54 children with primary bone tumors underwent resection and reconstruction of the proximal femur at a single institution. During that time, allograft-prosthesis composite reconstruction was used in very young children, in whom we prioritize bone stock preservation for future surgeries, and children with good response to chemotherapy, while modular prosthesis reconstruction was used in older children and children with metastatic disease at presentation and poor response to chemotherapy. We excluded three children in whom limb salvage was not possible and 11 children who underwent either reconstruction with free vascularized fibular graft and massive bone allograft (n = 3), an expandable prosthesis (n = 3), a massive bone allograft reconstruction (n = 2), a rotationplasty (n = 1), standard (nonmodular) prosthesis (n = 1), or revision of preexisting reconstruction (n = 1). Further, we excluded two children who were not treated surgically, three children with no medical or imaging records, and three children with no follow-up. All the remaining 32 children with reconstruction of the proximal femur (12 children treated with modular prosthesis and 20 children treated with allograft-prosthesis composite reconstruction) were accounted for at a minimum follow-up time of 2 years. Children in the allograft-prosthesis group were younger at the time of diagnosis than those in the modular prosthesis group (median 8 years [range 1 to 16 years] versus 15 years [range 9 to 17 years]; p = 0.001]), and the follow-up in the allograft-prosthesis composite group was longer (median 5 years [range 1 to 23 years] versus 3 years [range 1 to 15 years]; p = 0.37). Reconstruction with hemiarthroplasty was performed in 19 of 20 children in the allograft-prosthesis composite group and in 9 of 12 children in the modular prosthesis group. A bipolar head was used in 16 of 19 children, and a femoral ceramic head without acetabular cup was used in 3 of 19 children in the allograft-prosthesis composite reconstruction group. All 9 children in the modular prosthesis group were reconstructed with a bipolar hemiarthroplasty. Reconstruction with total arthroplasty was performed in one child in the allograft-prosthesis composite group and in three children in the modular prosthesis group. For both groups, we calculated the cumulative incidence of reoperation for any reason and the cumulative incidence of reconstruction removal or revision arthroplasty; we also reported qualitative descriptions of serious complications treated nonoperatively in both groups. RESULTS The cumulative incidence of any reoperation at 10 years did not differ between the groups with the numbers available (36% [95% confidence interval 15% to 58%] in the allograft-prosthesis composite group versus 28% [95% CI 5% to 58%] in the modular proximal femoral replacement group). The cumulative incidence of reconstruction removal or revision arthroplasty at 10 years likewise did not differ between the groups with the numbers available (10% [95% CI 2% to 28%] versus 12% [95% CI 0% to 45%], respectively). In the allograft-prosthesis composite group (20 children), hip instability (n = 3), nonunion (n = 2), fracture of the greater trochanter (n = 1), screw loosening (n = 1), limb-length discrepancy (n = 1), and coxalgia due to acetabular wear (n = 1) were treated surgically without reconstruction removal. Complications treated without surgery included resorption of the allograft at the trochanteric region (n = 4), fracture of the greater trochanter (n = 4), limb-length discrepancy (n = 6), and coxalgia due to acetabular wear (n = 2). In the modular prosthesis group (12 children), hip instability (n = 1), coxalgia due to acetabular wear (n = 1), and limb-length discrepancy (n = 1) were treated surgically without reconstruction removal. Complications treated without surgery included hip instability (n = 2), stress shielding (n = 6), infection (n = 1), sciatic nerve palsy (n = 1), and limb-length discrepancy (n = 3). CONCLUSION Although the two groups of children were not directly comparable due to differences in age and clinical characteristics, both modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur after bone tumor resection appear to be reasonable options with similar revision-free survival and complications. Therefore, the type of reconstruction following proximal resection in children with bone sarcoma should be chosen taking into consideration factors such as patient age, bone size, implant availability, technical expertise, and the surgeon's preference. Although children treated with expandable prostheses were not included in this study, such prostheses may be useful in bridging the surgical defect while correcting residual limb-length discrepancies even though they face limitations such as small intramedullary diameter, short residual bone segments, as well as stress shielding, loosening, and breakage. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ahmed Atherley O’Meally
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopedic Surgery, Complejo Hospitalario Metropolitano CSS, Panama, Panama
| | - Giovanni Rizzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Monica Cosentino
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Hisaki Aiba
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Ayano Aso
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Konstantina Solou
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- University of Patras, Patras, Greece
| | - Laura Campanacci
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Federica Zuccheri
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Maria Donati
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Costantino Errani
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Errani C, Atherley O’Meally A, Tsukamoto S, Mavrogenis AF, Tanaka Y, Manfrini M. An algorithm for surgical treatment of children with bone sarcomas of the extremities. SICOT J 2024; 10:38. [PMID: 39364963 PMCID: PMC11451188 DOI: 10.1051/sicotj/2024033] [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: 04/30/2024] [Accepted: 08/02/2024] [Indexed: 10/05/2024] Open
Abstract
INTRODUCTION Limb salvage surgery in children following bone sarcoma resection is a challenging problem because of the small size of the bones, the lack of appropriate size-matched implants, and the risk of limb-length discrepancy once skeletal growth is complete, secondary to the loss of the epiphyseal plate. Although several reconstruction options are available in children with bone sarcomas, such as vascularized fibula, massive bone allograft, extracorporeal devitalized autograft, endoprosthesis, and allograft-prosthesis composite, a consensus has not been reached on the best reconstruction method. The purpose of the present study is to propose an algorithm for reconstruction after resection of bone sarcomas in children. METHODS In this review, we analyzed reports on limb reconstruction in children following treatment for bone sarcoma, to provide a comprehensive overview of the different reconstruction options in children with bone sarcomas, the outcomes, and the risks and benefits of the different surgical approaches. RESULTS Despite a high risk of complications and the necessity for limb-lengthening procedures, prosthetic or biological reconstructions seem to achieve good functional outcomes in children with bone sarcoma. The use of massive bone graft seems to be recommended for intercalary reconstructions, with a free vascularized fibular graft for long defects, while for osteoarticular reconstruction a modular or expandable prosthesis or an allograft-prosthesis composite seems to have good results. For reconstruction of the proximal humerus, modular prosthesis or allograft-prosthesis composite are more commonly used than expandable prosthesis since there are fewer functional constraints related to possible limb-length discrepancy on the upper limb compared to the lower limb. DISCUSSION We discuss the advantages and limitations of the different available surgical options for bone reconstruction following tumor resection in children and propose an algorithm of potential surgical treatments for children with bone sarcomas of the extremities.
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Affiliation(s)
- Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
| | - Ahmed Atherley O’Meally
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University 840, Shijo-cho, Kashihara Nara 634-8521 Japan
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine 41 Ventouri Street, Holargos Athens 15562 Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University 840, Shijo-cho, Kashihara Nara 634-8521 Japan
| | - Marco Manfrini
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
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Campanacci DA, Scanferla R, Muratori F, Scolari F, Scoccianti G, Tamburini A, Beltrami G. Allograft-prosthesis composite after proximal femur bone tumor resection in pediatric age: Is it effective in preserving bone stock? J Child Orthop 2024; 18:531-539. [PMID: 39421396 PMCID: PMC11483815 DOI: 10.1177/18632521241269338] [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: 03/11/2024] [Accepted: 06/18/2024] [Indexed: 10/19/2024] Open
Abstract
Purpose The purpose of the study was to answer the following questions. What was functional results of pediatric patients receiving a short stem allograft-prosthesis composite of the proximal femur? What was complication rate and revision-free implant survival? Was it possible to preserve the bone stock of the proximal femur in pediatric patients? Methods We reviewed 10 pediatric patients treated with proximal femur resection for a primary bone tumor and reconstruction with short stem allograft-prosthesis composite, with at least 24 months follow-up. The median age was 9 years (4-13) at surgery. The mean resection length was 15 cm (6-29). In six cases, fixation was performed with a short plate positioned under the great trochanter while in four cases a long plate extended over the great trochanter was employed. Results Nine complications that required surgical revision were assessed in six patients (one wound dehiscence, two nonunions, two fractures, one acetabular wear, three hypometria), while allograft-prosthesis composite removal was required in three patients. The revision-free survival was 57% (95% confidence interval 33%-100%) at 5 and 10 years. The graft removal-free survival was 75% (95% confidence interval 50%-100%) at 5 and 10 years. The mean Musculo-Skeletal Tumor Society Score was 28 (20-30). Conclusions Allograft-prosthesis composites with short stem and compression plate represents an effective reconstructive option after proximal femur resection for primary bone tumors in growing patients, preserving bone stock. The use of a compression plate extended over the greater trochanter seemed to reduce failure rate.
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Affiliation(s)
- Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Florence, Italy
| | - Roberto Scanferla
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Florence, Italy
| | - Francesco Muratori
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Florence, Italy
| | - Federico Scolari
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Florence, Italy
| | - Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Careggi University Hospital, Florence, Italy
| | - Angela Tamburini
- Department of Paediatric Oncology, Meyer University Hospital, Florence, Italy
| | - Giovanni Beltrami
- Department of Paediatric Orthopaedics, Meyer University Hospital, Florence, Italy
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Kelly SP, Ramkumar DB, Crawford B, Lozano-Calderon SA, Gebhardt MC, Anderson ME. Management of limb length discrepancy after bone sarcoma resection about the knee in the skeletally immature. J Pediatr Orthop B 2024; 33:497-502. [PMID: 37712771 DOI: 10.1097/bpb.0000000000001124] [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: 09/16/2023]
Abstract
Patients with bone sarcomas increasingly choose limb salvage. This can lead to issues with limb length discrepancy (LLD) for the skeletally immature. We synthesize management options into an algorithm and report our results. Patients with bone sarcomas involving any location from the femoral diaphysis to the tibial diaphysis 12 years or younger were reviewed. Our clinical pathway prescribed patients with metadiaphyseal lesions to intercalary allograft reconstruction, epiphyseal lesions and less than 5 cm expected LLD to osteoarticular allograft and patients with more than 5 cm expected LLD to extendable prosthesis. Twenty patients met inclusion criteria: 11 with osteoarticular allografts, 5 with extendable prostheses and 4 with intercalary allografts; median age 11.5 years; median follow-up 8.2 years; and final median LLD 1.6 cm. Five patients had contralateral epiphysiodesis, two patients underwent contralateral femoral shortening and a median of 6 (range 4-8) lengthenings were performed for extendable prostheses. Four patients had residual LLD over 3 cm. There were 13 revisions in 8 patients and 2 amputations. Limb-salvage in paediatric bone sarcoma of the knee can be managed with multiple techniques producing satisfactory results in regards to LLD. Careful pre-operative planning and shared decision making is a requisite given the high rate of secondary procedures for both LLD and reconstructive failures. Level of evidence: Level III Retrospective Comparative Study.
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Affiliation(s)
- Sean P Kelly
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii
| | - Dipak B Ramkumar
- Department of Orthopaedic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Brooke Crawford
- Department of Orthopaedic Surgery, University of Miami Health System, Miami, Florida
| | | | - Mark C Gebhardt
- Department of Orthopaedic Surgery, Boston Children's Hospital, Massachusetts, USA
| | - Megan E Anderson
- Department of Orthopaedic Surgery, Boston Children's Hospital, Massachusetts, USA
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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.
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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
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Öztürk R. Expandable endoprostheses in skeletally immature patients: Where we are. World J Orthop 2024; 15:312-317. [PMID: 38680670 PMCID: PMC11045467 DOI: 10.5312/wjo.v15.i4.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/26/2024] [Accepted: 03/15/2024] [Indexed: 04/16/2024] Open
Abstract
Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality. Until the early 1990s, the treatment options for these patients were rotationplasty or amputation. Multimodal approaches that combine imaging, chemotherapy, and surgical techniques have enabled the development of limb-preserving methods with satisfactory results. In order to overcome inequality problems, expandable prostheses have been developed in the 1980s. Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative. Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures, but the complication rate remains high. Therefore, although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children, they are still a suitable interim choice until full adulthood is achieved. Due to reported high complication rates, the procedures require significant experience and are recommended for use only in specialized cancer centers.
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Affiliation(s)
- Recep Öztürk
- Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen 45143, Germany
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Zan P, Shen J, Liu K, Wang H, Cai Z, Ma X, Sun W. Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children. Front Pediatr 2023; 11:1168637. [PMID: 37416814 PMCID: PMC10320852 DOI: 10.3389/fped.2023.1168637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/09/2023] [Indexed: 07/08/2023] Open
Abstract
Purpose To explore the application of Custom-made Semi-joint prosthesis replacement combined with Ligament Advanced Reinforcement System (LARS) ligament reconstruction for the limb salvage surgery (LSS) of malignant tumors in the distal femur and provide selections for the LSS of malignant tumors in skeletal immature children. Methods A total of 8 children with malignant tumors in the distal femur who underwent Custom-made Semi-joint prosthesis replacement combined LARS ligament reconstruction for LSS from January, 2018 until December, 2019 in our bone and soft tissue tumor center were retrospectively recruited. The prosthesis related complications, oncological prognosis and knee function were observed, and the surgical efficacy was comprehensively evaluated. Results The average follow-up time was 36.6 months (30-50 months). The average osteotomy length was 13.2 cm (8-20 cm) according to the preoperative imaging results and the length of the customized prosthesis. Two years after operation, the average MSTS-93 score was 24.4 (16-29) which indicated good limb functions. The range of motion of the knee was 0°-120°, with an maximum average of 100°. At last follow-up, the average height of the children increased by 8.4 cm (6-13 cm), and the average limb shortening was 2.7 cm (1.8-4.6 cm). One patient had wound complications in the early postoperative period, wound scab fell off to form superficial ulcer, in whom debridement and suturing were performed. One patient developed hematogenous disseminated prosthesis infection 2 years after surgery, and the prosthesis is now in situ with anti-infection treatment. One patient developed pulmonary metastasis during follow-up, and received chemotherapy and targeted therapy with lesion well controlled. At the last follow-up, there was no local tumor recurrence or prosthesis loosening. Conclusion Under the premise of appropriate case selection, customized semi-joint prosthesis replacement combined with LARS ligament reconstruction provides a new option for LSS in children with distal femur malignant tumors. LARS ligament reconstruction ensures the stability and range of motion of the knee joint, which maximally preserves the epiphysis of the tibia side and the growth function of the tibia side, reduces the complications of limb length inequality in the long term and creates conditions for limb lengthening or total joint replacement in adults.
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Affiliation(s)
| | | | | | | | | | | | - Wei Sun
- Correspondence: Xiaojun Ma Wei Sun
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Zhao Z, Yang Y, Yan T, Tang X, Yang R, Guo W. Outcomes of Fixed-Hinged Knee Prosthesis for Distal Femoral Osteosarcoma in Skeletally Immature Patients: First Results. J Knee Surg 2023; 36:68-78. [PMID: 34187071 DOI: 10.1055/s-0041-1729623] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The best surgical choice for distal femur osteosarcoma in skeletally immature patients remains controversial. A fixed hinged knee prosthesis has been designed to preserve the growth plates in the adjacent tibia, expecting tibial growth to be continued. This study aims to report the (1) clinical outcomes after prosthetic replacement, (2) postoperative complications, and (3) length of discrepancy of the operative tibia with the unaffected tibia. Thirty-four skeletally immature patients (averaged 9 years at surgery; range, 5-12 years) with distal femoral osteosarcoma underwent placement of this hinged knee prosthesis between January 2015 and August 2018. Postoperative function and complications were assessed. Length discrepancy was measured using a series of full-length standing anteroposterior radiographs of the bilateral lower extremity. The average follow-up duration was 34 months (2.8 years). In the last follow-up, four patients expired because of pulmonary metastasis. Two patients presented with local recurrence of the soft tissue. Postoperatively, the flexion range of the knee joint range was between 100 and 130 degrees, with an average of 115.2 degrees. The mean functional score of living patients evaluated using the Musculoskeletal Tumor Society scoring system was 89.2% (range, 76.7-100%). Types 1 (three patients), 2 (one patient), 3 (two patients), and 5 (two patients) complications exist. Among them, three patients received revision surgery. The proximal tibial physis still grew after surgery, with an average of 74.3% (range, 30-100%) growth potential compared with the unaffected proximal tibial physis. Moreover, 27 children exhibited tibial length discrepancy compared with the contralateral tibia, and the mean discrepancy in tibial length was 1.1 cm (range, 0.2-3.1 cm). This hinged knee prosthesis can keep the growth potential in the adjacent tibia, provides satisfying functional outcomes, and has a lower postoperative complication rate. Thus, it could serve as an alternative intervention for distal femoral osteosarcoma in skeletally immature patients.
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Affiliation(s)
- Zhiqing Zhao
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
| | - Yi Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
| | - Taiqiang Yan
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, P.R. China
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Li Z, Lu M, Zhang Y, You Q, Wang Y, Li L, Ye Q, Wang Y, Luo Y, Min L, Zhou Y, Tu C. Three-dimensional printed customized uncemented unipolar prosthesis combined with ligament reconstruction for tumorous defect of the distal femur in children. BMC Musculoskelet Disord 2022; 23:1100. [PMID: 36527043 PMCID: PMC9756496 DOI: 10.1186/s12891-022-06053-7] [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: 07/14/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hemiarthroplasty following tumor resection of the distal femur in children provides a chance to preserve the proximal tibial physis for limb elongation. Based on three-dimensional (3D) printing technology, the uncemented unipolar prosthesis with joint stability reinforced structures (JSRSs) was custom-designed for our cases. This study aimed to describe the design and assess the short-term outcomes of this refined prosthetic hemiarthroplasty. METHODS Seven patients (four females and three males) received 3D-printed customized uncemented unipolar prosthesis for hemiarthroplasty after removal of the distal femur, from September 2019 to October 2020 at our Orthopedics department. The limb function, growth of the preserved proximal tibial physis, joint stability, and limb length discrepancy (LLD) were assessed. Complications were recorded. RESULTS Six patients survived with no evidence of metastasis or local recurrence at the last follow-up, and one patient died of lung metastasis at 19 months postoperatively. Follow-up ranged from 19 to 32 months, with an average of 26 months. Elongation of the tibia was observed in all cases. At the last follow-up, four patients exhibited equal growth length compared with the healthy contralateral tibia. LLD ranged from 0.8 to 1.6 cm with a mean of 1.3 cm. The average knee range of motion was 95.3° of flexion and 4.5° of extension. All patients achieved satisfactory postoperative limb function with a mean MSTS score of 25.8. The results of the drawer, Lachman, and pivot shift tests were negative in all patients. During follow-up, painless joint space narrowing was observed in two patients. The screw for ligament fixation loosened in one of the seven patients at 17 months postoperatively. No subluxation of the joint, angular deformity, or breakage of the implant was detected in the remaining patients. CONCLUSIONS 3D-printed customized uncemented unipolar prosthesis with JSRS would be a good choice for reconstructing tumorous defect in the distal femur in children.
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Affiliation(s)
- Zhuangzhuang Li
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Minxun Lu
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yuqi Zhang
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Qi You
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yitian Wang
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Longqing Li
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Qiang Ye
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yang Wang
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yi Luo
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Li Min
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yong Zhou
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Chongqi Tu
- grid.412901.f0000 0004 1770 1022Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041 People’s Republic of China ,grid.412901.f0000 0004 1770 1022Model Worker and Craftsman Talent Innovation Workshop of Sichuan province , West China Hospital, Sichuan University, Chengdu, People’s Republic of China
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Tibia Multiplanar Deformities and Growth Disturbance Following Expandable Endoprosthetic Distal Femur Replacement. J Clin Med 2022; 11:jcm11226734. [PMID: 36431210 PMCID: PMC9699560 DOI: 10.3390/jcm11226734] [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: 08/13/2022] [Revised: 09/29/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Expandable distal femur endoprosthesis (EDFE) is commonly used to compensate for the loss of the distal femoral epiphyseal plate in skeletally immature children who have undergone surgical resection of bone malignancies. However, the effect of the passive tibial component of the EDFE on tibial growth has not been extensively studied in the literature. This study aims to delineate the type, frequency, and associated risk factors of multiplanar proximal tibial deformities in skeletally immature children following the use of the expandable distal femur endoprosthesis (EDFE). Moreover, we plan to detect how these deformities influence the long-term functionality of the endoprosthesis in defining the need for subsequent implant revision or further surgical management. Patients and Methods: A total of 20 patients aged (7−12) years underwent expandable distal femur replacement. Two types of implants were used: Juvenile Tumor System (JTS) non-invasive prosthesis in 14 patients, and Modular Universal Tumor and Revision System (MUTARS)® Xpand Growing Prostheses in six patients. A scanogram and CT scan documented the measurements of longitudinal and multiplanar growth as leg length discrepancy (LLD), femur length discrepancy (FLD), tibia length discrepancy (TLD), and the yield values of rotational, sagittal, and coronal deformities of the tibia. The patients were followed up to assess the need for further management. Sex, age, size of tibial plate perforation, and type of implant used were studied for possible correlation with deformities or growth disturbance. Results: The patients were followed up for a mean of 3 (2−7) years. A total of 14 patients, (10 JTS, 4 implant cast) had a tibial deformity and/or growth disturbance. A single patient was found to have all deformities (growth, rotational, coronal, and sagittal). Fourteen patients were found to have an LLD ranging from 5.3 to 59 mm (median 21 mm), 12 had a TLD from 3 to 30 mm, (median 10 mm), and 11 patients showed evidence of malrotation from 6 to 32 degrees (median 11 degrees). TLD was found to contribute entirely to LLD in three patients, and >50% of LLDs in seven patients. All LLDs were treated conservatively, except in three patients; two received contralateral tibia epiphysiodesis and one received revision with a new implant. A single patient had a posterior tibia slope angle (PTSA) of −2.8 degrees, and three patients had a coronal deformity with a mean medial proximal tibia angle (MPTA) of 80.3 (77−83 degrees). Conclusions: Tibial growth disturbance and multiplanar deformities occur in the majority of patients following EDFE replacement, exacerbating LLD. Yet, these disturbances may be well tolerated, managed conservatively, and rarely mandate endoprosthetic revision or subsequent corrective surgery. Age at the time of surgery was found to be the only significant contributor to the development of tibia growth disturbance.
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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: 0.3] [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.
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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
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Abu El Afieh J, Gray M, Seah M, Khan W. Endoprosthetic Reconstruction in Ewing's Sarcoma Patients: A Systematic Review of Postoperative Complications and Functional Outcomes. J Clin Med 2022; 11:jcm11154612. [PMID: 35956228 PMCID: PMC9370018 DOI: 10.3390/jcm11154612] [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: 07/10/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Ewing's sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing's patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing's sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing's patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson's failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of 'good' functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES.
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Long-term outcomes of non-invasive expandable endoprostheses for primary malignant tumors around the knee in skeletally-immature patients. Arch Orthop Trauma Surg 2022; 142:927-936. [PMID: 33417027 DOI: 10.1007/s00402-020-03712-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/06/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Expandable endoprostheses are used to restore limb function and compensate for the sacrifice physis involved in carcinologic resection. Long-term outcomes of the last generation of knee "non-invasive" expandable endoprostheses are required. Objectives were to report on oncologic results of bone sarcoma resection around the knee with expandable endoprosthesis reconstruction and to compare the surgical outcomes of the "non-invasive" expandable endoprostheses used in our department. MATERIALS AND METHODS Retrospective study that included all children with bone sarcoma around the knee that underwent tumor resection reconstructed with non-invasive expandable prosthesis. Phenix-Repiphysis was used from 1994 to 2008 followed by Stanmore JTS non-invasive from 2008 to 2016. Survival and complications were recorded. Functional outcomes included Musculoskeletal Tumor Society (MSTS) score, knee range of motion, lower limb discrepancy (LLD). RESULTS Forty children (Sex Ratio = 1) aged a mean 8.8 years (range, 5.6-13.8) at surgery were included in the study. There were 36 osteosarcoma and 4 Ewing sarcoma that involved 33 distal femur and 7 proximal tibia. Cohort (n = 40) consisted of 28 Phenix-Repiphysis and 12 Stanmore with a mean follow-up of 9.8 ± 5.8 years and 6.1 ± 3.1 years, respectively. Postoperative infection rate was 7.5% in the cohort (3 Repiphysis). Functional results were significantly better in the Stanmore group with a mean MSTS of 87.6 ± 5.4% and knee flexion of 112 ± 38°. At last follow-up, implant survival was 100% in Stanmore group, whereas all living Phenix-Repiphysis were explanted. Mechanical failure was the primary cause for revision of Phenix-Repiphysis. Limb length equality was noted in 79% patients with Phenix-Repiphysis and 84% with Stanmore at last follow-up. CONCLUSION Chemotherapy and limb-salvage surgery yield good oncologic outcomes. Expandable endoprostheses are effective in maintaining satisfactory function and lower limb equality. With improvements made in the last generation of "non-invasive" prostheses, implants' survival has been substantially lengthened.
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Masrouha K, Abboud M, Saab R, Muwakkit SA, Khoury N, Haidar R, Saghieh S. Long-term follow-up of children treated with the Repiphysis expandable prosthesis for lower extremity bone sarcoma. J Pediatr Orthop B 2022; 31:e258-e263. [PMID: 34101677 DOI: 10.1097/bpb.0000000000000891] [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: 11/26/2022]
Abstract
Expandable endoprostheses provide a limb salvage option for skeletally immature patients with bone sarcoma of the lower extremities. Initial reports of the Repiphysis prosthesis were encouraging; however, medium-term follow-up revealed high complication rates. We report on the long-term follow-up of a cohort of patients treated with the Repiphysis prosthesis. Eleven patients were included in the study. Data collected included sex, age at surgery, duration of follow-up, site of disease, histologic diagnosis, number of lengthening sessions, amount lengthened, postoperative complications, endoprosthetic failure, mode of endoprosthetic failure, duration from index surgery to failure and to revision, type of revision surgery and final limb-length discrepancy. The average duration of follow-up from the time of surgery was 180 months (range, 144-215 months). Fifteen Repiphysis implants were used in 11 patients. All implants failed with an average time from surgery to failure of 36 months (range, 3-72 months). Twenty-four complications were observed: one wound dehiscence, two deep infections, 18 mechanical failures, implant collapse with destruction of proximal tibia epiphysis in two and one periprosthetic proximal femur fracture with dislodgement of the stem. Despite being an option for limb salvage, the Repiphysis prosthesis has a high rate of mechanical failure and need for revision, similar to other expandable implants. The authors, therefore, recommend full disclosure of the potential short- and long-term complications and need for revision, as well as alternative treatment options if their use is considered. Level of evidence: IV (Therapeutic).
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Affiliation(s)
- Karim Masrouha
- Divisions of Pediatric Orthopedic Surgery and Orthopedic Oncology, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Miguel Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | - Raya Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | - Samar A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | | | - Rachid Haidar
- Division of Orthopedic surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Said Saghieh
- Division of Orthopedic surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Lex JR, Adlan A, Tsoi K, Evans S, Stevenson JD. Frequency and reason for reoperation following non-invasive expandable endoprostheses: A systematic review. J Bone Oncol 2021; 31:100397. [PMID: 34712555 PMCID: PMC8529098 DOI: 10.1016/j.jbo.2021.100397] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/08/2021] [Accepted: 10/03/2021] [Indexed: 11/25/2022] Open
Abstract
Implant failure is the most common reason for revision of growing prostheses. Maximum prosthesis growth with a residual LLD is the most common mode of failure. Functional outcomes are good, but 1/ 5 patients have a persistent LLD over 2 cm. Background Non-invasive expandable endoprostheses (NIEPR) utilize an external electromagnetic field to drive an innate mechanical gearbox. This lengthens the extremity following oncological resections in children with a predicted limb length discrepancy (LLD), facilitating limb-salvage. This review was conducted to assess NIEPR implant survival rates and identify modes of implant failure unique to these prostheses. Methods Medline, EMBASE and the Cochrane Library databases were searched for all manuscripts evaluating implant survival of NIEPRs implanted into skeletally immature patients following resection of extremity sarcomas. Minimum follow-up of 12 months or implant failure was required for inclusion. Failures were classified using the latest ISOLS classification and exact implant-specific failure modality was also identified. Results 19 studies met inclusion criteria. Mean age was 10.0 years (7.7 – 11.4 years). The most common locations for NIEPR implantation were the distal femur (343, 76.7%) and proximal tibia (53, 119%). Mean follow-up was 65.3 months (19.4 – 163 months). The overall implant revision rate was 46.2% (0 – 100%); implant specific revisions included maximal prosthesis lengthening with persistent LLD (10.4%), failed extension mechanism (6.1%), implant fracture (7.7%), hinge fracture (1.4%) and bushing wear (0.9%). Persistent clinically significant (>20 mm) LLD at final follow-up was present in 19.2% (0 – 50%) of patients. The mean MSTS score was 85.1% (66.7–96.3%) at final follow-up. Conclusion Implant-related failures are the most common reason for NIEPR revision. Implant reliability appears to be improved with current designs. A sub-classification to the current classification system based on implant-specific failures for NIEPRs is proposed.
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Affiliation(s)
- Johnathan R Lex
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Amirul Adlan
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Scott Evans
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK
| | - Jonathan D Stevenson
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK.,Aston University Medical School, Aston University, Birmingham, UK
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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: 17] [Impact Index Per Article: 4.3] [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.
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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
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Zoccali C, Careri S, Attala D, Florio M, Milano GM, Giordano M. A New Proximal Femur Reconstruction Technique after Bone Tumor Resection in a Very Small Patient: An Exemplificative Case. CHILDREN-BASEL 2021; 8:children8060442. [PMID: 34070245 PMCID: PMC8225183 DOI: 10.3390/children8060442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
For patients too young to be fitted with an expandable prosthesis, limb salvage surgery requires other strategies. The main problems are related to the impossibility of implanting an expandable prosthesis to the residual bone growth that is much too big in relation to the bone size, with the precocious implant loosening and/or the residual absence of bone growth, as well as the problem of limb length and shape difference. In this paper, we report a possible reconstruction solution using a composite prosthesis for an Ewing’s sarcoma of the proximal femur in an infant patient. After resection, a femoral stem was cemented into the distal third of a homoplastic humerus; a carbon fiber plate was used to stabilize the bone/homograft interface. At the one-year follow-up, the patient was free of disease and able to walk with only a slight limp. This case report describes a possible solution for very small patients. An adult humerus is of the right size to replace a child’s lower limb segments, and the distal humerus can be shaped, maintaining a cortex stiff enough to support a prosthesis. Very young patients might obtain a faster osteointegration of the graft than adults, due to their higher biological activity and, in this case, the diapasonal shape of the allograft might also have contributed to accelerated fusion. Moreover, the use of a graft to fit the prosthesis avoids loosening issues due to canal widening, hypothetically providing more growing time before system failure and revision surgery. However, although this technique is promising, further studies are necessary to confirm our findings and to verify if this procedure allows easier future prosthesis implantation.
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Affiliation(s)
- Carmine Zoccali
- Oncological Orthopaedics Department, IRCCS—Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Silvia Careri
- Department of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy; (M.F.); (M.G.)
- Correspondence: ; Tel.: +39-06-68592313
| | - Dario Attala
- Muscular-Skeletal Tissue Bank–IRCCS–Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy;
| | - Michela Florio
- Department of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy; (M.F.); (M.G.)
| | - Giuseppe Maria Milano
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy;
| | - Marco Giordano
- Department of Orthopaedics and Traumatology, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy; (M.F.); (M.G.)
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Surgical Advances in Osteosarcoma. Cancers (Basel) 2021; 13:cancers13030388. [PMID: 33494243 PMCID: PMC7864509 DOI: 10.3390/cancers13030388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Osteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development. Abstract Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.
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Imanishi J, Tanabe M, Kurihara T, Torigoe T, Kikkawa J, Ohta A, Watanabe A, Tanaka R, Saita K, Kadono Y, Yazawa Y. Temporal hemiarthroplasty for distal femoral osteosarcoma in early childhood: a case report. World J Surg Oncol 2020; 18:280. [PMID: 33115497 PMCID: PMC7594408 DOI: 10.1186/s12957-020-02047-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/13/2020] [Indexed: 11/18/2022] Open
Abstract
Background Prosthetic reconstruction for distal femoral osteosarcoma is challenging for younger children. We herein report a successful case of limb-sparing surgery for a younger patient with distal femoral osteosarcoma requiring osteo-articular resection. Case presentation A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb-salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned. Conclusions This case report provides an example of limb-salvage surgery after distal femoral resection in a small child. The use of a temporary spacer utilizing partial cementation and preservation of the periosteum and induced membrane appears to afford a viable limb-salvage option after distal femoral resection for younger children. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12957-020-02047-8.
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Affiliation(s)
- Jungo Imanishi
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan. .,Department of Orthopaedic Surgery, Saitama Medical University Hospital, 38 Moro-hongo, Moroyama, Saitama, 3500495, Japan. .,Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, 1738605, Japan.
| | - Masayuki Tanabe
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan.,Department of Orthopaedic Surgery, Saitama Medical University Saitama Medical Center, 1981 Kamoda, Kawagoe, Saitama, 3508550, Japan
| | - Taisei Kurihara
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Tomoaki Torigoe
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Jun Kikkawa
- Department of Orthopaedic Surgery, Saitama Medical University Hospital, 38 Moro-hongo, Moroyama, Saitama, 3500495, Japan.,Department of Critical Care and Emergency, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Atsuhiko Ohta
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Atsuko Watanabe
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Ryuhei Tanaka
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical University Saitama Medical Center, 1981 Kamoda, Kawagoe, Saitama, 3508550, Japan
| | - Yuho Kadono
- Department of Orthopaedic Surgery, Saitama Medical University Hospital, 38 Moro-hongo, Moroyama, Saitama, 3500495, Japan
| | - Yasuo Yazawa
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 3501298, Japan
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Portney DA, Bi AS, Christian RA, Butler BA, Peabody TD. Outcomes of Expandable Prostheses for Primary Bone Malignancies in Skeletally Immature Patients: A Systematic Review and Pooled Data Analysis. J Pediatr Orthop 2020; 40:e487-e497. [PMID: 32501921 DOI: 10.1097/bpo.0000000000001459] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies. RESULTS A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004). CONCLUSIONS Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies. LEVEL OF EVIDENCE Level IV-retrospective case series with pooled data.
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Affiliation(s)
- Daniel A Portney
- Feinberg School of Medicine
- Department of Orthopaedic Surgery, University of Chicago, Chicago, IL
| | - Andrew S Bi
- Feinberg School of Medicine
- Department of Orthopaedic Surgery, New York University, New York, NY
| | - Robert A Christian
- Feinberg School of Medicine
- Department of Orthopaedic Surgery, Northwestern University, Evanston
| | - Bennet A Butler
- Feinberg School of Medicine
- Department of Orthopaedic Surgery, Northwestern University, Evanston
| | - Terrance D Peabody
- Feinberg School of Medicine
- Department of Orthopaedic Surgery, Northwestern University, Evanston
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Ji T, Yang Y, Li DS, Tang XD, Guo W. Limb Salvage Using Non-hinged Endoprosthesis and Staged Correction of Leg-length Discrepancy for Children with Distal Femoral Malignant Tumors. Orthop Surg 2019; 11:819-825. [PMID: 31489784 PMCID: PMC6819186 DOI: 10.1111/os.12525] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/05/2019] [Accepted: 07/21/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Limb salvage in pediatric patients remains a challenge. We describe a staged strategy. The procedure includes: (i) tumor removal and non-hinged static endoprosthesis reconstruction; (ii) leg length discrepancy (LLD) correction by shoe lift or distraction osteogenesis; and (iii) maturity reconstruction by regular endoprosthesis. The aim of the study was to investigate the results of non-hinged static megaprosthesis reconstruction and staged LLD correction in the treatment of malignant tumors in the distal femur in children. METHODS Non-hinged megaprostheses were implanted in 12 pediatric patients with osteosarcoma in the distal femur. The prosthesis consists of a femoral component with constrained condylar knee (CCK) design, and a tibial component with a small-diameter press-fit stem and derotation fins. A posterior stabilizing polyethylene component is fixed on the tibial component. The cases were prospectively followed up with focus on the growth rate of adjacent uninvolved bone in the salvaged limb, joint stability, knee stability, function outcome, length discrepancy, and surgery-related complications. RESULTS There were five girls and seven boys included in the study, with an average age at the time of primary surgery of 10.0 years (range, 8-12 years). All the tumors were located in the distal femur. The average follow up was 76.3 months (range, 24-139 months). The Ligament Augmentation and Reconstruction System (LARS) ligament was used in two patients to enhance the soft tissue reattachment and reconstruct medial collateral ligament (MCL). Ten patients were alive at the final follow-up and two had died of lung metastases. Expected LLD was 6.7 cm (range, 3.0-13.2 cm) at initial surgery. At the final follow-up, nine patients reached skeletal maturity and the actual LLD at the femur was 5.3 cm (range, 3.0-10.1 cm), excluding 1 cm correction at initial surgery by endoprosthesis. The proximal tibia physis showed an average of 86.7% (range, 56.5%-100%) growth of the contralateral side. The mean reduction in tibial length was 1.2 cm (range, 0.5-4.7 cm). Six patients received distraction osteogenesis at a mean length of 5.4 cm (range, 3.0-9.1 cm). Range of knee movement was between 85° and 125°, with an average of 102.5°. The Musculoskeletal Tumor Society 93 score of patients alive was 80.6 (range, 60-90). CONCLUSION Non-hinged static megaprosthesis followed by LLD correction with shoe lift or staged distraction osteogenesis appears to be an alternative option to treat children with malignant bone tumors around the knee.
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Affiliation(s)
- Tao Ji
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Yi Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Da-Sen Li
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Xiao-Dong Tang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
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Abstract
Tumour endoprostheses have facilitated limb-salvage procedures in primary bone and soft tissue sarcomas, and are increasingly being used in symptomatic metastases of the long bones. The objective of the present review was to analyse articles published over the last three years on tumour endoprostheses and to summarize current knowledge on this topic. The NCBI PubMed webpage was used to identify original articles published between January 2015 and April 2018 in journals with an impact factor in the top 25.9% of the respective category (orthopaedics, multidisciplinary sciences). The following search-terms were used: tumour endoprosthesis, advances tumour endoprosthesis, tumour megaprosthesis, prosthetic reconstruction AND tumour. We identified 347 original articles, of which 53 complied with the abovementioned criteria. Articles were categorized into (1) tumour endoprostheses in the shoulder girdle, (2) tumour endoprostheses in the proximal femur, (3) tumour endoprostheses of the knee region, (4) tumour endoprostheses in the pelvis, (5) (expandable) prostheses in children and (6) long-term results of tumour endoprostheses. The topics of interest covered by the selected studies largely matched with the main research questions stated at a consensus meeting, with survival outcome of orthopaedic implants being the most commonly raised research question. As many studies reported on the risk of deep infections, research in the future should also focus on potential preventive methods in endoprosthetic tumour reconstruction. Cite this article: EFORT Open Rev 2019;4:445-459. DOI: 10.1302/2058-5241.4.180081
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Affiliation(s)
- Maria A Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
| | - Dimosthenis Andreou
- Department of General Orthopaedics and Tumour Orthopaedics, University Hospital Muenster, Germany
| | - Per-Ulf Tunn
- Tumour Orthopaedics, HELIOS Klinikum Berlin-Buch, Germany
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
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Savvidou OD, Kaspiris A, Dimopoulos L, Georgopoulos G, Goumenos SD, Papadakis V, Papagelopoulos PJ. Functional and Surgical Outcomes After Endoprosthetic Reconstruction With Expandable Prostheses in Children: A Systematic Review. Orthopedics 2019; 42:184-190. [PMID: 31323102 DOI: 10.3928/01477447-20190625-02] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of bone sarcomas in children is associated with wide tumor re-section and segmental reconstruction. The optimal surgical approach is still under debate in the literature. During the past decade, the application of expandable prostheses has gained remarkable attention because it improves patients' appearance and allows limb growth preventing leg length discrepancy. A systematic review of the literature was performed to identify studies focusing on the functional and surgical outcomes of the application of expandable endoprostheses. [Orthopedics. 2019; 42(4):184-190.].
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Windhager R, Funovics P, Panotopoulos J, Hobusch G, Schinhan M. [Growing prostheses after sarcoma resection in children and adolescents]. DER ORTHOPADE 2019; 48:563-571. [PMID: 31123758 DOI: 10.1007/s00132-019-03753-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Growing prostheses are regarded as a valuable alternative to amputation and rotationplasty for the treatment of primary malignant bone and soft-tissue sarcomas in childhood. During the last three decades different devices have been introduced and technically improved from invasively to non-invasively extendable prostheses. THE CURRENT SITUATION OF STUDIES Despite the long period, only 21 peer-reviewed publications could be detected containing relevant numbers and results. In these papers, 590 patients with mean follow-up times of 81.1 months were reported who had been fitted with growing prostheses at the age of 12.6 years. Besides satisfactory functional results (78.3 out of 100 MSTS points) there was a high complication rate of 27.3% infections and 22.4% mechanical failure. COMPLICATIONS This increasing risk of infection over a long follow-up period, represents the biggest drawback of this method and, therefore, needs to be discussed extensively with the patients and parents when considering this procedure as an alternative to ablative surgery.
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Affiliation(s)
- R Windhager
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - P Funovics
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - J Panotopoulos
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - G Hobusch
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - M Schinhan
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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Sambri A, Staals E, Medellin MR, Abudu A, Gikas P, Pollock R, Briggs TWR, Donati DM, Manfrini M. Stanmore noninvasive extendible endoprosthesis in the treatment of bone sarcoma in the preadolescent. J Surg Oncol 2019; 120:176-182. [DOI: 10.1002/jso.25501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/03/2019] [Accepted: 04/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Sambri
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
| | - Eric Staals
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
| | - Manuel Ricardo Medellin
- Orthopedic OncologyRoyal Orthopaedic Hospital NHS TrustBirmingham UK
- Orthopedic OncologyInstituto Nacional de CancerologiaBogotà Colombia
| | - Adesegun Abudu
- Orthopedic OncologyRoyal Orthopaedic Hospital NHS TrustBirmingham UK
| | - Panagiotis Gikas
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | - Rob Pollock
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | - Tim WR Briggs
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | | | - Marco Manfrini
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
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Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review. Clin Orthop Relat Res 2019; 477:894-902. [PMID: 30801278 PMCID: PMC6437378 DOI: 10.1097/corr.0000000000000630] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Excision of bone tumors and endoprosthetic reconstruction allow patients early weightbearing and a potential functional advantage compared with amputation. These reconstructions do not restore the limb to normal status, however, and patients are subject to complications that may result in revision or loss of the limb. Because better understanding of these complications based on current information might help the patient and surgeon in decision-making, we undertook a systematic review of studies published on this topic. QUESTIONS/PURPOSES (1) What are the primary modes and proportion of failure of tumor endoprostheses in patients undergoing reconstruction after excision of primary extremity bone sarcomas? METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library for all studies published from April 15, 1998, to April 15, 2018. Three reviewers independently reviewed studies reporting endoprosthetic reconstruction survival and events requiring revision for primary extremity bone tumors treated with endoprosthetic reconstruction for inclusion and performed independent data extraction. We excluded all studies with fewer than five patients, any systematic review/meta-analyses, and any study not reporting on primary extremity bone tumors. All discrepancies were resolved by the study's senior author. Data extracted from included studies were any reoperation event for wound dehiscence, any operative fixation for a pathologic fracture, and any revision of the primary endoprosthesis for implant wear or breakage, deep infection not amenable to prosthesis retention, or for local recurrence. We assessed the overall quality of the evidence with the Methodological Index for Non-Randomized Studies (MINORS) approach with a higher MINORS score representative of a more methodologically rigorous study with a total possible score of 16 points for noncomparative and 24 points for comparative studies. Forty-nine studies met criteria for inclusion from an initial search return of 904 studies, of which no studies were randomized controlled trials. From a total patient population of 2721, there was a mean followup of 93 months (range, 1-516 months) with loss to followup or death occurring in 447 of 2118 (21%) patients with six studies not providing loss to followup data. The mean MINORS score was 14 for prospective studies and 11 for retrospective studies. RESULTS Overall, there were 1283 reoperations among the 2721 (47%) patients. Reoperation for mechanical endoprosthetic events (soft tissue dehiscence or periarticular soft tissue instability, aseptic loosening, or implant wear/fracture) occurred in 907 of 2721 (33%) patients. Aseptic loosening occurred at a mean of 75 months (range, 1-376 months) in 212 of 315 patients (67%). Deep infection requiring removal of the initial prosthesis occurred in 247 of 2721 (9%) patients with deep infection occurring at a mean of 24 months (range, 1-372 months) in the 190 infections (77%) with time to infection data available. Local recurrence rates requiring revision or amputation occurred in 129 (5%) of all patients. There was an overall primary endoprosthesis survival rate without any surgical reintervention of 63% among reporting studies at a mean of 79 months followup. CONCLUSIONS Failures of endoprosthetic reconstructions after extremity tumor surgery are common, most often resulting from implant wear or fracture, aseptic loosening, and infection. Importantly, the aggregated data are the first to attempt to quantify the time to specific complication types within this patient population. Deep infection not amenable to endoprosthesis retention appears to occur approximately 2 years postoperatively in most patients, with aseptic loosening occurring most commonly at 75 months. Although endoprosthetic reconstruction is one of the most common forms of reconstruction after bone tumor resection, the quality of published evidence regarding this procedure is of low quality with high loss to followup and data quality limiting interstudy analysis. The quality of the evidence is low with high loss to followup and inconsistent reporting of times to reintervention events. Although the most common modes of endoprosthetic failure in this population are well known, creation of quality prospective, collaborative databases would assist in clarifying and informing important elements of the followup process for these patients. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Gautam D, Malhotra R. Megaprosthesis versus Allograft Prosthesis Composite for massive skeletal defects. J Clin Orthop Trauma 2018; 9:63-80. [PMID: 29628687 PMCID: PMC5884048 DOI: 10.1016/j.jcot.2017.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/20/2017] [Indexed: 02/09/2023] Open
Abstract
Massive skeletal defects are encountered in the setting of tumors necessitating excision, failed total hip arthroplasty with periprosthetic bone loss, periprosthetic fracture, complex trauma, multiple failed osteosynthesis and infection. Reconstruction of the segmental defects poses a tremendous challenge to the orthopaedic surgeons. The goal of osseous reconstruction of these defects is to restore the bone length and function. Currently the most commonly employed methods for reconstruction are either a megaprosthesis or an Allograft Prosthesis Composite (APC). Megaprosthesis, initially created for the treatment in neoplastic pathologies are being used for the non-neoplastic pathologies as well. The longevity of these implants is an issue as majority of the patients receiving them are the survivors of oncologic issue or elderly population, both in which the life expectancy is limited. However, the early complications like instability, infection, prosthetic breakage and fixation failure have been extensively reported in several literatures. Moreover, the megaprostheses are non-biological options preventing secure fixation of the soft tissue around the implant. The Allograft Prosthesis Composites were introduced to overcome the complications of megaprosthesis. APC is made of a revision-type prosthesis cemented into the skeletal allograft to which the remaining soft tissue sleeve can be biologically fixed. APCs are preferred in young and low risk patients. Though the incidence of instability is relatively low with the composites as compared to the megaprosthesis, apart from infection, the newer complications pertaining to APCs are inevitable that includes non-union, allograft resorption, periprosthetic fracture and potential risk of disease transmission. The current review aims to give an overview on the treatment outcomes, complications and survival of both the megaprostheses and APCs at different anatomic sites in both the upper and lower limbs.
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Affiliation(s)
| | - Rajesh Malhotra
- Corresponding author at: Room No 5019, Department of Orthopedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Jeys L, Morris G, Evans S, Stevenson J, Parry M, Gregory J. Surgical Innovation in Sarcoma Surgery. Clin Oncol (R Coll Radiol) 2017; 29:489-499. [PMID: 28502707 DOI: 10.1016/j.clon.2017.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/24/2022]
Abstract
The field of orthopaedic oncology relies on innovative techniques to resect and reconstruct a bone or soft tissue tumour. This article reviews some of the most recent and important innovations in the field, including biological and implant reconstructions, together with computer-assisted surgery. It also looks at innovations in other fields of oncology to assess the impact and change that has been required by surgeons; topics including surgical margins, preoperative radiotherapy and future advances are discussed.
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Affiliation(s)
- L Jeys
- Royal Orthopaedic Hospital, Birmingham, UK; School of Health and Life Sciences, Aston University, Birmingham, UK.
| | - G Morris
- Royal Orthopaedic Hospital, Birmingham, UK
| | - S Evans
- Royal Orthopaedic Hospital, Birmingham, UK
| | | | - M Parry
- Royal Orthopaedic Hospital, Birmingham, UK
| | - J Gregory
- Royal Orthopaedic Hospital, Birmingham, UK
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Pala E, Trovarelli G, Angelini A, Ruggieri P. Distal femur reconstruction with modular tumour prostheses: a single Institution analysis of implant survival comparing fixed versus rotating hinge knee prostheses. INTERNATIONAL ORTHOPAEDICS 2016; 40:2171-2180. [PMID: 27259557 DOI: 10.1007/s00264-016-3232-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the incidence of complications in distal femur reconstructions with modular prostheses, comparing fixed vs rotating hinge knee. METHODS Retrospective analysis of implant survival, complications, and functional results of the Rizzoli series on distal femur megaprosthesis. Between 1983 and 2010, 687 distal femur tumour modular prostheses were implanted: 491 fixed hinge and 196 rotating hinge knee prostheses. Failures of the prostheses were classified in five types: type 1, soft tissue failure; type 2, aseptic loosening; type 3, structural failure; type 4, infection; type 5, tumour progression. RESULTS Failure rate was 27 % (185/687). Implant survival to all types of failure was 70 % at ten years and 50 % at 20 years with no significant difference between fixed and rotating hinge knee prostheses (p = 0.0928). When excluding type 5 and type 1 failures, the overall survival was 78 % and 58 % at ten and 20 years. There was not a significant difference in implant survival to aseptic loosening (p = 0.5) and infection (p = 0.2) between fixed and rotating hinge knee prostheses. All cases of breakage of prosthetic components occurred in fixed hinge knee prostheses. Functional results, evaluated in 536 pts, were satisfactory in 91.4 % of cases with a mean score of 23.3 with a significantly better function for rotating hinge knee prostheses (p < 0.001). CONCLUSIONS The most frequent cause of failure was infection followed by aseptic loosening. Even if better results were expected for rotating hinge knee prostheses, there is no significant difference in overall implant survival. No cases of breakage of prosthetic components occurred in rotating hinge knee prosthesis. Functional results were significantly better for the rotating hinge knee prostheses. LEVEL OF EVIDENCE Therapeutic study, level IV (case series).
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Affiliation(s)
- Elisa Pala
- Department of Orthopedics, Istituto Rizzoli, University of Bologna, Bologna, Italy
| | - Giulia Trovarelli
- Department of Orthopedics, Istituto Rizzoli, University of Bologna, Bologna, Italy
| | - Andrea Angelini
- Department of Orthopedics, Istituto Rizzoli, University of Bologna, Bologna, Italy.
| | - Pietro Ruggieri
- Department of Orthopedics and Orthopedic Oncology, University of Padova, Azienda Ospedaliera di Padova, Via Giustiniani, 235128, Padova, Italy
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