Proximal femoral reconstruction with custom mega prosthesis

Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis

PURPOSE

There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections.

METHODS

We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases.

RESULTS

We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively.

CONCLUSION

Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.

Long-Term Outcome of Endoprosthetic Replacement for Proximal Femur Giant Cell Tumor

INTRODUCTION

Giant cell tumor (GCT) of bone is locally aggressive benign tumor involving the epiphysis of long bones in young adults. Various treatment options include intralesional curettage, extended curettage, wide resection, resection and reconstruction and amputation. The main variables to be considered for planning treatment include the site of involvement and Campanacci stage of the tumor. Functional and oncological outcomes of these treatment options vary widely, the predominant detrimental factor being tumor recurrence rate.

AIM

A study was conducted to evaluate the long-term oncological and functional outcome of patients with GCT of the proximal femur that underwent tumor resection and endoprosthetic replacement.

MATERIALS AND METHODS

Eleven patients with Campanacci stage-III GCT of proximal femur who underwent wide excision of tumor and endoprosthesis replacement with a mean follow-up the duration of 10.6 years were assessed using standard proforma. The treatment outcome was evaluated using the Revised Musculoskeletal Tumor Society Rating Scale for the lower extremity.

RESULTS

At mean follow-up the duration of 10.6 years, none of the cases had tumor recurrence, infection, prosthesis loosening or dislocation. All the patients were community ambulators among whom eight patients were walking without support while three patients were using a cane for support. The mean total Musculoskeletal Tumor Society Score was 26.8 out of 30 indicating the good outcome.

CONCLUSIONS

The authors recommend that wide resection and endoprosthetic replacement should be considered as a preferred treatment option for proximal femur GCT as the functional, and oncological outcome is satisfactory with this modality of treatment.

Endoprosthetic replacement for giant cell tumour of the proximal femur

PURPOSE

To evaluate the functional and oncological outcomes of 12 patients with giant cell tumour (GCT) of the proximal femur treated with customized endoprosthesis.

METHODS

Nine men and 3 women aged 26 to 52 (mean, 36) years with Campanacci stage-III GCTs of the proximal femur were included. All underwent a wide excision of the tumour with clear margins and replacement using a customized, bipolar, cemented proximal femoral megaprosthesis. Functional outcomes were evaluated using the Musculoskeletal Tumor Society functional scores.

RESULTS

The mean follow-up period was 4.8 (range, 4-6) years. There were no instances of recurrence, dislocation, aseptic loosening, deep infection, or death. At the end of 4 years, 8 patients were walking unassisted, 2 used a cane to support during outdoor activities, one used a walking frame at home and outdoors, and one was lost to follow-up. The mean pain relief score was 5.0, the mean functional score was 4.3, the mean emotional acceptance of the procedure and its outcome was 4.7, the mean lower extremity score for support use was 4.7, for walking ability was 4.5, and for gait was 4.3, and the mean total score was 28.3 (out of the maximum of 30).

CONCLUSION

Endoprosthetic replacement for Campanacci stage-III GCT of the proximal femur achieves good to excellent functional and oncological outcomes.

Endoprosthetic reconstruction using total femoral custom mega prosthesis in malignant bone tumours

We analysed 17 patients with primary malignant bone tumour of the femur who underwent limb salvage surgery with the total femoral custom mega prosthesis during the period 1994-2008. The patients were in the age group of 12-73 years, with a mean age of 30.94 years. There were 14 males. The most common diagnosis was osteosarcoma. The average follow-up period was 54.05 months with the longest being 168 months. The average Musculoskeletal Tumour Society (MSTS) functional score was 66.6%. The two- to 14-year overall survival was 82.4%. Three patients died of disease and one patient required amputation. Complications encountered were deep infection and dislocation of the prosthesis.

Outcomes of modular proximal femoral replacement in the treatment of complex proximal femoral fractures: a case series

BACKGROUND

The treatment of complex femur fractures poses a significant challenge. Even with current advancements and the various implements available for the fixation of femoral fractures, results are often disappointing. This study sought to identify problems associated with and examine results of modular proximal femoral replacement. Outcomes were evaluated in two groups of patients: those receiving primary modular proximal femoral replacement for fractures and those treated with salvage arthroplasty for failed internal fixation.

METHODS

Twelve patients who had received modular proximal femoral replacement as primary treatment for proximal femoral fractures were evaluated along with nine patients treated with salvage proximal femoral replacement for failed internal fixation. After the surgical procedure, patients were evaluated at regular follow-up intervals and contacted by phone at the conclusion of this study. Patient functional results were evaluated using the Merle D'Aubigne hip rating scale, which measures pain, motion and ambulatory status. Routine radiographs were also obtained at each patient visit.

RESULTS

On average, patients who received modular proximal femoral replacement as the primary surgery for their femoral fractures enjoyed a high-level functional result and had few complications. Subjects who received salvage femoral replacement had a less optimal outcome and experienced more complications. Nonetheless, final post-operative MDA score was significantly increased from pre-operative levels.

CONCLUSION

Modular proximal femoral replacement is a viable option in the primary fracture or revision setting, and has been shown to have a reasonable outcome, especially when the nature of initial injury is taken into account.

Lower limb salvage surgery: modular endoprosthesis in bone tumour treatment

We retrospectively analysed 90 patients who underwent "en bloc" resection and modular endoprosthesis reconstruction in the lower limbs between 1987-2003. After proximal femur resection, reconstruction was performed with a modular endoprosthesis by Howmedica (KFTR, designed by Kotz) and modular revision endoprosthesis by W. Link or Lima-Lto (Revision system, designed by Wagner). The knee joint was reconstructed with a modular endoprosthesis (Howmedica, KFTR designed by Kotz) after distal femur or proximal tibia resection. Malignant bone tumours were present in 58 patients (64.5%), benign tumours in 16 (17.8%), metastases in 8 (8.9%), tumour-like lesions in 4 (4.4 %) and non-tumour-related destruction of the femur in 4 patients (4.4%). High-grade tumours were found in the majority of malignant bone tumours (70.7%). Treatment complications, which occurred in 26 patients, were: local recurrence of the tumour, deep infection, acetabular destruction following hemiarthroplasty, recurrent dislocations of endoprosthesis, periprosthetic fracture and hardware problems. In total, 23 patients (25.6%) died due to tumours. Endoprostheses should be considered as a treatment of choice for bone tumours in the hip and knee joint region. Advances in limb salvage surgery are, and will long continue to be, a great challenge for orthopaedic oncologists of the 21st century.