CORR Insights™: High infection rate outcomes in long-bone tumor surgery with endoprosthetic reconstruction in adults: a systematic review

The Use of Proximal Femur Replacement for the Management of Oncologic Lesions in the Proximal Femur: A Review

With improved chemotherapeutic treatment, patients with primary or metastatic bone tumor have improved prognoses and longer life expectancies; therefore, durable limb-salvage constructs are critical. For tumors of the proximal femur, endoprosthetic replacement is an option for treatment in primary and metastatic disease, with the goals being tumor and pain control, earlier mobilization, shorter recovery period, and, in primary tumors, cure. This study provides a summary of current concepts in the treatment of oncologic lesions in the proximal femur with endoprostheses. Discussion of the inherent complications of these constructs is presented as well as the risks and treatment of reconstruction failure.

Surgical Site Infection after Bone Tumor Surgery: Risk Factors and New Preventive Techniques

The management of malignant bone tumors requires multidisciplinary interventions including chemotherapy, radiation therapy, and surgical tumor resection and reconstruction. Surgical site infection (SSI) is a serious complication in the treatment of malignant bone tumors. Compared to other orthopedic surgeries, the surgical treatment of malignant bone tumors is associated with higher rates of SSIs. In patients with SSIs, additional surgeries, long-term administrations of antibiotics, extended hospital stays, and the postponement of scheduled adjuvant treatments are required. Therefore, SSI may adversely affect functional and oncological outcomes. To improve surgical outcomes in patients with malignant bone tumors, preoperative risk assessments for SSIs, new preventive techniques against SSIs, and the optimal use of prophylactic antibiotics are often required. Previous reports have demonstrated that age, tumor site (pelvis and tibia), extended operative time, implant use, body mass index, leukocytopenia, and reconstruction procedures are associated with an increased risk for SSIs. Furthermore, prophylactic techniques, such as silver and iodine coatings on implants, have been developed and proven to be efficacious and safe in clinical studies. In this review, predictive factors of SSIs and new prophylactic techniques are discussed.

Periprosthetic Joint Infection after Endoprosthetic Reconstruction: Saving the Limb-Salvage

BACKGROUND

This study evaluates mega-endoprosthetic survival after revision for periprosthetic joint infection (PJI) and two-staged reconstruction using a cement spacer. Mega-endoprosthetics offer patients an important treatment option for limb salvage. However, PJI is a devastating complication which affects between 2-10% of patients. It commonly results in revisions, amputation, and sometimes death. Literature in terms of success rates, limb salvage and Megaprostheses survival after revision for infection is limited. We present here our experience and the impact of length of the spacer in prostheses survival.

METHODS

A retrospective chart review was implemented using Fisher's exact test for categorical data and the Kaplan-Meier method for prosthesis survival. Patient information was acquired through our institution's electronic medical records. Variables such as diagnosis, complications, length of cement spacer, and number of surgeries were recorded. We analyzed spacer length and prosthesis survival based on these variables.

RESULTS

Fisher's Exact test showed no correlation between length of spacer and amount of repeat surgery (p = 0.245). After two-stage revision and mega-prosthesis insertion, there was a 63.2% chance of complication and a 26.3% chance of amputation. This indicates a 73.7% probability for limb salvage in this sample (Kaplan-Meier).

CONCLUSION

These data suggest long-term viability of mega-endoprostheses after two-stage revision despite a high complication rate.

Risk factors for surgical site infection after malignant bone tumor resection and reconstruction

BACKGROUND

Use of an implant is one of the risk factors for surgical site infection (SSI) after malignant bone tumor resection. We developed a new technique of coating titanium implant surfaces with iodine to prevent infection. In this retrospective study, we investigated the risk factors for SSI after malignant bone tumor resection and to evaluate the efficacy of iodine-coated implants for preventing SSI.

METHODS

Data from 302 patients with malignant bone tumors who underwent malignant bone tumor resection and reconstruction were reviewed. Univariate analyses were performed, followed by multivariate analysis to identify risk factors for SSI based on the treatment and clinical characteristics.

RESULTS

The frequency of SSI was 10.9% (33/302 tumors). Pelvic bone tumor (OR: 4.8, 95% CI: 1.8-13.4) and an operative time ≥ 5 h (OR: 3.4, 95% CI: 1.2-9.6) were independent risk factors for SSI. An iodine-coated implant significantly decreased the risk of SSI (OR: 0.3, 95% CI: 0.1-0.9).

CONCLUSION

The present data indicate that pelvic bone tumor and long operative time are risk factors for SSI after malignant bone tumor resection and reconstruction, and that iodine coating may be a promising technique for preventing SSI.

Risk factors for postoperative deep infection in bone tumors

BACKGROUND

Postoperative deep infection after bone tumor surgery remains a serious complication. Although there are numerous reports about risk factors for postoperative deep infection in general surgery, there is only a small number of reports about those for bone tumor surgery. This retrospective study aimed to identify risk factors for postoperative deep infection after bone tumor resection.

METHODS

We reviewed data of 681 patients (844 bone tumors) who underwent surgery. Associations between variables, including age, recurrent tumor, pathological fracture, surgical site (pelvis/other), chemotherapy, biological reconstruction, augmentation of artificial bone or bone cement, the use of an implant, intraoperative blood loss, operative time, additional surgery for complications, and postoperative deep infection were evaluated.

RESULTS

The rate of postoperative deep infection was 3.2% (27/844 tumors). A pelvic tumor (odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.0-11.3) and use of an implant (OR: 9.3, 95% CI: 1.9-45.5) were associated with an increased risk of deep infection.

CONCLUSIONS

This retrospective study showed that pelvic tumor and use of an implant were independent risk factors for deep infection. This information will help surgeons prepare an adequate surgical plan for patients with bone tumors.