Purse-string capsule repair to reduce proximal femoral arthroplasty dislocation for tumor--a novel technique with results

Postoperative Outcomes of Total Femur Replacement in Oncologic and Nononcologic Patients: A Systematic Review of the Literature

BACKGROUND

Total femur replacement (TFR) is used for primary reconstruction after extensive tumor resection or as a revision surgery due to prosthetic failure. Studies on TFR rates of failure and functional outcomes are scarce. The purpose of our study was to compare the modes of failure, amputation rates, and functional outcomes after TFR between oncologic and nononcologic patients.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were for this manuscript. Our study was registered on PROSPERO (413582). Quality assessment of all studies was performed using Strengthening the Reporting of Observational Studies in Epidemiology checklist. Endoprosthesis failure was assessed using the Henderson classification and functional outcomes using the Musculoskeletal Tumor Society score. Weighted means and standard deviations were calculated.

RESULTS

Overall failure rate was similar between groups. Henderson type 4 failures were more common within the nononcologic group, while the others were more frequently found in the oncologic group. Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Amputations occurred mainly after type 4 and type 5 failures. Functional outcome was better within the oncologic group (70.5 versus 61.7, respectively; P < .001).

CONCLUSIONS

Total femoral replacement in the oncologic and nononcologic group is associated with a high rate of failure (31% and 32.5%, respectively). Overall amputation rate was higher in the oncologic group mainly due to type 5 failure. Functional outcome was better within the oncologic group.

LEVEL OF EVIDENCE

Level III.

Synthetic Ligament-Assisted Functional Soft-Tissue Reconstruction in Tumor-Related Proximal Femoral Replacements

BACKGROUND

Soft-tissue functional reconstruction is important for restoring hip function in proximal femoral replacement for tumor resection. This study evaluated the functional outcome and postoperative complications of a specific synthetic ligament for soft-tissue functional reconstruction in proximal femoral replacement for tumor resection.

METHODS

This cohort included 80 patients (40 men and 40 women, mean age, 40 years (range, 10 to 79)) who had benign invasive tumors (n = 13), primary malignant bone tumors (n = 40), or bone metastases (n = 27). Patients' medical records, imaging files, surgical details, and postoperative pathological diagnoses were collected. Tumor staging was performed with the Enneking staging criteria. Lower limb and hip functions were assessed using the Musculoskeletal Tumor Society scoring system and Harris Hip score, respectively.

RESULTS

Mean postoperative Musculoskeletal Tumor Society and Harris Hip scores were 27 (range, 24 to 30) and 90 (range, 76 to 97), respectively, indicating satisfactory range of motion and stability. Trendelenburg gait was observed in 3 osteosarcoma patients (3.8%), and 6 patients showed unequal lower-limb lengths. Reoperations occurred in 5 cases, including 3 cases of deep vein thromboses and 1 case each of giant cell granuloma and periprosthetic infection. There were 27 patients who had bone metastases who did not require reoperation.

CONCLUSIONS

The synthetic ligament reconstruction of the hip with proximal femoral replacement for tumor resection was associated with improved outcomes. Its implementation exhibits the potential to reduce postoperative incidences of hip dislocation and periprostheses infection, thereby warranting its prospective clinical application.

Acetabular complications are the most common cause for revision surgery following proximal femoral endoprosthetic replacement : what is the best bearing option in the primary and revision setting?

AIMS

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

METHODS

This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%).

RESULTS

At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%).

CONCLUSION

Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633-1640.

Capsular repair vs capsulectomy in total hip arthroplasty

BACKGROUND

A major complication of total hip arthroplasty is dislocation. The hip joint capsule can be incised and repaired, or can be excised.

SOURCES OF DATA

We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines focusing on capsular repair and capsulectomy.

AREAS OF AGREEMENT

We identified 31 articles (17 272 patients). Capsular repair produced a lower blood loss (465.2 vs 709.2 ml), and the procedure lasted 102.5 vs 96.08 min in patients who underwent capsulectomy. The patients undergoing capsulectomy experienced a dislocation rate of 3.06%, whereas in the patients undergoing capsular repair, the dislocation rate was 0.65%.

AREAS OF CONTROVERSY

Most studies are retrospective observational studies, with no prospective randomized trials.

GROWING POINTS

Capsular preservation is association with a lower dislocation rate and a lower blood loss. Capsular excision does take statistically less time, but it is uncertain how a 6 min difference is clinically relevant.

AREAS TIMELY FOR DEVELOPING RESEARCH

Appropriately powered randomized clinical trials should be conducted to better define the association between the chosen implants, approach and outcome.

"Purse-String" Capsular Closure for Decreasing Dislocation Rates in Proximal Femur Replacements

Hip joint dislocation is the most common complication after a proximal femur replacement. As the utilization of proximal femur replacements continues to increase, it becomes imperative for surgeons to find the optimal method to decrease postoperative dislocation and its sequelae. These cases often involve extensive soft-tissue deficits that require reconstruction to provide postoperative strength and stability. Patients report good functional outcomes; however, dislocation remains a concern. Although “described” previously in the literature, the authors illustrate the “purse-string” hip joint capsular closure technique to help other surgeons understand it and apply to their practice as deemed necessary. We also present the senior author's results with using a modified version of the “purse-string” hip joint capsular closure technique.

En-Bloc Resection of Metastases of the Proximal Femur and Reconstruction by Modular Arthroplasty is Not Only Justified in Patients with a Curative Treatment Option-An Observational Study of a Consecutive Series of 45 Patients

Background: There is little conformity regarding the surgical treatment of metastasis of the proximal femur, especially in palliative patients with limited life expectancy. Patients and Methods: En-bloc resection of secondary bone malignancies of the proximal femur and reconstruction by modular arthroplasty was performed in a consecutive series of 45 patients. The mean follow-up period was 16.4 months (0.6–74.7). Results: The survival rate of all patients was 6.6% (95% CI: 0–14.9) at 74.7 months. There was no significant difference in patients with a solitary or disseminated disease at index operation (log-rank p = 0.1214). Recurrent dislocation was the most frequent local complication (n = 6) necessitating an open reduction in four cases. The use of a Trevira tube showed a higher risk of dislocation compared to the simple bonding of remaining soft tissue (6 out of 28 vs. 0 out of 17; Fisher test: p = 0.0463). The worst-case survival rate with the removal of the arthroplasty for any cause and/or loss to follow-up was 80.0% (95% CI: 44.9–100) at 74.7 months (n = 1 due to low-grade infection). Conclusions: En-bloc resection of metastases and reconstruction by modular arthroplasty is reliable even in patients with very limited life expectancy. Local complications due to tumor growth or instability after intralesional surgery could be managed successfully but recurrent dislocation as the most frequent complication has to be taken into account. The simple bonding of remaining soft tissue around the prosthesis without the use of an attachment tube may reduce the dislocation rate and reoperation risk.

The stability of the hip after the use of a proximal femoral endoprosthesis for oncological indications: analysis of variables relating to the patient and the surgical technique

AIMS

Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability.

PATIENTS AND METHODS

In a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability.

RESULTS

A total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients.

CONCLUSION

Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: Bone Joint J 2017;99-B:531-7.

Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability

PURPOSE

The purpose of this systematic review was to critically evaluate the available literature exploring the role of the hip joint capsule in the normal state (stable) and pathologic states (instability or stiffness). Furthermore, we examined the various ways that arthroscopic hip surgeons address the capsule intraoperatively: (1) capsulotomy or capsulectomy without closure, (2) capsulotomy with closure, and (3) capsular plication.

METHODS

Two independent reviewers (B.D.G. and B.G.D.) performed a systematic review of the literature using PubMed and the reference lists of related articles by means of defined search terms. Relevant studies were included if these criteria were met: (1) written in English, (2) Levels of Evidence I to V, (3) focus on capsule and its role in hip stability, and (4) human studies and reviews. Articles were excluded if they evaluated (1) total hip arthroplasty constructs using bony procedures or prosthetic revision, (2) developmental dysplasia of the hip where reorientation osteotomies were used, (3) syndromic instability, and (4) traumatic instability with associated bony injury.

RESULTS

By use of the search method described, 5,085 publications were reviewed, of which 47 met appropriate criteria for inclusion in this review. Within this selection group, there were multiple publications that specifically addressed more than 1 of the inclusion criteria. Relevant literature was organized into the following areas: (1) capsular anatomy, biomechanics, and physiology; (2) the role of the capsule in total hip arthroplasty stability; (3) the role of the capsule in native hip stability; and (4) atraumatic instability and capsulorrhaphy.

CONCLUSIONS

As the capsuloligamentous stabilizers of the hip continue to be studied, and their role defined, arthroscopic hip surgeons should become facile with arthroscopic repair or plication techniques to restore proper capsular integrity and tension when indicated.

LEVEL OF EVIDENCE

Level IV, systematic review.

Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques

BACKGROUND

Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients.

METHODS

The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management.

RESULTS

Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies.

CONCLUSIONS

Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena.