Custom-made cement-linked mega prostheses: a salvage solution for complex periprosthetic femoral fractures

Contemporary Outcomes of Proximal Femoral Replacement as a Salvage Treatment in Nononcologic Severe Bone Loss

BACKGROUND

Severe proximal femoral bone loss remains a challenging problem in revision total hip arthroplasty (rTHA). Proximal femoral replacements (PFRs) are salvage options for severe bone loss in complex rTHA. The purpose of this study was to describe the survivorship and clinical outcomes of PFR for nononcologic indications.

METHODS

We performed a retrospective review of 49 patients who underwent 50 PFRs from January 2014 to May 2021 at a single institution. Indications for PFR included periprosthetic femur fracture (n = 20), reimplantation after periprosthetic joint infection (n = 18), aseptic loosening with severe proximal femoral bone loss (n = 10), heterotopic ossification (n = 1), and instability (n = 1). The mean age was 70 years. The mean body mass index was 28 and 25 (50%) patients were women. The mean follow-up was three years. Kaplan-Meier analysis was used to assess survivorship free from reoperation, rerevision, and dislocation.

RESULTS

The 2-year survivorship free from all-cause reoperation was 78%, and the 2-year survivorship free from rerevision was 87%. Overall, there were 11 (22%) reoperations, with indications including periprosthetic joint infection (n = 6), aseptic loosening (n = 2), hematoma evacuation (n = 1), instability (n = 1), and delayed wound healing (n = 1). There were eight (16%) patients who dislocated after PFR. The mean Hip Injury and Osteoarthritis Outcome Score for Joint Replacement increased from 48 preoperatively to 77 at two years postoperatively (P < 0.001).

CONCLUSIONS

In this series of PFRs performed in complex rTHA, there was low 2-year survivorship free from all-cause reoperation (78%) and rerevision (87%). Furthermore, the dislocation rate was high at 16%. However, only one patient (2%) was revised for femoral component aseptic loosening. This study highlights the complexity of these patients and the utilization of PFR as a salvage option.

Survival Rates and Patient-Reported Outcomes Support the Use of Custom Cement-Over Megaprosthesis (CCOM) in Complex Revision Lower Limb Arthroplasty

BACKGROUND

Patients presenting with periprosthetic osteolysis or fracture between ipsilateral hip and knee arthroplasties are challenging to treat successfully. Long-stem implants, osteopenic bones, and patient comorbidities all represent considerable surgical challenges. Poor results of fracture fixation in this group, coupled with the desire to retain well-performing implants and minimize soft-tissue trauma led to the developmentof the custom cement-over megaprostheses (CCOM). The aims of the study were to evaluate implant survivals, complications, and patient outcomes in those undergoing CCOM within our institution.

METHODS

A retrospective analysis of patients undergoing CCOM between 2002 and 2022 was performed. We studied 34 cases, 33 patients, one patient underwent staged bilateral surgery with 26 women and 8 men.

INDICATIONS

trauma (16), failure of implants /aseptic loosening (9), or joint pathology. The mean Charlson comorbidity index was 3.5 (range, 0 to 8). All patients were followed up (mean 75 months [range, 9 to 170]) at 6 weeks, 6 months, 1 year, and annually thereafter. The VAS, EuroQol-5D-3L and MSTS scores were collected at 1 year.

RESULTS

Implant survival defined by the primary outcome (all-cause revision of the implant at any time point) at 12 months of 97% (32 of 33). In surviving patients, implant survival was 90% (18 of 20) and all 7 survived at 5 and 10 years, respectively. Implant survival including those in the primary outcome group and those free of infection at 12 months was 84.8% (28 of 33) and in surviving patients, implant survival was 70% (14 of 20) and 7 out of 7 at 5 and 10 years, respectively.

CONCLUSIONS

The CCOM technique demonstrates good implant survivorships and satisfactory patient-reported outcomes in complex, often frail patients who have compromised bone stock. This series confirms the technique as an established alternative to total femoral replacement in these cases.

Proximal femoral replacement for non-neoplastic conditions: a systematic review on current outcomes

Proximal femoral replacement (PFR) is a well-established treatment for neoplasia of the proximal femur. The use of this surgical technique for non-neoplastic conditions has increased over the years. We carried out a systematic review of the literature to study the indications, complications, and functional results when PFR is used for non-neoplastic conditions. Twenty-seven studies were included in the review with a total of 828 PFRs with a mean follow-up of 50 months (range 1-225 months). The main indications were infection (28%), periprosthetic fracture (27%), aseptic loosening (22%), and fracture (16%). The rate of reoperation was 20.3% overall. The overall revision rate was 15.4%. The main complications were dislocation (10.2%) and infection (7.3%). After 2010, the rates of reoperation (25.5% versus 18.2%), loosening (9.4% versus 3.2%), and dislocation (15.7% versus 7.9%) were lower than before 2010. The 30-day mortality ranged from 0% to 9%. The hip function scores improved post-surgery. In conclusion, the use of PFR in non-neoplastic conditions remains a marginal tool, associated with low direct mortality and high complication rates, but we expect its use to increase in the near future.

Revision of a Fractured Titanium Modular Revision Hip Stem Without Removal of the Well-Fixed Part of the Stem: A New Approach Using a Cemented Tube

Component fracture is a rare cause for revision in total hip arthroplasty. For a fractured well-fixed long femoral stem, the options are limited. We sought to develop a technique to address this problem with lower morbidity. A newly developed cemented tube was constructed and cemented onto a fractured Revitan revision hip femoral stem to retain the distal well-fixed component. At the 2-year follow-up, the Harris Hip Score, pain level, and radiographic images were analyzed. At the 2-year follow-up, no radiological signs of loosening or failure could be observed. The patient's preoperative Harris Hip Score improved from 42.8 to 97 points. The pain level improved from 7/10 to 0/10. Our case report depicts excellent clinical and radiographic outcomes at 2-year follow-up by a newly developed cemented tube technique. This technique is a potential new option for revision of fractured well-fixed diaphyseal stems without major bone loss. Our successful results suggest this technique is worthy of consideration and further study.

Acute Distal Femoral Replacement for Fractures About the Knee in the Elderly

Distal femoral replacement (DFR) is a reasonable treatment option when used for select indications. In the setting of comminuted intra-articular distal femoral fractures, distal femoral arthroplasty should be considered in low-demand patients with poor bone quality. This article summarizes the existing literature plus the authors' personal experience with DFR use for distal femoral fractures of the native knee.

Interprosthetic Femoral Sleeves in Revision Arthroplasty: A 20-Year Experience

BACKGROUND

Interprosthetic femoral fractures in patients with ipsilateral stemmed total hip arthroplasty (THA) and total knee arthroplasty (TKA) can be technically demanding to treat surgically. Nonunion and implant failure are among the main complications following fixation of interprosthetic femoral (IF) fractures. Total femoral arthroplasty (TFA) is associated with a high incidence of infection and instability. IF sleeves have been designed to avoid the disadvantages of these techniques and to provide a stable construct. The aim of this study was to present the results with this device from a single center.

METHODS

We reviewed 26 patients who underwent revision arthroplasty procedures, using custom-made cemented IF sleeves between 1997 and December 2017 in our institution. Two-part sleeves were used in 18 patients and one-part sleeves in 8 patients. The most common indication was an IF fracture (18 patients). Patients were monitored for postoperative complications, implant failure, and re-revision. The minimum follow-up of the survivors with nonrevised sleeves was 12 months.

RESULTS

Twenty-three patients were included for the final analysis. The mean survivorship of the IF sleeve was 4.6 years at latest follow-up (mean 48.5 months; range 12 to 156). The overall rate of complications was 47.8%. The rate of mechanical failure was 21.7%. Late infections occurred in 3 patients (13%). At the latest follow-up, the mean Harris Hip Score was 69.9 points (range 39 to 94), and the mean functional Knee Society Score was 42.5 points (range 0 to 90), with average knee flexion of 95° (range 90° to 100°).

CONCLUSION

The IF sleeve is a valid technique for the management of selected patients with IF fractures, particularly when a stable fracture fixation is not possible. Hip instability is not a concern, and functional improvement is achievable. Careful planning is required preoperatively to avoid mechanical failure.

Interprosthetic Fractures of the Femur

As the rate of hip and knee arthroplasty procedures increases, so will the rate of interprosthetic fractures. Several factors, including bone quality, bone quantity, and stability of the prosthetic components, play a role in determining the appropriate operative treatment. Patients with stable components should undergo reduction and internal fixation, while patients with loose components should undergo either revision arthroplasty, with or without additional fixation, or conversion to total femur replacement. Despite implant and technique advances, complications remain frequent. [Orthopedics. 2018; 41(1):e1-e7.].

Partial humeral replacement for peri-prosthetic fractures of the humerus

INTRODUCTION

Treating peri-prosthetic fractures of the humerus can be very challenging, especially when there is poor bone stock and in the presence of adjacent joint prostheses. We discuss the option of a partial humeral replacement as a salvage procedure for such cases with some technical comments.

METHODS

This paper presents a technique which utilises a custom- made cemented connector to incorporate the existing well functioning elbow or shoulder replacement with a commercially available partial humeral replacement (PHR) or to an existing prosthetic humeral stem.

RESULTS

Our series involves 6 patients with severe rheumatoid arthritis, all female, with a mean age of 62.5 years. Their surgeries were performed over a span of 10 years, with an average follow up of 49 months. All had a well functioning implant at final follow-up, with a mean Mayo Elbow Performance score of 65. There were no cases of infection, nerve injury or dislocation in our patients. There were 2 deaths in our series, from unrelated medical causes at 2 and 4 years following their surgery.

CONCLUSION

Although a partial humeral replacement connected to a well functioning implant is a rare procedure for salvage of a humeral peri-prosthetic fracture, it can be a viable option in certain patient populations. Every attempt should be made to maintain the secondary shoulder stabilisers at the proximal humerus as a functioning unit.

Periprosthetic fractures associated with total knee arthroplasty

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty.

Cite this article: Bone Joint J 2016;98-B:1489–96.

How to salvage a salvage endoprosthesis

Custom-made endoprostheses can be linked to existing well-fixed implants in the treatment of complex periprosthetic femoral fractures. By adopting this salvage approach, secure implants can be retained in favour of patients undergoing more tissue disruptive procedures such as total femoral replacements. In this piece, we present a unique case illustrating a salvage strategy for treating a failed cement-linked salvage endoprosthesis, a complex scenario which to our knowledge has never before been reported.