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Wier J, Liu KC, Piple AS, Christ AB, Longjohn DB, Oakes DA, Heckmann ND. Factors Associated With Failure Following Proximal Femoral Replacement for Salvage Hip Surgery for Nononcologic Indications. J Arthroplasty 2023; 38:2429-2435.e2. [PMID: 37209911 DOI: 10.1016/j.arth.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Proximal femoral replacement (PFR) is used when extensive proximal femoral bone loss is encountered during revision total hip arthroplasty. However, further data on 5-to-10-year survivorship and predictors of failure are needed. Our aim was to assess the survivorship of contemporary PFRs used for nononcologic indications and determine factors associated with failure. METHODS A single-institution retrospective observational study was conducted between June 1, 2010 and August 31, 2021 for patients undergoing PFR for non-neoplastic indications. Patients were followed for a minimum of 6 months. Demographic, operative, clinical, and radiographic data were collected. Implant survivorship was determined via Kaplan-Meier analysis of 56 consecutive cemented PFRs in 50 patients. RESULTS At a mean follow-up of 4 years, the mean Oxford Hip Score was 36.2 and patient satisfaction was rated at an average of 4.7 of 5 on the Likert scale. Radiographic evidence of femoral-sided aseptic loosening was determined in 2 PFRs at a median of 9.6 years. The 5-year survivorship with all-cause reoperation and revision as end points was 83.2% (95% Confidence Interval [CI]: 70.1% to 91.0%) and 84.9% (95% CI: 72.0% to 92.2%), respectively. The 5-year survivorship was 92.3% (95% CI: 78.0% to 97.5%) for stem length > 90 mm compared to 68.4% (95% CI: 39.5% to 85.7%) for stem length ≤ 90 mm. A construct-to-stem length ratio (CSR) ≤ 1 was associated with a 91.7% (95% CI: 76.4% to 97.2%) survival, while a CSR > 1 was associated with a 73.6% (95% CI: 47.4% to 88.1%) survival. CONCLUSION A PFR stem length ≤ 90 mm and CSR > 1 were associated with increased rates of failure.
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Affiliation(s)
- Julian Wier
- Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kevin C Liu
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Amit S Piple
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Alexander B Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Donald B Longjohn
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Daniel A Oakes
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
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Sambri A, Parisi SC, Zunarelli R, Di Prinzio L, Morante L, Lonardo G, Bortoli M, Montanari A, De Cristofaro R, Fiore M, De Paolis M. Megaprosthesis in Non-Oncologic Settings-A Systematic Review of the Literature. J Clin Med 2023; 12:4151. [PMID: 37373844 DOI: 10.3390/jcm12124151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb.
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Affiliation(s)
- Andrea Sambri
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Stefania Claudia Parisi
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Zunarelli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Di Prinzio
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Morante
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Gianluca Lonardo
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marta Bortoli
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Montanari
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Roberto De Cristofaro
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Michele Fiore
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Massimiliano De Paolis
- Orthopedic and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Zanchini F, Piscopo A, Cipolloni V, Vitiello R, Piscopo D, Fusini F, Cacciapuoti S, Panni AS, Pola E. The major proximal femoral defects: megaprosthesis in non oncological patients - A case series. Orthop Rev (Pavia) 2023; 15:38432. [PMID: 36776276 PMCID: PMC9907321 DOI: 10.52965/001c.38432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We identified 39 patients (23 female and 16 male) underwent hip revisions through mega-prosthesis. The most common causes were periprosthetic fractures, periprosthetic osteolysis and consequences of infected arthroplasty. The average follow-up was 5 years (2.1 to 6.5), and average age was 69 years (47 to 78). At the final follow-up all the implants resulted functional and osteointegrated. The Merle D'Aubignè and Postel hip rating scale was used for the evaluation, better results were observed in periprosthetic fractures. Postoperative complications occurred in eight patients. Thus, megaprosthesis were a reasonable surgical option in the management of major femoral defects.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ernico Pola
- Fondazione Policlinico Gemelli IRCSS, Rome, Italy
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Zavras AG, Fice MP, Dandu N, Rossi DM, Gitelis S, Blank AT, Levine BR, Colman MW. Indication for Proximal Femoral Replacement Is Associated With Risk of Failure. J Arthroplasty 2022; 37:917-924. [PMID: 35032605 DOI: 10.1016/j.arth.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/21/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Proximal femoral replacement (PFR) is reserved as a salvage procedure after failed total hip arthroplasty (THA) or after wide margin resection of tumors involving the proximal femur. Although failure of the PFR construct remains a significant problem, indication has not previously been investigated as a risk factor for failure. METHODS This study retrospectively evaluated patients who underwent PFR over a consecutive 15-year period for primary sarcoma or metastatic disease of the proximal femur, compared with conversion to PFR after failed THA. PFR failure was defined as recurrent prosthetic dislocations, periprosthetic fracture, aseptic loosening, or infection that ultimately resulted in revision surgery. RESULTS Overall, 99 patients were evaluated, including 58 in the neoplasm and 41 in the failed THA cohorts. Failed THA patients were older (P < .001), with a greater proportion having comorbid hypertension (P = .008), cardiac disease (P = .014), and history of prior ipsilateral and intracapsular surgeries (P < .001). The failure rate was significantly higher in failed THA patients (39.0% vs 10.3%; P < .001) with significantly shorter implant survivorship on Kaplan-Meier analysis (P = .003). A multivariate Cox proportional hazards model showed that THA failure was the only independent predictor for PFR failure (hazard ratio: 4.26, 95% confidence interval: 1.66-10.94; P = .003). CONCLUSION This study revealed significantly worse PFR implant survivorship in patients undergoing PFR for the indication of failed THA compared with neoplasm. Although the underlying etiology of this relationship remains to be explicitly outlined, poor bone quality and soft tissue integrity, multiple prior surgeries, and comorbid conditions are likely contributing factors.
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Affiliation(s)
- Athan G Zavras
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Michael P Fice
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Navya Dandu
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - David M Rossi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Steven Gitelis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Alan T Blank
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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5
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Di Martino A, Pederiva D, Bordini B, Di Carlo G, Panciera A, Geraci G, Stefanini N, Faldini C. Proximal femoral replacement for non-neoplastic conditions: a systematic review on current outcomes. J Orthop Traumatol 2022; 23:18. [PMID: 35348913 PMCID: PMC8964877 DOI: 10.1186/s10195-022-00632-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/19/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Alberto Di Martino
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy. .,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy.
| | - Davide Pederiva
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Lab, IRCCS - Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Gabriele Di Carlo
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Alessandro Panciera
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Geraci
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Niccolò Stefanini
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Faldini
- Department of Biomedical and Neurimotor Sciences - University of Bologna, Piazza di Porta S. Donato, 2, 40127, Bologna, Italy.,Ist Orthopaedic Department, IRCCS - Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
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Siddiqi A, Mahmoud Y, Manrique J, Molloy RM, Krebs VE, Piuzzi NS. The Use of Megaprostheses in Nononcologic Lower-Extremity Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202202000-00010. [PMID: 35180180 DOI: 10.2106/jbjs.rvw.21.00185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function. » Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise. » Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function. » Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status. » Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs.
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Affiliation(s)
- Ahmed Siddiqi
- Orthopaedic Institute Brielle Orthopaedics, Manasquan, New Jersey.,JFK University Medical Center, Hackensack Meridian Health, Edison, New Jersey.,Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutely, New Jersey
| | - Yusuf Mahmoud
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Nutely, New Jersey
| | - Jorge Manrique
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Mancino F, Di Matteo V, Mocini F, Cacciola G, Malerba G, Perisano C, De Martino I. Survivorship and clinical outcomes of proximal femoral replacement in non-neoplastic primary and revision total hip arthroplasty: a systematic review. BMC Musculoskelet Disord 2021; 22:933. [PMID: 34749680 PMCID: PMC8576938 DOI: 10.1186/s12891-021-04711-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Several studies have evaluated the survivorship and clinical outcomes of proximal femoral replacement (PFR) in complex primary and revision total hip arthroplasty with severe proximal femoral bone loss; however, there remains no consensus on the overall performance of this implant. We therefore performed a systematic review of the literature in order to examine survivorship and complication rates of PFR usage. METHODS A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords. RESULTS In all, 18 articles met the inclusion criteria. A total of 578 PFR were implanted. The all-cause reoperation-free survivorship was 76.6%. The overall complication rate was 27.2%. Dislocation was the most common complication observed and the most frequent reason for reoperation with an incidence of 12.8 and 7.6%, respectively. Infection after PFR had an incidence of 7.6% and a reoperation rate of 6.4%. The reoperation rate for aseptic loosening of the implant was 5.9%. Overall, patients had improved outcomes as documented by postoperative hip scores. CONCLUSION PFR usage have a relatively high complication rate, however, it remains an efficacious treatment option in elderly patients with osteoporotic bone affected by severe proximal femoral bone loss. Modular designs have shown reduced dislocations rate and higher survivorship free from dislocation. However, PFR should only be used as salvage procedure when no other reconstruction options are available.
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Affiliation(s)
- Fabio Mancino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy.
- Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168, Rome, Italy.
- Adult Reconstruction and Joint Replacement Service, Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico, Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Roma, RM, Italy.
| | - Vincenzo Di Matteo
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Fabrizio Mocini
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Giorgio Cacciola
- Orthopaedic Institute of Southern Italy "Franco Scalabrino", Messina, Italy
| | - Giuseppe Malerba
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Carlo Perisano
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
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8
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Abdelaziz H, Schröder M, Shum Tien C, Ibrahim K, Gehrke T, Salber J, Citak M. Resection of the proximal femur during one-stage revision for infected hip arthroplasty : risk factors and effectiveness. Bone Joint J 2021; 103-B:1678-1685. [PMID: 34719276 DOI: 10.1302/0301-620x.103b11.bjj-2021-0022.r1] [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: 12/16/2022]
Abstract
AIMS One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. METHODS In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. RESULTS Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years' time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. CONCLUSION Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678-1685.
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Affiliation(s)
- Hussein Abdelaziz
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
| | - Michael Schröder
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
| | - Calvin Shum Tien
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
| | - Kahled Ibrahim
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Hospital, Bochum, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Germany
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9
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Megaprostheses in Nononcologic Hip and Knee Revision Arthroplasty. J Am Acad Orthop Surg 2021; 29:e743-e759. [PMID: 33788804 DOI: 10.5435/jaaos-d-20-01052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/21/2021] [Indexed: 02/01/2023] Open
Abstract
Megaprostheses as a means of limb salvage originated in orthopaedic oncology, and implant evolution was initially driven by developments within this field. Improvements in imaging modalities and in chemotherapeutics prolonged patient survival and promoted a transformation in the surgeon's mentality from salvage operation to functional limb reconstruction. As primary arthroplasty operations became more popular, megaprostheses found new utility in hip and knee revision arthroplasty. In this capacity, these implants provided much needed alternatives to traditional arthroplasty revision options for addressing massive bone loss and complex periprosthetic fractures. The indications for megaprostheses continue to expand with advances in design, stability, and overall longevity. Thus, greater numbers of orthopaedic surgeons in arthroplasty and traumatology have to be familiar with this technology. Importantly, each anatomic location presents unique considerations for reconstruction; however, additional variables such as the quantity of bone loss, the quality of remaining bone stock, and fracture type also influence implant selection. Ultimately, there is still much to be optimized in the use of megaprostheses for hip and knee revision arthroplasty. High multifactorial complication and revision surgery rates compared with conventional prostheses make these implants for many a "last resort" option.
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10
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Döring K, Vertesich K, Martelanz L, Staats K, Böhler C, Hipfl C, Windhager R, Puchner S. Proximal femoral reconstruction with modular megaprostheses in non-oncological patients. INTERNATIONAL ORTHOPAEDICS 2021; 45:2531-2542. [PMID: 34259887 PMCID: PMC8514345 DOI: 10.1007/s00264-021-05080-8] [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: 01/28/2021] [Accepted: 05/11/2021] [Indexed: 12/28/2022]
Abstract
Introduction Multiple revision hip arthroplasties and critical trauma might cause severe bone loss that requires proximal femoral replacement (PFR). The aim of this retrospective study was to analyse complication- and revision-free survivals of patients who received modular megaprostheses in an attempt to reconstruct massive non-neoplastic bone defects of the proximal femur. Questions/purposes (1) What were general complication rates and revision-free survivals following PFR? (2) What is the incidence of complication specific survivals? (3) What were risk factors leading to a diminished PFR survival? Materials and methods Twenty-eight patients with sufficient follow-up after receiving a modular proximal femoral megaprosthesis were identified. The indications for PFR included prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, non-union and critical femoral fracture. Complications were grouped according to the ISOLS-classification of segmental endoprosthetic failure by Henderson et al. Results Overall, the complication-free survival was 64.3% at one year, 43.2% at five years and 38.4% at ten years, with 16 patients (57%) suffering at least one complication. Complications were dislocation in eight patients (29%), PJI in 6 patients (21%), periprosthetic fracture in five patients (18%), and aseptic loosening in six patients (21%). Prosthesis stem cementation showed a lower risk for revision in a cox proportional hazard model (95% CI 0.04–0.93, HR 0.2, p = 0.04). Conclusion PFR with modular megaprostheses represents a viable last resort treatment with high complication rates for patients with severe proximal femoral bone loss due to failed arthroplasty or critical fractures. In revision arthroplasty settings, PFR cementation should be advocated in cases of impaired bone quality.
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Affiliation(s)
- Kevin Döring
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Klemens Vertesich
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Luca Martelanz
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Hipfl
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria.
| | - Stephan Puchner
- Division of Orthopaedics, Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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Powell-Bowns MFR, Oag E, Ng N, Pandit H, Moran M, Patton JT, Clement ND, Scott CEH. Vancouver B periprosthetic fractures involving the Exeter cemented stem. Bone Joint J 2021; 103-B:309-320. [PMID: 33517729 DOI: 10.1302/0301-620x.103b2.bjj-2020-0695.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). METHODS This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan-Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. RESULTS Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. CONCLUSION When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309-320.
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Affiliation(s)
| | - Erlend Oag
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nathan Ng
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Hemant Pandit
- Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - James T Patton
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
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