Stump lengthening after hip disarticulation using a modular endoprosthesis in 5 patients

[Endoprostheses for stump formation after hip disarticulation]

BACKGROUND

Hip disarticulation is a psychologically and physically demanding procedure. However, it remains a therapeutical option whenever limb salvage proves impossible due to sarcoma, severe implant-associated infections or trauma. The stump lengthening procedure (SLP) is a surgical technique that allows partial salvage of the thigh through endoprosthetic proximal femur replacement after hip disarticulation, depending on the amount of viable soft tissue coverage. This leads to a more appealing visual appearance, facilitates prosthetic fitting and significantly improves limb function.

OBJECTIVES

Description of indications for SLP, surgical technique, presentation of clinical and functional outcomes.

METHODS

Review of applying literature and presentation of outcomes of our own SLP collective.

RESULTS

The risk of local recurrence does not increase after SLP compared to hip disarticulation. While the majority of patients can be fitted with an exoprosthesis, a walking aid is usually necessary for ambulation. Exoprostheses are usually worn throughout the entire day, and patients manage distances of a mean of 2000 metres, even if reconstruction lengths are less than 10 cm. Patients aged 50 years or older tend to wear their exoprosthesis for shorter periods of daywear and achieve significantly poorer functional scores. Postoperative complications are common at a rate of 52%. Periprosthetic infection (21%) and soft tissue perforation of the implant with subsequent implant-associated infection (14%) were the most severe complications observed.

CONCLUSIONS

The stump lengthening procedure poses a feasible alternative to classic hip disarticulation in patients with multiple prior operations and/or advanced stages of disease. It leads to satisfactory cosmetic and functional results without jeopardizing local tumor control. Stump perforation presents as the most common complication. Apart from improving the ability to sit down comfortably, both patients treated with a curative and palliative intent manage to ambulate using exoprostheses. With increasing age at the time of operation, walking aids are necessary for ambulation.

Limb salvage: When, where, and how?

From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance in the treatment of musculoskeletal sarcomas. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality and the unique challenges of reconstruction in skeletally immature individuals are also discussed. Striking the right balance between adequate resection, while yet retaining or reconstructing tissue for acceptable function and cosmesis is a difficult task. Complications are not uncommon and patients and their families need to be counseled regarding the potential setbacks that may occur in the course of their eventual road to recovery, Limb salvage entails a well orchestrated effort involving various specialties and better outcomes are likely to be achieved with centralization of expertise at regional centers.

Limb salvage in musculoskeletal oncology: Recent advances

The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.

Custom-made endoprostheses for the femoral amputation stump: an alternative to hip disarticulation in tumour surgery

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.

[Overlooked osteosarcoma in a patient undergoing total knee arthroplasty. A case report]

A 72-year-old woman presented with pain, swelling, and decreased range of motion of the left knee joint after total knee arthroplasty in 2005. We performed standard x-rays, which were highly suspicious for an osteosarcoma of the distal femur; this was proven by open biopsy. Retrospectively, the x-rays taken before implantation of the prosthesis showed suspicious findings. Because the femur was tumor-contaminated, with the intramedullary adjustment far-reaching proximally, a limb salvage procedure was no longer possible. To improve function, we decided to perform a stump-lengthening procedure using a special implant. With regard to the dismal consequences, we recommend that every suspicious finding before an elective surgical procedure be examined with further diagnostics and, if necessary, histological confirmation.

Characteristics and outcome of infections associated with tumor endoprostheses

INTRODUCTION

Infection associated with prosthesis used after tumor resection is a common and serious complication. The purpose of the current retrospective study was to describe the course of infection in patients with a tumor endoprosthesis and the determination of risk factors associated with failed limb salvage.

MATERIAL AND METHODS

30 patients with an infection associated with a tumor endoprosthesis were investigated with regard to treatment strategies, number and type of revision operations, duration of hospital stay, determination of risk factors associated with failed limb salvage and final outcome.

RESULTS

Limb salvage related to the complication infection was achieved in 19 patients (63.3%). Two-stage reimplantation of an endoprosthesis was successful in 14 patients but subsequently failed in one patient. Out of 11 patients where limb salvage failed, an amputation was performed in 6 patients, a rotationplasty in 4, and stump lengthening procedure in 1 patient. A poor soft tissue condition was a significant (P<0.05) risk factor for failed limb salvage. No patient receiving chemotherapy with a poor soft tissue condition had limb salvage surgery. The mean number of revision operations per patients was 2.6. The mean duration of hospital stay was 68 days.

CONCLUSION

Infection associated with prosthesis is a serious complication and is involved with long hospitalization. Limb salvage failed mostly in the case of a poor soft tissue condition. In these cases repeated revision surgery should be avoided and ablative surgery recommended at an early stage. Rotationplasty is an alternative to amputation in the case of an infection of the proximal or distal part of the femur.