How Often Do Acetabular Erosions Occur After Bipolar Hip Endoprostheses in Patients With Malignant Tumors and Are Erosions Associated With Outcomes Scores?

Hip Arthroplasty Outcomes in Patients with Metastatic Bone Disease

Background/Objective

The hip is a common location for metastatic bone disease (MBD) and surgical intervention is often indicated to relieve pain and improve function. MBD of the hip is usually treated with hemiarthroplasty or with total hip arthroplasty if there are acetabular lesions. As treatment for metastatic disease evolves and patients may expect to live longer after diagnosis, further evaluation of the complications and functional outcomes associated with hip arthroplasty for MBD are necessary.

Methods

This was a retrospective review of patients who underwent hip arthroplasty for MBD at a single institution between 2007 and 2021. Outcomes included rates of reoperation, complications, and overall survival.

Results

Ninety-three cases in 91 patients were included. Total hip arthroplasty (THA) was performed in 52 cases (55.9%), hemiarthroplasty in 15 (16.1%), and complex arthroplasty, including proximal femur replacement or THA with complex acetabular reconstruction, was performed in 26 (28%). There were 11 reoperations in five patients and six dislocations. Median survival was 10.4 months and one-year overall survival was 53.3%. There was a significant increase in the proportion of patients who were able to ambulate independently (35.2% vs 17.6%; p=0.02) and a significant decrease in patients confined to a wheelchair (18.7% vs 3.3%; p=0.045) after surgery.

Conclusions

Hip arthroplasty for MBD leads to relatively low rates of complications and reoperations in this population known to have high postoperative morbidity and mortality. Hip arthroplasty provides the majority of MBD patients with a durable reconstruction that exceeds their lifespan and enables them to return to an acceptable level of function.

Proximal femoral tumor resection followed by joint prosthesis replacement: a systematic review and meta-analysis

BACKGROUND

This study aimed to determine the prognostic outcome of hip joint replacement after resection of proximal femoral tumors by reviewing original studies.

METHODS

Two researchers independently searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to July 17, 2022. Then, the literature was screened by inclusion criteria. The basic information, primary outcomes, and secondary outcomes were extracted for weighted combined analysis. The quality of the included literature was evaluated using the Newcastle-Ottawa scale.

RESULTS

Twenty-four retrospective cohort studies comprising 2081 patients were included. The limb salvage rate was 98%. The survival rates at 1, 2, 3, 4, and 5 years were 80, 72, 65, 64, and 55% for patients with primary tumors and the rate at 1, 2, 3, 4, and 5 years were 44, 25, 17, 14, and 11% for patients with bone metastases, respectively.

CONCLUSION

As chemotherapy and radiotherapy treatment progressed, joint reconstruction after proximal femoral tumor resection improved patients' function and quality of life.

Is bipolar hemiarthroplasty an appropriate type of hip articulation following proximal femoral or total femoral resections for musculoskeletal malignancies?

BACKGROUND

Different approaches are applied for reconstruction in patients with a musculoskeletal malignancy which require a proximal femoral or total femoral resection. We aimed to evaluate the treatment outcomes of patients who underwent a proximal femoral or total femoral resection due to bone and soft tissue tumors and had an endoprosthetic reconstruction by a bipolar hemiarthroplasty type of hip articulation.

METHODS

We retrospectively identified 133 patients who underwent a proximal femoral or total femoral endoprosthetic replacement after resection of a bone or soft tissue malignancy. There were 74 male and 59 female patients, with a mean age of 55.02 ± 16.92 years (range 11-84 years) and a median follow-up of 24.47 ± 24.45 months (range 6-164 months). Patient demographics, surgical, and oncological data were recorded. Acetabular wear was measured using the classification proposed by Baker. Functional assessment was performed using the Musculoskeletal Tumor Society (MSTS) functional score.

RESULTS

There was no statistically significant difference among primary diagnostic groups in terms of gender, prosthesis type, trochanter major resection, local recurrence, complication/revision rate, and MSTS Score (p > 0.05, for each parameter). On the other hand, a statistically significant difference was detected in terms of degree of acetabular erosion among diagnostic groups (p < 0.001); the acetabular erosion rate (AER) was found to be lower in patients with metastatic carcinoma than in patients with a diagnosis of primary bone or soft tissue sarcoma. The univariable analysis revealed that the effect of age, primary diagnosis, localization, follow-up time, and presence and number of distant organ metastasis variables on AER were found to be statistically significant (p = 0.018, p = 0.035, p = 0.002, p = 0.007, p = 0.031, p = 0.040, respectively).

CONCLUSION

In patients who undergo a proximal femoral or a total femoral resection due to a musculoskeletal tumor, bipolar hemiarthroplasty is an adequate type of hip articulation method, since it does not affect the revision requirements and functional outcomes of patients with acetabular erosion.

Long-term outcome of patients with primary or secondary tumors of the proximal femur treated by bipolar modular tumor prosthesis

PURPOSE

The proximal femur is a common area for primary and also metastatic bone tumors. The objective of this study was to assess the long-term functional and oncological outcomes of patients with malignant primary or secondary tumors of the proximal femur, who underwent proximal femoral resection then reconstruction using bipolar modular tumor prosthesis.

METHODS

Sixty patients with proximal femoral malignant tumors underwent resection and bipolar modular prosthesis between 2000 and 2016, were retrospectively reviewed. Based on diagnosis and presence or absence of pathological fracture, patients were divided into groups. The functional outcome of the patients was evaluated using the Musculoskeletal Tumor Society (MSTS) functional scoring system for the lower extremities.

RESULTS

The mean age was 38 (9-80) years at the time of primary surgery. Pathological fracture was the presentation in 28 patients. The study included 44 patients with primary bone tumor and 16 patients with a secondary bone tumor. The mean MSTS functional score of the patients was 24.3 (range, 18-30) points with no significant difference in patients with primary or secondary tumors. The rate of complications in the present series was 45%. The most frequent complication was an infection in 10 patients (16.7%), followed by aseptic loosening in 7 patients (11.7%). Local recurrence of primary bone tumors occurred in three out of 44 patients (6.8%).

CONCLUSION

Modular bipolar tumor prosthesis has a good long-term functional result in both primary and secondary tumors of the proximal femur, with no significant effect of age, presence or absence of pathological fracture or femoral resection length on the functional outcome. It was found that the only statistically significant variable regarding the risk of infection is previous surgeries.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

No Difference Between Hemiarthroplasty and Total Hip Arthroplasty in the Treatment of Pathologic Femoral Neck Fractures

BACKGROUND

Hemiarthroplasty (HA) and total hip arthroplasty (THA) have been widely discussed as treatment options for displaced osteoporotic femoral neck fractures. Pathologic femoral neck fractures from primary or metastatic tumors are comparatively rare and poorly investigated. The purpose of this study was to compare outcomes, complications, and perioperative survival for HA and THA in the treatment of pathologic femoral neck fractures of neoplastic etiology.

METHODS

A multicenter retrospective cohort study identified patients with pathologic femoral neck fractures treated with HA or THA from 2005 to 2018. Demographics, American Society of Anesthesiologists classification, Charlson comorbidity index, Dorr classification, histopathologic diagnosis, and surgical data were compared. The primary outcome was reoperation. Secondary outcomes included 90-day mortality, estimated blood loss, length of stay, periprosthetic fracture, periprosthetic joint infection, and Eastern Cooperative Oncology Group performance status.

RESULTS

There were 116 patients with HA and 48 patients with THA, with no differences between groups with regard to American Society of Anesthesiologists classification, Charlson comorbidity index, or Dorr classification. There were no differences between HA and THA in the primary outcome of reoperation (5.2% vs 4.2%, P = 1.00) or secondary outcomes of perioperative 90-day overall mortality (30.2% vs 25.0%, P = .51), estimated blood loss, transfusion rates, length of stay, discharge location, periprosthetic joint infection, periprosthetic fracture, or preoperative or postoperative Eastern Cooperative Oncology Group performance status.

CONCLUSIONS

Both HA and THA are viable options for the treatment of patients with pathologic femoral neck fractures and demonstrated no differences in reoperations, complications, perioperative 90-day mortality, or functional outcome scores.

LEVEL OF EVIDENCE

Level III.

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.

The Surgical Management of Proximal Femoral Metastases: A Narrative Review

The proximal femur is a common location for the development of bony metastatic disease. Metastatic bone disease in this location can cause debilitating pain, pathologic fractures, reduced quality of life, anemia or hypercalcemia. A thorough history, physical examination and preoperative investigations are required to ensure accurate diagnosis and prognosis. The goals of surgical management is to provide pain relief and return to function with a construct that provides stability to allow for immediate weightbearing. Current surgical treatment options include intramedullary nailing, hemiarthroplasty or total hip arthroplasty and endoprosthetic reconstructions. Oligometastatic renal cell carcinoma must be given special consideration as tumor resection and reconstruction has survival benefit. Both tumor and patient characteristics must be taken into account before deciding on the appropriate surgical intervention.

Is three-dimensional-printed custom-made ultra-short stem with a porous structure an acceptable reconstructive alternative in peri-knee metaphysis for the tumorous bone defect?

Background

Long-lasting reconstruction after extensive resection involving peri-knee metaphysis is a challenging problem in orthopedic oncology. Various reconstruction methods have been proposed, but they are characterized by a high complication rate. The purposes of this study were to (1) assess osseointegration at the bone implant interface and correlated incidence of aseptic loosening; (2) identify complications including infection, endoprosthesis fracture, periprosthetic fracture, leg length discrepancy, and wound healing problem in this case series; and (3) evaluate the short-term function of the patient who received this personalized reconstruction system.

Methods

Between September 2016 and June 2018, our center treated 15 patients with malignancies arising in the femur or tibia shaft using endoprosthesis with a 3D-printed custom-made stem. Osseointegration and aseptic loosening were assessed with digital tomosynthesis. Complications were recorded by reviewing the patients’ records. The function was evaluated with the 1993 version of the Musculoskeletal Tumor Society (MSTS-93) score at a median of 42 (range, 34 to 54) months after reconstruction.

Results

One patient who experienced early aseptic loosening was managed with immobilization and bisphosphonates infusion. All implants were well osseointegrated at the final follow-up examination. There are two periprosthetic fractures intraoperatively. The wire was applied to assist fixation, and the fracture healed at the latest follow-up. Two patients experienced significant leg length discrepancies. The median MSTS-93 score was 26 (range, 23 to 30).

Conclusions

A 3D-printed custom-made ultra-short stem with a porous structure provides acceptable early outcomes in patients who received peri-knee metaphyseal reconstruction. With detailed preoperative design and precise intraoperative techniques, the reasonable initial stability benefits osseointegration to osteoconductive porous titanium, and therefore ensures short- and possibly long-term durability. Personalized adaptive endoprosthesis, careful intraoperative operation, and strict follow-up management enable effective prevention and treatment of complications. The functional results in our series were acceptable thanks to reliable fixation in the bone-endoprosthesis interface and an individualized rehabilitation program. These positive results indicate this device series can be a feasible alternative for critical bone defect reconstruction. Nevertheless, longer follow-up is required to determine whether this technique is superior to other forms of fixation.

High conversion rate to total hip arthroplasty after hemiarthroplasty in young patients with a minimum 10 years follow-up

Background

This study aimed to evaluate the follow-up results of bipolar hemiarthroplasty (BHA) for more than 10 years in patients aged < 60 years and to analyze the risk factors for acetabular erosion after BHA.

Methods

This retrospective study included 114 patients who underwent BHA were followed-up for at least 10 years. The mean age was 54.1 years, and the mean follow-up duration was 13.8 years. The patients were divided into two groups according to the presence of acetabular erosion, and the preoperative parameters were compared between the two groups. Moreover, the risk factors related to acetabular erosion after BHA were analyzed using statistical comparisons.

Results

Reoperation was performed in 44 of the 114 patients (38.6 %). The survival rate when the end point was reoperation related to acetabular erosion was found to be significantly time-dependent: 73.2 % at 5 years, 48.8 % at 10 years, and 25.9 % at 15 years. The acetabular erosion group showed significantly younger age at the time of surgery, higher body mass index (BMI), more avascular necrosis of the femoral head, and smaller prosthetic femoral head. The final multivariate logistic regression analysis showed that young age at the time of surgery were independent risk factors for acetabular erosion after BHA in patients aged < 60 years.

Conclusions

The minimum 10-year follow-up outcomes of BHA in patients aged < 60 years showed a relatively high conversion rate to total hip arthroplasty. When considering BHA in younger patients, more careful decisions should be made with respect to patient’s choice, keeping in mind that long-term survival cannot be guaranteed.