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Lee CC, Chen CW, Yen HK, Lin YP, Lai CY, Wang JL, Groot OQ, Janssen SJ, Schwab JH, Hsu FM, Lin WH. Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone. Clin Orthop Relat Res 2024:00003086-990000000-01687. [PMID: 39051924 DOI: 10.1097/corr.0000000000003185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 06/20/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. QUESTIONS/PURPOSES (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? METHODS Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. RESULTS Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. CONCLUSION Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Chia-Che Lee
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Chih-Wei Chen
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Hung-Kuan Yen
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu branch, Hsinchu, Taiwan
| | - Yen-Po Lin
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu branch, Hsinchu, Taiwan
| | - Cheng-Yo Lai
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Hsin-Chu branch, Hsinchu, Taiwan
| | - Jaw-Lin Wang
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Olivier Q Groot
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stein J Janssen
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Joseph H Schwab
- Department of Orthopedics and Neurosurgery, Cedars Sinai Hospital, Los Angeles, CA, USA
| | - Feng-Ming Hsu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Radiation Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Wei-Hsin Lin
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Jain N, Campano D, Gottlich C, Yu A, Brindley G, Callan A, Blank A. Total Humeral Endoprosthetic Reconstruction: A Systematic Review. Orthopedics 2024; 47:e106-e113. [PMID: 38690850 DOI: 10.3928/01477447-20240424-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction. MATERIALS AND METHODS Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases. RESULTS Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies. CONCLUSION THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].
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Gonzalez MR, Werenski JO, Lozano-Calderon SA. Postoperative Outcomes of Total Humerus Replacement for Oncologic Reconstruction of the Upper Limb: A Systematic Review of the Literature. JBJS Rev 2024; 12:01874474-202405000-00006. [PMID: 38768282 DOI: 10.2106/jbjs.rvw.24.00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Total humerus replacement (THR) is a reconstruction procedure performed after resection of massive humeral tumors. However, there is limited literature on the rates of failure and functional outcomes of this implant. Our study aimed to determine the main failure modes, implant survival, and postoperative functional outcomes of THR. METHODS A comprehensive search of the PubMed and Embase databases was conducted. We registered our study on PROSPERO (448684) and used the Strengthening the Reporting of Observational Studies in Epidemiology checklist for quality assessment. The Henderson classification was used to assess endoprosthesis failure and the Musculoskeletal Tumor Society (MSTS) score for functional outcomes. Weighted means and standard deviations were calculated. RESULTS Ten studies comprising 171 patients undergoing THR were finally included. The overall failure rate was 32.2%. Tumor progression (12.6%) and prosthetic infections (9.4%) were the most common failure modes, followed by soft-tissue failures (5.9%), aseptic loosening (3.5%), and structural failure (1.8%). Two-year, 5-year, and 10-year implant survival rates for the entire cohort were 86%, 81%, and 69.3%. Ten-year implant survival for primary THRs was 78.3%, compared with 38.6% for revision THRs (p = 0.049). The mean MSTS score at the last follow-up was 77%. Patients whose implants did not fail had a higher MSTS score (79.3%) than those with failed implants (71.4%) (p = 0.02). CONCLUSION One-third of THR will fail, mostly due to tumor progression and prosthetic infection. Overall functional scores were acceptable, with MSTS scores displaying great hand and elbow function but limited shoulder function. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Li Z, Lu M, Zhang Y, Gong T, Wang J, Luo Y, Zhou Y, Min L, Tu C. Computer-aided Design and 3D-printed Personalized Stem-plate Composite for Precision Revision of the Proximal Humerus Endoprosthetic Replacement: A Technique Note. Orthop Surg 2023; 15:3000-3005. [PMID: 37723892 PMCID: PMC10622279 DOI: 10.1111/os.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/12/2023] [Accepted: 07/23/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Aseptic loosening is considered to be a rather uncommon complication in proximal humerus endoprosthetic replacement (PHER). However, patients with aseptic loosening often suffer severe bone loss, which poses a great challenge in following revision. Under this situation, a standard stemmed endoprosthesis is unavailable for revision limb salvage. Computer-aided design and 3D-printed personalized implants are an emerging solution for reconstructing complex bone defects. CASE PRESENTATION Here, we present a 67-year-old male who underwent PHER after tumor resection and developed aseptic loosening with severe periprosthetic osteolysis around the stem. Computer-aided design and 3D-printed personalized stem-plate composite was used for the precision revision of this patient. During the follow-up, encouraging results were observed, with good endoprosthetic stability and satisfactory limb function. CONCLUSION Computer-aid design and 3D-printed personalized stem-plate composite used in the present case could help to achieve good endoprosthetic stability and satisfactory limb function. This 3D-printed personalized stem-plate composite seems to be an effective method for the precise revision of PHER in patients with severe periprosthetic osteolysis. In addition, it also provides a novel method for similar revision surgery of other joints or primary endoprosthetic replacement with severe bone defects.
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Affiliation(s)
- Zhuangzhuang Li
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Minxun Lu
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Yuqi Zhang
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Taojun Gong
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Jie Wang
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Yi Luo
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Yong Zhou
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Li Min
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
| | - Chongqi Tu
- Department of Orthopaedics, Orthopaedic Research Institute, West China HospitalSichuan UniversityChengduChina
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan ProvinceChengduChina
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Lesensky J, Belzarena AC, Daniel M. Reconstruction with a double-constrained implant design after complex shoulder extra-articular resection. World J Surg Oncol 2023; 21:295. [PMID: 37723520 PMCID: PMC10506192 DOI: 10.1186/s12957-023-03173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/09/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Approximately, one-third of patients with tumors of proximal humerus will require an extra-articular resection to achieve oncologic margins. This procedure yields poor functional outcomes with a considerable rate of revisions. Unconstrained implants are prone to instability hindering also function of the elbow and hand, whereas constrained shoulder reconstructions suffer from early aseptic loosening of the glenoid component due to bone overload. The purpose of this study was to develop a constrained implant suitable for extra-articular resection with loss of function in deltoid and rotator cuff, which would provide both stability and passive motion, whilst also decreasing the risk of aseptic loosening of the glenoid component. METHODS In cooperation with Czech Technical University in Prague, we devised an implant consisting of two constrained joints in series connected by a dumbbell piece. The biomechanical analysis showed a reduction of load transfer to the glenoid component with a torque of 8.6 Nm capable of generating an 865-N pulling force on bone screw to just 0.07 Nm, hence shielding the glenoid component from undesired forces and decreasing the risk of aseptic loosening. Three patients with extra-articular resection with a total loss of function of both rotator cuff and deltoid muscle received this type of reconstruction. The average follow-up was 16 months. RESULTS The surgical technique is straightforward. The surgery took 175 min on average with average blood loss of 516 ml. There were no surgical- or implant-related complications. All three patients were pain-free and had a stable shoulder joint after the reconstruction. All had fully functional elbow, wrist, and hand joints. The average Musculoskeletal Tumor Society (MSTS) score was 21/30 (70%). All patients were pleased with the results. CONCLUSION The presented innovative implant design has demonstrated to be a promising alternative for reconstruction in these challenging cases.
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Affiliation(s)
- Jan Lesensky
- Department of Orthopaedics, First Medical Faculty, University Hospital Na Bulovce, Charles University, Prague, Czech Republic.
| | - Ana C Belzarena
- Department of Orthopedic Surgery, University of Missouri, Columbia, USA
| | - Matej Daniel
- Department of Mechanics, Biomechanics, and Mechatronics, Faculty of Mechanical Engineering, Czech Technical University in Prague, Prague, Czech Republic
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Schneider KN, Ellerbrock M, Gosheger G, Westphal LM, Deventer N, Klingebiel S, Rickert C, Theil C. Distal Humeral Replacement in Patients with Primary Bone Sarcoma: The Functional Outcome and Return to Sports. Cancers (Basel) 2023; 15:3534. [PMID: 37444644 DOI: 10.3390/cancers15133534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
Distal humeral replacement (DHR) is a limb-salvage option for the endoprosthetic reconstruction of bone defects following the resection of a primary bone sarcoma. As primary bone sarcomas are only occasionally located around the distal humerus, there is a paucity of information regarding postoperative function, and patients' resumption of sporting activities. With advances in diagnostics and in surgical and oncological treatment leading to an increased patient life expectancy and higher quality of life, patients' functional outcome and return to sports activities are of increasing interest. Between 1997 and 2021, a total of 24 patients underwent DHR with a single-design modular implant at a tertiary sarcoma center. A total of 14 patients who died of their disease were excluded, leaving a study cohort of 10 patients, with a median age of 30 years on the day of surgery (IQR 20-37). At the last follow-up, after a median of 230 months (IQR 165-262), the median MSTS was 19 (IQR 13-24), the median TESS was 79 (IQR 66-87), the median SEV was 38% (IQR 24-53), the median TS was 6 (IQR 4-7), and the median WAS was 3 (IQR 1-8). Among the variables of gender, surgery on the dominant extremity, intraoperative nerve resection, extra-articular tumor resection, chemotherapy, radiotherapy, and revision surgeries, none were associated with a better/lower functional outcome score or return to sports activities. However, a higher level of sports performance prior to diagnosis (WAS > 10) was associated with a higher level of sports performance postoperatively (p = 0.044).
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Affiliation(s)
| | - Moritz Ellerbrock
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Lucia Maria Westphal
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Niklas Deventer
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Sebastian Klingebiel
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Carolin Rickert
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
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Li Z, Lu M, Zhang Y, Gong T, Min L, Zhou Y, Luo Y, Tu C. 3D-printed custom-made short stem with porous structure for fixation of massive endoprosthesis in joint-preserving reconstruction after tumor resection. J Orthop Surg Res 2023; 18:468. [PMID: 37386639 DOI: 10.1186/s13018-023-03954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Large malignant bone tumors and revision limb salvage procedures often result in massive bone loss, leaving a short residual bone segment that cannot accommodate a standard stem for endoprosthesis fixation. Three-dimensional-printed (3DP) short stem with porous structure seems to be an alternative for short-segment fixation. This retrospective study aims to evaluate surgical outcomes, radiographical results, limb functions, and complications of using 3DP porous short stems in massive endoprosthesis replacement. METHODS Between July 2018 to February 2021, 12 patients with massive bone loss undergoing reconstruction with custom-made, short-stemmed massive endoprostheses were identified. Endoprosthesis replacement involved the proximal femur (n = 4), distal femur (n = 1), proximal humerus (n = 4), distal humerus (n = 1), and proximal radius (n = 2). RESULTS The mean percentage of resected bone was 72.4% of the whole length of the bone, ranging from 58.4 to 88.5%. The mean length of 3DP porous short stems was 6.3 cm. The median follow-up was 38 months (range, 22-58 months). The mean MSTS score was 89%, ranging from 77% to 93%. Radiographical assessment results showed bone in-growth to the porous structure in 11 patients, and the implants were well osseointegrated. Breakage of the 3DP porous short stem occurred in one patient intraoperatively. The patient developed aseptic loosening (Type 2) four-month after surgery and underwent revision with a plate applied to assist fixation. The implant survivorship was 91.7% at 2 years. No other complications were detected, such as soft-tissue failures, structural failures, infection, or tumor progression. CONCLUSIONS 3DP custom-made short stem with porous structure is a viable method for fixation of the massive endoprosthesis in the short segment after tumor resection, with satisfactory limb function, great endoprosthetic stability, and low complication rates.
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Affiliation(s)
- Zhuangzhuang Li
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Minxun Lu
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yuqi Zhang
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Taojun Gong
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Li Min
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yong Zhou
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yi Luo
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
| | - Chongqi Tu
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
- Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
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El Motassime A, Meschini C, Di Costa D, Rovere G, Matrangolo MR, De Maio F, Farsetti P, Ziranu A, Maccauro G, Vitiello R. Functional Outcomes and Shoulder Instability in Reconstruction of Proximal Humerus Metastases. Curr Oncol 2023; 30:3571-3579. [PMID: 37185385 PMCID: PMC10136526 DOI: 10.3390/curroncol30040272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023] Open
Abstract
(1) Background: Some of the goals of orthopedic surgical oncology are saving limbs and function. The humerus is the third most frequent site in primary tumors and one of the most involved sites for metastases. Prosthetic replacement with modular megaprosthesis is one of the treatment choices, but there are several types of complications, such as problems with function and pain. The aim of our study is to assess functional outcomes and shoulder instability in the reconstruction of proximal humerus metastases. (2) Methods: This is a retrospective observational study. Twenty-eight patients, with proximal humerus metastases, admitted to the department of Orthopaedics and Traumatology of our University Hospital between 2014 and 2022 were recruited. Each patient underwent resection and prosthetic replacement surgery with modular megaprosthesis. Clinical evaluation was assessed through MSTS score, WOSI index, and DASH score. (3) Results: Twenty patients were included in the study. Fairly good results, especially regarding pain, function, and emotional acceptance, were obtained in all three tests: DASH, MSTS, and WOSI. Patients who reported shoulder instability actually have worse outcomes than those who report having stable shoulders. In addition, patients with a resection >10 cm have worse outcomes than those who had a resection of 10 cm. No significant differences were found between the deltopectoral approach group and the lateral approach group. (4) Conclusions: Reconstructive surgery with megaprosthesis of the proximal humerus in patients with metastases can be considered a treatment option, especially in patients with pathological fractures or injuries with a high risk of fracture and good life expectancy. This study shows how this type of surgery affects instability, but in terms of functionality, pain, and patient satisfaction, it gives satisfactory results.
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Affiliation(s)
- Alessandro El Motassime
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Cesare Meschini
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Doriana Di Costa
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Rovere
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Rosaria Matrangolo
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Fernando De Maio
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Pasquale Farsetti
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Antonio Ziranu
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulio Maccauro
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
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9
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Denissen JJPM, Koenders N, van Hinte G, Groen F, van der Wees PJ, van der Geest ICM, Dierselhuis EF. Functional outcomes after reversed shoulder megaprosthesis following resection of malignant bone tumor in the proximal humerus: a systematic review and meta-analysis. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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10
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Ellerbrock M, Theil C, Gosheger G, Deventer N, Klingebiel S, Rickert C, Schneider KN. Function and return to sports after proximal humeral replacement in patients with primary bone sarcoma. J Orthop Traumatol 2022; 23:59. [PMID: 36571630 PMCID: PMC9792634 DOI: 10.1186/s10195-022-00678-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/04/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Improved patient and limb survival rates have led to an increased interest in the functional outcome and return to sports of patients undergoing megaprosthetic reconstruction in musculoskeletal oncology. This study evaluates the functional outcome and postoperatively performed level of sports in patients undergoing proximal humeral replacement (PHR) following resection of a primary bone sarcoma and identifies potential beneficial and limiting factors. PATIENTS AND METHODS Between 2007 and 2020, a total of 606 patients underwent resection of a primary bone sarcoma and reconstruction with a single-design modular implant. For 112 (18%) patients, the location of the tumour was the proximal humerus. Exclusion criteria were death (n = 65), patients living overseas (n = 8), and subsequent amputation (n = 1), leaving 38 patients for evaluation, of whom 32 were available for the study (13 women, median age 42 years). Clinical data regarding oncological and surgical treatment as well as subsequent complications were obtained from the patients' electronic medical records. Functional outcome was determined using the Musculoskeletal Tumor Society Score (MSTS) and Toronto Extremity Salvage Score (TESS) as well as the Subjective Shoulder Value (SSV). Return to sports was assessed using the Tegner Activity Score (TS) and the modified Weighted Activity Score (WAS). RESULTS At the last follow-up after a median of 30 months (IQR 22-58), median MSTS was 18 (IQR 12-24), median TESS was 80% (IQR 69-87), median SSV was 35% (IQR 10-58), median TS was 5 (IQR 4-6) and median WAS was 5 (IQR 0-10). Preservation of the axillary nerve, a reverse shoulder reconstruction and a WAS of > 10 prior to surgery were associated with better functional outcome and return to sports activity scores. CONCLUSION Following PHR, good to excellent functional outcomes are possible, and patients regularly return to participate in sports activities-most commonly in low-impact types of sports, but some individuals are even able to participate in high-impact sports activities. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Moritz Ellerbrock
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Niklas Deventer
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Sebastian Klingebiel
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
| | - Carolin Rickert
- Department of Orthopaedics and Tumor Orthopaedics, Albert-Schweitzer Campus 1, 48149 Münster, Germany
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11
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Gazendam A, Ghert M. What’s New in Musculoskeletal Tumor Surgery. J Bone Joint Surg Am 2022; 104:2131-2144. [PMID: 37010478 DOI: 10.2106/jbjs.22.00811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Michelle Ghert
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
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12
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Guo Y, Liu F, Bian X, Lu K, Huang P, Ye X, Tang C, Li X, Wang H, Tang K. Effect of Pore Size of Porous-Structured Titanium Implants on Tendon Ingrowth. Appl Bionics Biomech 2022; 2022:2801229. [PMID: 35510044 PMCID: PMC9061050 DOI: 10.1155/2022/2801229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/27/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The reconstruction of a tendon insertion on metal prostheses is a challenge in orthopedics. Of the available metal prostheses, porous metal prostheses have been shown to have better biocompatibility for tissue integration. Therefore, this study is aimed at identifying an appropriate porous structure for the reconstruction of a tendon insertion on metal prostheses. Methods Ti6Al4V specimens with a diamond-like porous structure with triply periodic minimal surface pore sizes of 300, 500, and 700 μm and a porosity of 58% (designated Ti300, Ti500, and Ti700, respectively) were manufactured by selective laser melting and were characterized with micro-CT and scanning electron microscopy for their porosity, pore size, and surface topography. The porous specimens were implanted into the patellar tendon of rabbits. Tendon integration was evaluated after implantation into the tendon at 4, 8, and 12 weeks by histology, and the fixation strength was evaluated with a pull-out test at week 12. Results The average pore sizes of the Ti300, Ti500, and Ti700 implants were 261, 480, and 668 μm, respectively. The Ti500 and Ti700 implants demonstrated better tissue growth than the Ti300 implant at weeks 4, 8, and 12. At week 12, the histological score of the Ti500 implant was 13.67 ± 0.58, and it had an area percentage of type I collagen of 63.90% ± 3.41%; both of these results were significantly higher than those for the Ti300 and Ti700 implants. The pull-out load at week 12 was also the highest in the Ti500 group. Conclusion Ti6Al4V implants with a diamond-like porous structure with triply periodic minimal surface pore size of 500 μm are suitable for tendon integration.
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Affiliation(s)
- Yupeng Guo
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Fei Liu
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Xuting Bian
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Kang Lu
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Pan Huang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Xiao Ye
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Chuyue Tang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Xinxin Li
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Huan Wang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Kanglai Tang
- Department of Orthopedics/Sports Medicine Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing 400038, China
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13
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Theil C, Schwarze J, Gosheger G, Moellenbeck B, Schneider KN, Deventer N, Klingebiel S, Grammatopoulos G, Boettner F, Schmidt-Braekling T. Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection. Cancers (Basel) 2022; 14:cancers14020351. [PMID: 35053514 PMCID: PMC8773828 DOI: 10.3390/cancers14020351] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection. Abstract Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.
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Affiliation(s)
- Christoph Theil
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Jan Schwarze
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Georg Gosheger
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Burkhard Moellenbeck
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Kristian Nikolaus Schneider
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Niklas Deventer
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Sebastian Klingebiel
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA;
| | - Tom Schmidt-Braekling
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
- Correspondence:
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14
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Ahrens H, Theil C, Gosheger G, Rödl R, Deventer N, Rickert C, Ackmann T, Schwarze J, Klingebiel S, Schneider KN. The Bateman-Type Soft Tissue Reconstruction around Proximal or Total Humeral Megaprostheses in Patients with Primary Malignant Bone Tumors-Functional Outcome and Endoprosthetic Complications. Cancers (Basel) 2021; 13:cancers13163971. [PMID: 34439124 PMCID: PMC8392651 DOI: 10.3390/cancers13163971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/23/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
We aimed to evaluate the functional outcome and endoprosthetic complications following the Bateman-type soft tissue reconstruction around proximal or total humeral replacements in patients undergoing resection of a primary malignant bone tumor. Between September 2001 and December 2018, a total of 102 patients underwent resection of a primary malignant bone tumor and subsequent reconstruction with a modular humeral megaprosthesis in our department. Fifteen (15%) of these patients underwent a Bateman-type soft tissue reconstruction and were included in this retrospective study. The median Musculoskeletal Tumor Society (MSTS) score was 21, the median Toronto Extremity Salvage Score (TESS) was 70, and the median American Shoulder and Elbow Surgeons (ASES) score was 72. Fifty-three percent (8/15) of all patients required a revision surgery after a median time of 6 months. There were 2 soft tissue failures, 3 infections and 3 tumor recurrences. The revision-free implant survivorship amounted to 53% (95% confidence interval (CI) 28-81) after 1 year and 47% (95% CI 22-73) at last follow-up. The Bateman-type reconstruction is a feasible option for soft tissue reconstruction but functional outcome is overall limited and the risk for revision surgery within the first postoperative year is high.
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15
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Fourman MS. CORR Insights®: What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors? Clin Orthop Relat Res 2021; 479:1765-1767. [PMID: 33739330 PMCID: PMC8277275 DOI: 10.1097/corr.0000000000001732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Massachusetts General Hospital / Harvard Medical School, Boston, MA, USA
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16
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Periprosthetic Stress Shielding of the Humerus after Reconstruction with Modular Shoulder Megaprostheses in Patients with Sarcoma. J Clin Med 2021; 10:jcm10153424. [PMID: 34362209 PMCID: PMC8347309 DOI: 10.3390/jcm10153424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 01/03/2023] Open
Abstract
(1) Background: Modular megaprosthetic reconstruction using a proximal humerus replacement has emerged as a commonly chosen approach after bone tumor resection. However, the long-term risk for revision surgery is relatively high. One factor that might be associated with mechanical failures is periprosthetic osteolysis around the stem, also known as stress shielding. The frequency, potential risk factors, and the effect on implant survival are unknown. (2) Methods: A retrospective single-center study of 65 patients with sarcoma who underwent resection of the proximal humerus and subsequent reconstruction with a modular endoprosthesis. Stress shielding was defined as the development of bone resorption around the prosthesis stem beginning at the bone/prosthesis interface. The extent of stress shielding was measured with a new method quantifying bone resorption in relation to the intramedullary stem length. All patients had a minimum follow-up of 12 months with conventional radiographs available and the median follow-up amounted to 36 months. (3) Results: Stress shielding was observed in 92% of patients (60/65). The median longitudinal extent of stress shielding amounted to 14% at last follow-up. Fifteen percent (10/65) showed bone resorption of greater than 50%. The median time to the first radiographic signs of stress shielding was 6 months (IQR 3–9). Patients who underwent chemotherapy (43/65) showed a greater extent of stress shielding compared to those without chemotherapy. Three percent (2/65) of patients were revised for aseptic loosening, and one patient had a periprosthetic fracture (1/65, 1.5%). All these cases had >20% extent of stress shielding (23–57%). (4) Conclusions: Stress shielding of the proximal humerus after shoulder reconstruction with modular megaprosthesis is common. It occurs within the first year of follow-up and might be self-limiting in many patients; however, about one third of patients shows progression beyond the first year. Still, mechanical complications were rare, but stress shielding might be clinically relevant in individual cases. The extent of stress shielding was increased in patients who underwent perioperative chemotherapy. Stress shielding can be quantified with an easy method using the stem length as a reference.
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17
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Theil C, Schneider KN, Gosheger G, Dieckmann R, Deventer N, Hardes J, Schmidt-Braekling T, Andreou D. Does the Duration of Primary and First Revision Surgery Influence the Probability of First and Subsequent Implant Failures after Extremity Sarcoma Resection and Megaprosthetic Reconstruction? Cancers (Basel) 2021; 13:cancers13112510. [PMID: 34063771 PMCID: PMC8196552 DOI: 10.3390/cancers13112510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Tumor endoprostheses are a common type of reconstruction after the resection of an extremity bone sarcoma. However, in the long-term, first and subsequent implant failures leading to revision surgery are common. One potential risk factor for implant failure is the length of surgery. This study investigates the impact of the length of surgery on prosthetic survival in 568 patients with sarcoma. Patients who had a first implant failure had a longer surgery; however, there were no differences in the infection-free survival, but only in the probability of mechanical failure. Patients with a subsequent revision surgery for infection had a shorter duration of surgery during the first revision. In conclusion, a shorter surgery appears beneficial; however, longer surgeries are not clearly associated with infection. In revision surgery, a longer operating time, indicating a more thorough debridement, may be desirable. Abstract Complications in megaprosthetic reconstruction following sarcoma resection are quite common. While several risk factors for failure have been explored, there is a scarcity of studies investigating the effect of the duration of surgery. We performed a retrospective study of 568 sarcoma patients that underwent megaprosthetic reconstruction between 1993 and 2015. Differences in the length of surgery and implant survival were assessed with the Kaplan–Meier method, the log-rank test and multivariate Cox regressions using an optimal cut-off value determined by receiver operating curves analysis using Youden’s index. 230 patients developed a first and 112 patients a subsequent prosthetic failure. The median duration of initial surgery was 210 min. Patients who developed a first failure had a longer duration of the initial surgery (225 vs. 205 min, p = 0.0001). There were no differences in the probability of infection between patients with longer and shorter duration of initial surgery (12% vs. 13% at 5 years, p = 0.492); however, the probability of mechanical failure was higher in patients with longer initial surgery (38% vs. 23% at 5 years, p = 0.006). The median length of revision surgery for the first megaprosthetic failure was 101 min. Patients who underwent first revision for infection and did not develop a second failure had a longer median duration of the first revision surgery (150 min vs. 120 min, p = 0.016). A shorter length of the initial surgery appears beneficial, however, the notion that longer operating time increases the risk of deep infection could not be reproduced in our study. In revision surgery for infection, a longer operating time, possibly indicating a more thorough debridement, appears to be associated with a lower risk for subsequent revision.
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Affiliation(s)
- Christoph Theil
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
- Correspondence: ; Tel.: +49-2514-4278
| | - Kristian Nikolaus Schneider
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
| | - Ralf Dieckmann
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
- Department of Orthopedics, Krankenhaus der Barmherzigen Brueder, Nordallee 1, 54292 Trier, Germany
| | - Niklas Deventer
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
| | - Jendrik Hardes
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
- Department of Musculoskeletal Oncology, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Tom Schmidt-Braekling
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (K.N.S.); (G.G.); (R.D.); (N.D.); (J.H.); (T.S.-B.); (D.A.)
- Department of Orthopedic Oncology and Sarcoma Surgery, Sarcoma Centre Berlin-Brandenburg, Helios Klinikum Bad Saarow, 15526 Bad Saarow, Germany
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