Outcomes of Intercalary Prosthetic Reconstruction for Pathological Diaphyseal Femoral Fractures Secondary to Metastatic Tumors

What Is the Prosthetic Survival After Resection and Intercalary Endoprosthetic Reconstruction for Diaphyseal Bone Metastases of the Humerus and Femur?

BACKGROUND

Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival.

QUESTIONS/PURPOSES

(1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score?

METHODS

We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system.

RESULTS

Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years).

CONCLUSION

Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision.

LEVEL OF EVIDENCE

Level IV, therapeutic study .

Clinical efficacy of customized modular prosthesis in the treatment of femoral shaft metastases

Purpose

To examine clinical outcomes of a specialized modular prosthesis used to fill a bone deficiency following removal of femoral shaft metastases.

Methods

Eighteen patients with femoral shaft metastases who underwent en bloc resection and implantation of a personalized modular prosthesis between December 2014 and December 2019 were retrospectively analyzed. Pain, limb function, and quality of life were evaluated using the visual analog scale (VAS), Musculoskeletal Tumor Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale. The Kaplan–Meier technique was used to analyze patient survival.

Results

The operation duration was 90–150 min (mean, 115 min), and the osteotomy length was 9–16 cm (mean, 11.72 cm). The patients were followed for 12–62 months (mean, 25.28 months). The VAS and NHP ratings were lower at 3, 6, and 12 months after surgery than before surgery, while the MSTS, ISOLS, and KPS scores were higher after surgery than they had been before. These differences were statistically significant (P&lt;0.05). The survival period was between 7 and 62 months (mean, 20.89 months), and the rates of survival at 1-year and 2-year were 72.22% and 27.78%, respectively. Except for two patients with aseptic prosthesis loosening during the follow-up period, there were no problems.

Conclusion

En bloc excision and implantation of a personalized modular prosthesis can reduce pain and improve the ability of patients with femoral shaft metastases to perform daily activities, thereby improving their quality of life.

Design and performance analysis of 3D-printed stiffness gradient femoral scaffold

Studies on 3D-printed porous bone scaffolds mostly focus on materials or structural parameters, while the repair of large femoral defects needs to select appropriate structural parameters according to the needs of different parts. In this paper, a kind of stiffness gradient scaffold design idea is proposed. Different structures are selected according to the different functions of different parts of the scaffold. At the same time, an integrated fixation device is designed to fix the scaffold. Finite element method was used to analyze the stress and strain of homogeneous scaffolds and the stiffness gradient scaffolds, and the relative displacement and stress between stiffness gradient scaffolds and bone in the case of integrated fixation and steel plate fixation. The results showed that the stress distribution of the stiffness gradient scaffolds was more uniform, and the strain of host bone tissue was changed greatly, which was beneficial to the growth of bone tissue. The integrated fixation method is more stable, less stress and evenly distributed. Therefore, the integrated fixation device combined with the design of stiffness gradient can repair the large femoral bone defect well.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Preliminary results of a new intercalary modular endoprosthesis for the management of diaphyseal bone metastases

OBJECTIVES

This study aims to evaluate functional outcomes of patients and to analyze complication rates of modular intercalary endoprosthetic reconstruction after resection of metastatic diaphyseal bone lesions.

PATIENTS AND METHODS

Between December 2017 and February 2020, 22 patients (15 males, 7 females; median age: 64.2 years; range, 49 to 91) who underwent reconstruction with modular intercalary endoprostheses for metastatic bone tumors at five different centers were retrospectively analyzed. Age, sex, diagnosis, follow-up duration, previous treatments of patients, and resection lengths were recorded. The Musculoskeletal Tumor Society Scores (MSTS) were used to assess functional status of available patients at the final follow-up. Failures were categorized according to the Henderson classification.

RESULTS

Locations of the resected tumors included 10 humeri (45.5%), five tibiae (22.7%), and seven femurs (31.8%). The length of the resected tissues ranged from 35 mm to 180 mm. Seven patients (31.8%) died of disease, and one patient died of pneumonia within follow-up period. The functional outcomes of surviving patients were satisfying with a median MSTS score of 86.9% (range, 70 to 100%) at a median follow-up of 17 (range, 8 to 26) months. There were two cases of type II (9%), one cases of type IIIa (4.5%), two cases of type IIIb (9%), and one case of type IV (4.5%) failure. Complications were most commonly observed in tibial reconstructions.

CONCLUSION

The good short-term functional results were achieved in surviving patients. Uncomplicated patients were able to perform daily living activities without limitations. The overall rate of complications was relatively low and, among them, mechanical problems were the most commonly encountered problems.

Cement Intercalary Reconstruction After Bone Tumor Resection

The optimal type of reconstruction after intercalary tumor resection is unclear. Megaprosthetic and biologic reconstructions may restore bone stock, but their complexity may result in complications and delays in rehabilitation and initiation of adjuvant treatment. Instead, cement spacer permanent reconstruction can be performed as index surgery. The authors studied the files of 20 patients who had bone tumors of the humerus and femur and underwent wide margin resection and permanent cement spacer intercalary reconstruction. Mean follow-up was 52 months (range, 2-255 months). The authors evaluated the survival and function of the patients and the outcome of the cement spacer reconstructions. Five patients who had metastatic bone disease died of their disease with their cement spacer reconstruction in place without complications. One patient who had bone sarcoma experienced a local recurrence that was treated with hip disarticulation. Three patients who had bone sarcomas were converted to biologic reconstruction because of disease remission and had improved prognosis without complications related to cement spacer reconstruction. Two patients experienced mechanical failure of femoral reconstruction and underwent revision with an intercalary biologic reconstruction. No patient who had a cement spacer humeral reconstruction experienced a complication, and no patient experienced infection of the reconstruction. Mean Musculoskeletal Tumor Society score of the patients with cement spacer humeral and femoral reconstructions was 85% and 82%, respectively. [Orthopedics. 2021;44(4):e593-e599.].

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.

En bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases

PURPOSE

To evaluate the short-term clinical efficacy and complications of en bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases.

METHODS

A total of 21 patients with humeral diaphyseal bone metastases treated with en bloc resection and intercalary prosthesis implantation from August 2014 to August 2019 were retrospectively analysed. The visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale were used to assess pain, limb function, and quality of life. Survival of the patients was analysed using the Kaplan-Meier method.

RESULTS

The patients were followed up for 12-57 months (mean: 22 months); the operative time was 68-114 minutes (mean: 76.24 min); the osteotomy length was 6.5-10 cm (mean: 8.02 cm); and the intra-operative blood loss was 95-125 ml (mean: 104.71 ml). At three, six and 12 months after surgery, the VAS and NHP scores were lower, whereas the MSTS, ISOLS, and KPS scores were higher than those before surgery, and the differences were statistically significant (P < 0.05). The survival time was four to 24 months (mean: 19.46 months). Thesix month and one year survival rates were 80.95% and 52.38%, respectively. During the follow-up period, no complications occurred except for aseptic prosthesis loosening in one patient.

CONCLUSIONS

En bloc resection and intercalary prosthesis implantation can reduce pain, improve limb function, prolong survival time, and improve quality of life in patients with humeral diaphyseal bone metastases.

Limb salvage surgery with joint preservation for malignant humeral bone tumors: operative procedures and clinical application

BACKGROUND

However, the application of limb salvage with joint preservation is controversial. The purpose of this study is to propose a selection strategy of joint-sparing operative procedures for humeral malignancies based on tumor origin, site and bone strength.

METHODS

The medical data of 28 patients with humeral malignancies treated at our institute from January 2010 to December 2016 were analyzed retrospectively. The patients had a median age of 51 years (range, 8-82 years). Bone strength scoring system was utilized to evaluated bone strength of the tumor. Four joint-sparing surgical methods were performed on selected patients. Evaluation of limb function was based on the Musculoskeletal Tumor Society scoring system. Two-sample t-test was used to compare patient group data such as bone strength score and postoperative Musculoskeletal Tumor Society score.

RESULTS

The mean follow-up period for the 7 patients with primary malignancies was 45 months (range, 15-66 months). One patient died due to recurrence and lung metastasis, while the remaining 6 patients (6/7, 85.7%) survived without recurrence. For the 21 patients with metastases, 5 survived with tumors, with an average survival time of 25.8 months (range, 9-48 months). The rest died from progression of the primary tumors. The mean bone strength score for the biological reconstruction group and non-biological reconstruction group was respectively 9.7 ± 1.3 and 12.9 ± 1.2. A significant difference between the 2 groups (p < 0.05) was found. Mean postoperative Musculoskeletal Tumor Society score was respectively 27.2 ± 1.8 and 26.1 ± 1.7 for the 2 groups. There was no significant difference between the 2 groups (p > 0.05). Non-oncological complications included fracture (1), aseptic loosening (1) and radial nerve injury (1).

CONCLUSIONS

Alcohol devitalized autograft replantation is applicable for diaphyseal humeral primary malignancies, with a good response to chemotherapy and a low bone strength score (≤10). In situ microwave ablation is suitable for diaphyseal and (or) metaphyseal low-grade malignant bone tumors or metastases with a low bone strength score (≤10). Intercalary prosthetic reconstruction is preferred for diaphyseal metastases with a high bone strength score (> 10).

Intercalary prosthetic reconstruction for pathologic diaphyseal humeral fractures due to metastatic tumors: outcomes and improvements

BACKGROUND

There is a high aseptic loosening rate for intercalary prosthetic reconstruction for malignant tumors. We evaluated outcomes and complications of intercalary prosthetic reconstruction for pathologic diaphyseal humeral fractures and report the application of an extracortical plate that can prevent early loosening.

METHODS

We retrospectively analyzed 9 patients who underwent intercalary prosthetic reconstruction for pathologic diaphyseal humeral fractures secondary to metastatic diseases between March 2011 and September 2017. Procedures were intercalary prosthetic reconstruction in 4 patients (group A) and an implanted intercalary prosthesis with a plate in 5 patients (group B). Operative time, blood loss, complications, and functional score were noted.

RESULTS

Mean operative time for group A and B was 80 ± 14 and 94 ± 5 minutes, respectively; blood loss was 115 ± 26 and 120 ± 31 mL respectively; and follow-up was 11.5 ± 10.1 and 6.2 ± 4.4 months, respectively. At final follow-up, all patients in group A had died, and 3 patients in group B had died; mean survival was 11.5 ± 10.1 and 9.3 ± 1.2 months, respectively. The mean postoperative Musculoskeletal Tumor Society score was 24.5 ± 2.4 and 26.2 ± 0.8, respectively. The mean postoperative American Shoulder and Elbow Surgeons score was 85.5 ± 4.20 and 87 ± 2.6, respectively. There were no significant differences between the 2 groups (P > .05). There was 1 aseptic loosening and 1 radial nerve injury in group A; there were no complications in group B.

CONCLUSIONS

The intercalary prosthesis yielded satisfactory outcomes in patients with pathologic diaphyseal humeral fractures, and an extracortical plate can prevent early aseptic loosening.