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Potter BK. CORR Insights®: Is High-dose Radiation Therapy Associated With Early Revision Due to Aseptic Loosening in Patients With a Sarcoma of the Lower Extremities Reconstructed With a Cemented Endoprosthesis? Clin Orthop Relat Res 2023; 481:488-490. [PMID: 36136055 PMCID: PMC9928827 DOI: 10.1097/corr.0000000000002415] [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: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K Potter
- Norman M. Rich Professor and Chair, Department of Surgery at the Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA
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Arnold MT, Geiger EJ, Hart C, Greig D, Trikha R, Sekimura T, Eckardt JJ, Bernthal NM. Is High-dose Radiation Therapy Associated With Early Revision Due to Aseptic Loosening in Patients With a Sarcoma of the Lower Extremities Reconstructed With a Cemented Endoprosthesis? Clin Orthop Relat Res 2023; 481:475-487. [PMID: 35977001 PMCID: PMC9928754 DOI: 10.1097/corr.0000000000002360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/20/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The durability of endoprostheses after limb salvage surgery is influenced by surgical factors (resection length, implant location, and residual bone quality), implant design (modular versus custom design, rotating versus fixed hinge, coating, collars, and the use of cross pins), and host factors (patient's immune status, activity levels, and age). In general, radiation therapy increases the risk of fractures, infection, delayed wound healing, and impaired osseointegration. Several studies have shown exposure to radiation to be associated with higher endoprosthesis revision rates and higher periprosthetic infection rates, but results are inconsistent. Although radiation therapy is not routinely used in the treatment of many bone sarcomas in current practice, it is still used in high doses after resection and prosthetic reconstruction in patients who have Ewing sarcoma with close or positive margins and in patients with soft tissue sarcoma. It is also used in varying doses after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. These patients may be at an increased risk of complications due to their radiation exposure, but this is a difficult question to study given the rarity of these diagnoses and poor overall survival of these patients. We therefore leveraged a large, longitudinally collected, 40-year endoprosthesis database that included patients who received radiation to the extremity for many bone and soft tissue sarcomas to investigate the association between preoperative or postoperative radiation therapy and endoprosthesis survival. QUESTIONS/PURPOSES (1) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from amputation or revision due to any cause? (2) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from revision specifically due to aseptic loosening? (3) Is receiving preoperative or postoperative radiation therapy for the treatment of Ewing sarcoma of the femur specifically associated with decreased implant survivorship free from revision specifically due to aseptic loosening? METHODS This was a retrospective, comparative study using our institution's database of 822 endoprostheses. Between 1980 and 2019, we treated 541 patients with primary cemented endoprostheses of the extremities. Of those patients, 8% (45 of 541) were excluded due to unknown radiation status, 3% (17 of 541) because of prior failed allograft, 15% (83 of 541) due to metastatic disease from a carcinoma, 1% (6 of 541) due to a nononcologic diagnosis, 4% (20 of 541) due to benign tumor diagnosis, 16% (87 of 541) due to upper extremity tumor location, 9% (49 of 541) due to not receiving chemotherapy, and 3% (14 of 541) due to expandable prostheses. Of the remaining 220 patients, 6% (13) were considered missing because they did not have 2 years of follow-up and did not reach a study endpoint. No patients had surgery within the last 2 years of the study end date. In all, 207 patients met inclusion criteria and were eligible for analysis. Patients who had received radiation to the lower extremities at any point in their treatment course were included in the radiation group and were compared with patients who did not receive radiation. For patients where radiation dose was available, the radiation group was subdivided into a low-dose (≤ 3000 cGy) and high-dose (> 3000 cGy) group. Revision surgery was defined as any surgery necessitating removal or replacement of the tibial or femoral stem. The complications necessitating revision or amputation were poor wound healing, aseptic loosening, implant breakage, deep infection, and tumor progression. The primary outcome of interest was implant survival free from revision or amputation due to any cause. The secondary outcome of interest was implant survival free from revision or amputation specifically due to aseptic loosening. The Kaplan-Meier survivorship curves were generated with implant survival free from revision or amputation as the endpoint and patient death as a competing risk. A log-rank test was used to identify differences in survivorship between the patients who received radiation and those who did not. Multivariate regression was used to identify factors associated with decreased implant survival. An odds ratio was used to determine relative effect size among the factors associated with decreased implant survival. RESULTS The mean implant survival time for patients who did not receive radiation was 18.3 years (95% confidence interval [CI] 15.4 to 21.3) whereas the mean implant survival time for patients who received low- and high-dose radiation were 19.1 years (95% CI 14.5 to 23.7; p = 0.59) and 13.8 years (95% CI 8.2 to 19.5; p = 0.65), respectively. The mean implant survival free from revision for aseptic loosening for patients who did not receive radiation was 27.1 years (95% CI 24.1 to 30.1) whereas the mean implant survival for patients who received low- and high-dose radiation were 24.1 years (95% CI 19.1 to 29.1; p = 0.34) and 16.4 years (95% CI 10.6 to 22.2; p = 0.01), respectively. Patients who received high-dose radiation had decreased 5-year implant survivorship free from amputation or revision due to aseptic loosening (73% [95% CI 44% to 89%]) compared with patients who did not receive radiation (95% [95% CI 90% to 99%]; p = 0.01). For patients treated for Ewing sarcoma of the femur, the 5-year implant survival free from amputation or revision due to aseptic loosening for patients who did not receive radiation (100% [95% CI 100% to 100%]) was no different compared with patients who received radiation (71% [95% CI 35% to 90%]; p = 0.56). CONCLUSION The results of this study may apply to scenarios where radiation is used, such as Ewing sarcoma with positive margins or local recurrence and after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. Surgeons may consider closer monitoring for early clinical and radiographic signs of aseptic loosening in patients who received high-dose radiation. These patients may also benefit from constructs that have increased resistance to aseptic loosening such as cross-pin or side plate fixation. The association between radiation and aseptic loosening should be further studied with larger studies with homogeneity in tumor diagnosis and prosthesis. The dose-dependent relationship between radiation and bone-related complications may also benefit from controlled, laboratory-based biomechanical studies. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Michael T. Arnold
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Erik J. Geiger
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Christopher Hart
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Danielle Greig
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Rishi Trikha
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Troy Sekimura
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Jeffrey J. Eckardt
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
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Tsantes AG, Altsitzioglou P, Papadopoulos DV, Lorenzo D, Romanò CL, Benzakour T, Tsukamoto S, Errani C, Angelini A, Mavrogenis AF. Infections of Tumor Prostheses: An Updated Review on Risk Factors, Microbiology, Diagnosis, and Treatment Strategies. BIOLOGY 2023; 12:biology12020314. [PMID: 36829589 PMCID: PMC9953401 DOI: 10.3390/biology12020314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
Several causes contribute to the high infection rate in tumor prostheses, including extensive tissue dissection and patients' immunosuppression due to the neoplastic disease. Most of these infections develop within the first 2 years following surgery with 70% of them occurring during the first year, while they are often associated with a low pathogen burden. The pathogenesis of infections in tumor prostheses is linked to bacteria developing in biofilms. Approximately half of them are caused by Staphylococcus spp., followed by Streptococcus spp., Enterococcus spp., and Enterobacteriaceae spp., while multiple pathogens may be isolated in up to 25% of the cases, with coagulase-negative Staphylococci (CoNS) and Enterococccus spp. being the most frequent pair. Although early detection and timely management are essential for complete resolution of these challenging infections, prompt diagnosis is problematic due to the highly varying clinical symptoms and the lack of specific preoperative and intraoperative diagnostic tests. Surgical management with one- or two-stage revision surgery is the mainstay for successful eradication of these infections. The recent advances in laboratory diagnostics and the development of biofilm-resistant prostheses over the past years have been areas of great interest, as research is now focused on prevention strategies. The aim of this study is to review and consolidate the current knowledge regarding the epidemiology, risk factors, microbiology, and diagnosis of infections of tumor prostheses, and to review the current concepts for their treatment and outcomes.
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Affiliation(s)
- Andreas G. Tsantes
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Pavlos Altsitzioglou
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitrios V. Papadopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 14233 Athens, Greece
| | - Drago Lorenzo
- Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
| | | | | | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara 634-8521, Japan
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Andrea Angelini
- Department of Orthopaedics and Orthopaedic Oncology, University of Padova, 35122 Padova, Italy
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-210-6542800
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Schneider KN, Bröking JN, Gosheger G, Lübben T, Hardes J, Schorn D, Smolle MA, Theil C, Andreou D. What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors? Clin Orthop Relat Res 2021; 479:1754-1764. [PMID: 33595237 PMCID: PMC8277276 DOI: 10.1097/corr.0000000000001677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/20/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure. QUESTIONS/PURPOSES We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score? METHODS Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease. RESULTS The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function. CONCLUSION Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Jan Niklas Bröking
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Timo Lübben
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Jendrik Hardes
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Dominik Schorn
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Dimosthenis Andreou
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
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Zöllner SK, Amatruda JF, Bauer S, Collaud S, de Álava E, DuBois SG, Hardes J, Hartmann W, Kovar H, Metzler M, Shulman DS, Streitbürger A, Timmermann B, Toretsky JA, Uhlenbruch Y, Vieth V, Grünewald TGP, Dirksen U. Ewing Sarcoma-Diagnosis, Treatment, Clinical Challenges and Future Perspectives. J Clin Med 2021; 10:1685. [PMID: 33919988 PMCID: PMC8071040 DOI: 10.3390/jcm10081685] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Ewing sarcoma, a highly aggressive bone and soft-tissue cancer, is considered a prime example of the paradigms of a translocation-positive sarcoma: a genetically rather simple disease with a specific and neomorphic-potential therapeutic target, whose oncogenic role was irrefutably defined decades ago. This is a disease that by definition has micrometastatic disease at diagnosis and a dismal prognosis for patients with macrometastatic or recurrent disease. International collaborations have defined the current standard of care in prospective studies, delivering multiple cycles of systemic therapy combined with local treatment; both are associated with significant morbidity that may result in strong psychological and physical burden for survivors. Nevertheless, the combination of non-directed chemotherapeutics and ever-evolving local modalities nowadays achieve a realistic chance of cure for the majority of patients with Ewing sarcoma. In this review, we focus on the current standard of diagnosis and treatment while attempting to answer some of the most pressing questions in clinical practice. In addition, this review provides scientific answers to clinical phenomena and occasionally defines the resulting translational studies needed to overcome the hurdle of treatment-associated morbidities and, most importantly, non-survival.
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Affiliation(s)
- Stefan K. Zöllner
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
| | - James F. Amatruda
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Sebastian Bauer
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Medical Oncology, Sarcoma Center, University Hospital Essen, 45147 Essen, Germany
| | - Stéphane Collaud
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Thoracic Surgery, Ruhrlandklinik, University of Essen-Duisburg, 45239 Essen, Germany
| | - Enrique de Álava
- Institute of Biomedicine of Sevilla (IbiS), Virgen del Rocio University Hospital, CSIC, University of Sevilla, CIBERONC, 41013 Seville, Spain;
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, 41009 Seville, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Jendrik Hardes
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Wolfgang Hartmann
- Division of Translational Pathology, Gerhard-Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany;
- West German Cancer Center (WTZ), Network Partner Site, University Hospital Münster, 48149 Münster, Germany
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute and Medical University Vienna, 1090 Vienna, Austria;
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - David S. Shulman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Arne Streitbürger
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Beate Timmermann
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre, 45147 Essen, Germany
| | - Jeffrey A. Toretsky
- Departments of Oncology and Pediatrics, Georgetown University, Washington, DC 20057, USA;
| | - Yasmin Uhlenbruch
- St. Josefs Hospital Bochum, University Hospital, 44791 Bochum, Germany;
| | - Volker Vieth
- Department of Radiology, Klinikum Ibbenbüren, 49477 Ibbenbühren, Germany;
| | - Thomas G. P. Grünewald
- Division of Translational Pediatric Sarcoma Research, Hopp-Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Translational Pediatric Sarcoma Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center, 69120 Heidelberg, Germany
| | - Uta Dirksen
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
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Kiran M, Alsousou J, Dalal N, Ralte P, Kumar G, Kapoor B. Is a single dose of preoperative antibiotic therapy effective for patients treated with megaendoprosthesis after metastatic bone tumour resection? Musculoskelet Surg 2021; 106:187-193. [PMID: 33400185 DOI: 10.1007/s12306-020-00692-6] [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: 09/11/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
Purpose The timing and number of doses of antibiotics required for megaendoprosthetic replacement (MPR) in metastatic bone disease (MBD) is a matter of debate. The aim of our study is to present the results of a prospective cohort of MPR for MBD receiving a single dose of antibiotic at induction of anaesthesia. METHODS All patients who underwent primary MPR in MBD were included in this prospective study. All penicillin-sensitive patients received one dose of cefuroxime 1.5gm intravenous at induction. In penicillin-allergic patients, teicoplanin 1.2gm and ciprofloxacin 500 mg intravenous was administered. The patients were followed up in the wound clinic and the specialist MBD clinic at 2 weeks, 3 months, 6 months and then annually. Data collected included demographics, primary tumours, surgical procedures, complications and duration of follow-up. All calculations were performed using SPSS® 25(IBM, USA). A p value ≤ 0.05 was considered to be significant. RESULTS There were 51 patients with a mean age of 65.4 years. Procedures included proximal femoral replacement (35), distal femoral replacement (7), proximal humeral replacement (4), distal humeral replacement (3) and total femoral replacement (2). Thirty-seven patients received cefuroxime, and fourteen patients received teicoplanin and ciprofloxacin at induction of anaesthesia. The deep infection rate was 1.9%. Thirty-seven patients died with a median survival of 10 months (1 to 51 months). Mean follow-up was 18.9 months (1 to 70 months). CONCLUSION Single dose of preoperative antibiotics at anaesthetic induction seems to be safe and effective for preoperative prophylaxis in orthopaedic oncology.
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Affiliation(s)
- M Kiran
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK.
| | - J Alsousou
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - N Dalal
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - P Ralte
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - G Kumar
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
| | - B Kapoor
- Department of Trauma and Orthopaedics, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP, UK
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Theil C, Röder J, Gosheger G, Deventer N, Dieckmann R, Schorn D, Hardes J, Andreou D. What is the Likelihood That Tumor Endoprostheses Will Experience a Second Complication After First Revision in Patients With Primary Malignant Bone Tumors And What Are Potential Risk Factors? Clin Orthop Relat Res 2019; 477:2705-2714. [PMID: 31764339 PMCID: PMC6907292 DOI: 10.1097/corr.0000000000000955] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients. QUESTIONS/PURPOSES (1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision? METHODS Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models. RESULTS A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009). CONCLUSIONS Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- C Theil
- C. Theil, J. Röder, G. Gosheger, N. Deventer, R. Dieckmann, D. Schorn, J. Hardes, D. Andreou Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, Muenster, Germany
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Abstract
BACKGROUND The majority of osteoarticular defects after tumor resection in adolescent and adult patients are reconstructed using megaendoprosthetic implants. However, even infant and pre-teen children undergo reconstruction of defects using so-called growing prostheses with an increasing frequency. OBJECTIVES Presentation of current techniques, outcomes and the most common complications of megaendoprosthetic reconstruction following tumour resection. METHODS Selective literature review and discussion of current concepts and knowledge in megaendoprosthetic reconstruction against personal experience and treatment strategies. RESULTS Megaendoprosthetic reconstructions achieve good functional results and long-term limb salvage (ca. 90% of cases) in adolescent and adult patients. Still, periprosthetic infection and mechanical failure of joint components are among the most common complications observed. In infant and pre-teen children treated by reconstruction using a growing prosthesis, mandatory maintenance operations-in the process of elongating the implant-must also be considered when assessing complication risks. CONCLUSIONS Megaendoprosthetic reconstructions of osteoarticular defects are a standard procedure in adolescent and adult patients. Despite a substantial complication rate, limb salvage is achieved in a majority of patients. When using growing prostheses in younger children, one needs to be aware of additional servicing procedures that occur independently of those arising from complications.
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Du Z, Tang S, Yang R, Tang X, Ji T, Guo W. Use of an Artificial Ligament Decreases Hip Dislocation and Improves Limb Function After Total Femoral Prosthetic Replacement Following Femoral Tumor Resection. J Arthroplasty 2018; 33:1507-1514. [PMID: 29366726 DOI: 10.1016/j.arth.2017.12.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/10/2017] [Accepted: 12/14/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hip dislocation is a major complication of total femoral prosthetic reconstruction (TFR) after femoral tumor resection. Hip dislocation can occur because of inadequate functional abductor musculature, inadequate hip capsule repair, or a long lever arm after total femur replacement. To eliminate the negative effects of these factors on the risk of hip dislocation, the use of artificial ligaments may help to increase the stability of the hip joint. We aimed to determine whether application of an artificial ligament would improve limb function and active range of movement (ROM) after TFR. METHODS Fifty-eight patients who underwent femoral tumor resection and TFR were included. A band-shaped artificial ligament was wrapped spirally around the proximal site of the total femur prosthesis for periacetabular soft tissue reconstruction in 12 patients. The other 46 patients did not consent to receiving the artificial ligament. Complications including hip dislocation and infection, limb function, and active hip ROM were compared between patients who did and did not receive the artificial ligament. RESULTS The hip dislocation rate was lower in the patients who received the artificial ligament. The risk of deep infection did not differ between groups. The group that received the ligament also achieved better limb function and active ROM on flexion and abduction. CONCLUSION Patients treated with total femur resection and endoprosthetic replacement with an artificial ligament for periacetabular soft tissue reconstruction had a more stable hip joint, better limb function, and greater active hip ROM than did patients who did not receive an artificial ligament.
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Affiliation(s)
- Zhiye Du
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
| | - Shun Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
| | - Tao Ji
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, People's Republic of China; Key Laboratory for Musculoskeletal Tumor of Beijing, Peking University People's Hospital, Beijing, People's Republic of China
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Lu Y, Li M, Li L, Wei S, Hu X, Wang X, Shan G, Zhang Y, Xia H, Yin Q. High-activity chitosan/nano hydroxyapatite/zoledronic acid scaffolds for simultaneous tumor inhibition, bone repair and infection eradication. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017; 82:225-233. [PMID: 29025652 DOI: 10.1016/j.msec.2017.08.043] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 01/06/2023]
Abstract
Implanted biomaterials combined tumor inhibition and bone repair property are urgently needed to address the huge bone destruction and the high local recurrence following primary surgery in bone tumor therapy. In this work, a high-activity chitosan/nano hydroxyapatite (CS/nHA) scaffold containing zoledronic acid (CS/nHA/Zol) was prepared with a facile method. The prepared CS/nHA/Zol scaffolds exhibited excellent tumor inhibition property towards giant cell tumor of bone (GCT) in vitro through inducing cells apoptosis by up-regulating pro-apoptosis genes expression and reducing the osteoclastic activity of tumor cells by down-regulating osteoclastic genes. Meanwhile, the prepared scaffolds possessed well biocompatibility and osteoinductivity as compared to pure CS/nHA scaffolds. Furthermore, the prepared scaffolds also presented outstanding antibacterial activity against clinical pathogenic S. aureus and E. coli. These overall findings successfully demonstrated the prepared CS/nHA/Zol scaffolds had a multifunction of tumor therapy, bone repair, and antibacterium, which provides a new approach possessed promising advantages in bone tumor therapy.
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Affiliation(s)
- Yao Lu
- Southern Medical University, No. 1023, South Shatai Road, Baiyun District, Guangzhou, Guangdong 510515, China; Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Mei Li
- Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Lihua Li
- Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Shuzhen Wei
- Department of Blood Bank, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Xiaoming Hu
- Southern Medical University, No. 1023, South Shatai Road, Baiyun District, Guangzhou, Guangdong 510515, China; Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Xiaolan Wang
- Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Guiqiu Shan
- Department of Blood Bank, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Yu Zhang
- Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China
| | - Hong Xia
- Southern Medical University, No. 1023, South Shatai Road, Baiyun District, Guangzhou, Guangdong 510515, China; Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China.
| | - Qingshui Yin
- Southern Medical University, No. 1023, South Shatai Road, Baiyun District, Guangzhou, Guangdong 510515, China; Guangdong Key Laboratory of Orthopaedic Technology and Implant Materials, Key Laboratory of Trauma and Tissue Repair of Tropical Area of PLA, Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command of PLA, No. 111, Liuhua Road, Yuexiu District, Guangzhou, Guangdong 510010, China.
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Jeys L, Morris G, Evans S, Stevenson J, Parry M, Gregory J. Surgical Innovation in Sarcoma Surgery. Clin Oncol (R Coll Radiol) 2017; 29:489-499. [PMID: 28502707 DOI: 10.1016/j.clon.2017.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/24/2022]
Abstract
The field of orthopaedic oncology relies on innovative techniques to resect and reconstruct a bone or soft tissue tumour. This article reviews some of the most recent and important innovations in the field, including biological and implant reconstructions, together with computer-assisted surgery. It also looks at innovations in other fields of oncology to assess the impact and change that has been required by surgeons; topics including surgical margins, preoperative radiotherapy and future advances are discussed.
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Affiliation(s)
- L Jeys
- Royal Orthopaedic Hospital, Birmingham, UK; School of Health and Life Sciences, Aston University, Birmingham, UK.
| | - G Morris
- Royal Orthopaedic Hospital, Birmingham, UK
| | - S Evans
- Royal Orthopaedic Hospital, Birmingham, UK
| | | | - M Parry
- Royal Orthopaedic Hospital, Birmingham, UK
| | - J Gregory
- Royal Orthopaedic Hospital, Birmingham, UK
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12
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Schmidt-Braekling T, Streitbuerger A, Gosheger G, Boettner F, Nottrott M, Ahrens H, Dieckmann R, Guder W, Andreou D, Hauschild G, Moellenbeck B, Waldstein W, Hardes J. Silver-coated megaprostheses: review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:483-489. [PMID: 28265758 DOI: 10.1007/s00590-017-1933-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/26/2017] [Indexed: 01/06/2023]
Abstract
Periprosthetic infection remains one of the most serious complications following megaendoprostheses. Despite a large number of preventive measures that have been introduced in recent years, it has not been possible to further reduce the rate of periprosthetic infection. With regard to metallic modification of implants, silver in particular has been regarded as highly promising, since silver particles combine a high degree of antimicrobial activity with a low level of human toxicity. This review provides an overview of the history of the use of silver as an antimicrobial agent, its mechanism of action, and its clinical application in the field of megaendoprosthetics. The benefits of silver-coated prostheses could not be confirmed until now. However, a large number of retrospective studies suggest that the rate of periprosthetic infections could be reduced by using silver-coated megaprostheses.
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Affiliation(s)
- Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany.
| | - Arne Streitbuerger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - Markus Nottrott
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Helmut Ahrens
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Ralf Dieckmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Wiebke Guder
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Dimosthenis Andreou
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Gregor Hauschild
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Wenzel Waldstein
- Department of Orthopedics, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jendrik Hardes
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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Kapoor SK, Thiyam R. Management of infection following reconstruction in bone tumors. J Clin Orthop Trauma 2015; 6:244-51. [PMID: 26566338 PMCID: PMC4600835 DOI: 10.1016/j.jcot.2015.04.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/24/2015] [Indexed: 01/03/2023] Open
Abstract
Limb salvage surgery in bone tumors has evolved in recent years and includes all of the surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. This dramatic change came about as the result of three important developments, i.e. effective chemotherapy, improved precision imaging techniques and advances in reconstructive surgery. Reconstruction with a modular custom-made oncological endoprosthesis (megaprosthesis) has become a common procedure nowadays. These large foreign bodies make infection a common and feared complication. However, the occurrence of complications may be multifactorial, including a poor nutritional and compromised immune status due to chemotherapy and/or radiotherapy, a lengthy operation, extensive dissection and resection of soft tissues, inadequate soft-tissue coverage, a longer exposure of the wound resulting in infection, etc. Management of postoperative infection in these cases remains a challenge. This article analyses the current literature available for these cases and summarizes the cause and different available methods of treatment.
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Affiliation(s)
- Sudhir K. Kapoor
- Dean and Officiating HOD, Department of Orthopaedics, ESI-PGIMSR, Basaidarapur, New Delhi 110015, India
| | - Rajesh Thiyam
- Senior Resident, Department of Orthopaedics, ESI PGIMSR, Basaidarapur, New Delhi 110015, India
- Corresponding author.
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14
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Mavrogenis AF, Pala E, Angelini A, Calabro T, Romagnoli C, Romantini M, Drago G, Ruggieri P. Infected Prostheses after Lower-Extremity Bone Tumor Resection: Clinical Outcomes of 100 Patients. Surg Infect (Larchmt) 2015; 16:267-75. [DOI: 10.1089/sur.2014.085] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Elisa Pala
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Andrea Angelini
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Teresa Calabro
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Carlo Romagnoli
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Matteo Romantini
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Gabriele Drago
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Pietro Ruggieri
- Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
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Abstract
BACKGROUND Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.
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Abstract
The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.
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Affiliation(s)
- Ajay Puri
- Department of Orthopaedic Oncology Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Hwang N, Grimer RJ, Carter SR, Tillman RM, Abudu A, Jeys LM. Early results of a non-invasive extendible prosthesis for limb-salvage surgery in children with bone tumours. ACTA ACUST UNITED AC 2012; 94:265-9. [PMID: 22323698 DOI: 10.1302/0301-620x.94b2.27536] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We reviewed our initial seven-year experience with a non-invasive extendible prosthesis in 34 children with primary bone tumours. The distal femur was replaced in 25 cases, total femur in five, proximal femur in one and proximal tibia in three. The mean follow-up was 44 months (15 to 86) and 27 patients (79%) remain alive. The prostheses were lengthened by an electromagnetic induction mechanism in an outpatient setting and a mean extension of 32 mm (4 to 80) was achieved without anaesthesia. There were lengthening complications in two children: failed lengthening in one and the formation of scar tissue in the other. Deep infection developed in six patients (18%) and local recurrence in three. A total of 11 patients required further surgery to the leg. Amputation was necessary in five patients (20%) and a two-stage revision in another. There were no cases of loosening, but two patients had implant breakage and required revision. The mean Musculoskeletal Tumor Society functional score was 85% (60% to 100%) at last known follow-up. These early results demonstrate that the non-invasive extendible prosthesis allows successful lengthening without surgical intervention, but the high incidence of infection is a cause for concern.
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Affiliation(s)
- N Hwang
- University Hospital Coventry Warwickshire, Clifford Bridge Road, Coventry, Warwickshire CV2 2DX, UK.
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Mavrogenis AF, Papagelopoulos PJ, Coll-Mesa L, Pala E, Guerra G, Ruggieri P. Infected tumor prostheses. Orthopedics 2011; 34:991-8; quiz 999-1000. [PMID: 22147218 DOI: 10.3928/01477447-20111021-24] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infection of tumor prostheses has been a major concern because of the extensive soft tissue dissection, long operating times, and patients' immunosuppression by cancer and adjuvant treatments. Infections most often present within 2 years postoperatively, with approximately 70% of postoperative deep infections presenting within 12 months after surgery. They are typically low organism burden infections, the pathogenesis of which is related to bacteria growing in biofilms. Staphylococci are the most common pathogens involved in prosthetic joint infections, accounting for approximately 50% of infections overall, followed by streptococci, enterococci, Enterobacteriaceae species, Pseudomonas aeruginosa, and anaerobe species. Multiple pathogens may be isolated in approximately 25% of cases, with the most common combination being coagulase-negative Staphylococcus and group-D Streptococcus. Early diagnosis and appropriate treatment are necessary. However, diagnosis may be challenging because clinical symptoms are highly variable and numerous preoperative and intraoperative diagnostic laboratory tests are nonspecific. In most cases, a 1- or 2-stage revision surgery is necessary for eradicating the megaprosthetic infection. Prevention of infection is important. The future will see technical advances for infections of tumor prostheses in areas such as microbiological diagnostics and biofilm-resistant prostheses.
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Hanna SA, Sewell MD, Aston WJS, Pollock RC, Skinner JA, Cannon SR, Briggs TWR. Femoral diaphyseal endoprosthetic reconstruction after segmental resection of primary bone tumours. ACTA ACUST UNITED AC 2010; 92:867-74. [PMID: 20513887 DOI: 10.1302/0301-620x.92b6.23449] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Segmental resection of malignant bone disease in the femoral diaphysis with subsequent limb reconstruction is a major undertaking. This is a retrospective review of 23 patients who had undergone limb salvage by endoprosthetic replacement of the femoral diaphysis for a primary bone tumour between 1989 and 2005. There were 16 males and seven females, with a mean age of 41.3 years (10 to 68). The mean overall follow-up was for 97 months (3 to 240), and 120 months (42 to 240) for the living patients. The cumulative patient survival was 77% (95% confidence interval 63% to 95%) at ten years. Survival of the implant, with failure of the endoprosthesis as an endpoint, was 85% at five years and 68% (95% confidence interval 42% to 92%) at ten years. The revision rate was 22% and the overall rate of re-operation was 26%. Complications included deep infection (4%), breakage of the prosthesis (8%), periprosthetic fracture (4%), aseptic loosening (4%), local recurrence (4%) and metastases (17%). The 16 patients who retained their diaphyseal endoprosthesis had a mean Musculoskeletal Tumour Society score of 87% (67% to 93%). They were all able to comfortably perform most activities of daily living. Femoral diaphyseal endoprosthetic replacement is a viable option for reconstruction following segmental resection of malignant bone disease. It allows immediate weight-bearing, is associated with a good long-term functional outcome, has an acceptable complication and revision rate and, most importantly, does not appear to compromise patient survival.
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Affiliation(s)
- S A Hanna
- The Sarcoma Unit Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4 LP, UK.
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Sewell MD, Spiegelberg BGI, Hanna SA, Aston WJS, Bartlett W, Blunn GW, David LA, Cannon SR, Briggs TWR. Total femoral endoprosthetic replacement following excision of bone tumours. ACTA ACUST UNITED AC 2009; 91:1513-20. [PMID: 19880899 DOI: 10.1302/0301-620x.91b11.21996] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We undertook a retrospective review of 33 patients who underwent total femoral endoprosthetic replacement as limb salvage following excision of a malignant bone tumour. In 22 patients this was performed as a primary procedure following total femoral resection for malignant disease. Revision to a total femoral replacement was required in 11 patients following failed segmental endoprosthetic or allograft reconstruction. There were 33 patients with primary malignant tumours, and three had metastatic lesions. The mean age of the patients was 31 years (5 to 68). The mean follow-up was 4.2 years (9 months to 16.4 years). At five years the survival of the implants was 100%, with removal as the endpoint and 56% where the endpoint was another surgical intervention. At five years the patient survival was 32%. Complications included dislocation of the hip in six patients (18%), local recurrence in three (9%), peri-prosthetic fracture in two and infection in one. One patient subsequently developed pulmonary metastases. There were no cases of aseptic loosening or amputation. Four patients required a change of bushings. The mean Musculoskeletal Tumour Society functional outcome score was 67%, the mean Harris Hip Score was 70, and the mean Oxford Knee Score was 34. Total femoral endoprosthetic replacement can provide good functional outcome without compromising patient survival, and in selected cases provides an effective alternative to amputation.
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Affiliation(s)
- M D Sewell
- Institute of Orthopaedics and Musculoskeletal Science, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
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Laskar S, Mallick I, Gupta T, Muckaden MA. Post-operative radiotherapy for Ewing sarcoma: when, how and how much? Pediatr Blood Cancer 2008; 51:575-80. [PMID: 18561167 DOI: 10.1002/pbc.21657] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Postoperative radiotherapy in Ewing family of tumors has undergone continuous evolution over the last few decades to establish its role in the combined modality management of these tumors. The process of evolution is still far from over. This review analyzes the evidence from major multi-institutional prospective trials as well as large retrospective institutional series in Ewing tumors to determine the current standards and controversies in postoperative radiation. The indications of PORT, radiation dose-fractionation, timing, target volumes and treatment planning, as well as the late effects are reviewed. A summary of evidence based consensus is presented and unresolved aspects are discussed. Pediatr Blood Cancer 2008;51:575-580. (c) 2008 Wiley-Liss, Inc.
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Affiliation(s)
- S Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai 400012, India.
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