Femoral Reconstruction Research Articles

How is the outcome of the Limb Preservation System™ for reconstruction of hip and knee?

BackgroundDespite tremendous advantages in the development and application of megaprostheses in tumour and revision surgery, complications are still not infrequently observed. Only two studies investigating the outcome of the LPS™ system in the proximal femur and distal femur/proximal tibia have been published thus far. Herein, mid-term implant survival rates one of the largest cohort of patients treated with the LPS™-system are presented aiming tp answer: 1) How is the outcome of the LPS™ system in the proximal femur and distal femur/proximal tibia? 2) Which factors are associated with altered implant survival? 3) What is the cumulative risk of complications according to Henderson? HypothesisThe LPS™-system is associated with high complication rates that depend on implant site, with infections being most common. Patients and methodsFifty-seven patients who received the LPS™-system at the proximal femur (n=31), distal femur (n=21) and proximal tibia (n=5) between 2004 and 2010 for oncological (n=40) or non-oncological (n=17) causes, were retrospectively included. Median follow-up was 5.0 years (range, 0-12.4 years). Complications were classified according to Henderson into instability/soft tissue failure (type 1), aseptic loosening (type 2), structural failure (type 3), periprosthetic infection (type 4), tumour progression (type 5). Competing-risk-analyses were applied to estimate implant survival with death as the competing event. ResultsTwenty-six patients (45.6%) developed a complication, of whom 9 (29.0%) had a proximal femoral and 17 (65.4%) a distal femoral/proximal tibial implant. Type 4 complications were most common (n=11), followed by type 3 (n=6, including 2 yoke-fractures), type 1 and 2 (n=4 each), and type 5 (n=1). The only factor associated with the development of complications in the multivariate model was a distal femoral/proximal tibial implant (hazard-ratio: 7.418, 95% confidence-interval: 2.193-26.096, p=0.001), irrespective of reason for reconstruction and use of muscular flaps. The cumulative-incidence of failure including all complications was 34.3%, 40.7% and 67.1% at 3, 5 and 10 years, respectively. DiscussionThe LPS™-system may be used for proximal femoral reconstructions both in the oncological and non-oncological setting. Rates of complications are higher in our cohort than reported in literature for other, comparable, megaprosthesis systems. Especially in the distal femur/proximal tibia, complication rates were high, partially attributable to the former implant design leading to fractures of the yoke-mechanism. As the implant has been remodelled after these issues became evident, there is no objection to use this megaprosthesis system today. Level of evidenceIV, Observational Study.

Preserving hip treatment of steroid-induced osteonecrosis of the femoral head

Objective To investigate the early diagnosis and treatment options for steroid-induced osteonecrosis of the femoral head (SONFH). Methods Retrospective analysis was conducted in 73 patients with unilateral SONFH from January 2010 to June 2017. There were 27 males and 46 females, aged 34.26±10.35 years (range, 20-45 years). The following type of cases were included, 21 cases of ARCO I, 24 cases of IIa, 8 cases of IIb, 18 cases of IIc and 2 cases of IIIa. Patients with ARCO I were limited in weight and were treated with low molecular weight heparin sodium and ginkgo dharma drugs after excluding bleeding risk. Core decompression was performed in patients with ARCO IIa and IIb vascularized greater trochanter bone transfer was conducted in patients with IIc and IIIa. During the follow-up duration, when the ARCO I progressed to ARCO IIa and IIb, the core decompression was performed. When the ARCO IIa and IIb progressed to the ARCO IIc or IIIa, the vascularized greater trochanter bone transfer was conducted. Vascularized greater trochanter bone combined with the tantalum rod was implanted in ARCO IIIb. The femoral head reconstruction with the larger trochanter bone flap or joint replacement was performed in ARCO IIIc and above. The Harris hip score was used to evaluate the clinical outcomes. The femoral head survival curve of SONFH was drawn with the end of joint replacement. Results All 73 patients were followed up for an average of 29 months (range, 18 to 48 months). After treatment of 21 patients with ARCO I, a total of 14 (67%) patients had no ARCO staging progress. After 6 months, three patients progressed to ARCO IIb and 4 patients progressed to ARCO IIc. All 32 patients with ARCO IIa and IIb were treated, of which 25 (78%) did not progress but 4 patients progressed to ARCO IIIa at 6 months. Only one patient progressed to ARCO IIIb at 6 months, and 2 patient progressed to ARCO IIIc at 12 months. There were 18 patients with ARCO IIc underwent treatment, of which 14 patients (78%) did not progress but 2 patients progressed to ARCO IIIa at 6 months and 2 patients progressed to ARCO IIIc at 24 months and to ARCO IV at 42 months, respectively. Two patients of ARCO IIIa, 1 patient did not progress and the other one progressed to ARCO IV at 36 months. The Harris hip score was 90.48±5.36 before treatment and 91.76±8.19 at the last follow-up. The difference was not statistically significant (t=1.231, P=0.402). The Harris hip score of patients with ARCO IIa and IIb in creased from 75.22±8.30 to 84.47±16.77 with statistically significant difference (t=5.624, P<0.001). The Harris hip score of patients with ARCO IIc and IIIa increased from 59.80±9.24 to 77.75±20.75 with statistically significant difference (t=12.033, P<0.001). Four patients eventually underwent arthroplasty. The femoral head survival rate was 98.6% at 2 years and 94.5% at 4 years. Conclusion The SONFH can be diagnosed early by screening, and is treated by different reserving hip methods according to severe stages. The short-term clinical effects are satisfied. Key words: Glucocorticoids; Femur head necrosis; Free tissue flaps; Decompression, surgical

Functional outcome of surgical treatment of adults with extremity osteosarcoma after megaprosthetic reconstruction\u2014single-center experience

BackgroundOsteosarcoma is the most common primary malignant bone tumor in adults and is usually located in the long bones. Standard treatment consists of perioperative chemotherapy and radical surgical resection. Limb-sparing surgery using a variety of reconstructive techniques remains the gold standard.MethodsIn our study, we retrospectively analyzed 90 adult patients operated at our institution between 2000 and 2017 for extremity osteosarcoma that underwent limb-sparing reconstruction with the megaprosthesis. Sixty-one patients underwent resection and reconstruction of the distal femur, 9 patients—proximal femur, 7 patients—proximal tibia, 5 patients—total femoral resection and reconstruction, 5 patients—proximal humeral resection, and 3 patients—other types of resection with endoprosthetic reconstruction. The median follow-up time was 41 months, median overall survival was 86 months (3–225 months), and progression-free survival was 81 months (1–86 months). Functional assessment was made on 48 out of 56 living patients, after endoprosthetic reconstruction. The assessment was made according to MSTS functional scale.ResultsIn 14 cases (15%), the endoprosthesis had to be explanted, or amputation was performed for local recurrence or septic complication. Due to a mechanical failure of the implant, we had to perform a revision in 5 patients (5%). Eighteen out of 74 patients with endoprosthesis died of the disease. The median MSTS score was 84% (53–100%), and the best result of 85% was achieved in patients after distal femoral resection with endoprosthetic reconstruction.ConclusionCareful planning of the treatment of patients with extremity osteosarcoma that is performed at the referral centers gives the possibility of long-term survival with a good and excellent functional result.

Intramedullary Nailing of a Periprosthetic Intertrochanteric Fracture in the Setting of Prior Hip Resurfacing: A New Technique for Fracture Fixation

We report the case of a 61-year-old male individual with a history of left hip resurfacing arthroplasty who sustained a left intertrochanteric fracture after a mechanical fall. While prior reports have described internal fixation with a femoral reconstruction nail or small frag locking compression plate for periprosthetic intertrochanteric fractures sustained around a Birmingham resurfacing prosthesis, our case is unusual in that the fracture extended into the lesser trochanter as well as the basicervical femoral neck. We present our technique for fracture fixation with a lateral entry femoral reconstruction nail and a derotation screw for this unstable injury as an alternative to currently available treatment options, which are limited to revision total hip arthroplasty.

Analysis of vascularized fibula graft integration to the extracorporeal irradiated bone after replantation: 2-year follow-up

Background: Major bone segmental defects in oncologic patients continue as a therapeutic challenge to orthopedic surgeons. The few alternatives for its management and the relationship between functional outcome and surgical complications remain among the main restrictions for the indication of different techniques. One of these alternatives is the vascularized fibular graft in association with the creation of a bone channel made from resection of the tumor bone segment after being submitted to the extracorporeal irradiation technique. There is little subject information about long-term follow-up either prospective than retrospective studies. Aim of the study: Retrospective evaluation of vascularized fibular graft union capacity from diaphysis and metaphysis and its integration to the irradiated bone after transplantation. Methods: Eleven patients submitted to extracorporeal irradiation technique and replantation with vascularized fibular graft had their radiographic images on 6, 12 and 24 months of postoperative period evaluated. Results: We observed 45,4% in diaphysis integration in the first year and 72,7% in the second year of follow-up, progressive in the diaphysis focus, and maintenance of the metaphysis focus (33,3%). Conclusion: The fibula has a good capacity for bone integration, showing less influence on the union of the metaphysis portion.Descriptors: Bone Transplantation; Osteosarcoma; Microsurgery; Surgical Oncology.ReferencesMyers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89(12):1632-37.Muscolo DL, Ayerza MA, Aponte-Tinao L, Farfalli G. Allograft reconstruction after sarcoma resection in children younger than 10 years old. Clin Orthop Relat Res. 2008;466(8):1856-62.Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br. 2012;94(7):982-88.Hong AM, Millington S, Ahern V, McCowage G, Boyle R, Tatersall M et al. Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients. Ann Oncol. 2013;24(10):2676-80.Manfrini M, Vanel D, De Paolis M, Malaguti C, Innocenti M, Ceruso M et al. Imaging of vascularized fibula autograft placed inside a massive allograft in reconstruction of lower limb bone tumors. AJR Am J Roentgenol. 2004;182(4):963-70.Spira E, Lubin E. Extracorporeal irradiation of bone tumor. A preliminary report. Isr J Med Sci. 1968;4(5):1015-19.Krieg AH, Davidson, AW, Stalley PD. Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br. 2007;89(3):366-71.Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir. 2001;33(4):277-82.Ortiz-Cruz E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am. 1997;79(1):97-106.Farfalli GL, Aponte-Tinao L, Lopez-Millán L, Averza MA, Muscolo DL. Clinical and functional outcomes of tibial intercalary allografts after tumor resection. Orthopedics. 2012;35(3):e391-96.Aponte-Tinao L, Farfalli GL, Ritacco LE, Averza MA, Muscolo DL. Intercalary femur allografts are an acceptable alternative after tumor resection. Cln Orthop Relat Res. 2012;470(3):728-34.

Total hip arthroplasty with femoral osteotomy and modular prosthesis for proximal femoral deformity

BackgroundSevere anatomical abnormalities exist in proximal femoral deformities (PFDs). Total hip arthroplasty (THA) is associated with drawbacks such as high surgical complexity, long operation time, requirement for high surgical skills, high incidences of postoperative complications, and poor efficacy.ObjectiveThis study aimed to investigate the short-term efficacy of THA with femoral osteotomy and modular prosthesis implantation for femoral fixation and reconstruction in patients with PFD.MethodsA total of 15 patients (15 hips) with rotational PFD treated with THA with femoral osteotomy and modular prosthesis between August 2012 and September 2014 were included. There were 10 male (10 hips) and 5 female (5 hips) patients. Preoperative limb shortening, intraoperative osteotomy length, and postoperative limb length were recorded. The Harris hip score was adopted for assessing the clinical results. Postoperative radiography was performed to observe the prosthesis position, as well as the presence or absence of abnormalities such as osteolysis, loosening, and subsidence of the prosthesis.ResultsAll 15 patients were followed up postoperatively, with a mean follow-up duration of 62.5 (range 20–85) months. The postoperative limb-length discrepancy (1.0 ± 0.5 cm) was significantly less than the preoperative discrepancy (3.2 ± 1.2 cm) (t = − 2.501, P = 0.002). The Harris hip score significantly improved from a mean of 47.2 ± 9.9 points preoperatively to 89.7 ± 3.9 points during the last follow-up visit (t = 21.31, P = 0.001). Immediate postoperative radiographs showed restoration of limb alignment after femoral osteotomy, excellent initial press-fit fixation of the S-ROM prosthesis, and good canal filling. According to Engh’s criteria, all 15 hips were graded as ingrown bones. No infection, prosthesis loosening, periprosthetic fracture, or other complications occurred.ConclusionIn patients with femoral deformities treated with THA, precise osteotomy, good coaptation of the osteotomy surfaces, and correct choice of modular S-ROM prostheses for femoral reconstruction and fixation remain the key factors for surgical success.

Relative Contribution of Acetabular and Femoral Reconstruction to Prosthetic Joint Instability Risk after Primary Total Hip Arthroplasty

AbstractProsthetic joint instability is a challenging concern for a minority of total hip arthroplasty (THA) patients. Placement of the acetabular component within the traditional safe zone does not eliminate dislocation, and the relative contribution of femoral length and offset to instability risk has not been well defined. The authors compared 53 dislocated primary THAs treated against an age- and gender-matched cohort of 134 stable primary THAs. Anteroposterior and cross-table lateral radiographs were used to determine whether reconstructions met targets for acetabular inclination (30–50 degrees), acetabular anteversion (5–30 degrees), femoral length (0–9.9 mm) and femoral offset (0–9.9 mm). Statistical analysis was performed to assess univariate and multivariate relationships with an instability event; statistical significance was set using a two-sided p-value &lt; 0.05. Forty-seven (88.7%) of the dislocating hips had nonoptimal acetabular or femoral reconstructions. While a similar proportion of patients in the study and control groups had acetabular reconstruction within the safe zone (51.5 vs. 47.2%, p = 0.63) patients with unstable hips were more likely to have acetabular component inclination outside of the target zone (30.2 vs. 7.5%, p &lt; 0.01), acetabular anteversion &lt; 15 degrees (30.2 vs. 3.7%, p &lt; 0.0001), reduced femoral length (35.9 vs. 3.7%, p &lt; 0.0001), and reduced femoral offset (41.5 vs. 7.46%, p &lt; 0.0001). Stepwise multivariate logistic regression was performed and identified femoral head size less than 32 mm (OR 2.9, 95% CI 1.4–6.2) and higher inclination angle (OR 1.1, 95% CI 1.04–1.2) as significant independent risk factors for hip instability. The authors' study findings suggest that insufficient acetabular anteversion, femoral length, and femoral offset reconstruction contribute significantly to instability risk following THA. Using a larger femoral head is protective, but should be balanced against long-term volumetric wear risk.

Treatment of aortic and peripheral prosthetic graft infections with bovine pericardium

ObjectiveGraft infections are rare but serious complications of vascular operations. The aim of this study was to evaluate the results of in situ reconstruction with bovine pericardium in infected aortic and peripheral vessel fields. MethodsA retrospective cohort study was conducted with a focus on the treatment of infected grafts with bovine pericardium. We retrospectively reviewed 19 consecutive patients with prosthetic graft infections and in situ repair with bovine pericardium. All operations were done between March 2015 and January 2018. No other materials were used. Excision of the infected graft, radical débridement of the infected tissue, and in situ reconstruction with bovine pericardium were applied in all patients. Short-term outcomes including primary patency, freedom of reinfection, mortality, and complication rates were analyzed. ResultsBovine pericardium was used in 19 patients (84% male) with a median age of 70 years (range, 56-84 years) to reconstruct the descending aorta (n = 1), abdominal aorta (n = 5), iliac artery (n = 4), and femoral artery (n = 9). Graft infections were observed in all patients (one thoracic endovascular aneurysm repair, three infrarenal endovascular aneurysm repairs, two open aortic repairs, four iliac-femoral reconstructions, and nine femoral reconstructions including two closure device infections after coronary angiography). Ten patients (53%) had a complication perioperatively and postoperatively. The 30-day mortality was 10.5%; the total mortality rate after 1 year was 32%. There was no reinfection after bovine reconstruction observed in our cohort. Graft occlusions were detected in two cases during follow-up (median, 6 months; range, 1-47 months). ConclusionsBovine pericardium reconstruction shows a good short-term outcome after aortic or peripheral graft infections. It is associated with good patency, low reinfection rate, and acceptably low early mortality rate. It can be a good therapeutic option in prosthetic graft infections when in situ repair with a prosthetic (even soaked) or autologous vein or homograft is not recommended or is not possible.

Fluorescent indocyanine green angiography: Preliminary results in microsurgery monitoring

IntroductionPedicled flaps and free-tissue transfer flaps are used routinely to reconstruct hard and soft tissue defects in head and neck, limb, hand, thoracic and abdominopelvic reconstructive surgery. But failure remains a constant concern, particularly in free-tissue transfers. Usually failure is due to blood supply compromise. Indocyanine green (ICG), a fluorescent dye is a suitable tracer for vessel perfusion. The objective of this study is to evaluate the fluorescent indocyanine green angiography (FA ICG) in free flaps procedures. Materiel and methodsPatients who had microsurgical flap reconstruction were included during the study period in a single center. The FA ICG was used at specific times. Intra-veinous injections of 0.1mg/kg of INFRACYANINE® (concentration 2.5mg/mL) were done intraoperatively. The Fluobeam® device programmed on sensitivity and mapping to interpret the data, was used. These different injections allowed to checked skin paddle perforators vessels, osseous perforators vessels, arterial and venous patency after anastomosis and the cutaneous, muscular and osseous perfusion. ResultsA total of 12 patients enrolled were 10 males and 1 female. Their mean age was 54.5 years (range 25–75 years). Of the 12 flaps, 8 were free flaps with 4 fibular flaps (3 for mandibular reconstruction and one for femur reconstruction); 2 radial forearm flaps for maxillary reconstruction; one latissimus free flap for tibia skin coverage and one retroauricular fasciocutaneous free flap for thumb skin coverage. We got to modify specific steps during surgery with 8 patients by using the FA ICG to anticipate potential complications: modifying the draw of the skin paddle, recut of this paddle, modifying the osteotomies, re-doing the anastomosis or modifying the position of the pivot point. DiscussionEvaluation of microvascular flap perfusion is still based on subjective clinical features. Clinical monitoring is observer-dependent and does not allow information sharing, test reproducibility, and consistent postoperative follow-up. The successful of salvage rate is linked to the delay between the onset of ischemia and its clinical assessment. FA ICG could be a reliable method for monitoring free-tissue transfers. This technique is objective, non invasive and facilitate a complex reconstructive procedure to augment is liability. This technique may be used such a pedagogical tool for young practitioners in their first microsurgery procedures.

BLADDER RECONSTRUCTION DURING SEPARATION OF A CONJOINT TWIN ISCHIOPAGUS TRIPUS

Objective: Conjoined twins represent one of the rarest congenital anomalies occurring with a varying incidence of about approximately 1 : 50.000 - 1 : 200.000 births. Ischiopagus conjoined twinning (Fuse at the hip region) is even rare representing only 6% of all conjoined twins. Here we report our experience in lower urinary tract reconstruction during separation of a conjoined twin ischiopagus tripus in Hasan Sadikin Hospital, Bandung. Case(s) Presentation: Two years old female conjoined twins, weighing in total of 8 kilograms, were brought to our hospital. The twins were fused at the lower halves of their bodies with two separate lower limbs at the right side and a fused left lower limb. External genitalia were absent. From CT Angiography we found four kidneys, two in each child with two separate bladders, with right ureter of baby A and left ureter of baby B enter the right bladder, while left ureter of baby A and right ureter of baby B enter the left bladder. There was one cloaca that drains urine and feces. During the separation surgery, we performed ureteroneocystostomy and temporary ureteral stenting, followed by cystostomy. The pediatric surgeon performed bowel separation by stapling technique, pelvic wall separation, ileostomy, and pelvic floor reconstruction. The orthopedic surgeon performed femur separation, pelvic floor reconstruction, reconstruction of the pelvic ring, and femur reconstruction. The patients underwent defect closure, which performed by plastic surgeon. The operation was successful, without any complication to the kidney and the urinary tract of both babies. Discussion: Ischiopagus conjoined twins are the most complex conjoined twins and occur in only 6% of all conjoined twin cases. Ischiopagus is usually located along the axis with the head located on the opposite side. This case usually has one umbilicus and the two bodies are fused below this level, the union occurs in the lower abdomen and the pelvis. The internal organs that usually coalesce in cases of ischiopagus conjoined twins are liver, lower gastrointestinal, and genitourinary. The fused gastrointestinal part is the ileo-colic part of terminal ileum (Meckel's diverticulum). Conclusion: The separation of conjoined twin is a unique challenge due to its complex anatomy and physiology. Although advancement in imaging and monitoring has improved the survival rate separation can be successfully achieved only with meticulous planning and team work.

Acetabular Erosion After Bipolar Hemiarthroplasty in Proximal Femoral Replacement for Malignant Bone Tumors

BackgroundHemiarthroplasty megaprosthetic proximal femur reconstruction after tumor resection is a widespread procedure in orthopedic oncology. One potential complication is acetabular wear requiring secondary acetabular revision. The study’s purpose is to investigate prevalence of acetabular erosion, secondary revisions, and potential risk factors. MethodsWe retrospectively identified 112 patients who underwent proximal femur replacement after resection of a malignant bone tumor and had radiological follow-up longer than 12 months. Patient demographic, surgical, and oncologic factors were recorded, acetabular wear was measured using the classification proposed by Baker, and prosthetic failure was classified using the International Society on Limb Salvage classification. Functional assessment was performed using the Musculoskeletal Tumor Society Score and Harris Hip Score. ResultsPrevalence of acetabular wear was 28.6%. Secondary conversion to total hip arthroplasty was required in 5 patients (4.6%), all treated for primary bone tumors. No patient treated for metastatic tumor had higher grade acetabular wear or required revision. Significant risk factors for the development of acetabular wear were age under 40 (P = .035) and longer follow-up (63 vs 43 months, P = .004). Other patient, surgical, or adjuvant treatment-related factors were not associated with acetabular revision or acetabular wear. The dislocation rate in the patient cohort was 0.9%. ConclusionBipolar hemiarthroplasty proximal femoral replacement represents a durable reconstruction after tumor resection. Hip instability is rare. Acetabular erosion is rare and can be successfully treated with conversion to total hip arthroplasty. Young patients with long-term survival over 10 years are at risk. In reconstruction for metastases, instability and acetabular wear are rare.

Classifications in Brief: The Hartofilakidis Classification of Developmental Dysplasia of the Hip

Classifications in Brief: The Hartofilakidis Classification of Developmental Dysplasia of the Hip

Virtual Geometric Reconstruction of Australopithecine Femora: A Methodological Evaluation

The fragmentary nature of fossils, and the need to extract as much information from them as possible, mandates that broken portions be reconstructed. Virtual reconstruction using geometric morphometric techniques based on the thin plate spline (TPS) function can be used to locate landmarks that represent missing portions of fossil specimens. Here we evaluate the accuracy of TPS‐based reconstruction in artificially damaged australopithecine distal femora.Surface models of modern human (n=35) and chimpanzee (n=37) distal femora, as well as those of two australopiths (casts of A.L. 129‐1a and A.L. 333‐4), were created using a structured light scanner. Articular surfaces were trimmed from the rest of the surface model. 1007 sliding semilandmarks were distributed across the articular surface, and semilandmarks were then slid to minimize the bending energy of the TPS function relative to an updated Procrustes average. Fossils were then virtually destroyed by removing semilandmarks to mimic the type of destruction observed in other fossil specimens. Removed portions increased from a small, central hole in the middle of each condyle to removal of the entire condyle. Average chimpanzee and human femora were used as references to create two separate reconstructions using geometric reconstruction based on the TPS function. Procrustes distances (PD) between each reconstruction and the original fossil were calculated to evaluate reconstruction accuracy.Reconstructions based on both human and chimpanzee averages deviated further from the original fossils as the level of artificial damage increased. When the entire medial condyle was reconstructed, the original morphology of both australopithecine fossils was intermediate between the human‐based and chimpanzee‐based reconstructions. For these reconstructions, Procrustes distances indicate that both A.L. 129‐1a and A.L. 333‐4 are most similar to the human‐based reconstruction (A.L. 129‐1a: PD = 0.001 vs. 0.002; A.L. 333‐4: PD = 0.002 vs. 0.003). When the entire lateral condyle was reconstructed, the fossils fell outside the possible morphologies bounded by the human‐based and chimpanzee‐based reconstructions. Procrustes distances indicate that both fossils are more similar to the human‐based reconstructions than those based on the average chimpanzee (A.L. 129‐1a: PD = 0.004 vs. 0.005; A.L. 333‐4: PD = 0.005 vs. 0.009). These results suggest that while the australopithecine medial femoral condyle may be considered an interpolation between chimpanzee and human morphology, the lateral condyle does not follow the same trend. For australopithecine distal femur reconstructions to be accurate, medial and lateral condyles should be considered separately.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Modular tumor prostheses: are current stem designs suitable for distal femoral reconstruction? A biomechanical implant stability analysis in Sawbones.

High loosening rates after distal femoral replacement may be due to implant design not adapted to specific anatomic and biomechanical conditions. A modular tumor system (MUTARS®, Implantcast GmbH) was implanted with either a curved hexagonal or a straight tapered stems in eight Sawbones® in two consecutively generated bone defect (10cm and 20cm proximal to knee joint level). Implant-bone-interface micromotions were measured to analyze main fixation areas and to characterize the fixation pattern. Although areas of highest relative micromotions were measured distally in all groups, areas and lengths of main fixation differed with respect to stem design and bone defect size. Regardless of these changes, overall micromotions could only be reduced with extending bone defects in case of tapered stems. The tapered design may be favorable in larger defectswhereas the hexagonal may be advantageous in defects located more distally.

A 2-stage Distal Femur Reconstruction with Expandable Endoprosthesis in a Pediatric Patient Presenting with a Pathologic Fracture through an Osteosarcoma

Osteosarcoma in pediatric patients has traditionally been treated with amputation, especially if there is a pathologic fracture through the tumor.We report the case of a 12-year-old boy who sustained a pathologic fracture through distal femoral osteosarcoma. After neoadjuvant chemotherapy, he underwent limb saving surgery: wide excision of the osteosarcoma followed by a second-stage reconstruction with an expandable tumor endoprosthesis. He has a functional score of 93% and is free of disease 8 years since diagnosis and 2 years since the end of lengthening.This is the first reported case in Philippine medical literature of limb saving surgery in osteosarcoma reconstructed with an expandable endoprosthesis.

A Reliable Femoral Osteotomy in Total Hip Arthroplasty for Hartofilakidis Type C Developmental Dysplasia of the Hip: Proximal Femoral Reconstruction

BackgroundProcedure of the femur is extremely challenging during total hip arthroplasty (THA) for Hartofilakidis type C developmental dysplasia of the hip. The main purpose of this study is to compare the clinical effectiveness of proximal femoral reconstruction (PFR) with subtrochanteric transverse osteotomy (STO). MethodsBetween 2006 and 2015, 33 primary THAs in 26 patients were performed with PFR and 16 hips in 13 patients underwent STO. The mean follow-up was 4.2 (range, 2.2-10.8) years in PFR group and 5.9 (range, 3.5-11.3) years in STO group. At the final follow-up, clinical scores and radiographic results were evaluated for 33 hips in PFR group and 15 hips in STO group. ResultsPostoperative Harris hip scores and implant position did not differ between the treatment groups. The mean length of the oblique osteotomy line at proximal femur was 6.9 cm (range, 5.8-7.6 cm) in PFR group. The amount of bone union occurred within 6 months after surgery was 24 (72.7%) hips in PFR group and 9 (60.0%) in STO group. Three major postoperative complications occurred in PFR group, and medial femoral calcar erosion was noted in 1 hip in STO group. ConclusionSimilar with STO, the clinical results of PFR technique are a reliable solution for femoral procedure during THA in patients with Hartofilakidis type C developmental dysplasia of the hip.

Distal femoral reconstruction following failed total knee arthroplasty is accompanied with risk for complication and reduced joint function

BackgroundSubstantial bone loss following failed total knee arthroplasty (TKA) represents a major challenge in revision arthroplasty, that can require distal femoral reconstruction (DFR). In this study, we aimed to assess the clinical outcome and the complication frequencies of individuals who underwent DFR with modular megaprostheses. Additionally, we aimed to compare functional outcome measures after DFR in these sophisticated cases to an age-matched control group of total knee prostheses to quantify the potential loss of function.MethodsA retrospective chart review of 30 consecutive patients after DFR from 1997 to 2017 with a mean age of 74.38 years (± 10.1) was performed. Complications were classified according to the Henderson classification. Knee Society Score (KSS) was calculated and range of motion (ROM) was assessed.ResultsThirteen (43.3%) patients had at least one complication requiring revision surgery. Revision-free survival was 74.8% at one year, 62.5% at three and 40.9% at 10 years post-op. Soft-tissue failure complications were found in three (10.0%) patients, aseptic loosening in four (13.3%) patients, structural failure in one (3.3%) patient and infection in eight (26.6%) patients. Of those with infection, five (16.6%) experienced ongoing prosthetic joint infection and three (10.0%) developed new infection after distal femur reconstruction. Patients with DFR achieved 69.3% of KSS pain score, 23.1% KSS function score and 76.2% of ROM compared to patients with primary TKA.ConclusionsDFR after failed TKA represents a treatment procedure with high risk for complication in this particular group. Despite the prospect of rapid postoperative mobilization, reduced functionality, range of motion and mobilization have to be considered when choosing this treatment option.

Acetabular and femoral reconstruction in total hip replacement for adult hip dysplasia: A technical guide for surgeons in our environment

Hip dysplasia is abnormal development of the hip joint resulting in joint incongruity and characterised by a shallow acetabulum, inadequate femoral head coverage and femoral and acetabular version abnormalities. Childhood hip dysplasia is uncommon in this environment because of child swaddling practices. Adolescent onset forms are however not uncommon and present in adulthood more frequently than is recognized for total hip arthroplasty. Clinical and radiologic evaluation is key for diagnosis and surgical planning. The pathologic abnormalities on both sides of the hip joint present formidable challenges to total hip arthroplasty which remains the mainstay of treatment for end-stage arthritis secondary to adult hip dysplasia. Posterior approach is preferred in our unit as it provides excellent acetabular exposure and enables assessment of sciatic nerve integrity when addressing leg-length discrepancy common in this condition. Leg lengthening more than 3–4 cm should, however, be avoided with arthroplasty for this condition. We outline technical tips for successful total hip arthroplasty for this condition. This study aims to describe total hip arthroplasty in the setting of adult hip dysplasia. The objectives are to describe the pathologic changes in adult hip dysplasia, the evaluation of these patients and surgical technique.

Proximal femoral reconstructions: A European “Italian” experience. A case series

Background: The aim of the study was to analyze our experience with a single system of modular proximal femoral replacement, evaluating oncologic results, complications, and functional results. Methods: We reviewed data on 38 patients (21 men and 17 women; mean age 59 y) treated with proximal femoral reconstructions by two orthopaedic surgeons. Reconstruction was performed in all patients with a MUTARS® modular proximal femoral prosthesis and an acetabular reconstruction in eight patients. Diagnoses included primary bone sarcomas (21), bone metastases (15), and radioinduced osteonecrosis (2). The stem was press fit in 11 patients and cemented in 27. Results: At a mean follow-up of 1.9 yr, 12 patients were alive with no evidence of disease, three have no evidence of disease after treatment of a recurrence or metastasis, 12 were alive with disease, and nine had died. The two with osteonecrosis were not included in this analysis. Complications occurred in seven patients: four type I (wound dehiscence in one and dislocation in three), one type II, one type IV, and one type V failures, while type III failures did not occur. At last follow-up, 89% of patients (34/38) had retained their implant. The mean Musculoskeletal Tumor Society (MSTS) score was 24.7 (14-30), with excellent or good results in all patients except one. Conclusion: The overall survival of this prosthesis was satisfactory with good implant survival in proximal femoral reconstruction. The most frequent cause of failure was dislocation. The incidence of infection was low. Functional results were good or excellent. Level of Evidence: IV; case series.

Comparison of Proximal Femoral Geometry and Risk Factors between Femoral Neck Fractures and Femoral Intertrochanteric Fractures in an Elderly Chinese Population.

Background:Few studies have investigated the differences in proximal femoral geometry and risk factors between patients with different types of hip fracture, especially in elderly Chinese. This study aimed to assess the differences in proximal femoral geometry parameters between patients with femoral neck fractures and patients with intertrochanteric fractures to provide guidance for individualized customized prosthesis and accurate reconstruction of proximal femurs in elderly Chinese patients.Methods:We retrospectively studied the electronic medical records of 198 elderly patients over 65 years of age who were admitted to the orthopedic department with hip fractures between January 2017 and December 2017 in The Third Hospital, Hebei Medical University. Age, fracture site, gender, and proximal femoral geometry parameters (neck shaft angle [NSA], center edge angle [CEA], femoral head diameter [FHD], femoral neck diameter [FND], femoral neck axial length [FNAL], hip axial length [HAL], and femoral shaft diameter [FSD]) were recorded. Student's t-test was used to compare the continuous variables, Chi-square test was used to analyze categorical variables, and multiple logistic stepwise regression analysis was used to evaluate the influencing factors of hip fracture type.Results:Statistically significant differences in NSA (137.63 ± 4.56° vs. 132.07 ± 4.17°, t = 1.598, P < 0.001), CEA (37.62 ± 6.77° vs. 43.11 ± 7.09°, t = 5.597, P < 0.001), FND (35.21 ± 3.25 mm vs. 34.09 ± 3.82 mm, t = 2.233, P = 0.027), and FNAL (99.30 ± 7.91 mm vs. 103.58 ± 8.39 mm, t = 3.715, P < 0.001) were found between the femoral neck fracture group and femoral intertrochanteric fracture group. FHD, FND, FSD, HAL, and FNAL were different between sexes (all P < 0.001). The greater NSA was the risk factor for femoral neck fractures (odds ratio [OR]: 0.70, P < 0.001), greater CEA and longer FNAL were risk factors for femoral intertrochanteric fractures (OR: 1.15, 1.17, all P < 0.001), and greater FND was a protective factor for femoral intertrochanteric fractures (OR: 0.74, P < 0.001).Conclusions:We demonstrate differences in geometric morphological parameters of the proximal femur in different hip fracture types, as well as an effect of sex. These differences should be considered in the selection of prostheses for fracture internal fixation and hip replacements. These data could help guide the design of individualized customized prostheses and improve the accurate reconstruction of the proximal femur for elderly Chinese hip fracture patients.