Tumor Prosthesis Research Articles

Precision tumour resection and reconstruction using image-guided computer navigation

The use of a navigation system in musculoskeletal tumour surgery enables the integration of pre-operative CT and MRI images to generate a precise three-dimensional anatomical model of the site and the extent of the tumour. We carried out six consecutive resections of musculoskeletal tumour in five patients using an existing commercial computer navigation system. There were three women and two men with a mean age of 41 years (24 to 47). Reconstruction was performed using a tumour prosthesis in three lesions and a vascularised fibular graft in one. No reconstruction was needed in two cases. The mean follow-up was 6.9 months (3.5 to 10). The mean duration of surgery was 28 minutes (13 to 50). Examination of the resected specimens showed clear margins in all the tumour lesions and a resection that was exactly as planned.

Experience with Cemented Large Segment Endoprostheses for Tumors

Published reports dealing with tumor prosthesis have yet to establish a clear advantage of using either cemented or cementless implants. We examined the outcome and complications with modular cemented implants in 135 patients identified from our database to strengthen the argument for routine use of cemented constructs. The minimum followup was 1.4 months (mean, 57 months; median, 47 months; range, 1.4-157 months). The majority of patients (104) had sarcoma. The complications included: 11 infections, three of which underwent amputation and one a stem revision; eight local recurrences, five of which underwent amputation; three hip dislocations; and three incidents of shoulder instability. One periprosthetic femur fracture was stabilized operatively. There was no aseptic loosening or stem fracture. The 5-year survival rates for distal femoral and proximal humeral replacements were 84% and 70%; the 10-year survival rates were 79% and 59%. The 5-year survival rates for proximal femur and proximal tibia replacements were 78% and 37%. Average Musculoskeletal Tumor Society 1987 scores and Toronto Extremity Salvage Scores were 21.5 and 73% for proximal femur, 28.1 and 67% for distal femur, and 21 and 78% for proximal humerus. The survival of the endoprostheses related to site of bone resection. Cemented constructs of modern design in the context of tumor surgery provide good short-term results.

Endoprosthetic reconstruction after wide resection of primary bone tumor around the knee

To evaluate the effect and complication of the endoprosthetic reconstruction after wide resection of primary bone tumor around the knee. The retrospective analysis was performed on 83 patients undergoing the prosthetic reconstruction after the resection of the primary tumor around the knee between December 1995 and December 2005. All the diagnoses were pathologically confirmed (58 patients with osteosarcoma, 2 with osteosarcomatosis, 1 with parosteal osteosarcoma, 4 with malignant fibrous histiocytoma, 13 with giant cell tumor of bone, 1 with leiomyosarcoma, 2 with Ewing's sarcoma, 2 with chondrosarcoma). The distal femur group was involved in 44 patients, proximal tibia group in 34 (including 33 deficit in proximal tibia, 1 deficit both in proximal tibia and distal femur), total femur replacement group in 5. After operation, the Musculoskeletal Tumor Society (MSTS) score was used to evaluate the recovery of their corresponding functions. The follow-up for 12 - 130 months (with a median of 41 months) revealed that the 3-year survival rate of the prosthesis was 88.2%, and the 5-year survival rate was 82.1%. As for the complications, local recurrence developed in 6 patients, peri-prosthesis infection in 2 patients, aseptic loosening in 2 patients. The mean MSTS core was 25.0 (19.0 - 29.0) in the distal femur group, 24.4 (17.0 - 28.0) in the proximal tibia group, and 19.0 (16.0 - 21.0) in the total femur replacement group. As to the statistical analysis, the function of the former two groups were greater than the latter one (F = 11.666, P < 0.001), however, there was no significant difference between the former 2 groups (F = 0.813, P = 0.370). Taken together, the tumor prosthesis gives a satisfactory functional outcome after the tumor around the knee is removed with a lower incidence of complication.

Orthopaedic limb salvage with a mega prosthesis in a patient with haemophilia A and inhibitors – a case report

Inhibitors against FVIII or FIX in patients with haemophilia are a common and serious complication. Until recently, elective surgery was associated with major bleeding despite the availability of a sufficient substitution therapy. We report about the major orthopaedic reconstruction of the right limb in a patient with severe haemophilia A and inhibitors. This reconstruction was the after effect of a traumatic periprosthetic fracture of the right femur after total knee replacement 6 months ago. This fracture could be stabilized by internal fixation. Two months later, a non-traumatic femur fracture occurred. Therefore, we removed the distal part of the femur and the joint replacement, and implanted a custom made tumour prosthesis (Type MUTARS (c), Münster). These three successive operations, which included emergency and elective surgery, were performed within 8 months. This is, to the best of our knowledge, the first patient with inhibitors undergoing such a complicated reconstruction of a limb. We conclude that successful elective orthopaedic surgery could be accomplished safely in this patient with high responding inhibitors using recombinant FVIIa. After a follow-up of 9 months, no major complications were seen.

Intramedullary Strut Substitution and Impaction Allografting Cemented Revision for the Treatment of a Periprosthetic Fracture in a Severely Compromised Femur

Revision for the treatment of a B3 periprosthetic femoral fracture often requires proximal femoral allograft arthroplasty in physiologically young or tumor prostheses in elderly patients. Extramedullary strut allograft augmentation can only be used when the host femur is structurally adequate for the insertion of the revision stem (periprosthetic femoral fractures type B2) and appears to be an attractive biological concept as early incorporation to the host bone results in a sound biomechanical construct. We report here the simultaneous use of whole femur intramedullary strut substitution along with an extramedullary strut graft placement, with impaction allografting revision to a long cemented femoral prosthesis, to augment the deficient metadiaphyseal bone stock (Paprosky type IV) for the treatment of a complex type B3 periprosthetic femoral fracture.

Aseptic Loosening is Uncommon with Uncemented Proximal Tibia Tumor Prostheses

Aseptic Loosening is Uncommon with Uncemented Proximal Tibia Tumor Prostheses

Aseptic Loosening is Uncommon with Uncemented Proximal Tibia Tumor Prostheses

Aseptic loosening is a frequent cause of failure of cemented proximal tibia tumor endoprostheses. Uncemented prostheses may lessen this risk. We identified complications including aseptic loosening that affected prosthetic survival, limb survival and functional outcome for 44 consecutive patients after sarcoma resection from the proximal tibia and uncemented endoprosthetic reconstruction. At a mean final followup of 60 months (range, 9-152 months), there were no cases of aseptic loosening. Twelve (27%) patients suffered 14 complications leading to prosthetic failure due to infection (n = 7), stem fracture (n = 2), rotational instability (n = 1), vascular compromise (n = 2) and local tumor relapse (n = 2). However, limb salvage was successful in 37 of 44 (84%) patients. Functional assessment for 35 patients revealed a mean Toronto Extremity Salvage Score of 77/100 (range, 33-98) and Musculoskeletal Tumor Society 1987 and 1993 scores of 25/35 (range, 13-31) and 75/100 (range, 33-97), respectively. Mean knee joint flexion was 91 degrees (range, 0-110 degrees ) and knee extension lag was 6 degrees (range, 0-30 degrees ). Three patients with knee extensor complications had inferior functional outcomes. Aseptic loosening is uncommon with uncemented proximal tibia reconstruction, but decreasing other complications at this location remains challenging. Therapeutic study, level IV-1 (case series).

Papers Presented at the 2005 Meeting of the Musculoskeletal Tumor Society

Papers Presented at the 2005 Meeting of the Musculoskeletal Tumor Society

Uncemented Tumor Endoprostheses at the Knee

Although cemented tumor endoprostheses are the most commonly used method for reconstruction of the distal femur or proximal tibia after resection of primary bone tumors, aseptic loosening remains a common complication. Uncemented tumor prostheses may minimize this problem. We investigated the root causes of prosthetic failure for 99 patients with a fixed-hinge, bone-ingrowth Kotz Modular Femur and Tibia Resection System endoprosthesis and compared complications that led to implant failure with results in the literature. Of the 74 distal femoral implants and 25 proximal tibial implants, 25 patients had complications that resulted in prosthetic failure (removal of the prosthesis) at a median of 24.1 (range, 0.8-72.6) months. Failure was caused by prosthesis (n = 18) or oncologic-related (n = 7) complications. However, limb-salvage was possible for 87 of 99 patients. Smaller stem size in the distal femur and longer bone resection length in the proximal tibia were significantly associated with increased risk of prosthetic failure by multivariate analysis. The risk of stem fracture (6 of 99 patients) and infection (10 of 99 patients) was higher than other reports, but aseptic loosening (2 of 99 patients) was uncommon. These results suggest that although the bone-ingrowth surface of this prosthesis leads to a very low aseptic loosening rate, the higher risk of stem fracture and infection must be addressed in future implant designs. Therapeutic study, level IV-1 (case series).

Femoral neck prosthesis in the case of femoral neck fracture and ipsilateral long stem-knee tumour prosthesis

Femoral neck fracture in the case of a previously implanted ipsilateral tumour knee-prosthesis represents a challenging situation because of the long proximal stem of the knee implant. Avoiding total femur replacement, we implanted a femoral neck prosthesis (Eska Cut 2000) in a 65 year old patient to preserve as much of the femur free of implant as possible, minimizing the risk of a periprosthetic or interprosthetic fracture. At 2.5 years postoperatively, there were no signs of loosening, migration or periprosthetic fracture with a good functional result. In our case, the femoral neck prosthesis avoided the implantation of a total femur replacement. Nevertheless, this prosthesis must be considered critically and cannot be recommended as the standard implant for femoral neck fracture in the case of an ipsilateral long stem-knee prosthesis.

Pigmented villonodular synovitis of the knee joint

Pigmented villonodular synovitis is a rare proliferative disorder of the synovial membrane most frequently found in the knee. The etiopathology of the disease is still not understood. Present terminology differentiates between a localized (LPVNS) and a diffuse (DPVNS) form. Currently, MRI is the diagnostic imaging technique of choice. The localized form (LPVNS) can be cured definitely in almost all cases by partial arthroscopic synovectomy, whereas the treatment of the diffuse form (DPVNS) is discussed controversially concerning an arthroscopic or total synovectomy by open arthrotomy. We report a case rarely found in the literature of a patient suffering from a diffuse form of PVNS localized in the right knee joint. In this case PVNS acted as a locally aggressive and destructive lesion of immense extent invading femoral, tibial and fibular bone and the whole extending muscular system. We performed a radical synovectomy by open arthrotomy. By implanting a tumor prosthesis we prevented progression of the disease. Apart from adequate diagnosis, we recommend complete and aggressive resection of the affected tissue by performing an open arthrotomy.

Periprosthetic Bone Remodeling Around a Prosthesis for Distal Femoral Tumors: Longitudinal Follow-up

Serial measurements using dual-energy x-ray absorptiometry (DEXA) were undertaken to evaluate progressive periprosthetic bone loss in patients treated for primary bone tumors of the distal femur using an uncemented tumor prosthesis. Twelve patients underwent sequential DEXA analysis on average 26.5 and 90.9 months postsurgery. Changes in bone mineral density were measured in regions of interest (ROIs) around the prosthesis stem. The test-retest reliability coefficient ( r) ranged from 0.92 to 0.99 for all ROI. In the most distal ROI (ROI1), 10 of 11 patients with 2 measurements showed no change or a small increase in absolute bone mineral density. The results in other ROIs were similar. This longitudinal DEXA data suggest that progressive bone resorption is not problematic with an uncemented distal femur endoprosthesis at intermediate follow-up.

Reconstruction of Knee Joint with Total Elbow Endoprosthesis in Eight Years Old Osteosarcoma of Distal Femur: A Case Report

Although the reconstruction with tumor prosthesis is a routine procedure for extremity sarcomas, this option has some technical limitation in children under 10 years old. Customized expandable tumor prosthesis is too expensive in most cases and arthrodesis of any kind is not functional. This report presents one case of osteosarcoma of distal femur in eight years old child which was reconstructed with adult type total elbow endoprosthesis as a reconstructive option, and includes brief review of the literature.

Treatment of Infected Tumor Prosthesis in Malignant Bone Tumor

Purpose: The analysis points used in this study were the features, durations, and outcomes following different treatment modalities for an infected tumor prosthesis (TP). These were used to define an appropriate strategy for infected TP. Materials and Methods: From December 1986 to November 1999, 215 patients underwent a TP replacement operation in our hospital, and 17 patients with an infected TP were eligible for the study. Forty-two operative procedures were performed on 17 patients (scarectomy 11 cases, partial TP removal and bone cementation 9 cases, complete TP removal and bone cementation 20 cases, and amputation 2 cases). Freedom from infection was defined as no sign of inflammation for 3 months after the operation and its objective variables were CRP, ESR, physical examination, and culture free body fluid. Although one patient received several procedures, we considered each event as a separate variable. The survival rates of the procedures were analysed by Kaplan-Meier plots and these were compared using the log rank test. Results: The cumulative survival of each procedure was 0% by scarectomy at 11 months, 0% by partial TP removal and bone cementation at 12 months, and 34% by complete TP removal and bone cementation at 79 months. Significant differences in survival were found for these procedures (p

Treatment of Vancouver B3 Periprosthetic Femur Fractures With a Fluted Tapered Stem

Periprosthetic femur fractures around a hip arthroplasty associated with a loose stem and severely deficient or comminuted bone typically have been treated with substitution for the proximal femur using an allograft prosthetic composite or a tumor prosthesis. Eight patients (mean age, 68 years; range, 34-80 years) with Vancouver Type B3 femur fractures were treated with revision using a long modular fluted tapered uncemented stem with retention of the proximal femur. Access to the failed prosthesis and joint was gained through the fracture or osteotomy and soft tissue attachments to the fracture fragments were maintained. One patient died within 1 week. The remaining patients were followed up 1 to 2 years (mean, 1.5 years). At final followup, all patients had stable implants and all acute fractures were healed. Marked reconstitution of proximal femoral bone stock was observed consistently. All surviving patients were ambulatory and none had more than mild pain. The preliminary results of this method show a high rate of stable implant fixation and fracture healing with preservation and reconstitution of the host femur.

TREATMENT OF PERIPROSTHETIC FEMORAL FRACTURES FOLLOWING TOTAL HIP ARTHROPLASTY WITH FEMORAL COMPONENT REVISION

Revision total hip arthroplasty is indicated for most periprosthetic fractures that occur around the stem of the femoral implant. The purpose of the present study was to assess the results and complications of revision total hip arthroplasty for the treatment of periprosthetic femoral fractures. We evaluated 118 hips in 116 patients who underwent revision total hip arthroplasty because of an acute Vancouver type-B periprosthetic femoral fracture. The femoral implant used for the revision was a cemented stem in forty-two hips, a proximally porous-coated uncemented stem in twenty-eight, an extensively porous-coated stem in thirty, and an allograft-prosthesis composite or tumor prosthesis in eighteen. The mean duration of follow-up was 5.4 years. Kaplan-Meier analysis demonstrated that the probability of survival was 90% at five years and 79.2% at ten years with revision or removal of the femoral implant for any reason as the end point. Sixteen femoral components were rerevised: ten were rerevised because of loosening; three, because of loosening in association with a fracture nonunion; two, because of recurrent dislocation; and one, because of a new periprosthetic fracture. Additionally, six femoral implants were resected because of deep infection (five) or prosthetic loosening (one). Radiographs of the ninety-six hips with a surviving implant showed that twenty-one had evidence of loosening of the femoral implant, four had a nonunion of the femoral fracture, and two had both a nonunion and loosening of the femoral implant. Revision total hip arthroplasty for the treatment of a periprosthetic fracture around the stem of the femoral implant successfully restored function for most patients. The greatest long-term problems were prosthetic loosening and fracture nonunion. Better results were seen when an uncemented, extensively porous-coated stem was used.

Surgical treatment of malignant and aggressive bone tumors around the knee by segmental resection and rotationplasty.

In patients having malignant or aggressive bone tumors around the knee joint and requiring amputation, segmental resection and rotationplasty was performed and the clinical results were analyzed. Twenty-six patients underwent segmental resection and rotationplasty between February 1988 and June 1994. The mean follow-up period was 57 (6 - 120) months and the average age of patients was 21.4 (5 - 37) years. Out of 26 patients, there were 18 osteosarcomas (>/= stage IIB), 2 synovial sarcomas, and 6 giant cell tumors. Clinical results were evaluated by the Shriner's rating system. Four patients were excluded due to death or amputation and the remaining twenty-two patients were included for assessment. Eighteen patients had excellent results, 3 good, and 1 fair. Range of motion of the ankle joint was -11 (dorsiflexion) - 80 (plantarflexion) degrees and daily walking activity was possible. Local recurrence developed in 2 patients and distant metastasis in 10. Early complications include 3 thromboses and 1 sepsis, and late complications were 6 nonunion, 2 malrotation and 1 stiffness of the ankle joint. Rotationplasty, which is functionally excellent, may serve as an effective partial limb salvage procedure, especially in patients younger than 10 years old who are expected to have leg length discrepancy or loosening of the tumor prosthesis due to the growth of the medullary cavity or when amputation is inevitable for a wide resection margin.

Work status after distal femoral Kotz reconstruction for malignant tumors of bone

Brown A, Parsons JA, Martino C, Griffin A, Bell RS, Wunder JS, Davis AM. Work status after distal femoral Kotz reconstruction for malignant tumors of bone. Arch Phys Med Rehabil 2003;84:62-8. Objective: To determine the proportion of patients who experienced altered work status after reconstruction with a modular tumor prosthesis and adjuvant chemotherapy for primary sarcoma of the distal femur. Design: We reviewed an institution's tumor database and patients' charts. Disability and work status data were collected preoperatively, at 1 year and 2 years postoperatively and at final follow-up. Setting: Acute-care teaching hospital in Ontario, Canada. Participants: Thirty-six eligible patients. Interventions: Not applicable. Main Outcome Measures: Work status was plotted over time to identify unexpected deviations (based on age and preoperative status), and subjects were assigned to altered work status (defined by detrimental changes in productivity, eg, change from full-time work to not working) or expected work status (defined by ongoing work or students progressing to higher education). Disability was measured with the Toronto Extremity Salvage Score and the Musculoskeletal Tumor Society score. Results: Nine patients (25%) experienced altered work status. There were no significant differences in disability ratings or demographic information between the 2 groups. Baseline job demand and living environment (rural vs urban, P=.001) were predictive by logistic regression. Conclusions: Patients with physically demanding jobs, and those living rurally, are at greatest risk for altered work status. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Reconstruction of the proximal humerus after wide resection of tumours

In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumors of the proximal humerus. An osteoarticular allograft was used in 11, a clavicula pro humero operation in 15 and a tumour prosthesis in 19. The glenoid was resected with the proximal humerus in 25 patients. The axillary nerve was resected in 42 patients. The complication rate was lowest after reconstruction with a tumour prosthesis. The clavicula pro humero operation resulted in the most revisions. Cumulative survival rates for all the reconstructive procedures were similar. At follow-up at two years the functional results for the three reconstructive procedures were the same with a mean functional rating of 79% (Musculoskeletal Tumor Society). Excision of the glenoid had no influence on the functional result. Our findings indicate that the use of a tumour prosthesis is the most reliable limb-salvage procedure for the proximal humerus. The clavicula pro humero is an appropriate procedure if a prosthesis cannot be used.

Reconstruction of the proximal humerus after wide resection of tumours.

In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumours of the proximal humerus. An osteoarticular allograft was used in 11, a clavicula pro humero operation in 15 and a tumour prosthesis in 19. The glenoid was resected with the proximal humerus in 25 patients. The axillary nerve was resected in 42 patients. The complication rate was lowest after reconstruction with a tumour prosthesis. The clavicula pro humero operation resulted in the most revisions. Cumulative survival rates for all the reconstructive procedures were similar. At follow-up at two years the functional results for the three reconstructive procedures were the same with a mean functional rating of 79% (Musculoskeletal Tumor Society). Excision of the glenoid had no influence on the functional result. Our findings indicate that the use of a tumour prosthesis is the most reliable limb-salvage procedure for the proximal humerus. The clavicula pro humero is an appropriate procedure if a prosthesis cannot be used.