Use Of Megaprosthesis Research Articles

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series

BackgroundManaging distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock.MethodsA consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields.ResultsFive patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures.ConclusionsThe indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

Functional audit of the use of megaprosthesis for limb reconstruction in musculoskeletal tumors – A retrospective single-center study

IntroductionMedical advancements in musculoskeletal oncology has significantly reduced the mortality rate associated with limb-sparing surgery, making it comparable to amputation. The use of modular megaprosthesis for sarcoma treatment has now become a standard practice. However, these non-biological implants are not without their complications. Materials and methodsA retrospective cohort study was conducted on all patients who underwent wide resection of locally aggressive and malignant bone tumors, followed by reconstruction with megaprosthesis between January 2018 and January 2023 at tertiary care hospital. Patients were evaluated based on oncological outcomes, functional outcomes, and complications with a minimum follow-up period of 6 months. ResultsThe study included a total of 30 patients, comprising 16 males and 14 females, with a mean age of 33.6 ± 15.6 years. They all underwent wide resection and reconstruction with megaprosthesis. Diagnosis among the patients included 19 cases of giant cell tumors, 5 cases of osteosarcomas, 2 cases of metastatic bone tumors, and 1 case each of chondrosarcoma, malignant fibrous histiocytoma, multiple myeloma, and chondromyxoid fibroma. These tumors were predominantly located in the distal femur (15 patients) and proximal tibia (12 patients). The average follow-up period was 33 ± 21 months, resulting in an average final Musculoskeletal Tumor Society (MSTS) score of 81 % ± 9 %. Complications were observed in 21 patients, with infection being the most common, specifically Type 4 (10 patients, 37 %), followed by Type 1 (4 patients, 13 %) and Type 3 (4 patients, 13 %). Two patients (7 %) experienced Type 5 complications, while three succumbed to their illnesses. Additionally, two patients required amputation, one due to local recurrence and the other due to a deep-seated infection. ConclusionMegaprosthesis is a viable reconstruction option following wide resection of bone tumors. Infection remains the most common issue, and cost poses a significant challenge.

The use of megaprosthesis in the treatment of proximal and distal femur nonunions in the elderly

Management of nonunion in the elderly patient are always a challenge for the orthopedic surgeon. The patient’s clinical condition is often critical, and normal nonunion management strategies are burdened with a high rate of failure. Megaprostheses have been designed for the management of bone tumors, but in the literature many cases of use in non-neoplastic conditions are described. They are, however, burdened by a high rate of complications, and in particular dislocations and periprosthetic infections. Proximal and distal femur replacement should therefore be considered as a salvage strategy to be used in the most severe cases of nonunion in the elderly patient.

“Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience”

Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature. Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing. Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes. Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.

Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies.

Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality. The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence. 2a.

The use of megaprosthesis in elderly patients: a case series

Objective. Herein, we present a case series of patients treated with megaprosthesis who sustained high energy trauma with comminuted articular hip or knee fracture, complex periprosthetic fractures or pathological fractures.Methods. We retrospectively reviewed 15 consecutive patients who sustained knee re- placement/revision (7 patients) and 8 patients who underwent hip replacement/revision with megaprosthesis between 2014 and 2018. In the knee group, there was 1 man and 6 women, while in the hip group there were 3 men and 5 women.In knee group, preoperative indications were: periprosthetic fracture; highly comminuted distal femoral fracture; metastatic localization of distal femur; nonunion of distal femoral fracture in one case.In the hip group, preoperative indications were: subtrochanteric pathological fractures; peri- prosthetic fracture; recurrent infection; recurrent tumoral lesions.Preoperative evaluation included standard radiographs; CT-scan with 3D reconstruction for tailored implant planning; MRI only for pathological localization.Results. Mean clinical follow-up with radiographic control was 44 months (range 23-71). All complications were managed before the patient left the hospital. During the follow-up period, 13 of 15 patients regained walking ability as before surgery. At the end of follow-up, 6 patients had died due to causes not related to the surgery.Conclusions. The use of megaprosthesis offers useful solutions for different pathologies such as tumors, infections, comminu ed fractures, and periprosthetic fractures in the elderly patient with good functional results.

When numbers don’t satisfy science: multicenter studies and digital protocols

Megaprostheses were introduced in oncological orthopedic surgery for reconstruction after bone tumor resections with good results; more recently, megaprostheses have been receiving an increasing role even in non-neoplastic hip and knee conditions like periprosthetic and very comminuted osteoporotic fractures and in treatment for resistant non-union of femur fractures. Nevertheless, literature about the use of megaprosthesis, especially in non-oncological musculoskeletal conditions, is still lacking high evidence level studies showing long-term outcomes. The purpose of this paper is carry out a review of the current megaprosthesis literature and present a multicenter study on a new prosthetic implant (“SMS multicentric study”), collecting the data on the use of a single implant (Smart Modularity System/SMS) in 11 orthopedic centers in order to obtain clinical and radiographic results.

Megaprosthesis as a treatment modality for persistent distal femoral nonunion in middle aged adults

Introduction:Managing distal femur non-union can be a struggle for any orthopedician as it brings along many perplexities which may not lead to satisfactory patient outcome. The target in these cases should be to reduce the morbidity and allow early rehabilitation of the patient and to accomplish this, megaprostheses can be a feasible option. The orthodox use of megaprostheses is in the musculo-skeletal oncologic surgeries but its use can be extended to traumatic etiologies. These can be offered as a single stage definite procedure in patients who have already undergone several previous surgeries. Here we report a series of four cases of persistent non-union of distal femur treated with megaprostheses and recommend this modality for achieving the desired goal but the indication should be meticulously selected.Hypotheses:Megaprosthesis as a definitive treatment option in persistent distal femur non-union and prevention of repeated surgical intervention.Methods:Four cases of persistent distal femur nonunion with failed osteosynthesis were selected who were initially treated with a distal femur locking plate. Results were assessed in terms of range of motion, limb length discrepancy, knee society score and osteointegration of the components.Results:The mean age of the patients at the time of DFEPR was 49 years (42-55).The mean follow up of patients was for approximately 2 years, with the longest follow up being 3.5 years for the first operated case of the series. The range of motion was from full extension to about 105 degrees of flexion with two patients having an extension lag of 10 degrees. Patients were ambulatory without support. Postoperatively, the mean knee society score was 83 (78–88) at last follow-up as compared to 29 (21-36) in the pre-operative period. No case of infection or loosening was reported. There was 1 cm of shortening in one patient in the operated limb which was compensated by giving shoe raise. Good osseointegration of the megaprosthesis was revealed on both anteroposterior and lateral radiographs.Conclusion:Although there are very limited studies on the use of megaprosthesis for traumatic cases, it can be considered as an alternative when we are left with only arthrodesis or amputation as the final option. Despite the operative challenges, there is marked improvement in pain and functional capacity as experienced by these severely limited patients, which are the hallmarks of a successful salvage. The use of distal femur mega-prosthesis is a novel acumen in cases, where bone stock at the fracture site at distal end of femur is so severely compromised that traditional revision osteosynthesis would not provide stable and durable fixation. The indications for this surgery must be rigorously selected and should only complement osteosynthesis procedures, which remain the reference treatment option.

Pedicle frozen autograft\u2013prosthesis composite reconstructions for malignant bone tumors of the proximal femur

BackgroundLimb salvage surgery is becoming increasingly popular after tumor resection in the lower extremity. Biological reconstruction and use of megaprosthesis are main methods for malignant bone tumors of the proximal femur, which remain controversial due to short- and long-term complication in the proximal femur. Tumor-bearing bone treated by liquid nitrogen is one of biological reconstruction. This study aimed to evaluate the mid- and long-term functional outcomes and complications in patients treated with frozen autograft–prosthesis composite (FAPC) reconstructions in the proximal femur.MethodsThis retrospective study included 19 patients (10 women, 9 men) with malignant tumors of the proximal femur who underwent tumor-wide resection and FAPC reconstruction (mean age, 46 years; range, 9–77 years). The mean follow-up period of 69 months (range, 9–179 months). Functional outcomes, oncological outcome and complications were evaluated by Musculoskeletal Tumor Society score, clinical and radiological examinations.ResultsThe overall survival rate was 68.4%, and the mean Musculoskeletal Tumor Society functional score was 26.4 points (88%). FAPC survival rates were 100 and 50% at 5 and 10 years, respectively. Five of the 19 patients (26%) had complications: 2 required prosthesis removal and 2 developed a deep infection around acetabular. Wear of the acetabulum occurred in 2 cases, while disease recurrence was occurred in 1 case. There were no cases of greater trochanter avulsion, obvious absorption around frozen bone, prosthesis loosening or leg length discrepancy.ConclusionsDue to without femoral osteotomy, this technique features satisfactory functional outcome and provide biomechanical stability that is comparable to those of other methods of biological reconstruction or megaprosthesis.

The use of knee mega-prosthesis for the management of distal femoral fractures: A systematic review

IntroductionDistal femur fractures (DFFs) are unusual and difficult to deal, especially in elderly patients. A consensus about a gold-standard treatment has not been reached yet. Available options include both conservative and surgical management. In elderly patients a prosthetic replacement could be a valid treatment option. Literature is lacking about the use of mega-prosthesis in this type of fractures. The purpose of the present systematic review is to examine which fracture, both acute and chronic, involving distal femur should be treated by using a mega-prosthesis. Materials and MethodsStudies were identified by searching electronic databases. All studies that enrolled people of any age affected by a DFFs treated by using a megaprosthesis were included. Primary outcomes of the present reviews were: ROM, functional assessment and complications. Two review authors independently selected eligible trials. Disagreements at any stage were resolved by consensus or a third party adjudication. Descriptive statics was used to summarize the data. ResultsThirteen article were finally included in the review. One hundred-four patients were treated with knee megaprosthesis. Three categories of patients were identified: 29 patients were affected by supracondylar femur fracture; 51 patients occurred with a periprosthetic fracture; 24 patients suffered a non-union of a previous supracondylar fracture. The follow-up varied between 6 months to 58 months. All studies showed good results in terms of improving quality of life, resuming activities of daily living (ADLs), early mobilization, ROM, shorter hospital stay. Although not frequent, the only reported complications were infection and aseptic loosening. DiscussionThe present review showed that the use of knee megaprosthetic implants could represent a valid treatment option aiming to reduce patients’ immobilitazion and hospital stay. Good clinical outcomes with low rate of complications were reported by all included studies. Literature is lacking about long-term outcomes and complications. Moreover studies comparing knee prostheses and other types of surgical treatment (intramedullary nails, plate fixation system) are needed. ConclusionsMegaprosthesis represent a viable treatment option in patients affected by DFFs (either acute, periprostethic or non-union) because they allow immediate weight-bearing, shorter hospital stay, a fast recovery of knee function and ADLs.

Modular megaprosthesis for proximal femoral tumors

Objectives Limb salvage surgery is the preferred treatment for proximal femoral tumors. The use of modular prosthesis following resection of the tumor is the preferred method, a procedure that is technically demanding. The resection of tumor at the level of proximal femur results in loss of abductors and other musculature necessary for hip stability. This often leads to a higher instability rate. Hip dislocation is a recognized problem after the use of megaprosthesis, with rates of dislocation varying from 1.7% to ∼28%.Patients and methods Between March 2003 and March 2008, 15 patients in our series had resection of the proximal femoral primary malignant tumors and implantation of a modular megaprostheses, using a bipolar acetabular cup. There were seven women and eight men, with a mean age of 37 years (18–68 years). The diagnoses were osteosarcoma (two), chondrosarcoma (eight), malignant fibrous histiocytoma (two), and giant cell tumor (three). All patients had a complete tumor workup before surgery that included routine blood work, bone scan, computed tomography of the chest, and MRI of the femur. All patients had an open biopsy. They were given preoperative radiotherapy and chemotherapy as required.Results The mean follow-up was 5 years (range, 5 months–10 years). Two patients died of causes not related to the prosthesis. The postoperative Musculoskeletal Tumor Society score was 26 (range, 23–30) for the remaining 13 patients. There were one subluxation treated conservatively, and one erosion of the acetabulum that needed conversion into total hip replacement. No infections and local recurrence were encountered.Conclusion Proximal femoral modular megaprosthesis is a good option for reconstruction after resection of proximal femoral tumors.

The use of megaprosthesis in the treatment of periprosthetic knee fractures.

The optimum treatment for periprosthetic fractures in the region of the distal femur is undefined. Although internal fixation for prostheses which are stable is commonly utilised, this can lead to very prolonged morbidity and failure of the fracture to unite. Where the prosthesis is either loose or infected, revision surgery is required and a 'tumour type' prosthesis can be successfully utilised. The outcome of 27 patients treated by an endoprosthetic replacement for periprosthetic fracture of the distal femur between 1988 and 2013 are reported. Two cases were treated by two-stage revision due to persistent infection. Clinical outcomes were assessed by Knee Society score and Knee Society pain scores. All 27 patients mobilised rapidly in the post-operative period and infection where present was eradicated by the technique. There have been no cases of further revision in the patients where clinical follow-up is available. Knee Society scores following treatment averaged 88 and pain scores 43 at six months post-operatively. Eight patients have died during the long study period reflecting the age of the study population. The use of a tumour-type endoprosthesis in situations of comminuted periprosthetic fractures associated with a loose prosthesis shows favourable results with low complication rates and rapid mobilisation.

Successful salvage of an unstable Girdlestone's excision arthroplasty with a megaprosthesis of the hip.

The functional results after a Girdlestone's excision arthroplasty of the hip are unpredictable with high patient dissatisfaction and complication rates. We report such a case of symptomatic patient, which was managed successfully with a megaprosthesis of the hip with constrained acetabular liner. The use of megaprosthesis for a failed and symptomatic Girdlestone's excision arthroplasty of the hip has not been reported before.