Long-term Results of Intercalary Endoprosthetic Short Segment Fixation Following Extended Diaphysectomy

Tedesco, Nicholas S; Horn, Alexandra L Van; Henshaw, Robert M.

doi:10.3928/01477447-20170918-04

Cited by 3 publications

(6 citation statements)

References 24 publications

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“…The study by Tedesco et al [ 23 ], the findings presented in this patient collective, as well as the case series published by Guder et al [ 7 ], seem to support that adaptations of stem design depending on implantation site might solve the high rates of aseptic loosening observed after segmental endoprosthetic reconstruction.…”

Section: Discussionsupporting

confidence: 77%

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Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

Streitbürger

Hardes

Nottrott

et al. 2020

Arch Orthop Trauma Surg

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Introduction Intercalary endoprosthetic reconstructions have been reserved for patients with a limited life expectancy due to reports of high rates of early mechanical and reconstruction failure. Materials and methods In this study, we retrospectively analyzed 28 patients who underwent intercalary endoprosthetic reconstruction of the femur (n = 17) or tibia (n = 11) regarding reconstruction survival and causes of complications and reconstruction failure. Results A total of 56 stems were implanted in this collective, 67.9% of which were implanted using cementation. Eight different stem designs were implanted. The mean patient age at the time of operation was 42.3 years. The mean bone defect needing reconstruction measured 18.5 cm. Resection margins were clear in 96.4% of patients. Of twenty-six complications, five were not implant-associated. We observed infection in 10.7% (n = 3) and traumatic periprosthetic fracture in 3.6% (n = 1) of cases. The most frequent complication was aseptic stem loosening (ASL) (53.8%; n = 14) occurring in eight patients (28.6%). The metaphyseal and meta-diaphyseal regions of femur and tibia were most susceptible to ASL with a rate of 39.1% and 31.3% respectively. No ASLs occurred in epiphyseal or diaphyseal location. Overall reconstruction survival was 43.9% and 64.3% including patients who died of disease with their implant intact. Overall limb survival was 72.7%. Conclusions Proper planning of segmental reconstructions including stem design with regard to unique anatomical and biomechanical properties is mandatory to address the high rates of ASL in metaphyseal and metadiaphyseal stem sites. With continued efforts of improving stem design in these implantation sites and decreasing rates of mechanical failure, indications for segmental megaendoprostheses may also extend to younger patients with the localized disease for their advantages of early weight bearing and a lack of donor-site morbidity.

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Section: Discussionsupporting

confidence: 77%

“…While they report no cases of aseptic loosening, three mechanical failures had to undergo revision surgery. Yet, secondary adjacent joint replacement and amputation were avoided in those cases [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

Streitbürger

Hardes

Nottrott

et al. 2020

Arch Orthop Trauma Surg

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“…Reasonable preservation of the native joints at two ends of the femur or tibia benefits the restoration of lower-limb function [ 36 ]. In the literature, the patients with segmental bone defects in the lower extremities received an MSTS score ranging from 22.5 to 28 [ 29 , 31 , 35 – 38 ]. However, the majority of these endoprosthetic reconstructions involved diaphysis with the assistance of cement, and satisfactory function was obtained resulting from satisfactory initial stability and following early mobilization.…”

Section: Discussionmentioning

confidence: 99%

“…The establishment method of bone implant interface construct, including a compressive osseointegration method, a cemented stem, or an uncemented stem, is crucial for the performance of each intercalary endoprosthesis [ 13 , 24 , 33 ]. The compressive osseointegration method has been documented with reasonable 5-year and 10-year survival by enhancing osseointegration, yet its application in critical bone defects around the knee is rare [ 34 , 35 ]. The cemented stem contributes to rigid early fixation but lacks osteoconductivity, resulting in widely reported aseptic loosening (range, 0 to 53.8%) [ 29 , 31 , 32 , 35 – 38 ].…”

Section: Introductionmentioning

confidence: 99%

“…The compressive osseointegration method has been documented with reasonable 5-year and 10-year survival by enhancing osseointegration, yet its application in critical bone defects around the knee is rare [ 34 , 35 ]. The cemented stem contributes to rigid early fixation but lacks osteoconductivity, resulting in widely reported aseptic loosening (range, 0 to 53.8%) [ 29 , 31 , 32 , 35 – 38 ]. Besides, cross-pin has been introduced to cemented fixation in the peri-knee metaphysis, whereas the strength of bone-stem construct is reduced by the centric pinholes, leading to foreseeable stem fracture [ 30 ].…”

Section: Introductionmentioning

confidence: 99%

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Is three-dimensional–printed custom-made ultra-short stem with a porous structure an acceptable reconstructive alternative in peri-knee metaphysis for the tumorous bone defect?

Wang

et al. 2021

World J Surg Onc

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Background Long-lasting reconstruction after extensive resection involving peri-knee metaphysis is a challenging problem in orthopedic oncology. Various reconstruction methods have been proposed, but they are characterized by a high complication rate. The purposes of this study were to (1) assess osseointegration at the bone implant interface and correlated incidence of aseptic loosening; (2) identify complications including infection, endoprosthesis fracture, periprosthetic fracture, leg length discrepancy, and wound healing problem in this case series; and (3) evaluate the short-term function of the patient who received this personalized reconstruction system. Methods Between September 2016 and June 2018, our center treated 15 patients with malignancies arising in the femur or tibia shaft using endoprosthesis with a 3D-printed custom-made stem. Osseointegration and aseptic loosening were assessed with digital tomosynthesis. Complications were recorded by reviewing the patients’ records. The function was evaluated with the 1993 version of the Musculoskeletal Tumor Society (MSTS-93) score at a median of 42 (range, 34 to 54) months after reconstruction. Results One patient who experienced early aseptic loosening was managed with immobilization and bisphosphonates infusion. All implants were well osseointegrated at the final follow-up examination. There are two periprosthetic fractures intraoperatively. The wire was applied to assist fixation, and the fracture healed at the latest follow-up. Two patients experienced significant leg length discrepancies. The median MSTS-93 score was 26 (range, 23 to 30). Conclusions A 3D-printed custom-made ultra-short stem with a porous structure provides acceptable early outcomes in patients who received peri-knee metaphyseal reconstruction. With detailed preoperative design and precise intraoperative techniques, the reasonable initial stability benefits osseointegration to osteoconductive porous titanium, and therefore ensures short- and possibly long-term durability. Personalized adaptive endoprosthesis, careful intraoperative operation, and strict follow-up management enable effective prevention and treatment of complications. The functional results in our series were acceptable thanks to reliable fixation in the bone-endoprosthesis interface and an individualized rehabilitation program. These positive results indicate this device series can be a feasible alternative for critical bone defect reconstruction. Nevertheless, longer follow-up is required to determine whether this technique is superior to other forms of fixation.

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

Feltri¹,

Solaro

Martino

et al. 2022

Sci Rep

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

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Long-term Results of Intercalary Endoprosthetic Short Segment Fixation Following Extended Diaphysectomy

Cited by 3 publications

References 24 publications

Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

Is three-dimensional–printed custom-made ultra-short stem with a porous structure an acceptable reconstructive alternative in peri-knee metaphysis for the tumorous bone defect?

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

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