Outcome after Reconstruction of the Proximal Tibia – Complications and Competing Risk Analysis

Abstract

Background and ObjectivesThe proximal tibia (pT) is a common site for bone tumors. Improvements in imaging, chemotherapy and surgical technique made limb salvage surgery the treatment of choice. Yet, reconstructions of the pT have been associated with less favorable outcome compared to other parts of the extremities. The aim of this study was to evaluate the outcome of patients with a modular endoprosthetic reconstruction of the pT.MethodsEighty-one consecutive patients with an average age of 29 years underwent endoprosthetic reconstruction of the pT. Postoperative complications were categorized according to the ISOLS classification, and revision-free survival until first complication (any Type 1–5), soft tissue failure (Type 1), aseptic loosening (Type 2), structural failure (Type 3), infection (Type 4), and local tumor progression (Type 5) was estimated by using a Fine-Gray model for competing risk analyses for univariate and multivariable regression with Firth’s bias correction.ResultsA total of 45 patients (56%) had at least one complication. Cumulative incidence for complication Types 1 to 5 at 5 years with death and amputation as competing events revealed a risk of 41% for the first complication, 14% for Type 1, 16% for Type 2, 11% for Type 3, 17% for Type 4, and 1% for Type 5.ConclusionDespite inclusion of amputation and death as strong competing events, pT replacements are still associated with a high risk of postoperative failures. The results suggest that infection and soft tissue failures (Type 1 and 5) seem to depend from each other. Sufficient soft tissue reconstruction and closure allow better function and reduce the risk of infection as the most prominent complication. The use of a rotating hinge design has significantly reduced structural failures over time.

Silver-Coated Megaprosthesis of the Proximal Tibia in Patients With Sarcoma

“…However, the authors do not provide any data on the infection rate relative to the site of endoprosthetic arthroplasty. However, it is well known that patients with proximal tibia arthroplasties, in particular, are at high risk for periprosthetic infection, with rates ranging from 14% to 36% [5,14,15].…”

Assessment of fracture risk in proximal tibia with tumorous bone defects by a finite element method

“…The optimal management for the tumors remains a challenge in orthopedic surgery (Amanatullah, Williams, Fyhrie, & Tamurian, ). The proximal tibia (pT) is the second most common site for primary bone tumors (Puchner et al, ). Commonly the joint‐sparing practice of intralesional or marginal excision is carried out to treat benign or invasive bone tumors (Gouin & Dumaine, ) or specific malignant bone tumor(Song, Jeon, Kong, Cho, & Lee, ).…”

Extensor reconstruction of the knee using the fibular transposition technique after proximal tibial resection

“…Three of the five patients had shown no extensor lag and the overall average was four degrees. This is clearly superior compared with other reported series [5][6][7][8][9][10][11][12][13][14][15]19,20]. There are reports regarding the relative height of the patella as a cause of extensor lag.…”

“…Consequently, soft tissue reconstruction with or without skin grafting was not necessitated, and the operative time and the risk of infection were reduced. Numerous techniques have been described to reconstruct the extensor mechanism of the knee including: (1) direct fixation to the endoprosthesis using a screw/washer or sutures; (2) synthetic soft tissue augments (e.g., Dracon, polyester tapes, GoreTex strips); and (3) 'biologic' reconstruction utilizing local/free composite tissue transfers with or without synthetic materials [4][5][6][7][9][10][11][12][13][14][15][16][17]. Representative studies were tabulated in Table 3.…”

“…However, because tendinous tissue does not naturally grow on metal, controversy remains regarding reconstruction techniques for the extensor mechanism [4][5][6][7]. Originally, two techniques were introduced to reconstruct the patellar ligament [8].…”