Salvage of limb salvage in oncological reconstructions of the lower limb with megaprosthesis: how much to push the boundaries?

Abstract

Introduction Megaprosthesis represent the most commonly used limb salvage method after musculoskeletal tumor resections. Nevertheless, they are burdened by high complication rate, requiring several surgical revisions and eventually limb amputation. The aims of this study were to evaluate the effect of rescuing the limb with subsequent revisions on complication rates (a), incidence of amputations (b), and whether complications reduce functional outcome after the first surgical revision (c). Materials and methods We retrospectively reviewed 444 lower limb megaprosthesis implanted for primary musculoskeletal tumors or metastatic lesions, from February 2000 to November 2017. 59 patients received at least one revision megaprosthesis surgery. MSTS score was used to assess final functional results. Complication-revision-amputation free survival rates were calculated both at 5 and 10 years of follow-up. Results Complication free survival, revision free survival and amputation free survival at 10 years were 47% and 53%, 61% and 67%, 90% and 86% among all 444 patients and the group of 59 revised patients, respectively. The incidence of further complications after the first complication was 26% in the group treated with no subsequent revision surgeries and 51% in the group with at least one revision surgery. We found a trend of inverse linear relationship between the number of complications needing subsequent revision surgeries and the final MSTS. Conclusion The number of further revision surgeries after limb salvage with megaprosthesis increases the incidence of complications. Repeated surgical revisions, in particular after infection, increase the amputation rate. The most frequent causes of failure were structural failures and infections. MSTS score was superior for patients undergoing limb salvage than amputees. However, MSTS progressively decreased with multiple revisions becoming inferior to the functional score of an amputated patient.

Aseptic loosening of tumor endprostheses in distal femur after revision surgery: a retrospective study

“…According to Heyberger's study, prosthesis revision surgery could enable patients to achieve similar joint function to the initial replacement, while disease-speci c and health-related outcomes were improved [22]. Despite the fact that revision surgery of tumor prosthesis is di cult and has a high failure rate [17], it remains the best option for patients seeking to save limbs and improve limb function [15]. Patients can still have good lower limb function after revision, which helps to improve their quality of life.…”

“…Repeated revision surgery not only put patients under a lot of physical, psychological, and nancial stress, but it also made surgery more di cult because of anatomical position dislocation, thin bone, and soft tissue contracture caused by repeated surgery. According to literature studies, revision prostheses have more complications than initial replacement prostheses [17,18]. As a result, reducing secondary revision surgery and paying attention to the long-term effect of prostheses is a huge challenge for bone oncologists [19].…”

Primary Cooperative Application of a LARS® Tube and 3D‐Printed Prosthesis for Reconstruction of the Distal Radius after en bloc Resection of Giant Cell Tumor of Bone: A Comparative Retrospective Study

“…Implants of a fibula autograft (FA) are an acceptable alternative to reconstitute a bone and soft tissue defect after en bloc resection of a distal radial GCTB; however, there are several disadvantages of this reconstruction method, including progressive degenerative changes and instability of the wrist joint. When using FA to rebuild the distal radial region, several common autograft‐related complications, including wrist osteoarthritis, distal radioulnar joint diastasis, and bone nonunion, may often emerge postoperatively 7,8 . In addition, this reconstruction modality may cause a time‐consuming operative period and potential risk for fibula donor‐site related complications 9,10 .…”

“…When using FA to rebuild the distal radial region, several common autograft-related complications, including wrist osteoarthritis, distal radioulnar joint diastasis, and bone nonunion, may often emerge postoperatively. 7,8 In addition, this reconstruction modality may cause a time-consuming operative period and potential risk for fibula donor-site related complications. 9,10 Meanwhile, endoprostheses are regarded as another mainstay for such reconstruction, in which subluxation of the wrist and aseptic loosening are two common complications that may lead to failure of prosthetic implantation, particularly with unstable anchorage of surrounding soft tissues.…”

Aseptic loosening of tumor prostheses in distal femur after revision surgery: a retrospective study

“…Repeated revision surgery not only puts patients under a lot of physical, psychological, and financial stress but also it makes surgery more difficult because of anatomical position dislocation, thin bone, and soft tissue contracture caused by repeated surgery. According to literature studies, revision prostheses have more complications than initial replacement prostheses [ 15 , 16 ]. As a result, reducing the incidence of secondary revision surgery and paying attention to the long-term effect of prostheses are a huge challenge for bone oncologists [ 17 ].…”