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Author(s): Henderson, Eric R; Keeney, Benjamin J; Husson, Emily G; Bernthal, Nicholas M; Ji, Tao; Pala, Elisa; Funovics, Philipp T; Groundland, John S; Lozano-Calderon, Santiago; Puchner, Stephan; Zoller, Stephen D; Ruggieri, Pietro; Windhager, Reinhard; Guo, Wei; Hornicek, Francis J; Letson, G Douglas; Temple, H Thomas | Abstract: BackgroundThere is scant evidence to guide decision-making for patients considering total femoral replacement (TFR). We aimed to identify the indication, patient, disease, and surgical technique-related factors associated with failure. We hypothesized that failure occurs more frequently in the setting of revision surgical procedures, with infection as the predominant failure mode.MethodsWe performed a retrospective cohort study of patients receiving total femoral endoprostheses for oncological and revision arthroplasty indications; 166 patients met these criteria. Our primary independent variable of interest was TFR for a revision indication (arthroplasty or limb salvage); the primary outcome was failure. Analyses were performed for patient variables (age, sex, diagnosis group, indication), implant variables (model, decade, length, materials), and treatment variables. We analyzed TFR failures with respect to patient factors, operative technique, and time to failure. We conducted bivariate logistic regressions predicting failure and used a multivariate model containing variables showing bivariate associations with failure.ResultsForty-four patients (27%) had treatment failure. Failure occurred in 24 (23%) of 105 primary TFRs and in 20 (33%) of 61 revision TFRs; the difference was not significant (p = 0.134) in bivariate analysis but was significant (p = 0.044) in multivariate analysis. The mean age at the time of TFR was 37 years in the primary group and 51 years in the revision group (p = 0.0006). Of the patients who had mechanical failure, none had reoccurrence of their original failure mode, whereas all 8 patients from the nonmechanical cohort had reoccurrence of the original failure mode; this difference was significant (p = 0.0001).ConclusionsTFR has a high failure rate and a propensity for deep infection, especially in the setting of revision indications and prior infection. All failed TFRs performed for revision indications for infection or local recurrence failed by reoccurrence of the original failure mode and resulted in amputation.Level of evidenceTherapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background After proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the reverse total shoulder arthroplasty (RTSA) are felt to be useful in other reconstructions where rotator cuff function is compromised, so it seemed logical that it might help in tumor reconstructions as well in patients where the deltoid muscle and its innervation can be preserved. Questions/purposes In patients with a tumor of the proximal humerus that can be resected with preservation of the deltoid muscle, (1) What complications are associated with tumor resection and reconstruction with a modular RTSA? (2) What are the functional results of modular RTSA in these patients? Methods From January 2011 to January 2018, we treated 52 patients for bone tumors of the proximal humerus. Of these, three patients were treated with forequarter amputation, 14 were treated with standard modular proximal humerus implants, seven were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. Generally, we used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. Conversely, we preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, we retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. We excluded three patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and three patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were nine men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was performed in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon (PR) and shoulder surgeon (AC). Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society score (range 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range 0 to 100). The statistical analysis was performed using Kaplan-Meier curves. Results Complications occurred in five of 22 patients; there was a shoulder dislocation (Type I) in four patients and aseptic loosening (Type II) in one. Function in these patients on the outcomes scales we used was generally satisfactory; the mean Musculoskeletal Tumor Society score was 29, the mean Constant score was 61, and the mean American Shoulder and Elbow Surgeons score was 81. Conclusions Although this was a small series of patients with heterogeneous diagnoses and resection types, and we were not able to directly compare the results of this procedure with those of other available reconstructions, we found patients treated with RTSA achieved reasonable shoulder function after resection and reconstruction of a proximal humerus tumor. It may not be valuable in all tumor resections, but in patients in whom the deltoid can be partly spared, this procedure appears to reasonably restore short-term shoulder function. However, future larger studies with longer follow-up are needed to confirm these findings. Level of evidence Level IV, therapeutic study.

Various megaprostheses are currently available for reconstruction of the proximal femur after tumor resection. This study evaluates the survival and complications of a modular megaprosthesis for reconstruction of the proximal femur.We studied the medical files of 109 tumor patients (age range 16-86 years) who underwent proximal femoral reconstruction with the MRP(®) megaprosthesis from 2002 to 2011. There were 70 patients with metastases, 34 patients with bone sarcomas, and five patients with hematological malignancies; 82 were primary and 27 were revision reconstructions. Mean follow-up was 2.5 years; 31 patients had a minimum five-year follow-up. We evaluated the survival and function of the patients, and the survival and complications of the megaprostheses.Survival was significantly higher for the patients with bone sarcomas compared to those with metastases and hematological malignancies. Mean MSTS functional score was similar between patients with bone sarcomas and those with hematological malignancies and metastases, and between patients with primary and those with revision reconstructions. Overall survival of the MRP(®) megaprostheses was 74 % at 5 and 9 years. Fourteen (13.6 %) major complications occurred at a mean period of 1.4 years (range 3 months to 4.5 years); these included infection (5.8 %), dislocation (3.9 %), local recurrence (2.9 %), and acetabular fracture (1 %).MRP(®) megaprostheses are a valuable reconstruction option after tumor resection of the proximal femur.

The use of custom-made 3D-printed prostheses for reconstruction of severe bone defects in selected cases is increasing. The aims of this study were to evaluate (1) the feasibility of surgical reconstruction with these prostheses in oncologic and non-oncologic settings and (2) the functional results, complications, and outcomes at short-term follow-up. We analyzed 13 prospectively collected patients treated between June 2016 and January 2018. Diagnoses were primary bone tumour (7 patients), metastasis (3 patients), and revision of total hip arthroplasty (3 patients). Pelvis was the most frequent site of reconstruction (7 cases). Functional results were assessed with MSTS score and complications according to Henderson et al. Statistical analysis was performed using Kaplan-Meier and log-rank test curves. At a mean follow-up of 13.7 months (range, 6–26 months), all patients except one were alive. Oncologic outcomes show seven patients NED (no evidence of disease), one NED after treatment of metastasis, one patient died of disease, and another one was alive with disease. Overall survival was 100% and 80% at one and two years, respectively. Seven complications occurred in five patients (38.5%). Survival to all complications was 62% at two years of follow-up. Functional outcome was good or excellent in all cases with a mean score of 80.3%. 3D-printed custom-made prostheses represent a promising reconstructive technique in musculoskeletal oncology and challenging revision surgery. Preliminary results were satisfactory. Further studies are needed to evaluate prosthetic design, fixation methods, and stability of the implants at long-term.

Background Metastatic lesions to the proximal femur occur frequently and require special consideration due to the high risk of pathologic fractures. Type of surgery might influence patient survival considering the growing concept of oligometastases. In fact, the use of modular tumor megaprosthesis is increasing in the last decades compared to intramedullary nailing. Aim of this study was to evaluate oncological and functional results of treatment in patients with pathologic or impending fracture of the proximal femur, with patient survival being the primary, complications the secondary, and functional results the tertiary endpoint. Methods Between 2016 and 2017, 40 patients with pathologic fracture (29 cases) or impending fracture according to the Mirels score (11 cases) of the proximal femur, were treated in our Institute and prospectively collected. There were 29 females (72.5%) and 11 males (27.5%), with a mean age at diagnosis of the metastasis of 63.6 years (range 35 to 92 years). Patients were treated due to bone metastases (commonly develop from breast cancer) or hematologic malignancies. Considering number of lesions, 17 patients had less than three bone metastases. Surgical procedures included intramedullary nailing (7 patients), conventional endoprosthesis (4 patients) and modular endoprosthetic replacement (29 patients). Adjuvant treatments included chemotherapy (13 cases), radiation therapy (8 cases) or both (15 cases), and selective arterial embolization (6 pre-op). Oncological results were evaluated considering the survival of patients. Functional results were assessed as pain intensity in VAS score and MSTS score. Results The mean follow-up of patients was 10.2 months (range 6–26.3 years). At the latest evaluation, 23 patients were alive with disease, 3 patients were alive without evidence of disease and 14 patients were dead with disease. There was a significant better survival in patients treated with PFR compared to IMN and EPR groups (p = 0.0080). No differences in term of survival were found comparing impending vs actual pathological fracture and oligo vs multiple metastases. After surgery, all patients experienced improvement in quality of life resulting from reduction in pain. Mean MSTS score was 22.4. The overall complications rate was 22.5%. The most frequent complication was dislocation followed by wound dehiscence and deep infections. Conclusion Modular tumour prosthesis for proximal femur replacement provides good functional outcome, relative low incidence of complications and higher life quality in the medium term. Oncologic results were influenced by type of surgery, biased by the correct indications for resection and nailing. Preoperative general health condition, life expectancy and ambulatory capacity may influence treatment strategy. With the numbers available, the patients with actual pathologic or impending fracture of the proximal femur treated with resection had a significantly higher survival, especially those with metastases from renal carcinoma or multiple myeloma.

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2–19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins ( P =.140) or site ( P =.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft ( P =.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed. [ Orthopedics. 2015; 38(2):87–93.]

AimsInstability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability.Patients and MethodsIn a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability.ResultsA total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients.ConclusionStability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: Bone Joint J 2017;99-B:531–7.

Radiation therapy and chemotherapy, while they remain an essential part of the multidisciplinary treatment of cancers, they have led to unwanted complications. Radiation-induced complications include wound and bone, growth, nervous system, tumorigenic, lung, gastrointestinal, hepatic and other complications. In this article we review the side effects of radiation therapy in musculoskeletal oncology emphasizing on bone, present our long experience, and discuss the current literature regarding radiation-induced bone complications and their management and outcome.

The choices of treatment for patients with extensive tumors of the femur include total femur megaprosthesis or large allograft-prosthetic composites. Previous reports suggest variable survival ranging from 60-70% at 1 to 2 years. However, these studies described earlier prostheses and techniques. Questions/purposes: To confirm previous reports we determined (1) risk of local recurrence; (2) overall survivorship; and (3) function in patients with total femur reconstructions for tumors. Methods: We retrospectively reviewed 23 patients with total femur megaprostheses implanted between 1987 and 2006 after resection of bone tumors. Two patients lost at followup were excluded; the remaining 21 included 15 males and six females with a mean age of 21 years. The mean followup was 48 months (range, 1 month 17 years). Function was assessed according to the MSTS System II. Results: No patient developed a local recurrence during followup. At last followup, six patients were continuously disease-free at a mean of 148 months, one patient had no evidence of disease after treatment of a recurrence, one patient was alive with disease, and 13 patients died of their disease at a mean time of 17 months. In 15 patients evaluated with the MSTS score, the mean score was 66%; four patients had over 75%, eight from 51% to 75%, three from 26% to 50%. Four patients (19%) had complications requiring further surgery in absence of trauma. A fifth patient had a posttraumatic periprosthetic fracture. Conclusions: A total femur prosthesis allows a limb-preserving procedure in tumors with extensive femoral involvement or in the presence of a skip lesion along the femur. The prognosis of these tumors is poor, but this reconstruction provides function with a relatively low rate of major complications. © 2010 The Association of Bone and Joint Surgeons®.

Bone tumours and tumour-like lesions of the hip in children are rare. Signs and symptoms of these tumours are generally nonspecific. Delay of diagnosis is not uncommon. A high index of suspicion in young patients presenting with persistent pain and without history of trauma, that is unresolved with conservative therapy should prompt further investigation, including radiographs or computed tomography scan of the pelvis. In the experience of the Istituto Rizzoli, in patients less than 14 years (mean 9 years, ranged from 6 months to 14 years), 752 tumours and tumours-like lesions occurred in the pelvis or proximal femur, involving the hip. Tumour-like lesions accounted for 322 cases (simple bone cyst in 255, eosinophilic granuloma in 43, aneurismal bone cyst in 34), benign tumours for 340 cases (osteoid osteoma in 229, fibrous dysplasia in 63, exostosis in 48) and malignant tumours for 80 cases (Ewing's sarcoma in 53 and osteosarcoma in 27). The epidemiology, pathology, clinical presentation, and radiograph findings are discussed for each of these tumours.Treatment of these tumours differs from observation or minimally invasive treatment for most pseudo-tumoural lesions, intralesional excision or termoablation for benign bone tumours and wide resection for malignant bone tumours. In this latter group, chemotherapy is required and often administered pre- and postoperatively.

To evaluate the incidence of complications in distal femur reconstructions with modular prostheses, comparing fixed vs rotating hinge knee. Retrospective analysis of implant survival, complications, and functional results of the Rizzoli series on distal femur megaprosthesis. Between 1983 and 2010, 687 distal femur tumour modular prostheses were implanted: 491 fixed hinge and 196 rotating hinge knee prostheses. Failures of the prostheses were classified in five types: type 1, soft tissue failure; type 2, aseptic loosening; type 3, structural failure; type 4, infection; type 5, tumour progression. Failure rate was 27 % (185/687). Implant survival to all types of failure was 70 % at ten years and 50 % at 20 years with no significant difference between fixed and rotating hinge knee prostheses (p = 0.0928). When excluding type 5 and type 1 failures, the overall survival was 78 % and 58 % at ten and 20 years. There was not a significant difference in implant survival to aseptic loosening (p = 0.5) and infection (p = 0.2) between fixed and rotating hinge knee prostheses. All cases of breakage of prosthetic components occurred in fixed hinge knee prostheses. Functional results, evaluated in 536 pts, were satisfactory in 91.4 % of cases with a mean score of 23.3 with a significantly better function for rotating hinge knee prostheses (p

The authors reviewed the files of all patients with chordomas who were admitted and treated at their institutions from 1975 to 2012. Patients were categorized by early local recurrence and metastasis. Aggressive clinical behavior was defined as local recurrence and metastasis within 24 months of diagnosis and adequate treatment (wide en bloc resection with microscopically negative tumor margins). According to these criteria, 13 patients (14.3%) had aggressive chordomas, including 7 men and 6 women, with mean age of 54 years (range, 37–65 years) at diagnosis and treatment. All patients had preoperative tumor biopsy, followed by resection with partial (7 patients) or total sacrectomy (6 patients). In all cases, biopsy and histologic analysis of resected tumor specimens showed conventional chordomas. Resection margins were wide (grossly negative) in 6 patients and wide contaminated in 7 patients. Mean maximum tumor diameter was 11.8 cm (range, 5–21 cm). Mean follow-up was 43 months (range, 8–131 months). Rates of local recurrence, metastasis, and death were evaluated. At the last follow-up, all patients had local recurrence at a mean of 13 months (range, 5–22 months). Histologic examination of recurrent tumors showed a dedifferentiated chordoma with a fibrosarcoma component in 2 patients and no histologic change in the remaining patients. In addition, 8 patients had metastases at a mean of 13 months (range, 4–24 months) and died of their disease. All histologic findings of metastatic lesions were similar to those of primary tumors. Early diagnosis of aggressive tumors requires close follow-up of patients with chordomas. Metastasis is common, with resultant poor survival. [ Orthopedics. 2017; 40(2):e248–e254.]

BACKGROUND: Infection of megaprostheses after bone tumor resection is a major concern; management is challenging. This study evaluated the survivability from such infections, the microbial isolates, treatment tactics, and outcome of megaprosthesis reconstructions. MATERIALS AND METHODS: We studied 1,161 patients retrospectively who underwent megaprosthesis reconstruction for limb salvage after a sarcoma from 1983 to 2010. The mean followup was 9 y (range 3-20 y). We evaluated the overall survival of the megaprosthesis reconstructions in patients with infection and the survival with respect to the type of megaprosthesis, site of reconstruction, cemented or cementless fixation, type of tumor, adjuvant treatments, microbial isolate(s), treatment tactics, and outcome. RESULTS: The incidence of infection was 8.6%. The most common microbial isolate was Staphylococcus epidermidis (47%). Overall survival with definitive management of infection was 88% at 10 y and 84% at 20 y. Survival was higher for cementless reconstructions and not different with respect to the type of megaprosthesis, site of reconstruction, or adjuvant therapy. Infections resolved completely with one- or two-stage surgery in 75% of patients. The rate of amputation because of infection was 21%. CONCLUSIONS: Megaprosthesis reconstructions may be infected in 8.6% of cases. Infections more commonly occur late, caused usually by S. epidermidis. The survival rate is higher with cementless megaprosthesis reconstructions and no different with respect to the type of tumor or megaprosthesis or the adjuvant treatments. One-stage revision is effective for acute post-operative infections; however, two-stage revision surgery is necessary for early and late infections. The rate of amputation because of occurrence or persistence of megaprosthesis infection is 21%.

BACKGROUND: Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions. QUESTIONS/PURPOSES: The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system. METHODS: Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2-8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%). RESULTS: At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8-30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306). CONCLUSIONS: Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND: Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved? MATERIALS AND METHODS: We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed. RESULTS: Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934). CONCLUSIONS: The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Background Previous studies reported variable outcome of proximal tibial resections and reconstructions. Therefore, we evaluated the survival, Musculoskeletal Tumor Society (MSTS) function, and complications of patients and reconstructions in this location. Materials and Methods We reviewed the files of 225 patients with proximal tibial tumors treated with proximal tibial resection, fixed or rotating hinge megaprosthetic reconstruction and extensor mechanism reattachment using sutures, mechanical clamping, artificial ligaments, and/or gastrocnemius flap from 1985 to 2010 (mean follow-up, 90 months; median, 56; range, 2-294). Survival of patients and reconstructions, type of hinge, extensor mechanism reconstruction, MSTS function, and complications were analyzed. Results Survival of patients with sarcomas was 68% and 62% at 5 and 10 years. Survival of megaprosthetic reconstructions was 82% and 78% at 5 and 10 years, without any difference between fixed and rotating hinge megaprostheses. MSTS function was significantly better in univariate and multivariate analysis for rotating compared to fixed hinge megaprostheses, without any difference between the types of extensor mechanism reconstructions. Most common complications were infection (12%), aseptic loosening (6%), and extensor mechanism rupture (3%). Conclusions Rotating hinge proximal tibia megaprosthetic reconstructions have better function compared to fixed hinge, regardless of the type of extensor mechanism reconstruction.

In periarticular knee resections, the relative lack of soft tissue coverage and need to reattach the extensor mechanism after en bloc resection of the tibial tuberosity with the tumor specimen complicate reconstructions and decrease postoperative function and stability of the knee joint. Distal femoral reconstructions are less problematic; muscular attachments are relatively few, neurovascular structures are not immediately adjacent to bone, and the knee extensor mechanism is usually not compromised from bone tumors. In the proximal tibia, the close proximity of the neurovascular structures in the popliteal fossa and peroneal nerve at the lateral aspect of the leg make reconstruction more difficult. Poor function is mostly related to unreliable options for knee extensor mechanism reattachment and poor soft tissue coverage. Successful and reliable attachment of the soft tissues has been a significant advance that improved functional outcomes. This article describes techniques for the reconstruction of the extensor mechanism of the knee after proximal tibia resections. Combined reconstruction techniques using direct reattachment of the patellar tendon with synthetic materials to megaprosthetic or allograft reconstructions for immediate stability, augmentation with autologous bone graft or substitutes at the attachment site, and coverage with the medial gastrocnemius muscle flap and supplementary flaps for long-term stability of the reattachment are currently considered the gold standard.

Study Design: Retrospective case series. Objective: To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors. Summary of Background Data: Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign. Methods: We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test. Results: No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection. Conclusion: Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Introduction Aim of this study was to analyze (1) survival, local recurrence (LR), and metastasis rates between the three histological tumor grades; (2) whether type of treatment and tumor site influenced prognosis for each histologic grade. Methods We retrospectively studied 296 patients with central conventional chondrosarcomas (CS) (87 grade 1, 162 grade 2, and 47 grade 3). The femur was the most common site (91 cases), followed by the pelvis (82) and other less frequent sites. Type of surgery was related with histologic grade. Margins were wide in 222 cases, marginal in 23, and intralesional in 51 cases. Results At a mean of 7 years, 201 patients remained continuously NED, 33 were NED after treatment of relapse, 15 were AWD, 35 were died of disease, and 12 of other causes. Survival was 92% at 5 years and 84% at 10 years, significantly influenced by histological grading. In grade 3 CS, two factors influenced survival: type of surgery (resection vs. amputation, P = 0.051) and site (P = 0.039). The two significant factors lost their significance at multivariate analysis. Conclusion Central conventional CS with low/intermediate grade has a good prognosis, while high-grade tumors have poor outcome. Tumor relapses are strictly related with histologic grade.

We retrospectively studied the files of 669 patients with musculoskeletal tumors treated with limb salvage and reconstruction using fixed-hinge knee megaprostheses. We used the KMFTR® prosthesis from 1983 to 1989 in 126 patients, and the HMRS® prosthesis thereafter in 543 patients because of the anatomical femoral stem with one lateral flange for improved stress-shielding, the new hinge design and new generation polyethylene placed centrally in the metallic hinge, and the improved function compared to the former prosthesis. Distal femoral reconstructions were done in 474, proximal tibia in 163, extrarticular knee joint in nine, and total femoral in 23 patients. At 10 and 20 years follow-up, survival to breakage was 95% and 85%, to aseptic loosening 94% and 82%, to infection 90% and 82%, and to polyethylene wear 95% and 37%. A statistically significant higher survival to breakage of the HMRS® prostheses was observed. No statistical difference of survival to breakage regarding the site of reconstruction, aseptic loosening, infection, polyethylene wear and mean functional score between the two types of prostheses was observed.

Background: Massive endoprostheses provide orthopaedic oncologists with many reconstructive options after tumor resection, although failure rates are high. Because the number of these procedures is limited, failure of these devices has not been studied or classified adequately. This investigation is a multicenter review of the use of segmental endoprostheses with a focus on the modes, frequency, and timing of failure. Methods: Retrospective reviews of the operative databases of five institutions identified 2174 skeletally mature patients who received a large endoprosthesis for tumor resection. Patients who had failure of the endoprosthesis were identified, and the etiology and timing of failure were noted. Similar failures were tabulated and classified on the basis of the risk of amputation and urgency of treatment. Statistical analysis was performed to identify dependent relationships among mode of failure, anatomic location, and failure timing. A literature review was performed, and similar analyses were done for these data. Results: Five hundred and thirty-four failures were identified. Five modes of failure were identified and classified: soft-tissue failures (Type 1), aseptic loosening (Type 2), structural failures (Type 3), infection (Type 4), and tumor progression (Type 5). The most common mode of failure in this series was infection; in the literature, it was aseptic loosening. Statistical dependence was found between anatomic location and mode of failure and between mode of failure and time to failure. Significant differences were found in the incidence of failure mode Types 1, 2, 3, and 4 when polyaxial and uniaxial joints were compared. Significant dependence was also found between failure mode and anatomic location in the literature data. Conclusions: There are five primary modes of endoprosthetic failure, and their relative incidences are significantly different and dependent on anatomic location. Mode of failure and time to failure also show a significant dependence. Because of these relationships, cumulative reporting of segmental failures should be avoided because anatomy-specific trends will be missed. Endoprosthetic design improvements should address failure modes specific to the anatomic location. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Long bone pathological fractures in patients with primary and metastatic bone tumours are difficult to treat and their management may alter the prognosis of the disease and jeopardize survival. The aim of this article was to review the relevant studies reporting on the management of tumour patients with pathological fractures of the long bones, to discuss the most suitable approach in these patients, to highlight specific treatment recommendations, and finally based on this analysis and our clinical practice, to propose a treatment algorithm for decision making and treatment. © 2010 Elsevier Ltd. All rights reserved.

Thromboembolic risk in orthopedic oncology is high due to several factors. The aim of this study was to assess clinically significant thromboembolic disease in 986 patients operated on with a prosthetic reconstruction of the lower limbs after the resection of bone tumors and prophylactically treated with low-molecular-weight heparin (LMWH).Between 1983 and 2006, 986 patients had uncemented megaprostheses after a resection of the lower limbs for bone tumors. Antithromboembolic prophylaxis was always administered with LMWH from the immediate postoperative time until the time of complete weight-bearing. Phlebographies and vascular ecodoppler were not performed postoperatively on a regular basis. Patients were followed in the clinic with imaging studies for several years (lower limb CT, MRI, CT of the chest for malignant tumors). The diagnosis of symptomatic venous thromboembolism (VTE) was established or excluded on clinical evidence and MRI study.Among the 986 cases treated, only 11 patients (1.1%) showed a major thromboembolic event confirmed clinically and through imaging. One of these patients died with pulmonary embolism a few days after surgery. Two cases of thromboembolism occurred in patients with a vascular bypass.Despite general oncologic and orthopedic factors favoring VTE, the clinical occurrence of this event was extremely low in this series, probably due to a consistent and careful prophylaxis, prolonged until the time of complete weight-bearing.