Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

Aims

Porous metaphyseal cones can be used for fixation in revision total knee arthroplasty (rTKA) and complex TKAs. This metaphyseal fixation has led to some surgeons using shorter cemented stems instead of diaphyseal engaging cementless stems with a potential benefit of ease of obtaining proper alignment without being beholden to the diaphysis. The purpose of this study was to evaluate short term clinical and radiographic outcomes of a series of TKA cases performed using 3D-printed metaphyseal cones.

Aims

Hip reconstruction after resection of a periacetabular chondrosarcoma is complex and associated with a high rate of complications. Previous reports have compared no reconstruction with historical techniques that are no longer used. The aim of this study was to compare the results of tantalum acetabular reconstruction to both historical techniques and no reconstruction.

Aims

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

Aims

Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA.

The unacceptable failure rate of cemented femoral revisions led to many different cementless femoral designs employing fixation in the damaged proximal femur with biological coatings limited to this area. The results of these devices were uniformly poor and were abandoned for the most part by the mid-1990's. Fully porous coated devices employing distal fixation in the diaphysis emerged as the gold standard for revisions with several authors reporting greater than 90% success rate 8–10 years of follow-up. Surgical techniques and ease of insertion improved with the introduction of the extended trochanteric osteotomy as well as curved, long, fully porous coated stems with diameters up to 23mm. The limits of these stems were stretched to include any stem diameter in which even 1–2cm of diaphyseal contact could be achieved. When diaphyseal fixation was not possible (Type IV), the alternatives were either impaction grafting or allograft prosthetic composite (APC). As the results of fully porous coated stems were very carefully scrutinised, it became apparent that certain types of bone loss did not yield the most satisfactory results both clinically and radiographically. When less than 4cm of diaphyseal press fit (Type IIIB) was achieved, the mechanical failure rate (MFR) was over 25%. It also became apparent that even when there was 4–6cm diaphyseal contact (Type IIIA), and the stem diameter was 18mm or greater, post-operative pain and function scores were significantly less than those with smaller diameter stems. This was probably due to poorer quality bone. Many of these Type IIIA and Type IIIB femurs had severe proximal torsional remodeling leading to marked distortion of anteversion. This made judging the amount of anteversion to apply to the stem at the time of insertion very difficult, leading to higher rates of dislocation. These distortions were not present in Type I and Type II femurs. This chain of events which was a combination of minimal diaphyseal fixation, excessively stiff stems and higher dislocation rates led to the conversion to modular type stems when these conditions existed. For the past 13 years, low modulus taper stems of the Wagner design have been used for almost all Type IIIA and Type IIIB bone defects. The taper design with fluted splines allows for fixation when there is less than 2cm of diaphysis. The results in these femurs even with diameters of up to 26mm have led to very low MFRs and significantly less thigh pain. Independent anteversion adjustment is also a huge advantage in these modular stems. Similar success rates, albeit with less follow-up, have been noted in Type IV femurs

Aims

Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction.

Aims

Following the resection of an extensive amount of bone in the treatment of a tumour, the residual segment may be insufficient to accept a standard length intramedullary cemented stem. Short-stemmed endoprostheses conceivably have an increased risk of aseptic loosening. Extra-cortical plates have been added to minimise this risk by supplementing fixation. The aim of this study was to investigate the survivorship of short-stemmed endoprostheses and extra-cortical plates.

The technique involves impaction of cancellous bone into a cavitary femur. If segmental defects are present, the defects can be closed with stainless steel mesh. The technique requires retrograde fill of the femoral cavity with cancellous chips of appropriate size to create a new endomedullary canal. By using a set of trial impactors that are slightly larger than the real implants the cancellous bone is impacted into the tube. Subsequent proximal impaction of bone is performed with square tip or half moon impactors. A key part of the technique is to impact the bone tightly into the tube especially around the calcar to provide optimal stability. Finally a polished tapered stem is cemented using almost liquid cement in order to achieve interdigitation of the implant to the cancellous bone. The technique as described is rarely performed today in many centers around the world. In the US, the technique lost its interest because of the lengthy operative times, unacceptable rate of peri-operative and post-operative fractures and most importantly, owing to the success of tapered fluted modular stems. In centers such as Exeter where the technique was popularised, it is rarely performed today as well, as the primary cemented stems used there, rarely require revision. There is ample experience from around the globe, however, with the technique. Much has been learned about the best size and choice of cancellous graft, force of impaction, surface finish of the cemented stem, importance of stem length, and the limitations and complications of the technique. There are also good histology data that demonstrate successful vascularization and incorporation of the impacted cancellous bone chips and host bone. Our experience at the clinic was excellent with the technique as reported in CORR in 2003 by M Cabanela. The results at mid-term demonstrated minimal subsidence and good graft incorporation. Six of 54 hips, however, had a post-operative distal femoral fracture requiring ORIF. The use of longer cemented stems may decrease the risk of distal fracture and was subsequently reported by the author after reviewing a case series from Exeter. Today, I perform this technique once or twice per year. It is an option in the younger patient, where bone restoration is desired. Usually in a Paprosky Type IV femur, where a closed tube can be recreated and the proximal bone is reasonable. If the proximal bone is of poor quality, then I prefer to perform a transfemoral osteotomy, and perform an allograft prosthetic composite instead of impaction grafting, and wrap the proximal bone around the structural allograft. I prefer this technique as I can maintain the soft tissues over the bone and avoid the stripping that would be required to reinforce the bone with struts or mesh. Another indication for its use in the primary setting is in the patient with fibrous dysplasia

The Vancouver classification separates periprosthetic femur fractures after THA into three regions (A - trochanteric, B - around or just below the stem, and C - well below the stem), with fractures around or just below the stem further separated into those with a well-fixed (B1) or loose stem and good (B2) or poor (B3) bone stock. Trochanteric fractures may be associated with osteolysis and require treatment that addresses osteolysis as well as ORIF of displaced fractures. Fractures around a well-fixed stem can be treated with ORIF using cerclage or cable plating, while those around a loose stem require implant revision usually to a longer cementless tapered or distally porous coated cementless stem. Fractures around a loose stem with poor bone stock in which salvage of the proximal femur is not possible require replacement of the proximal femur with an allograft prosthetic composite or proximal femoral replacement. Fractures well below the stem can be treated with conventional plating methods. Periprosthetic acetabular fractures are rare and usually occur in the early post-operative period or late as a result of osteolysis or trauma. These can generally be separated into those with a stable acetabular component which can be treated non-operatively, and those with an unstable component often with discontinuity or posterior column instability which require complex acetabular reconstruction utilizing plating or revision to a cup-cage

When fracture of an extensively porous-coated femoral component occurs, its removal at revision total hip arthroplasty (THA) may require a femoral osteotomy and the use of a trephine. The remaining cortical bone after using the trephine may develop thermally induced necrosis. A retrospective review identified 11 fractured, well-fixed, uncemented, extensively porous-coated femoral components requiring removal using a trephine with a minimum of two years of follow-up.

The mean time to failure was 4.6 years (1.7 to 9.1, standard deviation (sd) 2.3). These were revised using a larger extensively porous coated component, fluted tapered modular component, a proximally coated modular component, or a proximal femoral replacement. The mean clinical follow-up after revision THA was 4.9 years (2 to 22, sd 3.1). The mean diameter of the femoral component increased from 12.7 mm (sd 1.9) to 16.2 mm (sd 3.4; p >  0.001). Two revision components had radiographic evidence of subsidence that remained radiographically stable at final follow-up. The most common post-operative complication was instability affecting six patients (54.5%) on at least one occasion.

A total of four patients (36.4%) required further revision: three for instability and one for fracture of the revision component. There was no statistically significant difference in the mean Harris hip score before implant fracture (82.4; sd 18.3) and after trephine removal and revision THA (81.2; sd 14.8, p = 0.918).

These findings suggest that removal of a fractured, well-fixed, uncemented, extensively porous-coated femoral component using a trephine does not compromise subsequent fixation at revision THA and the patient’s pre-operative level of function can be restored. However, the loss of proximal bone stock before revision may be associated with a high rate of dislocation post-operatively.

Cite this article: Bone Joint J 2015;97-B:1192–6.

Vancouver A: If minimal displacement and prosthesis stable can treat nonoperatively. If displacement is unacceptable and/or osteolysis is present consider surgery. AL: Rare, avulsions from osteopenia and lysis. If large, displaced and include large portion of calcar-can destabilise stem and prompt femoral revision. AG: More common. Often secondary to lysis. Does not usually affect implant stability. Minimal displacement. Treat closed × 3 months. Revise later is needed to remove the particle generator, debride defects and bone graft. Displaced with good host bone stock. Consider early ORIF and bone grafting. Vancouver B:. B1: Rarely non-operative. ORIF with femoral component retention. Need to carefully identify stem fixation. B2's classified as B1's are doomed to fail. B1's correctly identified treated with plate, allograft struts or both. High union rates with component retention. B2: Femoral revision +/− strut allograft. Best results seen with patients revised with uncemented, extensively porous coated femoral stems. May use modular, fluted taper stems. B3: Proximal femoral replacement - Tumor prosthesis, Allograft Prosthetic Composite (APC). Uncemented femoral stem - Extensively porous coated, Fluted, tapered stem, Allograft strut. Vancouver C: Treat with standard fracture techniques. These fractures are away from the femoral prosthesis. Rarely nonoperative. Fixation options – Cerclage, Strut Allograft, Plate fixation, Retrograde IM nail, or a Combination thereof. Avoid stress risers between implants. Bypass (overlap) fixation. Consider allowing 2.5 cortical diameters between devices

The unacceptable failure rate of cemented femoral revisions led to many different cementless femoral designs employing fixation in the damaged proximal femur with biological coatings limited to this area. The results of these devices were uniformly poor and were abandoned for the most part by the mid 1990's. Fully porous coated devices employing distal fixation in the diaphysis emerged as the gold standard for revisions with several authors reporting greater than 90% success rate at 8–10 years of follow-up. Surgical techniques and ease of insertion improved with the introduction of the extended trochanteric osteotomy as well as curved, long, fully porous coated stems with diameters up to 23 mm. The limits of these stems were stretched to include any stem diameter in which even 1–2 cm of diaphyseal contact could be achieved. When diaphyseal fixation was not possible (Type IV), the alternatives were either impaction grafting or allograft prosthetic composite (APC). As the results of fully porous coated stems were very carefully scrutinised, it became apparent that certain types of bone loss did not yield the most satisfactory results both clinically and radiographically. When less than 4 cm of diaphyseal press fit (Type IIIB) was achieved, mechanical failure rate (MFR) was over 25%. It also became apparent that even when there was 4–6 cm. diaphyseal contact (Type IIIA), and the stem diameter was 18 mm or greater, post-op pain and function scores were significantly less than those with smaller diameter stems. This was probably due to poorer quality bone. Many of these Type IIIA and Type IIIB femurs had severe proximal torsional remodeling leading to marked distortion of anteversion. This made judging the amount of anteversion to apply to the stem at the time of insertion very difficult, leading to higher rates of dislocation. These distortions were not present in Type I and Type II femurs. This chain of events which was a combination of minimal diaphyseal fixation, excessively stiff stems and higher dislocation rates led to the conversion to modular type stems when these conditions existed. For the past 8 years, low modulus taper stems of the Wagner design have been used for almost all Type IIIA and Type IIIB bone defects. The taper design with fluted splines allows for fixation when there is less than 2 cm of diaphysis. The results in these femurs even with diameters of up to 26 mm have led to very low M.F.R.'s and significantly less thigh pain. Independent anteversion adjustment is also a hug advantage in these modular stems. Similar success rates, albeit with less follow-up, have been noted in Type IV femurs

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone

Background: Massive bone loss from the proximal femur is a complex problem, occurring in multiple-revision hip arthroplasties, and malignancy. Allograft prosthetic composites (APCs) are used to restore bone loss and provide better function of the limb. Material and Methods: Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss due to an average of 2 previous revisions, had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases. Results: At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Minor complications occurred in 13 other cases. Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05). Conclusion: Reconstruction of massive proximal femoral bone loss with an allograft-implant composite is a demanding procedure. Preservation of bone stock is a great advantage of this biologic means of reconstruction. Specific technical issues should be known and followed so to avoid failure and need for early re-revision

Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions.

The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures.

The proximal humerus is the third most common site for primary sarcoma of bone. Since the 1970’s the treatment of primary bone sarcoma has changed from amputation to limb salvage. This has been due to advances in chemotherapy, imaging and surgical techniques. The literature has shown that the survival after limb salvage is similar to that of amputation. The optimum method of reconstruction of the shoulder remains controversial. The aim of our study was to review the cases of primary bone sarcoma of the proximal humerus treated at Middlemore Hospital. The New Zealand Bone Tumour Registry was searched for all lesions of the proximal humerus, with the diagnosis of chondrosarcoma, Ewing’s sarcoma or osteosarcoma. These records were reviewed for presentation status, biopsy, and type of reconstruct ion, chemotherapy, complications and recurrence. Outcomes measured in months of disease free survival and overall survival. The Bone Tumour Registry identified 29 patients who were treated at Middlemore Hospital with the primary diagnosis of Ewing’s sarcoma, chondrosarcoma or osteosarcoma of the proximal humerus. Results were available for 26 of the 29 patients (90% follow-up). Of these 29 patients six had chondrosarcoma, four Ewing’s sarcoma and 19 osteosarcoma. The patients with chondrosarcoma had an average age of 50 years. three patients were treated with endoprosthesis (mean survival 48 months) and one with vascularised fibula reconstruction (status 27 months ANED). Of the four patients with Ewing’s sarcoma, two had surgical reconstruction, one with intercalary allograft reconstruction (status 96 months ANED) and one with endoprosthesis (status 84 months ANED). The 19 patients with osteosarcoma had an average age 27 years, 15 patients were treated surgically. Three had endoprosthetic reconstruction (mean survival 29 months), two allograft prosthetic composite reconstruction (mean survival 23 months), three vascularised fibula reconstruction (mean survival 217 months), one total shoulder replacement and proximal humeral autograft (status 68 months ANED), one hemiarthroplasty (status 21 months DOD) and one proximal humeral allograft (status 31 months ANED). 4 patients were treated with primary amputation (mean survival 55.25 months). The mean overall survival for limb salvage surgery in our institution is 74 months compared to 55.25 months for amputation; this is consistent with the published literature. Function of a salvaged upper limb is superior to amputation. A salvaged limb is socially and emotionally more acceptable for patients than amputation. Limb salvage remains the priority in the treatment of primary bone tumours of the proximal humerus

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005)