Aims

Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary intramedullary fixation within the ilium combined with a monoflange for rotational stability, was anticipated to overcome this obstacle. The aim of this study was to evaluate the design with regard to functional outcome, complications, and acetabular reconstruction.

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

The February 2024 Oncology Roundup. 360. looks at: Does primary tumour resection improve survival for patients with sarcomas of the pelvis with metastasis at diagnosis?; Proximal femur replacements for an oncologic indication offer a durable endoprosthetic reconstruction option: a 40-year experience; The importance of awaiting biopsy results in solitary pathological proximal femoral fractures: do we need to biopsy solitary pathological fractures?; Effect of radiotherapy on local recurrence, distant metastasis, and overall survival in 1,200 extremity soft-tissue sarcoma patients; What to choose in bone tumour resections? Patient-specific instrumentation versus surgical navigation; Optimal timing of re-excision in synovial sarcoma patients: immediate intervention versus waiting for local recurrence; Survival differences of patients with resected extraskeletal osteosarcoma receiving two different (neo) adjuvant chemotherapy regimens; Solitary versus multiple bone metastases in the appendicular skeleton: should the surgical treatment be different?

Aims

The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA).

Aims

The aim of this study was to examine the implant accuracy of custom-made partial pelvis replacements (PPRs) in revision total hip arthroplasty (rTHA). Custom-made implants offer an option to achieve a reconstruction in cases with severe acetabular bone loss. By analyzing implant deviation in CT and radiograph imaging and correlating early clinical complications, we aimed to optimize the usage of custom-made implants.

Abstract. Background. Atypical femur fracture (AFF) is a well known complication of Bisphosphonate therapy. Due to prolonged suppression of bone re-modelling in these fractures, surgical complications are difficult to manage. The aim of this study was to analyze the causes of surgical complications in AFF fixations and provide algorithm for management. Method. In this retrospective 10-year study (2010–2020), we identified patients surgically treated for AFF. We included patients who underwent revision surgery for any cause. Data collection included demographics, surgical complications, details of revision surgery and time to union. Result. Out of 57 patients who were operated for AFF, 17 underwent revision fixation. The average age was 69 with only 2 males. Around two-third (64%) were sub-trochanteric fractures and method of fixation in 64% cases was intra-medullary nail. The most common complication was non-union (12), followed by stress fracture and infection in 3 and 2 cases respectively. In most cases inadequate reduction and sub-optimal fixation was perceived as cause of failure except two cases which got infected. Revision fixation in all cases included improved bone contact (non-union site osteotomy), use of bone morphogenic proteins and improved fixation with augmentation device (either nail or plate). Follow up at 1 year showed fracture union in 12 cases, remaining 5 revision fixations failed, 3 of which were managed with proximal femur replacement. Conclusion. High rate of non-union after fixation in AFF. Optimizing the fixation construct results in union in most cases. However, arthroplasty should be considered in elderly patients with poor bone quality

Aims

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

The use of endoprosthesis implants is frequent for tumours involving the proximal third of the femur and not amenable to primary arthroplasty or internal fixation. In this population, these implants are preferentially cemented given poor bone quality associated with systemic diseases and treatments. Loosening is a common complication of these implants that have been linked to poor bone quality, type of implants and importantly cementing technique. Thus, these techniques vary between different surgeons and based mainly on previous experience. One of the most successful cementing techniques in the arthroplasty literature is the French paradox. This technique involves removing the cancellous bone of the proximal femoral metaphysis and selects the largest stem to tightly fit the created cavity delineated by cortical bone. Cementing the implant results in a very thin cement layer that fills the inconsistent gaps between the metal and the bone. To our knowledge, no previous report exists in the literature assessing loosening in proximal femur replacement using the French paradox cementing technique. In this study, we sought to examine (1) rates of loosening in proximal femur replacement, and (2) the oncological outcomes including tumour recurrence and implant related complications. A retrospective study of 42 patients underwent proximal femur replacement between 1990 and 2018 at our institution. Of these, 30 patients met our inclusion criteria. Two independent reviewers have evaluated the preoperative and the most recent postoperative radiographs using the International Society of Limb Salvage (ISOLS) radiographic scoring system and Gruen classification for femoral stem loosening. Additionally, the acetabulum was evaluated for erosion according to the criteria of Baker et al. The mean age of this cohort was 60.5 (19–80), with 60% being males. The primary origin was metastatic in 17 (56.7%) patients, bone sarcoma in 10 (33.3%) patients and soft tissue sarcoma in 3 (10%) patients. Pathological fractures were present in 11 (36.7%) patients. Seven (23.3%) patients had prior intramedullary nailing. Preoperative radiotherapy was used in 8 (26.7%) and postoperative radiotherapy in 17 (56.7%) patients. The mean clinical follow-up was 25.2±26.3 months and the mean radiographical follow-up was 24.8±26 months. The mean ISOLS score for both reviewers was found to be 89±6.5% and 86.5±6.1%, respectively. Additionally, the first reviewer found two patients to be possibly loos (6.7%) compared to one (3.3%) patient for the second reviewer. No components scored as probably or definitely loose and non-required revision for either loosening or metal failure. Furthermore, both reviewers showed no acetabular erosion in 25 (83.3%) and 24 (80%) patients, respectively. On the other hand, the overall rate of complications was 36.6% with 11 complications reported in 30 patients. Local recurrence occurred in five (16.6%) patients. Prosthetic Dislocation was the most frequent complications with eight dislocations in four patients. Despite complications, our results showed no radiographic evidence of stem loosening. Cementing proximal femur prosthesis with a tight canal fit and with a thin cement mantle appears to be a viable option at short and medium term

Aims

The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

The management of proximal femoral bone loss is a significant challenge in revision hip arthroplasty. A possible solution is the use of a modular proximal femur endoprosthesis (EPR). Although the survivorship and functional outcome of megaprostheses used in tumour surgery has been well described, outcome of EPRs used in revision hip surgery has received less attention. The aim of this study was to determine the 5-year outcome following proximal femur EPR and determine factors that influence it.

This was a retrospective consecutive case series of all EPRs (n=80) performed for non-neoplastic indications, by 6 surgeons, in our tertiary referral centre, between 2005–2014. Patient demographics and relevant clinical details were determined from notes. The most common indications for the use of EPRs included infection (n=40), peri-prosthetic fracture (n=12) and failed osteosynthesis of proximal femoral fractures/complex trauma (n=11). Outcome measures included complication and re-operation rates, implant survival and assessment of functional outcome using the Oxford-Hip-Score (OHS).

The mean age at surgery was 69 years and mean follow-up was 4 (0 – 11) years. The mean number of previous hip operations was 2.4 (range: 0 – 17). Twenty-five patients sustained a complication (31%), the most common being infection (n=9) and dislocation (n=4). By follow-up, further surgery was required in 18 (22%) hips, 9 of which were EPR revisions. 5-yr implant survivorship was 87% (95%CI: 76 – 98%). Mean OHS was 28 (range: 4 – 48). Inferior survival and outcome were seen in EPRs performed for the treatment of infection. Infection eradication was achieved in 34/41 with the index EPR procedure and in 40/41 hips by follow-up.

Limb salvage was achieved in all cases and acceptable complication- and re-operation rates were seen. EPRs for periprosthetic fractures and failed osteosynthesis had best outcome. We recommend the continued use of proximal femur EPR in complex revision surgery.

Excision of the proximal femur for tumour with prosthetic reconstruction using a bipolar femoral head places a considerable load on the unreplaced acetabulum.

We retrospectively reviewed the changes which occur around the affected hip joint by evaluating the post-operative radiographs of 65 consecutive patients who underwent proximal prosthetic arthroplasty of the femur, and in whom an acetabular component had not been used. There were 37 men and 28 women with a mean age of 57.3 years (17 to 93). Radiological assessment included the extent of degenerative change in the acetabulum, heterotopic ossification, and protrusio acetabuli.

The mean follow-up was 9.1 years (2 to 11.8). Degenerative changes in the acetabulum were seen in three patients (4.6%), Brooker grade 1 or 2 heterotopic ossification in 17 (26%) and protrusion of the prosthetic head in nine (13.8%).

A total of eight patients (12.3%) needed a revision. Five were revised to the same type of prosthesis and three (4.6%) were converted to a total hip arthroplasty.

We conclude that radiological evidence of degenerative change, heterotopic ossification and protrusion occur in a few patients who undergo prosthetic arthroplasty of the proximal femur for tumour. The limited extent of these changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in these patients.

Cite this article: Bone Joint J 2015;97-B:1704–9

The use of megaprostheses is accompanied with periprosthetic infection in up to 15% of cases. Among metals with antimicrobial activity, silver has raised the interest of investigators because of its good antimicrobial activity. The aim of this study was to determine the infection rate of silver-coated megaprostheses in comparision to uncoated titanium prostheses. We prospectively identified 40 patients who were treated with a silver-coated proximal femur (n=17) or proximal tibia (n=23) replacement (Mutars. ®. , Implantcast, Germany). Patients with a silver-coated tumor endoprosthesis were compared with 74 (proximal femur replacement n=33, proximal tibia n=41) retrospectively assessed patients with a titanium endoprosthesis regarding the number of infections. In the titanium group a proximal femur replacement was associated with the highest infection rate (18.2%; time of infection in mean 15 months postoperatively). In the silver-group infection could be reduced to 5.9% (time of infection 12 months postoperatively). In patients with a proximal tibia replacement the infection rate could be reduced from 17.1% (time of infection in mean 28 months postoperatively) to 4.3% (time of infection 4 months postoperatively) in the silver group. Regarding the final, successful treatment of infection it can be stated that in the silver group the patients could be treated either by intravenous antibiotics only or by a one-stage exchange of the prosthetic body. In the titanium group seven patients (53%) were treated by a two-stage reimplantation of the prosthesis, in 4 patients (31%) an amputation and in one patient rotationplasty was performed. We conclude that silver-coated megaendoprostheses can reduce the risk of infection on a short-term followup. Importantly, minor revisions in the case of infection in patients with a silver-coated prostheses were more often successful. Further studies with more patients and a longer followup are necessary in order to evaluate the possible benefit of silver exactly

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions. There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection. The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants. We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement

Arthritis of the hip in the young adult can be a disabling condition. Recent years have witnessed extensive research related to the management of this condition. This article reviews the current status with regard to aetiology, diagnosis and treatment of arthritis of the hip in the young adult.

Introduction: Allograft-Prosthesis Composite represents a reliable option for proximal femur replacement after resection for bone tumor. It provides advantages over megaprostheses because of better soft tissue repair and superior abduction strength, quality of gait, hip stability, and load transfer by healed bone rather than prosthetic stem, with potential impact on implant survival. Purpose of this paper was to review details of the surgical technique and results. Methods: A retrospective study of 62 patients who had resection of the proximal femur because of a bone tumor and reconstruction with an Allograft-Prosthesis Composite was undertaken. The basic surgical technique consisted of an uncemented tapered long stem prosthesis (i.e. Wagner or Wagner-type stem) cemented in the allograft and press-fitted in the host bone, achieving bone-bone contact through a transverse osteotomy. Details of the surgical technique included: 1) accurate preoperative planning, canal sizing and implant selection; 2) under-reaming of the proximal 5–10 mm of the host medullary canal, depending upon bone quality and diameter of the selected stem; 3) allograft preparation and prosthesis cementation in the allograft; 4) introduction of the composite implant, pressfitted in host medullary canal, until bone-bone contact is achieved; 5) careful repair of abductors and iliopsoas to corresponding allograft tendon insertions. Key points for successful fixation are absolute rotational stability and satisfactory circumferential bone-bone contact at the time of surgery. Postoperative regimen consisted of hip, followed by progressive bracing and toe-touch weight-bearing for 6 weeks, weight-bearing. Results: There were 2 septic failures. Two patients developed asymptomatic nonunion. There were no dislocations. Most common complication was fracture of the allograft greater trochanter (30%), which required surgery in only 1 case and never substantially affected function. The incidence of trochanteric fracture decreased from 63% in the first 27 patients to 5% in the following 35 patients by switching implant design from a valgus 145° neck angle to 135° neck angle, improving offset and abductors function. Bone grafting of the allograft-host union was required in 10% of the cases. According to MSTS, results were satisfactory in 90% of the patients, with average score 91% (75%–96%). Discussion and Conclusion: Allograft-Prosthesis Composite is a successful procedure for reconstruction of the proximal femur. Careful surgical technique is the key to excellent function and low complication rate