Aims. We have evaluated the survivorship, outcomes, and failures of an interlocking, reconstruction-mode stem-sideplate implant used to preserve the native hip joint and achieve proximal fixation when there is little residual femur during large endoprosthetic reconstruction of the distal femur. Methods. A total of 14 patients underwent primary or revision reconstruction of a large femoral defect with a short remaining proximal femur using an interlocking, reconstruction-mode stem-sideplate for fixation after oncological distal femoral and diaphyseal resections. The implant was attached to a standard endoprosthetic reconstruction system. The implant was attached to a standard endoprosthetic reconstruction system. None of the femoral revisions were amenable to standard cemented or uncemented stem fixation. Patient and disease characteristics, surgical history, final ambulatory status. ,. and Musculoskeletal Tumor Society (MSTS) score were recorded. The percentage of proximal femur remaining was calculated from follow-up radiographs. Results. All 14 at-risk native hip joints were preserved at a mean final follow-up of 6.0 years (SD 3.7), despite a short residual femur, often after proximal osteotomies through the lesser trochanter. Overall, 13 of 14 stems had long-term successful fixation. Eight patients required no reoperation. Three patients required reoperation due to implant-related issues, and three patients required reoperation for wound healing problems or infection. There were no dislocations or fractures. At final follow-up the mean MSTS score was 24.9 (SD 4.1). Nine patients required no ambulation aids, and only one had a Trendelenburg gait. Conclusion. This interlocking, reconstruction-mode stem-sideplate reliably preserves native hip joint anatomy and function after large femoral resection with a short remaining proximal femur, both in the primary and revision setting. This is particularly important for preventing or delaying total femoral arthroplasty in
We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone. The search terms used in combination were “multicentric”, “giant cell tumour”, and “bone”. Exclusion criteria were: reports lacking data, with only an abstract; papers not reporting data on multicentric GCT; and papers on multicentric GCT associated with other diseases. Additionally, we report three patients treated under our care.Aims
Methods
Aims. For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. Methods. We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. Results. The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). Conclusion. TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and
Aims. After intercalary resection of a bone tumour from the femur,
reconstruction with a vascularized fibular graft (VFG) and massive
allograft is considered a reliable method of treatment. However,
little is known about the long-term outcome of this procedure. The
aims of this study were to determine whether the morbidity of this
procedure was comparable to that of other reconstructive techniques,
if it was possible to achieve a satisfactory functional result, and
whether biological reconstruction with a VFG and massive allograft
could achieve a durable, long-lasting reconstruction. Patients and Methods. A total of 23 patients with a mean age of 16 years (five to 40)
who had undergone resection of an intercalary bone tumour of the
femur and reconstruction with a VFG and allograft were reviewed
clinically and radiologically. The mean follow-up was 141 months
(24 to 313). The mean length of the fibular graft was 18 cm (12 to
29). Full weight-bearing without a brace was allowed after a mean
of 13 months (seven to 26). Results. At final follow-up, the mean Musculoskeletal Tumor Society Score
of 22 evaluable patients was 94% (73 to 100). Eight major complications,
five fractures (21.7%), and three nonunions (13%) were seen in seven
patients (30.4%). Revision-free survival was 72.3% at five, ten,
and 15 years, with fracture and nonunion needing surgery as failure endpoints.
Overall survival, with removal of allograft or amputation as failure
endpoints, was 94.4% at five, ten, and 15 years. Discussion. There were no complications needing surgical revision after five
years had elapsed from surgery, suggesting that the mechanical strength
of the implant improves with time, thereby decreasing the risk of
complications. In
Rotating-hinge knee prostheses are commonly used to reconstruct the distal femur after resection of a tumour, despite the projected long-term burden of reoperation due to complications. Few studies have examined the factors that influence their failure and none, to our knowledge, have used competing risk models to do so. The purpose of this study was to determine the risk factors for failure of a rotating-hinge knee distal femoral arthroplasty using the Fine-Gray competing risk model. We retrospectively reviewed 209 consecutive patients who, between 1991 and 2016, had undergone resection of the distal femur for tumour and reconstruction using a rotating-hinge knee prosthesis. The study endpoint was failure of the prosthesis, defined as removal of the femoral component, the tibial component, or the bone-implant fixation; major revision (exchange of the femoral component, tibial component, or the bone-implant fixation); or amputation.Aims
Methods
Local recurrence remains a challenging and common problem following curettage and joint-sparing surgery for giant cell tumour of bone (GCTB). We previously reported a 15% local recurrence rate at a median follow-up of 30 months in 20 patients with high-risk GCTB treated with neoadjuvant Denosumab. The aim of this study was to determine if this initial favourable outcome following the use of Denosumab was maintained with longer follow-up. Patients with GCTB of the limb considered high-risk for unsuccessful joint salvage, due to minimal periarticular and subchondral bone, large soft tissue mass, or pathological fracture, were treated with Denosumab followed by extended intralesional curettage with the goal of preserving the joint surface. Patients were followed for local recurrence, metastasis, and secondary sarcoma.Aims
Methods
We used a knee-sparing distal femoral endoprosthesis in
We have made a retrospective study of 1001 custom-made prostheses used as replacements after surgery for bone tumours. There were 493 distal femoral, 263 proximal femoral and 245 proximal tibial prostheses. Aseptic loosening was shown to be the principal mode of failure of the implants, and 71 patients had revision for aseptic loosening of a cemented intramedullary stem. The probability of a patient surviving aseptic loosening for 120 months was 93.8% for a proximal femoral replacement, 67.4% for a distal femoral prosthesis and 58% for a proximal tibial implant. In patients with distal femoral replacements the age of the patient at the time of operation and the percentage of bone resected were related to the risk of aseptic loosening.
Aims
Patients and Methods
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 study involved 37 patients who underwent limb salvage surgery
for a primary neoplasm of bone between 1998 and 2013. Endoprosthetic
replacement involved the proximal humerus in nine, the proximal
femur in nine, the distal femur in 13 and the proximal tibia in
six patients. There were 12 primary (32%) and 25 revision procedures (68%).
Implant survivorship was compared with matched controls. The amount
of bone that was resected was >
70% of its length and statistically
greater than the standard control group at each anatomical site.Aims
Patients and Methods
The aim of this study was to analyse a group of patients with
non-metastatic Ewing’s sarcoma at presentation and identify prognostic
factors affecting the development of local recurrence, in order
to assess the role of radiotherapy. A retrospective review of all patients with a Ewing’s sarcoma
treated between 1980 and 2012 was carried out. Only those treated
with chemotherapy followed by surgery and/or radiotherapy were included.
Patients were grouped according to site (central or limb) for further
analysis of the prognostic factors.Aims
Patients and Methods
To assess complications and failure mechanisms of osteoarticular
allograft reconstructions for primary bone tumours. We retrospectively evaluated 38 patients (28 men, 74%) who were
treated at our institution with osteoarticular allograft reconstruction
between 1989 and 2010. Median age was 19 years (interquartile range
14 to 32). Median follow-up was 19.5 years (95% confidence interval
(CI) 13.0 to 26.1) when 26 patients (68%) were alive. In addition, we
systematically searched the literature for clinical studies on osteoarticular
allografts, finding 31 studies suitable for analysis. Results of
papers that reported on one site exclusively were pooled for comparison.Aims
Patients and Methods
Children treated for osteosarcoma around the knee often have
a substantial leg-length discrepancy at skeletal maturity. The aim
of this study was to investigate the results of staged skeletal
reconstruction after a leg lengthening procedure using an external
fixator in these patients. We reviewed 11 patients who underwent staged reconstruction with
either an arthroplasty (n = 6) or an arthrodesis (n = 5). A control
group of 11 patients who had undergone wide excision and concurrent
reconstruction with an arthroplasty were matched for gender, location,
and size of tumour. We investigated the change in leg-length discrepancy,
function as assessed by the Musculoskeletal Tumor Society Scale
(MSTS) score and complications.Aims
Patients and Methods
The aims of this retrospective study were to report the feasibility
of using 3D-printing technology for patients with a pelvic tumour
who underwent reconstruction. A total of 35 patients underwent resection of a pelvic tumour
and reconstruction using 3D-printed endoprostheses between September
2013 and December 2015. According to Enneking’s classification of
bone defects, there were three Type I lesions, 12 Type II+III lesions,
five Type I+II lesions, two Type I+II+III lesions, ten type I+II+IV
lesions and three type I+II+III+IV lesions. A total of three patients
underwent reconstruction using an iliac prosthesis, 12 using a standard
hemipelvic prosthesis and 20 using a screw-rod connected hemipelvic
prosthesis.Aims
Patients and Methods
Massive endoprostheses rely on extra-cortical bone bridging (ECBB)
to enhance fixation. The aim of this study was to investigate the
role of selective laser sintered (SLS) porous collars in augmenting
the osseointegration of these prostheses. The two novel designs of porous SLS collars, one with small pores
(Ø700 μm, SP) and one with large pores (Ø1500 μm, LP), were compared
in an ovine tibial diaphyseal model. Osseointegration of these collars
was compared with that of a clinically used solid, grooved design
(G). At six months post-operatively, the ovine tibias were retrieved and
underwent radiological and histological analysis.Aims
Materials and Methods
Giant cell tumour is the most common aggressive
benign tumour of the musculoskeletal system and has a high rate of
local recurrence. When it occurs in proximity to the hip, reconstruction
of the joint is a challenge. Options for reconstruction after wide
resection include the use of a megaprosthesis or an allograft-prosthesis
composite. We performed a clinical and radiological study to evaluate
the functional results of a proximal femoral allograft-prosthesis
composite in the treatment of proximal femoral giant cell tumour
after wide resection. This was an observational study, between 2006
and 2012, of 18 patients with a mean age of 32 years (28 to 42)
and a mean follow-up of 54 months (18 to 79). We achieved excellent
outcomes using Harris Hip Score in 13 patients and a good outcome
in five. All allografts united. There were no complications such
as infection, failure, fracture or resorption of the graft, or recurrent
tumour. Resection and reconstruction of giant cell tumours with
proximal femoral allograft–prosthesis composite is a better option
than using a prosthesis considering preservation of bone stock and excellent
restoration of function. A good result requires demanding bone banking techniques, effective
measures to prevent infection and stability at the allograft-host
junction. Cite this article:
We retrospectively reviewed 101 consecutive patients
with 114 femoral tumours treated by massive bone allograft at our
institution between 1986 and 2005. There were 49 females and 52
males with a mean age of 20 years (4 to 74). At a median follow-up
of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed.
The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and
failure of fixation were studied. The most adverse factor on the
outcome was the use of intramedullary nails, followed by post-operative
chemotherapy, resection length >
17 cm and age >
18 years at the
time of intervention. The simultaneous use of a vascularised fibular
graft to protect the allograft from mechanical complications improved
the outcome, but the use of intramedullary cementing was not as
successful. In order to improve the strength of the reconstruction and to
advance the biology of host–graft integration, we suggest avoiding
the use of intramedullary nails and titanium plates, but instead
using stainless steel plates, as these gave better results. The
use of a supplementary vascularised fibular graft should be strongly
considered in adult patients with resection >
17 cm and in those
who require post-operative chemotherapy.
Monostotic fibrous dysplasia of the proximal
femur has a variable clinical course, despite its reported limited tendency
to progress. We investigated the natural history and predisposing factors
for progression of dysplasia in a group of 76 patients with a mean
follow-up of 8.5 years (2.0 to 15.2). Of these, 31 (41%) presented
with an asymptomatic incidental lesion while 45 (59%) presented
with pain or a pathological fracture. A group of 23 patients (30%)
underwent early operative treatment for pain (19: 25%) or pathological
fracture (4: 5%). Of the 53 patients who were initially treated non-operatively,
45 (85%) remained asymptomatic but eight (15%) needed surgery because
of pain or fracture. The progression-free survival of the observation
group was 81% ( The risk of experiencing pain or pathological fracture is considerable
in monostotic fibrous dysplasia of the proximal femur. Patients
presenting with pain, a limp or radiological evidence of microfracture
have a high chance of needing surgical treatment. Cite this article:
Avascular necrosis (AVN) is a serious complication
of high-dose chemotherapy for haematological malignancy in childhood.
In order to describe its incidence and main risk factors and to
evaluate the current treatment options, we reviewed 105 children
with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic
or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall,
eight children (7.6%) developed AVN after a mean of 16.8 months (8
to 49). There were four boys and four girls with a mean age of 14.4
years (9.8 to 16.8) and a total of 18 involved sites, 12 of which
were in the femoral head. All these children were aged >
nine years
(p <
0.001). All had received steroid treatment with a mean cumulative
dose of prednisone of 5967 mg (4425 to 9599) compared with a mean
of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No
difference existed between genders and no thrombophilic disorders
were identified. Their initial treatment included 11 core decompressions
and two bipolar hip replacements. Later, two salvage osteotomies
were done and three patients (four hips) eventually needed a total
joint replacement. We conclude that AVN mostly affects the weight-bearing
epiphyses. Its risk increases with age and higher steroid doses.
These high-risk patients may benefit from early screening for AVN. Cite this article:
We undertook a cemental unipolar proximal femoral endoprosthetic replacement in 131 patients with a mean age of 50 years (2 to 84). Primary malignant tumours were present in 54 patients and 67 had metastatic disease. In addition, eight patients had either lymphoma or myeloma and two had non-oncological disorders. The mean follow-up was 27 months (0 to 180). An acetabular revision was required later in 14 patients, 12 of whom had been under the age of 21 years at the time of insertion of their original prosthesis. The risk of acetabular revision in patients over 21 years of age was 8% at five years compared with 36% in those aged under 21 years. All the unipolar hips in this younger age group required revision within 11 years of the initial operation. We conclude that unipolar replacement should not be used in younger patients and should be avoided in patients with a life expectancy of more than five years.