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Distal Femur Allograft Prosthetic Composite Reconstruction for Short Proximal Femur Segments following Tumor Resection

DOI: 10.1155/2013/397456

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Abstract:

Short metaphyseal segments remaining after distal femoral tumor resection pose a unique challenge. Limb sparing options include a short stemmed modular prosthesis, total endoprosthetic replacement, cross-pin fixation to a custom implant, and allograft prosthetic composite reconstruction (APC). A series of patients with APC reconstruction were evaluated to determine functional and radiologic outcome and complication rates. Twelve patients were retrospectively identified who had a distal femoral APC reconstruction between 1994 and 2007 to salvage an extremity with a segment of remaining bone that was less than 20 centimeters in length. Seventeen APC reconstructions were performed in twelve patients. Eight were primary procedures and nine were revision procedures. Average f/u was 89 months. Twelve APC reconstructions (71%) united and five (29%) were persistent nonunions. At most recent followup 10 patients (83%) had a healed APC which allowed WBAT. One pt (8%) had an amputation and one pt (8%) died prior to union. Average time to union was 19 months. Four pts (33%) or five APC reconstructions (29%) required further surgery to obtain a united reconstruction. Although Distal Femoral APC reconstruction has a high complication rate, a stable reconstruction was obtained in 83% of patients. 1. Introduction Resection of large skeletal tumors can result in short metaphyseal juxtaarticular segments of host bone which can pose a reconstructive challenge to the musculoskeletal tumor surgeon. In addition, aseptic loosening or fracture around a standard reconstruction can lead to loss of bone stock so that only a short metaphyseal segment of host bone remains for fixation in revision surgery. Limb salvage reconstructive options in this scenario include the use of a standard endoprosthesis with fixation of the stem into the short segment of host bone, use of custom implants allowing for cross-pin fixation of the endoprosthesis to the host bone, use of an endoprosthesis to replace the entire bone, and use of a composite of an allograft and an endoprosthesis [1–3]. Use of a standard, modular endoprosthesis with cement or press fit fixation in this setting has not been directly investigated to our knowledge; however, the use of a short stem cemented into the metaphyseal segment would be expected to have a high rate of aseptic loosening due to the high stress imparted on the relatively short interface between host bone and cement [2] (Figure 1). Use of cross-pin fixation of a custom prosthesis to host bone has been described previously with a low rate of aseptic loosening

References

[1]  C. P. Cannon, J. J. Eckardt, J. M. Kabo et al., “Custom cross-pin fixation of 32 tumor endoprostheses stems,” Clinical Orthopaedics and Related Research, no. 417, pp. 285–292, 2003.
[2]  J. J. Eckardt, F. R. Eilber, G. Rosen et al., “Endoprosthetic replacement for stage IIB osteosarcoma,” Clinical Orthopaedics and Related Research, no. 270, pp. 202–213, 1991.
[3]  H. G. Morris, R. Capanna, D. Campanacci, M. del Ben, and A. Gasbarrini, “Modular endoprosthetic replacement after total resection of the femur for malignant tumour,” International Orthopaedics, vol. 18, no. 2, pp. 90–95, 1994.
[4]  H. J. Mankin, F. J. Hornicek, and M. Harris, “Total femur replacement procedures in tumor treatment,” Clinical Orthopaedics and Related Research, no. 438, pp. 60–64, 2005.
[5]  W. G. Ward, F. Dorey, and J. J. Eckardt, “Total femoral endoprosthetic reconstruction,” Clinical Orthopaedics and Related Research, no. 316, pp. 195–206, 1995.
[6]  P. S. Unwin, S. R. Cannon, R. J. Grimer, H. B. Kemp, R. S. Sneath, and P. S. Walker, “Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb,” Journal of Bone and Joint Surgery B, vol. 78, no. 1, pp. 5–13, 1996.
[7]  S. S. Kohles, M. D. Markel, M. G. Rock, E. Y. Chao, and R. Vanderby Jr., “Mechanical evaluation of six types of reconstruction following 25, 50, and 75% resection of the proximal femur,” Journal of Orthopaedic Research, vol. 12, no. 6, pp. 834–843, 1994.
[8]  M. D. Markel, F. Gottsauner-Wolf, M. G. Rock, F. J. Frassica, and E. Y. S. Chao, “Mechanical characteristics of proximal femoral reconstruction after 50% resection,” Journal of Orthopaedic Research, vol. 11, no. 3, pp. 339–349, 1993.
[9]  J. Bickels, I. Meller, R. M. Henshaw, and M. M. Malawer, “Reconstruction of hip stability after proximal and total femur resections,” Clinical Orthopaedics and Related Research, no. 375, pp. 218–230, 2000.
[10]  Y. Farid, P. P. Lin, V. O. Lewis, and A. W. Yasko, “Endoprosthetic and allograft-prosthetic composite reconstruction of the proximal femur for bone neoplasms,” Clinical Orthopaedics and Related Research, no. 442, pp. 223–229, 2006.
[11]  D. J. Biau, V. Dumaine, A. Babinet, B. Tomeno, and P. Anract, “Allograft-prosthesis composites after bone tumor resection at the proximal tibia,” Clinical Orthopaedics and Related Research, no. 456, pp. 211–217, 2007.
[12]  S. Gitelis and P. Piasecki, “Allograft prosthetic composite arthroplasty for osteosarcoma and other aggressive bone tumors,” Clinical Orthopaedics and Related Research, no. 270, pp. 197–201, 1991.
[13]  M. J. Hejna and S. Gitelis, “Allograft prosthetic composite replacement for bone tumors,” Seminars in Surgical Oncology, vol. 13, pp. 18–24, 1997.
[14]  A. I. Harris, S. Gitelis, M. G. Sheinkop, A. G. Rosenberg, and P. Piasecki, “Allograft prosthetic composite reconstruction for limb salvage and severe deficiency of bone at the knee or hip,” Seminars in Arthroplasty, vol. 5, no. 2, pp. 85–94, 1994.
[15]  R. M. Wilkins and C. M. Kelly, “Revision of the failed distal femoral replacement to allograft prosthetic composite,” Clinical Orthopaedics and Related Research, no. 397, pp. 114–118, 2002.

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