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Segmental resection of malignant bone disease in the femoral diaphysis with subsequent limb reconstruction is a major undertaking. This is a retrospective review of 23 patients who had undergone limb salvage by endoprosthetic replacement of the femoral diaphysis for a primary bone tumour between 1989 and 2005.
There were 16 males and seven females,...
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The best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following...
Citations
... However, this method has some disadvantages. Hanna et al. reported the outcomes of 23 patients treated with prosthetic reconstruction after the segmental resection of primary bone tumours, and the complications included breakage of the prosthesis (8%), aseptic loosening (4%), and periprosthetic fractures (4%) 12 . Sewell et al. reported the outcomes of 18 patients treated with intercalary diaphyseal prosthetic reconstruction for malignant tibial bone tumours, and the complications included four cases of aseptic loosening, and two cases of periprosthetic fracture 13 . ...
To illustrate the surgical technique and explore clinical outcomes of the reconstruction for the malignant and metastatic bone tumour of proximal femur with metallic modular intercalary prosthesis. Sixteen patients who underwent modular intercalary prosthetic reconstruction after tumour resection were included from April 2012 and October 2020. Prosthesis and screws parameters, resected bone length and residual bone length, clinical outcomes and survivorship were analyzed. All patients were followed up for an average of 19 months (range 1–74). In our series, 12 patients died of the progression of the primary disease at the final follow-up. The cumulative survivorship since the treatment of proximal femoral metastasis was 78.6% (11 patients) at 6 months and 38.5% (5 patients) at 1 year. The mean MSTS score was 22.25 ± 4.55 among all patients. There were no cases of loosening or breakage of the prostheses, plates or screws, despite the various measurements of prostheses and residual bones. Modular intercalary prosthetic reconstruction was an effective method for malignant tumour of the proximal femur, including the advantages of providing early pain relief, quickly restoring postoperative function, required a short operation time, and preserving the adjacent joints.
... The infection rates varied in former reported literatures from 0% and 18% [7,8,19,29]. Sanders et al. [8] reported an overall infection rate of 6% for 32 patients at an median 7.7 years follow-up and Hanna et al. [30] reported an overall infection rate of 4% for 16 patients at an average 4 years follow-up. Infection occured in two patients in our study. ...
Purpose The aim of this study was to analyze the long-term clinical outcomes of intercalary allograft reconstruction for primary malignant bone tumors in lower extremities.
Methods A retrospective study was conducted on 29 patients (16 males, 13females) who underwent intercalary allograft reconstruction for primary malignant bone tumors in lower extremities between September 2007 and December 2012. The average age were 23.4 ± 15.1 years (range, 9–64) and the most common pathological type was osteosarcoma (17) followed by Ewing’s sarcoma (4), adamantinoma (4), chondrosaroma in 2, angiosarcoma of bone in 1 and undifferentiated pleomorphic sarcoma in 1. The tumor locations were in the femur in 13 and the tibius in 16. All complications and allograft failures occuered were recorded in this study. The oncological outcomes included local control, metastasis, progression-free survival and overall survival. The functional outcomes were evaluated by Musculoskeletal Tumor Society Score (MSTS-93).
Results 29 patients was included in this retrosepective study and there were no patients lost in the follow-up period. The mean follow-up time was 149.8 ± 42.1 months (43–194). Three patients (10.3%) deceased in the last follow-up due to distant metastasis. The average diaphyseal bone resection length was 172.7 ± 29.2 mm (range, 130 to 240mm). The average allograft survival time was 134.4 ± 53.7 months (range, 6 to 194 months). The mean union time was 16.3 (6–29) months and overall survivorship of the allograft was 82.7% (24/29) at an average 12.5 years follow-up. The average MSTS-93 score was 86% (range, 70–100%). Ninteen patients (66.5%) had at least one complication in the follow-up time. The common unoncological complications were bone non-union (8), fracture (3), infection (2) and leg length discrepancy (LLD, 2).
Conclusions The intercalary allograft reconstruction is a reliable technique to resolve the massive bone defects after primary diaphyseal bone tumor resection in lower extremities with acceptable long-term function and satisfaction.
Level of evidence: level IV Therapeutic.
... Complications most commonly include aseptic loosening, mechanical failure, and infection, similar to other endoprosthetic reconstructions. However, there are limited number of studies that report outcomes after reconstruction with an intercalary endoprosthesis [1,11,[13][14][15][16][17][18][19]. ...
... Case 5 had six subsequent surgeries including; 1) Excision of a symptomatic soft tissue bursal sac at seven months after initial surgery; 2) Revision of the collar and bolts of the endoprosthesis and free anterolateral thigh flap at eight months after initial surgery; 3) Removal of free flap and In a large study evaluating intercalary endoprosthesis reconstruction of the lower extremity, cumulative failure of the construct was found to be 60% at 10 years. We theorize our complication rate is on the higher end of this spectrum due to the lack of humeral implants, which have a much lower complication rate compared to lower extremity implants [1,17]. Similar to other studies, we found a high rate of complication of femoral reconstructions [1]. ...
... Previous studies have reported MSTS scores between 76%-90% [1,11,[13][14][15][16][17][18][19]. While we were unable report MSTS scores in our study, of the seven patients (77%) who had documentation of their ambulatory status, all were ambulatory at final follow up, and the rate of limb salvage in our study was 100%. ...
Background: Modular intercalary endoprostheses is a potential reconstructive option infrequently studied for diaphyseal defects of long bone. The purpose of this study was to examine the 1) Method of failure rate of revision after reconstruction with modular intercalary endoprostheses based on the anatomic site and 2) Describe the functional status of the patient and use of assistive devices with ambulation. Methods: A retrospective chart review was performed on patients with modular intercalary endoprosthesis from 2005-2019. Inclusion criteria included long bone defects secondary to tumor resection, trauma, or infection, and treated with intercalary or knee spanning endoprosthesis in the primary or revision setting. Ambulatory status, complications, and reoperations were collected and analyzed using descriptive statistics. Results: Nine patients out of twelve were included with three femur prostheses, three tibia prostheses, and three knee spanning arthrodesis. Mean age was 46-years-old and mean follow-up was 52 months. The four complications included structural failure and aseptic loosening in a femoral prosthesis, soft tissue failure (Type I) in a tibia prosthesis, and a local wound infection of one knee arthrodesis. All seven patients with reported ambulatory status were ambulatory at final follow-up. Conclusion: Our study demonstrates that modular intercalary endoprosthesis is a reconstruction option that can be used for defects after tumor resection, trauma, or infection. These data warrant further investigation into the use of an intercalary endoprosthesis for patients with diaphyseal defects of the long bone.
... Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. [1] Traditionally, the distal femur and proximal tibia were the most common sites for osteosarcomas. In the last century, patients with osteosarcoma had a low survival rate and often underwent amputation. ...
Limb salvage treatment for malignant bone tumors in children includes prosthetic and biological reconstruction. Early function following prosthesis reconstruction is satisfactory; however, there are several complications. Biological reconstruction is another way to treat bone defects. We evaluated the effectiveness of reconstruction of bone defects by liquid nitrogen inactivation of autologous bone with preserving epiphysis in 5 cases of periarticular osteosarcoma of the knee. We retrospectively selected 5 patients with articular osteosarcoma of the knee who underwent epiphyseal-preserving biological reconstruction in our department between January 2019 and January 2020. Femur involvement occurred in 2 cases and tibia involvement occurred in 3 cases, with an average defect of 18 cm (12-30 cm). The 2 patients with femur involvement were treated with inactivated autologous bone by liquid nitrogen with vascularized fibula transplantation. Among the patients with tibia involvement, 2 were treated with inactivated autologous bone with ipsilateral vascularized fibula transplantation and 1 was treated with autologous inactivated bone with contralateral vascularized fibula transplantation. Bone healing was evaluated by regular X-ray examination. At the end of the follow-up, lower limb length, knee flexion, and extension function were evaluated. Patients were followed up for 24 to 36 months. Average bone-healing time was 5.2 months (3-8 months). All patients achieved bone healing with no tumor recurrence and no distant metastasis and all patients survived. The lengths of both lower limbs were equal in 2 cases, with shortening by ≤1 cm in 1 case and shortening by 2 cm in 1 case. Knee flexion was >90° in 4 cases and between 50 and 60° in 1 case. The Muscle and Skeletal Tumor Society score was 24.2 (range 20-26). Inactivation of autogenous bone with the epiphysis preserved by liquid nitrogen combined with vascularized fibula reconstruction for periarticular osteosarcoma of the knee in children is safe and effective. This technique supports bone healing. Postoperative limb length and function, and short-term effects were satisfactory.
... Based on the development of surgical techniques and implant materials, considerable scientific investigations have been carried out to improve oncological segmental resection, which requires the reconstruction of intercalary prostheses in the extremities [3]. However, how to preserve more anatomical structures and how to acquire better postoperative prognosis while ensuring safe surgical margins remain difficult issues when applying an intercalary prosthesis that involves both diaphyseal and proximal metaphyseal regions to reconstitute segmental massive bone defects, particularly in the femur [4,5]. Generally, there exists a pivotal point that the guarantee of steady bone-implant integration and acceptable postoperative function often requires sufficiently long and thick stems in modular or customized prostheses, which are utilized in the segmental resection of diaphyseal tumors [6], and Ahlmann et al. proposed that the implant stem should be applied at least 5.0 cm to stabilize the internal fixation [7]. ...
Background
To reconstruct massive bone defects of the femoral diaphysis and proximal end with limited bilateral cortical bone after joint-preserving musculoskeletal tumor resections, two novel 3D-printed customized intercalary femoral prostheses were applied.
Methods
A series of nine patients with malignancies who received these novel 3D-printed prostheses were retrospectively studied between July 2018 and November 2021. The proximal and diaphyseal femur was divided into three regions of interest (ROIs) according to anatomic landmarks, and anatomic measurements were conducted on 50 computed tomography images showing normal femurs. Based on the individual implant-involved ROIs, osteotomy level, and anatomical and biomechanical features, two alternative 3D-printed prostheses were designed. In each patient, Hounsfield Unit (HU) value thresholding and finite element analysis were conducted to identify the bone trabecula and calcar femorale and to determine the stress distribution, respectively. We described the characteristics of each prosthesis and surgical procedure and recorded the intraoperative data. All patients underwent regular postoperative follow-up, in which the clinical, functional and radiographical outcomes were evaluated.
Results
With the ROI division and radiographic measurements, insufficient bilateral cortical bones for anchoring the traditional stem were verified in the normal proximal femur. Therefore, two 3D-printed intercalary endoprostheses, a Type A prosthesis with a proximal curved stem and a Type B prosthesis with a proximal anchorage-slot and corresponding locking screws, were designed. Based on HU value thresholding and finite element analysis, the 3D-printed proximal stems in all prostheses maximally preserved the trabecular bone and calcar femorale and optimized the biomechanical distribution, as did the proximal screws. With the 3D-printed osteotomy guide plates and reaming guide plates, all patients underwent the operation uneventfully with a satisfactory duration (325.00 ± 62.60 min) and bleeding volume (922.22 ± 222.36 ml). In the follow-up, Harris Hip and Musculoskeletal Tumor Society scores were ameliorated after surgery ( P < 0.001 and P < 0.001, respectively), reliable bone ingrowth was observed, and no major complications occurred.
Conclusions
Two novel 3D-printed femoral intercalary prostheses, which achieved acceptable overall postoperative outcomes, were used as appropriate alternatives for oncologic patients with massive bone defects and limited residual bone and increased the opportunities for joint‐preserving tumor resection. Several scientific methodologies utilized in this study may promote the clinical design proposals of 3D-printed implants.
... It offers a potential replacement therapy for significant loss of bone either due to disease or injury. In practice segmental resection of malignant bone disease in femoral diaphysis and amputation due to injury and infection is a major undertaking (9) . For reconstruction of Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0 bone defect, allografts from orthopaedic bone Bank is invariable used. ...
... However, the lower long-term graft survival rate of the prostheses is a major concern when applied in young patients [7,14]. The survival of the prostheses was 68% at 10 years in Hanna's series [15]. Shehadeh et al. found that the survival curve of the prostheses showed a constant decline over time and the implant survival was 72% at 10 years and 37% at 20 years [16]. ...
This study aimed to evaluate the clinical outcomes and complications of reconstruction with a composite free fibula inside other biological grafts. We retrospectively reviewed 26 patients who underwent reconstruction after bone tumor resection of the diaphysis of the long bone. Surgical data, time to bony union, functional outcomes, and complications were evaluated in all cases. The median follow-up was 72.5 months. The limb salvage rate was 100%. Primary osseous union was achieved in 90.4% of the junctions. The union rates at the metaphyseal and diaphyseal junctions were 100% and 85.7%, respectively (p = 0.255). The mean time of bony union in the upper (87.5%) and lower (91.7%) extremity was 4.6 ± 1.6 months and 6.9 ± 2 months, respectively. The mean MSTS score was 27.2 ± 3.2, with a mean MSTS rating of 90.7%. Complications occurred in 15.4% of the cases. The administration of vascularized or non-vascularized grafts did not significantly influence the union time (p = 0.875), functional outcome (p = 0.501), or blood loss (p = 0.189), but showed differences in operation time (p = 0.012) in lower extremity reconstruction. A composite free fibula inside other biological grafts provides a reasonable and durable option for osseous oncologic reconstruction of the long bone diaphysis of the extremities with an acceptable rate of complications. A higher union rate was achieved after secondary bone grafting. In lower-extremity reconstruction, two plates may be considered a better option for internal fixation. Vascularizing the fibula did not significantly affect the union time.
... There are several options to achieve reconstruction of intercalary meta-/diaphyseal defects following tumor resection. Segmental prosthesis has been widely used to provide good function with quick recovery; however, prosthesis' durability becomes an issue over time [17,18]. It cannot be considered a permanent solution for reconstruction. ...
Background
For patients with malignant limb tumors, salvage surgery can be achieved using endoprosthesis or biological reconstructions like allograft or autograft. In carefully selected patients, resected bone can be recycled after sterilization using methods like autoclaving, irradiation, pasteurization or freezing with liquid nitrogen. We evaluated the clinical outcome and complications of malignant limb tumors treated with intercalary resection and frozen autograft reconstruction.
Methods
We reviewed 33 patients whose malignant bone tumors were treated by wide resection and reconstruction with recycling liquid nitrogen-treated autografts between 2006 and 2017. Limb function, bone union at the osteotomy site and complications were evaluated. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system.
Results
The cohort comprised 16 males and 17 females, with a mean age of 35.4 years (14–76 years). The most common tumor was osteosarcoma (7 cases). Tumors were located in the humerus (5), ulna (1), femur (10) and tibia (17). The mean follow-up was 49.9 months (range 12–127 months). Of the 33 patients, 16 remained disease-free, and 3 were alive with disease. The mean size of the defect after tumor resection was 11.6 cm (range 6–25 cm). Bone union was achieved in 32 patients, with a mean union time of 8.8 months (range 4–18 months). Complications included 1 graft nonunion, 2 infections (1 superficial, 1 deep infection), 1 leg length discrepancy, 2 graft fractures and 3 local recurrences. The mean MSTS score was 87.2% (range 70–100%).
Conclusion
Liquid nitrogen-treated tumor-bearing autograft is an effective option for biological reconstruction after meta-/diaphyseal tumor resection of long bones. This method has excellent clinical outcomes and is especially recommended for patients with no severe osteolytic bone tumors.
... While a prosthetic replacement has become the mainstream. In total, there are four choices of the prosthesis in this method, including the custommade/modular megaprosthesis [1], allograft prosthetic composite (APC) [2], Compliant Pre-stress (CPS) implant [3], and the intercalary prosthesis [4][5][6][7]. ...
Background
Hip-preserved reconstruction for patients with ultrashort proximal femur segments following extensive femoral diaphyseal tumor resection is a formidable undertaking. A customized intercalary prosthesis with a rhino horn-designed uncemented stem was developed for the reconstruction of these extensive skeletal defects.
Methods
This study was designed to analyze and compare the differences in the biomechanical behavior between the normal femur and the femur with diaphyseal defects reconstructed by an intercalary prosthesis with different stems. The biomechanical behavior under physiological loading conditions is analyzed using the healthy femur as the reference. Five three-dimensional finite element models (healthy, customized intercalary prosthesis with four different stems implemented, respectively) were developed, together with a clinical follow-up of 12 patients who underwent intercalary femoral replacement.
Results
The biomechanical results showed that normal-like stress and displacement distribution patterns were observed in the remaining proximal femur segments after reconstructions with the rhino horn-designed uncemented stems, compared with the straight stem. Stem A showed better biomechanical performance, whereas the fixation system with Stem B was relatively unstable. The clinical results were consistent with the FEA results. After a mean follow-up period of 32.33 ± 9.12 months, osteointegration and satisfactory clinical outcomes were observed in all patients. Aseptic loosening (asymptomatic) occurred in one patient reconstructed by Stem B; there were no other postoperative complications in the remaining 11 patients.
Conclusion
The rhino horn-designed uncemented stem is outstanding in precise shape matching and osseointegration. This novel prosthesis design may be beneficial in decreasing the risk of mechanical failure and aseptic loosening, especially when Stem A is used. Therefore, the customized intercalary prosthesis with this rhino horn-designed uncemented stem might be a reasonable alternative for the reconstruction of SSPF following extensive tumor resection.
... The most common anatomical site of Ewing's sarcoma was the proximal humerus, followed by the proximal femur, distal femur and distal tibia. In three studies, the cancer was in the femoral diaphysis but the exact location was not specified [17,26,30]. The most common type of prosthesis used in these studies was Stanmore, which was used in 23 patients in seven studies. ...
... Other prostheses included were Repiphysis, MUTARS, Kotz, LUMiC, RESTOR, Lewis, HMRS and Non Hinged CCK megaprosthesis ( Table 2). Six studies used non-expanding prostheses [17,18,22,25,26,29], while the remaining eleven studies involved expanding prostheses [14][15][16][19][20][21]23,24,27,28,30]. Some studies used an expanding Stanmore prosthesis; however, three studies used custom made non-expanding Stanmore implants [17,18,22]. ...
... Six studies used non-expanding prostheses [17,18,22,25,26,29], while the remaining eleven studies involved expanding prostheses [14][15][16][19][20][21]23,24,27,28,30]. Some studies used an expanding Stanmore prosthesis; however, three studies used custom made non-expanding Stanmore implants [17,18,22]. ...
Ewing’s sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing’s patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing’s sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing’s patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson’s failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of ‘good’ functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES.
