Endoprosthetic replacement for bony metastases.

A series of 38 patients with long bone metastases treated at the Birmingham Bone Tumour Treatment Service with resection of the metastatic lesion and replacement of the bone defect with an endoprosthesis was reviewed. The majority of cases had pathological fractures due to a massive destructive lesion. Two-thirds of the patients had a solitary metastasis. Metastases from hypernephroma and breast carcinoma accounted for the majority of cases. All the patients were independently mobile after the endoprosthetic replacement and were pain free. The average survival rate after the endoprosthetic replacement was 14.7 months and this varies with the primary tumour. The indications for endoprosthetic replacement for the treatment of long bone metastases are outlined and the results and complications are discussed. It is concluded that endoprosthetic replacement for bony metastases is an effective palliative procedure for a selected group of patients.     

Endoprosthetic replacement of the proximal humerus

Endoprosthetic replacement of the proximal humerus has been performed in our unit on 25 occasions between 1950 and 1982. The indication for surgery was destruction of the proximal half of the humerus so extensive that the only alternatives were reconstruction or amputation. Of the patients with tumours two died from metastases, and three from unrelated causes; local recurrence necessitated amputation in two patients. Minor complications were frequent, but there were no deep infections and, after 1964, no prosthesis became loose. Active shoulder movement after operation was considerably limited, but passive movement was good and function of the elbow and hand were preserved.     

Endoprosthetic replacement of the ankle joint

Endoprosthetic replacement of the ankle joint is considered to be a modern alternative of the well-tried fusions of the joint. We try to explain indications and limits of alloarthroplasty in comparison to arthrodesis. The recent technical evolution will be presented: starting with the two-component-("first generation") and leading to the three-component ("second generation") designs, Suitable for cemented and cementless implantation as well. Results of three-component endoprostheses in the literature and our own experiences with implants of both generations especially regarding the time of survival will be discussed. Basing on the actual knowledge, we try to deduce a prognosis of the future way of ankle replacement.     

Endoprosthetic replacement of the proximal tibia

We have performed endoprosthetic replacement after resection of tumours of the proximal tibia on 151 patients over a period of 20 years. During this period limb-salvage surgery was achieved in 88% of patients with tumours of the proximal tibia. Both the implant and the operative technique have been gradually modified in order to reduce complications. An initial rate of infection of 36% has been reduced to 12% by the use of a flap of the medial gastrocnemius, to which the divided patellar tendon is attached. Loosening and breakage of the implant have been further causes of failure. We found that the probability of further surgical procedures being required was 70% at ten years and the risk of amputation, 25%. The development of a new rotating hinge endoprosthesis may lower the incidence of mechanical problems. Limb salvage for tumours of the proximal tibia is fraught with complications, but the good functional outcome in successful cases justifies its continued use.     

Intraarterial cisplatin in the management of stage IIB osteosarcoma in the pediatric and adolescent age group

Sixty patients with extremity osteosarcoma were treated with intraarterial cisplatin. This was followed by surgical resection (amputation or limb salvage) and postoperative adjuvant chemotherapy utilizing two different protocols. Seventy-five percent of patients achieved an initial response. Overall disease-free survival was 58%. The number of patients treated with limb-salvage surgery gradually increased to the extent that 80% of newly-registered patients achieved a response and were subjected to limb salvage. Disease-free survival was 48% in amputation and 68% in limb salvage. The only factors found to have prognostic significance in determining disease-free survival were extent of tumor destruction induced by preoperative chemotherapy and tumor size.     

Endoprosthetic joint replacement of the contracted elbow joint

In a retrospective study 14 patients were reviewed 63 months after the implantation of a semi-constrained total elbow prosthesis in fourteen stiff or ankylosed elbows with a preoperative range of elbow motion of 30 degrees or less. The result, according to the Mayo Elbow Performance score, was excellent for four elbows, good for four, fair for one, and poor for five. The average arc of flexion improved from 7 to 68 degrees postoperatively with an average increase of 34 degrees in flexion, and 27 degrees in extension. There were seven complications affecting seven of the 14 elbows and four of these seven elbows underwent a revision procedure. Replacement for a stiff elbow is the least predictable, has the lowest overall rate of success and highest complication rate, than any other procedure. Nevertheless, these disadvantages must be placed in the context of alternative intervention options. The semiconstrained total elbow arthroplasty seems to be a useful option for patients older than 50 years with intrinsic stiffness involving more than 50% of the articular surface and with an ankylosed or very stiff elbow.     

Endoprosthetic replacement of the humerus and elbow joint

Between 1969 and 1985 26 patients with destructive lesions of the distal humerus were treated by endoprosthetic replacement; each implant was custom-made and incorporated part of the distal humerus or the entire bone as well as a hinged total elbow replacement. Recurrence occurred in three of the patients with tumours, and three prostheses were removed because of deep infection in patients with previously compound injuries of the elbow. Another three loosened without infection, but none needed revision or removal and no amputations resulted. Other complications included nerve palsies, but the only deaths were from metastases. A useful range of elbow movement, with a stable arm and good hand function, was achieved in every patient.     

Endoprosthetic replacement of the proximal humerus. Long-term results

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire. The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45 degrees in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up.     

Endoprosthetic replacement of diaphyseal bone defects. Long-term results

We retrospectively studied 35 patients who underwent endoprosthetic reconstruction of diaphyseal bone defects after excision of primary sarcomas. The patients were treated between February 1979 and May 1999 and had more than 5 years follow-up. There were 22 males and 13 females and the median age at diagnosis was 29 (8–75) years. The bone defect measured a mean of 19 (10–27.6) cm. There were 29 femoral reconstructions, three tibial and three humeral. Cumulative overall survival for all patients was 65% at 10 years. Cumulative overall survival for prosthetic reconstruction, using revision surgery as an end point, was 63% at 10 years. Cumulative risk of failure of reconstruction, including infection, fracture, aseptic loosening, local recurrence and amputation, was 60% at 10 years. Tibial and humeral reconstructions fared less well than femoral. Endoprosthetic replacement is a useful method of reconstructing long intercalary defects, especially if situated in the femur.

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Résumé Nous avons étudié rétrospectivement 35 malades qui ont subi une reconstruction endoprothétique après excision diaphysaire dun sarcome primaire. Les malades ont été traités entre février 1979 et mai 1999 et avaient plus de 5 ans de suivi. Il y avait 22 hommes et 13 femmes et lâge médian au diagnostic était de 29 (8–75) ans. Le défaut osseux mesurait en moyenne 19 (10–27.6) cm. Il y avait 29 reconstructions fémorales, trois tibiales et trois humérales. La survie totale cumulative pour tous les malades était 65% à 10 ans. La survie totale cumulative pour la reconstruction prothétique, en utilisant la chirurgie de révision comme élément final, était de 63% à 10 ans. Le risque cumulatif déchec en incluant: linfection, la fracture, le démontage aseptique, la récidive locale et lamputation étaient de 60% à 10 ans. Les reconstructions tibiales et humérales sont allées moins bien que les fémorales. Le remplacement endoprothétique est une méthode utile pour reconstruire de longues pertes de substance intercalaires, surtout si elles sont situées sur le fémur.

     

Endoprosthetic surface replacement of the head of the humerus

The concept of an endoprosthetic surface replacement of the humeral head differs from that of stemmed endoprostheses. It is the replacement of the destroyed joint surface with reconstruction of the normal anatomy and minimal bone resection. The aim of this prospective study was to evaluate the short-term results of a newly developed cup arthroplasty (Durom-Cup) for the humeral head. In a prospective study, 39 patients with 46 Durom-Cups were evaluated preoperatively and every 3 months postoperatively. The average follow-up was 15 +/- 9 months. The group included 28 shoulders with rheumatoid arthritis, 15 joints with osteoarthritis, and 3 humeral head necroses. The Constant-score and SAS-function score were used. The Constant-score increased from 20.25 +/- 9.06 points preoperatively to 46.62 +/- 14.05 at 3 months, to 48.11 +/- 14.49 at 6 months, and to 55.25 +/- 11.6 at 9 months postoperatively. The Constant-score stayed at this level during further follow-up and was 55.81 +/- 16.31 at 12 months postoperatively. The best results were seen in the group of humeral head necroses with a Constant-score of 71.0 +/- 12.2 compared to 54.66 +/- 13.89 in the group of osteoarthritis and 56.78 +/- 13.33 in patients with rheumatoid arthritis at 12 months postoperatively. The results with the Durom-Cup are encouraging so that cup arthroplasty seems to be a good alternative to stemmed prostheses. The main advantages of the humeral head resurfacing are the bone-preserving fixation and the relatively simple surgical technique.     

Endoprosthetic replacement of the distal femur for bone tumours: long-term results

We investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur after resection of a tumour. Survival of the implant and 'servicing' procedures have been documented using a prospective database, review of the design of the implant and case records. In total, 335 patients underwent a distal femoral replacement, 162 having a fixed-hinge design and 173 a rotating-hinge. The median age of the patients was 24 years (interquartile range 17 to 48). A total of 192 patients remained alive with a mean follow-up of 12 years (5 to 30). The risk of revision for any reason was 17% at five years, 33% at ten years and 58% at 20 years. Aseptic loosening was the main reason for revision of the fixed-hinge knees while infection and fracture of the stem were the most common for the rotating-hinge implant. The risk of revision for aseptic loosening was 35% at ten years with the fixed-hinge knee, which has, however, been replaced by the rotating-hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason fell by 52% when the rotating-hinge implant was used. Improvements in the design of distal femoral endoprostheses have significantly decreased the need for revision operations, but infection remains a serious problem. We believe that a cemented, rotating-hinge prosthesis with a hydroxyapatite collar offers the best chance of long-term survival of the prosthesis.     

Endoprosthetic replacement of the distal tibia and ankle joint for aggressive bone tumours

Below knee amputation remains the treatment of choice for most patients with aggressive tumours of the distal tibia. We report the clinical and functional outcome of limb preserving surgery and endoprosthetic reconstruction of the distal tibia and ankle joint in five patients who declined amputation. The mean age was 32 years. Two had osteosarcoma, one Ewing’s sarcoma, leiomyosarcoma and Giant cell tumour. Three patients developed significant complications including local recurrence, wound dehiscence and infection, and fibula impingement. Despite these complications the patients declined amputation even in the presence of significant discomfort. Early function was excellent in all patients but deteriorated with time. The patients still maintained an Enneking Score of more than 50%. Some patients are unwilling to undergo amputation for aggressive tumours of the distal tibia. For these, excision and reconstruction with endoprosthesis allow early functional recovery but there is significant medium term morbidity and functional deterioration.

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Résumé  L’amputation au dessous du genou reste le traitement de choix pour la plupart des patients présentant des tumeurs agressives au niveau de l’extrémité distale du tibia. Nous rapportons ici les résultats cliniques et fonctionnels de 5 patients qui, ayant refusé toute amputation à ce niveau, ont bénéficié d’une chirurgie conservatrice et d’une reconstruction prothétique de l’extrémité inférieure du tibia et de la cheville. L’age moyen était de 32 ans. Deux patients présentaient un ostéosarcome; les autres présentaient un sarcome d’Ewing, un leiomyo-sarcome et une tumeur à cellules géantes. Trois patients ont présenté des complications sérieuses: récidive locale, désunion et infection, conflit au niveau de la fibula. Malgré ces complications aux conséquences fonctionnelles lourdes, tous les patients ont refusé l’amputation. Le résultat fonctionnel précoce a été excellent pour tous les patients mais s’est détérioré avec le temps. Certains patients refusent de subir une amputation pour une tumeur agressive de l’extrémité inférieure du tibia. Pour ces patients, l’excision et la reconstruction à l’aide d’endo-prothèses permettent d’obtenir un bon résultat fonctionnel précoce cependant la morbidité ainsi que la détérioration fonctionnelle avec le temps reste importante.

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Accepted: 16 August 1999     

Endoprosthetic replacement for primary tumours around the knee: experience from Peking University

In developing countries locally-made low-cost prostheses are mainly used in limb-salvage surgery to alleviate the economic burden. We retrospectively collected data on 104 patients treated by limb-salvage surgery between July 1997 and July 2005. We used a locally-designed and fabricated stainless-steel endoprosthesis in each case. Oncological and functional outcomes were evaluated at a mean follow-up of 47 months (12 to 118). A total of 73 patients (70.2%) were free from disease, nine (8.7%) were alive with disease, 19 (18.2%) had died from their disease and three (2.9%) from unrelated causes. According to the Musculoskeletal Tumor Society scoring system, the mean functional score was 76.3% (SD 17.8). The five-year survival for the implant was 70.5%. There were nine cases (8.7%) of infection, seven early and two late, seven (6.7%) of breakage of the prosthesis, three (2.9%) of aseptic loosening and two (1.9%) of failure of the polyethylene bushing. Multivariate analysis showed that a proximal tibial prosthesis and a resection length of 14 cm or more were significant negative prognostic factors. Our survival rates and Musculoskeletal Tumor Society functional scores are similar to those reported in the literature. Although longer follow-up is needed to confirm our results, we believe that a low-cost custom-made endoprosthesis is a cost-effective and reliable reconstructive option for limb salvage in developing countries.     

Endoprosthetic replacement of the shoulder joint. Possibilities and their analysis

Functional and anatomic characteristics of the shoulder girdle are special problems, that have to be solved in the process of using an artificial joint replacement to improve the function of a painful shoulder, which is restricted in movement. Seen from a biomechanical point of view, besides a safe fixation of the prosthesis the stability and kinematic of the artificial joint are of considerable importance for the success of the endoprosthetic treatment. The efforts of meeting these requirements by a respective prosthesis design led to a variety of prosthesis types. This study shows the possibilities for prosthetic replacement of the shoulder joint and comprises an analysis of all systems, which are available on the market, as well as of the patent applications of the past 15 years. The prostheses are listed according to their stability. Relative to the state of destruction of the joint unconstrained prosthesis types with completely free and partially restricted mobility, as well as constrained types of joints are being discussed.     

Histopathologic risk stratification of stage IIB colorectal cancer

Purpose

To stratify stage IIB (pT4a PN0) colorectal cancer in terms of histopathologic findings.

Methods

We reviewed the medical records of 80 patients who underwent surgery for stage IIB colorectal cancer. The disease-free survival (DFS) and overall survival (OS) rates were evaluated and correlated with the presence or absence of “Tumor Necrosis”, “Crohn’s-like lymphoid reaction”, and “Perineural Invasion”.

Results

Patients with “Tumor Necrosis” had significantly lower DFS rates (p < 0.0001), those with “Crohn’s-like lymphoid reaction” had significantly higher DFS rates (p = 0.037), and those with “Perineural Invasion” had significantly lower DFS rates (p < 0.0001). Patients with “Tumor Necrosis” had significantly lower OS rates (p = 0.016), those with “Crohn’s-like lymphoid reaction” had significantly higher OS rates (p = 0.022), and those with “Perineural Invasion” had significantly lower OS rates (p = 0.003).

Conclusions

Since stage IIB colorectal cancers accompanied by the pathological findings of “Tumor Necrosis” and “Perineural Invasion”, but with the absence of “Crohn’s-like lymphoid reaction” carried a poor prognosis, the efficacy of adjuvant chemoradiation must be considered for these patients.

     

Endoprosthetic replacement of the distal humerus following resection of bone tumours

Between 1988 and 2006, 18 patients had a custom-made endoprosthetic replacement of the distal humerus for bone tumours at our institution. There were 11 primary malignant neoplasms, six secondary deposits, and one benign aggressive tumour. The mean follow-up was for 4.4 years (1 to 18.2). Complications occurred in nine patients and included aseptic loosening in three (16.6%), local recurrence in two (11%), infection in two (11%), neuropraxia of the radial nerve in one (5.5%) and a peri-prosthetic fracture in one (5.5%). Excision was inadequate in four patients (22%), all of which developed local recurrence and/or metastases. There were seven deaths from the primary disease after a mean of 2.3 years (1 to 5), one of whom had an above-elbow amputation for local recurrence seven months before death. The remaining six had satisfactory elbow function at their last follow-up. The 11 living patients were evaluated using the Musculoskeletal Tumour Society and Toronto Extremity Salvage scoring systems. The mean scores achieved were 76% (67% to 87%) and 73% (59% to 79%), respectively. Overall, 17 of 18 patients had significant improvement in the degree of their pain following operation. Custom-made endoprosthetic reconstruction of the elbow for bone tumours is a viable treatment in carefully selected patients. It maintains satisfactory function and provides good pain relief.     

IIB osteosarcoma. Current management and survival statistics in the USSR

Three hundred and ninety-three patients with IIB osteosarcoma were treated at the author's institution between 1955 and 1986. In the first stage of the study, 88 patients were treated with surgery only. The five-year disease-free survival rate was 7%. In the second stage of the study, the efficacy of preventive chemotherapy after radical surgery was studied in 55 patients. The five-year disease-free survival rate was 34.4%. In the third stage of the study, the efficacy of combination therapy consisting of preoperative treatment, limb-saving surgery, and preventive chemotherapy was studied in 66 patients. The five-year disease-free survival rate was 35.5%. The authors examined results in 21 patients with Grade IV responses to evaluate the relationship between prognosis and morphogenic changes after preoperative radiotherapy and chemotherapy. The five-year disease-free survival rate was 57.9%. In the fourth stage of the study (conducted in 1986), two regimens of preoperative chemotherapy were initiated. The first regimen consists of intraarterial platinum infusions to patients with lower extremity bone damage. The second regimen consists of high-dose methotrexate infusions. The preliminary conclusion is that primary tumor damage is significantly more marked after intraarterial cisplatin infusion.