Outcome of expandable prostheses in children.

BACKGROUND: Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved? MATERIALS AND METHODS: We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed. RESULTS: Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934). CONCLUSIONS: The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Survival analysis of patients with femoral metastases.

BACKGROUND: Previous studies reported on surgical indications for patients with femoral metastases. However, few studies analyzed the spectrum of femoral metastatic presentation. We performed this study to evaluate the survival of patients with femoral metastases, and clarify the treatment of femoral impending and actual pathological fractures. MATERIALS AND METHODS: We retrospectively studied 110 patients with femoral metastases from various cancers treated with nailing or resection and megaprosthetic reconstruction from 1995 to 2010. The mean follow-up was 18 months. Survival was analyzed with respect to different metastatic presentations regarding gender, type of cancer, number, and location of femoral metastases, type of surgery, and pathological fracture. RESULTS: Univariate predictors of survival were the pathological fracture and type of surgery; multivariate predictor was only the pathological fracture. Survival was significantly higher in patients with resection compared to nailing, impending compared to actual fracture, solitary metastasis and impending fracture, actual fracture treated with resection, proximal femoral actual fracture and distal femoral impending fracture treated with resection. CONCLUSIONS: Patients with femoral metastases have better survival when present with impending compared to actual pathological fracture. Although with a higher rate of complications, patients with pathological fractures of the proximal and distal femur may benefit from resection.

Side effects of radiation in musculoskeletal oncology: clinical evaluation of radiation-induced fractures.

Radiation therapy and chemotherapy, while they remain an essential part of the multidisciplinary treatment of cancers, they have led to unwanted complications. Radiation-induced complications include wound and bone, growth, nervous system, tumorigenic, lung, gastrointestinal, hepatic and other complications. In this article we review the side effects of radiation therapy in musculoskeletal oncology emphasizing on bone, present our long experience, and discuss the current literature regarding radiation-induced bone complications and their management and outcome.

Acute renal failure in orthopaedic surgery.

Orthopaedic diseases affect a broad spectrum of patients, and many of these have concomitant medical problems that may differ from those of the general surgical population. Acute postoperative renal failure is thought to arise secondary to acute tubular necrosis from volume depletion, reduction in glomerular filtration rate, hypotension, and nephrotoxic drugs. If acute renal failure occurs and necessitates hemodialysis, morbidity and mortality are significantly increased. To enhance the literature, we performed this study to review the rates and risk factors for acute renal failure in orthopaedic surgery. This information may be useful for orthopaedic surgeons and treating physicians during the rehabilitation stage, to provide a rationale to stratify a patient's risk of acute renal failure or death on the basis of perioperative medical factors and type of surgery, or for improved perioperative monitoring, better surveillance, and preventive measures to reduce this risk.

Outcome of surgical treatment of 54 Periprosthetic femoral fractures after total hip arthroplasty at mid term follow-up.

PURPOSE: The aim of the present study was to review the outcome of the surgical treatment of 54 periprosthetic femoral fractures (PFF) after total hip arthroplasty at a mean follow-up of 45 months. At final follow-up, the clinical outcome was measured using the Harris Hip score (HHS), the Karnofsky score (KS), while, the radiographic results were evaluated using the Beals and Tower's criteria. RESULTS: There were 13 post-operative complications that occurred in 10 patients with an overall re-operation rate of 11%. At final follow-up the mean HHS was 64 (range 20-100) and the mean KS was 66 (range 30-100). The radiological results were excellent in 89%, good in 9% and poor 2% of patients. The mortality rate was 0% at 3 months and 3.7% at one year post-operatively. The mean last HHS and KS of patients older than 75 years or with comorbidities were lower than that of patients younger than 75 years or without comorbidities. CONCLUSIONS: Although this study have shown that the surgical treatment of PFF was associated with a low re-operative rate, a good to excellent radiological results and a low mortality rate at 3 months and 1 year postoperatively, there was a marked functional deterioration in many patients. This decline of function could be attributed to the advanced age of patients and the presence of comorbidities.

Side effects of chemotherapy in musculoskeletal oncology.

With recent advances in medical and orthopedic oncology, radiation therapy and single- or multiple-agent perioperative chemotherapy are currently applied as an essential part of the multidisciplinary treatment to improve disease-free and overall survival of patients with primary and metastatic bone and soft tissue tumors. However, these treatments have led to unwanted complications. A better understanding of the effects of various antineoplastic agents on bone, soft tissue, and organs may provide the basis for the more efficacious use of antiproliferative drugs when fracture healing or allograft incorporation is required. This knowledge may also provide a rationale for concurrent treatment with drugs that protect against or compensate for adverse effects in osseous repair resulting from chemotherapy.

Side effects of radiation in musculoskeletal oncology.

Radiation therapy is applied for systemic effects to patients with bone and soft tissue tumors and for local effects that facilitate the surgical procedure. However, while it remains an essential treatment of cancers, radiation therapy is associated with unwanted complications. The purpose of this review is to summarize information regarding the complications of radiation in musculoskeletal oncology and their management. Because preoperative radiotherapy is associated with an increased risk of wound complications and postoperative radiation is associated with an increased risk of postradiation fractures, the physician requires additional information in deciding on the best method of treatment, and such information is provided in this review.

Middle term results of tantalum acetabular cups in total hip arthroplasty following pelvic irradiation.

OBJECTIVES: The aim of this study was to evaluate the middle term cup survival, assess the functional implementation and the radiographic evolution of tantalum acetabular cups implanted on patients with a history of pelvic radiotherapy. METHODS: From 2005 to 2013, we performed 12 THA replacements (4 males 8 females; mean age: 46.6 years (range 25-75)) on irradiated bone with Trabecular metal acetabular cups, 8 primary implants and 4 revision implants. The mean radiation dose delivered was 5500 cGy (range 3000 cGy-13,600 cGy). The mean follow-up was 68 months, ranging from 38 to 136. Postoperative follow-up time was assessed at 1, 3, 6 and 12 months, then annually. Double projection radiographs were requested at each control. Radiographic signs of loosening were investigated by X-rays looking for radiolucent lines. We used the Harris hip score for the clinical and functional evaluation. RESULTS: To now none of the 12 patients in the series needed any revision surgery for aseptic loosening. In the revision group one patient have been revised for septic loosening, two patients have been treated by conservative procedure for hip dislocation. Post-operative Harris hip score improved from an average of 46 points to 85.3 points. At last follow-up we found only in one case radiographic signs of progressive lucent line, without clinical sign of failure. CONCLUSION: In a clinical setting, tantalum cup seems to provide a good stability due to the integration of the trabecular metal to the underline cancellous bone. The reported results, in agreement with literature data, propose the use of tantalum cups in irradiated bone. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Infected Prostheses after Lower-Extremity Bone Tumor Resection: Clinical Outcomes of 100 Patients.

BACKGROUND: Infection of megaprostheses after bone tumor resection is a major concern; management is challenging. This study evaluated the survivability from such infections, the microbial isolates, treatment tactics, and outcome of megaprosthesis reconstructions. MATERIALS AND METHODS: We studied 1,161 patients retrospectively who underwent megaprosthesis reconstruction for limb salvage after a sarcoma from 1983 to 2010. The mean followup was 9 y (range 3-20 y). We evaluated the overall survival of the megaprosthesis reconstructions in patients with infection and the survival with respect to the type of megaprosthesis, site of reconstruction, cemented or cementless fixation, type of tumor, adjuvant treatments, microbial isolate(s), treatment tactics, and outcome. RESULTS: The incidence of infection was 8.6%. The most common microbial isolate was Staphylococcus epidermidis (47%). Overall survival with definitive management of infection was 88% at 10 y and 84% at 20 y. Survival was higher for cementless reconstructions and not different with respect to the type of megaprosthesis, site of reconstruction, or adjuvant therapy. Infections resolved completely with one- or two-stage surgery in 75% of patients. The rate of amputation because of infection was 21%. CONCLUSIONS: Megaprosthesis reconstructions may be infected in 8.6% of cases. Infections more commonly occur late, caused usually by S. epidermidis. The survival rate is higher with cementless megaprosthesis reconstructions and no different with respect to the type of tumor or megaprosthesis or the adjuvant treatments. One-stage revision is effective for acute post-operative infections; however, two-stage revision surgery is necessary for early and late infections. The rate of amputation because of occurrence or persistence of megaprosthesis infection is 21%.