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Der proximale und komplette Femurersatz

Proximal and total femur replacement

Operative Orthopädie und Traumatologie volume 24, pages 215–226 (2012)Cite this article

Zusammenfassung

Operationsziel

Ziel der Operation ist die Rekonstruktion segmentaler Knochensubstanzverluste des proximalen Femur nach weiter Tumorresektion oder nach Revisionseingriffen in der Hüftendoprothetik.

Indikationen

Aggressive benigne und primär maligne Knochentumoren des proximalen Femur, stabilitätsgefährdende Knochenmetastasen, ausgeprägter segmentaler Knochensubstanzverlust des proximalen Femur oder periprothetische Frakturen.

Kontraindikationen

Lokale floride Infektionen. Relative Kontraindikationen: Sehr kurze Lebenserwartung (< 3 Monate) und nicht vorhandenes azetabuläres Lager.

Operationstechnik

Anterolateraler Zugang, Darstellung und Ablösung des M. iliopsoas und des M. gluteus medius mit Sicherheitsabstand zum Knochen. Armierung der Sehnenstümpfe mit nichtresorbierbarem Nahtmaterial. Distale Durchtrennung von M. vastus lateralis, M. vastus intermedius und M. rectus femoris in Abhängigkeit der extraossären Tumorausdehnung. Distale Femurosteotomie mit Sicherheitsabstand von mindestens 3 cm zum Tumor. Bei totalem Femurersatz zusätzliche laterale Arthrotomie mit Resektion der Bänder und Menisken. Präparation des Markraums unter Schutz mit Verbrügge-Zange. Nach Probereposition mit Probekomponenten Implantation der definitiven Komponenten unter Einstellung der Antetorsion in 5°-Schritten. Vor Reposition Überstülpen und Fixieren eines Anbindungsschlauchs. Refixierung der Muskulatur am Anbindungsschlauch. Bei totalem Femurersatz Präparation des Tibiaschafts, Montage der Femurkomponenten und Kopplung mit der distalen Femurkomponente.

Weiterbehandlung

Infektionsprophylaxe, 20 kg Teilbelastung, Bewegungsschiene.

Ergebnisse

Von Juni 2007 bis Dezember 2011 erfolgte bei 20 Patienten die Implantation eines proximalen MUTARS®-Femurersatzes und bei 2 Patientinnen die Implantation eines totalen MUTARS®-Femurs. Das mittlere Alter zum Operationszeitpunkt betrug 62,0 ± 18,1 Jahre (18–82 Jahre). Die Operationsindikationen waren 3 primär maligne Knochentumore und 19 Femurmetastasen. Zum Zeitpunkt der Datenerhebung konnten 15 Patienten mit einem mittleren Nachuntersuchungszeitraum von 20,3 ± 17,2 Monaten (4–51 Monate) nachuntersucht werden. Bezogen auf alle 22 Fälle traten 3 tiefe Protheseninfektionen (13,6%) und 2 Luxationen (9,1%) auf. Von den 15 nachuntersuchten Patienten hatten 3 ein sehr gutes (20%), 4 ein gutes (26,7%), 6 ein zufriedenstellendes (40%) und 2 (13,3%) ein schlechtes funktionelles Ergebnis im MSTS-Score nach Enneking.

Abstract

Objective

Reconstruction of segmental bone defects of the proximal femur following wide tumor resection or revision arthroplasty.

Indications

Aggressive benign or primary malignant bone tumors of the proximal femur; destructive metastases; massive segmental bone defects of the proximal femur; periprosthetic fractures.

Contraindications

Local infection; very short life expectancy (< 3 months); massive deficiency of acetabular bone stock.

Operative technique

Anterolateral approach. Exposure and detachment of the iliopsoas and gluteus medius muscle from the proximal femur with a sufficient safety margin to the bone; distal transsection of the vastus lateralis/intermedius and rectus femoris muscle according to the extraosseous tumor extension; distal femur osteotomy al least 3 cm beyond the farthest point of tumor extension; in case of total femur replacement, additional lateral arthrotomy of the knee with resection of the ligaments and menisci; reaming of the medullary canal after securing the shaft with a Verbrugge clamp; trial assembly and reduction followed by the definitive implantation of the prosthesis with adjustment of the femoral neck anteversion in 5° increments; soft tissue reconstruction and fixation to an attachment tube covering the prosthesis; in case of total femur replacement, the preparation of the tibia is followed by the coupling of the tibial and femoral components.

Postoperative management

Infection prophylaxis, 20 kg partial weight bearing, continuous passive motion.

Results

A total of 20  patients with proximal femur replacement and 2 patients with total femur replacement implanted between June 2007 and December 2011 were retrospectively reviewed. Three patients had primary malignant bone tumors, while 19 patients underwent resection for metastatic disease. The mean age at surgery was 62.0 ± 18.1 years (18–82 years). Fifteen patients with a mean follow-up of 20.3 ± 17.2 months (4–51 months) were studied. Among the 22 cases, periprosthetic infection occurred in 3 patients (13.6%), dislocation in 2 patients (9.1%). Evaluation of the functional outcome in 15 patients using the MSTS score by Enneking revealed 3 very good (20%), 4 good (26.7%), 6 fair (40%), and 2 poor (13.3%) results.

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Literatur

  1. Althausen P, Althausen A, Jennings LC et al (1997) Prognostic factors and surgical treatment of osseous metastases secondary to renal cell carcinoma. Cancer 80:1103–1109

    PubMed  Article  CAS  Google Scholar 

  2. Ascherl R (2010) Infection management of megaimplants. Orthopade 39:980–993

    PubMed  Article  CAS  Google Scholar 

  3. Berbari EF, Hanssen AD, Duffy MC et al (1998) Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 27:1247–1254

    PubMed  Article  CAS  Google Scholar 

  4. Bickels J, Jelinek JS, Shmookler BM et al (1999) Biopsy of musculoskeletal tumors. Current concepts. Clin Orthop Relat Res 368:212–219

    PubMed  Article  Google Scholar 

  5. Bickels J, Meller I, Henshaw RM et al (2000) Reconstruction of hip stability after proximal and total femur resections. Clin Orthop Relat Res 375:218–230

    PubMed  Article  Google Scholar 

  6. Bielack SS, Kempf-Bielack B, Delling G et al (2002) Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 20:776–790

    PubMed  Article  Google Scholar 

  7. Chandrasekar CR, Grimer RJ, Carter SR et al (2008) Modular endoprosthetic replacement for metastatic tumours of the proximal femur. J Orthop Surg Res 3:50

    PubMed  Article  Google Scholar 

  8. Della Valle CJ, Paprosky WG (2003) Classification and an algorithmic approach to the reconstruction of femoral deficiency in revision total hip arthroplasty. J Bone Joint Surg Am 85-A(Suppl 4):1–6

  9. Dürr HR, Refior HJ (1998) Prognosis of skeletal metastases. Orthopade 27:294–300

    PubMed  Google Scholar 

  10. Enneking WF, Dunham W, Gebhardt M et al (1990) A system for the classification of skeletal resections. Chir Organi Mov 75:217–240

    PubMed  CAS  Google Scholar 

  11. Enneking WF, Dunham W, Gebhardt M et al (1993) A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop 286:241–246

    PubMed  Google Scholar 

  12. Fottner A, Szalantzy M, Wirthmann L et al (2010) Bone metastases from renal cell carcinoma: patient survival after surgical treatment. BMC Musculoskelet Disord 11:145

    PubMed  Article  Google Scholar 

  13. Fox EJ, Hau MA, Gebhardt MC et al (2002) Long-term follow-up of proximal femoral allografts. Clin Orthop Relat Res 397:106–113

    PubMed  Article  Google Scholar 

  14. Gebhardt MC, Flugstad DI, Springfield DS et al (1991) The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. Clin Orthop Relat Res 270:181–196

    PubMed  Google Scholar 

  15. Gosheger G, Gebert C, Ahrens H et al (2006) Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res 450:164–171

    PubMed  Article  Google Scholar 

  16. Gosheger G, Goetze C, Hardes J et al (2008) The influence of the alloy of megaprostheses on infection rate. J Arthroplasty 23:916–920

    PubMed  Article  Google Scholar 

  17. Gosheger G, Hillmann A, Lindner N et al (2001) Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Relat Res 393:264–271

    PubMed  Article  Google Scholar 

  18. Grimer RJ, Belthur M, Chandrasekar C et al (2002) Two-stage revision for infected endoprostheses used in tumor surgery. Clin Orthop Relat Res 395:193–203

    PubMed  Article  Google Scholar 

  19. Heisel C, Kinkel S, Bernd L et al (2006) Megaprostheses for the treatment of malignant bone tumours of the lower limbs. Int Orthop 30:452–457

    PubMed  Article  Google Scholar 

  20. Jeys LM, Grimer RJ, Carter SR et al (2005) Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am 87:842–849

    PubMed  Article  CAS  Google Scholar 

  21. Jeys LM, Kulkarni A, Grimer RJ et al (2008) Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg Am 90:1265–1271

    PubMed  Article  CAS  Google Scholar 

  22. Kabukcuoglu Y, Grimer RJ, Tillman RM et al (1999) Endoprosthetic replacement for primary malignant tumors of the proximal femur. Clin Orthop Relat Res 358:8–14

    PubMed  Article  Google Scholar 

  23. Lin PP, Mirza AN, Lewis VO et al (2007) Patient survival after surgery for osseous metastases from renal cell carcinoma. J Bone Joint Surg Am 89:1794–1801

    PubMed  Article  Google Scholar 

  24. Mankin HJ (2003) The changes in major limb reconstruction as a result of the development of allografts. Chir Organi Mov 88:101–113

    PubMed  Google Scholar 

  25. McDonald DJ, Capanna R, Gherlinzoni F et al (1990) Influence of chemotherapy on perioperative complications in limb salvage surgery for bone tumors. Cancer 65:1509–1516

    PubMed  Article  CAS  Google Scholar 

  26. Menendez LR, Ahlmann ER, Kermani C et al (2006) Endoprosthetic reconstruction for neoplasms of the proximal femur. Clin Orthop Relat Res 450:46–51

    PubMed  Article  Google Scholar 

  27. Mittermayer F, Windhager R, Dominkus M et al (2002) Revision of the Kotz type of tumour endoprosthesis for the lower limb. J Bone Joint Surg Br 84:401–406

    PubMed  Article  CAS  Google Scholar 

  28. Morris HG, Capanna R, Campanacci D et al (1994) Modular endoprosthetic replacement after total resection of the femur for malignant tumour. Int Orthop 18:90–95

    PubMed  Article  CAS  Google Scholar 

  29. Palumbo BT, Henderson ER, Groundland JS et al (2011) Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques. Cancer Control 18:160–170

    PubMed  Google Scholar 

  30. Sharma S, Turcotte RE, Isler MH et al (2007) Experience with cemented large segment endoprostheses for tumors. Clin Orthop Relat Res 459:54–59

    PubMed  Article  Google Scholar 

  31. Unni K (1996a) Chondrosarcoma primary, secondary, dedifferentiated, and clear cell. In: Unni K (Hrsg) Dahlin’s bone tumor. General aspects and data on 11,987 cases. JB Lippincott, Philadelphia S 71–108

  32. Unni K (1996b) Ewing-Tumor. In: Unni K (Hrsg) Dahlin’s bone tumor. General aspects and data on 11,987 cases. JB Lippincott, Philadelphia, S 249–261

  33. Unni K (1996c) Osteosarcoma. In: Unni K (Hrsg) Dahlin’s bone tumor. General aspects and data on 11,987 Cases. JB Lippincott, Philadelpia, S 143–183

  34. Unwin PS, Cannon SR, Grimer RJ et al (1996) Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br 78:5–13

    PubMed  CAS  Google Scholar 

  35. Winkelmann W (2010) Reconstruction of the proximal femur with the MUTARS(R) system. Orthopade 39:942–948

    PubMed  Article  CAS  Google Scholar 

  36. Zeegen EN, Aponte-Tinao LA, Hornicek FJ et al (2004) Survivorship analysis of 141 modular metallic endoprostheses at early follow-up. Clin Orthop Relat Res 420:239–250

    PubMed  Article  Google Scholar 

  37. Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351:1645–1654

    PubMed  Article  CAS  Google Scholar 

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Affiliations

  1. Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Rheinische Friedrich-Wilhems-Universität Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland

    P.H. Pennekamp & D.C. Wirtz

  2. Orthopädische Klinik und Poliklinik, Schwerpunkt Tumororthopädie, LMU München, München, Deutschland

    H.R. Dürr

Authors
  1. P.H. Pennekamp
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  2. D.C. Wirtz
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  3. H.R. Dürr
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Correspondence to P.H. Pennekamp.

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Pennekamp, P., Wirtz, D. & Dürr, H. Der proximale und komplette Femurersatz. Oper Orthop Traumatol 24, 215–226 (2012). https://doi.org/10.1007/s00064-011-0061-7

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Schlüsselwörter

  • Ersatzarthroplastik
  • MUTARS
  • Megaprothese
  • Knochenneoplasien
  • Knochenmetastase

Keywords

  • Arthroplasty replacement
  • MUTARS
  • Megaprosthesis
  • Bone neoplasms
  • Bone metastasis