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Radiographic assessment of distal femur cemented stems in tumor endoprostheses

  • Original Article • KNEE - TUMORS
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Background

Distal femoral endoprosthesis (DFE) has become the optimal method of reconstruction in the skeletally mature patients treated for malignant bone tumor. Albeit literature has reported wide range of aseptic loosening in cemented components (6–32%), few authors showed that cement was not detrimental to long-term success of primary distal femoral implants possibly relating to cementing technique.

Methods

A series of consecutive of DFE (MRS and GMRS, Styker Orthopaedics, Mahwah, NJ) was retrospectively reviewed for evidence of loosening on plain radiographs. All prostheses had the standard straight 127-mm stem and a cemented polyethylene tibial component. Cementing technique involved reaming line to line to the selected stem size and cementing without pressurization. Radiographs were assessed by two independent blinded reviewers and scored for radiolucent zones (>1 mm) and graded as not loose, possibly, probable and definite loose. Furthermore, the final reamer/stem diameters, length of resection, tumor type, adjuvant treatment modalities, bushing exchange/revision surgery and infection rate were recorded.

Results

There were 70 patients and none were lost to follow-up. The average radiographic follow-up was 7.2 years (58% had f/u >5 years). Examiner A found 89% of femoral components to be “Not Loose” and 11% (n = 6) “Possibly Loose”. Examiner B found 96% of femoral components to be “Not Loose” and 4% (n = 2) to be “Possibly Loose”. No components scored as probably or definitely loose. Two DFE stems were reported as “Possibly Loose” by both reviewers. No femoral stem required revisions for either loosening, femur fracture or metal failure. Although infection was frequent, there was no septic loosening.

Conclusion

Despite our study limitations, no radiographic evidence of loosening was found. Cementing distal femur prosthesis with a tight canal fit and with a thin and inconsistent cement mantle appears to be a viable option at short and medium term.

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References

  1. Damron TA (1997) Endoprosthetic replacement following limb-sparing resection for bone sarcoma. Semin Surg Oncol 13(1):3–10

    Article  CAS  PubMed  Google Scholar 

  2. Bickels J, Wittig JC, Kollender Y, Henshaw RM, Kellar-Graney KL, Meller I, Malawer MM (2002) Distal femur resection with endoprosthetic reconstruction: a long-term followup study. Clin Orthop Relat Res 400:225–235

    Article  Google Scholar 

  3. Bergin PF, Noveau JB, Jelinek JS, Henshaw RM (2012) Aseptic loosening rates in distal femoral endoprostheses: does stem size matter? Clin Orthop Relat Res 470(3):743–750

    Article  PubMed  Google Scholar 

  4. Henderson ER, Groundland JS, Pala E, Dennis JA, Wooten R, Cheong D, Windhager R, Kotz RI, Mercuri M, Funovics PT, Hornicek FJ, Temple HT, Ruggieri P, Letson GD (2011) Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am 93(5):418–429

    Article  PubMed  Google Scholar 

  5. Henderson ER, O’Connor MI, Ruggieri P, Windhager R, Funovics PT, Gibbons CL, Guo W, Hornicek FJ, Temple HT, Letson GD (2014) Classification of failure of limb salvage after reconstructive surgery for bone tumours: a modified system Including biological and expandable reconstructions. Bone Joint J 96-B(11):1436–1440

    Article  CAS  PubMed  Google Scholar 

  6. Coathup MJ, Batta V, Pollock RC, Aston WJ, Cannon SR, Skinner JA, Briggs TW, Unwin PS, Blunn GW (2013) Long-term survival of cemented distal femoral endoprostheses with a hydroxyapatite-coated collar: a histological study and a radiographic follow-up. J Bone Joint Surg Am 93:1569–1575

    Article  Google Scholar 

  7. Biau D, Faure F, Katsahian S, Jeanrot C, Tomeno B, Anract P (2006) Survival of total knee replacement with a megaprosthesis after bone tumor resection. J Bone Joint Surg Am 88(6):1285–1293

    PubMed  Google Scholar 

  8. Kawai A, Muschler GF, Lane JM, Otis JC, Healey JH (1998) Prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. Medium to long-term results. J Bone Joint Surg Am 80(5):636–647

    Article  CAS  PubMed  Google Scholar 

  9. Jeys LM, Kulkarni A, Grimer RJ, Carter SR, Tillman RM, Abudu A (2008) Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg Am 90(6):1265–1271

    Article  CAS  PubMed  Google Scholar 

  10. Guo W, Ji T, Yang R, Tang X, Yang Y (2008) Endoprosthetic replacement for primary tumours around the knee: experience from Peking University. J Bone Joint Surg Br 90(8):1084–1089

    Article  CAS  PubMed  Google Scholar 

  11. Kawai A, Lin PP, Boland PJ, Athanasian EA, Healey JH (1999) Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors. J Surg Oncol 70(2):109–115

    Article  CAS  PubMed  Google Scholar 

  12. Frink SJ, Rutledge J, Lewis VO, Lin PP, Yasko AW (2005) Favorable long-term results of prosthetic arthroplasty of the knee for distal femur neoplasms. Clin Orthop Relat Res 438:65–70

    Article  PubMed  Google Scholar 

  13. Gosheger G, Gebert C, Ahrens H, Streitbuerger A, Winkelmann W, Hardes J (2006) Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res 450:164–171

    Article  PubMed  Google Scholar 

  14. Houdek MT, Wagner ER, Wilke BK, Wyles CC, Taunton MJ, Sim FH (2015) Late complications and long-term outcomes following aseptic revision of a hip arthroplasty performed for oncological resection. Hip Int 25(5):428–434

    Article  PubMed  Google Scholar 

  15. Houdek MT, Wagner ER, Wilke BK, Wyles CC, Taunton MJ, Sim FH (2016) Long term outcomes of cemented endoprosthetic reconstruction for periarticular tumors of the distal femur. Knee 23(1):167–172

    Article  PubMed  Google Scholar 

  16. Ahlmann ER, Menendez LR, Kermani C, Gotha H (2006) Survivorship and clinical outcome of modular endoprosthetic reconstruction for neoplastic disease of the lower limb. J Bone Joint Surg Br 88(6):790–795

    Article  CAS  PubMed  Google Scholar 

  17. Turcotte RE (2007) Endoprosthetic replacements for bone tumors, review of the most recent literature. Curr Opin Orthop 18(6):572–578

    Article  Google Scholar 

  18. Langlais F, Belot N, Ropars M, Lambotte JC, Thomazeau H (2006) The long-term results of press-fit cemented stems in total knee prostheses. J Bone Joint Surg Br 88(8):1022–1026

    Article  CAS  PubMed  Google Scholar 

  19. Kinkel S, Lehner B, Kleinhans JA, Jakubowitz E, Ewerbeck V, Heisel C (2010) Medium to long-term results after reconstruction of bone defects at the knee with tumor endoprostheses. J Surg Oncol 101(2):166–169

    CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  21. Bhangu AA, Kramer MJ, Grimer RJ, O’Donnell RJ (2006) Early distal femoral endoprosthetic survival: cemented stems versus the Compress implant. Int Orthop 30(6):465–472

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. O’Donnell PW, Griffin AM, Eward WC, Sternheim A, Wunder JS, Ferguson PC (2014) Early follow-up of a custom non-fluted diaphyseal press-fit tumour prosthesis. Int Orthop 38(1):123–127

    Article  PubMed  Google Scholar 

  23. Virolainen P, Inoue N, Nagao M, Frassica FJ, Chao EY (2005) The effect of multidrug chemotherapy on bone graft augmented prosthesis fixation. J Orthop Res 23(4):795–801. doi:10.1016/j.orthres.2005.01.006

    Article  CAS  PubMed  Google Scholar 

  24. Avedian RS, Goldsby RE, Kramer MJ, O’Donnell RJ (2007) Effect of chemotherapy on initial compressive osseointegration of tumor endoprostheses. Clin Orthop Relat Res 459:48–53

    Article  CAS  PubMed  Google Scholar 

  25. Sharma S, Turcotte RE, Isler MH, Wong C (2006) Limb salvage with a cemented rotating hinge endoprosthesis for tumours of distal femur. Clin Orthop Relat Res 450:28–32

    Article  PubMed  Google Scholar 

  26. Noble AR, Branham DB, Willis MC, Owen JR, Cramer BW, Wayne JS, Jiranek WA (2005) Mechanical effects of the extended trochanteric osteotomy. J Bone Joint Surg Am 87(3):521–529

    Article  PubMed  Google Scholar 

  27. Blunn GW, Briggs TW, Cannon SR, Walker PS, Unwin PS, Culligan S, Cobb JP (2000) Cementless fixation for primary segmental bone tumor endoprostheses. Clin Orthop Relat Res 372:223–230

    Article  Google Scholar 

  28. Zwart HJ, Taminiau AH, Schimmel JW, van Horn JR (1994) Kotz modular femur and tibia replacement. 28 tumor cases followed for 3 (1–8) years. Acta Orthop Scand 65(3):315–318

    Article  CAS  PubMed  Google Scholar 

  29. Pala E, Henderson ER, Calabrò T, Angelini A, Abati CN, Trovarelli G, Ruggieri P (2013) Survival of current production tumor endoprostheses: complications, functional results, and a comparative statistical analysis. J Surg Oncol 108(6):403–408

    Article  CAS  PubMed  Google Scholar 

  30. Pedtke AC, Wustrack RL, Fang AS, Grimer RJ, O’Donnell RJ (2012) Aseptic failure: how does the Compress(®) implant compare to cemented stems? Clin Orthop Relat Res 470(3):735–742

    Article  PubMed  Google Scholar 

  31. Ward WG, Johnston KS, Dorey FJ, Eckardt JJ (1993) Extramedullary porous coating to prevent diaphyseal osteolysis and radiolucent lines around proximal tibial replacements. A preliminary report. JBJS Am 75(7):976–987

    Article  CAS  PubMed  Google Scholar 

  32. Healey JH, Morris CD, Athanasian EA, Boland PJ (2013) Compress knee arthroplasty has 80% 10-year survivorship and novel forms of bone failure. Clin Orthop Relat Res 471(3):774–783

    Article  PubMed  Google Scholar 

  33. Skinner JA, Todo S, Taylor M, Wang JS, Pinskerova V, Scott G (2003) Should the cement mantle around the femoral component be thick or thin? J Bone Joint Surg Br 85(1):45–51

    Article  CAS  PubMed  Google Scholar 

  34. Barrack RL, Mulroy RD Jr, Harris WH (1992) Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg Br 74(3):385–389

    CAS  PubMed  Google Scholar 

  35. Gruen TA, McNiece GM, Amstutz HC (1979) “Modes of failures” of cemented stem-types femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141:17–27

    Google Scholar 

  36. Harris WH, McGann WA (1986) Loosening of the femoral component after use of the medullary-plug cementing technique. Follow-up note with a minimum five-year follow-up. J Bone Joint Surg Am 68(7):1064–1066

    Article  CAS  PubMed  Google Scholar 

  37. Malkani AL, Settecerri JJ, Sim FH, Chao EY, Wallrichs SL (1995) Long-term results of proximal femoral replacement for non-neoplastic disorders. J Bone Joint Surg Br 77(3):351–356

    Article  CAS  PubMed  Google Scholar 

  38. Pugh LR, Clarkson PW, Phillips AE, Biau DJ, Masri BA (2014) Tumor endoprosthesis revision rates increase with peri-operative chemotherapy but are reduced with the use of cemented implant fixation. J Arthroplasty 29(7):1418–1422

    Article  PubMed  Google Scholar 

  39. Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ (2007) Endoprosthetic replacement of the distal femur for bone tumours: long-term results. J Bone Joint Surg Br 89(4):521–526. Erratum in: J Bone Joint Surg Br 89(5):706

  40. Sim IW, Tse LF, Ek ET, Powell GJ, Choong PF (2007) Salvaging the limb salvage: management of complications following endoprosthetic reconstruction for tumours around the knee. Eur J Surg Oncol 33(6):796–802

    Article  PubMed  Google Scholar 

  41. Langlais F, Kerboull M, Sedel L (2003) Ling RS (2003) The “French paradox”. J Bone Joint Surg Br 85(1):17–20

    Article  CAS  PubMed  Google Scholar 

  42. Postel M, Kerboul M, Evrard M, Courpied JP (eds) (1987) In: translated by Brueton R. Total hip replacement. Springer, Berlin, pp 6–17

    Book  Google Scholar 

  43. Farfalli GL, Boland PJ, Morris CD, Athanasian EA, Healey JH (2009) Early equivalence of uncemented press-fit and compress femoral fixation. Clin Orthop Relat Res 467(11):2792–2799. doi:10.1007/s11999-009-0912-9

    Article  PubMed  PubMed Central  Google Scholar 

  44. El Masri F, Kerboull L, Kerboull M, Courpied JP, Hamadouche M (2010) Is the so-called ‘French paradox’ a reality?: long-term survival and migration of the Charnley-Kerboull stem cemented line-to-line. J Bone Joint Surg Br 92(3):342–348

    Article  PubMed  Google Scholar 

  45. Johnston RC, Fitzgerald RH Jr, Harris WH, Poss R, Müller ME, Sledge CB (1990) Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results. J Bone Joint Surg Am 72(2):161–168. No abstract available. Erratum in: J Bone Joint Surg Am 1991 Jul;73(6):952

  46. Harris WH, McCarthy JC Jr, O’Neill DA (1982) Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 64(7):1063–1067

    Article  CAS  PubMed  Google Scholar 

  47. Tanzer M, Turcotte R, Harvey E, Bobyn JD (2003) Extracortical bone bridging in tumor endoprostheses. Radiographic and histologic analysis. J Bone Joint Surg Am 85:2365–2370

    Article  PubMed  Google Scholar 

  48. Virolainen P, Inoue N, Nagao M, Ohnishi I, Frassica F, Chao EY (1999) Autogenous onlay grafting for enhancement of extracortical tissue formation over porous-coated segmental replacement prostheses. J Bone Joint Surg Am 81(4):493–499

    Article  CAS  PubMed  Google Scholar 

  49. Turcotte RE, Sim FH, Pritchard DJ, Chao EYS, Donati D (1991) Long term follow-up of Walldius hinged total knee arthroplasties. In: Langlais F, Tomeno B (eds) Limbs salvage—major reconstructions in oncologic and non-tumorous conditions. Springer, Berlin, pp 277–284

    Google Scholar 

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

    Article  PubMed  Google Scholar 

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Acknowledgements

We would like to thank the Cedars Cancer Foundation, the McGill University Hospital Foundation and the Montreal General Hospital Foundation for their support. The authors would like to thank Ms. Cindy Wong RN and Mr. Firas Dandachli MD M.Sc. for their invaluable help in the conduction of this work. We would like also to acknowledge Dr. Michael Tanzer for his contribution to the study design.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, McGill University Health Centre, 1650 Cedars Ave, Montreal, QC, H3G 1A4, Canada

    R. E. Turcotte & N. A. Stavropoulos

  2. University of Alberta, Edmonton NW, AB, T5R 5W9, Canada

    J. Toreson

  3. Department of Radiology, McGill University Health Centre, 1650 Cedars Ave, Montreal, QC, H3G 1A4, Canada

    M. Alsultan

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  1. R. E. Turcotte
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  2. N. A. Stavropoulos
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Correspondence to R. E. Turcotte.

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Conflict of interest

Dr. Turcotte reports other from Stryker Canada, during the conduct of the study. Dr. Stavropoulos, Dr. Toreson and Dr. Alsultan have nothing to disclose.

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Turcotte, R.E., Stavropoulos, N.A., Toreson, J. et al. Radiographic assessment of distal femur cemented stems in tumor endoprostheses. Eur J Orthop Surg Traumatol 27, 821–827 (2017). https://doi.org/10.1007/s00590-017-1965-1

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