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Survival of Modern Knee Tumor Megaprostheses: Failures, Functional Results, and a Comparative Statistical Analysis

  • Symposium: 2013 Meetings of the Musculoskeletal Tumor Society and the International Society of Limb Salvage
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions.

Questions/purposes

The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system.

Methods

Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2–8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%).

Results

At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8–30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306).

Conclusions

Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

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

    Article  CAS  PubMed  Google Scholar 

  2. Bacci G, Ferrari S, Bertoni F, Ruggieri P, Picci P, Longhi A, Casadei R, Fabbri N, Forni C, Versari M, Campanacci M. Long-term outcome for patients with nonmetastatic osteosarcoma of the extremity treated at the Istituto Ortopedico Rizzoli according to the Istituto Ortopedico Rizzoli/osteosarcoma-2 protocol: an updated report. J Clin Oncol. 2000;18:4016–4027.

    CAS  PubMed  Google Scholar 

  3. Bacci G, Ferrari S, Comandone A, Zanone A, Ruggieri P, Longhi A, Bertoni F, Forni C, Versari M, Rimondini S. Neoadjuvant chemotherapy for Ewing’s sarcoma of bone in patients older than thirty-nine years. Acta Oncol. 2000;39:111–116.

    Article  CAS  PubMed  Google Scholar 

  4. Bacci G, Picci P, Ferrari S, Avella M, Prever BA, Ruggieri P, Casadei R, Lari S, Monti C, Cazzola A. Neoadjuvant chemotherapy for nonmetastatic osteosarcoma for the extremities: the recent experience at the Rizzoli Institute. Cancer Treat Res. 1993;62:299–308.

    Article  CAS  PubMed  Google Scholar 

  5. Bacci G, Picci P, Ferrari S, Ruggieri P, Casadei R, Tienghi A, Brach del Prever A, Gherlinzoni F, Mercuri M, Monti C. Primary chemotherapy and delayed surgery for nonmetastatic osteosarcoma of the extremities. Results in 164 patients preoperatively treated with high doses of methotrexate followed by cisplatin and doxorubicin. Cancer. 1993;72:3227–3238.

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed Central  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  8. Campanacci M. Bone and Soft Tissue Tumors. New York, NY, USA: Springer-Verlag; 1999:1–70.

    Book  Google Scholar 

  9. Cannon SR. Massive prosthesis for malignant bone tumours of the limbs. J Bone Joint Surg Br. 1997;79:497–506.

    Article  CAS  PubMed  Google Scholar 

  10. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumor of the distal femur. J Bone Joint Surg Br. 1994;76:178–186.

    CAS  PubMed  Google Scholar 

  11. Capanna R, Ruggieri P, Biagini R, Ferraro A, DeCristofaro R, McDonald D, Campanacci M. The effect of quadriceps excision on functional results after distal femoral resection and prosthetic replacement of bone tumors. Clin Orthop Relat Res. 1991;267:186–196.

    PubMed  Google Scholar 

  12. Capanna R, van Horn JR, Biagini R, Ruggieri P, Bettelli G, Campanacci M. Reconstruction after resection of the distal fibula for bone tumor. Acta Orthop Scand. 1986;57:290–294.

    Article  CAS  PubMed  Google Scholar 

  13. Eckardt JJ, Eilber FR, Dorey FJ, Mirra JM. The UCLA experience in limb salvage surgery for malignant tumours. Orthopedics. 1985;8:612–621.

    CAS  PubMed  Google Scholar 

  14. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 1980;153:106–120.

    PubMed  Google Scholar 

  15. Flint MN, Griffin AM, Bell RS, Ferguson PC, Wander JC. Aseptic loosening is uncommon with uncemented proximal tibia tumor prostheses. Clin Orthop Relat Res. 2006;450:52–59.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  17. Grimer RJ, Belthur M, Chandrasekar C, Carter SR, Tillman RM. Two-stage revision for infected endoprostheses used in tumor surgery. Clin Orthop Relat Res. 2002;395:193–203.

    Article  PubMed  Google Scholar 

  18. Hardes J, Gebert C, Schwappach A, Ahrens H, Streitburger A, Winkelmann W, Gosheger G. Characteristics and outcome of infections associated with tumor endoprostheses. Arch Orthop Trauma Surg. 2006;126:289–296.

    Article  CAS  PubMed  Google Scholar 

  19. Heisel C, Breusch SJ, Schmid G, Bernd L. Lower limb salvage surgery with MUTARS endoprostheses: 2 to 7 year results. Acta Orthop Belg. 2004;70:142–147.

    PubMed  Google Scholar 

  20. Heisel C, Kinkel S, Bernd L, Ewerbeck V. Megaprostheses for the treatment of malignant bone tumours of the lower limbs. Int Orthop. 2006;30:452–457.

    Article  PubMed Central  PubMed  Google Scholar 

  21. 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. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011;93:418–429.

    Article  PubMed  Google Scholar 

  22. Horowitz SM, Lane JM, Otis JC, Healy JH. Prosthetic arthroplasty of the knee after resection of a sarcoma in the proximal end of the tibia: a report of sixteen cases. J Bone Joint Surg Am. 1991;73:286–293.

    CAS  PubMed  Google Scholar 

  23. Ilyas I, Kurar A, Moreau PG, Younge DA. Modular megaprosthesis for distal femoral tumors. Int Orthop. 2001;25:375–377.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  24. Jeys LM, Grimer RJ, Carter SR, Tillman RM. Periprosthetic infection in patients treated for an oncological orthopaedic condition. J Bone Joint Surg Am. 2005;87:842–849.

    Article  CAS  PubMed  Google Scholar 

  25. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1985;53:457–481.

    Article  Google Scholar 

  26. Kotz R, Dominkus M, Zettl T, Ritschl P, Windhager R, Gadner H, Zielinski C, Salzer-Kuntschik M. Advances in bone tumour treatment in 30 years with respect to survival and limb salvage. A single institution experience. Int Orthop. 2002;26:197–202.

    Article  PubMed Central  PubMed  Google Scholar 

  27. Lee SH, Oh JH, Lee KS, Yoo KH, Kim HS. Infection after prosthetic reconstruction in limb salvage surgery. Int Orthop. 2002;26:179–184.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  28. Luksch R, Tienghi A, Hall KS, Fagioli F, Picci P, Barbieri E, Gandola L, Eriksson M, Ruggieri P, Daolio P, Lindholm P, Prete A, Bisogno G, Tamburini A, Grignani G, Abate ME, Podda M, Smeland S, Ferrari S. Primary metastatic Ewing’s family tumors: results of the Italian Sarcoma Group and Scandinavian Sarcoma Group ISG/SSG IV Study including myeloablative chemotherapy and total-lung irradiation. Ann Oncol. 2012;23:2970–2976.

    Article  CAS  PubMed  Google Scholar 

  29. Malawer MM, Chou LB. Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas. J Bone Joint Surg Am. 1995;77:1154–1165.

    CAS  PubMed  Google Scholar 

  30. Mavrogenis AF, Pala E, Angelini A, Ferraro A, Ruggieri P. Proximal tibial resections and reconstructions: clinical outcome of 225 patients. J Surg Oncol. 2013;107:335–342.

    Article  PubMed  Google Scholar 

  31. Mirra JM, Picci P, Gold RH, eds. Bone Tumors: Clinical, Radiologic and Pathologic Correlations. Vol. 1. Philadelphia, PA, USA: Lea & Febiger; 1989:248–262.

  32. Mittermayer F, Krepler P, Dominkus M, Schwameis E, Sluga M, Heinzl H, Kotz R. Long-term followup of uncemented tumor endoprostheses for the lower extremity. Clin Orthop Relat Res. 2001;388:167–177.

    Article  PubMed  Google Scholar 

  33. Myers GJC, Abudu AT, Carter SR, Tillman RM, Grimer RJ. Endoprosthetic replacement of the distal femur for bone tumors. Long term results. J Bone Joint Surg Br. 2007;89:521–526.

    Article  CAS  PubMed  Google Scholar 

  34. Myers GJC, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumors. J Bone Joint Surg Br. 2007;89:1632–1637.

    Article  CAS  PubMed  Google Scholar 

  35. Natarajan MV, Sivaseelam A, Ayyappan S, Bose JC, Sampath Kumar M. Distal femoral tumours treated by resection and custom mega-prosthetic replacement. Int Orthop. 2005;29:309–313.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Orlic D, Smerdelj M, Kolundzic R, Bergovec M. Lower limb salvage surgery: modular endoprosthesis in bone tumour treatment. Int Orthop. 2006;30:458–464.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  37. Plotz W, Rechl H, Burgkart R, Messmer C, Schelter R, Hipp E, Gradinger R. Limb salvage with tumor endoprostheses for malignant tumors of the knee. Clin Orthop Relat Res. 2002;405:207–215.

    Article  PubMed  Google Scholar 

  38. Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a long-term oncological, functional and quality of life study. J Bone Joint Surg Am. 1994;76:649–656.

    CAS  PubMed  Google Scholar 

  39. Ruggieri P, Bosco G, Pala E, Errani C, Mercuri M. Local recurrence, survival and function after total femur resection and megaprosthetic reconstruction for bone sarcomas. Clin Orthop Relat Res. 2010;468:2860–2866.

    Article  PubMed Central  PubMed  Google Scholar 

  40. Ruggieri P, Mavrogenis AF, Pala E, Abdel-Mota’al M, Mercuri M. Long term results of fixed-hinge megaprostheses in limb salvage for malignancy. Knee. 2012;19:543–549.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  42. Turcotte RE. Endoprosthetic replacements for bone tumors: review of the most recent literature. Curr Opin Orthop. 2007;18:572–578.

    Article  Google Scholar 

  43. Unwin PS, Cannon SR, Grimer RJ, Kemp HB, Sneath RS, Walker PS. Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br. 1996;78:5–13.

    CAS  PubMed  Google Scholar 

  44. Wunder JS, Leitch K, Griffin AM, Davis AM, Bell RS. Comparison of two methods of reconstruction for primary malignant tumors at the knee: a sequential cohort study. J Surg Oncol. 2001;77:89–99.

    Article  CAS  PubMed  Google Scholar 

  45. Zeegen EN, Aponte-Tinao LA, Hornicek FJ, Gebhardt MC, Mankin HJ. Survivor analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat Res. 2004;420:239–250.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Bologna, Italy

    Elisa Pala MD, Giulia Trovarelli MD, Teresa Calabrò MD, Andrea Angelini MD, Caterina N. Abati MD & Pietro Ruggieri MD, PhD

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  1. Elisa Pala MD
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  2. Giulia Trovarelli MD
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  4. Andrea Angelini MD
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  5. Caterina N. Abati MD
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  6. Pietro Ruggieri MD, PhD
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Correspondence to Pietro Ruggieri MD, PhD.

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Pala, E., Trovarelli, G., Calabrò, T. et al. Survival of Modern Knee Tumor Megaprostheses: Failures, Functional Results, and a Comparative Statistical Analysis. Clin Orthop Relat Res 473, 891–899 (2015). https://doi.org/10.1007/s11999-014-3699-2

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  • DOI: https://doi.org/10.1007/s11999-014-3699-2

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