Top

Clinical Orthopaedics and Related Research®

Published in:

Open Access 01-08-2010 | Clinical Research

Cemented Distal Femoral Endoprostheses for Musculoskeletal Tumor: Improved Survival of Modular versus Custom Implants

Authors: Adam J. Schwartz, MD, J. Michael Kabo, PhD, Fritz C. Eilber, MD, Frederick R. Eilber, MD, Jeffrey J. Eckardt, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 8/2010

Abstract

Background

Advocates of newer implant designs cite high rates of aseptic loosening and failure as reasons to abandon traditional cemented endoprosthetic reconstruction of the distal femur.

Questions/purposes

We asked whether newer, modular distal femoral components had improved survivorship compared with older, custom-casted designs.

Patients and Methods

We retrospectively reviewed 254 patients who underwent distal femoral endoprosthetic reconstruction. We excluded two patients with cementless implants, 27 with expandable prostheses, and 39 who had a nontumor diagnosis. This left 186 patients: 101 with older custom implants and 85 with contemporary modular implants. The minimum followup was 1 month (mean, 96.0 months; range, 1–336 months). The tumor was classified as Stage IIA/IIB in 122 patients, Stage IA/IB or benign in 43, and Stage III or metastatic in 21.

Results

Kaplan-Meier analysis revealed overall 10-, 20-, and 25-year implant survival rates of 77%, 58%, and 50%, respectively, using revision of the stemmed components as an end point. The 85 modular components had a greater 15-year survivorship than the 101 custom-designed implants: 93.7% versus 51.7%, respectively. Thirty-five stemmed components (18.8%) were revised for aseptic loosening in 22 patients, implant fatigue fracture in 10, infection in two, and local recurrence in one.

Conclusions

Cemented modular rotating-hinge distal femoral endoprostheses demonstrated improved survivorship compared with custom-casted implants during this three-decade experience. Patients with low-grade disease and long-term survivors of high-grade localized disease should expect at least one or more revision procedures in their lifetime.

Level of Evidence

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

Bacci G, Briccoli A, Longhi A, Ferrari S, Mercuri M, Faggioli F, Versari M, Picci P. Treatment and outcome of recurrent osteosarcoma: experience at Rizzoli in 235 patients initially treated with neoadjuvant chemotherapy. Acta Oncol. 2005;44:748–755.CrossRefPubMed

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.CrossRefPubMed

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

Bradish CF, Kemp HB, Scales JT, Wilson JN. Distal femoral replacement by custom-made prostheses: clinical follow-up and survivorship analysis. J Bone Joint Surg Br. 1987;69:276–284.PubMed

Brigman BE, Hornicek FJ, Gebhardt MC, Mankin HJ. Allografts about the knee in young patients with high-grade sarcoma. Clin Orthop Relat Res. 2004;421:232–239.CrossRefPubMed

Cannon CP, Eckardt JJ, Kabo JM, Ward WG Sr, Kelly CM, Wirganowicz PZ, Asavamongkolkul A, Nieves R, Eilber FR. Custom cross-pin fixation of 32 tumor endoprostheses stems. Clin Orthop Relat Res. 2003;417:285–292.PubMed

Cannon CP, Zeegen E, Eckardt JJ. Techniques in endoprosthetic reconstruction. Oper Tech Orthop. 2005;14:225–235.CrossRef

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

Choong PF, Sim FH, Pritchard DJ, Rock MG, Chao EY. Megaprostheses after resection of distal femoral tumors: a rotating hinge design in 30 patients followed for 2–7 years. Acta Orthop Scand. 1996;67:345–351.CrossRefPubMed

10.

Dahlin DC. Bone Tumors: General Aspects and Data on 6221 Cases. Springfield, IL: Charles C. Thomas; 1978:226–273.

11.

Damron TA, Ward WG, Stewart A. Osteosarcoma, chondrosarcoma, and Ewing’s sarcoma: National Cancer Data Base Report. Clin Orthop Relat Res. 2007;459:40–47.CrossRefPubMed

12.

Eckardt JJ, Eilber FR. Endoprosthetic replacement. Curr Orthop. 1993;7:148–156.CrossRef

13.

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

14.

Eckardt JJ, Eilber FR, Grant TO, Mirra JM, Weisenberger TH, Dorey FJ. Management of Stage IIB osteogenic sarcoma: experience at the University of California, Los Angeles. Cancer Treatment Symposia. Volume 3: National Institutes of Health Consensus Development Conference on Limb Sparing Treatment of Adult Soft Tissue Sarcomas and Osteosarcomas. Washington, DC: National Institutes of Health; 1985:117–130.

15.

Eckardt JJ, Eilber FR, Rosen G, Mirra JM, Dorey FJ, Ward WG, Kabo JM. Endoprosthetic replacement for Stage IIB Osteosarcoma: the UCLA Experience 1980–1988. Clin Orthop Relat Res. 1991;270:202–213.PubMed

16.

Eckardt JJ, Kabo JM, Kelley CM, Ward WG Sr, Asavamongkolkul A, Wirganowicz PZ, Yang RS, Eilber FR. Expandable endoprosthesis reconstruction in skeletally immature patients with tumors. Clin Orthop Relat Res. 2000;373:51–61.CrossRefPubMed

17.

Eckardt JJ, Kabo JM, Kelly CM, Ward WG Sr, Cannon CP. Endoprosthetic reconstructions for bone metastases. Clin Orthop Relat Res. 2003;415(suppl):S254–S262.CrossRefPubMed

18.

Eckardt JJ, Lesavoy MA, Debrow TJ, Wachym PA. Exposed endoprosthesis: management protocol using muscle and myocutaneous flap coverage. Clin Orthop Relat Res. 1990;251:220–229.PubMed

19.

Eilber FR, Eckardt J, Morton DL. Advances in the treatment of sarcomas of the extremity: current status of limb salvage. Cancer. 1984;54(11 suppl):2695–2701.CrossRefPubMed

20.

Eilber FR, Mirra J, Eckardt J, Kern D. Intra-arterial adriamycin, radiation therapy, and surgical excision for extremity skeletal and soft tissue sarcomas. Dev Oncol. 1984;26:141–154.

21.

Enneking W. Modification of the system for functional evaluation in the surgical management of musculoskeletal tumors. Limb Salvage in Musculoskeletal Oncology. New York: Churchill-Livingston; 1987:626–639.

22.

Enneking WF. Staging of musculoskeletal tumors. In: Enneking WF, ed. Musculoskeletal Tumor Surgery. Vol 1. New York, NY: Churchill Livingstone; 1983:87–88.

23.

Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286:241–246.PubMed

24.

Enneking WF, Shirley PD. Resection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. J Bone Joint Surg Am. 1977;59:223–236.PubMed

25.

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

26.

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

27.

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.CrossRefPubMed

28.

Henshaw R, Malawer M. Review of endoprosthetic reconstruction in limb-sparing surgery. In: Malawer MM, Sugarbaker PH, eds. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Norwell, MA: Kluwer Academic Publishers; 2001:383–404.

29.

Horowitz SM, Glasser DB, Lane JM, Healey JH. Prosthetic and extremity survivorship after limb salvage for sarcoma: how long do the reconstructions last? Clin Orthop Relat Res. 1993;293:280–286.PubMed

30.

Hua J, Walker PS. A comparison of cortical strain after cemented and press-fit proximal and distal femoral replacement. J Orthop Res. 1992;10:739–744.CrossRefPubMed

31.

Huvos AG. Bone tumors: malignant—osteogenic sarcoma. Bone Tumor: Diagnosis, Treatment and Prognosis. Philadelphia, PA: WB Saunders; 1979:85–155.

32.

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

33.

Kabo JM, Yang RS, Dorey FJ, Eckardt JJ. In vivo rotational stability in the kinematic rotating-hinge knee. Clin Orthop Relat Res. 1997;336:166–176.CrossRefPubMed

34.

Kaplan EL, Meier P. Nonparametric estimation from incomplete observation. J Am Stat Assoc. 1958;53:457–481.CrossRef

35.

Kawai A, Muschler GF, Lane JM, Otis JC, Healey JH. 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. 1998;80:636–647.CrossRefPubMed

36.

Kay RM, Kabo JM, Seeger LL, Eckardt JJ. Hydroxyapatite-coated distal femoral replacements: preliminary results. Clin Orthop Relat Res. 1994;302:92–100.PubMed

37.

Kotz R, Salzer M. Rotation-plasty for childhood osteosarcoma of the distal part of the femur. J Bone Joint Surg Am. 1982;64:959–969.PubMed

38.

Kramer MJ, Tanner BJ, Horvai AE, O’Donnell RJ. Compressive osseointegration promotes viable bone at the endoprosthetic interface: retrieval study of Compress implants. Int Orthop. 2008;32:567–571.CrossRefPubMed

39.

Lewis IJ, Nooij MA, Whelan J, Sydes MR, Grimer R, Hogendoorn PC, Memon MA, Weeden S, Uscinska BM, van Glabbeke M, Kirkpatrick A, Hauben EI, Craft AW, Taminiau AH; MRC BO06 and EORTC 80931 collaborators; European Osteosarcoma Intergroup. Improvement in histologic response but not survival in osteosarcoma patients treated with intensified chemotherapy: a randomized phase III trial of the European Osteosarcoma Intergroup. J Natl Cancer Inst. 2007;99:112–128.CrossRefPubMed

40.

Link MP, Goorin AM, Horowitz M, Meyer WH, Belasco J, Baker A, Ayala A, Shuster J. Adjuvant chemotherapy of high-grade osteosarcoma of the extremity: updated results of the Multi-Institutional Osteosarcoma Study. Clin Orthop Relat Res. 1991;270:8–14.PubMed

41.

Link MP, Goorin AM, Miser AW, Green AA, Pratt CB, Belasco JB, Pritchard J, Malpas JS, Baker AR, Kirkpatrick JA, et al. The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity. N Engl J Med. 1986;314:1600–1606.CrossRefPubMed

42.

Machin D, Palmar MKB. Comparison of 2 survival curves. In: Machin D, Palmar MKB, eds. Survival Analysis: A Practical Approach. Chichester, UK: Bookcraft; 1995:66–75.

43.

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.PubMed

44.

Malo M, Davis AM, Wunder J, Masri BA, Bell RS, Isler MH, Turcotte RE. Functional evaluation in distal femoral endoprosthetic replacement for bone sarcoma. Clin Orthop Relat Res. 2001;389:173–180.CrossRefPubMed

45.

Marcove RC, Lewis MM, Rosen G, Huvos AG. Total femur and total knee replacement: a preliminary report. Clin Orthop Relat Res. 1977;126:147–152.PubMed

46.

Marina N, Gebhardt M, Teot L, Gorlick R. Biology and therapeutic advances for pediatric osteosarcoma. Oncologist. 2004;9:422–441.CrossRefPubMed

47.

Mirra JM. High grade malignant intraosseous lesions associated with ‘reactive’ osteoid and woven-bone production. Bone Tumors: Diagnosis and Treatment. Philadelphia, PA: JB Lippincott; 1980:138–161.

48.

Mittermayer F, Windhager R, Dominkus M, Krepler P, Schwameis E, Sluga M, Kotz R, Strasser G. Revision of the Kotz type of tumour endoprosthesis for the lower limb. J Bone Joint Surg Br. 2002;84:401–406.CrossRefPubMed

49.

Muscolo DL, Ayerza MA, Aponte-Tinao LA, Ranalletta M. Use of distal femoral osteoarticular allografts in limb salvage surgery. J Bone Joint Surg Am. 2005;87:2449–2455.CrossRefPubMed

50.

Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. Endoprosthetic replacement of the distal femur for bone tumours: long-term results. J Bone Joint Surg Br. 2007;89:521–526.CrossRefPubMed

51.

National Institutes of Health. Limb-sparing treatment of adult soft-tissue sarcomas and osteosarcomas. National Institutes of Health Consensus Development Conference Statement. Natl Inst Health Consens Dev Conf Consens Statement. 1985;5:18.

52.

Ries LAG, Smith MA, Gurney JG, Linet M, Tamra T, Young JL, Bunin GR, eds. Cancer Incidence and Survival Among Children and Adolescents: United States SEER Program 1975–1995. NIH Publication Number 99–4649. Bethesda, MD: National Institutes of Health; 1999.

53.

Roberts P, Chan D, Grimer RJ, Sneath RS, Scales JT. Prosthetic replacement of the distal femur for primary bone tumours. J Bone Joint Surg Br. 1991;73:762–769.PubMed

54.

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.PubMed

55.

Schwab JH, Agarwal P, Boland PJ, Kennedy JG, Healey JH. Patellar complications following distal femoral replacement after bone tumor resection. J Bone Joint Surg Am. 2006;88:2225–2230.CrossRefPubMed

56.

Seeger LL, Farooki S, Yao L, Kabo JM, Eckardt JJ. Custom endoprostheses for limb salvage: a historical perspective and imaging evaluation. AJR Am J Roentgenol. 1998;171:1525–1529.PubMed

57.

Sharma S, Turcotte RE, Isler MH, Wong C. Cemented rotating-hinge endoprosthesis for limb salvage of distal femur tumors. Clin Orthop Relat Res. 2006;450:28–32.CrossRefPubMed

58.

Shih LY, Sim FH, Pritchard DJ, Rock MG, Chao EY. Segmental total knee arthroplasty after distal femoral resection for tumor. Clin Orthop Relat Res. 1993;292:269–281.PubMed

59.

Shin DS, Weber KL, Chao EY, An KN, Sim FH. Reoperation for failed prosthetic replacement used for limb salvage. Clin Orthop Relat Res. 1999;358:53–63.CrossRefPubMed

60.

Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68:1331–1337.PubMed

61.

Torbert JT, Fox EJ, Hosalkar HS, Ogilvie CM, Lackman RD. Endoprosthetic reconstructions: results of long-term followup of 139 patients. Clin Orthop Relat Res. 2005;438:51–59.CrossRefPubMed

62.

Ward WG, Johnston KS, Dorey FJ, Eckardt JJ. Extramedullary porous coating to prevent diaphyseal osteolysis and radiolucent lines around proximal tibial replacements: a preliminary report. J Bone Joint Surg Am. 1993;75:976–987.PubMed

63.

Ward WG, Johnston KS, Dorey FJ, Eckardt JJ. Loosening of massive femoral cemented endoprostheses: radiographic evidence of loosening mechanism. J Arthroplasty. 1997;12:741–750.CrossRefPubMed

64.

Ward WG, Yang R-S, Eckardt JJ. Endoprosthetic bone reconstruction following malignant tumor resection in skeletally immature patients. Orthop Clin North Am. 1996;27:493–502.PubMed

65.

Weis LD. The success of limb-salvage surgery in the adolescent patient with osteogenic sarcoma. Adolesc Med. 1999;10:451–458, xii.PubMed

66.

Wilkins RM, Cullen JW, Camozzi AB, Jamroz BA, Odom L. Improved survival in primary nonmetastatic pediatric osteosarcoma of the extremity. Clin Orthop Relat Res. 2005;438:128–136.CrossRefPubMed

67.

Wilkins RM, Cullen JW, Odom L, Jamroz BA, Cullen PM, Fink K, Peck SD, Stevens SL, Kelly CM, Camozzi AB. Superior survival in treatment of primary nonmetastatic pediatric osteosarcoma of the extremity. Ann Surg Oncol. 2003;10:498–507CrossRefPubMed

68.

Wilkins RM, Kelly CM. Revision of the failed distal femoral replacement to allograft prosthetic composite. Clin Orthop Relat Res. 2002;397:114–118.CrossRefPubMed

69.

Winkler K, Beron G, Kotz R, Salzer-Kuntschik M, Beck J, Beck W, Brandeis W, Ebell W, Erttmann R, Göbel U, et al. Neoadjuvant chemotherapy for osteogenic sarcoma: results of a Cooperative German/Austrian study. J Clin Oncol. 1984;2:617–624.PubMed

70.

Wu CC, Henshaw RM, Pritsch T, Squires MH, Malawer MM. Implant design and resection length affect cemented endoprosthesis survival in proximal tibial reconstruction. J Arthroplasty. 2008;23:886–893.CrossRefPubMed

71.

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

Title: Cemented Distal Femoral Endoprostheses for Musculoskeletal Tumor: Improved Survival of Modular versus Custom Implants
Authors: Adam J. Schwartz, MD
J. Michael Kabo, PhD
Fritz C. Eilber, MD
Frederick R. Eilber, MD
Jeffrey J. Eckardt, MD
Publication date: 01-08-2010
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 8/2010
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-009-1197-8

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Cemented Distal Femoral Endoprostheses for Musculoskeletal Tumor: Improved Survival of Modular versus Custom Implants

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 8/2010

MRI-guided Navigation Surgery with Temporary Implantable Bone Markers in Limb Salvage for Sarcoma

Medicine versus Orthopaedic Service for Hospital Management of Hip Fractures

Case Report: Fibroxanthoma: A Complication of a Biodegradable Screw

Immunologic Adverse Reaction Associated with Low-carbide Metal-on-metal Bearings in Total Hip Arthroplasty

Sonographic Identification of the Intracompartmental Septum in de Quervain’s Disease

Laboratory Indicators for Early Detection and Surgical Treatment of Vibrio Necrotizing Fasciitis