Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved ...survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients.
(1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision?
Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models.
A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range IQR 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 95% CI 1.066 to 3.856; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 95% CI 0.215 to 2.546; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 95% CI 1.092 to 3.132; p = 0.022) but not after preoperative radiotherapy (HR 1.174 95% CI 0.505 to 2.728; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 95% CI 1.497 to 15.823; p = 0.009).
Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication.
Level III, therapeutic study.
Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved ...survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients.
(1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision?
Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models.
A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range IQR 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 95% CI 1.066 to 3.856; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 95% CI 0.215 to 2.546; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 95% CI 1.092 to 3.132; p = 0.022) but not after preoperative radiotherapy (HR 1.174 95% CI 0.505 to 2.728; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 95% CI 1.497 to 15.823; p = 0.009).
Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication.
Level III, therapeutic study.
Intramedullary limb lengthening via lengthening nails has been performed for more than three decades to overcome leg length inequalities. Plate-assisted bone segment transport (PABST) has recently ...been described for the reconstruction of segmental bone defects. We modified this procedure by using the ipsilateral fibula as a “biological plate” and report on its technical particularities and application in the reconstructive treatment of adamantinomas of the tibia in two patients. Both patients were successfully treated by wide resection and reconstruction of the tibial bone via bone segment transport through an expandable intramedullary nail using the remaining ipsilateral fibula to provide stabilization and guidance. This procedure was titled “fibula-assisted segment transport” (FAST). This is a new and promising technique that allows an entirely biological reconstruction of large bone defects of the tibia.
Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas ...invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system.
This is a retrospective analysis of 151 patients (with median follow-up in survivors of 44 months (interquartile range 12 to 77)) who underwent hemipelvectomy with iliosacral resection at a single centre between 2007 and 2019. The proposed classification differentiates the extent of iliosacral resection and defines types S1 to S6 (S1 resection medial and parallel to the sacroiliac joint, S2 resection through the ipsilateral sacral lateral mass to the neuroforamina, S3 resection through the ipsilateral neuroforamina, S4 resection through ipsilateral the spinal canal, and S5 and S6 contralateral sacral resections). Descriptive statistics and the chi-squared test were used for categorical variables, and the Kaplan-Meier survival analysis were performed.
Resections were S1 in 25/151 patients (17%), S2 in 70/151 (46%), S3 in 33/151 (22%), S4 in 77/151 (11%), S5 in 4/151 (3%), and S6 in 2/151 (1%). An internal hemipelvectomy was performed in 113/151 patients (75%), and 38/151 patients (25%) had an external hemipelvectomy. The predominant types of sarcoma were high-grade osteosarcoma in 48/151 patients (32%), chondrosarcoma in 41/151 (27%), Ewing sarcoma in 33/151 (22%), pleomorphic sarcoma in 17/151 (11%), and others in 2/151 (8%). LR was found in 24/151 patients (15%) with S3, S5, with S6 resections showing the highest rate of LR (p = 0.038). Overall, 19/151 patients (16%) had evidence of metastastic disease at the time of surgery and these patients showed poorer survival when compared to patients with no metastasis.
The proposed classification can help to report and compare different surgical and reconstructive approaches in these difficult cases who are still have a considerable risk of LR. Cite this article:
2022;104-B(2):290-296.
Zusammenfassung
Megaprothesen werden zur endoprothetischen Rekonstruktion knöcherner Defektstrecken eingesetzt, welche insbesondere aus der extremitätenerhaltenden Resektion von Knochtentumoren ...entstehen können. Periprothetische Infektionen sind dabei eine schwerwiegende Komplikation und stellen ein Risiko für das Implantat- und Extremitätenüberleben betroffener Patienten dar. Neben einer Infektion mit koagulasenegativen Staphylokokken muss an der oberen Extremität insbesondere eine (Low-grade‑)Infektion mit Cutibakterien ausgeschlossen werden, wofür die Langzeitbebrütung (> 14 Tage) der mikrobiologischen Proben obligat ist. Zur nachhaltigen Infektsanierung sollte ein zweizeitiger Prothesenwechsel erwogen werden, der jedoch aufgrund der klinischen Besonderheiten im tumororthopädischen Patientenkollektiv an der oberen Extremität nicht immer erreicht werden kann.
Amputationen am Mittelfuß Budny, T.; Schulze, M.; Gosheger, G. ...
Fuss & Sprunggelenk,
September 2019, 2019-09-00, Volume:
17, Issue:
3
Journal Article
Peer reviewed
Das Ziel bei Amputationen am Mittelfuß ist ein möglichst schmerzfreier und prothetisch versorgbarer Stumpf mit voll belastbarer Haut. Dafür hervorragend geeignet ist die Haut der Fußsohle. Selbst für ...den Barfußgang können diese Stümpfe dann im Idealfall geeignet sein. Patienten mit Gefühlsstörungen sollte man jedoch aufgrund des erhöhten Verletzungsrisikos vom Barfußgang abraten. Amputationen im Mittelfußbereich bis zur Chopart-Gelenklinie führen ferner zu keiner Beinlängendifferenz und benötigen keinen Höhenausgleich. Die Resektion von Mittelfußknochen unter Erhalt der Zehen ist funktionell mit einer transmetatarsalen Amputation vergleichbar. Da hierbei die körperliche Integrität erhalten bleibt, findet der Begriff der „inneren Amputation“ häufig Anwendung. Ihnen und allen anderen Amputationen im Mittelfußbereich haftet teilweise weiterhin das Vorurteil an, dass sie schlecht versorgbar seien. Allerdings ist dies Folge unzureichender Kenntnisse über die Amputationstechnik und die postoperative Versorgung, welche sich in den letzten Jahren deutlich verbessert hat.
The aim for amputation of the midfoot is to achieve a stump that is as painless as possible which can be treated prosthetically under full weight-bearing skin. For this purpose, the plantar skin is perfectly suitable. These stumps may also be suitable for barefoot walking. However, patients with sensory disorders should be advised not to walk barefoot because of the increased risk of injury. In addition, amputations in the metatarsal region up to the Chopart's joint level do not lead to any difference in leg length and consequently do not require a compensation of the leg length. The resection of metatarsal bones while preserving the toes is comparable to a transmetatarsal amputation in function. As the physical integrity is preserved, the procedure is also known as ”internal amputation”. This procedure and other amputations of the midfoot have still partially the prejudice, that the fitting of shoes or prosthesis is difficult. Recent advances in surgical technique and prosthetic fit have addressed these problems but are still not well-established.
Abstract
Background
Blood transfusions are common medical procedures and every age group requires detailed insights and treatment bundles. The aim of this study was to examine the association of ...anaemia, co-morbidities, complications, in-hospital mortality, and transfusion according to age groups to identify patient groups who are particularly at risk when undergoing surgery.
Methods
Data from 21 Hospitals of the Patient Blood Management Network Registry were analysed. Patients were divided into age subgroups. The incidence of preoperative anaemia, co-morbidities, surgical disciplines, hospital length of stay, complications, in-hospital mortality rate, and transfusions were analysed by descriptive and multivariate regression analysis.
Results
A total of 1 117 919 patients aged 18–108 years were included. With increasing age, the number of co-morbidities and incidence of preoperative anaemia increased. Complications, hospital length of stay, and in-hospital mortality increased with age and were higher in patients with preoperative anaemia. The mean number of transfused red blood cells (RBCs) peaked, whereas the transfusion rate increased continuously. Multivariate regression analysis showed that increasing age, co-morbidities, and preoperative anaemia were independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion.
Conclusion
Increasing age, co-morbidities, and preoperative anaemia are independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion. Anaemia diagnosis and treatment should be established in all patients.
We describe the 2-year follow-up of an open-label trial (CT-AMT-011-01) of AAV1-LPL(S447X) gene therapy for lipoprotein lipase (LPL) deficiency (LPLD), an orphan disease associated with ...chylomicronemia, severe hypertriglyceridemia, metabolic complications and potentially life-threatening pancreatitis. The LPL(S447X) gene variant, in an adeno-associated viral vector of serotype 1 (alipogene tiparvovec), was administered to 14 adult LPLD patients with a prior history of pancreatitis. Primary objectives were to assess the long-term safety of alipogene tiparvovec and achieve a ≥40% reduction in fasting median plasma triglyceride (TG) at 3-12 weeks compared with baseline. Cohorts 1 (n=2) and 2 (n=4) received 3 × 10(11) gc kg(-1), and cohort 3 (n=8) received 1 × 10(12) gc kg(-1). Cohorts 2 and 3 also received immunosuppressants from the time of alipogene tiparvovec administration and continued for 12 weeks. Alipogene tiparvovec was well tolerated, without emerging safety concerns for 2 years. Half of the patients demonstrated a ≥40% reduction in fasting TG between 3 and 12 weeks. TG subsequently returned to baseline, although sustained LPL(S447X) expression and long-term changes in TG-rich lipoprotein characteristics were noted independently of the effect on fasting plasma TG.
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