Search Results (27)

Background/Objectives: Periprosthetic joint infections (PJIs) represent a serious complication following musculoskeletal tumor resection and megaprosthetic reconstruction. Local antibiotic administration may reduce infection risk by achieving high local drug concentrations. The aim of this study was to evaluate whether local vancomycin powder reduces postoperative periprosthetic infections in bone tumor surgeries involving megaprostheses. Methods: This retrospective cohort study included 276 patients who underwent bone tumor resection and megaprosthetic reconstruction. Study subjects were divided into two groups: the control group (n = 142) that received standard perioperative intravenous antibiotics, and the vancomycin group (n = 134) that received an additional 1 g of vancomycin powder locally at wound closure. Periprosthetic joint infections were defined using the 2018 International Consensus Meeting (ICM) criteria and monitored for 2 years. A multivariable competing risks regression model was used to assess the independent effect of local vancomycin on infection risk. Results: Periprosthetic joint infections occurred in 28 patients in the control group (19.7%) vs. eight patients in the vancomycin group (5.9%, p = 0.001). The most frequently isolated pathogens were coagulase-negative staphylococci (52.7%), followed by Staphylococcus aureus (22.2%). Among infected patients in the vancomycin group, only two had Gram-positive infections, suggesting efficacy against staphylococcal PJIs. The multivariable regression confirmed a significantly lower risk of infection in the vancomycin group (hazard ratio [HR]: 0.40, 95% confidence interval [CI]: 0.16–0.95, p = 0.040), while pelvic tumors were associated with a higher infection risk (HR: 5.82, p < 0.001). Conclusions: Our results indicate that local vancomycin may reduce periprosthetic infection rates in oncologic megaprosthetic reconstruction without added complications. Randomized studies are warranted to confirm these findings and refine dosing strategies. Full article

Background/Objectives: Bone reconstruction using megaprostheses is increasingly performed following bone tumour resections, including sarcomas, to enhance patient outcomes and quality of life. However, this is a complex patient group, and there is little consensus as to postoperative rehabilitation and associated outcomes. Methods: A systematic search was conducted in MEDLINE and EMBASE databases according to the Implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science (PERSiST) guidelines. Studies describing rehabilitation protocols and functional outcomes following bone tumour resection and modular oncologic megaprosthesis reconstruction were included. All papers were individually assessed for methodological quality using the Joanna Briggs Institute (JBI) critical appraisal tool. Results: The search generated 105 records, 28 underwent full-text review, and 13 studies were included. Available data reflect 371 patients with a mean age of 49.17 (S.D. 21.40) years and a mean postoperative follow-up of 41.88 (S.D. 32.88) months. Surgical indications were documented as sarcomas in 9 studies, and tumour metastasis to the bone in 10 studies. Rehabilitation protocols were reported in 5 studies following proximal humerus resection with a mean dislocation rate of 14.5% (S.D. 5.26). All protocols advised brace immobilisation for a period ranging between 10 days and 6 months. Superior Constant-Murley shoulder score was reported in patients with early active isometric exercises at 6 weeks. Six studies reported proximal femur prosthesis rehabilitation and functional outcomes, with a mean dislocation rate of 10% (S.D. 9.82). Enhanced outcomes were reported in studies employing early mobilisation. Two studies assessed distal femur prosthesis; both studies reported similar protocols with full weight bearing 3 weeks following surgery. The methodological quality of the studies varied, but was overall modest, with 10/13 studies meeting at least 50% of JBI reporting criteria. Conclusions: The existing literature on rehabilitation and outcomes in orthopaedic oncology patients following arthroplasty with megaprosthesis is limited, with rehabilitative protocols variably described. However, it seems that early active mobilisation does not increase the risk of joint dislocations or infections. Full article

Background: Long bone metastases are common in patients with metastatic renal cell carcinoma (RCC). One potential surgical treatment option is resection and megaprosthetic reconstruction. However, implant complications and survival are poorly understood. This study analyzes patient and implant survival as well as associated risk factors. Methods: This is a retrospective study from a single academic center, analyzing 86 patients that underwent resection and megaprosthetic reconstruction performed between 1993 and 2017. The most common location of megaprosthetic reconstruction was the proximal femur (PFR) in 38% (33 of 86) of patients. We calculated overall patient survival and associated risk factors using the Kaplan–Meier method and implant survivorship using a competing risk analysis. Results: A total of 73% (63/86) of patients died of their disease after a median of 19 (IQR 9–37) months following surgery, and a median of 71 (IQR 31–132) months after the initial diagnosis of RCC. The overall survival probability was 29% (95% CI 18–40%) five years after surgery. The five-year risk of revision surgery (within a competing risk framework) was 18% (95% CI 11–28). A total of 8% (7 of 86) of patients underwent an exchange of the implant itself. Patients with total bone replacements had a higher revision risk (SHR 19.46 (95% CI 6.9–54.9), p < 0.01). Furthermore, the revision risk was higher with increasing reconstruction length per mm (SHR 1.01 (95% CI 1.01–1.02), p = 0.03) and prolonged surgical time per minute (SHR: 1.01 (95% CI 1.0–1.02), p < 0.01). Local postoperative radiation treatment (RTX) was associated with an increased risk for revisions (SHR 2.59 (95% CI 0.96–6.95), p = 0.06). Conclusions: Modular megaprostheses demonstrated a fairly low risk of implant revision although postoperative radiation therapy and total bone replacements are associated with an increased risk. Full article

Background: Multimodal treatment of bone sarcomas has improved survival and allowed limb salvage surgery in the majority of these patients. Periprosthetic joint infection (PJI) constitutes a challenging complication. Controversy remains regarding the risk factors for PJI. Here, we aim to identify them. We also discuss pathogens and treatments. Methods: The authors reviewed the institutional database to retrieve endoprostheses implanted after bone sarcoma resection from 2014 to 2021. In total, 66 eligible patients were identified. Results: A total of 14 (21.21%) periprosthetic infections were diagnosed. Of these, 10 occurred in men (71.43%, p = 0.143). Mean BMI, age at the time of surgery, and ASA score were significantly higher among patients who developed PJI (p = 0.003, 0.044, and 0.033, respectively). Site was an important factor as well (p = 0.029). The number of comorbidities and the Charlson Comorbidity Index were also higher among these patients (p = 0.264, 0.060, respectively). Histology did not play a role in PJI (p = 0.385). Conclusions: Our data allow surgeons to better understand and control risk factors for PJI. We identified BMI, age, ASA score, site, and the Charlson Comorbidity Index as the main risk factors. Polymicrobial infections and methicillin-resistant Staphylococcus aureus are associated with recurrent infections. A multicentric study with a larger cohort is needed. Full article

Background and Objectives: To date, the gold standard of care for bone sarcomas is limb salvage surgical resection. In cases where the tumor arises in the distal femur or proximal tibia near the joint line, knee-sacrificing surgery is typically performed, followed by reconstruction with oncological megaprostheses. This study aims to evaluate the effectiveness of a precise 3D-based surgical approach for knee-sparing tumor resections, assessing its feasibility and its impact on surgical, oncological, and functional outcomes. Materials and Methods: This single-center retrospective study presents the surgical and oncological outcomes of knee-sparing surgeries following bone sarcoma resections. All patients underwent either intercalary or geographic resection, and reconstruction was tailored to each patient, using either an allograft or a titanium alloy Ti64 implant, depending on the specific requirements of the case. Results: A total of 23 patients (average age 21.04 years, 14 males) were included, with an average postoperative follow-up of 58 months (range: 12–102 months). Clear surgical margins were achieved in all patients, with 16 patients (69.5%) showing wide negative margins (R0) and the rest showing close negative margins (R1). Resections were primarily intercalary (17 patients, 73.9%), with 6 patients (26.1%) undergoing geographic resections. Reconstruction methods included allografts (9 patients, 39.3%), vascularized fibula and allograft (8 patients, 34.7%), and printed Ti64 cage reconstructions (6 patients, 26.0%). At the last follow-up, 19 patients (82.6%) were disease-free, 3 patients (13.4%) were alive with evidence of disease, and 1 patient (4%) was dead of disease. Complications included four cases of non-union that required revision surgery, as well as two local recurrences, which necessitated revision surgery to a modular endoprosthesis and above-knee amputation. The average MSTS at the final follow-up was 23.16 ± 5.91. Conclusions: The use of 3D-printed PSIs for knee-sparing bone tumor resections has emerged as the gold standard, enhancing both surgical and oncological outcomes. A future challenge lies in improving reconstruction techniques, shifting from traditional allografts to customized Ti64 printed lattice implants. As personalized healthcare and additive manufacturing continue to advance, the future of orthopedic oncology will likely see more precise, durable, and biologically integrated implants, further improving patient outcomes. Full article

Total hip arthroplasty (THA) is commonly performed for conditions like osteoarthritis, avascular necrosis, hip fractures, and hip dysplasia. Complications following THA can result in major proximal femoral defects (MPFD), which are challenging to manage. Megaprostheses provide a solution, offering stability and early weight-bearing, though they present their own challenges. However, maintaining hip symmetry with megaprostheses is challenging in accurately restoring femoral offset, acetabular orientation, and soft tissue tension. These factors can contribute to instability, altered biomechanics, and functional impairment. Therefore, achieving hip symmetry through femoral and acetabular offset, limb length discrepancy (LLD), and center of rotation (COR) is an important consideration. Achieving proper symmetry may improve gait, quality of life, and overall outcomes. This case series includes 10 patients with non-tumoral pathology treated with megaprostheses for complications after THA between 2014 and 2024. Megaprosthesis conversion was performed for sepsis (n = 2), aseptic loosening (n = 4), and periprosthetic fracture (n = 4). Dislocation occurred in 20%, with one case showing restored hip symmetry but dislocating due to trauma and noncompliance. Another case had an LLD of 3 cm, contributing to dislocation. Periprosthetic infection was observed in 20%, managed with a two-stage approach. Although hip symmetry was not fully restored in all patients, strict follow-up and rehabilitation were essential for improving functionality and quality of life. Megaprosthesis is an effective solution for MPFD in non-oncological patients when performed correctly. Restoring hip symmetry is challenging and depends on patient care and compliance, though it is an important factor influencing outcomes. Full article

(1) Background: The use of tumor megaprostheses faces challenges, but the published series are typically small and offer limited solutions. Our aim was to compile a large series; describe patient profiles and surgical techniques; analyze prosthetic survival identifying factors affecting survival; and provide a basis for future subanalyses. (2) Methods: This is a retrospective observational multicenter study that included patients with a tumor megaprosthesis in any anatomical location. Demographic, etiologic, and surgical variables were analyzed. Data on complications and survival were also collected. (3) Results: Our series includes a total of 816 prostheses (585 primary, 181 revision, and 50 second revision). The patients’ mean age was 44.2 ± 20.8 years. Primary surgeries were performed on the femur (n = 404; 69.1%), tibia (n = 79; 13.5%), humerus (n = 74; 12.6%), pelvis (n = 20; 3.4%), and scapula (n = 4; 0.7%). Survival following primary surgery was 73.3% at 10 years. No statistically significant differences were found with respect to survival from primary surgery between males and females (p = 0.194), between the different etiologies (p = 0.540), or between the lower and the upper limb (p = 0.618). In contrast, statistically significant survival differences were found when the type of fixation was analyzed (p < 0.001). (4) Conclusions: This study analyzed one of the largest series of patients treated with tumor megaprostheses, demonstrating their acceptable survival and validating them as a treatment option for bone tumors. Full article

The optimal management of bone tumors requires a multidisciplinary strategy to guarantee high-quality care. At specialized centers, the medical team responsible for managing patients with bone cancer comprises oncologists, surgeons, radiologists, pathologists, and rehabilitation specialists. The goal of treatment is to achieve long-term survival with minimal disability and pain. Postoperative rehabilitation is a fundamental therapeutic approach to enhance functionality and sustain the utmost quality of life following a limb-sparing surgery. Currently, megaprostheses are used for reconstructing bone defects after tumor resection, but in the literature, only a few studies have investigated rehabilitation outcomes in terms of functionality and impact on daily activities. This narrative review explores the functional and quality of life outcomes after the implantation of MUTARS^® prostheses in patients with lower extremity bone tumors. A comprehensive search was conducted on PubMed and Scopus using the following MESH terms: “MUTARS”, “Megaprosthesis”, “bone”, “tumors”, “metastasis”, “lower limb”, “rehabilitation”, “outcome”, and “quality of life”, and 10 studies were included. The most frequent oncological pathology was found to be primitive bone tumors treated with modular prostheses. The outcome measures used were the Henderson et al. classification, Harris Hip Scale, Musculoskeletal Tumor Society score, Visual Analog Scale, Range Of Motion, Karnofsky Performance Scale, and quality of life questionnaire. MUTARS^® is a well-established treatment option after bone tumor resection, although it involves extensive and complex post-resection reconstruction that exposes joints and tissues to substantial mechanical stress. Proper rehabilitation after MUTARS^® surgery is a fundamental therapeutic step, although there is still insufficient evidence in the literature focusing on functional and rehabilitative outcomes. Therefore, more studies and guidelines are needed to define standardized rehabilitation protocols for clinical practice after orthopedic oncologic surgery. Full article

Background: Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants’ infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors. Methods: We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons. Results: The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively. Conclusions: The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management. Full article

Background: Post-radiation fractures are a significant complication of cancer treatment, often being challenging to manage and impacting patients’ quality of life. This study systematically reviews the literature on fractures in irradiated bones, focusing on risk factors, treatment modalities, and prevention strategies. Factors increasing fracture risk include exposure to high doses of radiation of at least 50 Gy, female gender, menopausal age, and periosteal stripping. Additionally further risk factors are the size of the original tumor and osteoporosis. Methods: A search of PubMed yielded 541 articles, with 4 were ultimately included in the review. These retrospective studies focused on patients undergoing Combined Limb-Sparing Surgery and Radiation Therapy for soft tissue sarcoma. Results: Results show post-radiation fractures affect approximately 4% of patients, with the femur being the most frequently affected site. Intramedullary nailing emerges as the gold standard treatment, with prosthetic replacement or megaprostheses used in the metaepiphyseal region and as salvage procedures. Non-union and infection remain formidable complications. Conclusions: This study highlights the importance of prophylactic nailing in fracture prevention and the efficacy of free vascularized fibular flaps to achieve bone union during revision surgeries. Limited case availability and patient follow-up hinder comprehensive studies, impacting treatment outcomes. Full article

Periprosthetic joint infection is a feared complication after the megaprosthetic reconstruction of oncologic and non-oncologic bone defects of including the knee or hip joint. Due to the relative rarity of these procedures, however, optimal management is debatable. Considering the expanding use of megaprostheses in revision arthroplasty and the high revision burden in orthopedic oncology, the risk of PJI is likely to increase over the coming years. In this non-systematic review article, we present and discuss current management options and the associated results focusing on studies from the last 15 years and studies from dedicated centers or study groups. The indication, surgical details and results in controlling infection are presented for debridement, antibiotics, irrigation and retention (DAIR) procedure with an exchange of the modular components, single-stage implant exchange, two-stage exchanges and ablative procedures. Full article

Delayed fracture healing can have devastating functional consequences, including pseudoarthrosis. Many factors can contribute to delayed healing, including decreased vascularity, micro-motion at the fracture site, large fracture gaps, multiple traumas at the same site, compromised metabolic status, surgical complications, and other conditions. A 61-year-old female patient was referred to our hospital with left distal humeral pseudarthrosis, accompanied by chronic pain and disability. Two years prior, the patient suffered a traumatic incident. At another medical facility, the patient underwent open reduction and internal fixation surgery with simultaneous ulnar nerve transposition. She showed favorable postoperative recovery. Unfortunately, approximately one year later, the patient sustained a second trauma to the same arm. This led to peri-implant fracture and post-traumatic aseptic degradation of the osteosynthesis system which was subsequently removed. Twelve months after the last surgery, the patient was referred to our hospital and, after thorough consideration of the therapeutic options, we decided to perform left elbow arthroplasty with left distal humeral reconstruction by using Zimmer’s Comprehensive Segmental Revision System. This approach is generally reserved for tumors, and only a handful of cases of megaprostheses for non-tumoral indications have been previously reported. The surgery and perioperative care of our patient were optimal, there were no complications, and the patient recovered arm functionality following rehabilitation. Full article

Megaprostheses are well-known, reliable, and effective reconstruction prostheses used in oncologic surgery for limb salvage in patients affected by primary or metastatic bone tumors. Rehabilitation plays a major role after MUTARS replacement, with the aim of improving function after surgery and maintaining the highest possible quality of life. Only a few studies have been published about the use of megaprostheses for the upper limb. The aim of this narrative review is to describe the results of functional and rehabilitative outcomes of patients affected by bone primary or metastatic bone cancer of the upper limb and surgically treated with MUTARS prostheses. A comprehensive search was conducted on PubMed and Scopus using the following MESH terms: “Mutars”, “Megaprosthesis”, “bone”, “tumors”, “metastasis”, “upper limb”, “rehabilitation”, “outcome”, “quality of life”, and 10 studies were included. The most frequent oncological pathology was found to be metastases of the proximal humerus treated with modular endoprosthesis or modular reverse implants. Outcome measures used were ROM, MSTS, ASES, DASH, Constant-Murley score, Enneking score, VAS, MEP, TESS, and WOSI. Reconstruction of the proximal humerus with the MUTARS system seemed to be a valid treatment option after bone tumor resection. Rehabilitation after MUTARS surgery is very relevant, but currently, functional and rehabilitative outcomes are inadequately represented in the literature. Hence, further studies are needed to define standardized rehabilitation protocols after oncological orthopedic surgery that can be applied routinely in clinical practice. Full article

Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the “gold standard” for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV. Full article

Few data are available about results after procedures of resection and megaprosthesis at the hip in very elderly patients. The aim of our study was to ascertain survival and complications in patients aged 80 or older undergoing these major orthopedic procedures. A consecutive series of 27 procedures in 26 patients aged 80–93 years was evaluated. In total, 15 procedures were performed due to oncological diseases, 6 were performed following joint arthroplasty failures or periprosthetic fractures, and 6 were performed after trauma or trauma sequelae. Survival of the patients ranged from 0 to 122 months. Overall survival was 56% at 3 years, 24% at 5 years, and 16% at 8 years. An early postoperative death during the first 3 months occurred in five patients (18.5%). The only preoperative parameter negatively affecting survival was preoperative hemoglobin lower than 11 g/dL. Local complications were similar to reported rates in all-age patients’ series. In our experience, resection and megaprosthetic reconstruction can also be a valid choice in very elderly patients, with 56% of patients living more than two years from surgery and 24% more than five. Nevertheless, early postoperative deaths are frequent. A multidisciplinary evaluation of frailty of the patient must be accomplished, and patients and relatives must be informed about the risks of the procedure. Full article