Endoprosthetic Proximal Femoral Hemiarthroplasty Versus Total Hip Endoprosthetic Reconstruction After Proximal Femoral Resections in Young Adults

Background Metastatic tumors are the most common malignant lesion of the proximal femur, with carcinomas being the most frequent. The proximal femur and midfemur are common sites for primary bone sarcomas; approximately16% of Ewing's sarcomas, 13% chondrosarcomas and 10% of osteosarcomas develop at these locations. The major aim in the management of patients who have bone malignancies is prolonging their survival. Primary bone sarcomas that require surgical resection can be treated by either amputation or limb salvage. Most studies which compared both approaches reported that limb salvage had no adverse effect on patients’ survival on long-term. Objective This is a systematic review of literature with meta-analysis study that compare the functional outcomes and complications of the methods; proximal femoral hemi versus total arthroplasty after proximal femur resection followed by endoprosthetic reconstruction and provide recommendations by the best available evidence. Methods We included Randomized control trails (RCTs), including cluster RCTs, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies and controlled clinical trials. We excluded cross-sectional studies, case reports, review articles, letters to the editor, meeting abstracts, and technique papers. Search results conducted to systematic review management software and manually screened for eligibility were included. Critical appraisal checklist was used to assess the search results based on the inclusion/exclusion criteria. Results Twenty-three studies are included. Quality appraisal demonstrated that all but one study is retrospective. The pooled results from the meta-analysis showed that the rate of aseptic loosening was only 2% when reconstruction occurs with endoprosthetic proximal femoral hemiarthroplasty. There was unimportant heterogeneity in the included studies. The rate of conversion to total hip arthroplasty (THA) is 4.6% to 8% of oncological patients. The rate of periprosthetic fracture was only 1% Conclusion Proximal femoral endoprosthesis has definitive benefits in the treatment of primary or metastatic tumors affecting the proximal femur. The implants tend to improve the function and quality of life of patients with metastatic disease and high-grade localized disease. It also provides them with a relatively pain-free limb with good functional capacity. With continuing advances in the surgical and oncological fields, there is a great potential for curative limb salvage surgery in the long term. Reconstruction with endoprosthetic Proximal femoral hemiarthroplasty after proximal femoral resection in young adults can confer additional stability with a reduced dislocation rates and systemic complications as compared to total hip arthroplasty.

The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study

Background: An endoprosthetic reconstruction in musculoskeletal oncology patients is associated with significant blood loss. The purpose of this study is to evaluate the safety and efficacy of tranexamic acid (TXA) for these patients and to assess any changes in their hemostatic profile using rotational thromboelastometry (ROTEM). Methods: A retrospective observational study was performed including 61 patients with primary or metastatic bone tumors who underwent surgery. Group A (n = 30) received both intravenous and local TXA whereas Group B (n = 31) was the control group. The primary outcomes were perioperative blood loss and blood unit transfusions and the secondary outcomes included the incidence of thromboembolic complications and a change in blood coagulability as reflected by ROTEM parameters. Results: The median difference in blood loss between the two groups was 548.5 mL, indicating a 29.2% reduction in the 72 h blood loss following TXA administration (p < 0.001). TXA also led to a reduced transfusion of 1 red blood cell (RBC) unit per patient (p < 0.001). The two groups had similar rates of thromboembolic complications (p = 0.99). The antifibrinolytic properties of TXA were confirmed by the significantly higher INTEM, FIBTEM and EXTEM LI60 (p < 0.001, p = 0.005 and p < 0.001, respectively) values in the TXA group. Conclusion: Tranexamic acid was associated with a significant reduction in perioperative blood loss and transfusion requirements without a complete shutdown of the fibrinolysis. Larger studies are warranted to assess the frequency of these outcomes in musculoskeletal oncology patients.

Endoprosthetic Reconstruction in Limb Salvage for Malignant Bone Tumours in Children

Background: The management of malignant bone tumors in children has come a long way in the past few decades. The transition from amputation to limb salvage has been made possible due to the rapid development in the diagnosis and the oncological management of these malignant tumors. However, there exist significant reservations regarding endoprosthetic reconstruction in children. Material and methods: A mini-review was conducted of articles detailing the use of prosthetic reconstruction following tumor resection in children. The data regarding complications and functional outcomes following surgery were collected and presented. Results: The studies reviewed reported a 5-year survival rate between 60 – 70 %. Uniform across the studies was the need for multiple surgeries when endoprosthesis was used for limb reconstruction, ranging between 2.8 – 3.5 surgeries. The most common complication noted across the studies was related to soft tissue problems such as joint instability followed by structural failure of the prosthesis. Infections were noted with a frequency of 10 – 15 %. Studies showed successful management of limb length discrepancy with expandible prosthesis. Musculoskeletal Tumor Society (MSTS) score used to evaluate the functional outcome showed satisfactory outcomes. Conclusion: Limb salvage surgery, with recent advances in technique and prosthesis design, is an attractive option in children with extremity malignant bone tumors. In recent time, endoprosthetic reconstruction of extremities have yielded good functional results and are well accepted by the child and the parents. The purpose of this mini-review is to shed some light on the use of endoprosthetic reconstruction in children following tumor resection with its potential benefits and drawbacks.

Implant survival and functional results of endoprosthetic reconstruction for proximal femoral metastases with pathological fractures

Background: This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures. Methods: A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated. Results: The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95–0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30–56.6%) and the median KPS score was 40 (30–50). Postoperative third month, the median MSTS score was 56.6 (53.3–86.6%) and the median KPS score was 60 (40–70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure. Conclusion: Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.