Aseptic Loosening in Cemented Custom-Made Prosthetic Replacements for Bone Tumours of the Lower Limb

Background Patients with failed distal femoral megaprostheses often have bone loss that limits reconstructive options and contributes to the high failure rate of revision surgery. The Compress 1 Compliant Pre-stress (CPS) implant can reconstruct the femur even when there is little remaining bone. It differs from traditional stemmed prostheses because it requires only 4 to 8 cm of residual bone for fixation. Given the poor long-term results of stemmed revision constructs, we sought to determine the failure rate and functional outcomes of the CPS implant in revision surgery. Questions/purposes (1) What is the cumulative incidence of mechanical and other types of implant failure when used to revise failed distal femoral arthroplasties placed after oncologic resection? (2) What complications are characteristic of this prosthesis? (3) What function do patients achieve after receiving this prosthesis? Methods We retrospectively reviewed 27 patients who experienced failure of a distal femoral prosthesis and were revised to a CPS implant from April 2000 to February 2013. Indications for use included a minimum 2.5 mm cortical thickness of the remaining proximal femur, no prior radiation, life expectancy [10 years, and compliance with protected weightbearing for 3 months. The cumulative incidence of failure was calculated for both mechanical (loss of compression between the implant anchor plug and spindle) and other failure modes using a competing risk analysis. Failure was defined as removal of the CPS implant. Followup was a minimum of 2 years or until implant removal. Median followup for patients with [CI], 4%-33%) at both 5 and 10 years. These failures occurred early at a median of 5 months. The cumulative incidence of other failures was 18% (95% CI, 7%-45%) at 5 and 10 years, all of which were deep infection. Three patients required secondary operations for cortical insufficiency proximal to the anchor plug in bone not spanned by the CPS implant and unrelated to the prosthesis. Median MSTS score was 27 (range, 24-30). Conclusions Revision distal femoral replacement arthroplasty after a failed megaprosthesis is often difficult as a result of a lack of adequate bone. Reconstruction with the CPS implant has an 11% failure rate at 10 years. Our results are promising and demonstrate the durable fixation provided by the CPS implant. Further studies to compare the CPS prosthesis and other reconstruction options with respect to survival and functional outcomes are warranted. Level of Evidence Level IV, therapeutic study.

Section: Resultsmentioning

confidence: 99%

mentioning

confidence: 99%

Revision Distal Femoral Arthroplasty With the Compress® Prosthesis Has a Low Rate of Mechanical Failure at 10 Years

Zimel

Farfalli

Zindman

et al. 2016

“…In a large study by Jeys et al [13], including 228 distal femoral EPRs, aseptic loosening accounted for 13.6% of all failures with a median time to revision due to mechanical failure of 9.3 years. Moreover, Mittermayer et al [20] and Unwin et al [27] found, at 10 years postoperatively, 24% and 32.6%, respectively, of patients who had distal femoral EPR underwent revision for aseptic loosening. In our current study, the overall rate of aseptic failure was 7.7% at 6.2 years.…”

Section: Discussionmentioning

confidence: 99%

Aseptic Failure: How Does the Compress® Implant Compare to Cemented Stems?

Pedtke

Wustrack

Fang

et al. 2012

Background Failure of endoprosthetic reconstruction with conventional stems due to aseptic loosening remains a challenge for maintenance of limb integrity and function. The Compress 1 implant (Biomet Inc, Warsaw, IN, USA) attempts to avoid aseptic failure by means of a unique technologic innovation. Though the existing literature suggests survivorship of Compress 1 and stemmed implants is similar in the short term, studies are limited by population size and followup duration.Questions/purposes We therefore compared (1) the rate of aseptic failure between Compress 1 and cemented intramedullary stems and (2) evaluated the overall intermediate-term implant survivorship. Methods We reviewed 26 patients with Compress 1 implants and 26 matched patients with cemented intramedullary stems. The patients were operated on over a 3-year period. Analysis focused on factors related to implant survival, including age, sex, diagnosis, infection, aseptic loosening, local recurrence, and fracture. Minimum followup was 0.32 years (average, 6.2 years; range, 0.32-9.2 years).

“…The relative length of prosthetic replacement has been associated with distal femoral prosthetic failure, particularly when the femoral resection exceeds 40% of the overall length of the femur. Reduction of the femoral deficiency to less than 40% of the overall bone length may mitigate this effect [9,11]. There is a tradeoff, however.…”

Section: Discussionmentioning

confidence: 99%

Telescope Allograft Method to Reconstitute the Diaphysis in Limb Salvage Surgery

Healey

Abdeen

Morris

et al. 2009

We propose a surgical technique for structural allograft reconstitution of the diaphysis of long bones, maximizing surface contact between host and allograft bone. This method, analogous to a telescope, overlaps the graft and host bone, theoretically increasing bone surface contact substantially. We report the outcome of 22 telescoped allograft junction sites in 19 patients who lacked sufficient host bone to accommodate a regular-length stemmed implant. This joint-sparing reconstruction preserved 15 of 16 adjacent joints at risk for replacement. Five patients needed additional surgery, but none for nonunion. The diaphyseal length could be reconstructed enough so that a short prosthesis (less than the critical 40% of total bone length) could be used. This biologic method to reconstruct major segments of the diaphysis is best suited for patients with quantitatively or qualitatively deficient residual bone stock after tumor resection or prosthetic revision. We believe it is an excellent technique for revision knee megaprostheses when there is a short remnant of proximal femur.