Is osseous reattachment of the greater trochanter necessary compared to soft‐tissue‐only abductor repair in proximal femoral megaprosthesis reconstruction?

Abstract

Background One of the challenges to surgical reconstruction following oncologic proximal femur resection is reliable re‐establishment of the abductor mechanism. Surgical and functional outcomes following re‐approximation of the abductor mechanism to a metallic endoprosthetic after tumor resection of the proximal femur have not been well established in the literature. Methods A retrospective review was performed, inclusive of patients who received a proximal femur replacement with a metallic endoprosthesis following tumor resection. Patients were divided into two groups: (1) those that received an abductor repair involving a trochanteric osteotomy and osseous fixation of the greater trochanter/abductor mechanism to the endoprosthesis, and (2) those that did not have a trochanteric osteotomy and therefore had an abductor repair consisting of only soft tissue reattachment to the endoprosthesis. The two groups were assessed for demographic characteristics, diagnosis, surgical outcomes including rates of complication and failure, radiographic evidence of trochanteric failure, and functional outcomes. Descriptive statistics, comparative statistics, and logistic regression analyses were performed to discern differences between the two study groups. Results Fifty‐three patients were included in the analysis, 29 had abductor reconstructions involving reattachment of the greater trochanter to the metallic endoprosthesis and 24 had soft tissue reconstruction of the abductor mechanism without bony fixation. There were no differences between the two groups for demographic data, cancer diagnosis, follow up, or survivorship. Radiographic evidence of trochanteric dissociation from the endoprosthesis was observed in 45% of osteotomy cases. Only 10% of patients in the trochanter osteotomy group and 38% of the soft tissue only group were able to resume a normal, non‐Trendelenburg gait at final postoperative visit (p = .024). Need for an assistive ambulatory device was seen in 83% and 67% of the osteotomy and soft‐tissue‐only patients, respectively (p = .21). Conclusion Re‐establishing the abductor mechanism following proximal femur oncologic resection remains a challenge to orthopedic oncologists. Even when possible, salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function in this series, when compared to a similar cohort that received a soft‐tissue‐only abductor repair. Abductor mechanism reconstruction with a greater trochanteric osteotomy and subsequent fixation to the proximal femur endoprosthesis had a high rate of radiographic failure. Additionally, reattachment of the greater trochanter to the proximal femur endoprosthesis demonstrated no improvement in Trendelenburg gait or reliance on an assistive ambulatory device when compared to a soft‐tissue‐only abductor repair.

What’s New in Musculoskeletal Tumor Surgery

“…Christ et al reported on a small series of 12 patients who underwent proximal femoral reconstruction with compliant compression fixation and found that hypertrophic bone at the bone-implant interface was not common, as it is in distal femoral reconstructions 22 . Finally, Groundland et al reported that, in patients who underwent proximal femoral endoprosthetic reconstruction, salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function compared with soft-tissue-only abductor repair 29 .…”

Macrophages and vimentin in tissues adjacent to megaprostheses and mesh in reconstructive surgeries

“…Groundland et al compared the functional results of a soft tissue repair or reattachment of the bony greater trochanter to a prosthesis. Contrary to expectations, the incidence rate of a Trendelenberg gait was lower with the soft tissue repair than with reattachment of the bony greater trochanter [ 19 ]. Assuming that bone integration to the metal surface is occurring, surface modification of the prosthesis appears to provide a low rate of aseptic loosening of the stem [ 20 ].…”

“…In all of these procedures, the gastrocnemius flap technique is considered the “gold standard” of reconstruction methods for knee extension [ 18 ]. Additionally, for functional preservation after megaprosthetic replacement of the proximal femur, reconstruction of the gluteus medius muscle is encourage, given that failure of the hip abduction may lead to a Trendelenberg gait [ 19 ]. Groundland et al compared the functional results of a soft tissue repair or reattachment of the bony greater trochanter to a prosthesis.…”

“…However, surface modification of the proximal tibia component has not been used as a mainstream reconstruction method for knee extension [ 18 ]. Furthermore, the proximal femur component will not serve for hip abduction by bony greater trochanter conjugation to metal surfaces [ 19 ]. Transmission of muscle power to the prosthesis via soft tissue integration to metal is an alternative strategy that deserves further investigation.…”

Erratum

“…In the article by Groundland J, Brown JM, Jones KB, Randall RL, 1 the author names Jeffrey Brown and Kevin Jones have been corrected to read "Jeffrey M. Brown" and "Kevin B. Jones".…”