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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 106-110

Concomitant bone regeneration to restore bone stock during revision distal femur replacement after large tumor resection

1 Department of Surgery, Sloan Kettering Institute, New York, NY, USA
2 Montefiore Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
3 Columbia University Medical Center, New York, NY, USA
4 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Date of Web Publication4-Mar-2019

Correspondence Address:
Daniel Eduardo Prince
Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jllr.jllr_17_18

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Loss of bone stock is a common problem in revision arthroplasty, specifically in large distal femur replacements (DFRs) after tumor resection. It can lead to worse functional outcomes and increased risk of revision procedures. Restoration of bone using distraction osteogenesis (DO) with an intramedullary nail may be an appropriate solution for this problem, especially in younger adults who may require future surgical interventions. In this series of three patients, we describe the successful use of DO through an internal device to address bone loss after a large osseous resection and revision endoprosthetic reconstruction. Bone stock was restored with a combination of lengthening and bone transport using a multistage revision strategy: removal of existing hardware, treatment of infection if present, lengthening of proximal femur with a temporary antibiotic spacer in the distal femur, and reimplantation of a definitive DFR after bone stock restoration. A magnetically actuated internal lengthening intramedullary rod was utilized to perform the proximal femur osteoplasty. Conversion to a definitive weight-bearing DFR was achieved in two patients; one patient required an above-the-knee amputation for chronic osteomyelitis which could not be controlled after numerous debridements and courses of IV antibiotics. In this patient, the infection could be eradicated from the lengthened bone, the regenerate bone served to provide length to the amputation stump and fully remodeled to provide full weight-bearing and prosthetic use. DO was successfully used in three patients for revision DFR and bone stock restoration. In one of the two patients who required revision surgery for infection, amputation was ultimately required. All three patients achieved successful bone regeneration.

Keywords: Bone regeneration, distal femur replacement, femur lengthening, tumor resection

How to cite this article:
Schwarzkopf E, Sachdev R, Boddapati V, Prince DE. Concomitant bone regeneration to restore bone stock during revision distal femur replacement after large tumor resection. J Limb Lengthen Reconstr 2018;4:106-10

How to cite this URL:
Schwarzkopf E, Sachdev R, Boddapati V, Prince DE. Concomitant bone regeneration to restore bone stock during revision distal femur replacement after large tumor resection. J Limb Lengthen Reconstr [serial online] 2018 [cited 2021 Jul 28];4:106-10. Available from: https://www.jlimblengthrecon.org/text.asp?2018/4/2/106/253389

  Introduction Top

In the last three decades, limb-salvage surgery (LSS) has replaced amputation as the most common method for the removal of malignant bone tumors and is used in about 85%–95% of all sarcomas in the extremities.[1],[2] Compared with amputation, LSS provides superior functional and cosmetic results with comparable life expectancy and rates of local recurrence.[2]

The preservation of bone stock and bone length is an additional concern, especially in young patients. Various techniques have been described to restore bone stock in the femur after failed reconstructions, infection, or large resections: endoprostheses or endoprosthetic combinations, extendable prostheses, telescoped allografts, arthrodesis, vascularized bone grafts, Masquelet technique involving the induction of a fibrous tissue membrane around the bone defect site, rotationplasty, and limb-lengthening techniques.[3],[4],[5],[6],[7],[8],[9] Nonunion or malunion at the allograft-host bone junction, persistent limb-length discrepancy, stem loosening, fatigue fracture of the stem, or even progressive deformity of the reconstructed segment are only some of the complications that can occur.[4],[6],[7],[9] Prosthetic infection causes significant morbidity and may ultimately lead to amputation, with rates of prosthetic infections in the treatment of bone tumors reported from 3% to 43% with lower rates in the upper extremity.[10],[11],[12],[13],[14],[15],[16] Management and successful eradication of infection in tumor-related megaprostheses include irrigation without revision of the prosthesis (6% success),[17],[18] one-stage revision of prosthesis (42%–44% success),[19] two-stage revision with implantation of a cement spacer (52%–72% success),[20],[21] arthrodesis with an intramedullary device (86%–95% success),[22],[23],[24],[25] arthrodesis with external fixation (64%–90% success),[22],[23],[25] arthrodesis with a vascularized fibular graft (47% success),[19] and amputation (98% success).[19],[26] Chronic and recurrent prosthetic infections are associated with poor results.[11],[14],[27],[28],[29] Retaining any of the original, well-fixed endoprosthetic components significantly increases the risk of recurrent infection in both one-stage and two-stage revisions.[18],[30] Kapoor and Thiyam report the risk of amputation due to infected tumor prostheses for oncological reconstructions between 23.5% and 87%.[10],[20],[29],[31],[32],[33],[34] Total femur megaprosthesis infections carry the highest risk of amputation as high as 70%.[35]

Distraction osteogenesis (DO) for regenerating bone stock requires multiple surgical interventions with potential complications, including premature or delayed consolidation, joint contracture, or neuropathy.[5] The benefits of this surgical technique are regeneration of physiologic bone and simultaneous management of both osseous defects and length discrepancy. From a surgical technique, DO allows acute shortening of the osseous defect to compensate for a soft-tissue defect before primary closure, followed by a gradual lengthening phase with an internal or external device with measured soft-tissue stretch and facilitates joint range of motion.[5] In this series, we describe the successful use of DO using a staged reconstruction with an internal device in three patients who underwent revision endoprosthetic reconstruction with significant bone loss.

  Case Reports Top

Case 1

A 19-year-old male presented with several months of left knee pain, attributed to sports, and an ipsilateral 2-cm limb-length discrepancy. High-grade osteogenic sarcoma of the left distal femur was diagnosed and confirmed with biopsy. Metastatic workup revealed a single-lung nodule that resolved with chemotherapy. The patient received three cycles of neoadjuvant chemotherapy, followed by extraarticular resection of the distal femur and knee joint with negative margins and reconstruction with a press-fit distal femur replacement (DFR) (Biomet; Warsaw, IN) [Figure 1]a. Two weeks postoperatively, he developed a periprosthetic infection with methicillin-sensitive Staphylococcus aureus and underwent an exchange of polyethylene components, irrigation, and debridement, and coating of the implant with antibiotic-impregnated cement. After the wound healed, the patient completed the remaining cycles of adjuvant chemotherapy without recurrence of infection. Eight months after completing chemotherapy, the patient developed a large periprosthetic effusion that was positive for S. aureus on aspiration. He then underwent a two-stage revision arthroplasty with complete explant of the prosthesis and implantation of a magnet-actuated internal lengthening intramedullary rod (Precise; Medtronic, Minneapolis, MN). DO, at a rate of 1 mm/day, was initiated for a total lengthening of 65 mm. Subsequently, S. aureus was detected through intraoperative culture, and a new vancomycin and tobramycin-impregnated articulated antibiotic spacer was replaced at the time of irrigation and debridement (Biomet; Warsaw, IN) [Figure 1]b. A second proximal femur osteoplasty was performed with exchange of the intramedullary lengthening rod. DO was resumed at 1 mm/day. Since the patient was nonadherent to the patient-controlled lengthening regimen with the externally controlled unit, the proximal osteotomy site prematurely consolidated after 35 mm of lengthening. A repeat percutaneous osteotomy was performed in the distal femur, and DO was resumed for an additional 30 mm. At the final surgery, the antibiotic spacer was removed and a compress DFR (Biomet; Warsaw, IN) was placed [Figure 1]c. Six months after revision DFR, the patient had no pain, an Eastern Cooperative Oncology Group (ECOG) performance score of 1, a Musculoskeletal Tumor Society (MSTS) lower extremity score of 28, flexion to 100°, and full ambulation. No local recurrence developed; however, 30 months after completing chemotherapy, a recurrence of the lung metastasis required further treatment. The regenerate bone matured without complication, and the patient achieved excellent function until he succumbed to metastatic disease 36 months after initial surgery.
Figure 1: (a) After reconstruction with a press-fit distal femur replacement (b) After removal of the existing distal femur replacement and insertion of an internal lengthening nail and a distal femur articulating cement spacer (c) After removal of the antibiotic spacer and implantation of a distal femur replacement

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Case 2

A 9-year-old female with high-grade osteogenic sarcoma of the left distal femur underwent chemotherapy, followed by wide resection with negative margins and reconstruction with an extensible DFR at an outside institution. Due to implant failure, she required three revision surgeries, including implantation of an extensible prosthesis. Ultimately, she required a DFR that resulted in a 10.5-cm leg-length discrepancy with a knee flexion contracture of 15° and chronic pain [Figure 2]a. Utilizing the multistaged approach outlined below, an osteoplasty of the proximal femur with internal lengthening was performed, requiring multiple procedures to achieve a total bone regeneration length of 20 cm, including 12 cm of femoral length and 8 cm of diaphyseal bone stock restoration. First, removal of the existing DFR and insertion of an internal lengthening nail (Precise; Medtronic, Minneapolis, MN) and a distal femur articulating cement spacer (Biomet; Warsaw, IN) linked to the existing proximal tibia implant were performed. One year after insertion of the lengthening nail, bone transport of 8 cm was achieved with osseous consolidation. The patient underwent another osteoplasty for lengthening of 6 cm, followed 3 months later by second-stage osteoplasty for an additional 6 cm and bone grafting of the left distal femur [Figure 2]b. The patient completed the lengthening process without difficulties, and 1 year later, underwent conversion to a custom ingrowth DFR without signs of local recurrence, infection, or metastatic disease [Figure 2]c. One year after her last surgery, the patient had an ECOG score of 1, MSTS score of 26, and knee flexion to 80°.
Figure 2: (a) Before limb-lengthening surgery: the patient had a distal femur replacement with 10.5 cm of ipsilateral leg-length discrepancy (b) After limb-lengthening surgery (c) After implantation of custom distal femur replacement

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Case 3

A 31-year-old male with low-grade osteogenic sarcoma of the left distal femur underwent wide resection with negative margins and reconstruction with a standard DFR [Figure 3]a. Two months after initial surgery, the patient suffered a traumatic periprosthetic fracture and he underwent revision of the distal femoral component to a cemented DFR. Three years later, the patient had a periprosthetic joint infection and a concomitant fracture of the bone and stem at the distal femur, necessitating a two-stage revision to a long-cemented stem. The patient did well for almost 8 years when pain in his left thigh returned and radiographs revealed osteolysis and hardware loosening of the distal femoral component with subsidence leading to a 5-cm length discrepancy. The patient underwent hardware removal, osteoplasty of the proximal left femur with internal lengthening (Precise; Medtronic, Minneapolis, MN), and insertion of articulated distal femur cement spacer (Biomet, Warsaw, IN) [Figure 3]b. The patient achieved a restoration of bone stock of 6 cm and bone lengthening of 4 cm. However, he developed chronic osteomyelitis with extended beta-lactamase-resistant E. coli that was treated with numerous washouts, exchanges of antibiotic spacers, and courses of intravenous antibiotics. Twelve months after insertion of the intramedullary lengthening nail, the patient underwent the removal of all hardware and arthrodesis with an antibiotic-coated fusion nail (Stryker, Kalamazoo, MI). Despite numerous debridements and courses of antibiotics, the infection could not be eradicated. An above-the-knee amputation was performed 2 months after attempted arthrodesis [Figure 3]c. The lengthened femoral bone was retained and has remodeled, allowing full weight-bearing on the end of this residual limb. One year after amputation, the patient was ambulating well with prosthesis and had an MSTS lower extremity score of 20, an ECOG performance score of 1, and no signs of local recurrence, infection, or metastatic disease.
Figure 3: (a) After resection and reconstruction with a standard distal femur replacement (b) Internal distraction osteogenesis was performed to achieve restoration of bone stock and lengthening (c) After above the knee amputation due to osteomyelitis

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  Discussion Top

Endoprosthesis-related complications may be mechanical (aseptic loosening, stem fractures, failure of attachment to soft tissue, etc.) and/or nonmechanical (infection, wound necrosis, tumor recurrence, etc.).[36] Periprosthetic infection is common among cancer patients, occurring at a rate of 5.7%–15% of all cases and 43% of revision cases.[11] It is also associated with loss of bone stock, which increases the risk of aseptic loosening, nonunion, and fracture.[37],[38] However, the benefits of increased bone stock availability for revision surgery include higher rates of union, lower rates of bony reabsorption, and potential future revision arthroplasty, if necessary.[39]

For the management of periprosthetic infections, authors consider two-stage revision, the gold standard;[21],[20],[40] however, a single-stage exchange of the prosthesis without removing the stems is possible in selected cases.[41] However, some authors advocate a single-stage exchange of the prosthesis without removing the stems in selected cases, despite studies showing a higher rate of persistent infection if any original components are maintained, even stable, well-fixed implants.[18],[30] The advantages are the avoidance of large bone defects, the need for only one operation putting a smaller burden on the patients, a shorter period of hospitalization, and the potential for lower costs. The cumulative drawbacks of both periprosthetic infection and revision surgery are decreased bone stock, increased limb-length discrepancy, and higher infection recurrence.

The concept of concomitant limb lengthening while treating a periprosthetic infection has been previously reported.[42],[43] This process was first described by Manzotti et al., who reported the case of a 17 years old treated with knee arthrodesis with concurrent tibial and femoral lengthening for an infected total knee arthroplasty (TKA) with multiple failed arthroplasties; the patient achieved appropriate limb function without recurrence of infection at 9-month follow-up.[43] In a case series reported by Kinik, a patient with an initial 220-mm bone defect after osteosarcoma resection and a chronic infection was successfully treated with arthrodesis and simultaneous limb lengthening with the Ilizarov method.[42]

Arthrodesis for the treatment of chronically infected and revised TKA with external fixation or internal fixation can be successful.[22],[23],[24],[25] Knee arthrodesis rates utilizing intramedullary fixation are slightly higher at 85%–95% compared to external fixation at 65%–90%.[22],[23],[25] External fixation pin sites have been shown to pose a high risk for infection in subsequent endoprosthetic implantation even many years later.[44] The internal lengthening intramedullary implant was utilized over external fixation to perform the DO to decrease the risk of superficial pin site infections, deep fixator-related infections, and colonization of the bone pin tracts. Theoretically, the tibia and humerus could be treated with the described technique; however, this has not yet been indicated nor performed by the authors. By employing concomitant limb lengthening, bone stock can be regenerated, leading to stable, functional outcomes with equal risk of complications compared to other salvage methods for infected megaprostheses.

The current case series is limited by the small number of patients, the follow-up duration, and the retrospective nature of the study which prevents randomization and inherently includes treatment bias by the authors. The study is limited without a comparison group for function, cost, patient-reported outcome, or number of surgical interventions to alternative reconstructive options such as arthrodesis. However, arthrodesis alone would not address the significant length discrepancy of these patients given the large bone defects and would similarly require additional surgical intervention to address the discrepancy.

  Conclusion Top

Management of periprosthetic infection following reconstruction in bone tumors requires careful planning, and different techniques exist to treat chronic infections. DO is one option to address the problem of periprosthetic infection and tumor-related bone loss simultaneously. Although our case report has several limitations due to a limited number of patients and relatively short-term follow-up, it highlights the use of DO for revision DFR to restore bone stock.

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Conflicts of interest

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