Minimising aseptic loosening in extreme bone resections

Abstract

Aims Following the resection of an extensive amount of bone in the treatment of a tumour, the residual segment may be insufficient to accept a standard length intramedullary cemented stem. Short-stemmed endoprostheses conceivably have an increased risk of aseptic loosening. Extra-cortical plates have been added to minimise this risk by supplementing fixation. The aim of this study was to investigate the survivorship of short-stemmed endoprostheses and extra-cortical plates. Patients and Methods The study involved 37 patients who underwent limb salvage surgery for a primary neoplasm of bone between 1998 and 2013. Endoprosthetic replacement involved the proximal humerus in nine, the proximal femur in nine, the distal femur in 13 and the proximal tibia in six patients. There were 12 primary (32%) and 25 revision procedures (68%). Implant survivorship was compared with matched controls. The amount of bone that was resected was > 70% of its length and statistically greater than the standard control group at each anatomical site. Results The mean follow-up was seven years (one to 17). The mean length of the stem was 33 mm (20 to 60) in the humerus and 79 mm (34 to 100) in the lower limb. Kaplan-Meier analysis of survival of the implant according to anatomical site confirmed that there was no statistically significant difference between the short-stemmed endoprostheses and the standard stemmed controls at the proximal humeral (p = 0.84), proximal femoral (p = 0.57), distal femoral (p = 0.21) and proximal tibial (p = 0.61) sites. In the short-stemmed group, no implants with extra-cortical plate osseointegration suffered loosening at a mean of 8.5 years (range 2 to 16 years). Three of ten (30%) without osseointegration suffered aseptic loosening at a mean of 7.7 years (range 2 to 11.5 years). Conclusion When extensive resections of bone are required in the surgical management of tumours, and in revision cases, the addition of extra-cortical plates to short medullary stems has shown non-inferiority to standard length medullary stems and minimises aseptic failure. Cite this article: Bone Joint J 2017;99-B:1689–95.