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Lower limb reconstruction in tumor patients using modular silver-coated megaprostheses with regard to perimegaprosthetic joint infection: a case series, including 100 patients and review of the literature

  • Orthopaedic Surgery
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Abstract

Purpose and objective

Bone resection regarding adequate surgical margins is the treatment of choice for malignant bone tumors. In the case of metastasis-related complications, so-called skeletal-related events, it is highly important to achieve pain relief and a stable joint situation to re-mobilize the patients immediately following surgery. To bridge the often large osseous defect zones after tumor resection, both cemented and uncemented modular endoprosthetic systems are widely used. Patients undergoing tumor-related endoprosthetic orthopedic surgery are facing high risk for develo** a periprosthetic joint infection (PJI). The immunocompromised condition due to anti-neoplastic treatment and long operation time with large exposure of tissue contributes to a high risk of infection.

Methods

The authors present a case series of 100 patients (31% primary bone tumor and 69% metastasis-related surgery) undergoing tumor-related lower limb salvage surgery with special regard to periprosthetic joint infection and the management of this “difficult to treat” situation. Furthermore, a review of the current literature regarding infection following bone tumor resection and endoprosthetic reconstruction is performed and discussed.

Results

The median follow-up was 24 months (range 12–108 months). Ten patients (10%) suffered from a periprosthetic joint infection. We recorded six acute infections (type I) <4 weeks after surgery, one infection >4 weeks after surgery (type II), and three late infections (type III). According to the definition of Laffer et al., three of our patients (30%) are probably free of infection, one patient died of PJI-associated sepsis, and five patients were free of infection, but without restoration of the affected joint.

Conclusion

In conclusion, our own results show that perimegaprosthetic joint infection among silver-coated implants, in patients undergoing tumor-related surgery of the lower limb, is lower compared to non-silver-coated implants. Due to heterogeneity of patients and potential treatment options, the treatment regime should be tailored for the patients’ individual situation.

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References

  1. Heisel C, Kinkel S, Bernd L, Ewerbeck V (2006) Megaprostheses for the treatment of malignant bone tumours of the lower limbs. Int Orthop 30(6):452–457. doi:10.1007/s00264-006-0207-7

    Article  PubMed  PubMed Central  Google Scholar 

  2. Graci C, Maccauro G, Muratori F, Spinelli MS, Rosa MA, Fabbriciani C (2010) Infection following bone tumor resection and reconstruction with tumoral prostheses: a literature review. Int J Immunopathol Pharmacol 23(4):1005–1013

    Article  CAS  PubMed  Google Scholar 

  3. Ercolano LB, Christensen T, McGough R, Weiss K (2013) Treatment solutions are unclear for perimegaprosthetic infections. Clin Orthop Relat Res 471(10):3204–3213. doi:10.1007/s11999-013-2852-7

    Article  PubMed  PubMed Central  Google Scholar 

  4. Cho WH, Song WS, Jeon DG, Kong CB, Kim JI, Lee SY (2012) Cause of infection in proximal tibial endoprosthetic reconstructions. Arch Orthop Trauma Surg 132(2):163–169. doi:10.1007/s00402-011-1405-3

    Article  PubMed  Google Scholar 

  5. Eckardt JJ, Eilber FR, Rosen G, Mirra JM, Dorey FJ, Ward WG, Kabo JM (1991) Endoprosthetic replacement for stage IIB osteosarcoma. Clin Orthop Relat Res 270:202–213

    Google Scholar 

  6. Flint MN, Griffin AM, Bell RS, Wunder JS, Ferguson PC (2007) Two-stage revision of infected uncemented lower extremity tumor endoprostheses. J Arthroplast 22(6):859–865. doi:10.1016/j.arth.2006.11.003

    Article  Google Scholar 

  7. Gosheger G, Gebert C, Ahrens H, Streitbuerger A, Winkelmann W, Hardes J (2006) Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res 450:164–171. doi:10.1097/01.blo.0000223978.36831.39

    Article  PubMed  Google Scholar 

  8. Gosheger G, Goetze C, Hardes J, Joosten U, Winkelmann W, von Eiff C (2008) The influence of the alloy of megaprostheses on infection rate. J Arthroplast 23(6):916–920. doi:10.1016/j.arth.2007.06.015

    Article  Google Scholar 

  9. Henderson ER, Groundland JS, Pala E, Dennis JA, Wooten R, Cheong D, Windhager R, Kotz RI, Mercuri M, Funovics PT, Hornicek FJ, Temple HT, Ruggieri P, Letson GD (2011) Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Jt Surg Am 93(5):418–429. doi:10.2106/JBJS.J.00834

    Article  Google Scholar 

  10. Holzer G, Windhager R, Kotz R (1997) One-stage revision surgery for infected megaprostheses. J Bone J Surg Br 79(1):31–35

    Article  CAS  Google Scholar 

  11. Jeys LM, Kulkarni A, Grimer RJ, Carter SR, Tillman RM, Abudu A (2008) Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Jt Surg Am 90(6):1265–1271. doi:10.2106/JBJS.F.01324

    Article  CAS  Google Scholar 

  12. Morii T, Yabe H, Morioka H, Beppu Y, Chuman H, Kawai A, Takeda K, Kikuta K, Hosaka S, Yazawa Y, Takeuchi K, Anazawa U, Mochizuki K, Satomi K (2010) Postoperative deep infection in tumor endoprosthesis reconstruction around the knee. J Orthop Sci Off J Jpn Orthop Assoc 15(3):331–339. doi:10.1007/s00776-010-1467-z

    Google Scholar 

  13. Roberts P, Chan D, Grimer RJ, Sneath RS, Scales JT (1991) Prosthetic replacement of the distal femur for primary bone tumours. J Bone Jt Surg Br 73(5):762–769

    CAS  Google Scholar 

  14. Wirganowicz PZ, Eckardt JJ, Dorey FJ, Eilber FR, Kabo JM (1999) Etiology and results of tumor endoprosthesis revision surgery in 64 patients. Clin Orthop Relat Res 358:64–74

    Article  Google Scholar 

  15. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M (1994) Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Jt Surg Br 76(2):178–186

    CAS  Google Scholar 

  16. Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops HS, van Horn JR (2000) Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol 73(4):198–205

    Article  CAS  PubMed  Google Scholar 

  17. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M (2002) Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res 403:8–15

    Article  Google Scholar 

  18. Jacofsky DJ, Haidukewych GJ, Zhang H, Sim FH (2004) Complications and results of arthroplasty for salvage of failed treatment of malignant pathologic fractures of the hip. Clin Orthop Relat Res 427:52–56

    Article  Google Scholar 

  19. Sokolovski VA, Voloshin VP, Aliev MD, Zubikov VS, Saravanan SA, Martynenko DV, Nisichenko DV, Strelnikov KN (2006) Total hip replacement for proximal femoral tumours: our midterm results. Int Orthop 30(5):399–402. doi:10.1007/s00264-006-0124-9

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Farid Y, Lin PP, Lewis VO, Yasko AW (2006) Endoprosthetic and allograft-prosthetic composite reconstruction of the proximal femur for bone neoplasms. Clin Orthop Relat Res 442:223–229

    Article  PubMed  Google Scholar 

  21. Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ (2007) Endoprosthetic replacement of the distal femur for bone tumours: long-term results. J Bone Jt Surg Br 89(4):521–526. doi:10.1302/0301-620X.89B4.18631

    Article  CAS  Google Scholar 

  22. Bickels J, Wittig JC, Kollender Y, Henshaw RM, Kellar-Graney KL, Meller I, Malawer MM (2002) Distal femur resection with endoprosthetic reconstruction: a long-term followup study. Clin Orthop Relat Res 400:225–235

    Article  Google Scholar 

  23. Guo Z, Li J, Pei GX, Li XD, Wang Z (2010) Pelvic reconstruction with a combined hemipelvic prostheses after resection of primary malignant tumor. Surg Oncol 19(2):95–105. doi:10.1016/j.suronc.2009.04.003

    Article  PubMed  Google Scholar 

  24. Aljassir F, Beadel GP, Turcotte RE, Griffin AM, Bell RS, Wunder JS, Isler MH (2005) Outcome after pelvic sarcoma resection reconstructed with saddle prosthesis. Clin Orthop Relat Res 438:36–41

    Article  PubMed  Google Scholar 

  25. Wittig JC, Bickels J, Priebat D, Jelinek J, Kellar-Graney K, Shmookler B, Malawer MM (2002) Osteosarcoma: a multidisciplinary approach to diagnosis and treatment. Am Fam Physician 65(6):1123–1132

    PubMed  Google Scholar 

  26. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR, Infectious Diseases Society of A (2013) Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am 56(1):1–10. doi:10.1093/cid/cis966

    Article  Google Scholar 

  27. Patel R, Osmon DR, Hanssen AD (2005) The diagnosis of prosthetic joint infection: current techniques and emerging technologies. Clin Orthop Relat Res 437:55–58

    Article  Google Scholar 

  28. Laffer RR, Graber P, Ochsner PE, Zimmerli W (2006) Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect Off Publ Euro Soc Clin Microbiol Infect Dis 12(5):433–439. doi:10.1111/j.1469-0691.2006.01378.x

    CAS  Google Scholar 

  29. Wimmer MD, Randau TM, Petersdorf S, Pagenstert GI, Weisskopf M, Wirtz DC, Gravius S (2013) Evaluation of an interdisciplinary therapy algorithm in patients with prosthetic joint infections. Int Orthop 37(11):2271–2278. doi:10.1007/s00264-013-1995-1

    Article  PubMed  PubMed Central  Google Scholar 

  30. Donati D, Biscaglia R (1998) The use of antibiotic-impregnated cement in infected reconstructions after resection for bone tumours. J Bone Jt Surg Br 80(6):1045–1050

    Article  CAS  Google Scholar 

  31. Donati D, D’Arenzo R, Ercolani C, Boriani S (1995) Infection in limb salvage surgery for bone tumors. Euro J Orthop Surg Traumatol Orthop Traumatol 5(1):71–74. doi:10.1007/BF02716222

    Article  CAS  Google Scholar 

  32. Grimer RJ, Belthur M, Chandrasekar C, Carter SR, Tillman RM (2002) Two-stage revision for infected endoprostheses used in tumor surgery. Clin Orthop Relat Res 395:193–203

    Article  Google Scholar 

  33. Grimer RJ, Carter SR, Tillman RM, Sneath RS, Walker PS, Unwin PS, Shewell PC (1999) Endoprosthetic replacement of the proximal tibia. J Bone Jt Surg Br 81(3):488–494

    Article  CAS  Google Scholar 

  34. Hardes J, Gebert C, Schwappach A, Ahrens H, Streitburger A, Winkelmann W, Gosheger G (2006) Characteristics and outcome of infections associated with tumor endoprostheses. Arch Orthop Trauma Surg 126(5):289–296. doi:10.1007/s00402-005-0009-1

    Article  CAS  PubMed  Google Scholar 

  35. Hardes J, von Eiff C, Streitbuerger A, Balke M, Budny T, Henrichs MP, Hauschild G, Ahrens H (2010) Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma. J Surg Oncol 101(5):389–395. doi:10.1002/jso.21498

    PubMed  Google Scholar 

  36. Kuhne CA, Taeger G, Nast-Kolb D, Ruchholtz S (2003) Knee arthrodesis after infected tumor mega prosthesis of the knee using an intramedullary nail for callus distraction. Langenbeck’s Arch Surg Dtsch Ges Fur Chir 388(1):56–59. doi:10.1007/s00423-003-0360-z

    CAS  Google Scholar 

  37. Mittermayer F, Krepler P, Dominkus M, Schwameis E, Sluga M, Heinzl H, Kotz R (2001) Long-term followup of uncemented tumor endoprostheses for the lower extremity. Clin Orthop Relat Res 388:167–177

    Article  Google Scholar 

  38. Jeys L, Grimer R (2009) The long-term risks of infection and amputation with limb salvage surgery using endoprostheses. Recent Results Cancer Res Fortschr Der Krebsforsch Progres Dans Les Rech Sur Le Cancer 179:75–84

    Google Scholar 

  39. Piccioli A, Donati F, Giacomo GD, Ziranu A, Careri S, Spinelli MS, Giannini S, Giannicola G, Perisano C, Maccauro G (2016) Infective complications in tumour endoprostheses implanted after pathological fracture of the limbs. Injury. doi:10.1016/j.injury.2016.07.054

    Google Scholar 

  40. Donati F, Di Giacomo G, Ziranu A, Spinelli S, Perisano C, Rosa MA, Maccauro G (2015) Silver coated prosthesis in oncological limb salvage surgery reduce the infection rate. J Biol Regul Homeost Agents 29(4 Suppl):149–155

    CAS  PubMed  Google Scholar 

  41. Ogose A, Hotta T, Kawashima H, Kawaji Y, Endo N (2005) Ischial weight-bearing brace after the infection of megaprosthesis a salvage method for resection arthroplasty. J Arthrop 20(7):954–956. doi:10.1016/j.arth.2005.07.004

    Article  Google Scholar 

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Authors and Affiliations

  1. Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany

    J. Schmolders, S. Koob, P. Schepers, P. H. Pennekamp, S. Gravius, D. C. Wirtz, R. Placzek & A. C. Strauss

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Schmolders, J., Koob, S., Schepers, P. et al. Lower limb reconstruction in tumor patients using modular silver-coated megaprostheses with regard to perimegaprosthetic joint infection: a case series, including 100 patients and review of the literature. Arch Orthop Trauma Surg 137, 149–153 (2017). https://doi.org/10.1007/s00402-016-2584-8

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