As effective chemotherapeutic regimens were developed, limb salvage using various techniques gained popularity among orthopaedic oncologists [ 1 , 11 , 19 , 20 , 24 , 37 , 45 , 49 , 60 , 69 ]. Numerous studies document relatively high implant survival after limb salvage for tumors involving the distal femur [ 3 , 4 , 8 , 26 , 27 , 29 , 35 , 43 , 44 , 50 , 54 , 55 , 57 , 61 , 71 ].
Studies that are available, however, do not stratify patients on the basis of tumor grade, stage of disease, or life expectancy to define the disease-specific survival of implants. This makes it difficult for surgeons to accurately predict how long the implants will last for a given patient population and life expectancy. Additionally, there are limited data available with which to compare implant survival of contemporary modular implant designs with older custom-designed implants no longer in use [ 8 , 44 , 48 , 70 ].
Critics of a cemented endoprosthetic reconstruction technique cite rates of aseptic loosening from 8. Given the paucity of long-term data concerning cemented distal femoral implants and the heightened interest in alternate fixation designs, we sought to answer the following four questions: 1 Do newer cemented modular implant designs have improved survivorship compared with older custom-designed components?
Patients and Methods We retrospectively reviewed the electronic and paper charts of all patients who underwent cemented distal femoral endoprosthetic reconstructions for musculoskeletal tumors between December and December We excluded 68 patients: 39 patients had distal femoral reconstructions or a diagnosis other than musculoskeletal tumor; 27 with a tumor-related diagnosis were skeletally immature and underwent distal femoral reconstruction with the intent to perform multiple expansion procedures at a later date, possibly including complete prosthesis exchange; two patients underwent reconstruction with a cementless implant.
We previously reported our results of expandable and cementless implants for tumors of the distal femur [ 16 , 17 , 36 , 64 ] and did not include them in the current analysis. Their mean age at the time of surgery was The patients were analyzed overall and according to implant type. The latter group was treated as a single cohort owing to similarity in life expectancy among patients with these four diagnoses. No patients were recalled specifically for this chart review study.
All patients underwent staging which included plain radiography and MRI of the limb, CT of the chest and total body scintigraphy prior to biopsy.
There were 33 patients with benign bone tumours who had grade-3 lesions and two who had grade-2 lesions. When indicated, patients received the standard pre-operative chemotherapy regime in use at the time of their treatment. Operative technique. All operations were carried out by a single surgeon LRM. Tumour resection was performed with the goal of obtaining adequate disease-free margins.
For resection of tumours of the proximal femur, biopsy tracts were excised en bloc with the specimen through a posterolateral approach to the hip. The abductor muscles were detached from the specimen by transection through the tendon or muscle.
Wide resection with tumour-free margins was obtained in all patients. All resections of the hip were intra-articular. The articulation was bipolar in 62 patients and a total hip arthroplasty in This choice was based on pre-operative anticipated survival and intra-operative assessment of the acetabulum and surrounding soft-tissue attachments.
All femoral stems were fixed with a polymethyl-methacrylate PMMA cement mantle of 1 mm to 2 mm, after reaming the host femur 2 mm larger than the diameter of the stem. Acetabular components, when used, were cemented. Reconstruction of the abductor muscles was performed by suturing the tendons to the remaining host soft tissue without direct attachment to the endoprosthesis. For resection of tumours about the knee, a medial or lateral parapatellar arthrotomy was performed depending on the location of the lesion.
For tumours arising from the proximal tibia, the insertion of the extensor mechanism on the tibial tuberosity was resected en bloc with the lesion.
Wide tumour-free margins were obtained for all patients. A total of resections of the knee were intra-articular and three were extra-articular. The MSRS endoprosthesis, with a rotating kinematic hinged knee mechanism, was used to reconstruct the segmental defects arising from resection of the tumour. A total of 78 patients had reconstruction for tumours of the distal femur and 30 for neoplasms of the proximal tibia.
All the components were cemented to allow immediate post-operative weight-bearing. The stems were fixed with a PMMA cement mantle of 1 mm to 2 mm with the routine use of modern cementing techniques of pressurisation and an intramedullary cement plug. The patella was resurfaced routinely. Reconstruction of the extensor mechanism was performed after proximal tibial resection as described by Malawer and Sugarbaker. A medial gastrocnemius transpositional muscle flap was then rotated anteriorly to cover the proximal tibia and knee, and was sutured to the underlying patellar tendon, quadriceps and joint capsule.
The gastrocnemius flap ensured adequate soft-tissue coverage around the prosthesis and provided mechanical and biological reinforcement of the extensor mechanism. After distal femoral reconstruction a medial gastrocnemius rotational flap was transposed when adequate soft-tissue coverage could not be achieved locally.
Total femoral reconstruction was performed as described by Malawer and Sugarbaker. The incision was extended distally to the anterolateral aspect of the patellar tendon and tibial tuberosity. A transverse tibial osteotomy was performed approximately 1 cm below the joint line, as for a standard knee arthroplasty. Endoprosthetic reconstruction was performed with the MSRS system using bipolar hip components and a rotating kinematic hinge knee mechanism. The hip abductors were reconstructed by directly suturing the tendons to the remaining soft tissue.
A medial gastrocnemius interposition flap was performed in all patients to provide adequate soft-tissue coverage about the knee. Post-operatively, intravenous antibiotics were routinely administered until all drains were removed by the third post-operative day. Patients with proximal femoral and distal femoral reconstructions were allowed to bear full weight immediately after surgery without a brace or cast. Those who underwent distal femoral reconstruction began mobilisation of the knee on the second post-operative day.
The protocol for patients who had undergone proximal tibial resection included immobilisation of the knee in full extension for three weeks to allow healing of the extensor mechanism. After removal of the knee brace, patients began physiotherapy, concentrating on knee extension exercises to prevent an extensor lag. Once full extension had been achieved, efforts were directed towards improving flexion of the knee.
Patients who had total femoral replacement were mobilised post-operatively with an abduction brace and were restricted to partial weight-bearing. At four to six weeks, once active hip abduction had been achieved, the brace was discarded and full weight-bearing was allowed.
The patients were reviewed every three months for the first two years after operation, then every six months for three additional years and annually thereafter. Failure of the endoprosthetic reconstruction was defined as revision of any or all components of the implant, removal of the prosthesis or amputation of the limb.
The records were inspected for the onset of any complications. Causes of failure leading to revision included infection, recurrence of the tumour, aseptic loosening, fatigue failure, peri-prosthetic fracture and dislocation. The functional outcome was assessed in all surviving patients using the revised Musculoskeletal Tumour Society functional rating system.
An investigator not involved in clinical care interviewed patients by telephone or at their latest follow-up and completed a questionnaire with each patient. Statistical analysis. Patients who died with their original implant in place were censored. The starting point was defined as the date of implantation of the prosthesis and the end-point as the need for revision, removal of the implant or amputation.
The end-point for limb survival was amputation. The log rank test and Cox proportional hazards regression model were used to analyse the association between the various clinical variables and failure of the implant. A p value of less than 0. Results A total of 35 prostheses The rate of revision was The reasons for failure in these patients are outlined in Table II. There was, however, a trend towards greater implant survivorship in females, older patients and in those with metastatic disease.
The mean age of the patients in whom the initial endoprosthetic reconstruction ultimately failed was 36 years 11 to The mean interval between the initial surgery and failure was 36 months 1 to There were five amputations 2.
One patient with a proximal femoral endoprosthesis developed a deep infection and chose to have an amputation. Two further amputations, one after distal femoral and one after proximal tibial reconstruction, were performed for infection. The remaining two patients underwent above-knee amputations for local recurrence of tumour.
One patient had a malignant fibrous histiocytoma of the proximal tibia, and the other an osteogenic sarcoma of the distal femur. The mean interval between endoprosthetic reconstruction and amputation was Overall survivor-ship of the limb without amputation was There was local recurrence in six patients 2. In three this occurred at the proximal femur, in two at the distal femur and in one at the proximal tibia.
Of those patients in whom there was recurrence at the proximal femur, one had a recurrent haemangioendothelioma and two developed recurrent metastases renal-cell carcinoma, squamous-cell carcinoma. Two of these patients underwent revision, one to a cemented acetabulum and the other to a larger femoral component. The remaining patient had the implant removed but without re-implantation. Of the two patients with distal femoral recurrences, one underwent above-knee amputation and the other successful revision for recurrent osteogenic sarcoma.
The single patient with a proximal tibial recurrence had an amputation. The mean time from initial resection to recurrence was 21 months 2. At the time of this study all patients with local recurrence had died from their disease.The gender, age, diagnosis and location of the tumour were not prognostic variables for failure. Four distal femoral stems and one proximal tibial stem were successfully revised at a mean Introduction Before the s, the majority of high-grade musculoskeletal tumors involving the distal femur were treated with transfemoral amputation owing to an unacceptably high rate of recurrence associated with local resection [ 10 , 19 , 31 , 47 ]. This may reduce the rate of aseptic loosening by allowing load sharing with the prosthesis. Although the proximal femur is one of the most successful sites of endoprosthetic reconstruction, instability remains the most common complication associated with large segmental reconstruction of the proximal femur and is a frequent cause of failure. After removal of the knee brace, patients began physiotherapy, concentrating on knee extension exercises to prevent an extensor lag. Touching College, Kotli F. All links were carried out by a single surgeon. The results in the remaining who had limb salvage about Shopkeepers millennium thesis writing text years ago, and is considered to. Essay about computer benefits life without essay for communication be confident in your argument.
Of the two patients with distal femoral recurrences, one underwent above-knee amputation and the other successful revision for recurrent osteogenic sarcoma. The Siberianor Amur, youth P.
Intra-operative assembly allows for the uncertainty of the margin of tumour resection, as well as offering an element of expandability when used for reconstruction in skeletally immature patients. Modular endoprosthetic replacement of the lower limb is a durable and long-term reconstructive option after resection of a tumour. Infection occurred in 5. There were 33 patients with benign bone tumours who had grade-3 lesions and two who had grade-2 lesions. There was fatigue failure of the implant in nine patients 4.
Overall survivor-ship of the limb without amputation was A total of 35 Where tigers live and what they eat South China Tiger - This is the most endangered type of tiger. Wide tumour-free margins were obtained for all patients. Press Releases The photos show a male Amur tiger pass by, followed by a female and three cubs within the span of about two minutes. This includes some larger mammals such as water buffalo, deer, and wild boar.
At four to six weeks, once active hip abduction had been achieved, the brace was discarded and full weight-bearing was allowed. See the Guidelines for Authors for a complete description of levels of evidence. Overall, the mean time from endoprosthetic replacement to dislocation was 4.
Terjemah Sitap orang tahu mengenai harimau khusunya kebuasan mereka dalam instink berburu dan kemampuan untuk bertahan dan juga kepunahan mereka.
Report text Tigers Tigers Every flag know tigers especially in thier article of youth instincts and skill for survival Best cover letter for customer service representative their extinction. Tigers are hunted for their report, pelt and body parts that are used in folk remedies. There were five amputations 2. All femoral stems were fixed with a polymethyl-methacrylate PMMA cement mantle of 1 mm to 2 mm, after reaming the host femur 2 mm larger than the diameter of the stem. Black tigers have been reported less frequently from the dense forests of Myanmar Burma , Bangladesh , and eastern India. The decreased incidence of fatigue failure of the stem may be related to several changes of design, including forging rather than casting to increase in strength and the use of stronger alloys.
A medial gastrocnemius interposition flap was performed in all patients to provide adequate soft-tissue coverage about the knee. Image credit: Shutterstock The tiger life Tigers are solitary creatures; they like to spend most of their time alone, roaming their massive territories looking for food. One patient had a malignant fibrous histiocytoma of the proximal tibia, and the other an osteogenic sarcoma of the distal femur. The incision was extended distally to the anterolateral aspect of the patellar tendon and tibial tuberosity.
Abstract Background Advocates of newer implant designs cite high rates of aseptic loosening and failure as reasons to abandon traditional cemented endoprosthetic reconstruction of the distal femur.
Two further amputations, one after distal femoral and one after proximal tibial reconstruction, were performed for infection. Mechanical failure occurred in nine patients 4. Additionally, there are limited data available with which to compare implant survival of contemporary modular implant designs with older custom-designed implants no longer in use [ 8 , 44 , 48 , 70 ].
All operations were carried out by a single surgeon LRM.
The end-point for limb survival was amputation. Instability was not found after any distal femoral, proximal tibial or total femoral reconstructions.
We have studied the survivorship of modular endoprosthetic reconstructions in the treatment of both primary bone tumours and metastatic disease of the lower limb, and assessed the rate of revision, cause of failure and ultimate functional outcome.