Marcel Henrichs

Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma.

The placement of megaprostheses in patients with bone sarcoma is associated with high rates of infection, despite prophylactic antibiotic administration. In individual cases, secondary amputation is unavoidable in the effort to cure infection.

Giant Cell Tumors of the Axial Skeleton

Background. We report on 19 cases of giant cell tumor of bone (GCT) affecting the spine or sacrum and evaluate the outcome of different treatment modalities. Methods. Nineteen patients with GCT of the spine (n = 6) or sacrum (n = 13) have been included in this study. The mean followup was 51.6 months. Ten sacral GCT were treated by intralesional procedures of which 4 also received embolization, and 3 with irradiation only. All spinal GCT were surgically treated. Results. Two (15.4%) patients with sacral and 4 (66.7%) with spinal tumors had a local recurrence, two of the letter developed pulmonary metastases. One local recurrence of the spine was successfully treated by serial arterial embolization, a procedure previously described only for sacral tumors. At last followup, 9 patients had no evidence of disease, 8 had stable disease, 1 had progressive disease, 1 died due to disease. Six patients had neurological deficits. Conclusions. GCT of the axial skeleton have a high local recurrence rate. Neurological deficits are common. En-bloc spondylectomy combined with embolization is the treatment of choice. In case of inoperability, serial arterial embolization seems to be an alternative not only for sacral but also for spinal tumors.

Treatment and outcome of giant cell tumors of the pelvis

Background and purpose Giant cell tumors (GCTs) of bone rarely affect the pelvis. We report on 20 cases that have been treated at our institution during the last 20 years. Methods 20 patients with histologically benign GCT of the pelvis were included in this study. 9 tumors were primarily located in the iliosacral area, 6 in the acetabular area, and 5 in the ischiopubic area. 8 patients were treated by intralesional curettage and 6 by intralesional resection with additional curettage of the margins. 3 patients with iliacal tumors were treated by wide resection. 2 patients were treated by a combination of external beam irradiation and surgery, and 1 patient solely by irradiation. In addition, 9 patients received selective arterial embolization one day before surgery. Of the 6 patients with acetabular tumors, 1 secondarily received an endoprosthesis and 1 was primarily treated by hip transposition. The patients were followed for a median time of 3 (1–11) years. Results 1 patient with a pubic tumor developed a local recurrence 1 year after intralesional resection and additional curettage of the margins. The recurrence presented as a small soft tissue mass within the scar tissue of the gluteal muscles and was treated by resection. No secondary sarcoma was detected and none of the patients developed pulmonary metastases or multicentricity. No major complication occurred during surgery. Interpretation We conclude that most GCTs of the pelvis can be treated by intralesional procedures. For tumors of the iliac wing, wide resection can be an alternative. Surgical treatment of tumors affecting the acetabular region often results in functional impairment. Pre-surgical selective arterial embolization appears to be a safe procedure that may reduce the risk of local recurrence.

Surgical difficulties encountered with use of modular endoprosthesis for limb preserving salvage of failed allograft reconstruction after malignant tumor resection.

We reviewed outcomes and discussed surgical difficulties encountered in 10 patients who had modular endoprosthesis for limb preserving salvage of failed allograft reconstruction after malignant tumor resection. Mean allograft survival time before failure was 127.4 months (range, 14-264 months). Mean length of follow-up since endoprosthesis revision surgery was 62.8 months (range, 16-132 months). There was one endoprosthesis failure, resulting in a mean endoprosthesis survival time of 56.9 months (range, 16-132). Complications included arterial laceration, nerve injury, periprosthetic crack fracture, aseptic loosening, and infection. Modular endoprosthesis remain a viable option that should be considered in any limb preserving salvage of failed allograft reconstructions. However, altered anatomy, poor/short remnant host bone, periprosthetic fractures, inadequate soft tissue coverage and infection remain important difficulties encountered.

Komplikationsmanagement bei Megaprothesen

ZusammenfassungHintergrundMegaprothesen finden zunehmende Anwendung nach knöcherner Segmentresektion bei Knochensarkomen, Skelettmetastasen und bei ausgedehnten knöchernen Defekten in der Revisionsendoprothetik.FragestellungBeschreibung der Inzidenz der häufigsten Komplikationen in der Megaprothetik. Darstellung des Komplikationsmanagements mitsamt Therapieempfehlungen.Material und MethodenEs erfolgte eine selektive Literaturrecherche sowie das Einbringen eigener Erfahrungen zur Darstellung aktueller Erkenntnisse auf dem Gebiet des Komplikationsmanagements in der Megaprothetik.ErgebnisseProspektiv-randomisierte Studien oder Metaanalysen fehlen zu diesem Thema. Die Literaturrecherche zeigt dennoch, dass neben dem Lokalrezidiv die periprothetische Infektion die gravierendste Komplikation darstellt. Der zweizeitige Prothesenwechsel ist weiterhin als Goldstandard zu betrachten, auch wenn in ausgesuchten Fällen ein einzeitiger Wechsel unter Belassung der Prothesenschäfte gerechtfertigt erscheint. Die periprothetische Infektion ist jedoch weiterhin mit einem nicht unerheblichen Risiko der sekundären Amputation vergesellschaftet. Mechanische Komplikationen wie der Verschleiß des Gelenkmechanismus bei megaprothetischem Ersatz des Kniegelenks und die aseptische Schaftlockerung sind in der Regel extremitätenerhaltend therapierbar. Eine Luxation eines proximalen Femurersatzes stellt bei Verwendung eines bi- oder tripolaren Pfannensystems die Ausnahme dar.SchlussfolgerungenKomplikationen in der Megaprothetik sind in den meisten Fällen durch Revisionsoperationen zu beherrschen.AbstractBackgroundMegaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty.ObjectivesThe incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described.Materials and methodsThe current knowledge and our own experience of complication management with the use of megaprostheses are presented.ResultsProspective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups.ConclusionsComplications with the use of megaprostheses can be successfully treated by revision surgery in most cases.BACKGROUND Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.

Management of complications in megaprostheses

ZusammenfassungHintergrundMegaprothesen finden zunehmende Anwendung nach knöcherner Segmentresektion bei Knochensarkomen, Skelettmetastasen und bei ausgedehnten knöchernen Defekten in der Revisionsendoprothetik.FragestellungBeschreibung der Inzidenz der häufigsten Komplikationen in der Megaprothetik. Darstellung des Komplikationsmanagements mitsamt Therapieempfehlungen.Material und MethodenEs erfolgte eine selektive Literaturrecherche sowie das Einbringen eigener Erfahrungen zur Darstellung aktueller Erkenntnisse auf dem Gebiet des Komplikationsmanagements in der Megaprothetik.ErgebnisseProspektiv-randomisierte Studien oder Metaanalysen fehlen zu diesem Thema. Die Literaturrecherche zeigt dennoch, dass neben dem Lokalrezidiv die periprothetische Infektion die gravierendste Komplikation darstellt. Der zweizeitige Prothesenwechsel ist weiterhin als Goldstandard zu betrachten, auch wenn in ausgesuchten Fällen ein einzeitiger Wechsel unter Belassung der Prothesenschäfte gerechtfertigt erscheint. Die periprothetische Infektion ist jedoch weiterhin mit einem nicht unerheblichen Risiko der sekundären Amputation vergesellschaftet. Mechanische Komplikationen wie der Verschleiß des Gelenkmechanismus bei megaprothetischem Ersatz des Kniegelenks und die aseptische Schaftlockerung sind in der Regel extremitätenerhaltend therapierbar. Eine Luxation eines proximalen Femurersatzes stellt bei Verwendung eines bi- oder tripolaren Pfannensystems die Ausnahme dar.SchlussfolgerungenKomplikationen in der Megaprothetik sind in den meisten Fällen durch Revisionsoperationen zu beherrschen.AbstractBackgroundMegaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty.ObjectivesThe incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described.Materials and methodsThe current knowledge and our own experience of complication management with the use of megaprostheses are presented.ResultsProspective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups.ConclusionsComplications with the use of megaprostheses can be successfully treated by revision surgery in most cases.BACKGROUND Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.

Silver-coated megaprostheses in the proximal femur in patients with sarcoma

BackgroundProximal femur replacements in patients with sarcoma are associated with high rates of infection. This study is the largest one comparing infection rates with titanium versus silver-coated megaprostheses in sarcoma patients.MethodsInfection rates were assessed in 99 patients with proximal femur sarcoma who underwent placement of a titanium (n = 35) or silver-coated (n = 64) megaprosthesis. Treatments administered for infection were also analyzed.ResultsInfections occurred in 14.3% of patients in the titanium group, in comparison with 9.4% of those in the silver group, when the development of infection was the primary end point. The 5- and 10-year event-free survival rates for the prosthesis relative to the parameter of infection were 90% in the silver group and 83% in the titanium group. The overall infection rates were 10.9% in the silver group and 20% in the titanium group. Two patients each in the silver and titanium groups ultimately had to undergo amputation. The need for two-stage prosthesis exchanges (57.1% in the titanium group) declined to 14.3% in the silver group.ConclusionUsing a silver-coated proximal femoral replacement nearly halved the overall infection rate. When infections occurred, it was usually possible to avoid two-stage prosthesis exchanges in the silver group.

Komplikationsmanagement bei Megaprothesen@@@Management of complications in megaprostheses

ZusammenfassungHintergrundMegaprothesen finden zunehmende Anwendung nach knöcherner Segmentresektion bei Knochensarkomen, Skelettmetastasen und bei ausgedehnten knöchernen Defekten in der Revisionsendoprothetik.FragestellungBeschreibung der Inzidenz der häufigsten Komplikationen in der Megaprothetik. Darstellung des Komplikationsmanagements mitsamt Therapieempfehlungen.Material und MethodenEs erfolgte eine selektive Literaturrecherche sowie das Einbringen eigener Erfahrungen zur Darstellung aktueller Erkenntnisse auf dem Gebiet des Komplikationsmanagements in der Megaprothetik.ErgebnisseProspektiv-randomisierte Studien oder Metaanalysen fehlen zu diesem Thema. Die Literaturrecherche zeigt dennoch, dass neben dem Lokalrezidiv die periprothetische Infektion die gravierendste Komplikation darstellt. Der zweizeitige Prothesenwechsel ist weiterhin als Goldstandard zu betrachten, auch wenn in ausgesuchten Fällen ein einzeitiger Wechsel unter Belassung der Prothesenschäfte gerechtfertigt erscheint. Die periprothetische Infektion ist jedoch weiterhin mit einem nicht unerheblichen Risiko der sekundären Amputation vergesellschaftet. Mechanische Komplikationen wie der Verschleiß des Gelenkmechanismus bei megaprothetischem Ersatz des Kniegelenks und die aseptische Schaftlockerung sind in der Regel extremitätenerhaltend therapierbar. Eine Luxation eines proximalen Femurersatzes stellt bei Verwendung eines bi- oder tripolaren Pfannensystems die Ausnahme dar.SchlussfolgerungenKomplikationen in der Megaprothetik sind in den meisten Fällen durch Revisionsoperationen zu beherrschen.AbstractBackgroundMegaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty.ObjectivesThe incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described.Materials and methodsThe current knowledge and our own experience of complication management with the use of megaprostheses are presented.ResultsProspective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups.ConclusionsComplications with the use of megaprostheses can be successfully treated by revision surgery in most cases.BACKGROUND Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.