R. P. H. Veth

Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. A 15- to 20-year follow-up.

This study presents the clinical and radiological results of 62 consecutive acetabular revisions in 58 patients, at a mean of 16.5 years follow-up (15 to 20). The Kaplan-Meier survivorship for the cup with end-point revisions for any reason, was 79% at 15 years (95% confidence interval (CI); 67 to 91). Excluding two revisions for septic loosening at three and six years, and one revision of a well-fixed cup after 12 years in the course of a femoral revision, the survivorship was 84% at 15 years (95% CI; 73 to 95). At review there were no additional cases of loosening, although seven acetabular reconstructions showed radiolucent lines in one or two zones. Acetabular revision using impacted large morsellised bone chips (0.7 cm to 1.0 cm) and a cemented cup, is a reliable technique of reconstruction, when assessed at more than 15 years.

Aneurysmal bone cysts treated by curettage cryotherapy and bone grafting

We treated 26 patients with 27 aneurysmal bone cysts by curettage and cryotherapy and evaluated local tumour control, complications and functional outcome. The mean follow-up time was 47 months (19 to 154). There was local recurrence in one patient. Two patients developed deep wound infections and one had a postoperative fracture. We compared our results with previous reports in which several different methods of treatment had been used and concluded that curettage with adjuvant cryotherapy had similar results to those of marginal resection, and that no major bony reconstruction was required. We recommend the use of cryotherapy as an adjuvant to the surgical treatment of aneurysmal bone cysts. It provides local tumour control. Combination with bone grafting achieved consolidation of the lesion in all our patients.

Limb salvage surgery for primary bone sarcoma of the lower extremities : Long-term consequences of endoprosthetic reconstructions

AbstractBackground: Adjuvant chemotherapy and endoprosthetic replacement for bone sarcomas of the lower extremity is well established. The specific long-term consequences of these endoprosthetic reconstructions for the patients affected limb are unknown. Method: The oncologic results and the survival of the endoprostheses were reviewed in 32 patients with primary bone sarcoma of the femur or proximal tibia. There were 26 high-grade sarcomas, and 6 low-grade sarcomas. A proximal femoral endoprosthesis was used for reconstruction in 4 patients, a total or push-through femoral endoprosthesis in 11 patients, a distal femoral endoprosthesis in 15 patients, and a proximal tibial endoprosthesis in two patients. Results: Median survival was 10 years (range, 1.1 to 18.9 years) for patients with high-grade sarcoma, and 8.1 years (range, 7.1 to 10 years) for patients with low-grade sarcomas. Distant metastases developed in seven patients (22%), all with stage IIB sarcoma, with concomitant local recurrence in 3 patients (9%). Five-year overall and disease-free survival rates for high-grade sarcomas were 81% and 73%, respectively. The overall endoprosthetic survival rate was 87% at 5 years, 80% at 10 years, and 56% at 15 years. Median follow-up of the original endoprostheses was 8.3 years (range, 0.6 to 18.7 years). Endoprosthesis-related complications occurred in 13 patients (41%); most complications were mechanical failures. The highest complication rate was found in distal femoral replacements (60%); amputation was necessary in both patients treated with a proximal tibial endoprosthesis. Five endoprostheses (16%) were revised. An amputation of the involved limb was performed in four patients (13%): in two patients because of local recurrence and in the other two patients because of infection. For patients alive at follow-up, the median functional Enneking evaluation score was 22 points (range, 12 to 28 points), with the highest functional scores in patients with a distal femoral endoprosthesis, and the lowest functional scores in patients with total or push-through femoral replacements. Conclusion: Endoprosthetic reconstructions gave satisfying functional results in most patients after long-term survival. However, the proximal tibial and distal femoral endoprosthesis are particularly at risk for long-term endoprosthetic complications requiring additional surgical procedures.

Treatment of benign and low-grade malignant intramedullary chondroid tumours with curettage and cryosurgery

AIMS To shed light on the controversy surrounding the methods of evaluating, staging and final treatment of intramedullary chondroid lesions. Controversy particularly exists for enchondroma and low-grade chondrosarcoma located in the extremities, because their accurate distinction is hampered by their radiographical and histological similarity. METHODS Since 1991 we have treated 22 patients (mean age: 39.6 years) with 26 lesions (three chondroblastomas, 14 enchondromas and nine grade 1 chondrosarcomas) with curettage, cryosurgery and bone grafting. RESULTS After a mean follow-up of 26 months no recurrences were observed. Complications consisted of two post-operative fractures, one wound infection and one intraoperative venous gas embolism. All bone grafts incorporated, resulting in full weight-bearing capacity and excellent functional results. CONCLUSION The usefulness of a combination of curettage and cryosurgery as adjuvant therapy is considered to be equal to marginal resection according to orthopaedic oncological principles. The pre-operative assessment of these lesions and cryosurgical technique is described in detail.

Impacted morsellized bone grafting and cemented primary total hip arthroplasty for acetabular protrusion in patients with rheumatoid arthritis.

Between 1979 and 1989, we performed 36 primary total hip replacements in 31 rheumatoid arthritis patients with protrusio acetabuli. The deficient acetabulum was reconstructed with autologous morsellized bone grafts from the femoral head. 3 patients were lost to follow-up. 12 patients (13 hips) died within 8 years postoperatively, none had a revision. 16 patients (20 hips) were reviewed at an average follow-up of 12 (8-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component, 6.5 and 8 years after primary surgery, which means a 90% (95% CI: 77%-100%) survival rate at 12 years (Kaplan Meier analysis). This technique is a good option in cases with protrusio acetabuli due to rheumatoid arthritis.

The management of clear cell sarcoma.

Clear cell sarcoma is a rare soft tissue tumour, constituting approximately 1% of all soft tissue sarcomas. Prognosis is reported to be poor due to the great propensity to metastasise regionally and distantly. In this paper, we report the surgical experience of two university hospitals. Both disease-free and overall survival after resection of clear cell sarcoma in this limited study were excellent, which may be explained by relatively small tumour size in seven out of eight patients and adjuvant radiation treatment. The current treatment for clear cell sarcoma is wide local tumour excision, with adjuvant radiation therapy for resection margins of less than 1 mm.

Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up.

BACKGROUND Acetabular revision in patients with rheumatoid arthritis is often difficult because of the poor quality and quantity of the acetabular bone stock. The purpose of this study was to evaluate the midterm clinical and radiographic outcomes of acetabular revision with use of an impaction bone-grafting technique and a cemented polyethylene cup. METHODS Thirty-five consecutive acetabular revisions were performed with impaction bone-grafting and use of a cemented cup in twenty-eight patients with rheumatoid arthritis. The average age at the revision was fifty-seven years. The minimum duration of follow-up of all reconstructions that were still functioning or that were followed until the time of death was three years (mean, 7.5 years; range, three to fourteen years). No patient was lost to follow-up, but five patients (six hips) died before the time of the review. The acetabular bone defects were classified as cavitary in twelve hips and as combined segmental-cavitary in twenty-three. RESULTS The five patients (six hips) who died had been doing well at the time of their latest follow-up. Of the remaining patients, six (six hips) had a repeat revision. The average Harris hip score of the living patients with a surviving implant at the time of follow-up was 82 points, and there was no or only mild pain in twenty-one of the twenty-three hips. Radiographic analysis of all twenty-nine hips that had not been revised showed loosening in one hip and a nonprogressive radiolucent line in one zone in two others. Kaplan-Meier analysis demonstrated a prosthetic survival rate, with aseptic loosening as the end point, of 90% at eight years. CONCLUSION Acetabular revision with impaction bone-grafting and a cemented cup in patients with rheumatoid arthritis had acceptable results at an average of 7.5 years postoperatively.

Pigmented villonodular synovitis

SummaryPigmented villonodular synovitis is a benign disease of the synovial membrane of joints, tendon sheaths, or bursae, which nevertheless can cause marked local destruction. Its diagnosis is often delayed because complaints and symptoms are nonspecific. Familiarity with the disease may ensure an earlier diagnosis and consequently early onset of therapy, which may prevent serious damage. This paper describes 18 patients suffering from localized or diffuse pigmented villonodular synovitis. Findings possibly suggestive of pigmented villonodular synovitis include hemarthrosis, soft tissue swelling, radiological evidence of cyst formation at a distance from the weight-bearing area of a joint, an increased triglyceride concentration, and a positive bone scan. A normal appearance on arthroscopy does not rule out the disease. Therapeutic results are better in the localized than in the diffuse form of the disease.

Design of a Lengthening Element for a Modular Femur Endoprosthetic System

A malignant tumour may develop around the knee joint of a child. In the majority of cases it will then be necessary to resect the involved bone with adjacent tissue. A joint team of Groningen University Hospital and University of Twente is currently working on the project of developing a modular endoprosthetic system to bridge the defect resulting from the resection. Since the other, normal, leg continues to grow, the endoprosthetic system will have to include an element the length of which can be adjusted non-invasively. The main conditions to be met by the lengthening element are non-invasive continuous adjustability and a maximum total lengthening of 114 mm. This was achieved by using an external magnetic field. Animal experiments showed that the lengthening element worked well, although moisture infiltrated the telescopic tubes and the lengthening element was covered by proliferating bone at an early stage. Also, the necessary magnetic field proved to be larger than calculated. In a revised design, these problems are resolved. In vitro tests show that the new lengthening element meets all requirements.

An extendable modular endoprosthetic system for bone tumour management in the leg

A modular endoprosthetic system has been developed at the Groningen University Hospital and the University of Twente. The system can bridge a defect resulting from the resection of a malignant bone tumour which has developed around the knee joint of a child. Since the other healthy leg continues to grow, the system includes an element whose length can be adjusted non-invasively by using an external magnetic field. In addition to this lengthening element, there are one hip and two knee components, connectors of various lengths, and fixation elements. The paper describes the elements of the modular endoprosthetic system. Tables are created by means of which the elemental composition of such an endoprosthesis can be determined for each individual patient.