Ist der distale Femurersatz als extremitätenerhaltendes Verfahren nach komplexen Frakturen am distalen Femur geeignet?

 

 Buy Article Permissions and Reprints

Zusammenfassung

Hintergrund: Der modulare distale Femurersatz wurde ursprünglich entwickelt, um eine belastbare und funktionelle untere Extremität nach Resektion gelenknaher primärer Knochentumoren mit großen knöchernen Defekten wiederherzustellen. Ziel der vorliegenden Untersuchung war es, die Indikationsstellung, Komplikationen und Funktion des distalen Femurersatzes nach komplexen Frakturen oder Frakturfolgen am distalen Femur zu erfassen und im Kontext vergleichbarer Studien zu bewerten. Patienten und Methode: 14 Patienten wurden retrospektiv untersucht, die aufgrund einer Fraktur oder Frakturfolgen mit ausgedehnten posttraumatischen Defekten des distalen Femurs mit einer Megaendoprothese versorgt wurden. Das Alter der Patienten zum Zeitpunkt der Operation betrug im Median 77,0 (IQB 70,0–81,5) Jahre (IQB: Interquartilbereich). Der mediane Nachuntersuchungszeitraum betrug 27,0 (IQB 13,5–37,5) Monate (Schwankungsbereich 10–49 Monate). Ergebnisse: Die Indikation zum distalen Femurersatz wurde in 3 Fällen nach periprothetischer Fraktur gestellt. In 3 Fällen war die Indikation eine Komplikation nach Osteosynthese einer periprothetischen Fraktur, in 8 Fällen waren Komplikationen nach Osteosynthese distaler Femurfrakturen der Grund für einen distalen Femurersatz. Die Implantation des distalen Femurersatzes erfolgte bei 5 Patienten zweizeitig, nachdem eine implantatassoziierte Infektion saniert wurde. Der Knee Society Score verbesserte sich im Median von präoperativ 20,0 (IQB 7,5–30,0) signifikant auf 80,0 (IQB 62,3–89,0) zum Zeitpunkt der Nachuntersuchung (p < 0,001). Komplikationen, die eine operative Revision erforderten, waren bei 7 der 14 Patienten (50 %) aufgetreten. Bei 2 Patienten traten Wundheilungsstörungen oder oberflächliche Infektionen auf, die chirurgisch behandelt werden mussten. Eine Ruptur des Streckapparats trat bei 1 Patientin auf, die sich im weiteren Verlauf auch eine periprothetische Fraktur zuzog. Bei 1 Patienten wurde eine frühzeitige Lockerung der femoralen Prothesenkomponente festgestellt. Die häufigste Komplikation war eine periprothetische Fraktur bei 4 Patienten. Drei Patienten verstarben ohne Zusammenhang zur Prothesenimplantation. Schlussfolgerung: Der distale Femurersatz ist eine wichtige Behandlungsoption zur Wiederherstellung einer funktionell belastbaren unteren Extremität bei ausgedehnten traumatischen und posttraumatischen Defekten. Insbesondere ältere Patienten erreichen dadurch in der überwiegenden Mehrzahl wieder ihre Gehfähigkeit. Die relativ hohe Komplikationsrate erfordert eine sehr sorgfältige Indikationsstellung.

Abstract

Background: Modular distal femur replacements originally were developed for reconstructing a full weight-bearing and functional extremity after resection of primary bone tumours with large bony defects located in proximity to joints. The aim of this study was to examine the use of the modular distal femur replacements for complex fractures and severe post-traumatic sequelae of the distal femur in context to comparable studies. Patients and Methods: Fourteen patients with complex fractures or post-traumatic sequelae and extensive bone defects requiring distal femur replacement were analysed retrospectively. Median age of the patients at the time of distal femoral replacement was 77 years and median follow-up interval was 27 months. Median follow-up was 27.0 (IQB 13.5–37.5) months (range 10–49 months). Results: The indication for distal femur replacement was a periprosthetic fracture in three cases. Three further periprosthetic fractures were treated with a megaendoprosthesis after failure of osteosynthesis. In eight patients a megaendoprosthesis was implanted due to complications following ostheosynthesis for distal femoral fractures. Distal femoral arthroplasty was performed as a two-stage procedure in five patients with implant-associated infections. A lateral approach was used in six patients and a medial arthrotomy was conducted in eight patients. The median Knee Society score (KSS) improved significantly from 20.0 (IQB 7.5–30.0) points preoperatively to 80.0 (IQB 62.3–89.0) points at follow-up (p < 0.001). Complications requiring surgical intervention were documented in seven of 14 patients (50 %). In two patients wound-healing disorders and superficial infections necessitated surgery. In one patient a rupture of the patellar tendon was diagnosed. This patient subsequently also sustained a periprosthetic fracture. Another patient developed early aseptic loosening of the femoral component. The most common complication was a periprosthetic fracture in four patients. Three patients died for reasons not related to distal femoral replacement. Conclusion: Distal femoral replacement is an important option in reconstituting a full weight-bearing and functional lower extremity after complex fractures and post-traumatic sequelae with massive bone destruction. Particularly elderly patients regain ambulatory ability in the vast majority of cases. The relatively high complication rate demands very thorough preoperative planning as well as prompt allocation of extensive surgical procedures in the case of an adverse event.

• Literatur

• 1 Choong PF, Sim FH, Pritchard DJ et al. Megaprostheses after resection of distal femoral tumors. A rotating hinge design in 30 patients followed 2–7 years. Acta Orthop Scand 1996; 67: 345-351
  PubMedGoogle Scholar
• 2 Kawai A, Muschler GF, Lane JM et al. Prosthetic knee replacement after resection of a malignant tumor of the distal femur: medium to long-term results. J Bone Joint Surg Am 1998; 80: 636-647
  CrossrefPubMedGoogle Scholar
• 3 Pennekamp PH, Wirtz DC, Dürr HR. Proximal and total femur replacement. Oper Orthop Traumatol 2012; 24: 215-226
  CrossrefPubMedGoogle Scholar
• 4 Bruns J, Delling G, Gruber H et al. Cementless fixation of megaprostheses using a conical fluted stem in the treatment of bone tumours. J Bone Joint Surg Br 2007; 89: 1084-1087
  CrossrefPubMedGoogle Scholar
• 5 Höll S, Schlomberg A, Gosheger G et al. Distal femur and proximal tibia replacement with megaprosthesis in revision knee arthroplasty: a limb-saving procedure. Knee Surg Sports Traumatol Arthosc 2012; 20: 2513-2518
  CrossrefPubMedGoogle Scholar
• 6 Berend KR, Lombardi AV. Distal femoral Replacement in Nontumor Cases with Severe Bone Loss and Instability. Clin Orthop Relat Res 2009; 467: 485-492
  CrossrefPubMedGoogle Scholar
• 7 Harris IE, Leff AR, Gitelis S et al. Function after amputation, arthrodesis, or arthroplasty for tumors about the knee. J Bone Joint Surg Am 1990; 72: 1477-1485
  Google Scholar
• 8 Chandrasekar CR, Grimer RJ, Carter SR et al. Modular endoprothetic replacement for tumors of the proximal femur. J Bone Joint Surg Br 2009; 91?B: 108-112
  PubMedGoogle Scholar
• 9 Dean BJ, Matthews JJ, Price A et al. Modular endoprosthetic replacement for failed internal fixation of the proximal femur following trauma. Int Orthop 2012; 36: 731-734
  CrossrefPubMedGoogle Scholar
• 10 Davila J, Malkani A, Paiso JM. Supracondylar distal femoral nonunions treated with a megaprosthesis in elderly patients: a report of two cases. J Orthop Trauma 2001; 15: 547-578
  PubMedGoogle Scholar
• 11 Springer BD, Sim FH, Hanssen AD et al. The modular segmental kinematic rotating hinge for nonneoplastic limb salvage. Clin Orthop Relat Res 2004; 421: 181-187
  CrossrefPubMedGoogle Scholar
• 12 Appleton P, Moran M, Houshian S et al. Distal femoral fractures treated by hinged total knee replacement in elderly patients. J Bone Joint Surg Br 2006; 88: 1065-1070
  CrossrefPubMedGoogle Scholar
• 13 Mortazavi SM, Kurd MF, Bender B et al. Distal femoral arthroplasty for the treatment of periprosthetic fractures after total knee arthroplasty. J Arthroplasty 2010; 25: 775-780
  CrossrefPubMedGoogle Scholar
• 14 Insall JN, Dorr LD, Scott RD et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; 248: 13-14
  PubMedGoogle Scholar
• 15 Su ET, DeWal H, Di Cesare PE. Periprosthetic femoral fractures above knee replacements. J Am Acad Orthop Surg 2004; 12: 12-20
  PubMedGoogle Scholar
• 16 Bargiotas K, Wohlrab D, Sewecke JJ et al. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. Surgical technique. J Bone Joint Surg Am 2007; 89 (Suppl. 02) S103-S110
  CrossrefPubMedGoogle Scholar
• 17 Garcia-Lopez I, Aguayo MA, Cuevas A et al. Knee arthrodesis with the Vari-Wall nail for treatment of infected total knee arthroplasty. Acta Orthop Belg 2008; 74: 809-815
  PubMedGoogle Scholar
• 18 Malek F, Somerson JS, Mitchel S et al. Does limb-salvage surgery offer patients better quality of life and functional capacity than amputations. Clin Orthop Relat Res 2012; 470: 2000-2006
  CrossrefPubMedGoogle Scholar
• 19 Renard AJ, Veth RP, Schreuder HW et al. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol 2000; 73: 198-205
  CrossrefPubMedGoogle Scholar
• 20 Rougraff B, Simon M, Kneisl J et al. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a long-term oncological, functional, and quality-of-life-study. J Bone Joint Surg Am 1994; 76: 649-656
  PubMedGoogle Scholar
• 21 Hardes J, Gebert C, Hillmann A et al. [Rotationplasty in the surgical treatment plan of primary malignant bone tumors. Possibilities and limits]. Orthopade 2003; 32: 965-970
  PubMedGoogle Scholar
• 22 Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res 1994; 299: 173-178
  PubMedGoogle Scholar
• 23 Fedorka CJ, Chen AF, McGarry WM et al. Functional ability after above-the-knee amputation for infected total knee arthroplasty. Clin Orthop Relat Res 2011; 469: 1024-1032
  CrossrefPubMedGoogle Scholar
• 24 Chen AF, Kinback NC, Heyl AE. Better function for fusions versus above-the-knee amputations for recurrent periprosthetic knee infection. Clin Orthop Relat Res 2012; 470: 2737-2745
  CrossrefPubMedGoogle Scholar
• 25 Springer BD, Hanssen AD, Sim FH et al. The kinematic rotating hinge prosthesis for complex knee arthroplasty. Clin Orthop Relat Res 2001; 392: 283-291
  CrossrefPubMedGoogle Scholar
• 26 Pour AE, Parvizi J, Slenker N et al. Rotating hinged knee replacement: use with caution. J Bone J Surg Am 2007; 89: 1735-1741
  PubMedGoogle Scholar
• 27 Petrou G, Petrou H, Tilkeridis C et al. Medium-term results with a primary cemented rotating-hinge total knee replacement: a 7- to 15-year follow-up. J Bone Joint Surg Br 2004; 86: 813-817
  CrossrefPubMedGoogle Scholar
• 28 Mnaymneh W, Emerson MH, Borja F et al. Massive allografts in salvage revisions of failed total knee arthroplasties. Clin Orthop Relat Res 1990; 260: 144-153
  PubMedGoogle Scholar
• 29 Clatworthy MG, Balance J, Brick GW et al. The use of structural allograft for uncontained defects in revision total knee arthroplasty. J Bone Joint Surg Am 2001; 83: 404-411
  CrossrefPubMedGoogle Scholar
• 30 Hinsenkamp M, Muylle L, Eastlund T et al. Adverse reactions and events related to musculoskeletal allografts: reviewed by the World Health Organisation project NOTIFY. Int Orthop 2012; 36: 633-641
  CrossrefPubMedGoogle Scholar
• 31 Prieto-Alhambra D, Javaid MK, Judge A et al. Fracture risk before and after total hip replacement in patients with osteoarthritis. Arthritis Rheum 2011; 63: 992-1001
  CrossrefPubMedGoogle Scholar
• 32 Myrs GJ, Abudu AT, Carter SR et al. Endoprosthetic replacement of the distal femur for bone tumors. J Bone Joint Surg Br 2007; 89: 521-526
  CrossrefPubMedGoogle Scholar
• 33 Hardes J, von Eiff C, Streitbuerger A et al. Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma. J Surg Oncol 2010; 101: 389-395
  PubMedGoogle Scholar
• 34 Haidukewych GJ, Springer BD, Jacofsky DJ et al. Total knee arthroplasty for failed internal fixation or nonunion of the distal femur. J Arthroplasty 2005; 20: 344-349
  CrossrefPubMedGoogle Scholar