How to salvage a salvage endoprosthesis

Anil Haldar; Shanjitha Kantharuban; Aadhar Sharma; Jerome A. Davidson; Timothy W.R. Briggs

doi:10.1093/jscr/rjv172

Haldar, Anil; Kantharuban, Shanjitha; Sharma, Aadhar; Davidson, Jerome A.; Briggs, Timothy W.R.

2016-01-01 00:00:00

Custom-made endoprostheses can be linked to existing well-ﬁxed implants in the treatment of complex periprosthetic femoral fractures. By adopting this salvage approach, secure implants can be retained in favour of patients undergoing more tissue disruptive procedures such as total femoral replacements. In this piece, we present a unique case illustrating a salvage strategy for treating a failed cement-linked salvage endoprosthesis, a complex scenario which to our knowledge has never before been reported. The patient went on to have a custom-made cement-linked in- INTRODUCTION ternal proximal femoral replacement, which had a hollow cylin- Custom-made cement-linked endoprostheses can be used to sal- drical design to accept the stem of the existing well-ﬁxed distal vage well-ﬁxed implants in the treatment of complex peripros- femoral component (Figs 3 and 4). This linked prosthesis ef- thetic femoral fractures [1–3]. To our knowledge, no cases of fectively converted her separate prostheses to a total femoral re- failed cement-linked salvage endoprostheses have been reported placement, sparing her distal femoral replacement from revision. and we therefore present a unique case illustrating a manage- She had no problems postoperatively and recovered well from ment strategy for this challenging scenario. her surgery. She remained well for 5 years, until she was referred back to our joint reconstruction unit due to a stress fracture in the stem CASE REPORT of the distal femoral component, just below the junction with the A 49-year-old female with severe rheumatoid arthritis was well cement-linked internal proximal femoral replacement (Fig. 5). known to our joint reconstruction service, having undergone After careful assessment of the radiographs and taking into multiple joint replacement surgeries including shoulder, hip consideration the complex nature of her failed salvage implant, and knee arthroplasties. Of relevance to this case, she had a a plan was made to design another custom-made component, right total hip replacement and an ipsilateral distal femoral this time a revision distal femoral prosthesis with a hollow cylin- replacement. drical section to accept the existing, well-ﬁxed salvage proximal She subsequently sustained a periprosthetic fracture at the femoral replacement. distal tip of her right total hip replacement (Fig. 1). An initial The prosthesis was designed using preoperative long-leg attempt was made to manage this fracture with a plate and calibrated measurement radiographs and manufactured using Dall-Miles cables (Fig. 2); however, the fracture did not unite. computer-aided design and computer-aided manufacture Received: October 7, 2015. Accepted: December 15, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | A. Haldar et al. Figure 2: Plate and Dall-Miles cable ﬁxation of periprosthetic fracture. Figure 1: Periprosthetic fracture distal tip of right total hip replacement. (CAD–CAM) techniques by Stanmore Implants Worldwide. The implant had a rotating hinge knee component and was made from a combination of hydroxyapatite-coated and silver (Aglu- na)-treated Cobalt–Chromium–Molybdenum (Co–Cr–Mo) and Ti- tanium–6Alumunium–4Vanadium (Ti–6Al–4V) alloys. The operation was carried out by the senior author and the customized distal femoral prosthesis was successfully cemented over the pre-existing internal proximal femoral replacement (Figs 6 and 7). Postoperatively, the patient was advised to partially weight- bear with crutches and made a good recovery. She was discharged home 4 days post-surgery and is now 2 months post-operation. Her knee is ﬂexing beyond 100°, which is more than she was able to achieve preoperatively and she has been cleared to fully weight-bear and return to her work as a solicitor. DISCUSSION We are experiencing more episodes of endoprosthetic failure [4], given the increasing use of endoprostheses in limb salvage surgery. Patients with salvage endoprostheses continue to have improved life expectancy and higher functional demands sec- ondary to successful adjuvant therapies for tumours and in- fections. Therefore, these patients are living longer and their Figure 3: Custom-made cement-linked internal proximal femoral replacement. How to salvage a salvage endoprosthesis | 3 Figure 4: Existing distal femoral replacement with stem linked to custom-made internal proximal femoral component visible in upper half of the image. implants are more likely to fail within their lifetime, which points to a growing need for strategies to manage failed endoprostheses. In our case, we have described a technique whereby an exist- ing adequately ﬁxed proximal femoral replacement was pre- served with the use of a cement-linked custom-made implant. This strategy avoided a revision total femoral replacement, which allowed for less soft tissue dissection and maintenance of soft tissue attachments, all of which help to reduce morbidity and may facilitate functional recovery [1]. The concept of prosthesis salvage using custom-made linked components has been documented in previous studies. Tillman et al.[2] published a case series of custom-made prostheses with a cylindrical design cemented over existing femoral compo- nents to treat periprosthetic femoral fractures. Their rationale was to perform these operations without sacriﬁcing ‘the good hip’ and thus avoiding the morbidity of a total femoral replace- ment. Five patients were included in their series and they re- ported no metalwork failures, dislocations, new infections or reoperations at a mean of 3.9 years. Similarly, Peters et al.[1] described work from the USA where linked total femoral replacements were performed as implant salvage procedures to limit surgical dissection and maintain soft tissue attachments. Seven cases in this study involved a new revision stemmed distal femoral prosthesis linking to an existing hip prosthesis with a custom intramedullary sleeve. In these patients, mean postoperative Harris Hip Scores and Hospital for Special Surgery knee scores were encouraging at 72 Figure 5: Full length femur radiograph illustrating fatigue fracture in stem of (range 60–81) and 79 (range 64–94), respectively. There were no original distal femoral component. 4 | A. Haldar et al. Figure 6: Retained proximal femoral component with new custom-made cement- linked distal femoral prosthesis visible in lower half of the image. dislocations; however, one linked construct required a single- stage exchange of the revision total knee component for sepsis. The intramedullary sleeve and hip prosthesis were retained, and the patient is on suppressive antibiotic therapy indeﬁnitely. Recent work from our own centre by Patel et al.[3] illustrated the use of custom-made cement-linked megaprostheses as a sal- vage solution for periprosthetic femoral fractures. This study in- cluded 15 patients, 10 with retained stemmed hip implants and 5 Figure 7: New custom-made distal femoral prosthesis cement-linked to original with retained knee implants. They report favourable results, with salvage proximal femoral component visible in upper half of the image. a 93.3% implant survival rate and mean Musculoskeletal Tumour Society Score of 22.6 at a mean 5.3 year follow-up. There were no reported dislocations and one patient had a superﬁcial wound infection, which was treated successfully with oral antibiotics. CONFLICT OF INTEREST STATEMENT These studies and particularly the work from our centre forged the basis of the principle we employed in our case, where- None declared. by preserving and salvaging complex endoprostheses is pre- ferred to performing more disruptive revision surgery or even opting for amputation. However, in our case, we went a step REFERENCES further by salvaging a salvage custom-made cement-linked pros- thesis, with a good early postoperative result. To our knowledge, 1. Peters CL, Hickman JM, Erickson J, Lombardi AV, Berend KR, this scenario has never before been reported and we believe that Mallory TH. Intramedullary total femoral replacement for sal- our technique will prove invaluable in the future, as the need to vage of the compromised femur associated with hip and knee salvage failed endoprostheses grows. arthroplasty. J Arthroplasty 2006;21:53–8. How to salvage a salvage endoprosthesis | 5 2. Tillman R, Kalra S,Grimer R,CarterS,Abudu A. Acustom- mega prostheses: a salvage solution for complex peripros- made prosthesis attached to an existing femoral component thetic femoral fractures. J Arthroplasty 2014;29:204–9. for the treatment of peri- and sub-prosthetic fracture. J Bone 4. Henderson ER, Groundland JS, Pala E, Dennis JA, Wooten R, Joint Surg Br 2006;88-B:1299–302. Cheong D, et al. Failure mode classiﬁcation for tumor endo- 3. Patel NK, Whittingham-Jones P, Aston WJ, Pollock RC, prostheses: retrospective review of ﬁve institutions and a lit- Skinner JA, Briggs TWR, et al. Custom-made cement-linked erature review. J Bone Joint Surg Am 2011;93:418–29.

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How to salvage a salvage endoprosthesis

$Custom-made endoprostheses can be linked to existing well-ﬁxed implants in the treatment of complex periprosthetic femoral fractures. By adopting this salvage approach, secure implants can be retained in favour of patients undergoing more tissue disruptive procedures such as total femoral replacements. In this piece, we present a unique case illustrating a salvage strategy for treating a failed cement-linked salvage endoprosthesis, a complex scenario which to our knowledge has never before been reported. The patient went on to have a custom-made cement-linked in- INTRODUCTION ternal proximal femoral replacement, which had a hollow cylin- Custom-made cement-linked endoprostheses can be used to sal- drical design to accept the stem of the existing well-ﬁxed distal vage well-ﬁxed implants in the treatment of complex peripros- femoral component (Figs 3 and 4). This linked prosthesis ef- thetic femoral fractures [1–3]. To our knowledge, no cases of fectively converted her separate prostheses to a total femoral re- failed cement-linked salvage endoprostheses have been reported placement, sparing her distal femoral replacement from revision. and we therefore present a unique case illustrating a manage- She had no problems postoperatively and recovered well from ment strategy for this challenging scenario. her surgery. She remained well for 5 years, until she was referred back to our joint reconstruction unit due to a stress fracture in the stem CASE REPORT of the distal femoral component, just below the junction with the A 49-year-old female with severe rheumatoid arthritis was well cement-linked internal proximal femoral replacement (Fig. 5). known to our joint reconstruction service, having undergone After careful assessment of the radiographs and taking into multiple joint replacement surgeries including shoulder, hip consideration the complex nature of her failed salvage implant, and knee arthroplasties. Of relevance to this case, she had a a plan was made to design another custom-made component, right total hip replacement and an ipsilateral distal femoral this time a revision distal femoral prosthesis with a hollow cylin- replacement. drical section to accept the existing, well-ﬁxed salvage proximal She subsequently sustained a periprosthetic fracture at the femoral replacement. distal tip of her right total hip replacement (Fig. 1). An initial The prosthesis was designed using preoperative long-leg attempt was made to manage this fracture with a plate and calibrated measurement radiographs and manufactured using Dall-Miles cables (Fig. 2); however, the fracture did not unite. computer-aided design and computer-aided manufacture Received: October 7, 2015. Accepted: December 15, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | A. Haldar et al. Figure 2: Plate and Dall-Miles cable ﬁxation of periprosthetic fracture. Figure 1: Periprosthetic fracture distal tip of right total hip replacement. (CAD–CAM) techniques by Stanmore Implants Worldwide. The implant had a rotating hinge knee component and was made from a combination of hydroxyapatite-coated and silver (Aglu- na)-treated Cobalt–Chromium–Molybdenum (Co–Cr–Mo) and Ti- tanium–6Alumunium–4Vanadium (Ti–6Al–4V) alloys. The operation was carried out by the senior author and the customized distal femoral prosthesis was successfully cemented over the pre-existing internal proximal femoral replacement (Figs 6 and 7). Postoperatively, the patient was advised to partially weight- bear with crutches and made a good recovery. She was discharged home 4 days post-surgery and is now 2 months post-operation. Her knee is ﬂexing beyond 100°, which is more than she was able to achieve preoperatively and she has been cleared to fully weight-bear and return to her work as a solicitor. DISCUSSION We are experiencing more episodes of endoprosthetic failure [4], given the increasing use of endoprostheses in limb salvage surgery. Patients with salvage endoprostheses continue to have improved life expectancy and higher functional demands sec- ondary to successful adjuvant therapies for tumours and in- fections. Therefore, these patients are living longer and their Figure 3: Custom-made cement-linked internal proximal femoral replacement. How to salvage a salvage endoprosthesis | 3 Figure 4: Existing distal femoral replacement with stem linked to custom-made internal proximal femoral component visible in upper half of the image. implants are more likely to fail within their lifetime, which points to a growing need for strategies to manage failed endoprostheses. In our case, we have described a technique whereby an exist- ing adequately ﬁxed proximal femoral replacement was pre- served with the use of a cement-linked custom-made implant. This strategy avoided a revision total femoral replacement, which allowed for less soft tissue dissection and maintenance of soft tissue attachments, all of which help to reduce morbidity and may facilitate functional recovery [1]. The concept of prosthesis salvage using custom-made linked components has been documented in previous studies. Tillman et al.[2] published a case series of custom-made prostheses with a cylindrical design cemented over existing femoral compo- nents to treat periprosthetic femoral fractures. Their rationale was to perform these operations without sacriﬁcing ‘the good hip’ and thus avoiding the morbidity of a total femoral replace- ment. Five patients were included in their series and they re- ported no metalwork failures, dislocations, new infections or reoperations at a mean of 3.9 years. Similarly, Peters et al.[1] described work from the USA where linked total femoral replacements were performed as implant salvage procedures to limit surgical dissection and maintain soft tissue attachments. Seven cases in this study involved a new revision stemmed distal femoral prosthesis linking to an existing hip prosthesis with a custom intramedullary sleeve. In these patients, mean postoperative Harris Hip Scores and Hospital for Special Surgery knee scores were encouraging at 72 Figure 5: Full length femur radiograph illustrating fatigue fracture in stem of (range 60–81) and 79 (range 64–94), respectively. There were no original distal femoral component. 4 | A. Haldar et al. Figure 6: Retained proximal femoral component with new custom-made cement- linked distal femoral prosthesis visible in lower half of the image. dislocations; however, one linked construct required a single- stage exchange of the revision total knee component for sepsis. The intramedullary sleeve and hip prosthesis were retained, and the patient is on suppressive antibiotic therapy indeﬁnitely. Recent work from our own centre by Patel et al.[3] illustrated the use of custom-made cement-linked megaprostheses as a sal- vage solution for periprosthetic femoral fractures. This study in- cluded 15 patients, 10 with retained stemmed hip implants and 5 Figure 7: New custom-made distal femoral prosthesis cement-linked to original with retained knee implants. They report favourable results, with salvage proximal femoral component visible in upper half of the image. a 93.3% implant survival rate and mean Musculoskeletal Tumour Society Score of 22.6 at a mean 5.3 year follow-up. There were no reported dislocations and one patient had a superﬁcial wound infection, which was treated successfully with oral antibiotics. CONFLICT OF INTEREST STATEMENT These studies and particularly the work from our centre forged the basis of the principle we employed in our case, where- None declared. by preserving and salvaging complex endoprostheses is pre- ferred to performing more disruptive revision surgery or even opting for amputation. However, in our case, we went a step REFERENCES further by salvaging a salvage custom-made cement-linked pros- thesis, with a good early postoperative result. To our knowledge, 1. Peters CL, Hickman JM, Erickson J, Lombardi AV, Berend KR, this scenario has never before been reported and we believe that Mallory TH. Intramedullary total femoral replacement for sal- our technique will prove invaluable in the future, as the need to vage of the compromised femur associated with hip and knee salvage failed endoprostheses grows. arthroplasty. J Arthroplasty 2006;21:53–8. How to salvage a salvage endoprosthesis | 5 2. Tillman R, Kalra S,Grimer R,CarterS,Abudu A. Acustom- mega prostheses: a salvage solution for complex peripros- made prosthesis attached to an existing femoral component thetic femoral fractures. J Arthroplasty 2014;29:204–9. for the treatment of peri- and sub-prosthetic fracture. J Bone 4. Henderson ER, Groundland JS, Pala E, Dennis JA, Wooten R, Joint Surg Br 2006;88-B:1299–302. Cheong D, et al. Failure mode classiﬁcation for tumor endo- 3. Patel NK, Whittingham-Jones P, Aston WJ, Pollock RC, prostheses: retrospective review of ﬁve institutions and a lit- Skinner JA, Briggs TWR, et al. Custom-made cement-linked erature review. J Bone Joint Surg Am 2011;93:418–29.$

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