Received: 27 May 2017
Accepted: 28 August 2017
Long-term outcomes of cement in cement technique for
revision endoprosthesis surgery
Nicholas M. Bernthal MD
Vishal Hegde MD
Stephen D. Zoller MD
Howard Y. Park MD
Jason H. Ghodasra MD
Daniel Johansen BS
Frederick Eilber MD
Chandhanarat Chandhanayingyong MD
Jeffrey J. Eckardt MD
Department of Orthopaedic Surgery,
University of California—Los Angeles, Santa
David Geffen School of Medicine at
University of California—Los Angele, Los
Division of Surgical Oncology, Department
of General Surgery, University of California—
Los Angeles, Los Angeles, California
Department of Orthopedic Surgery, Mahidol
University Faculty of Medicine Siriraj Hospital,
Bangkoknoi, Bangkok, Thailand
Nicholas M. Bernthal, MD, Department of
Orthopaedic Surgery, University of California
—Los Angeles, 1250 16th Street Suite 2150,
Santa Monica, CA 90404.
National Institute of Arthritis and
Musculoskeletal and Skin Diseases,
Grant numbers: 5K08AR069112-01,
Background and Objective: Cemented endoprosthetic reconstruction after resection
of primary bone sarcomas has been a standard-of-care option for decades. With
increased patient survival, the incidence of failed endoprostheses requiring revision
surgery has increased. Revision of cemented endoprotheses by cementing into the
existing cement mantle (CiC) is technically demanding.
Methods: This is a retrospective review of our endoprosthesis database of 512
consecutive cemented endoprosthetic reconstructions performed for oncologic
diagnoses between 1980 and 2014. A total of 54 implants (mean patient age 32 years,
range 13-81) were revised with a CiC technique. Outcomes evaluated were prosthesis
survival, revision surgery categorized according to the Henderson Failure Mode
Classification, complications, and functional scores.
Results: Fifteen-year Kaplan-Meier survival rate was 34% for initial revision and 39%
for subsequent revision implants. Mean revised Musculoskeletal Tumor Society
(MSTS) Score was 27 at latest follow-up. Infection rate was 2%, 9%, and 13% for
primary endoprostheses, initial revisions, and subsequent revisions, respectively. Limb
salvage rate was 87%.
Conclusions: At long-term follow up, endoprostheses revised with the CiC technique
showed consistent 15-year survival from initial (34%) to subsequent (39%) revision.
Despite a relatively high failure rate, these results are encouraging and demonstrate
that this is a conservative, repeatable technique.
cement in cement, endoprostheses, Kaplan-Meier survival, revision, sarcoma
With considerable advances in imaging, implant design, surgical
technique and chemotherapeutics, limb salvage surgery has sup-
planted amputation as the preferred intervention for the majority of
patients with a musculoskeletal malignancy.
As the ability to treat
these malignancies becomes progressively more sophisticated, the
utilization of endoprostheses continues to expand, and the survival of
patients undergoing endoprosthetic reconstruction continues to
improve. With 25-year implant survival rates reported to be
approximately 50%, an increasing number of patients will require
revision of their endoprosthesis.
J Surg Oncol. 2018;117:443–450. wileyonlinelibrary.com/journal/jso © 2017 Wiley Periodicals, Inc.