Megaprosthesis in large bone defects: opportunity or chimaera?

INTRODUCTION: The development of new megaprosthesis for the treatment of large bone defects provides important options to orthopaedic oncologic surgeons for the replacement of skeletal segments, such as the long bones of the upper and lower limbs and the relative joints. We implanted megaprosthesis using either a one-step or two-step technique depending on the patient's condition. The aim of this study was to evaluate retrospectively both clinical and radiological outcomes in patients who underwent lower limb megaprosthesis implant. MATERIALS AND METHODS: A total of 32 patients were treated with mono- and bi-articular megaprosthesis subdivided as follows: proximal femur, distal femur, proximal tibia and total femur. The mean follow-up of patients was about 18 months (range 3 months to 5 years). Clinical and serial radiographic evaluations were conducted using standard methods (X-ray at 45 days, 3, 6, 12, 18 and 24 months) and blood parameters of inflammation were monitored for at least 2 months. RESULTS: Although the mean length of follow-up was only 18 months, the first patients to enter the study were monitored for 5 years and showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. During surgery and, more importantly, in pre-operative planning, much attention should be given to the evaluation of the extensor apparatus, preserving it and, when necessary, reinforcing it with tendon substitutes. DISCUSSION: Megaprosthesis in extreme cases of severe bone loss and prosthetic failure is a potential solution for the orthopaedic surgeon. In oncological surgery, the opportunity to restore functionality to the patient (although not ad integrum) is important for both the patient and the surgeon. The high mortality associated with cancer precludes long-term patient follow-up; therefore, there is a lack of certainty about the survival of this type of prosthesis and any medium- to long-term complications that may occur. Nevertheless, patients should be considered as an oncologic patient, not because of the disease, but because of the limited therapeutic options available. CONCLUSIONS: Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases.

A multicentre, prospective, randomised comparison of the sliding hip screw with the Medoff sliding screw and side plate for unstable intertrochanteric hip fractures.

OBJECTIVE: This study aimed to compare the dynamic hip screw (DHS) and Medoff sliding plate (MSP) for unstable intertrochanteric hip fractures. DESIGN: A randomised, prospective trial design was used. SETTING: The study was undertaken in two level-1 trauma centres and one community hospital. PATIENTS/PARTICIPANTS: A total of 163 patients with unstable intertrochanteric hip fractures (Orthopaedic Trauma Association (OTA) 31-A2) were randomised to DHS or MSP. Inclusion and exclusion criteria were designed to focus on isolated unstable intertrochanteric hip fractures in ambulatory patients. INTERVENTION: Randomisation was performed intra-operatively, after placement of a 135° guide wire. Follow-up assessments were performed at regular intervals for a minimum of 6 months. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was re-operation rate. The secondary outcome was patient function, evaluated using a validated outcome measure, the Hip Fracture Functional Recovery Score. Tertiary outcomes included: mortality, hospital stay, quality of reduction and malunion rate. RESULTS: A total of 86 patients were randomised to DHS and 77 to MSP. The groups had similar patient demographics, pre-fracture status and in-hospital course. The quality of reduction was the same for each group, but the operative time was longer in the MSP group (61.6 vs. 50.1min, P=0.01). The rate of re-operation was low (3/86 in DHS and 2/77 in MSP) with no statistically significant difference. The functional outcomes were the same for both groups, with functional recovery scores at 6 months of 51.0% in the DHS arm and 49.7% in the MSP arm. CONCLUSIONS: The two techniques produced similar results for the clinically important outcomes of the need for further surgery and functional status of the patients at 6 months' follow-up.

Elderly patient's mortality and morbidity following trochanteric fracture. A prospective study of 100 cases.

BACKGROUND: Trochanteric fractures are a major source of mortality, morbidity and functional impairment in the elderly. Morbidity is closely related to the degree of instability and comminution and is substantially influenced by the quality of reduction and internal fixation. Advanced age and associated co-morbidities are two decisive factors of mortality secondary to trochanteric fracture. OBJECTIVES: This prospective study examined the epidemiological profile of trochanteric fractures and assessed mortality and morbidity with the aim of establishing management guidelines and improving prevention strategies. MATERIAL AND METHODS: One hundred patients were included; 60% were male. Mean age was 76 years (range, 60-96 yrs). One, or more than one, co-morbidities were present in 68% of cases. The fractures were caused by a simple fall in 90% of cases. Fractures were classified according to the criteria of Ramadier and the ones of Ender. Sixty-five percent of these fractures were unstable. A dynamic hip screw was systematically used as the standard means of internal fixation. RESULTS: Anatomic and functional results were analyzed in 82 patients (18 had died within the first year following fracture occurrence). Mean follow-up period was 24 months (range, 12-36 months). Bone healing was achieved in 96% of cases. There were numerous postoperative complications (four cases of thromboembolism, fourteen immobility-related complications, two infections, six secondary displacement combined to loss of fixation, four non-unions, and nine malunions). At 2 years follow-up, 28 patients had died. Mortality was strongly correlated with older age (over 90 years), associated co-morbidity and fracture instability. Good functional outcomes (72%) correlated with younger age (60-74 years), fracture stability, adequate reduction and internal fixation. DISCUSSION: In stable trochanteric fractures, osteosynthesis by dynamic screw-plate is more effective than alternative techniques (blade-plate, nail-plate, Ender nail or even trochanteric nail). In unstable trochanteric fractures, delayed weight-bearing should be preferred to avoid mechanical complications. In fractures that are unstable or extend far below the lesser trochanter, trochanteric nailing is indicated since providing enhanced stability, but sometimes at the cost of insufficient reduction. The treatment objective should be the complete resumption of weight-bearing as early as possible with the fewest possible complications. Prevention consists in detecting and treating osteoporosis and countering the causes of falls in elderly subjects (muscular reinforcement and correction of neurosensory deficit). LEVEL OF EVIDENCE: Level III: Prospective diagnostic study.