Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications

Daniel Hameed; Jeremy A. Dubin; Carly Deter; Sandeep S. Bains; Zhongming Chen; Christopher G. Salib; Mallory C. Moore; Matthew T. Wallace; Albert J. Aboulafia

doi:10.1016/j.jor.2023.12.016

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doi:

10.1016/j.jor.2023.12.016

Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications

Daniel Hameed, Jeremy A. Dubin, Carly Deter, Sandeep S. Bains, Zhongming Chen, Christopher G. Salib, Mallory C. Moore, Matthew T. Wallace, Albert J. Aboulafia

LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA

∗Corresponding author: Albert J. Aboulafia. Aaboulaf@lifebridgehealth.org

Received: 2023-12-8, Accepted: 2023-12-19, Published: 2023-12-24

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Distal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

All patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

Revision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1–57.8).

The use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

1 Introduction

Bone tumors commonly develop in the extremities of long bones, particularly in the metaphyseal area surrounding the knee, posing a significant threat to a patient's quality of life.¹ Distal femoral replacement (DFR) plays a crucial role in limb salvage for individuals requiring bone resection due to neoplastic bone diseases.¹^,² This procedure has demonstrated high levels of patient satisfaction and successful return to daily activities for those with bone cancer.³ While limb salvage options may include bone grafts, DFR is preferred due to its lower rates of infection and nonunion.⁴ Nevertheless, a thorough evaluation of survivorship, complications, and outcomes is crucial to offer comprehensive guidance for long-term expectations.⁵

DFRs typically exhibit a reported failure rate of 12 %.⁵^,⁶ Recent literature indicates that aseptic loosening and infection are the two most common failure modes in distal femoral replacements.⁶^,⁷ For example, Lex et al. investigated reasons for reoperation following distal femoral replacement, revealing an 8.5 % infection rate and an 8.8 % aseptic loosening rate across all patient populations undergoing the procedure.⁸ In comparison to alternative salvage procedures like arthrodesis and amputation, DFR demonstrates improved cost-effectiveness and favorable postoperative outcomes.⁷^,⁸ Despite the increasing popularity of DFR for non-neoplastic indications, literature describing its use and outcomes for oncological reconstruction remains limited, despite advancements in surgical techniques over time.⁶^,^8–11

This study aims to investigate implant-related outcomes following distal femur replacement for oncologic conditions with a follow-up period exceeding 23 months. The specific outcomes under analysis include (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

2 Materials and methods

2.1

2.1 Study design

After obtaining approval from the Institutional Review Board, we conducted a retrospective analysis of the medical records of 27 patients (10 male and 17 female) (29 knees) who underwent distal femur replacement (DFR) for primary and non-primary tumors from 2010 to 2020. The inclusion criteria included: patients who underwent reconstructive surgery with DFR for any neoplastic indication between 2010 and 2020 with complete clinical follow-up and clinical notes, and pre-operative reports before DFR. Exclusion criteria included: (1) DFR for non-neoplastic indications; (2) any prior knee surgery before DFR; or (3) previous implantation before DFR. All procedures were performed by two fellowship-trained musculoskeletal oncologists, with the method of fixation determined by patient-specific factors, including age, tumor type, and bone quality. A standardized operative technique was utilized with a medial parapatellar approach. The crucial surgical part was resecting the principles as outlined by Enneking et al. in order to obtain an adequate surgical procedure.¹² The aim was to progress patients to full-weight bearing with physiotherapy over a 6-week period. Physiotherapy included: a progression from postural transitions in bed, transferring to a sitting position, and transitioning to a standing position focusing on active and passive mobilization exercises of the knee, foot, and ankle. Clinical follow-up included: physical, radiographical examination on a yearly basis, including collecting of complications and functional scores, such as KOOS Jr.

2.2

2.2 Demographic information

The average age at surgery was 57 ± 20.6 years. Neoplastic indications for DFR encompassed angiosarcoma (3.4 %), chondrosarcoma (13.8 %), diffuse B cell lymphoma (10.3 %), giant cell cancer (10.3 %), metastatic sarcoma (3.4 %), osteosarcoma (17.2 %), ovarian cancer (3.4 %), pleomorphic sarcoma (3.4 %), renal cell carcinoma (6.9 %), spindle cell sarcoma (3.4 %), and squamous cell carcinoma (3.4 %) (Refer to Table 1). The mean clinical follow-up duration was 22.5 months, and the study population exhibited a mean BMI of 30 kg/m2, predominantly comprising females (65.5 %), with a mean 5-item frailty index of 1.0 (indicative of comorbidity status) (Refer to Table 1).

Table 1 Demographics and baseline characteristics.

	Neoplastic (n = 29)
	n	%
Age (years)	57 ± 20.6
BMI (kg/m2)	30 ± 9.04
Gender
Female	19	65.5
Male	10	34.5
Total Follow-Up (months) 22.5 ± 33
5-item Frailty Index	1
COPD	3	10.3
DM	2	6.9
CHF	0	0
HTN	11	37.9
ADL	12	41.4
HIV	0	0
Hepatitis C	0	0
Renal Failure	0	0
CKD stage ≥ 3	0	0
Creatinine	0	0
Laterality
Left	12	41.4
Right	17	58.6
Neoplasm
Angiosarcoma	1	3.4
Chondrosarcoma 4		13.8
Diffuse B Cell Lymphoma	3	10.3
Giant Cell	2	6.9
Metastatic Breast cancer	2	6.9
Metastatic Colon cancer	2	6.9
Metastatic Lung cancer	3	10.3
Metastatic Sarcoma	1	3.4
Osteosarcoma	5	17.2
Ovarian Cancer	1	3.4
Pleomorphic Sarcoma	1	3.4
Renal Cell Carcinoma	2	6.9
Spindle Cell Sarcoma	1	3.4
Squamous Cell Carcinoma	1	3.4

2.3

2.3 Outcomes of interest

The primary outcome was infection-free survival, denoting the percentage of knee components that did not undergo subsequent reoperation for reinfection. Various secondary outcomes were assessed, including surgical and medical complications and patient-reported outcome scores. Patients underwent regular follow-ups by the treating surgeon and medical team. Revision was defined as any reoperation directly related to the index procedure. Documentation of all outcomes and complications was derived from patient electronic medical records. Investigated medical and surgical complications encompassed thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. For cases of PJIs, a synovectomy and extensive soft tissue debridement was performed as well as a femoral resection and intramedullary canal reaming. Additionally, wounds were copiously irrigated with normal saline and antiseptic solutions. Mechanical, intermittent compression stockings was supplemented with low-molecular-weight heparin for DVT prophylaxis. The patient-reported outcome measure (PROM) collected was the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR).

2.4

2.4 Data analysis

Continuous variables, including age and BMI, were summarized using means (±standard deviation), while categorical variables, such as gender, laterality, neoplasm type, and complications, were presented with frequency (%).

3 Results

3.1

3.1 Revision rates

Revision-free survivorship for patients was 72.4 % at 22.5 months. Eight out of the twenty-nine knees went on to be revised (27.6 %) (See Table 2). Furthermore, there were no revision cases due to femoral dislocations, periprosthetic fractures, or osteolysis. There was no difference in operation time (mean = 129 min) between the surgeries and no difference in outcomes among the various operative times.

Table 2 Outcomes and complications.

	Neoplastic (n = 29)
	n	%
ED visits (mean)	0.63
Readmissions (mean)	0.41
Revision	8	27.6
Aseptic Loosening	1	3.4
Femoral Dislocation	0	0.0
Patellar Dislocations	1	3.4
Prosthetic Joint Infection	3	10.3
PPFx	0	0.0
Osteolysis	0	0.0
Pneumonia	2	6.9
Thromboses	1	3.4
Death	3	10.3

3.2

3.2 Medical and surgical complications

PJI was the most common postoperative complication (10.3 %) (See Table 2). Aseptic loosening and patellar dislocation had a complication rate of 3.4 % (See Table 2). Two patients were found to have postoperative pneumonia (6.9 %), and one patient was diagnosed with thrombosis postoperatively (3.4 %) (See Table 2). A total of three patients (10.3 %) passed away during the follow-up period. Emergency department visits and inpatient readmissions were less than 1 per patient at 0.63 and 0.43, respectively (See Table 2). There was no difference in time to reoperation for the various complications.

3.3

3.3 Patient reported outcome measures

The mean pre-operative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score were 44.1. After 22.5 months of follow-up, the post-operative mean KOOS JR was 57.8.

4 Discussion

Distal femoral replacement (DFR) has become the preferred option for addressing knee-related bony malignancies.¹³ Recent advancements, including modularity and a rotating-hinge platform, have contributed to improved longevity, as evidenced by recent systematic reviews.¹⁴ However, there is a paucity of data on overall patient satisfaction and revision rates in those requiring DFR for neoplastic indications, especially with the growing focus on patient satisfaction and cost-effectiveness in healthcare.⁹ The key finding from our study underscores a revision-free survivorship of 72.4 % at 22.5 months for patients undergoing DFR for neoplastic indications. The most common cause for revision was infection, followed by aseptic loosening and patellar dislocation. The higher rate of PJI may be attributed to the local and systematic immunosuppression due to systematic treatment and overall disease in these patients. Patient satisfaction scores, particularly KOOS JR, showed a significant improvement from baseline to the final follow-up, progressing from 44.1 to 57.8.³ This data offers valuable insights into the durability of the procedure and the enhancement of patients' subjective experiences over time.

However, the current study is limited by a small sample size and a heterogeneous cohort that underwent surgery using implants from different manufacturers, potentially introducing selection bias. Despite this, indications for performing DFR were consistent among surgeons and discussed in a multidisciplinary group, minimizing bias. Another limitation is the retrospective nature of the study with a medium-term follow-up. Nevertheless, the study's strength lies in evaluating patient satisfaction and revision rates in those needing DFR for neoplastic indications.

Complications following distal femoral replacement have been extensively studied. Haijie et al. examined 40 studies with 4748 DFR cases, reporting mean survivorships of 78.3 %, 70.1 %, 61.6 %, and 38.3 % at five, ten, and 20 years, respectively, with infection and aseptic loosening being prominent complications.¹⁵ Our results align with a similar overall revision-free survivorship (72.4 %). Notably, none of the studies in the systematic review considered patient-reported outcomes, a crucial factor in our study.¹⁶ Staals et al. observed a cumulative revision-free survivorship of over 80 % at a decade in 299 cases undergoing DFR for bone sarcomas.⁴ However, their study lacked evaluation of patient-reported outcomes. Our research, while producing similar revision rates (28.3 % at five years and 35.7 % at ten years), offers invaluable insights with the inclusion of patient-reported outcomes.

Our results indicate a relatively low revision risk after tumor DFR, with significant improvement in patient-reported outcomes. DFR demonstrated satisfactory clinical outcomes with an acceptable complication rate, particularly crucial for this challenging patient population. The substantial improvement in patient satisfaction bodes well for future patients undergoing this procedure. However, further examination of clinical utility and investigation into issues such as infection is warranted. Future studies should explore innovations in surgical techniques or implants to reduce the incidence of failure modes.

Funding/Sponsorship

None.

Data availability

Available in a respository upon request.

Ethical approval

IRB exemption due to retrospective nature and public database.

Authors’ contribution

ZC- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

SB- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

JD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

DH- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Roles/Writing - original draft; and Writing - review & editing.

MM- Writing - review & editing.

CD- Writing - review & editing.

AA- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Visualization; Roles/Writing - original draft; and Writing - review & editing.

MW- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Visualization; Roles/Writing - original draft; and Writing - review & editing.

Use of AI tool- No use of AI tool.

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