Clinical experience of novel interconnected porous hydroxyapatite ceramics for the revision of tumor prosthesis: a case report
© Yoshida et al; licensee BioMed Central Ltd. 2009
Received: 29 July 2009
Accepted: 21 October 2009
Published: 21 October 2009
As for being cautious with tumor prostheses, revision of uncemented tumor prostheses in particular, it is necessary to remove cortical bone from the stem circumference with a chisel when the stem is extracted. This assures that bone in-growth will occur within the stem in itself. As a result, re-substitution of mass autogenous bone graft round a new stem is subsequently necessary. When rivision of uncemented tumor prosthesis of distal femur was performed, we evade fibula transplant by transplanting interconnected porous hydroxyapatite ceramic (IP-CA: Neobone) with a self bone, and reports its experience with the case that acquired enough strength.
In this report, we present the case of a 27-year-old female with stem breakage of tumor prosthesis and do revision surgery for prosthetic failure. In the case of revision surgery, autologous bone and Neobone were mixed, and this was transplanted to stem circumference. The Radiological Evaluation System of the ISOLS showed excellent results for all items. She can walk without using a cane or orthosis, and the score of the MSTS is 80%.
When revision of uncemented tumor prostheses of the distal femur was performed, we avoided fibula graft by using Neobone with the patient's own bone tissue. Our experience with this case may indicate that adequate strength is achieved.
In surgery for malignant bone tumors, the implantation of joint prostheses for tumors (tumor prostheses) after wide resection is an important reconstruction method. However, complications such as infection and prosthesis fracture develop in some cases [1, 2]. To enhance bone strength around the stem of a femoral component, we used an interconnected porous hydroxyapatite ceramic (IP-CA: Neobone) in combination with an autogenous bone graft.
Due to recent advances in surgery and chemotherapy for primary malignant bone tumors, the survival rate has increased, and the usefulness of tumor prostheses as a limb reconstruction method has also been confirmed. However, complications such as infection associated with these prostheses and their loosening and fracture have presented problems. Concerning stem fracture, in 1994, R Capanna et al. reported stem fracture of modular uncemented tumor prostheses in 6 (6.3%) of 95 patients. In 2001, Mittenmayer et al. reported major complications in 19 of 100 patients using uncemented tumor prostheses, consisting of 11 patients showing aseptic loosening and 4 each showing septic loosening and implant fracture . In addition, in 2006, G Gosheger et al. reported stem fracture in 4 (1.6%) of 250 patients using uncemented tumor prostheses. At our department, stem fracture has been observed in 5 patients, and the mean duration until the fracture was 4 years and 6 months (10 months-9 years). The system used was the KMFTR implant (Kotz Modular Femur and Tibia Reconstruction System) in 4 patients and the PH type 1 (Physio hinge type 1) in the remaining one. The stem diameter was 10 mm in 4 patients and 11 mm in 1. Both stems were relatively thin for the distal femur. After revision, the stem diameter was 10 mm in only 1 patient, and stems with a greater diameter than those in the previous operation were used in the others. The possible causes of stem fracture include improvement in patients' activity and stem loosening. In general, stem fracture is considered to be associated with the design (hinge-type structure) of prostheses themselves. Some authors have recommended the use of relatively thick rather than thin stems[3, 6]. Various tumor prostheses have been studied and developed by researchers, but optimal prostheses have not yet been produced.
Unlike conventional hydroxyapatite (HA) ceramics, IP-CA was developed employing a new concept with importance placed on interconnectivity among air pores. IP-CA also allows new bone to enter air pores in the deep area, and has adequate strength for clinical use. Myoui et al. used IP-CA in 62 surgically treated patients with benign bone tumor, bone fracture, and inflammatory diseases, and observed favorable clinical results. On X-ray films, the border between IP-CA granules and between IP-CA and bone became unclear due to marked osteosclerosis in 61% of the patients after 6 months. Concerning cautionary items at the time of filling during the operation, Nakase et al. described that the initial strength acquired is lower using IP-CA than cortical bone, and recommended that the initial strength should be made as high as possible by combining IP-CA with autogenous cortical bone in fragile areas such as the bone fracture area. In our patients, for the reinforcement of the femoral stem, IC-PA was mixed with autogenous cortical bone to achieve maximal initial strength. On X-ray films, the borders between IP-CA and autogenous bone became unclear. X-ray rating by Myoui et al. was Grade 3.
At the time of the revision of the tumor prosthesis, to enhance the strength of bone around the stem, we planned to use a large amount of autogenous bone. However, fibula grafting could be avoided by the grafting of both Neobone and autogenous bone. Although further careful observation of the course is necessary, favorable bone formation was observed. This grafting of both Neobone and autogenous bone may also be useful for preventing stress shielding in joint replacement with tumor prostheses.
Written informed consent was obtained from a relative of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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