Articles

 

Long term results of high dose vancomycin loaded spacers for treating infected massive prostheses

Poster spacer ciment athenes 2019-2               Delepine F, Alkhallaf S. Delepine G.

 

Aim

infection is of the most devastating complication of conservative surgery using massive prosthesis, leading frequently to amputation. The aim of this bi centric study is to precise the influence of spacer loaded with high doses of vancomycin on late results

 

Patients From 1984 to 2010, we operated more than 670 patients with bone sarcoma. Aged 4,5 to 82 years (mean 25 y). Histology was osteosarcoma (330), Ewing (175), chondrosarcomas (148), fibrosarcomas or MFH (23), giant cell tumours in others. In 502 cases, p received chemotherapy, and radiotherapy in 50 cases. The median follow-up from tumour removal is 20.5 years. 62 p suffered of deep infection of the material used to reconstruct the skeletal defect. 3 p were refered to us for recurrence of deep infection initially treated elsewhere. Altogether, we treated 65 patients for deep infections.

Method 28 p had debridment and cleaning of the prosthesis and long adapted antibiotherapy as first treatment. When ineffective (25/28), a removal of the prosthesis was performed with immediate re insertion of prosthesis in 19 cases. When infection recurred (16/19) and in 34 other patients the treatment included a two stages protocol with interposition of a spacer with antibiotic loaded cement during 4 to12 weeks .Until 2004, the spacer was made with gentamycin containing palacos mixed with conventional doses of antibiotics adapted to the germ. From 2004/6 we used high doses of vancomycin (4 g per batch of 40 g) with an average total dose of 11g of vancomycin per spacer. The new prosthesis was replaced secondarly when infection, cutaneous and muscular problems were solved.

RESULTS : At last control, 16 were amputated, following a mean of 6 ineffective procedures. 46 p. benefited from conservation surgery but a new prosthesis could be inserted only in 43, following a mean of 3.2 surgical procedures. Analysis shows the very bad prognostic value of initial radiotherapy, of distal locations, the importance of muscular coverage and the efficacy of high dose vancomycin in spacer. Up to date, none of the high dose vancomycin loaded spacers was followed by amputation

CONCLUSION Infection of massive prostheses is the most serious orthopaedic complication of limb salvage. Treatment must be preventive, avoiding any radiotherapy. Good prognostic factors of deep infection are early removal of the prosthesis, improvement of the muscular coverage, and use of spacers with high dose vancomycin.

 

slides 

Poster Ew périosté athenes 2019-2 (1)   

 

 

 

Long term follow-up of 7 periosteal Ewing. Key points for surgery 

F Delépine, G Delépine, S Alkhallaf

Aim of the study. Few cases of periosteal Ewing (PES) were reported and surgical implications of such a diagnosis has not been sufficiently underlined. Our goal is to evaluate the incidence of this topographic form and the consequence on surgery and long-term results.

Material. The 7 reported cases fulfilled the diagnosis criteria of Bator: Ewing of bone histologically proved, with pure periosteal location without medullary extension. The CT scan was the most reliable exam for diagnosis. Histology of resected specimen may ignore an initial medullary involvement cured by preoperative chemotherapy. M.R.I. can overestimate a PES with intense inflammatory reactive tissue inside the medullary canal.

Results

Out of 175 Ewing of bone of our file, only 7 (4 %) could be classified as PES. 6 involved the femoral bone (4 diaphyseal orand 2 metaphyso diaphyseal) and one the tibia (distal metaphysis). Age of patients at biopsy ranged 11 to 19. Two patients have been referred to us after biopsy. One was irradiated before we saw her. According to Ennecking classification, 3 were graded IIA and 4 II B. All patients were treated by resection after preoperative chemotherapy. With an median follow up of 198 months, all 7 patients are event free survivors.

In three cases a transcortical biopsy was performed compelling to perform a resection interrupting the long bone continuity; Two patients were reconstructed with long stem prosthesis and were re operated 2 and 4 times during the 18 and 19 years of follow up. For the distal tibia the limb salvage using allograft and vascularized fibula was followed by pseudarthrosis then infection with a total of 6 operations (in 3 years) before cure. In four cases the biopsy did not open the medullary bone; Nevertheless in three case sthe local extension compells to interrupt the long bone continuity before allograft reconstructions with 2 excellent and 1 good long-term results. The last case could benefit of partial resection of bone with cement filling and excellent immediate result.

Comments.With these cases (6 had been already reported), only 35 cases of PES have been described, 32 / 35 located on long bones. Most were stage II disease, treated by chemotherapy and surgery. At last follow up 33 / 35 patients (94 %) were in first remission confirming the good prognostic value of PES.

Conclusions.The surgical consequences of PES must be underlined. When computed imaging permits to suspect this diagnosis biopsy should be confined to the soft tissues and/or the cortical bone without medullary contamination. Such a procedure eventually permits subsequent partial resection without interruption of the bone continuity, allowing easier reconstruction and much better long term functional results.

 

slides

ISOLS2019 long term follow up of acetabular prostesis for malignancies

 

Very long-term follow-up of composite prostheses after periacetabular resection.

Fabrice Delépine, Gérard Delépine

 

Materials and methods.

The “hand on innominate prosthesis” described by us in 2003 (Sarcoma 2003) is made of a titanium cup, a set of long titanium screws and 2 or 3 packs of antibiotics loaded cement. To evaluate the orthopedic results of the implants, we take in account the score at last local control. We use the numerical rating assessing each of the seven variables of the MSTS system on a five-point scale, giving a maximum score of 35 points, recorded as 100 %. Between 1990-2007, 84 patients (p) with peri acetabular bone sarcoma (40), metastases (44) were treated by internal hemipelvectomy followed by this reconstructive procedure. 23 survivors (20/40 sarcomas, 3/44 metastases) have been followed more than 5 years. Histology of 23: chondrosarcoma: 8, osteosarcoma:5, Ewing: 5, MFH: 1, anaplasic sarcoma :1, renal cell carcinoma 2, thyroid 1. Resection included 4 zone 2, 6 zone 2+3, 9 zones 2+1, 3 zones 2+1+4, and 1, zones 1+2+3.

Results.

Median FU of these 23 p is 18,5 years (133- 301 months). Postoperative complications included 1 deep infection, 6 hip prosthesis dislocations (26%), 2 neurologic palsies. Late complications were 2 deep infections, 8 polyethylene wears and 8 loosening (5 iliac, 3 femoral). 17 p (73 %) had to be re operated. The type of orthopedic complications is significantly correlated with the topography of the resection: loosening of the iliac prosthesis threatens only resection of zone 1.

The mean functional result, rated according modified Ennecking’s grading system, was 80%. Result similar to those described in the literature for custom made innominate prosthesis and better than those of published alternative reconstructive procedures.

 

Conclusions.

The immediate weight bearing and the durability of such a procedure plea for using it after acetabulum resection of zone 2 and 3 (we did not observe loosening of the iliac reconstruction). Such a procedure can also be used after total iliac wing resection, even when including zone 4. But in this location loosening is frequent and pleas for reinforcing the reconstruction with the head and neck of femur when there are free of tumor as advocated by Puget (RCO 2012)