Tumorprothesen in der endoprothetischen Revisionschirurgie der unteren Extremität – Ergebnisse von 25 Patienten nach Versorgung mit einem modularen Tumor- und Revisionssystem (MUTARS®)

Zusammenfassung

Einleitung: Bei großen und gelenknahen knöchernen Defektsituationen nach vorangegangenen revisionsendoprothetischen Eingriffen besteht im Fall des erneuten Versagens die Möglichkeit der Versorgung durch modulare Implantatsysteme aus der tumorendoprothetischen Versorgung als sog. „Salvage Procedure“. Das Ziel der vorliegenden retrospektiven Studie ist die Evaluation von Patienten, die aufgrund großer und gelenknaher knöcherner Defektsituationen, welche nicht mit konventionellen Implantatsystemen versorgt werden konnten, hinsichtlich des klinisch-funktionellen Outcomes und der Komplikationsrate nach Implantation eines modularen Tumor- und Revisionssystems (MUTARS®, Firma Implantcast, Buxtehude, Deutschland).

Methodik: In unserer Klinik wurden im Zeitraum von 2005 bis 2014 insgesamt 25 Patienten mittels des MUTARS-Systems aufgrund einer konventionell nicht zu versorgenden ossären Defektsituation operativ revidiert. Der mittlere Nachbeobachtungszeitraum lag bei 16 Monaten (Spannweite: 12–72 Monate). Folgende Indikationen führten zum Revisionseingriff: Ein Patient stellte sich aufgrund einer gelockerten Kappenprothese mit Bildung eines Metallgranuloms vor, 2 Patienten mit einer Pseudarthrose nach Implantation eines Femurnagels, ein Patient mit einem „Cut-Out“ eines Femurnagels. Vier Patienten mussten aufgrund einer aseptischen und ein Patient aufgrund einer septischen Lockerung einer zuvor implantierten Endoprothese revidiert werden. Insgesamt wurden 6 Patienten aufgrund einer periprothetischen Fraktur revidiert. Weitere 10 Patienten wurden bei einer infektkonsolidierten Girdlestone-Situation nach Explantation einer Endoprothese aufgrund eines periprothetischen Infekts versorgt. Alle Patienten wurden in regelmäßigen Intervallen klinisch und radiologisch reevaluiert. Es wurden neben den Komorbiditäten der Patienten klinisch funktionelle-Parameter wie der Harris Hip Score erfasst. Des Weiteren wurde eine Outcome-Analyse bezüglich peri- und postoperativer Komplikationen und eine nativradiologische Verlaufsbeurteilung durchgeführt.

Ergebnisse: Insgesamt wurden 23 Patienten mit einem proximalen Femur versorgt. Drei Patienten erhielten zusätzlich zur Tumorprothese einen Beckenteilersatz aufgrund einer Beckendiskontinuität. Ein Patient wurde mit einem distalen Femur, und bei einem weiteren Patienten wurde das ganze Femur durch einen totalen Femurersatz endoprothetisch ersetzt. Die mittlere Krankenhausverweildauer lag bei 25 Tagen (Spannweite: 11–47 Tage). Wir verzeichneten eine Komplikationsrate von 24 %. Der Harris Hip Score stieg von 28 Punkten präoperativ auf 81 Punkte postoperativ.

Schlussfolgerung: Bei höhergradigen, knöchernen und gelenknahen Defektsituationen nach vorangegangener, gescheiterter endoprothetischer oder osteosynthetischer Versorgung, bietet das MUTARS-System eine suffiziente Versorgungsmöglichkeit mit modularer Adaptation an die jeweilige individuelle Defektkonstellation des Patienten. Die klinischen Ergebnisse sind im kurz- bis mittelfristigen Verlauf vielversprechend.

Abstract

Introduction/Background: With extended life expectancy, the number of primary joint arthroplasties has also increased. Revision surgery is also more often necessary, due to aseptic or septic loosening of the prosthesis or periprosthetic fracture. Large bone defects often occur in these patients and several non-modular, conventional implants are available to handle this difficult situation. Custom made implants offer an individually designed and defect-adapted shape with perfect covering of the lesion, but may delay the operation. The Modular Universal Tumor And Revision System (MUTARS®) offers the possibility to vary the length and angle of the femoral neck and the antetorsion angle. Thus, it permits intraoperative adaption to the individual patientʼs defect. The aim of our study is to present clinical, functional results and the rate of complications in a cohort of patients undergoing revision surgery for failed endoprosthetic replacement or failed trauma surgery, using the Modular Universal Tumor And Revision System with short-to midterm follow-up.

Patients and Methods: Between August 2005 and September 2014, 25 patients (17 female, 8 male) with an average age of 72 years (min. 56, max. 92 years) were included in a retrospective study using the MUTARS® system. The patients underwent surgical revision of osseous defects that were not susceptible to conventional care. The mean follow-up was 16 months (min. 12, max. 72 months). The indications which led to revision surgery were as follows: loosened metal-on-metal prosthesis with an acetabular defect caused by a metal-induced granuloma (n = 1), pseudoarthrosis after implantation of femur nail (n = 2), cut-out of a femur nail (n = 1), aseptic loosening of an implanted endoprosthesis (n = 4), septic loosening of an implanted endoprosthesis (n = 1), periprosthetic fracture (n = 6) and periprosthetic infection after two stage revision surgery (infection consolidated Girdlestone situation) (n = 10). All patients were followed up at regular intervals, both clinically and radiologically. Apart from comorbidities, clinical and functional parameters were measured, including the Harris Hip Score. An outcome analysis was also performed with respect to peri- and postoperative complications. Serial plain X-rays were followed-up.

Results: In all patients, stable reconstruction without the use of an allograft was possible. In total, 23 patients underwent surgery by using a proximal femur prosthesis; three patients also received a custom made acetabular component. One patient was treated by using a distal femur and one patient was treated by implantation of a total femur prosthesis. The average length of hospital stay was 25 days (min.11, max. 47 days). The Harris Hip Score improved from 28 points preoperatively to 81 points after surgery.In total we recorded 24 % of complications after surgery. Two patients suffered recurrent periprosthetic infection and the prosthesis had to be revised in a further two stage exchange; one patient had a tractus gap and was revised by surgery. Two patients suffered periprosthetic fracture due to trauma and the patient with the total femur prosthesis suffered recurrent periprosthetic infection of the silver – coated mega-prosthesis and committed suicide triggered by an episode of major depression.

Conclusion: Because of its modular nature, the Modular Tumor And Revision System (MUTARS®) can be used for highly variable intraoperative defect adaption. Good clinical and functional results were achieved in patients with excessive bone defects. However, the high rate of infection, even with silver coated mega-implants, is still a problem and should be studied further.

Schlüsselwörter

MUTARS® - Tumorprothese - aseptischer Wechsel - septischer Wechsel - knöcherner Defekt

Key words

MUTARS® - tumor prosthesis - aseptic loosening - periprosthetic infection - bone defect

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