The results of the use of biological bone reconstruction in performing oncological revision knee replacement

Introduction. With an increase in revision surgeries for oncological knee prostheses replacement, one of the most significant challenges has been the need to address substantial intramedullary defects affecting the diaphysis and metaepiphyses in these patients. Our study is based on our experience with biological reconstruction methods used during such operations. We have developed both the methodology and necessary tools for its implementation, as well as conducted a comprehensive evaluation of its practical application results.

Aim. To assess the effectiveness of using biological bone reconstruction techniques in oncologic revision knee arthroplasty.

Materials and methods. A retrospective study included 57 patients who underwent revision total oncology knee arthroplasty with the use of biological reconstruction for intramedullary bone defects between 2017 and 2023, with a follow-up period of at least 12 months. Of these, 45 (78.9 %) were operated due to instability of the prosthetic components, while 12 (21.1 %) were treated in the second stage after spacer implantation due to infection.

Distribution of patients by location of bone defect: 26 (45.5 %) had femoral bone defects, 4 (7 %) had tibial bone defects, and 27 (47.4 %) had combined lesions involving both bones. Among the participants, 59.6 % were female and 40.4 % were male. The median age was 48 years (Q₁–Q₃) 39.00–57.00; min 23 – max 72), and the median follow-up time was 48 months (Q₁–Q₃ 28.00–60.00; min 12 – max 150). Median blood loss values were 900 ml (Q₁–Q₃ 700.0–1100.0; min 400 – max 2200), operation duration was 220 minutes (Q₁–Q₃ 190.0–240.0; min 140 – max 300), and patient weight was 85 kg (Q₁–Q₃ 77.0–95.0; min 56 – max 180).

We assessed complication risks, functional outcomes, and survival rates of the implants. All patients were divided into two groups: Group 1 (n = 37 or 64.9 %), operated before the introduction of new instruments, and Group 2 (n = 20 or 35.1%), operated after their introduction. Parameters such as operation duration and blood loss volume were compared between the groups.

Results. Over the entire observation period from 2017 to 2024, three cases (5.3%) of complications were identified. Bone density assessment in the bone graft zone was performed via CT scan six months postoperatively, yielding a mean value of 690 HU (Q₁–Q₃ 570.0 – 790.0; min 340 – max 980).Analysis of lower limb function dynamics according to the MSTS scale pre- and post-operation revealed statistically significant improvements (p <0.001) (using Wilcoxon’s test).Five-year survival rate of knee prostheses after revision arthroplasty was 96 %.To analyze the effectiveness of introducing the newly developed instrumentation, we studied blood loss and operative times with and without its use. Using the instrumentation significantly reduced blood loss (p <0.001) and operative time (p <0.001) as determined by Mann-Whitney U-tests.

Conclusion. The five-year survival rates for constructs in patients undergoing surgery with biological bone reconstruction are comparable to those observed after primary implantations of oncologic prostheses.

1. Pala E., Trovarelli G., Calabrò T. et al. Survival of modern knee tumor megaprostheses: failures, functional results, and a comparative statistical analysis. Clin Orthop Relat Res 2015;473(3):891–9. DOI: 10.1007/s11999-014-3699-2

2. Bus M.P., van de Sande M.A., Fiocco M. et al. What are the long-term results of MUTARS® modular endoprostheses for reconstruction of tumor resection of the distal femur and proximal tibia? Clin Orthop Relat Res 2017;475(3):708–18. DOI: 10.1007/s11999-015-4644-8. Erratum in: Clin Orthop Relat Res 2017;475(3):922. DOI: 10.1007/s11999-015-4684-0

3. Gómez-Muñoz E., Navarro-Ruiz de Adana I., Cebrián-Parra J.L. et al. Evaluación funcional y calidad de vida en megaprótesis implantadas por tumores musculoesqueléticos en miembro inferior [Functional evaluation and quality of life in megaprostheses implanted by musculoskeletal tumors in the lower limb]. Acta Ortop Mex 2022;36(3):146–51. (In Spanish).

4. Sokolovsky A.V., Sokolovsky V.A., Bludov A.B. et al. Long-term results and modern principles of prevention and treatment of patients with aseptic instability of the endoprosthesis in oncology. Sarkomy kostei, miagkikh tkanei i opukholi kozhi = Bone and Soft Tissue Sarcomas, Tumors of the Skin 2022;14(1):11–24. DOI: 10.17650/2782-3687-2022-14-1-11-24

5. Henderson E.R., O’Connor M.I., Ruggieri P. et al. Classification of failure of limb salvage after reconstructive surgery for bone tumours: a modified system Including biological and expandable reconstructions. Bone Joint J 2014;96-B(11):1436–40. DOI: 10.1302/0301-620X.96B:11.34747

6. Henderson E.R., Groundland J.S., Pala E. et al. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am 2011;93(5):418–29. DOI: 10.2106/JBJS.J.00834

7. Boettner F., Bechler U., Springer B. et al. Impaction bone grafting in revision total knee arthroplasty-using mesh and cone to contain the defect: a report of 3 cases. Arthroplast Today 2020;6(3):578–84. DOI: 10.1016/j.artd.2020.07.001. Erratum in: Arthroplast Today 2022;15:225. DOI: 10.1016/j.artd.2022.01.008

8. PalaE., Trovarelli G., Angelini A., Maraldi M. et al. Megaprosthesis of the knee in tumor and revision surgery. Acta Biomed 2017;88(2S): 129–38. DOI: 10.23750/abm.v88i2-S.6523

9. Lei P.F., Hu R.Y., Hu Y.H. Bone defects in revision total knee arthroplasty and management. Orthop Surg 2019;11(1):15–24. DOI: 10.1111/os.12425

10. Jabbal M., Simpson A.H.R., Walmsley P. Mechanisms of bone loss in revision total knee arthroplasty and current treatment options. Orthop Rev (Pavia) 2023;15:75359. DOI: 10.52965/001c.75359

11. Steens W., Loehr J.F., Wodtke J., Katzer A. Morselized bone grafting in revision arthroplasty of the knee: a retrospective analysis of 34 reconstructions after 2–9 years. Acta Orthop 2008;79(5):683–8. DOI: 10.1080/17453670810016713

12. Sugita T., Aizawa T., Sasaki A. et al. Autologous morselised bone grafting for medial tibial defects in total knee arthroplasty. J Orthop Surg (Hong Kong) 2015;23(2):185–9. DOI: 10.1177/230949901502300214

13. Bedard N.A., Dugdale E.M., Couch C.C. et al. Diaphyseal impaction grafting combined with metaphyseal cones: outcomes in 88 revision total knee arthroplasties. J Bone Joint Surg Am 2024;106(14):1293–9. DOI: 10.2106/JBJS.23.01085

14. Bedard N.A., Cates R.A., Lewallen D.G. et al. Outcomes of a technique combining diaphyseal impaction grafting and metaphyseal cones for severe bone loss in revision total knee arthroplasty. Bone Joint J 2020;102-B(6_Supple_A):116–22. DOI: 10.1302/0301-620X.102B6.BJJ-2019-1511.R1

15. Li X., Han J., Shi X. et al. Zoledronic acid and denosumab for periprosthetic bone mineral density loss after joint arthroplasty: a systematic review and meta-analysis of randomized controlled trials. Arch Osteoporos 2023;18(1):37. DOI: 10.1007/s11657-023-01227-9

16. Bhandari M., Bajammal S., Guyatt G.H. et al. Effect of bisphosphonates on periprosthetic bone mineral density after total joint arthroplasty. A meta-analysis. J Bone Joint Surg Am 2005;87(2):293–301.

17. Liu Y., Xu J.W., Li M.Y. et al. Zoledronic acid for periprosthetic bone mineral density changes in patients with osteoporosis after hip arthroplasty-an updated meta-analysis of six randomized controlled trials. Front Med (Lausanne) 2021;8:801282. DOI: 10.3389/fmed.2021.801282

18. Enneking W.F., Dunham W., Gebhardt M.C. et al. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241–6.