Aseptic loosening (Type 2) accounted for 19% of all failures. Aseptic loosening in the distal part of the femur accounted for 6.8% of the failures and was the highest of all locations (Fig. 6). The rate of aseptic loosening failures for segmental endoprostheses was significantly higher in hinged joints than polyaxial articulations (p = 0.0004, Table III). Aseptic loosening was also higher with all lower extremity prostheses compared with all upper extremity prostheses, but the difference was not significant (p = 0.12).
Structural failures (Type 3) accounted for 17% of all failures and were highest with distal humeral and distal femoral replacements. Structural failure was lowest for proximal humeral and total femoral replacements. The rate of structural failure was significantly increased in the uniaxial endoprostheses compared with the polyaxial endoprostheses (p < 0.0001, Table III). Structural failures also occurred more often in the lower extremity compared with the upper extremity (p = 0.002).
Infection (Type 4) was the most common mode of failure overall and was the most common cause of failure at all locations except the proximal part of the femur. Infection accounted for all total humeral replacement failures. Type-4 failures occurred significantly more often in hinged prostheses than in polyaxial prostheses (p = 0.0001, Table III).
The relative incidence of endoprosthetic failures due to tumor progression (Type 5) was greatest with the distal humeral and proximal femoral replacements and least with total femoral and combined distal femoral-proximal tibial replacements; however, overall tumor progression rates were similar for all locations. Tumor progression failures occurred more often after primary tumor resection (4.7%) than after treatment of metastatic disease (2.2%); the difference was significant (p = 0.03). There were no significant differences in tumor progression when joint type or extremity was considered.
A chi-square test of independence was performed with a contingency table considering mode of failure and anatomic location. Mode of failure demonstrates significant dependence on anatomic location for all locations except total humeral replacement (p < 0.0001). The number of total humeral replacements was insufficient to be included in this analysis.
When failure incidence was analyzed chronologically in five-year increments, the rates of endoprosthetic failure decreased over time (Fig. 7). Failure rates for replacements of the proximal part of the humerus, proximal part of the femur, distal end of the femur, and proximal part of the tibia implanted from 1974 to 1988 were compared with those implanted from 1994 to 2008. The overall failure rate of endoprostheses implanted from 1974 to 1988 was 36%, whereas the failure rate from 1994 to 2008 was 20.9% (p < 0.0001). Significant reductions in failure incidence were seen for each anatomic location except the proximal part of the humerus, for which failure was reduced from 22% to 14% (p = 0.09).
Time to Failure
Time to failure differed significantly on the basis of the location of the endoprosthesis. The mean overall time to failure was forty-seven months (Table IV). The shortest mean time to failure by anatomic location (10.9 months) was observed in the distal humeral replacements. The longest mean time to failure was fifty-three months, observed in proximal humeral replacements. Intervals to failure were similar for proximal tibial and distal femoral replacements. A chi-square test of independence was performed with the use of a contingency table considering time to failure and anatomic location. Time to failure demonstrates significant dependence on anatomic location for all locations except total humeral replacement (p < 0.0001), but there was an insufficient number of total humeral replacements to be included in this analysis.
The interval from prosthetic reconstruction to failure varied widely with respect to the mode of failure. Soft-tissue failures were associated with the shortest mean time to failure (sixteen months), while aseptic loosening had the longest mean time to failure (seventy-six months). A chi-square test of independence with the use of a contingency table considering mode of failure and time to failure was performed. Time to failure demonstrates significant dependence on mode of failure for all locations except total humeral replacement (p < 0.0001).
Our literature review was based on 4359 patients who underwent limb preservation surgery following tumor resection3,4,6-8,11-13,16,17,19,27-84. Of these subjects, 237 (5.4%) had proximal humeral replacements; nine (0.2%), total humeral replacements; thirty-five (0.8%), distal humeral replacements with total elbow arthroplasty; 452 (10%), proximal femoral replacements; sixty-three (1.4%), total femoral replacements; 2861 (66%), distal femoral replacements; and 702 (16%), proximal tibial replacements (Table V).
Overall, 1271 primary procedures (29%) were considered failures. Total failure occurrences by anatomic location included seventy-eight (33%) of the 237 proximal humeral replacements, five of nine total humeral replacements, seventeen (49%) of thirty-five distal humeral replacements, ninety-one (20%) of 452 proximal femoral replacements, thirty (48%) of sixty-three total femoral replacements, 761 (27%) of 2861 distal femoral replacements, and 289 (41%) of 702 proximal tibial replacements (Table V).
Mode of failure demonstrated significant dependence on anatomic location for all locations (p < 0.0001). Soft-tissue failures were most common for endoprostheses located about the shoulder and hip, whereas aseptic loosening was the most common mode of failure in the lower extremities, especially with hinged knee arthroplasty. Time to failure for individual failure modes and anatomic sites was not commonly reported and could not be analyzed reliably.
Segmental metallic endoprostheses play an increasingly important role in limb reconstruction following tumor surgery. Reconstructive failures are common, and no large investigations have analyzed these failures and enabled their classification4,7,27,28,85. Several factors may contribute to failure. Soft-tissue stripping, wide excision of normal adjacent muscle and bone, and patient deconditioning predispose to joint instability86. The substantial lengths of these endoprostheses create high bending stresses at the prosthesis-bone interface and may contribute to loosening and periprosthetic or component fracture87. Constrained joint designs also impart substantial stress between the endoprosthesis and cement or endoprosthesis and bone, increasing the incidence of loosening87. Tumor progression remains a persistent threat to endoprosthesis and limb survival57,68. Extensive dissections, longer operative times, large endoprosthetic volume, and exposure to chemotherapy and radiation place patients at a higher risk of infection88-90.
Despite the high failure rates of these devices, the epidemiology of their failure has not been addressed sufficiently because of the paucity of procedures performed annually. The current study combines the collective experience of five institutions that perform a high volume of these procedures, and the investigation was done with two goals. The first was to analyze a large cohort of patients who had undergone limb preservation surgery with metallic segmental endoprostheses to delineate the incidence and mode of failure. The second goal was to derive a classification system based on these failure modes to facilitate understanding and uniform reporting of segmental failures as well as provide information for treatment decisions.
The results from the present study and a review of the literature indicate that there are five major modes of segmental endoprosthetic failure. These five modes are based on the categories of mechanical and nonmechanical failures4. We classified mechanical failures as soft-tissue failure (Type 1), aseptic loosening (Type 2), and structural breakage (Type 3). Nonmechanical failures were classified as infection (Type 4) and tumor progression (Type 5). In the present study, infection was the most common cause of failure, followed by aseptic loosening, tumor progression, structural failure, and soft-tissue failure, respectively.
Data from this study and a comprehensive literature review demonstrated significant dependence of failure mode on anatomic location. Risk of Type-1 failures for polyaxial joints was over five times that for uniaxial joints, and risk of Type-2 failures for distal femoral replacement was over twice that for proximal femoral replacement. Previous investigations of outcomes after reconstruction with segmental endoprostheses have generally taken a cumulative approach to reporting failures7,12,37,57,83; however, on the basis of the results in the current investigation, this should be avoided as it dilutes significant location-specific trends that could guide endoprosthetic design improvements.
Overall, the reports in the literature had results similar to our findings. The least common failure mode in the literature and in the current investigation was soft-tissue failure, predominantly about the hip and shoulder, reflecting the intrinsic instability of these joints. The proportion of patients who had structural failure of a prosthesis or failure due to disease progression was nearly identical in the literature and the current study.
The most striking difference between the current investigation and literature involved aseptic loosening. The overall incidence of aseptic loosening failures in the literature was 10%; the incidence in the current study was 4.7%. The incidence of aseptic loosening for distal femoral replacement was 12% in the literature and 6.8% in the current study. This finding may reflect the trend toward use of press-fit stems, which have a lower incidence of aseptic loosening than cement in the short term72, although some series have found that the differences are not significant and the comparatively short duration of press-fit use compared with cement does not allow for adequate comparison91. This difference may also be explained by different levels of expertise in complex reconstruction between the dedicated centers in this study and the wide variation in experience among individuals and groups reported in the literature. Lastly, this difference may also be explained by technological advances in the detection of latent infections, curtailing the onset of loosening that would have been judged previously to be aseptic; this would also help to explain the relative increase in failures due to infection in the present study compared with previous reports.
Infection was the most common mode of failure in the current study. Larger endoprostheses (total humeral, total femoral, and combined distal femoral-proximal tibial replacements) had a higher failure rate due to infection than the smaller endoprostheses, demonstrating the effect of the extensive dissections and longer operative times accompanying these procedures88,92. Proximal femoral replacement demonstrated the lowest infection rate in the current study, which may be due to the more robust vascular supply and soft-tissue envelope surrounding this joint. A similar trend was demonstrated by Jeys et al., who reported an infection rate of 23.1% about the tibia and 6.7% about the proximal part of the femur92.
Time to failure was also significantly dependent on anatomic location and mode of failure. Soft-tissue failures generally occurred early in the postoperative period but then leveled off by the end of the second postoperative year (Figs. 4, 5, and 6). Kabukcuoglu et al. reported similar findings in that proximal femoral replacement dislocation usually occurred within the first three months after surgery59.
Infection failures presented at an average of forty-seven months; however, half of all infections occurred within the first two years. Therefore, failures due to infection generally occur early in the postoperative period, but late infections are not uncommon. Jeys et al. reported a high incidence of infection in the first two years, with most infections occurring within the first ten years after surgery; however, they did not comment on a rationale for this trend92. We hypothesize that the effects of ongoing treatment for oncologic disease are likely responsible for these findings, but the data reported by Jeys et al. are inconsistent in this matter; radiation has been shown to be a significant risk factor, but chemotherapy has not. Regardless of etiology, these findings reinforce the importance of patient education, surveillance, and continuing preventive measures such as antibiotic prophylaxis for dental and invasive procedures over the lifetime of the patient.
While the relative incidence of tumor failures showed some variance, the absolute incidence of tumor progression failures ranged from 2.6% for total femoral replacement to 5.6% for distal humeral replacement, which was not significant. Therefore, no obvious recommendations to prevent progression in various anatomic sites can be made. The significant difference in tumor progression failures for patients with primary tumors and those with metastatic disease is likely due to the relatively shorter survival of the patients with metastatic disease.
The authors acknowledge limitations to this study. While the volume of patients reported is a strength of this investigation, the procedures were performed at multiple centers by surgeons using nonstandardized techniques and instrumentation. This investigation spans three and a half decades; therefore, adjuvant treatment of these tumors, and consequently patient and prosthesis survival, has evolved over the course of the period reviewed. Endoprosthetic designs and fixation methods have also evolved. Failure rates of cemented and noncemented segmental endoprostheses, however, have not been shown to be significantly different in medium-term follow-up91.
The classification system presented in this study is intended to place greatest emphasis on the most devastating causes of segmental endoprosthetic failure and, therefore, those that require the most urgent intervention. Among the five failure modes, infection (Type 4) and tumor progression (Type 5) are the most likely to result in amputation4,93. Soft-tissue failures (Type 1), aseptic loosening (Type 2), and structural failures (Type 3) may compromise function, but their occurrence is rarely threatening to life or limb, and the classification system was derived accordingly4. Future application of this classification system for reporting segmental outcomes will facilitate clearer communication of failure modes and a better understanding of their causes.
Investigation performed at the Sarcoma Program, H. Lee Moffitt Cancer and Research Institute, Tampa, Florida; Orthopaedic Oncology Division, Department of Orthopaedic Surgery, University of Miami, Miami, Florida; Division of Orthopaedic Oncology, Massachusetts General Hospital, Boston, Massachusetts; Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy; and Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (DePuy [Johnson & Johnson] and Stryker).
1. Rougraff BT Simon MA Kneisl JS Greenberg DB Mankin HJ Rougraff BT Simon MA Greenberg DB Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study. J Bone Joint Surg Am. 1994;76:649–56.
2. Simon MA Aschliman MA Thomas N Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68:1331–7.
3. Guo W Ji T Yang R Tang X Yang Y. Endoprosthetic replacement for primary tumours around the knee: experience from Peking University. J Bone Joint Surg Br. 2008;90:1084–9.
4. Wirganowicz PZ Eckardt JJ Dorey FJ Eilber FR Kabo JM. Etiology and results of tumor endoprosthesis revision surgery in 64 patients. Clin Orthop Relat Res. 1999;358:64–74.
5. Zeegen EN Aponte-Tinao LA Hornicek FJ Gebhardt MC Mankin HJ. Survivorship analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat Res. 2004;420:239–50.
6. Kotz R Ritschl P Trachtenbrodt J. A modular femur-tibia reconstruction system. Orthopedics. 1986;9:1639–52.
7. Asavamongkolkul A Eckardt JJ Eilber FR Dorey FJ Ward WG Kelly CM Wirganowicz PZ Kabo JM. Endoprosthetic reconstruction for malignant upper extremity tumors. Clin Orthop Relat Res. 1999;360:207–20.
8. Biau D Faure F Katsahian S Jeanrot C Tomeno B Anract P. Survival of total knee replacement with a megaprosthesis after bone tumor resection. J Bone Joint Surg Am. 2006;88:1285–93.
9. Chao EY Fuchs B Rowland CM Ilstrup DM Pritchard DJ Sim FH. Long-term results of segmental prosthesis fixation by extracortical bone-bridging and ingrowth. J Bone Joint Surg Am. 2004;86:948–55.
10. Damron TA Rock MG O’Connor MI Johnson ME An KN Pritchard DJ Sim FH Shives TC. Distal upper extremity function following proximal humeral resection and reconstruction for tumors: contralateral comparison. Ann Surg Oncol. 1997;4:237–46.
11. Donati D Zavatta M Gozzi E Giacomini S Campanacci L Mercuri M. Modular prosthetic replacement of the proximal femur after resection of a bone tumour a long-term follow-up. J Bone Joint Surg Br. 2001;83:1156–60.
12. Gosheger G Gebert C Ahrens H Streitbuerger A Winkelmann W Hardes J. Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res. 2006;450:164–71.
13. Grimer RJ Carter SR Tillman RM Sneath RS Walker PS Unwin PS Shewell PC. Endoprosthetic replacement of the proximal tibia. J Bone Joint Surg Br. 1999;81:488–94.
14. Hanna SA David LA Aston WJ Gikas PD Blunn GW Cannon SR Briggs TW. Endoprosthetic replacement of the distal humerus following resection of bone tumours. J Bone Joint Surg Br. 2007;89:1498–503.
15. Huckstep RL Sherry E. Replacement of the proximal humerus in primary bone tumours. Aust N Z J Surg. 1996;66:97–100.
16. Jeys LM Kulkarni A Grimer RJ Carter SR Tillman RM Abudu A. Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg Am. 2008;90:1265–71.
17. Malawer MM McHale KA. Limb-sparing surgery for high-grade malignant tumors of the proximal tibia. Surgical technique and a method of extensor mechanism reconstruction. Clin Orthop Relat Res. 1989;239:231–48.
18. Schneiderbauer MM Sierra RJ Schleck C Harmsen WS Scully SP. Dislocation rate after hip hemiarthroplasty in patients with tumor-related conditions. J Bone Joint Surg Am. 2005;87:1810–5.
19. Unwin PS Cannon SR Grimer RJ Kemp HB Sneath RS Walker PS. Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br. 1996;78:5–13.
20. Berry DJ Harmsen WS Cabanela ME Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002;84:171–7.
21. Söderman P Malchau H Herberts P. Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register. Acta Orthop Scand. 2000;71:354–9.
22. Söderman P Malchau H Herberts P Zügner R Regnér H Garellick G. Outcome after total hip arthroplasty: part II. Disease-specific follow-up and the Swedish National Total Hip Arthroplasty Register. Acta Orthop Scand. 2001;72:113–9.
23. Deshmukh AV Koris M Zurakowski D Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14:471–9.
24. Font-Rodriguez DE Scuderi GR Insall JN. Survivorship of cemented total knee arthroplasty. Clin Orthop Relat Res. 1997;345:79–86.
25. Gill DR Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am. 1998;80:1327–35.
26. Wilkins RM Kelly CM. Revision of the failed distal femoral replacement to allograft prosthetic composite. Clin Orthop Relat Res. 2002;397:114–8.
27. Ahlmann ER Menendez LR Kermani C Gotha H. Survivorship and clinical outcome of modular endoprosthetic reconstruction for neoplastic disease of the lower limb. J Bone Joint Surg Br. 2006;88:790–5.
28. Bickels J Wittig JC Kollender Y Henshaw RM Kellar-Graney KL Meller I Malawer MM. Distal femur resection with endoprosthetic reconstruction: a long-term followup study. Clin Orthop Relat Res. 2002;400:225–35.
29. Bradish CF Kemp HB Scales JT Wilson JN. Distal femoral replacement by custom-made prostheses. Clinical follow-up and survivorship analysis. J Bone Joint Surg Br. 1987;69:276–84.
30. Burrows HJ Wilson JN Scales JT. Excision of tumours of humerus and femur, with restoration by internal prostheses. J Bone Joint Surg Br. 1975;57:148–59.
31. Capanna R Morris HG Campanacci D Del Ben M Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Joint Surg Br. 1994;76:178–86.
32. Capanna R Ruggieri P Biagini R Ferraro A DeCristofaro R McDonald D Campanacci M. The effect of quadriceps excision on functional results after distal femoral resection and prosthetic replacement of bone tumors. Clin Orthop Relat Res. 1991;267:186–96.
33. Choong PF Sim FH Pritchard DJ Rock MG Chao EY. Megaprostheses after resection of distal femoral tumors. A rotating hinge design in 30 patients followed for 2-7 years. Acta Orthop Scand. 1996;67:345–51.
34. Freedman EL Eckardt JJ. A modular endoprosthetic system for tumor and non-tumor reconstruction: preliminary experience. Orthopedics. 1997;20:27–36.
35. Frink SJ Rutledge J Lewis VO Lin PP Yasko AW. Favorable long-term results of prosthetic arthroplasty of the knee for distal femur neoplasms. Clin Orthop Relat Res. 2005;438:65–70.
36. Futani H Minamizaki T Nishimoto Y Abe S Yabe H Ueda T. Long-term follow-up after limb salvage in skeletally immature children with a primary malignant tumor of the distal end of the femur. J Bone Joint Surg Am. 2006;88:595–603.
37. Gosheger G Hillmann A Lindner N Rödl R Hoffmann C Bürger H Winkelmann W. Soft tissue reconstruction of megaprostheses using a trevira tube. Clin Orthop Relat Res. 2001;393:264–71.
38. Griffin AM Parsons JA Davis AM Bell RS Wunder JS. Uncemented tumor endoprostheses at the knee: root causes of failure. Clin Orthop Relat Res. 2005;438:71–9.
39. Kawai A Healey JH Boland PJ Athanasian EA Jeon DG. A rotating-hinge knee replacement for malignant tumors of the femur and tibia. J Arthroplasty. 1999;14:187–96.
40. Kawai A Muschler GF Lane JM Otis JC Healey JH. Prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. Medium to long-term results. J Bone Joint Surg Am. 1998;80:636–47.
41. Kay RM Kabo JM Seeger LL Eckardt JJ. Hydroxyapatite-coated distal femoral replacements. Preliminary results. Clin Orthop Relat Res. 1994;302:92–100.
42. Malawer MM Chou LB. Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas. J Bone Joint Surg Am. 1995;77:1154–65.
43. Muschler GF Ihara K Lane JM Healey JH Levine MJ Otis JC Burstein AH. A custom distal femoral prosthesis for reconstruction of large defects following wide excision for sarcoma: results and prognostic factors. Orthopedics. 1995;18:527–38.
44. Natarajan MV Sivaseelam A Ayyappan S Bose JC Sampath Kumar M. Distal femoral tumours treated by resection and custom mega-prosthetic replacement. Int Orthop. 2005;29:309–13.
45. Roberts P Chan D Grimer RJ Sneath RS Scales JT. Prosthetic replacement of the distal femur for primary bone tumours. J Bone Joint Surg Br. 1991;73:762–9.
46. Rosen AL Strauss E. Primary total knee arthroplasty for complex distal femur fractures in elderly patients. Clin Orthop Relat Res. 2004;425:101–5.
47. Sanjay BK Moreau PG. Limb salvage surgery in bone tumour with modular endoprosthesis. Int Orthop. 1999;23:41–6.
48. Shih LY Sim FH Pritchard DJ Rock MG Chao EY. Segmental total knee arthroplasty after distal femoral resection for tumor. Clin Orthop Relat Res. 1993;292:269–81.
49. Sim FH Chao EY. Prosthetic replacement of the knee and a large segment of the femur or tibia. J Bone Joint Surg Am. 1979;61:887–92.
50. Zwart HJ Taminiau AH Schimmel JW van Horn JR. Kotz modular femur and tibia replacement. 28 tumor cases followed for 3 (1-8) years. Acta Orthop Scand. 1994;65:315–8.
51. Athwal GS Chin PY Adams RA Morrey BF. Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow. J Bone Joint Surg Br. 2005;87:1369–74.
52. Ross AC Sneath RS Scales JT. Endoprosthetic replacement of the humerus and elbow joint. J Bone Joint Surg Br. 1987;69:652–5.
53. Schwab JH Healey JH Athanasian EA. Wide en bloc extra-articular excision of the elbow for sarcoma with complex reconstruction. J Bone Joint Surg Br. 2008;90:78–83.
54. Sperling JW Pritchard DJ Morrey BF. Total elbow arthroplasty after resection of tumors at the elbow. Clin Orthop Relat Res. 1999;367:256–61.
55. Weber KL Lin PP Yasko AW. Complex segmental elbow reconstruction after tumor resection. Clin Orthop Relat Res. 2003;415:31–44.
56. Anderson ME Hyodo A Zehr RJ Marks KE Muschler GF. Abductor reattachment with a custom proximal femoral replacement prosthesis. Orthopedics. 2002;25:722–6.
57. Grimer RJ Taminiau AM Cannon SR; Surgical Subcommittee of the European Osteosarcoma Intergroup. Surgical outcomes in osteosarcoma. J Bone Joint Surg Br. 2002;84:395–400.
58. Johnsson R Carlsson A Kisch K Moritz U Zetterström R Persson BM. Function following mega total hip arthroplasty compared with conventional total hip arthroplasty and healthy matched controls. Clin Orthop Relat Res. 1985;192:159–67.
59. Kabukcuoglu Y Grimer RJ Tillman RM Carter SR. Endoprosthetic replacement for primary malignant tumors of the proximal femur. Clin Orthop Relat Res. 1999;358:8–14.
60. Kawai A Backus SI Otis JC Inoue H Healey JH. Gait characteristics of patients after proximal femoral replacement for malignant bone tumour. J Bone Joint Surg Br. 2000;82:666–9.
61. Masterson EL Ferracini R Griffin AM Wunder JS Bell RS. Capsular replacement with synthetic mesh: effectiveness in preventing postoperative dislocation after wide resection of proximal femoral tumors and prosthetic reconstruction. J Arthroplasty. 1998;13:860–6.
62. Morris HG Capanna R Del Ben M Campanacci D. Prosthetic reconstruction of the proximal femur after resection for bone tumors. J Arthroplasty. 1995;10:293–9.
63. Ogilvie CM Wunder JS Ferguson PC Griffin AM Bell RS. Functional outcome of endoprosthetic proximal femoral replacement. Clin Orthop Relat Res. 2004;426:44–8.
64. Sim FH Chao EY. Hip salvage by proximal femoral replacement. J Bone Joint Surg Am. 1981;63:1228–39.
65. Ward WG Johnston KS Dorey FJ Eckardt JJ. Loosening of massive proximal femoral cemented endoprostheses. Radiographic evidence of loosening mechanism. J Arthroplasty. 1997;12:741–50.
66. Zehr RJ Enneking WF Scarborough MT. Allograft-prosthesis composite versus megaprosthesis in proximal femoral reconstruction. Clin Orthop Relat Res. 1996;322:207–23.
67. Bos G Sim F Pritchard D Shives T Rock M Askew L Chao E. Prosthetic replacement of the proximal humerus. Clin Orthop Relat Res. 1987;224:178–91.
68. Springfield DS Schmidt R Graham-Pole J Marcus RB Jr Spanier SS Enneking WF. Surgical treatment for osteosarcoma. J Bone Joint Surg Am. 1988;70:1124–30.
69. Wada T Usui M Isu K Yamawakii S Ishii S. Reconstruction and limb salvage after resection for malignant bone tumour of the proximal humerus. A sling procedure using a free vascularised fibular graft. J Bone Joint Surg Br. 1999;81:808–13.
70. Campanacci M Costa P. Total resection of distal femur or proximal tibia for bone tumours. Autogenous bone grafts and arthrodesis in twenty-six cases. J Bone Joint Surg Br. 1979;61:455–63.
71. Flint MN Griffin AM Bell RS Ferguson PC Wunder JS. Aseptic loosening is uncommon with uncemented proximal tibia tumor prostheses. Clin Orthop Relat Res. 2006;450:52–9.
72. Horowitz SM Lane JM Otis JC Healey JH. Prosthetic arthroplasty of the knee after resection of a sarcoma in the proximal end of the tibia. A report of sixteen cases. J Bone Joint Surg Am. 1991;73:286–93.
73. Jeon DG Kawai A Boland P Healey JH. Algorithm for the surgical treatment of malignant lesions of the proximal tibia. Clin Orthop Relat Res. 1999;358:15–26.
74. Myers GJ Abudu AT Carter SR Tillman RM Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89:1632–7.
75. Natarajan MV Sivaseelam A Rajkumar G Hussain SH. Custom megaprosthetic replacement for proximal tibial tumours. Int Orthop. 2003;27:334–7.
76. Ozaki T Kunisada T Kawai A Takahara Y Inoue H. Insertion of the patella tendon after prosthetic replacement of the proximal tibia. Acta Orthop Scand. 1999;70:527–9.
77. Plötz W Rechl H Burgkart R Messmer C Schelter R Hipp E Gradinger R. Limb salvage with tumor endoprostheses for malignant tumors of the knee. Clin Orthop Relat Res. 2002;405:207–15.
78. Katznelson A Nerubay J. Total femur replacement in sarcoma of the distal end of the femur. Acta Orthop Scand. 1980;51:845–51.
79. Mankin HJ Hornicek FJ Harris M. Total femur replacement procedures in tumor treatment. Clin Orthop Relat Res. 2005;438:60–4.
80. Marcove RC Lewis MM Rosen G Huvos AG. Total femur and total knee replacement. A preliminary report. Clin Orthop Relat Res. 1977;126:147–52.
81. Nerubay J Katznelson A Tichler T Rubinstein Z Morag B Bubis JJ. Total femoral replacement. Clin Orthop Relat Res. 1988;229:143–8.
82. Ward WG Dorey F Eckardt JJ. Total femoral endoprosthetic reconstruction. Clin Orthop Relat Res. 1995;316:195–206.
83. Morgan HD Cizik AM Leopold SS Hawkins DS Conrad EU 3rd. Survival of tumor megaprostheses replacements about the knee. Clin Orthop Relat Res. 2006;450:39–45.
84. Abboud JA Patel RV Donthineni-Rao R Lackman RD. Proximal tibial segmental prosthetic replacement without the use of muscle flaps. Clin Orthop Relat Res. 2003;414:189–96.
85. Damron TA. Endoprosthetic replacement following limb-sparing resection for bone sarcoma. Semin Surg Oncol. 1997;13:3–10.
86. Giurea A Paternostro T Heinz-Peer G Kaider A Gottsauner-Wolf F. Function of reinserted abductor muscles after femoral replacement. J Bone Joint Surg Br. 1998;80:284–7.
87. Taylor SJ Walker PS Perry JS Cannon SR Woledge R. The forces in the distal femur and the knee during walking and other activities measured by telemetry. J Arthroplasty. 1998;13:428–37.
88. Berbari EF Hanssen AD Duffy MC Steckelberg JM Ilstrup DM Harmsen WS Osmon DR. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998;27:1247–54.
89. Hanssen AD Rand JA. Instructional course lectures, the American Academy of Orthopaedic Surgeons - evaluation and treatment of infection at the site of a total hip or knee arthroplasty. J Bone Joint Surg Am. 1998;80:910–22.
90. McDonald DJ Capanna R Gherlinzoni F Bacci G Ferruzzi A Casadei R Ferraro A Cazzola A Campanacci M. Influence of chemotherapy on perioperative complications in limb salvage surgery for bone tumors. Cancer. 1990;65:1509–16.
91. Ruggieri P Pala E Henderson E Marulanda G White B Novella C Cheong D Letson GD Mercuri M. Primary reconstructions of the lower limb with modular prostheses: an analysis of implant survival comparing cemented versus uncemented stems. Read at the Combined Meeting of the International Society of Limb Salvage and Musculoskeletal Tumor Society; 2009 Sep 24-27; Boston, MA.
92. Jeys LM Grimer RJ Carter SR Tillman RM. Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am. 2005;87:842–9.
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93. Jeys LM Grimer RJ Carter SR Tillman RM. Risk of amputation following limb salvage surgery with endoprosthetic replacement, in a consecutive series of 1261 patients. Int Orthop. 2003;27:160–3.