Aseptic loosening of tumor endprostheses in distal femur after revision surgery: a retrospective study

doi:10.21203/rs.3.rs-2497437/v1

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Research Article

Aseptic loosening of tumor endprostheses in distal femur after revision surgery: a retrospective study

https://doi.org/10.21203/rs.3.rs-2497437/v1

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published 31 May, 2023

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Background: More patients are having revision surgery because of aseptic loosening of tumor prostheses in distal femur, but the revision failure rate is also increasing, which is mainly due to the recurrence of aseptic loosening. The purpose of this study was to analyze the risk factors for recurrence of aseptic loosening after revision surgery of tumor prosthesis in the distal femur.

Method: A retrospective analysis was performed on 23 patients who had revision surgery for distal femur prosthesis due to aseptic loosening between June 2002 and June 2021. They were divided into two groups based on the condition of the prostheses after revision surgery: loosening group and control group. After the initial replacement, length and diameter of the prosthetic intramedullary stem were measured. The osteotomy length, femoral length and diameter, femoral intramedullary stem diameter, hip–knee–ankle angle (HKAA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and so on were measured as well. Following that, statistical analysis was performed.

Results: Patients in the loosening group had statistically significant differences in the ratio of prosthesis length to femur length (71.89±6.62) and the ratio of intramedullary stem diameter to medullary cavity diameter (25.50±6.90) (P < 0.05) when compared to the control group. The HKAA (175.58°±2.78°), mLDFA (94.42°±2.57°), and the deviation angle between the force line of the lower limb and the longitudinal axis of the tibial prosthesis (2.23°±1.09°) in the loosening group were significantly different from those in the control group (P < 0.05) on postoperative radiographs of the entire length of the lower limbs. The lowest score in intramedullary manubrium I indicated less osteolysis, while the highest score in intramedullary manubrium Ⅲ indicated the most serious osteolysis, and the difference was statistically significant (P < 0.05).

Conclusions: We conclude that using longer and thicker intramedullary stems can effectively reduce the incidence of aseptic loosening, and that using the original prosthesis carefully can reconstruct the standard line of lower limb force. The distal segment of the intramedullary stem is more prone to osteolysis and should be closely follow-up after surgery.

revision surgery

distal femur

tumor prosthesis

aseptic loosening

retrospective study

Tumor segmental resection and prosthesis replacement is a critical treatment method for limb tumors[1, 2]. Because bone tumors are more common in the distal femur[3-6], the design of tumor knee prosthesis and tumor prosthesis replacement in the distal femur are well developed. However, as patients' survival times and life expectancies increase[7], the incidence of mechanical complications such as aseptic loosening and structural failure rises[8]. Henderson classified complications into five types[9], with aseptic loosening being the most common[1, 10, 11]. More patients are having prosthesis revision surgery because of aseptic loosening, but the revision failure rate is also increasing[12-15],which is mainly due to the recurrence of aseptic loosening[16]. We also found these problems in the revision of distal femur prosthesis. Some patients experienced aseptic loosening after the first revision surgery and required revision. Repeated revision surgery not only put patients under a lot of physical, psychological, and financial stress, but it also made surgery more difficult because of anatomical position dislocation, thin bone, and soft tissue contracture caused by repeated surgery. According to literature studies, revision prostheses have more complications than initial replacement prostheses[17, 18]. As a result, reducing secondary revision surgery and paying attention to the long-term effect of prostheses is a huge challenge for bone oncologists[19].

Aseptic loosening all occurred on the femur side in patients with distal femur bone tumors who underwent tumor segmental resection and tumor prosthesis replacement, and no cases of aseptic loosening of tibial prosthesis have been observed so far. The key structure connecting the prosthesis to the femur is the intramedullary stem on the femoral side[20]. The stability of the tumor prosthesis is affected by the connection between the intramedullary stem and the femur. Therefore, intraoperative adaptation of the intramedullary stem is critical to the success of revision surgery. However, there is no study as we know that answer questions as following: how to choose the prosthetic intramedullary stem in revision surgery? Should the original intramedullary stem be used? Should a longer intramedullary stem be used? Or should a thicker intramedullary stem be used? This is an urgent clinical problem that must be addressed.

In this study, we examined the patients' X-ray films after the revision surgery, measured the length of the prosthetic stem, diameter of the stem, and deviation of the force line of the lower limbs, investigated the causes of aseptic loosening of the revision prosthesis and made recommendations to reduce the incidence of aseptic loosening.

1.1 Inclusion and exclusion criteria

Inclusion criteria: 1) The patient had previously undergone tumor segmental resection and prosthesis replacement due to bone tumors in the distal femur, and the fixation method was bone cement fixation; 2) Revision surgery was performed due to aseptic loosening, and the prosthesis was fixed with bone cement; 3) The appearance of aseptic loosening was supported by clinical symptoms and imaging studies; 4) There are full-length anteroposterior X-rays of both lower limbs after revision surgery.

Exclusion criteria: 1) Existence of tumor recurrence, periprosthetic infection, structural failure (prosthetic fracture, periprosthetic fracture, polyethylene liner wear, and so on), soft tissue failure (joint dislocation, incision aseptic dehiscence, and so on.); 2) Full-length anteroposterior X-ray film of both lower limbs was not standard and could not be effectively measured; 3) The last operation was followed up on in less than a year.

1.2 Patients

A total of 23 patients who underwent revision surgery of distal femur prosthesis due to aseptic loosening from June 2002 to June 2021 in PLA's 960th Hospital were selected. The mean age of the patients was (44.39±12.41) years old, including 15 males and 8 females, with a male-to-female ratio of 1.875: 1. There were 13 cases of giant cell tumor of bone, 7 cases of osteosarcoma, 2 cases of malignant fibrous histiocytoma, and 1 case of chondrosarcoma. 7 patients underwent chemotherapy and 7 patients had leg unequal length (affected limb shortening > 3cm) before revision. At the end of the study, all 23 patients survived, including 1 patient who underwent knee arthrodesis 5 years after revision surgery due to aseptic loosening. 9 of the 23 patients had aseptic loosening after revision surgery and were, therefore, included in the loosening group. The remaining 14 patients in this study had no complications such as aseptic loosening by the end of the follow-up period and were classified as control group.

1.3 Prosthesis

All of the knee prostheses were tumor-type, with 15 customized prostheses (manufactured by Beijing Lidakang Company) and 8 combined prostheses (provided by Shandong Weigao Company). There were 2 fixed hinge knee prostheses and 21 rotary hinge knee prostheses. There were 2 curved stem cases and 21 straight stem cases. Bone cement was used to secure all prostheses.

1.4 Surgical methods

The patient was placed in a supine position after a successful general anesthesia, and the surgical area was routinely disinfected, draped, and covered with a protective film. The original surgical incision was made and extended to the proximal end of the femur. The skin, subcutaneous tissue and fascia layer were cut layer by layer, the scar tissue around the knee joint was cut, the joint capsule was cut medial to the patellar, the space between the vastus lateralis and the rectus femoris muscle was separated, the intermedius femoris muscle was split, and the femoral shaft and the artificial knee joint were exposed by pushing and stripping. It was discovered that formation of grayish yellow boundary membrane tissue around the prosthesis, obvious loosening of the femur end, abnormal activity, the presence of bone cement and cortical space, the formation of callus at the distal femur end, covering part of the stem. After the dislocation of the knee prosthesis, the femur end was lifted retrograde, the callus around the prosthesis was chiseled out, and the femoral bone marrow stem prosthesis was removed. The intramedullary boundary membrane tissue and residual bone cement were thoroughly removed with curettage, and the proximal end was expanded along the longitudinal axis of the femoral shaft to the position of the intertrochanteric fossa. After the tibia was treated, the tibia prosthesis was retrogradely punched out in the medial foramen of the tibia nodule and the bone cement in the tibia medullary cavity was further scraped. After the distal medullary cavity was expanded, the hydrogen hydroxide and normal saline were rinsed repeatedly, the medullary cavity and incision were rinsed with pulse pressure, and the bone cement was injected into the bone marrow cavity of the tibia and femur, new tibia prosthesis and femur prosthesis of appropriate length and thickness were inserted. Following the solidification of the bone cement, the knee prostheses were reset, the polyethylene meniscus pad was placed, and the flexion and extension mobile knee joints demonstrated good force lines and activities. After the hemostatic was completely removed, hydrogen peroxide and a large amount of normal saline were rinsed, patella was trimmed, the instruments and dressing were checked, two drainage tubes were placed, the surgical incision was closed layer by layer, and sterile dressing was bound and fixed.

1.5 Imaging evaluation

1. The length and diameter of the intramedullary stem of the prosthesis after the initial replacement.

2. Osteotomy length, femoral length, extramedullary length of femoral prosthesis, femoral prosthesis intramedullary stem length, intramedullary stem diameter, femoral diameter, HKAA, mLDFA, mLDFA, the deviation angle between the force line of the lower limb and the longitudinal axis of the femoral prosthesis, and the deviation angle between the force line of the lower limb and the longitudinal axis of the tibial prosthesis after the revision surgery.

1.6 Measurement method

The standard full-length anteroposterior X-ray of both lower limbs of the patient was measured using Picture Archiving and Communication System (PACS, Qingdao Medicom Digital Engineering Company) with built-in length and angle. During measurement, the femoral head center (concentric circle method), the knee joint center (the midpoint of the intercondylar fossa of the femur and the tibial crest), and the ankle joint center (the midpoint of the line between the surface of the medial and lateral malleolus through the articular surface of the distal tibia) were marked.

Statistical analysis

Statistical analysis was performed using SPSS 25.0 (IBM Corporation, USA) statistical software. Normally distributed measurement data were expressed as mean ± standard deviation ( ±S), and analyzed using the T test on two independent samples; non-normally distributed measurement data were analyzed using the Kruskal-Wallis multiple independent samples method. Fisher's chi-square test was used to analyze the count data.

2.1 General result

5 patients (55.56%) in the loosening group had unequal lower limb length, which was statistically significant difference compared to 2 patients (14.29%) in the control group (p < 0.05).

There was no significant difference in age between the loosening group (44.44 ± 14.49) years and the control group (44.36 ± 11.47) years (p > 0.05). The time interval between initial replacement and initial revision in the loosening group was (114.69 ± 94.79) months, which was not significantly different from that in the control group (129.22 ± 86.48) months (p > 0.05). 2 patients in the loosening group (22.22%) and 5 patients (35.71%) in the control group received chemotherapy, which didn’t show statistically significant difference (p > 0.05) between two groups(Table 1).

Table 1

Comparison of general data
	Loosening group	Control group	χ²/T	P
Age[years,(\(\stackrel{-}{x}\)±S)]	44.44 ± 14.49	44.36 ± 11.47	0.016	0.987
Time interval between primary replacement and primary revision [months, (\(\stackrel{-}{x}\)±S)]	114.69 ± 94.79	129.22 ± 86.48	-0.756	0.477
Existence of unequal length of lower limbs [Number of cases, (%)]	5(55.56)	2(14.29)	19.398	0.001
Receiving chemotherapy [number of cases, ( %)]	2(22.22)	5(35.71)	0.471	0.657

2.2 Risk factors for aseptic loosening of prostheses

Compared with control group, patients in loosening group had statistical differences in the ratio of prosthesis length to femur length (71.89 ± 6.62) and the ratio of intramedullary stem diameter to medullary cavity diameter (25.50 ± 6.90) (p < 0.05). The proportion of femoral osteotomy and the length ratio of the extramedullary and intramedullary parts of the femoral prosthesis did not differ statistically.

In terms of the increase proportion of length and diameter of the intramedullary stem during the initial replacement and prosthesis revision, the increase proportion of loosening length (3.61 ± 7.23) and diameter (3.95 ± 4.59) were not statistically significant difference compared with the control group (p > 0.05) (Table 2).

Table 2

Comparison of prosthesis measurements between the loosening group and control group
	Loosening group	Control group	T/Z	P
Osteotomy ratio[%,(\(\stackrel{-}{x}\)±S)]	46.06 ± 0.11	44.24 ± 28.08	0.307	0.762
The length ratio of the extramedullary part to the intramedullary part of the femoral prosthesis [%, (\(\stackrel{-}{x}\)±S)]	96.27 ± 28.08	108.51 ± 74.38	-0.469	0.644
Prosthesis length/femur length[%, (\(\stackrel{-}{x}\)±S)]	71.89 ± 6.62	80.75 ± 8.39	-2.672	0.014
Femoral intramedullary stem diameter/medullary cavity diameter [%, (\(\stackrel{-}{x}\)±S)]	25.50 ± 6.90	35.06 ± 12.18	-2.457	0.014
Growth ratio of intramedullary stem length ^*[%, (\(\stackrel{-}{x}\)±S)]	3.61 ± 7.23^**	10.45 ± 21.23^**	-0.615	0.551
Growth ratio of intramedullary stem diameter [%, (\(\stackrel{-}{x}\)±S)]	3.95 ± 4.59^**	28.78 ± 26.71^**	-1.804	0.099
* Growth ratio= (length of prosthesis after revision - length of prosthesis after initial replacement) / length of prosthesis after initial replacement. ** The original prosthesis was re-implanted in 4 patients, so the growth rate was 0, which increased the dispersion of the data, but it conformed to the normal distribution.

The HKAA (175.58°±2.78°), mLDFA (94.42°±2.57°), and the deviation angle between the lower limb force line and the tibial segment prosthesis force line (2.23°±1.09°) in the loosening group were significantly different from those in the control group (p < 0.05), according to postoperative X-ray films of the full length of the lower limbs(Table 3).

Table 3

Comparison of lower limb force lines between the loosening group and control group
	Loosening group	Control group	T	P
HKAA[°, (\(\stackrel{-}{x}\)±S)]	175.5 ± 2.78	177.50 ± 1.25	-2.268	0.034
mLDFA[°, (\(\stackrel{-}{x}\)±S)]	94.42 ± 2.57	92.76 ± 1.24	2.129	0.045
mMPTA[°, (\(\stackrel{-}{x}\)±S)]	91.50 ± 1.42	91.14 ± 0.78	0.777	0.446
The deviation angle between the force line of the lower limb and the l longitudinal axis of the femoral prosthesis [°, (\(\stackrel{-}{x}\)±S)]	5.88 ± 1.90	6.75 ± 1.78	-1.109	0.280
The deviation angle between the force line of the lower limb and the longitudinal axis of the tibial prosthesis [°, (\(\stackrel{-}{x}\)±S)]	2.23 ± 1.09	0.83 ± 0.54	3.596	0.004

Binary logistic regression analysis was performed on the following single factors. We found that the ratio of extramedullary length to the intramedullary stem length greater than 1, the ratio of the length of the prosthesis to the length of the femur less than 0.8, the ratio of the diameter of the stem to the diameter of the femur less than 30%, and the existence of genu valgus and genu varus after surgery were not risk factors for aseptic loosening of prostheses(Table 4).

Table 4

Logistic regression analysis of risk factors affecting prosthesis aseptic loosening
Variable	OR ratio	95% CI	P Value
Extramedullary length/intramedullary stem length greater than 1	0.800	0.149, 4.297	0.795
Prosthesis length/femur length less than 0.8	4.467	0.702, 31.036	0.111
Intramedullary stem diameter/femur diameter less than 30%	0.167	0.016, 1.718	0.132
Knee valgus or genu varus after surgery ^*	5.000	0.821, 30.461	0.081
* Knee varus was defined as a postoperative hip-knee-ankle angle < 177°, and genu valgus was defined as a postoperative hip-knee-ankle angle > 183°

2.3 Bone changes around the intramedullary stem during aseptic loosening

We analyzed imaging on X-ray films of the femoral intramedullary stem in 13 patients undergoing prosthetic revision, with 8 groups after replacement to before revision surgery and 5 groups after first to second revision surgery. The X-ray films in the same group were set to the same ratio and gray scale, and the intramedullary stem was divided into three equal areas I, II, and III along the prosthesis's longitudinal axis (Fig. 1). During the progression of aseptic loosening, bone changes in various regions of the intramedullary stem were observed. X-ray films revealed that all cases had visible bone loss around the prosthesis, which was accompanied by osteolysis in some cases and cortical bone dissolution in others. Local or intraosseous bone resorption was defined as osteolysis[21]. Unilateral bone dissolution was defined as 1 point in the lateral cortex and 1 point in the medial bone. Table 5 showed the scores of 13 patients, and the scores were tested using a non-parametric test.

In this study, it was found that the score in area I of the intramedullary stem was the lowest, indicating less osteolysis, and the score in area III of the intramedullary stem was the highest, indicating the most severe osteolysis, and the difference was statistically significant (p <0.05).

Table 5

Kruskal-Wails H test for the scores of osteolysis zones I, II, and III
	I		III
osteolysis score	15.38	18.19	26.42
Kruskal-Wails H test	6.971
P	0.031

3.1 The importance of revision surgery

After revision surgery for tumor prostheses, aseptic loosening occurs again. Revision surgery should be actively performed without significant tumor factors affecting patients' life and health. According to Heyberger's study, prosthesis revision surgery could enable patients to achieve similar joint function to the initial replacement, while disease-specific and health-related outcomes were improved[22]. Despite the fact that revision surgery of tumor prosthesis is difficult and has a high failure rate[17], it remains the best option for patients seeking to save limbs and improve limb function[15]. Patients can still have good lower limb function after revision, which helps to improve their quality of life.

3.2 Influencing factors leading to aseptic loosening after prosthesis revision

In tumor prosthetic revision surgery, the lower extremity line of alignment is critical. At the apex of the intramedullary stem, the deviation of the anatomical axis and the line of force is very large, as is the resulting bending moment. The force line deviation of the prosthesis will increase the shear stress on the prosthesis and cause uneven distribution of conduction. Rubbing the apex of the intramedullary stem against the femur increased the possibility of the prosthesis protruding through the cortex and causing aseptic loosening. Force line deviation and aseptic loosening are mutually influencing processes. Aseptic loosening of the prosthesis will obviously aggravate gravity line deviation, and force line deviation will aggravate friction between the prosthesis and the femur, aggravate the fretting of the prosthesis and the formation of wear particles, and accelerate the occurrence of aseptic loosening. This is also why aseptic loosening is more common in patients with lower limb shortening. The primary cause of shortened limbs is osteolysis caused by aseptic loosening, which causes the prosthesis to settle and shift.

Aseptic loosening is affected by prosthesis length and diameter. Longer femur prostheses, particularly intramedullary stems, provide more bone-cement-prosthesis contact area, which improves stability. Shorter femur prostheses has shorter arms. The ratio of extramedullary part to intramedullary of the prosthesis was 96.27%±28.08%, which was not statistically different from that of 108.51%±74.38% in the loosening group. We believed this was due to the higher proportion of osteotomies in revision surgery. A larger proportion could result in a longer moment arm, and the stability of the prosthesis was dependent on the extension of the moment arm's distal fixation, as well as the insertion and locking of the internal wall of the femoral bone marrow cavity. Longer prosthetic lengths could be obtained by lengthening the intramedullary stem and reducing the length of the extramedullary part.

Aseptic loosening is a multifactorial interaction involving both mechanical and biological factors (prosthesis wear, fretting, stress shielding, structural design, and so on) and biological factors (chronic inflammatory response, osteolysis-related cytokine release and enzyme activation). Bone cement has poor torsion resistance, is non-degradable, and has no osteoinductive and conductive capabilities. The literature suggested that bone cement wear debris may activate T cells and macrophages around the prosthesis, as well as osteoclasts, causing osteolysis[23]. Bergin et al. discovered that a larger intramedullary stem/femur diameter ratio could reduce the rate of prosthesis loosening[24], and our study found a similar result, with a diameter of 35.06% ± 12.18% in the control group and 25.50% ± 6.90% in the loosening group. The larger diameter of the intramedullary stem allowed it to completely fill the femoral medullary cavity, and a good press fit reduced prosthesis fretting. Simultaneously, the larger diameter of the intramedullary stem reduced the amount of bone cement used and the rate at which it dissolves.

Chemotherapy had no effect on the aseptic loosening of the prosthesis, according to the findings of this study. Most studies assumed that chemotherapy would inhibit the growth of biologically fixed bone and affect the prosthesis's stability[25]. Pugh's study, on the other hand, concluded that the incidence of aseptic loosening of bone cement prostheses was low regardless of whether chemotherapy was administered[26]. As a result, we believed that chemotherapy will not cause cemented prosthesis loosening.

3.3 How to reduce the failure rate of prosthesis revision

Patients' survival rates and survival times have been significantly improved with adjuvant support such as neoadjuvant chemotherapy and targeted tumor therapy[27]. Meanwhile, patients have increasingly high expectations for postoperative limb function, which places high demands on the service life of prostheses. It is reflected not only in the prosthesis design, materials, processing technology, and so on, but also in the surgeon's operation skills.

When revising cemented distal femur prostheses, we recommend using longer, and thicker intramedullary stems. In theory, an intramedullary stem of sufficient length and diameter can completely fill the medullary cavity, fully press fit, and reduce prosthetic fretting. It is recommended to use the longest and thickest intramedullary stem possible while preserving sufficient cortical bone, as well as an intramedullary stem that fits the anatomical structure of the femoral medullary cavity, such as a curved stem. We were opposed to using the original prosthesis in revision surgery. This study included 4 patients who used the original prosthesis, 3 of whom developed aseptic loosening again after revision surgery. Meanwhile, a study on the increase ratio of length and diameter of the intramedullary stalk revealed that a higher increase ratio was beneficial to the prosthesis's stability.

The application of modern bone cement filling techniques can help to reduce the rate of prosthesis loosening after surgery[28].

When the prosthesis is inserted, proper alignment of the lower limb must be restored. Correct reconstruction of lower limb alignment is a critical step for long-term prosthesis stability and patient limb function recovery[29, 30]. The deviation of the anatomical axis and force line was significant at the tip of the intramedullary stem, as was the resulting bending moment. The skewed prosthetic force line would increase and unevenly distribute stress on the prosthesis, resulting in stress concentration and stress shielding, which would further friction the apex of the intramedullary stem with the femur and aggravate prosthetic fretting, leading to aseptic loosening. As a result, positioning the prosthesis along the force line is critical to the success of revision surgery.

3.4 Femoral osteolysis after initial replacement and before revision surgery

Periprosthetic osteolysis is required for aseptic loosening[31], but mechanical stress/strain is also required to cause movement of the prosthesis. A variety of factors contributed to aseptic loosening, including stress occlusion, stress concentration, prosthesis fretting at the prosthesis-bone cement interface, and wear particles. The main manifestations were the formation of a clear zone around the intramedullary stem due to a large number of osteolysis. For the study of bone changes, 13 groups of intramedullary peristem X-ray films were chosen after replacement and before revision. We found that osteolytic gaps at the prosthesis-cement interface in many sets of X-ray films, which widened and expanded with the progression of aseptic loosening, eventually leading to implant loosening. Osteolysis was found less frequently near the apex of the intramedullary stem, more frequently at the distal end of the intramedullary stem, and only in the distal segment of the intramedullary stalk did osteolysis in the lateral cortex occur. Because osteolysis is triggered by T cells activated by bone cement, it is more likely to occur in bone cement-filled areas. During long-term wear, bone cement produces particles and debris, which can cause inflammation and osteoclast activation[32], resulting in osteolysis, which can be linear, i.e. evenly distributed around the prosthesis, or localized, i.e. forming islands of bone loss closely associated with the prosthesis. Both linear and localized osteolysis will aggravate the prosthesis Micro-movement, leading to aseptic loosening.

All of the prostheses in this study were fixed with bone cement, which achieved immediate stability and function in the early and middle stages. However, bone cement was prone to fatigue brittleness and had a high incidence of aseptic loosening in the middle and late stages, which had been reported to be around 30% in 10 years[33, 34]. Although the biological stem's short-term function was inferior to that of the cement stem, once bone ingrowth and osseointegration were achieved, the biological stem's later stability would be superior to that of the cement stem[35]. It should be noted that the bio-fixed prosthesis stem's initial stability was critical[36, 37]. If initial stability was not achieved, fretting would result in the formation of fibrous tissue and thus aseptic loosening. As a result, for bio-fixed prosthesis, care should be taken to ensure adequate intraoperative compression and postoperative support fixation to ensure initial postoperative stability.

X-ray films of patients with aseptic loosening after revision showed that the ratios of prosthesis length to femur length and intramedullary stem diameter to medullary cavity diameter were smaller than those of patients without loosening. Meanwhile, patients with loosening had different degrees of lower limb alignment than patients without loosening, but these were not risk factors for the recurrence of aseptic loosening. However, we continued to believe that using longer and thicker intramedullary stems effectively reduced the incidence of aseptic loosening, and that using the original prosthesis carefully can reconstruct the standard line of lower limb force. The distal segment of the intramedullary stem was more prone to osteolysis and should be monitored closely after surgery.

HKAA hip–knee–ankle angle

mLDFA mechanical lateral distal femoral angle

mMPTA mechanical medial proximal tibial angle

Acknowledgements

Not applicable.

Authors’ contributions

LZM, XM, ZK and YXC designed the study. LZM drafted the manuscript. LZM, HZW and MZK accumulated the data. LZM and SYS analyzed the data. All authors read and approved the fnal manuscript.

Funding

No funds

Availability of data and materials

The dataset supporting the conclusions of this article is available on request—

please contact the corresponding author.

Ethics approval and consent to participate

This study was assessed by the Institutional Review Board of The 960th Hospital of the PLA and approved on compliance with the rules of ethics and scientific guide-lines. Informed consent was obtained from the patient’s representative for the publication of this work.

Consent for publication

Consent for publication has been obtained from all participated patients in the study.

Competing interests

The authors declared that they have no competing interests.

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No competing interests reported.

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published 31 May, 2023

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Aseptic loosening of tumor endprostheses in distal femur after revision surgery: a retrospective study

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Journal Publication

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Abstract

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Introduction

Materials And Methods

Results

2.1 General result

2.2 Risk factors for aseptic loosening of prostheses

2.3 Bone changes around the intramedullary stem during aseptic loosening

Discussions

3.1 The importance of revision surgery

3.2 Influencing factors leading to aseptic loosening after prosthesis revision

3.3 How to reduce the failure rate of prosthesis revision

3.4 Femoral osteolysis after initial replacement and before revision surgery

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1