CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 393, pp. 264–271
Soft Tissue Reconstruction of
Megaprostheses Using a Trevira Tube
Georg Gosheger, MD*; Axel Hillmann, MD*; Norbert Lindner, MD*;
Robert Rödl, MD*; Christiane Hoffmann, MD*; Horst Bürger, MD**;
and Winfried Winkelmann, MD*
In soft tissue reconstruction of megaprostheses,
the reattachment of soft tissue and joint cap-
sules is essential. Sixty-nine megaprostheses
were implanted and a trevira tube was applied
to support reconstruction of the capsule and soft
tissue. In cases of proximal femur replacement
(33 patients), total femur replacement (five pa-
tients), and proximal humerus replacement (16
patients), the trevira tube allowed for recon-
struction of the capsule and refixation of the
muscles and helped to minimize dislocation. In
cases of proximal tibia replacement (seven pa-
tients), arthrodesis of the knee (three patients),
total knee replacement (two patients), and distal
femur replacement (three patients), the trevira
tube allowed for attachment of muscle flaps and
extensor apparatus. Dislocation was observed in
two of 54 patients who had proximal femur re-
placements. No dislocation was observed in pa-
tients with a total femur endoprosthesis or a
proximal humerus endoprosthesis. The trevira
tube also was used to attach the gastrocnemius
From the *Department of Orthopaedics, and **Gerhard-
Domagk-Institute of Pathology, Westfälische Wilhelms-
Universität, Münster, Germany.
Reprint requests to Georg Gosheger, MD, Department of
Orthopaedics, Westfälische Wilhelms-Universität, Albert-
Schweitzer-Str. 33, 48149 Münster, Germany.
Received: April 17, 2000.
Revised: November 20, 2000; January 11, 2001.
Accepted: March 27, 2001.
264
© 2001 Lippincott Williams & Wilkins, Inc.
muscle in patients with a proximal tibia endo-
prosthesis and to reattach the rotator cuff in
patients with a proximal humerus prosthesis.
There was no significant increase in the rate of
infection. The histopathologic findings in six pa-
tients showed tissue ingrowth into the tube.
Since the introduction of chemotherapy for
treatment of malignant bone tumors, the num-
ber of patients eligible for limb salvage after
wide resection of tumors has increased.2,17,33
A wide resection of the tumor usually results
in a large segmental defect. Different proce-
dures, mainly endoprosthetic reconstruction and
allograft reconstruction, are well established
and have been described in the literature.1,11,21,23
In the 1970s and 1980s, custom-made endo-
prostheses were implanted most frequently.19,31
Because of the disadvantages of custom-made
prostheses including the time lost in producing
the device, the disadvantages which arose in-
traoperatively, and the poor adaptability of the
endoprosthesis, some orthopaedic surgeons be-
gan using modular endoprosthetic systems.3,5–7
The followup of patients with an endopros-
thetic replacement yielded numerous problems.
In addition to complications like aseptic loos-
ening, infection, and material failure, disloca-
tions of the unconstrained endoprosthesis were
reported.16,25,30 Proximal femur replacement is
Number 393
December, 2001 Reconstruction Using a Trevira Tube 265

thought to result in the most dislocations be-
cause of the lack of abductor force and the lack
of capsule.25,30
To avoid dislocation of an unconstrained
endoprosthesis (proximal femur replacement,
total femur replacement, and proximal humerus
replacement), a special trevira tube (polyethyl-
ene terephthalate) was developed. The trevira
tube is a knitted tube that is part of the Modular
Tumor and Revision System (Mutars®, Im-
plantcast Corp, Buxtehude, Germany). It is
characterized by a porous structure of 200
m
and a tensile strength of 4000 N.13 This tube is
attached, in cases of intraarticular resection, to
the rest of the capsular structures (Fig 1A), or to
the remaining bone using Mitek® Super Anchor
(Ethicon, Mitek Division, Norderstedt, Ger-
many) in cases of extraarticular resection. The
tube is fixed to the megaprosthesis and the mus-
cles are reattached to the prosthesis (Fig 1B). A
nonabsorbable suture is used for all attach-
ments to the trevira tube.
In proximal femoral replacement, refixa-
tion of the iliopsoas muscle and the gluteal
muscles is especially important for good post-
operative function. In proximal tibia replace-
ment, knee arthrodesis, total knee replace-
ment, and distal femur replacement, the trevira
tube allows reattachment of the extensor ap-
paratus (Fig 2A) and muscular structures, es-
pecially the gastrocnemius flap (Fig 2B).
This study retrospectively reviewed the
outcome of surgical replacements using the
Mutars® trevira tube for reconstruction. In
particular, the rate of dislocation, the func-
tional outcome, and the rate of infection were
observed and a histopathologic examination
of the ingrowth in six patients was done.
MATERIALS AND METHODS
Between March 1993 and November 1998, 69 pa-
tients (43 males, 26 females) with a mean age of 42.5
years (range, 10–76 years) received a megaprosthe-
sis implant in combination with reconstruction using
a trevira tube (Table 1).

Fig 1A–B. (A) Schematic draw-

ing of a proximal femur replace-
ment using a Mutars proximal fe-
mur replacement. Nonabsorbable
sutures are fixed to the remaining
capsular structures. (B) The tre-
vira tube is attached to the reten-
tion rings of the prosthetic device
using nonabsorbable sutures. The
abductor muscles then can be
reattached to the trevira tube. B
 Clinical Orthopaedics
266 Gosheger et al and Related Research

Fig 2A–B. (A) In proximal tibia

replacement, the patellar ten-
don can be reattached to the
trevira tube, again using nonab-
sorbable sutures in extension
position. (B) The gastrocnemius
flap is attached to the trevira
tube and to the patellar tendon
providing good soft tissue cov-
B
erage of the endoprosthesis.

TABLE 1. Patients’ Information

69 Patients Followup (9–78 months; mean, 31.6 months)

Entity Osteosarcoma 22 Soft tissue sarcoma 7

Chondrosarcoma 14 Metastasis of carcinoma 10
Ewing’s sarcoma 8 Others 8
Gender Male 43 Female 26
Age 10–76 (mean, 42.5) years
Replacement Proximal femur 33
Total femur 5
Proximal humerus 16
Proximal tibia 7
Arthrodesis of the knee 3
Total knee 2
Distal femur 3
MSTS score Proximal or total femur 30%–93%; mean, 67.5%
Proximal tibia or distal femur or total knee 43%–100%; mean, 78.2%
Proximal humerus 46%–83%; mean, 70.4%
Complications Dislocation hip or humerus 2/54 (3.7%)
Infection 6 (8.7%)
Aseptic loosening 1 (1.4%)
Periprosthetic fracture 1 (1.4%)

MSTS score  Musculoskeletal Tumor Society score.

Number 393
December, 2001
The indication for segmental replacement was a
bone defect after resection of malignant tumors in-
cluding osteosarcoma (22 patients), chondrosarcoma
(14 patients), Ewing’s sarcoma (eight patients), soft
tissue sarcoma (seven patients), metastasis of carci-
noma (10 patients), and other indications including
one lymphoma, one rheumatic disease with failed en-
doprosthesis of the humerus, one fibrous dysplasia,
one periprosthetic fracture of a knee prosthesis, one
pseudarthrosis after periprosthetic fracture after total
hip replacement, two failed megaprostheses of the
proximal tibia, and one failed megaprosthesis of the
proximal femur (eight patients).
The mean followup was 31.6 months with a
range from 9 to 78 months (Table 1). All patients
with an osteosarcoma or sarcoma received chemo-
therapy or combined chemotherapy and radiother-
apy (nine patients) before surgery. Six patients with
bone metastases were treated postoperatively with
radiotherapy. One patient with soft tissue sarcoma
was treated with adjuvant chemotherapy and radio-
therapy and one patient was treated with chemother-
apy only. The other patients with soft tissue sarco-
mas required surgery only. Forty-eight neoplasias
were resected intraarticularly with wide margins, 12
were resected extraarticularly with wide margins,
one was resected with marginal margins, and two
metastases of a carcinoma were resected with in-
tralesional margins. A proximal femur replacement
was done in 33 patients; in two patients proximal
femoral replacement was combined with a pelvis re-
construction because of an intraarticular chon-
drosarcoma. Total femur replacement was done in
five patients and proximal humerus replacement was
performed in 16 patients. Furthermore, endoprosthe-
ses were implanted after proximal tibia replacement
(seven patients), arthrodesis of the knee (three pa-
tients), total knee replacement (two patients), and
distal femur replacement (three patients). Forty-
eight megaprostheses were implanted without ce-
mentation and 21 were implanted using cement. The
length of the proximal humerus replacement ranged
from 6 to 20 cm (mean, 14.2 cm), for the proximal
femur replacement from 10 to 35 cm (mean, 19.75
cm), for the distal femur replacement from 16 to 30
cm (mean, 22.6 cm), for the total femur replacement
from 40 to 45 cm (mean, 44.3 cm), for the arthrode-
sis 22 cm, and for the total knee replacement 16 cm.
Perioperative antibiotics were given to 65 of 69 pa-
tients prophylactically.
The functional results of 65 patients were evalu-
ated according to the Musculoskeletal Tumor Soci-
Reconstruction Using a Trevira Tube 267
ety score10 for the following categories: pain, func-
tion, emotional acceptance, use of external support,
walking ability, gait, positioning of hand, manual
dexterity, and lifting ability. Clinical data were ob-
tained from the clinical charts, radiographs, and out-
patient clinical examination. In four of 69 patients,
a clinical examination and evaluation of the func-
tional result could not be done because the patients
came from abroad.
The ingrowth of fibrous tissue and the presence
of an inflammatory reaction were evaluated from
tissue sections (hematoxylin and eosin; elastica van
Gieson). Histologic analyses of specimens from six
patients who had revision surgery were done accord-
ing to the following procedures: The tissue was fixed
in formalin (4%; pH 7.0) and embedded in methyl-
methacrylate (Medim Corp, Buseck, Germany).
RESULTS
By using the trevira tube in proximal humerus
replacement, the complete rotator cuff was
reattached in 11 patients, only the subscapular
muscle was reattached in three patients, and
only the supraspinatus muscle could be reat-
tached in two patients.
In 21 patients with proximal femur replace-
ment, the hip abductors could be reattached
completely. In the other 10 patients, only a
tensor fascia lata or a musculus vastus reat-
tachment could be done. In total femur re-
placement, the abductors could be reattached
in all patients.
A gastrocnemius flap was applied in six of
seven patients requiring a proximal tibia re-
placement, in all patients (three patients) with
knee arthrodeses, and in one patient with a to-
tal knee replacement. One total knee replace-
ment was done without a gastrocnemius flap.
In distal femur replacement, the trevira tube
was used to reconstruct the extensor appara-
tus. In all patients with a reconstruction of the
extensor muscle (seven patients with a proxi-
mal tibia replacement, three patients with a
distal femoral replacement, and two patients
with a total knee replacement), there was no
avulsion of the extensor tendon.
In proximal humerus replacement, all pa-
tients were immobilized with a Gilchrist ban-

268 Gosheger et al
dage for 4 weeks. In proximal tibia replace-
ment and total knee replacement, all patients
were immobilized with a cast for 6 weeks af-
ter surgery to guarantee tissue ingrowth of the
extensor apparatus into the trevira tube.
For the proximal femur replacement, im-
mobilization was necessary in seven patients
because of multiple muscle flaps and a cast
was applied for 4 weeks. All other patients
were able to mobilize after surgery. One pa-
tient with a total femur replacement was im-
mobilized with a cast because of multiple reat-
tachments of muscle flaps.
Only two dislocations occurred in 54 un-
constrained endoprostheses (3.7%) (Table 1).
Both dislocations occurred in patients with a
proximal femur replacement with a cemented
acetabular component. The two dislocations
were not caused by poor position of the ac-
etabular component, but in one case because
of wrong torsion, in the other case because of
a small cup. There were no dislocations in pa-
tients with a bipolar cup and a trevira tube.
One of these patients was a 70-year-old
woman with metastasis of her breast cancer.
The other patient was a 60-year-old man with
lymphoma. Both patients were treated surgi-
cally with open revision and repositioning.
The 60-year-old man subsequently had an in-
fection develop. In all other unconstrained re-
placements (five patients with a total femur re-
placement, 16 patients with a proximal
humerus replacement), no dislocation oc-
curred when using the trevira tube.
No revision was necessary because of early
infection, but in six patients with late infec-
tions, revision surgery was required (mini-
mum, 4 months; maximum, 24 months; mean,
11.8 months). The late infections were ob-
served in three patients with proximal femur
replacements, one patient with distal femur re-
placement, one patient with total knee re-
placement, and one patient with proximal tibia
replacement. One patient with lymphoma had
an immunodeficiency and one patient with a
total knee replacement without a gastrocne-
mius flap had emergency surgery because of a
periprosthetic fracture. No predisposing factor
Clinical Orthopaedics
and Related Research
could be determined as the cause of infection
in the other patients. The prosthetic device
was replaced and limb salvage was possible in
all patients. The rate of infection in patients
with a trevira tube was compared with the rate
of infections in patients with a Mutars® endo-
prosthesis without a trevira tube (76 patients).
There was no significant increase in the rate of
infection (p  0.46; chi square test).
Aseptic loosening was observed in one dis-
tal femur replacement. The trevira tube was
used in three patients with a distal femur re-
placement for reconstruction of the extensor
apparatus. One patient with a proximal
humerus replacement fell on his shoulder and
sustained a periprosthetic fracture.
In 65 patients, a clinical examination in-
cluding evaluation of the Musculoskeletal Tu-
mor Society score was possible. Patients with
a proximal femur replacement or a total femur
replacement reached a mean active flexion of
80.4 (range, 50–115) in the hip. For active
extension, the range of motion (ROM) was 0
to 15 (average, 5.3). Range of motion of in-
ternal rotation (average, 15.7; range, 10–35)
and external rotation (average, 25; range,
15–40), and abduction (average, 15.7;
range, 0–30) and adduction (average, 20.4;
range, 10–30) were satisfactory. A positive
Trendelenburg sign was found in 20 of 38 pa-
tients. Two crutches were used by 10 of 38 pa-
tients and one cane was used by eight of 38 pa-
tients. Twenty patients did not use any
external support. The mean overall functional
outcome of patients with a proximal or total
femur replacement was 67.5% (range,
30%–93%) according to the Musculoskeletal
Tumor Society score.
The mean extensor lag of patients with re-
construction of the extensor apparatus (three
patients with a distal femoral replacement,
seven patients with a proximal tibia replace-
ment, and two patients with a total knee re-
placement) was 7.5 (range, 0–30). Extensor
force was determined as the angle of extension
that the patient could lift the tibia against grav-
ity. No avulsion of the extensor tendon was
observed. The active ROM for flexion was 70
Number 393
December, 2001
to 100 (average, 85.5). The mean overall
functional outcome of patients with recon-
struction of the extensor apparatus was 78.2%
(range, 43%–100%) according to the Muscu-
loskeletal Tumor Society score.
In patients with a proximal humerus re-
placement, the mean active abductor motion
against gravity was 37.5 (range, 0–75), the
anteversion was on average 35.0 (range,
5–79), and active ROM of internal rotation
was on average 15.2 (range, 10–35) and ex-
ternal rotation was on average 25.2 (range,
15–45), but there was an increased range of
passive motion in these patients especially in
external rotation (up to 120). The mean over-
all functional outcome of patients with a prox-
imal humerus replacement was 70.4% (range,
46%–83%) according to the Musculoskeletal
Tumor Society score.
It was possible to analyze the surrounding
soft tissue including the trevira tube in six pa-
tients who had revision surgery for aseptic
loosening of a distal femur (one patient), re-
vised periproshetic fracture (one patient), am-
putations for local recurrence (three patients),
and low-grade late infection (one patient). The
histopathologic findings showed tissue in-
growth of surrounding fibrous tissue into the
tube in all cases and no foreign body granu-
loma or inflammatory process (Fig 3).
Fig 3. The tissue section shows
a soft tissue ingrowth of the sur-
rounding fibrous tissue into the
polyethylene terephthalate fibers
(arrows). No foreign body granu-
loma or inflammation was ob-
served (Stain, hematoxylin and
eosin; magnification, 40x).
Reconstruction Using a Trevira Tube 269
DISCUSSION
Because of the progress in neoadjuvant or ad-
juvant systemic treatment of malignant bone
tumors, a limb salvage procedure using an en-
doprosthetic device can be done in an increas-
ing number of patients.2,17,33 Endoprosthetic
replacement often is accompanied by compli-
cations, including aseptic or septic loosening,
material malfunction such as stem fracture, or
wear of the polyethylene bushings.8,9,14,27
Some authors4,16,22,25,26,32 have reported dislo-
cations of megaprostheses. A frequent com-
plication (4%–37%) is postoperative disloca-
tion of the hip.4,22,26,32 In the current study,
using the trevira tube for capsular reconstruc-
tion of the hip in proximal femur replacement,
a dislocation occurred in two of 33 patients
(6%). Both dislocations occurred in patients
with a proximal femur replacement with a ce-
mented acetabular component after an ex-
traarticular tumor resection. These results cor-
respond to the results of Rock,28 who stated
that bipolar systems are more stable than con-
ventional hip arthroplasties. In the current
study, no dislocation was observed in patients
with a combination of a trevira tube and a
bipolar cup. In contrast to the results of other
authors, there was no dislocation in total fe-
mur replacements.12,18

270 Gosheger et al
Shin et al30 reported on 52 reoperations
(25%) in 208 endoprosthetic replacements per-
formed for limb salvage in patients with tumors.
In 24% of reoperations, dislocation was the rea-
son for revision in the unconstrained megaen-
doprostheses (hip, two of 16; humerus, four of
nine). Dislocation of the proximal humerus was
avoided by reconstructing the capsule with the
trevira tube.
In addition, the trevira tube allows early
mobilization of patients with a proximal or to-
tal femur replacement because of a good sta-
bility. In only a few patients (eight of 38 pa-
tients) is a cast necessary when reattachment
of multiple muscle flaps is required.
The trevira tube not only offers joint stabil-
ity but also allows for reattachment of the sur-
rounding muscles to the endoprosthetic de-
vice. Especially in proximal femur and total
femur replacement, the trevira tube allows
reattachment of the abductor muscles. In the
current study, the patients reached good active
abduction, but a positive Trendelenburg sign
was found in 20 of 38 patients. Twenty pa-
tients did not require external support. The
overall functional outcome of patients with a
proximal or total femur replacement was
67.5% according to the Musculoskeletal Tu-
mor Society score. The megaprostheses pro-
vide good function in daily life, with respect to
the clinical and functional results.
In patients with a proximal humerus replace-
ment, the active abductor capability against
gravity was on average 37.5. Olsson et al24
described similar functional results in 20 pa-
tients with proximal humerus replacement.
The clinical results and the mean overall func-
tional outcome (70.4% according to the Mus-
culoskeletal Tumor Society score) enables the
patient to fulfill daily activities. The abduction
capability could not be improved by using the
trevira tube as predicted previously, but a flail
shoulder and dislocation were avoided.
The mean extensor lag of patients with re-
construction of the extensor apparatus was
7.5. In contrast to Kotz et al,16 no avulsion of
the reattached extensor tendon was observed.
The mean overall functional outcome of pa-
Clinical Orthopaedics
and Related Research
tients with reconstruction of the extensor ap-
paratus was 78.2% according to the Muscu-
loskeletal Tumor Society score. This group
had the best results because external support is
not necessary and gait analysis showed good
results providing a good extension force.
Malawer and Price20 published results of
using gastrocnemius transposition flaps in
combination with large segmental resections
and prosthetic replacements. This method re-
duced postoperative complications. This was
confirmed by the current study, where 11 re-
placements were reconstructed with a gastroc-
nemius flap fixed to the trevira tube. Only one
patient needed revision surgery because of a
late infection, 7 months after primary surgery.
The biocompatibility with a soft tissue in-
growth into the trevira tube was seen in the
current study. In other studies, the biocompat-
ibility of the trevira tube also was con-
firmed.15,29 The analysis of the rate of infec-
tion of replacements using a trevira tube
showed no increase compared with replace-
ments without a trevira tube.
The trevira tube provides safe protection
against dislocation. In proximal tibia replace-
ment and distal femur replacement with re-
construction of the extensor apparatus, the
functional results can be improved, but in
proximal femur and proximal humerus re-
placement, the abductor capability could not
be improved as predicted previously.
Acknowledgements
The authors thank Dr. D. Rosenbaum for revising
the manuscript and F. Rickmeier for the medical il-
lustrations.
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