Limb Salvage for Shoulder Girdle Neoplasm / 대한정형외과학회잡지

Between 1987 and 1994, the authors analysed 29 patients who underwent limb sparing resection for shoulder girdle neoplasms. Follow up averaged 24 months. Primary bone and soft tissue malignancy were 23 cases, metastatic carcinoma 3, aggressive giant cell tumor 2, aneurysmal bone cyst 1. By Enneking's criteria, stage IIB 23 cases, stage III 3, stage I 2. The surgical margins were: wide(20), marginal(7), and intralesional(2). In 4 cases with S2345B resections(by Musculoskeletal Tumor Society classification), shoulder fusion were done with Ender nail and bone cement. Among twenty patients with S345A(3), S34A(6), S345B(11) resections, arthroplasty with Ender nail and bone cement were done in 11 cases, endoprothesis and its combination with bone cement in 4, vascu- larized fibula graft in I, shoulder fusion with fibula graft in 1, combination of autoclaved bone and endoprothesis were done in 3 cases. Four patients with S12B, no reconstruction were done. For one patient with S45A, segmental resection and reconstruction with autogenous pasteurized bone were done. Oncologic results are CDF 14, DOD 5, NED 3, AWD 7 cases. Complications were local recur- rence 3(10.3%), distal fragment loosening 1, subluxation of humeral head 1, graft site fracture 1, and infection in 1 case. MSTS functional scores for the whole 29 cases were 22.5(75% of normal). S2345B with fusion was 20(67%). For S345A(3) and S34A(6) score was 23.2(77%). For S345B(11), score was 21.7(72%). For S12B(4) and S45A(1), score was 25.8(86%). Although functional results are depend on the extent of bone and soft tissue resection, reconstruction of soft tissue seems to be important. The options for reconstruction of bony defect(endoprothesis complex, living fibula graft or IM nail and cement as a prothesis) did not affect functional outcome.

Reconstruction of Large Bone Defect after Bone and Soft Tissue Tumor Resection , using Jeat / 대한정형외과학회잡지

To fill the large bone defect after bone and soft tissue tumor resection, there are several options such as tumor prosthesis, bone cement with intramedullary nail, autogenous bone graft and allograft. We had used isotrophic autogenous bone graft by using the heat-treated bone removed from tumor site. We analyzed the periods for junctional union and regeneration of autoclaved or low-heat treated groups, and compared these two methods to know which method is better for reconstruction of the bone defect after tumor resection. From Jan. 1987 to Sept. 1993, twelve patients took heat-treated autogenous bone graft: 6 auto- claved, and 6 low heat-treated. Each group had 10 places of junction sites between host and grafted bone. The tumors were 2 cases of osteosarcoma, 3 parosteal osteosarcoma, 2 Ewing's sarcoma, 2 malignant soft tissue tumors, 1 giant cell tumor, and 2 metastases from thyroid cancer and synovial sarcoma. The graft sites were 4 in humerus, 4 pelvis and 4 femur. Two cases showed marginal surgical margin and others wide surgical margin. Here we compare4 the difference between autoclaved group(120℃, 2 atm., 20 min) and low heat-treated group(65℃, 30 min. in water) on the aspect of complications and period to achieve junctional union to host bone. Average follow-up period was 25.3(11 to 88) months. Graft related complications in autoclaved group were bone resorption(2 sites), fracture of grafted bone(2). For low heat-treated group there was no such complication. Nonunion occurred in 3 sites for autoclaved group and 1 for low heat-treated group. Average period for junctional union was 7.3 months(5 to 10 months) for autoclaved group and 6.1 months(5 to 9 months) for low heat-treated group. With these results, heat treated bone autograft may have several advantages such as easy accessi- bility, low cost and anatomical reconstruction of the bone defect. The low heat-treated autogenous bone graft may have more advantages than that of the autoclaved one, and this method may be ratio- nalized to fill the large bone defect made by tumor resection.

Surgical Treatment of Pulmonary Metastases form Malignant Bone and Soft Tissue Tumors / 대한정형외과학회잡지

In malignant bone and soft tissue tumors, lung is the most predilection site of metastasis and multiple pulmonary metastases is a poor prognostic factor. Aggressive treatment of pulmonary metastases may offer a chance of long term survival in selected patients whose primary tumors were controlled. We wanted to know the feasibility of pulmonary metastasectomy, whether it can prolong the survival. From Apr. 1989 to Dec. 1993, pulmonary metastasectomies were carried out for 20 patients, and followed up to Sept. 1994, with average follow-up period of 18.7(2-65) months. The primary malignant tumors were 8 in bone and 12 in soft tissues. Mean age was 27.5(12-70) years. Fifteen cases showed late metastasis after control of primary tumor(late metastasis group), and 5 cases showed pulmonary metastasis at first visit(initial stage III group). As a control we analyzed the survival of 24 cases of no treatment after pulmonary metastasis from bone or soft tissue sarcoma, during the same period of investigation. At final follow-up, in late metastasis group, 4 cases were in no evidence of disease (NED), 4 alive with disease (AWD) and 7 dead of disease (DOD). Tumor free interval (TFI) of NED and AWD was averaged 30 months, and for DOD 9.8 months. Five among 11 cases (45%) of multiple lung metastases and 3 among 4 cases (75%) of single metastasis were alive. In initial stage III group, 1 case was in NED, 1 AWD and 3 DOD. For late metastasis group, Kaplan-Meier's 5-year estimated survival rate from the first metastasectomy was 37.4%. The median survival period of 15 cases was 44 months. For initial stage III group, Kaplan-Meier's 9 months estimated survival rate was 40%. Median survival period was 8 months. Twenty four cases of no treatment cases died within 14 months from diagnosis of pulmonary metastasis. Their median survival period was 6 months. Pulmonary metastasectomy appears to prolong survival and occupies an important mode of treatment for late pulmonary metastases in malignant bone and soft tissue tumor patients. In the cases of initial stage III, more cases and follow up period are needed to have a conclusion.

Temporary Resection Arthrodesis in Malignant Bone and Soft Tissue Tumors around Knee Using Intramedullary Nail and Bone Cement / 대한정형외과학회잡지

So far with the advancement in treatment modalities for malignant bone and soft tissue sarcomas the survival rate become higher. Till now there are some questions who can survive. Temporary procedure not affecting the treatment schedule would have more advantages than primary permanent one. When there is higher possibility of survival, this can be switched to permanent one. From Dec. 1986 to Jan. 1994, we had performed 40 cases of temporary arthrodesis after segmental resection of malignant bone and soft tissure tumors around the knee by using intramedullary nail andbone cement. Thirty eight cases of bone tumors[osteosarcoma(33), malignant fibrous histiocytoma(MFH)(3), chondrosarcoma(1), Ewing's sarcoma(1)] and 2 cases of soft tissue sarcomas[MFH(1), squamous cell carcinoma(1)] were analysed. Types of intramedullary nail used were rigid(Huckstep, 23 cases) or flexible(Ender, 17 cases). Six cases(15%) showed mechanical implant failure due to fracture (Huckstep;5, Ender;1) between 2 to 20 months after operation. Rearthrodesis using Ender nail and bone cement(5) or arthroplasty using Kotz prosthesis(1) were done for fractured cases. The other complicaitons were deep infection(2), peroneal nerve palsy(2), or transfixing screw fracture(2). Second reconstruction procedure was carried out in 2 cases with arthroplasty using Kotz prothesis. For IM nail, multiple Ender nailing seems to be superior to the Huckstep in mechanical strength. Contrary to the primary permanent reconsturction of the bone defect, this procedure has several advantages: 1) simple and does not hinder postoperative chemotherapy, 2) even in the extensively involved cases, can save the limb if the neurovascular structures are spared, 3) in Stage III, can save the salvagable limb, 4) economic and immediate stability can be helpful in the patient's quality of life, 5) two years later, when the survival approaches plateau, we can switch to another kinds of salvage operation, 6) Ender nail was superior to Huckstep in mechanical stability, 7) can be used for children expecting leg lengthening near puberty. It is useful for sarcoma patients around knee who require prolonged chemotherapy anbd whose life expectancy is relatively unexpectable.

Survival of Stage IIB Osteosarcoma-Limb-Salvage vs Ampuration / 대한정형외과학회잡지

From Mar. 1985 to Dec. 1992, 170 cases of osteosarcoma, which were proved histologically were admitted in our department at least one time. Among them we analysed 89 cases of Ennekings stage IIB who took limb-salvage(54) or amputation(35) and followed our protocol, with non-randomized retrospective study. The average age of the 89 patiens was 17.0 years(7 to 57). Fifty-four cases of salvage group took neoadjuvant chemotherapy, 35 cases of amputation group took neoadjuvant or adjuvant chemotherapy. The result revealed prevalences of 2/54, 0/35 as to local recurrence; 15 of 54, 17 of 35 as to metastasis; 14 of 54, 15 of 35 as to death. Of the 2 patients who had a local recurrence, one died of metastasis and the other was lost follow up. According to Kaplan-Meier's plot 5-year continuously disease free survival rate for whole 89 cases of stage IIB was 43.1%, for salvage group 56.4%, for amputation group 34.0%. There were no signifcant difference in survival rate between salvage and amputation groups(p>0.05, by log-rank test). This result means the limb-salvage operation for Enneking's stage IIB osteosarcoma does not hinder patients survival.