Long-term Outcome of Total Femur Replacement

@#Introduction: Total femur replacement is an option instead of amputation for extensive bone tumour or after revision surgery with a massive bone loss. Over a long period of time the patients may need revision surgery, and this might affect the functional outcome. We reviewed all consecutive total femur replacements done for primary and revision surgery of primary bone tumours in our centre to evaluate the long-term functional outcome and survival. Materials and methods: All patients who had total femur resection and reconstruction with modular endoprosthesis replacement in our centre from June 1997 to May 2022 were reviewed. The respondents were surveyed through WhatsApp using google form which was translated into Bahasa Malaysia based on the Musculoskeletal Tumour Society Scoring System (MSTS). The data were presented as descriptive data on the final survival of the limb and prosthesis. Results: Ten patients underwent total femur replacement. There were eight osteosarcoma, one giant cell tumour and one chondromyxoid fibroma. Three patients with osteosarcoma succumbed to pulmonary metastases; all had good early post-operative functional outcomes without local recurrence. Seven patients were available for long term evaluation of function with a mean follow-up of 17.6 years (ranged 10-25 years). Four patients with total femur replacement had good functional outcomes (60-80%) without revision with 10-25 years follow-up. Three patients experienced acetabulum erosion and chronic pain that required early hip replacements. Two of them were complicated with superior erosions and bone loss and subsequently were managed with massive reconstruction using cemented acetabulum cage reconstruction. The other has diabetes mellitus with chronic infection following revision of distal femur endoprosthesis to total femur replacement and subsequently underwent limited hemipelvectomy after 14 years. Conclusion: Total femur replacement offers a good long term functional outcome and prosthesis survival and is a favourable option for limb salvage surgery.

Treatment and influencing factors of infection after limb salvage surgery for malignant tumor around knee joint / 中国修复重建外科杂志

Objective: To summarize the experience in the treatment of infection after limb salvage surgery for malignant tumor around knee joint, and explore the risk factor related to infection after limb salvage surgery. Methods: A clinical data of 212 patients with malignant tumor around the knee joint underwent limb salvage surgery between January 2008 and December 2017 were retrospectively analyzed. Among them, 14 cases had infection after limb salvage surgery. Two cases of acute infection were treated with sensitive antibiotics; 12 cases of chronic infection were treated with debridement and antibiotic bone cement occupying device implantation in the first stage, and prosthesis revision (8 cases), knee joint fusion (2 cases), or amputation (2 cases) in the second stage after infection control. The age, gender, preoperative chemotherapy cycle, bone marrow suppression, serum albumin, hemoglobin, operation time, postoperative drainage time, and blood transfusion volume were analyzed to screen the risk factors related to infection after limb salvage surgery. The infection and tumor recurrence were observed, and the limb function was evaluated by Enneking scoring system. Results: The univariate analysis showed that the preoperative chemotherapy cycle, bone marrow suppression, operation time, and postoperative drainage time were the influencing factors of postoperative infection ( P<0.05). Multivariate analysis showed that the operation time, preoperative chemotherapy cycle, and postoperative drainage time were risk factors of postoperative infection ( P<0.05). Among the 14 patients, 1 patient died of traffic accident at 6 months after the second stage operation, and 13 patients were followed up 12.2-48.0 months (mean, 19.9 months). Two cases of acute infection cured. Among the 11 patients with chronic infection, 2 cases of subluxation of the antibiotic bone cement occupying device after the first stage operation occurred; 9 cases of infection cured and 2 cases recurred. At 12 months after operation, except 1 case died by accident, the Enneking scores of the other 13 patients were 12-26, with an average of 20. At last follow-up, 1 case of lung metastasis was still alive, and no tumor metastasis or recurrence was found in the rest. Conclusion: The time of limb salvage surgery, preoperative chemotherapy cycle, and drainage time after limb salvage surgery are the risk factors of infection after limb salvage surgery. Early etiological examination and drug sensitivity test is the key to the treatment of infection. One-stage debridement combined with antibiotic bone cement occupying device can effectively cure infection and save patients' limbs.

A 2-stage distal femur reconstruction with expandable endoprosthesis in a pediatric patient presenting with a pathologic fracture through an osteosarcoma

@#<p style="text-align: justify;">Osteosarcoma in pediatric patients has traditionally been treated with amputation, especially if there is a pathologic fracture through the tumor.</p><p style="text-align: justify;">We report the case of a 12-year-old boy who sustained a pathologic fracture through distal femoral osteosarcoma. After neoadjuvant chemotherapy, he underwent limb saving surgery: wide excision of the osteosarcoma followed by a second-stage reconstruction with an expandable tumor endoprosthesis. He has a functional score of 93% and is free of disease 8 years since diagnosis and 2 years since the end of lengthening.</p><p style="text-align: justify;">This is the first reported case in Philippine medical literature of limb saving surgery in osteosarcoma reconstructed with an expandable endoprosthesis.</p>

Evaluation of the efficacy of pelvic malignant bone tumor resection and function reconstruction / 肿瘤研究与临床

Objective@#To discuss the efficacy of pelvic region Ⅰ-Ⅲ malignant bone tumor resection and function reconstruction.@*Methods@#A retrospective study was performed on 23 patients with pelvic malignant bone tumors who underwent limb salvage surgery in the Second Hospital of Shanxi Medical University from January 2010 to December 2018, including 12 males and 11 females, aged 19-78 years old. There were 22 cases of primary tumors, and 1 case of metastatic carcinoma. The tumor of 13 cases located in region Ⅰ, 2 cases in region Ⅱ, 5 cases in region Ⅲ, 1 case in region Ⅱ+Ⅲ, and 2 cases in region Ⅰ+Ⅱ. The surgical methods included resection + allograft, resection + pedicle screw reconstruction, resection + ipsilateral iliac bone graft reconstruction, and artificial hemipelvic replacement. The complications, outcomes, survival, and function recovery of patients were analyzed.@*Results@#None of the 23 patients died in the perioperative period. Five patients with tumor invasion region Ⅱ underwent hemipelvic replacement, and no serious complications occurred after operation; 15 patients underwent allogeneic bone graft or autologous bone graft after tumor resection, 2 of them had milder wound infection, and no serious complications were found in the others; 3 cases underwent pedicle screw reconstruction after tumor resection, and no obvious complications occurred after operation. By the end of follow-up, 12 patients died of local recurrence or lung metastases after surgery, including 4 patients who underwent hemipelvic replacement. The gait of 23 patients was changed to some extent, most of them were claudication; One patient needed to walk with two crutches.@*Conclusions@#The malignant bone tumors in the pelvic region Ⅰ and Ⅲ can achieve satisfactory postoperative results after extensive resection in the boundary of security. For pelvic region Ⅱ malignant bone tumors, the postoperative curative effect of half pelvic prosthesis reconstruction after resection in the boundary of security is acceptable.

Primary Osteosarcoma of the Distal Fibula treated with with a Five-Year Follow-up: A Case Report

Musculoskeletal tumours of the lower limbs especially malignant tumours are not common. The fibula is the site of primary bone tumours as reported in 2.4% of lower limb tumours with the proximal third being more frequently involved than the distal segment. Osteosarcoma is the most common primary malignant bone tumour of nonhaematopoietic origin, with distal fibular involvement in 0.47% of patients. The advances in imaging techniques and neo-adjuvant chemotherapy have now made it possible to accurately define the extent of tumour and plan limb salvage with tumour resection. The purpose of this case report is to highlight the successful outcome of limb salvage procedure with a five year follow up in an 11-year old boy with distal fibular osteosarcoma. Limb salvage surgery with distal fibulectomy and retention of the foot are a good alternative to radical amputation.

Present perceptions and trends of surgical margin in soft tissue sarcoma in limbs and trunk / 中国肿瘤临床

Limb salvage surgery with comprehensive treatment is the standard care for soft tissue sarcoma in the limbs and trunk. Marginal status is a key factor in determining the quality of surgical treatment, as well as in guiding the selection of adjuvant therapies. The goal of surgery is to obtain an appropriately negative margin, although no consensus exists regarding the adequate thickness of normal tissue cuff. With the development of auxiliary treatments, surgery for soft tissue sarcoma is becoming less extensive. Marginal resection combined with adjuvant therapies may be necessary to preserve limb functions when the tumor is close to critical vessels, nerves, or bones. When preparing the preoperative plans, additional considerations should include histologic type, location, presence of barriers, and response to adjuvant therapies.

Endoprosthetic Reconstruction in the Limb Salvage Surgery for Treatment of Malignant Bone Tumors / 대한정형외과학회잡지

Endoprosthetic replacement is the most frequently used surgical method for the skeletal reconstruction in the limb salvage surgery for malignant bone tumors. Modular prostheses are generally used for typical locations such as distal and proximal femur, proximal tibia and proximal humerus. Expandable prosthesis is used to overcome leg length discrepancy in growing children. Aseptic loosening, infection and mechanical failure are major complications resulting in revision surgery. Many efforts should be made to develop more durable and functional implants to improve the quality of life of sarcoma survivors.

Cirugía de salvamento de extremidades para paciente con tumor maligno de la cintura escapular. A propósito de un caso / Limb salvage surgery for patient withMalignant tumor of the shoulder girdle. A case report

Previo a los años 70, la amputación interescapulotorácica era el principal tratamiento para los tumores óseos malignos de la cintura escapular. Con la mejor comprensión del comportamiento biológico de éstos y aplicación de terapia adyuvante, 80-90% pueden ser resecados con seguridad, empleando procedimientos de salvamento de extremidades. Se trata de paciente masculino de 34 años de edad quien cursa con aumento de volumen en región escapular derecha, de un año de evolución, acompañado de dolor en articulación acromio-clavicular y limitación para movimientos de abducción y flexión. Radiológicamente, se observó área osteolítica en fosa supraespinosa de escápula derecha; la tomografía reveló lesión destructiva de acromio, cabeza humeral y tercio externo de clavícula, en gammagrama óseo: lesión única en escápula derecha; TAC de tórax sin evidencia de lesiones secundarias. Biopsia incisional reportó sarcoma de alto grado clasificado como estadío IIB de Enneking. Posterior a estudio de Angioresonancia, se decidió y realizó la cirugía de salvamento de extremidad denominada Thikoff Lindbergh tipo IVB, consistente en la resección oncológica de margen amplio de escápula, articulación glenohumeral, 2/3 externos de clavícula y 1/3 proximal de húmero derecho. La histopatología determinó bordes libres de enfermedad y el diagnóstico final fue Osteosarcoma de alto grado. Postoperatorio con excelentes resultados; es referido a oncología clínica y a fisioterapia. Aunque los osteosarcomas de huesos planos son relativamente raros, su aparición en huesos como escapula condicionan situaciones de difícil manejo, ya que la resección adecuada está sujeta a un correcto proceso de estadificación y a una técnica depurada y experimentada(AU)

Prior to the 70s, the forequarter amputation was the primary treatment for malignant bone tumors of the shoulder girdle. With better understanding of the biological behavior of these and application of adjuvant therapy, 80-90% can be safely resected using limb salvage procedures. Male patient is 34-year- old who was studying with increased volume in the right scapular region, a year of evolution, accompanied by pain in acromioclavicular joint and limitation of abduction and flexion movements. Radiologically, there was osteolytic area in right supraspinous fossa of scapula; tomography revealed destructive lesion of acromion, humeral head and the outer third of clavicle, in ganmagrama bone: single lesion in right scapula, CT scan without evidence of secondary lesions. Incisional biopsy reported high grade sarcoma classified as Enneking stage IIB. Angiography after study, it was decided and performed limb salvage surgery called Thikoff Lindbergh type IVB, consisting of oncological resection of scapula wide margin, glenohumeral joint, two thirds collarbone external third right proximal humerus. The histopathology determined disease-free edges and the final diagnosis was highgrade osteosarcoma. Postoperative with excellent results, is referred to physiotherapy and clinical oncology. Although osteosarcoma of flat bones are relatively rare, their occurrence in bone and scapula condition unwieldy situations as adequate resection is subject to proper staging process and a refined technique and experienced(AU)

A meta-analysis of limb-salvage versus amputation in the treatment of patients with Enneking II pathologic fracture osteosarcoma.

Introduction: The aim of this meta-analysis was to further explore whether the relapse, 5-year survival and metastasis the same or not between limb-salvage and amputation in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma. Materials and Methods: An electronic search of the Medline, EMBASE and CNKI was done on October 2014. The clinical studies about amputation or limb-salvage surgery in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma were searched and reviewed. The effect size of relapse, 5-year survival and metastasis between the amputation and limb-salvage surgery were pooled by stata11.0 software (Stata Corporation, College Station, TX, USA, http://www.stata.com;) using random or fixed effect model. The funnel plot and Egger's line regression test were used for evaluation of publication bias. Results: A total of 89 studies were identified and seven articles with 200 cases in the limb-salvage surgery group and 84 subjects in the amputation group were finally included in the meta-analysis. The pooled data indicated that no statistical different of risk for developing relapse between limb-salvage and amputation was found relative risk (RR) =1.40, 95% confidence interval (CI): 0.71-2.79, (P = 0.33). The 5-year survival rate of patients underwent limb-salvage surgery was smaller than patients received amputation RR = 1.86, 95%CI: 1.19-2.89, (P = 0.01); the metastasis rate of patients underwent limb-salvage surgery was significant decreased compared with patients received amputation RR = 0.56, 95% CI: 0.34-0.94, (P = 0.03). No publication bias was existed in this meta-analysis. Conclusion: Limb-salvage surgery does not increased the risk of relapse compared with amputation in the treatment of patients with limited stage Enneking‡U pathologic fracture osteosarcoma.

Limb Salvage Surgery Using Whole Knee Joint Allograft Reconstruction in Osteosarcoma / 대한정형외과학회잡지

Limb salvage should be considered after complete remission in young and physically active patients with osteosarcoma. Herein we described a patient who was treated with whole knee allograft reconstruction for the clinical implications of biological reconstruction which can avoid the problems with several consecutive sessions of mega-prosthesis revision. The mid-term result of this whole knee joint allograft reconstruction showed that it provided optimal joint congruence with durable joint stability, well balanced mechanical axis without joint space narrowing, and satisfactory gait pattern.

Limb Salvage Surgery with Tumor Prosthesis for the Malignant Bone Tumors Involving the Proximal Femur / 대한골관절종양학회지

PURPOSE: As well as patient survival, the restoration of postoperative function such as ambulation is important in limb salvage operations for treatment of malignant bone tumors involving the proximal femur. The authors analyzed clinical outcomes of limb salvage operations using tumor prostheses for metastatic or primary malignant bone tumors in the proximal femur. MATERIALS AND METHODS: From February 2005 to January 2014, 20 cases (19 patients) with malignant bone tumor involving the proximal femur with pain or complicated pathologic fracture were treated with segmental resection and limb salvage operations with tumor prostheses. Mean age was 63.1 years (range 35-86). Fourteen patients were male and six ones were female. The mean follow-up period was 20 months (1-94 months). There were 15 cases of metastatic bone tumor, 4 cases of osteosarcoma, and 1 case of multiple myeloma. The primary tumors of the metastatic bone tumors included 4 lung cancers, 3 hepatocellular carcinomas, and 3 renal cell carcinomas. Other primary tumors were breast cancer, thyroid cancer, colon cancer, prostate cancer, and malignant spindle cell tumor, each in 1 case. Modular tumor prostheses were used in all cases; (Kotz's(R) Modular Tumor prosthesis (Howmedica, Rutherford, New Jersey) in 3 cases, MUTARS(R) proximal femur system (Implantcast, Munster, Germany) in 17 cases). Perioperative pain was assessed with Visual Analogue Scales (VAS). Postoperative functional outcome was assessed with Musculoskeletal Tumor Society (MSTS) grading system. RESULTS: Out of 20 cases (19 patients), 11 cases (10 patients) survived at the last follow-up. Average postoperative survival of the 9 deceased patients was 10.1 months (1-38 months). VAS score improved from pre-operative average of 8.40 (5-10) to 1.35 (0-3) after operation. Average postoperative MSTS function score was 19.65 (65.50%, 7-28). The associated complications were 2 local recurrences, 3 hematomas, 3 infections, 2 scrotal swellings, and 1 dislocation. There was no case of periprosthetic fracture or loosening. CONCLUSION: Limb salvage operation with tumor prosthesis is an appropriate treatment for early pain reduction and functional restoration in malignant bone tumors in the proximal femur with pain an/or complicated pathologic fractures.

Outcome of Surgical Treatment of Pelvic Osteosarcoma: Hospital Universiti Sains Malaysia Experience

We reviewed the surgical treatment and outcomes of 13 patients with pelvic osteosarcoma treated in our centre in the past decade. The study sample included 9 males and 4 females with a mean age of 28.1 years. Four patients had ileal lesions, five had acetabulum lesions, one had a ischiopubis lesion, and three had involvement of the whole hemipelvis. Seven patients presented with distant metastases at diagnosis. Limb salvage was performed in 6 patients and amputation in 7. In 60% of cases in the limb salvage surgery group, we attempted wide resection with positive microscopic margin compared to only 16.7% in the amputation group. Local recurrence was higher in the limb salvage group. Overall survival was 18 months for mean follow up of 14.8 months. Median survival was 19 months in the limb salvage group compared to 9 months in amputation group. The outcome of surgical treatment of pelvic osteosarcoma remains poor despite advancements in musculoskeletal oncology treatment.

Correlation analysis on MRI measuring scope of medullary cavity osteosarcoma invasion and to determing reasonable bone cutting plane / 重庆医学

Objective To analyze MRI in measurement of osteosarcoma invasion medullary cavity function and determine the reasonable range of the accuracy of bone cutting plane .Methods Selected 30 osteosarcoma patients with limb-salvage surgery ,X-ray and M RI in preoperative ,postoperative naked eye tumor specimens scope of intramedullary tumor ,intraoperative bone marrow derived ,postoperative histopathological examination with tumor specimens counterparts to determine the micro range .Postoperative evaluated limb function of patients .Results The average rate of functional recovery in patients was 81% ,the range measured by X-ray was significantly less than the pathologic examination(P<0 .05) ,while MRI measured attack range similar to pathological ex-amination ,there was no significant difference .Conclusion The accuracy of scope of medullary cavity osteosarcoma invasion diag-nosed by MRI is high ,as the operation reference high reliability ,short-term follow-up showed that in intramedullary outside the boundary of a 30 mm as bone cutting plane is safe and effective .

The prognostic value of pathologic fractures in patients with high-grade classic osteosarcoma

Pathologic fracture in osteosarcoma has traditionally been associated with a poor prognosis and is an immediate indication for amputation of the affected extremity. This concept has been questioned and remains an area of debate, especially because advances in osteosarcoma treatment have today resulted in better survival and limb salvage rates. It is the objectives of this paper to analyze the survival and limb salvage rate of osteosarcoma patients presenting with pathologic fractures and compare these with the population of osteosarcoma patients without pathologic fractures. Over a 15-year period (1993-2008), these were 84 patients presenting with non-metastatic high-grade classic osteosarcoma of the extremities (Enneking Stage IIB) who received complete treatment from the University of the Philippines-Musculoskeletal Tumor (UP-MuST) Unit and who had a follow up of at least 2 years. Ten of these 84 patients had pathologic fractures prior to surgery. Their overall survival was 50%, similar to the 50.38% overall survival of the entire group of 84 osteosarcoma patients. Limb salvage rate was 60%, similar to the 59% rate of patients without pathologic fractures. This study shows that contrary to traditional teaching, overall survival for this subset of osteosarcoma patients with pathologic fractures is acceptable at 50% and is equal to that of the entire group of osteosarcoma patients. At the same time, successful limb salvage surgery is possible despite the presence of a pathologic fracture, especially in patients with good response to chemotherapy.