Outcome of expandable prostheses in children.

BACKGROUND: Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved? MATERIALS AND METHODS: We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed. RESULTS: Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934). CONCLUSIONS: The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Infections in surgery of primary tumors of the sacrum.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To evaluate the risk of infection, related treatment, and outcome after surgery of the 2 most common primary sacral tumors. SUMMARY OF BACKGROUND DATA: Rarity of sacral tumors has limited the number of population-based studies. Treatment depends on malignancy or local aggressiveness: wide resection is indicated for malignant lesions, intralesional surgery for benign. METHODS: We studied 82 patients with sacral chordomas (55 cases) or giant cell tumor (GCT) (27 cases) treated between 1976 and 2005. All patients had IV antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection; surgery of GCT was intralesional excision. Infections were classified as immediate postoperative, early (within 6 months), and late (more than 6 months from surgery). Mean follow-up was 9.5 years (range: 3-27 years). Some factors possibly influencing the risk of infection were statistically analyzed by Kaplan Meier curves and log-rank test. RESULTS: No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%) that required 1 or more surgical debridements combined with antibiotics, according to cultures. In 16 patients (70%), infection occurred within 4 weeks postoperatively, and in 7 within 6 months. Most frequent bacteria were Enterococcus (23%), Escherichia coli (20%), and Pseudomonas aeruginosa (18%). In 74% of cases, infection was multimicrobial. Level of resection, previous intralesional treatment elsewhere, tumor volume, and age did not statistically influence risk of infection. CONCLUSION: Type of surgery was the prominent factor related to a major risk of infection. Operating procedure time correlated as well. Resections of sacral chordoma imply a high risk of deep infection, while intralesional excision of GCT does not. All infections healed with surgical debridements and antibiotic therapy.

Short, full-dose adjuvant chemotherapy in high-risk adult soft tissue sarcomas: a randomized clinical trial from the Italian Sarcoma Group and the Spanish Sarcoma Group.

PURPOSE: A previous randomized clinical trial by the Italian Sarcoma Group (ISG) had shown a survival benefit of adjuvant chemotherapy (CT) in high-risk extremity soft tissue sarcoma (STS). However, the dose-intensity of the last two cycles was suboptimal. We then undertook a multicentric international phase III study to compare three and five cycles of the same CT. PATIENTS AND METHODS: Patients were randomly assigned either to receive three cycles of preoperative CT with epirubicin 120 mg/m(2) and ifosfamide 9 g/m(2) and granulocyte colony-stimulating factor (arm A) or to receive the same three cycles of preoperative CT followed by two further cycles of postoperative CT (arm B). Noninferiority of the primary end point, overall survival (OS), was assessed by the CI of the hazard ratio (HR; arm A/arm B) obtained from the Cox model. RESULTS: Between January 2002 and April 2007, 328 patients were recruited (164 patients in each arm). At a median follow-up of 63 months (interquartile range, 49 to 77 months), 100 deaths were recorded, 49 in arm A and 51 in arm B. Five-year OS probability was 0.70 for the entire group of patients (0.68 in arm A and 0.71 in arm B). The HR of arm A versus arm B was 1.00 (90% CI, 0.72 to 1.39). CONCLUSION: In this population of patients with high-risk localized STS, three cycles of full-dose preoperative CT were not inferior to five cycles. The outcome compares favorably with the expected survival of patients with high-risk STS and was superimposable on the CT arm of the previous ISG trial.

Long term results of fixed-hinge megaprostheses in limb salvage for malignancy.

We retrospectively studied the files of 669 patients with musculoskeletal tumors treated with limb salvage and reconstruction using fixed-hinge knee megaprostheses. We used the KMFTR® prosthesis from 1983 to 1989 in 126 patients, and the HMRS® prosthesis thereafter in 543 patients because of the anatomical femoral stem with one lateral flange for improved stress-shielding, the new hinge design and new generation polyethylene placed centrally in the metallic hinge, and the improved function compared to the former prosthesis. Distal femoral reconstructions were done in 474, proximal tibia in 163, extrarticular knee joint in nine, and total femoral in 23 patients. At 10 and 20 years follow-up, survival to breakage was 95% and 85%, to aseptic loosening 94% and 82%, to infection 90% and 82%, and to polyethylene wear 95% and 37%. A statistically significant higher survival to breakage of the HMRS® prostheses was observed. No statistical difference of survival to breakage regarding the site of reconstruction, aseptic loosening, infection, polyethylene wear and mean functional score between the two types of prostheses was observed.

Dedifferentiated chondrosarcoma revisited.

This article reviews recent molecular, biologic, therapeutic, and clinical findings in dedifferentiated chondrosarcoma. Dedifferentiated chondrosarcoma is one of the most malignant primary bone tumors characterized by two distinct histopathologic components: a well-differentiated chondral lesion sharply juxtaposed with a high-grade noncartilaginous component. Wide or radical surgical resection is mandatory. High-dose radiation therapy is confined to inaccessible sites and palliation. Chemotherapy is administered whenever the dedifferentiated component is chemosensitive and the patient is in good general condition. Despite this approach, metastases will result in poor survival of these patients.

Primary bone lymphoma: evaluation of chemoimmunotherapy as front-line treatment in 21 patients.

BACKGROUND: We performed a retrospective investigation to assess the efficacy of chemotherapy and rituximab as front-line treatment for primary bone lymphoma (PBL). PATIENTS AND METHODS: Between 1999 and 2009, 21 previously untreated patients received a diagnosis of PBL. All the patients were treated with anthracycline-containing chemotherapeutic regimens, with the addition of rituximab; 11 patients received consolidative radiation therapy after induction treatment. RESULTS: Patients' median age was 34 years (range, 18-82 years); all presented with diffuse large B-cell lymphoma. Complete responses were seen in 95.2% of the patients treated. No relapses were observed at a median follow-up of 43.9 months. Eight-year overall survival and disease-free survival were 95.2% and 100.0%, respectively. CONCLUSION: These data indicate that the combined chemotherapy plus rituximab treatment may represent a suitable front-line approach in PBL, with a high rate of responses and an excellent long-term survival.

Metastases of the pelvis: does resection improve survival?

Limited data are available to compare the outcome of wide en bloc resection and curettage for pelvic metastases. Previous studies have reported that curettage is associated with high mortality and decreased survival compared to wide resection and have justified consideration of a radical surgical approach to achieve pain palliation and tumor control. In this study, we aimed to evaluate the role of curettage/marginal resection compared to wide en bloc resection for patients with pelvic metastases. The hypothesis was that wide resection does not improve survival even in patients with solitary pelvic metastases.Between 1985 and 2009, twenty-one patients with pelvic metastases were treated with wide resection (12 patients) and curettage/marginal resection (9 patients) and adjuvants. Sixteen patients had solitary pelvic metastases. At a mean of 28 months (range, 2-152 months), we found no difference in survival to death or local recurrence with wide en bloc resection compared to curettage or marginal resection, even in patients with solitary pelvic metastases. The overall survival to death and local recurrence was 30% and 47% at 60 months, respectively. Survival to death of patients treated with wide resection was 18% at 60 months compared to 62% at 60 months of patients treated with curettage/marginal resection; no difference in survival to death between wide resection and curettage/marginal resection was observed even in patients with solitary pelvic metastases. Survival to local recurrence of patients treated with wide en bloc resection was 67% at 36 months compared to 26% at 36 months of patients treated with curettage/marginal resection; this was also not statistically significant. One patient treated with wide resection for a solitary pelvic metastasis had a postoperative complication.

Aggressive fibromatosis of the neck treated with a combination of chemotherapy and indomethacin.

Aggressive fibromatosis (desmoid tumor) of the neck is rare. When feasible, surgery is the best treatment option. However, complete excision with negative margins is not possible in most cases because of the involvement of vascular and nervous structures. Also, surgery results in poor functional and aesthetic outcomes. Sometimes debulking surgery with positive margins is performed, but the anatomy of the neck is a challenge for oncologic surgeons, and recurrences are not uncommon. Radiotherapy is seldom employed for the same reasons. On the other hand, systemic treatment with chemotherapy, hormone therapy, and noncytotoxic agents such as nonsteroidal anti-inflammatory drugs (NSAIDs) has been used with good results. We report a case of inoperable aggressive fibromatosis of the neck that was successfully treated for about 21 months with a combination of chemotherapy and the NSAID indomethacin. As far as we know, this is the first reported use of a combination of chemotherapy and an anti-inflammatory drug in the treatment of aggressive fibromatosis of the neck. We also review the literature on cases of aggressive fibromatosis of the neck that have been reported over the past 12 years.

Outcome of the intramedullary diaphyseal segmental defect fixation system for bone tumors.

BACKGROUND: Resection of diaphyseal malignant bone tumors is indicated for local control and impending pathological fracture or failure of prophylactic internal fixation. However, there are no large, long-term studies analyzing the results of intercalary reconstruction using segmental metallic spacers. MATERIALS AND METHODS: We present 24 patients treated with wide resection for primary or metastatic bone tumors involving the diaphysis of the femur, tibia, or humerus and reconstruction using a modular intramedullary diaphyseal segmental defect fixation system. The mean length of bone resection was 10 cm. The postoperative complications and outcome were evaluated. RESULTS: At a mean follow-up of 29 months, 17 patients were alive and 7 patients were dead of disease; no patient had local recurrence. Implant-related complications occurred in 8 patients, the most common being mechanical loosening and rotational instability. Loosening was most common in reconstructions of more than 10 cm length of bone resection. In all femoral reconstructions, mechanical failure occurred at the proximal stem. True limb length discrepancy of 2.0 cm was observed in one patient. Wound healing complications were not observed; range of motion and function of the adjacent joints was within normal limits. CONCLUSIONS: The modularity, ease of application and preservation of the adjacent joints are major advantages of segmental modular prostheses; however, the complications' rate is high. Complications occur most often at the proximal stem in femoral reconstructions and reconstructions for more than 10 cm length of bone resection. In these cases, the use of these implants should be reconsidered or not recommended.

Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review.

BACKGROUND: Massive endoprostheses provide orthopaedic oncologists with many reconstructive options after tumor resection, although failure rates are high. Because the number of these procedures is limited, failure of these devices has not been studied or classified adequately. This investigation is a multicenter review of the use of segmental endoprostheses with a focus on the modes, frequency, and timing of failure. METHODS: Retrospective reviews of the operative databases of five institutions identified 2174 skeletally mature patients who received a large endoprosthesis for tumor resection. Patients who had failure of the endoprosthesis were identified, and the etiology and timing of failure were noted. Similar failures were tabulated and classified on the basis of the risk of amputation and urgency of treatment. Statistical analysis was performed to identify dependent relationships among mode of failure, anatomic location, and failure timing. A literature review was performed, and similar analyses were done for these data. RESULTS: Five hundred and thirty-four failures were identified. Five modes of failure were identified and classified: soft-tissue failures (Type 1), aseptic loosening (Type 2), structural failures (Type 3), infection (Type 4), and tumor progression (Type 5). The most common mode of failure in this series was infection; in the literature, it was aseptic loosening. Statistical dependence was found between anatomic location and mode of failure and between mode of failure and time to failure. Significant differences were found in the incidence of failure mode Types 1, 2, 3, and 4 when polyaxial and uniaxial joints were compared. Significant dependence was also found between failure mode and anatomic location in the literature data. CONCLUSIONS: There are five primary modes of endoprosthetic failure, and their relative incidences are significantly different and dependent on anatomic location. Mode of failure and time to failure also show a significant dependence. Because of these relationships, cumulative reporting of segmental failures should be avoided because anatomy-specific trends will be missed. Endoprosthetic design improvements should address failure modes specific to the anatomic location.

Quality of life following limb-salvage surgery for bone sarcomas.

Limb-salvage surgery and reconstruction of bone defects is challenging in orthopedic oncology. Evaluation and improvement of the quality of life in these patients is difficult. Currently available metrics of function include clinical measures such as range of motion and muscle strength, measures of activities of daily living, scales that combine both clinical measures and activities of daily living, the original and the revised version of the Musculoskeletal Tumor Society Rating Scale, which includes symptoms, mobility and use of assistive devices, generic health status measures such as the Sickness Impact Profile, and the Reintegration to Normal Living, a measure of handicap. Most bone sarcoma survivors manage well; they are able to work and have an overall good quality of life, having adjusted to their physical limitations. To enhance the literature, we summarize the results of previous studies reporting on the quality of life after limb-salvage surgery of the upper and lower limb, discuss the complications and outcomes, and present our long-term experience and future view.

Palliative therapy for osteosarcoma.

Despite advances in diagnostic imaging, the evolution of neoadjuvant chemotherapy and the refinements in limb-salvage surgery, the progression-free survival rate remains poor for patients with metastatic, recurrent or unresectable osteosarcoma. Different therapeutic strategies for these subgroups of patients have been employed to control disease and prolong survival. Treatment options are limited and controversial, including systemic and localized therapies. Surgical resection, whenever feasible, is still the standard treatment in advanced osteosarcoma. The role of chemotherapy is unclear while the use of radiotherapy, embolization and thermal ablation is increasing. New therapeutic experimental approaches and novel target therapies are needed to improve the outcome of these subgroups of patients.

Post traumatic myositis ossificans: Sonographic findings.

PURPOSE: The aim of this paper is to describe the sonographic (US) features of post traumatic myositis ossificans (PTMO). METHODS: Fifteen patients with histopathological diagnosis of PTMO were included. The following US parameters were evaluated: presence of a mass, calcifications, power Doppler signals, and relationship with adjacent structures. RESULTS: Five patients (33.3%) were diagnosed as early PTMO and 10 (66.6%) as mature PTMO. In both early and mature PTMO, US showed an oval hypoechoic mass, without infiltrative borders, located in a muscular belly. In the early phase, a center of less echogenicity was observed, associated with an outer sheet-like hyperechoic peripheral rim, while, in the mature phase, peripheral calcification created more reflections and distal acoustic shadowing was observed. CONCLUSIONS: US is highly sensitive in the detection of PTMO, helps differentiate between PTMO and malignant soft tissue tumors, and can be used for follow-up of the lesions.

Percutaneous CT-guided biopsy of the musculoskeletal system: results of 2027 cases.

INTRODUCTION: Biopsy of the musculoskeletal system is useful in the management of bone lesions particularly in oncology but they are often challenging procedures with a significant risk of complications. Computed tomography (CT)-guided needle biopsies may decrease these risks but doubts still exist about their diagnostic accuracy. This retrospective analysis of the experience of a single institution with percutaneous CT-guided biopsy of musculoskeletal lesions evaluates the results of these biopsies for bone lesions either in the appendicular skeleton or in the spine, and defines indications. MATERIALS AND METHODS: We reviewed the results of 2027 core needle biopsies performed over the past 18 years at the authors' institution. The results obtained are subject of this paper. RESULTS: In 1567 cases the correct diagnosis was made with the first CT-guided needle biopsy (77.3% accuracy rate), in 408 cases the sample was not diagnostic and in 52 inadequate. Within 30 days these 408 patients underwent another biopsy, which was diagnostic in 340 cases with a final diagnostic accuracy of 94%. Highest accuracy rates were obtained in primary and secondary malignant lesions. Most false negative results were found in cervical lesions and in benign, pseudotumoral, flogistic, and systemic pathologies. There were 22 complications (18 transient paresis, 3 haematomas, 1 retroperitoneal haematoma) which had no influence on the treatment strategy, nor on patient outcome. CONCLUSION: This technique is reliable and safe and should be considered nowadays the gold standard for biopsies of the musculoskeletal system.

Late sarcoma development after curettage and bone grafting of benign bone tumors.

BACKGROUND AND AIM: Rarely sarcomas develop in previous benign lesions, after a long term disease free interval. We report the experience on these rare cases observed at a single Institution. PATIENTS AND METHODS: 12 cases curetted and grafted, without radiotherapy developed sarcomas, between 1970 and 2005, 6.5-28 years from curettage (median 18, average 19). Age ranged from 13 to 55 years (median 30, average 32) at first diagnosis; tumors were located in the extremities (9 GCT, benign fibrous histiocytoma, ABC, and solitary bone cyst). Radiographic and clinic documentation, for the benign and malignant lesions, were available. Histology was available for 7 benign and all malignant lesions. RESULTS: To fill cavities, autogenous bone was used in 4 cases, allograft in 2, allograft and tricalcium-phosphate/hydroxyapatite in 1, autogenous/allograft in 1, heterogenous in 1. For 3 cases the origin was not reported. Secondary sarcomas, all high grade, were 8 osteosarcoma, 3 malignant fibrous histiocytoma, and 1 fibrosarcoma. CONCLUSIONS: Recurrences with progression from benign tumors are possible, but the very long intervals here reported suggest a different cancerogenesis for these sarcomas. This condition is extremely rare accounting for only 0.26% of all malignant bone sarcomas treated in the years 1970-2005 and represents only 8.76% of all secondary bone sarcomas treated in the same years. This incidence is the same as that of sarcomas arising on fibrous dysplasia, and is lower than those arising on bone infarcts or on Paget's disease. This possible event must be considered during follow-up of benign lesions.

Gorham-Stout disease: the experience of the Rizzoli Institute and review of the literature.

Gorham-Stout disease (also known as "disappearing bone disease") was first described by Jackson in 1838, but was properly defined by Gorham and Stout in a series of 24 patients in 1954-1955. It is a rare disease of unknown etiology (about 200 cases reported in the literature) characterized by spontaneous progressive resorption of bone without malignant proliferation of vascular structures. The diagnosis is one of exclusion and it is based on combined histological, radiological, and clinical features. Benign vascular proliferation with fatty bone marrow and thinning of bony trabeculae is a typical histological feature. Standard radiographs of disappearing bone disease show progressive bony resorption with adjacent soft tissue involvement. Most cases of Gorham-Stout disease resolve spontaneously, but prognosis remains unpredictable. This study reports 13 cases of Gorham-Stout disease treated in our institution from 1968 to 2008. The aim of the work was to review our series and the literature on this rare disease, as well as to evaluate whether or not an optimal treatment can be identified and recommended.

Evolution of surgical treatment for sarcomas of proximal humerus in children: retrospective review at a single institute over 30 years.

BACKGROUND: Proximal humerus, although a common site for primary bone sarcomas, finds scant mention in literature as far as options and outcome of reconstruction in the skeletally immature skeleton are concerned. Reconstruction after resection of proximal humeral sarcomas in the immature skeleton poses specific challenges to the surgeon, and there has been a definite evolution of these techniques over the decades. We studied the evolution and compared the outcome of various techniques for such reconstruction over 3 decades at a single institution. METHODS: All 61 children younger than 13 years of age and treated for a primary sarcoma of the proximal humerus at Department of Musculoskeletal Oncology, Rizzoli Orthopedic Institute, from 1976 to 2006 were studied for techniques of resection and reconstruction, complications, surgical procedures needed during follow up, and functional and radiologic outcomes during and at final follow-up. The functional outcomes after various procedures were compared using the Musculoskeletal Tumor Society scoring system. RESULTS: A definite trend from amputation in the first decade, to the use of nonbiological reconstruction (endoprostheses, K nail cement spacer) in the second and biological reconstruction (vascular proximal fibula autograft, osteoarticular allograft, and allograft prosthesis composite) in the third decade was seen. There was a trend of improvement in the functional outcome over the 3 decades, although the complication rates and the need for repeated surgical procedures remained a major problem in all the techniques. CONCLUSIONS: Reconstruction of proximal humerus after resection for sarcomas is a challenging task. Although endoprostheses do have a definite role to play in reconstruction of proximal humerus in children, the use of biological techniques in well-selected patients is being carried out more often now than before, as is reflected in this series, with a potentially improved functional outcome. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Long-term results in children with massive bone osteoarticular allografts of the knee for high-grade osteosarcoma.

BACKGROUND: Reconstruction of distal femur or proximal tibia in growing patients is a challenge for the high rate of complications and limb length discrepancy at the end of growth. The purpose of this study was to evaluate the long-term outcome of children affected by high-grade osteosarcoma of the knee region, reconstructed by osteoarticular bone allograft of distal femur, and proximal tibia. METHODS: We retrospectively reviewed 25 patients treated for high-grade osteosarcoma, 13 in the distal femur and 12 in the proximal tibia. The mean follow-up was 124 months. Clinical and radiologic evaluation was carried out in the 20 long-term survivors with a minimum follow-up of 7 years from surgery. The rates of survival of the implants were estimated with use of the Kaplan-Meier method. Functional and radiographic evaluation was done according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up in all the patients that still had the allograft. RESULTS: Five patients died during the first 2 years of follow-up for disease-related causes. Of the remaining 20 osteoarticular allografts (10 of the distal femur and 10 of the proximal tibia), 12 failed: 4 in the distal femur and 8 in the proximal tibia. All the failures were related to a graft fracture, but in 4 patients with subchondral collapse the graft was maintained and converted into an allograft prosthetic composite. No deep infection of the primary reconstruction was observed. The overall rate of allograft survival was 70% at 5 years and 58% at 10 years in the distal femur, and 45% at 5 years and 20% at 10 years in the proximal tibia. At final follow-up, 8 patients still walked on the primary implant, 6 in the distal femur, and 2 in the proximal tibia. The functional outcome of these patients was evaluated as good in 5 patients (3 with distal femoral and 2 with proximal tibial allograft), and poor in 3. CONCLUSIONS: Although mechanical complications significantly affect the outcome, osteoarticular allografts may represent a viable option for reconstruction in children older than 8 with high-grade sarcomas about the knee. LEVEL OF EVIDENCE: Level IV.

68Ga-citrate PET/CT for evaluating patients with infections of the bone: preliminary results.

UNLABELLED: The aim of this work was to preliminarily evaluate the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of (68)Ga-citrate PET/CT in a population of patients with suspected bone infections. METHODS: We enrolled 31 patients with suspected osteomyelitis or diskitis who underwent a total of forty (68)Ga-citrate PET/CT scans. The results were compared with different combinations of diagnostic procedures (MRI, radiography, CT, or white blood cell scintigraphy), biopsy (when diagnostic), and follow-up data (at least 1 y) to determine the performance of (68)Ga-citrate PET/CT. RESULTS: We found a sensitivity of 100%, a specificity of 76%, a positive predictive value of 85%, a negative predictive value of 100%, and an overall accuracy of 90%. CONCLUSION: Although preliminary, these data confirm a possible role for (68)Ga-citrate in the diagnosis of bone infections, especially in consideration of its favorable characteristics.

The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome.

BACKGROUND: Phantom limb syndrome (PLS) is common after limb amputations, involving up to 90% of amputees. Although many different therapies have been evaluated, none has been found to be highly effective. Therefore, we evaluated the efficacy of a prolonged perineural infusion of a high concentration of local anesthetic solution in preventing PLS. METHODS: A perineural catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperatively at 5 mL/h using an elastomeric (nonelectronic) pump, and continued for 4 to 83 days after surgery. PLS was evaluated on the first postoperative day and then 1, 2, 3, and 4 weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours before each assessment period (i.e., until the sensation in the extremity returned). The severity of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 = no pain to 4 = intolerable pain, and "phantom" sensations were recorded as present or absent. If the VRS score was >1 or significant phantom sensations were present, the ropivacaine infusion was immediately restarted at 5 mL/h. If the VRS score remained at 0 to 1 and the patient had not experienced phantom sensations for 48 hours, the infusion was permanently discontinued and the catheter was removed. RESULTS: Median duration of the local anesthetic infusion was 30 days (95% confidence interval, 25-30 days). On postoperative day 1, 73% of the patients complained of severe-to-intolerable pain (visual analog scale >2). However, the incidence of severe-to-intolerable phantom limb pain was only 3% at the end of the 12-month evaluation period. At the end of the 12-month period, the percentage of patients with VRS pain scores were 0 = 84%, 1 = 10%, 2 = 3%, 3 = 3%, and 4 = none. However, phantom limb sensations were present in 39% of patients at the end of the 12-month evaluation period. All patients were able to manage the elastomeric catheter infusion system at home. CONCLUSION: Use of a prolonged postoperative perineural infusion of ropivacaine 0.5% seems to be an effective therapy for the treatment of phantom limb pain and sensations after lower extremity amputation.