Expandable endoprostheses in skeletally immature patients: Where we are.

Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality. Until the early 1990s, the treatment options for these patients were rotationplasty or amputation. Multimodal approaches that combine imaging, chemotherapy, and surgical techniques have enabled the development of limb-preserving methods with satisfactory results. In order to overcome inequality problems, expandable prostheses have been developed in the 1980s. Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative. Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures, but the complication rate remains high. Therefore, although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children, they are still a suitable interim choice until full adulthood is achieved. Due to reported high complication rates, the procedures require significant experience and are recommended for use only in specialized cancer centers.

Impact of Level of Surgery on the Functional Outcomes in Patients with Lower Extremity Bone Tumors Undergoing Amputation Versus Limb Salvage Surgery.

Limb salvage surgery is the preferred treatment for bone tumors in the current surgical practice. The aim of this study was to compare the functional outcomes between amputation and limb salvage surgery based on the level of surgery at two levels: knee and hip. A single institutional analysis of 137 patients with lower extremity bone tumors was done between 2014 and 2020. Eighty-seven patients treated with amputation were compared with 50 patients treated with limb salvage surgery based on following variables: age, gender, histology, anatomic site, and MSTS score. The mean MSTS scores were fairly better in patients who underwent surgery at knee level compared to those who underwent surgery at hip level. The mean MSTS score at 1-year follow-up was 22.0 in amputation group compared to 22.4 in limb salvage group, whereas at 2-year follow-up was 24.1 in amputation group compared to 25.1 in limb salvage group. At knee level, functional outcomes were similar after amputation and limb salvage. At hip level, patients undergoing amputation had poorer MSTS scores compared to limb salvage surgery at 2-year follow-up (p = 0.04). The functional outcomes for patients undergoing surgery at knee level were similar irrespective of type of surgery. At longer follow-up, patients undergoing amputation at hip level had a poorer functional outcome compared to limb salvage surgery. Although limb salvage was associated with similar MSTS scores when compared with amputation, it produced a better functional outcome especially for proximally located tumors.

Functional audit of the use of megaprosthesis for limb reconstruction in musculoskeletal tumors - A retrospective single-center study.

Introduction: Medical advancements in musculoskeletal oncology has significantly reduced the mortality rate associated with limb-sparing surgery, making it comparable to amputation. The use of modular megaprosthesis for sarcoma treatment has now become a standard practice. However, these non-biological implants are not without their complications. Materials and methods: A retrospective cohort study was conducted on all patients who underwent wide resection of locally aggressive and malignant bone tumors, followed by reconstruction with megaprosthesis between January 2018 and January 2023 at tertiary care hospital. Patients were evaluated based on oncological outcomes, functional outcomes, and complications with a minimum follow-up period of 6 months. Results: The study included a total of 30 patients, comprising 16 males and 14 females, with a mean age of 33.6 ± 15.6 years. They all underwent wide resection and reconstruction with megaprosthesis. Diagnosis among the patients included 19 cases of giant cell tumors, 5 cases of osteosarcomas, 2 cases of metastatic bone tumors, and 1 case each of chondrosarcoma, malignant fibrous histiocytoma, multiple myeloma, and chondromyxoid fibroma. These tumors were predominantly located in the distal femur (15 patients) and proximal tibia (12 patients). The average follow-up period was 33 ± 21 months, resulting in an average final Musculoskeletal Tumor Society (MSTS) score of 81 % ± 9 %. Complications were observed in 21 patients, with infection being the most common, specifically Type 4 (10 patients, 37 %), followed by Type 1 (4 patients, 13 %) and Type 3 (4 patients, 13 %). Two patients (7 %) experienced Type 5 complications, while three succumbed to their illnesses. Additionally, two patients required amputation, one due to local recurrence and the other due to a deep-seated infection. Conclusion: Megaprosthesis is a viable reconstruction option following wide resection of bone tumors. Infection remains the most common issue, and cost poses a significant challenge.

Tiptoe Walking in the Presence of Superimposed Aeromonas With Dengue Infection.

The rise in limb salvage surgeries has led to an increase in post-traumatic equinus contractures, resulting in secondary causes of tiptoe walking. There is notable evidence linking superimposed bacteremia to heightened risks of morbidity and mortality in dengue patients, particularly when the immune system is compromised, leading to documented cases of Aeromonas-induced necrotizing fasciitis with myonecrosis. A case report from August 2019 involves a five-year-old boy admitted for dengue fever, which progressed to severe bilateral leg necrotizing fasciitis caused by concurrent Aeromonas infection. The child further underwent urgent surgical debridement and post-operatively was diagnosed with necrotizing fascio-myositis of the bilateral leg. Despite urgent surgical intervention, the patient developed long-term complications of persistent equinus contractures in both legs, necessitating subsequent surgical Achilles tendon lengthening. This case underscores the potential fatality of superimposed Aeromonas septicaemia in dengue patients and emphasizes the need for vigilant monitoring and intervention in serious soft tissue infections in growing children and adolescents.

Whole Blood Titanium Concentration after Limb Salvage Surgery with Three-Dimensional-Printed Ti6Al4V Implants.

Background: Three-dimensional (3D)-printed customized implants can be fabricated and utilized for all bones with massive bone defects. The main safety issues with 3D-printed implants made of Ti6Al4V alloy are related to the release of metal debris and residual powder. In this study, we investigated the perioperative titanium concentrations in whole blood and peri-implant fluid samples of patients who underwent limb salvage surgery with a 3D-printed Ti6Al4V implant. Methods: Nineteen patients who underwent limb salvage surgery with 3D-printed Ti6Al4V implants were divided into two groups: the serial samples group and the follow-up group. To observe metal distribution and clearance in the body, serial samples of blood and peri-implant fluid from the surgical drain were prospectively collected for five patients in the serial samples group. For the remaining 14 patients who were followed up for more than a year, blood samples were collected only once. Results: In the serial samples group, the mean baseline titanium concentration was 0.78 µg/L (range, 0.1-2.2 µg/L): 3 patients showed peak concentration before the third postoperative month, while 2 patients still showed an increasing pattern at this point. Total titanium mass in the surgical drain showed a wash-out phenomenon in a week, with a significant uniform decrease (p = 0.04). In 14 patients in the follow-up group, the mean titanium concentration in the whole blood was 10.8 µg/L (range, 0.3-36.6 µg/L). For the 14 patients with a long-term follow-up, the aluminum and vanadium concentrations were all negligible. Conclusions: Whole blood titanium concentrations were higher after surgery using 3D-printed implants than after that using conventional orthopedic implants, but markedly lower than in patients with implant failure. None of the patients developed serious clinical adverse effects during follow-up.

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.

Encasement Of Popliteal Vascular Bundle Due Local Osteosarcoma Recurrence Treated With Wide Resection And Vascular Reconstruction.

Osteosarcoma is the most common primary bone malignancy. The prognosis of patients after local recurrence is generally poor and management of the locally recurrent disease is not well defined, especially in patients who have undergone limb-sparing surgery. A 20-year-old male presented a local recurrence of conventional osteosarcoma at the popliteal fossa with encasement of popliteal vascular bundle after previous tumor-wide resection and reconstruction with proximal tibia endoprosthesis. A wide resection "en bloc" of the lesion included part of the popliteal vessel. A bypass of both popliteal vessels, the vein with polytetrafluoroethylene (PTFE) prosthesis, and the artery with contralateral saphenous vein were performed to allow a limb salvage surgery. Local management of recurrent osteosarcoma in a previously reconstructed limb is highly individualized. This case confirms that preservation of lower limb function is possible using reconstruction techniques of bone and vessels in the sarcoma of the musculoskeletal system.

Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children.

Purpose: To explore the application of Custom-made Semi-joint prosthesis replacement combined with Ligament Advanced Reinforcement System (LARS) ligament reconstruction for the limb salvage surgery (LSS) of malignant tumors in the distal femur and provide selections for the LSS of malignant tumors in skeletal immature children. Methods: A total of 8 children with malignant tumors in the distal femur who underwent Custom-made Semi-joint prosthesis replacement combined LARS ligament reconstruction for LSS from January, 2018 until December, 2019 in our bone and soft tissue tumor center were retrospectively recruited. The prosthesis related complications, oncological prognosis and knee function were observed, and the surgical efficacy was comprehensively evaluated. Results: The average follow-up time was 36.6 months (30-50 months). The average osteotomy length was 13.2 cm (8-20 cm) according to the preoperative imaging results and the length of the customized prosthesis. Two years after operation, the average MSTS-93 score was 24.4 (16-29) which indicated good limb functions. The range of motion of the knee was 0°-120°, with an maximum average of 100°. At last follow-up, the average height of the children increased by 8.4 cm (6-13 cm), and the average limb shortening was 2.7 cm (1.8-4.6 cm). One patient had wound complications in the early postoperative period, wound scab fell off to form superficial ulcer, in whom debridement and suturing were performed. One patient developed hematogenous disseminated prosthesis infection 2 years after surgery, and the prosthesis is now in situ with anti-infection treatment. One patient developed pulmonary metastasis during follow-up, and received chemotherapy and targeted therapy with lesion well controlled. At the last follow-up, there was no local tumor recurrence or prosthesis loosening. Conclusion: Under the premise of appropriate case selection, customized semi-joint prosthesis replacement combined with LARS ligament reconstruction provides a new option for LSS in children with distal femur malignant tumors. LARS ligament reconstruction ensures the stability and range of motion of the knee joint, which maximally preserves the epiphysis of the tibia side and the growth function of the tibia side, reduces the complications of limb length inequality in the long term and creates conditions for limb lengthening or total joint replacement in adults.

Does a novel bridging collar in endoprosthetic replacement optimise the mechanical environment for osseointegration? A finite element study.

Introduction: Limb-salvage surgery using endoprosthetic replacements (EPRs) is frequently used to reconstruct segmental bone defects, but the reconstruction longevity is still a major concern. In EPRs, the stem-collar junction is the most critical region for bone resorption. We hypothesised that an in-lay collar would be more likely to promote bone ongrowth in Proximal Femur Reconstruction (PFR), and we tested this hypothesis through validated Finite Element (FE) analyses simulating the maximum load during walking. Methods: We simulated three different femur reconstruction lengths (proximal, mid-diaphyseal, and distal). For each reconstruction length one in-lay and one traditional on-lay collar model was built and compared. All reconstructions were virtually implanted in a population-average femur. Personalised Finite Element models were built from Computed Tomography for the intact case and for all reconstruction cases, including contact interfaces where appropriate. We compared the mechanical environment in the in-lay and on-lay collar configurations, through metrics of reconstruction safety, osseointegration potential, and risk of long-term bone resorption due to stress-shielding. Results: In all models, differences with respect to intact conditions were localized at the inner bone-implant interface, being more marked in the collar-bone interface. In proximal and mid-diaphyseal reconstructions, the in-lay configuration doubled the area in contact at the bone-collar interface with respect to the on-lay configuration, showed less critical values and trends of contact micromotions, and consistently showed higher (roughly double) volume percentages of predicted bone apposition and reduced (up to one-third) percentages of predicted bone resorption. In the most distal reconstruction, results for the in-lay and on-lay configurations were generally similar and showed overall less favourable maps of the bone remodelling tendency. Discussion: In summary, the models corroborate the hypothesis that an in-lay collar, by realising a more uniform load transfer into the bone with a more physiological pattern, creates an advantageous mechanical environment at the bone-collar interface, compared to an on-lay design. Therefore, it could significantly increase the survivorship of endo-prosthetic replacements.

THE MANAGEMENT OF THE VICTIMS WITH GUNSHOT WOUNDS OF THE EXTREMITIES WITH EXTENSIVE DEFECTS OF THE SOFT TISSUES AT THE LEVEL OF QUALIFIED MEDICAL CARE. CASE-SERIES.

OBJECTIVE: The aim: To highlight the original experience of diagnosis and treatment of patients with gunshot wounds of the extremities with extensive defects of the soft tissues. PATIENTS AND METHODS: Materials and methods: The total number of treated patients with massive gunshot wounds from February 2022 to March 2023 was 60 males. Basic labo¬ratory tests, X-rays of the affected limbs were performed to all patients. USS of the vessels with color Doppler was performed to those casualties who had no peripheral pulses on the wounded extremity. All injured persons underwent wound debridement and fasciotomy on the day of admission, 8 more casualties underwent surgical interventions on the major vessels and nerves. RESULTS: Results: Good treatment outcomes for patients with extensive soft tissue injury were achieved by early surgical intervention to remove non-viable tissue. Limb preservation was achieved in 98.3% of cases. CONCLUSION: Conclusions: The study's conclusion emphasizes the importance of a multidisciplinary approach to treating patients with gunshot wounds to the limbs with extensive soft tissue injury. Early surgical interventions with the removal of non-viable tissues are necessary for good outcomes. Revascularization of the affected limb is essential in case of major vessel injury if there is no thread to the life.

Functional results after reconstruction with modular tumor endoprostheses in patients with malignant bone tumors.

INTRODUCTION: The functional outcome in patients after limb salvage surgery, and in particular reconstructions with modular tumor endoprostheses, has been the subject of many international series, but only a few publications mention the functionality in a Bulgarian patient group. AIM: The aim of the present study was to analyze the functional outcome in a Bulgarian group of patients with malignant bone tumors that underwent resection and reconstruction with modular tumor endoprostheses. MATERIALS AND METHODS: Our series consists of 14 patients with malignant bone tumors who underwent limb salvage surgery and reconstruction with modular tumor endoprostheses between February 2012 and January 2021. Staging was done using the AJCC staging system for bone sarcoma. The MSTS score system was used to evaluate the functional results. RESULTS: The mean follow-up time was 38.5 months (range, 8 to 96). The mean MSTS score for our series was 70%. Distant metastases were found in 4 (28%) patients. Local recurrence occurred in 3 (21%) patients. The most severe late complication was a mechanical failure of the expanding mechanism in 1 patient. CONCLUSIONS: Reconstruction with modular tumor endoprostheses offer superb functionality and improved life quality in patients with primary malignant bone tumors.

Limb salvage surgery reconstructive techniques following long-bone lower limb oncological resection: a systematic review and meta-analysis.

BACKGROUND: Limb salvage surgery (LSS) is now considered the gold standard surgical treatment for lower limb bone sarcomas. However, there is a paucity of literature comparing the various LSS reconstructive options. The aim of this systematic review and meta-analysis was to compare functional outcomes and complications of LSS reconstructive techniques. METHODS: The primary aim of the meta-analysis was to determine functional outcomes from the pooled data utilizing the Musculoskeletal Tumour Society score (MSTS). Comparisons could then made for this outcome between biological and prosthetic, vascularised and non-vascularised, and prosthetic and composite reconstructions. The secondary aim was to compare complication outcomes of each reconstruction. Standardized mean difference (Cohen's d) and odds ratios were estimated using a random effects model. RESULTS: Fourteen studies with a total of 785 patients were included. We found structural failure was 75% less likely to occur in prosthetic reconstruction compared to biological (OR = 0.24; 95% CI: 0.07-0.79; P = 0.02). We did not find any evidence of difference in function (MSTS score) between vascularised verses non-vascularised reconstructions (Cohen's d = -1.14; 95% CI = -3.06 to 0.78; I2  = 87%). Other analyses comparing complications found no difference between the reconstructive groups. CONCLUSION: The study found no correlation between functional outcomes and the type of LSS reconstruction. Structural failure was more likely to occur in biological when compared with prosthetic reconstruction. There was no correlation between the incidence of other complications and the type of LSS technique. This suggests a role for improved approaches to reconstruction methods including bioprinting and bioresorbable devices.

Long-Term Outcomes of Limb-Salvage Surgery for Malignant Bone Tumors at a Single Institution in a Developing Country.

INTRODUCTION: With the introduction of neoadjuvant chemotherapy, increased expertise in surgical oncology, and advanced skeletal imaging techniques, limb salvage surgery is becoming the standard of care for treating malignant bone tumors. However, few studies have examined the outcomes of limb salvage surgery with relatively large sample sizes in developing countries. MATERIALS AND METHODS: Therefore, we conducted a retrospective study of 210 patients who received limb salvage surgery at King Hussein Cancer Center in Amman, Jordan, over a follow-up period of 1 to 14.5 years (2006-2019). RESULTS: Negative resection margins occurred in 203 (96.7%) patients and local control occurred in 178 (84.8%) patients. The mean functionality outcome for all patients was 90%, and 153 (72.9%) patients did not experience any complications. The 10-year survival rate for all patients was 69.7%, and the rate of secondary amputations was 4%. CONCLUSION: Therefore, we conclude that the outcomes of limb salvage surgery in a developing country are comparable to those in developed countries when adequate resources and trained orthopedic oncology teams are available.

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review.

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.

Survival and failure modes of the Compress® spindle and expandable distal femur endoprosthesis among pediatric patients: A multi-institutional study.

BACKGROUND: Expandable endoprostheses can be used to equalize limb length for pediatric patients requiring reconstruction following large bony oncologic resections. Outcomes of the Compress® Compliant Pre-Stress (CPS) spindle paired with an Orthopedic Salvage System expandable distal femur endoprosthesis have not been reported. METHODS: We conducted a multi-institutional retrospective study of pediatric patients with distal femoral bone sarcomas reconstructed with the above endoprostheses. Statistical analysis utilized Kaplan-Meier survival technique and competing risk analysis. RESULTS: Thirty-six patients were included from five institutions. Spindle survivorship was 86.3% (95% confidence interval [CI], 67.7-93.5) at 10 years. Two patients had a failure of osseointegration (5.7%), both within 12 months. Twenty-two (59%) patients had 70 lengthening procedures, with mean expansions of 3.2 cm (range: 1-9) over 3.4 surgeries. The expandable mechanism failed in eight patients with a cumulative incidence of 16.1% (95% CI, 5.6-31.5) at 5 years. Twenty-nine patients sustained International Society of Limb Salvage failures requiring 63 unplanned surgeries. Periprosthetic joint infection occurred in six patients (16.7%). Limb preservation rate was 91% at 10 years. CONCLUSIONS: There is a high rate of osseointegration of the Compress® spindle among pediatric patients when coupled with an expandable implant. However, there is a high rate of expansion mechanism failure and prosthetic joint infections requiring revision surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Comparing quality of life in lower extremity tumor patients undergoing limb salvage surgery and amputation: a meta-analysis.

Purpose: Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach. Method: The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures. Results: Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias. Conclusions: QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic.

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.

Management of Paediatric Proximal Tibia Osteosarcoma - A Novel Technique of Preservation of Physeal Growth.

Introduction: Osteosarcoma is a malignant tumor, the treatment of which is controversial between amputation and limb salvage surgery. Osteosarcoma occurring in a child is a challenge to manage due to the arrest of limb and the resultant limb length discrepancy. The management options for a child less than eight years of age are very limited. Case report: We present a case of a six year old child who was diagnosed to have osteosarcoma of proximal tibia. She was started on neoadjuvant chemotherapy, after which, she underwent wide resection and reconstruction with free vascularised fibular graft. The joint was fused using a locking compression plate and screws. The locking screws were inserted avoiding the distal femoral physis, enabling growth of the physis in future. Adjuvant chemotherapy was then given. Follow up radiographs showed Harris growth lines indicating growth to be occurring at the distal femoral physis. She was not found to have recurrence on last follow up four years after surgery. Conclusion: We found reconstruction using free fibular graft and arthrodesis using plate and screws, provided satisfactory results. An attempt can be made to preserve the distal femur physis.

Microsurgical Reconstruction in Orthopedic Tumor Resections as Part of a Multidisciplinary Surgical Approach for Sarcomas of the Extremities.

A central element of modern sarcoma therapy is complete surgical tumor resection with an adequate safety margin, embedded in an interdisciplinary multimodal therapy concept. Along with ensuring patient survival, functional limb preservation is an important goal for sarcomas of the extremities. This review provides an overview of the relevant literature on indications and goals of reconstructive options, the scope and contribution of microsurgical reconstructive procedures, and the associated interdisciplinary decision making and workup. Furthermore, the impact of (neo)-adjuvant therapy on reconstructive decisions will be highlighted. These aspects will be illustrated by four comprehensive case studies that demonstrate both useful strategies and the need for individually tailored therapies. Nowadays, extremity-preserving therapy is possible in more than 90% of sarcomas. Technical and procedural innovations such as microsurgery and microsurgical reconstructive procedures have significantly contributed to this evolution of therapy.

A Retrospective Cohort Analysis of Limb Salvage Surgery Using Mega Prosthesis in Bone Tumours at a Tertiary Care Centre in Eastern India.

Background The method known as "limb salvage surgery" (LSS) aids in the removal of extremity tumours, and reconstruction is completed with satisfactory oncologic, functional, and cosmetic outcomes. Oncologic clearance is given first priority, followed by functional outcomes. Worldwide, the trend has already shifted away from amputations and toward limb salvage surgery for eligible patients due to efficient chemotherapy regimens, improved imaging techniques, precise administration of enhanced radiation, better reconstructive choices, and developments in bio-engineering. The purpose of the present study was to determine the clinicopathological characteristics, surgical techniques, functional outcome, and prognostic factors of limb salvage surgery performed using mega prosthesis in primary malignant or benign resectable tumours. Methods Our retrospective cohort study was carried out over a period of two years and included 28 patients who received care for bone tumours. The data gathered comprised the demographic profile, clinical characteristics, histological characteristics, treatments given, functional results, and survival. LSS was performed on all patients by orthopaedics oncologists trained in the surgical oncology department. Following surgery, during the first two years, patients were examined at every three-month interval, then every six months until the fifth year, and then once a year after that. The Kaplan-Meier method was utilized to determine the median follow-up and recurrence-free survival (RFS). Results In our study, the mean age of study subjects was 30.0±10.9 years. Almost all of the subjects included in the study had lower limb bone tumours (96.4%). The most common site for the tumour was the distal femur (57.1%) followed by the proximal femur (32.2%). The most common type of benign tumour was giant cell tumour (GCT) (53.6%), including recurrences of giant cell tumour (GCT), and among malignant tumours, osteosarcoma was the most common (25.0%). The mean surgical resection of bone in limb salvage surgery was 125.2±24.2 mm. The most common post-operative complication was leg length discrepancy (LLD) among 25.0% of subjects, which was managed by shoe raise. The overall mean musculoskeletal tumour society (MTSS) score after LSS was 25.0±4.3. Using the Kaplan-Meier method analysis, we found that relapse-free survival was 83.7% among enrolled subjects at a median follow-up period of 80 months. Conclusion It can be difficult to surgically treat patients who have malignant bone tumours. In limb-sparing surgery for bone tumours, the modular segmental-replacement system prosthesis that we preferred produced satisfactory results in terms of tumour control and limb function. To get good long-term results, the case selection must be appropriate.