Compliance and satisfaction with intensive physiotherapy treatment during chemotherapy in patients with bone tumours and evaluation of related prognostic factors: An observational study.

The purpose of this study was to evaluate compliance and satisfaction of adult patients to intensive rehabilitation treatment during chemotherapy cycles after surgery for bone-musculoskeletal tumours, as well as to identify possible predictive factors. An observational, prognostic, prospective study was conducted. The study enrolled 27 patients who previously had undergone modular knee prosthesis surgery in the period between October 2014 and October 2015. The outcome was compliance to intensive rehabilitation treatment during hospitalisations in the chemotherapy unit and patient satisfaction 6 months' post-surgery. The variables taken into account were linked to the patient's characteristics, to the oncological pathology and to the chemotherapy treatment administered. Patients' compliance was 100% (range, 61-100). The presence of surgery complications (29.6%) produced 5% loss in compliance to treatment; likewise, chemotherapy treatment with prevalent use of ifosfamide reduced compliance to rehabilitation by 6%. The mean patient satisfaction score was 7.9 in the Likert scale from 0 to 10. Intensive physiotherapy starting during chemotherapy administration is a feasible treatment for bone tumour patients that have shown to be able to positively adhere to it. Rehabilitation treatments, within chemotherapy wards, should therefore be promoted according to satisfaction level as reported by patient.

Rotationplasty in adult cancer patients: what is the rehab strategy and what results can be expected? A case study.

BACKGROUND AND AIM: Rotationplasty is an important and demanding challenge for physiotherapists. The aim of this paper is to describe the functional outcome achieved by a patient undergoing rotationplasty in adult age following osteosarcoma. Case description and Methods: The patient was followed throughout the rehabilitation course and the results achieved were recorded at 6, 9 and 12 months after surgery. Findings and outcomes: The results progressively improved in terms of function, functional performance and quality of life. The MSTS and TESS scales showed an improvement respectively of 20 and 23 percentage points, reaching levels of 80% and 87%. The quality of life perceived by the patient increased in the three assessments, the mental health score at one-year follow-up is higher than that expected for the population. CONCLUSIONS: Rotationplasty, even in adult age, produces good results and in the treatment of tumours in adults this operation should be taken into consideration. Clinical relevance Rotationplasty in adult age following osteosarcoma combined with a rehabilitation program enabled a patient to reach a successful outcome in terms of functional performance and quality of life.

Gait analysis in tumor patients after distal femoral resection and implantation of a megaprosthesis.

We analysed nine patients who had had a megaprosthesis implanted into the distal femur and knee joint for treatment of sarcomas. Data obtained from the leg operated on were compared with those from the contralateral side and healthy volunteers. Gait data, kinematics, ground reaction forces and the EMG from five muscles around the knee joint were analysed by means of a video-based analysis system recording data from reflection markers ; a Kistler-plate recorded the GRF and a ten channel surface EMG the muscle activity. Muscle around the knee showed a cocontraction between the extensor and flexor muscles in the thigh and the calf in the operated leg as well as contralaterally. Gait characteristics exhibited a reduced speed, -cadence, and a shorter step. This correlated with a reduced flexion in the hip and knee joint. The GRF exhibited significant changes in the data representing the reduced gait dynamic.

What are the results using the modified trapdoor procedure to treat chondroblastoma of the femoral head?

BACKGROUND: Treatment of chondroblastoma in the femoral head is challenging owing to the particular location and its aggressive nature. There is little published information to guide the surgeon regarding the appropriate approach to treating a chondroblastoma in this location. We developed a modified trapdoor procedure to address this issue. The primary modification is that the window surface of the femoral head is covered by the ligamentum teres rather than cartilage as in the traditional procedure. QUESTIONS/PURPOSES: We assessed (1) the clinical presentation of chondroblastoma of the femoral head and treatment results with the modified trapdoor procedure in terms of (2) the frequency of local recurrence, (3) complications, and (4) functional outcomes using the Musculoskeletal Tumor Society (MSTS) score. METHODS: Between 1999 and 2010, we treated 14 patients for chondroblastoma of the femoral head. All patients received the modified trapdoor procedure. Of those, 13 were available for followup at a minimum of 36 months (mean, 66 months; range, 36-117 months) and one patient was lost to followup. There were nine males and four females, with a mean age of 18 years (range, 9-29 years). Clinical features were ascertained by chart and radiographic review, and recurrence, complications, and functional outcomes (MSTS score) were recorded from chart review. Patterns of bone destruction were evaluated using the Lodwick classification, which ranges from IA (geographic appearance with sclerotic rim) to III (permeative appearance). RESULTS: The symptoms at diagnosis were pain in nine patients and discomfort in four. The mean duration of symptom was 11 months (range, 1-36 months). The physis was open in two patients, closing in one, and closed in 10. The patterns of bone destruction were evaluated as Lodwick Class IA in six patients, Lodwick Class IB in five, and Lodwick Class IC in two. At latest followup, no local recurrence was observed. Two patients had postoperative complications. One had avascular necrosis of the femoral head and was treated with prosthesis replacement. The other had asymptomatic heterotopic ossification in the surgical field. The mean MSTS score was 29.6 (range, 28-30). CONCLUSIONS: Based on this small series, we believe our modified trapdoor procedure is a safe, effective means of treating a chondroblastoma in the femoral head, but additional clinical evaluation with more patients is necessary to confirm our findings. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Endoprosthetic proximal femur replacement: metastatic versus primary tumors.

Few studies have examined the impact of underlying diagnosis on the functional and oncologic outcomes following endoprosthetic proximal femur replacement (PFR). We performed a retrospective review of 61 consecutive cemented bipolar PFR in 59 patients for treatment neoplastic lesions with a minimum follow-up of 24 months. Twenty-two patients had primary bone tumors and 39 had metastatic disease. Average follow-up for the 30 surviving patients was 55.4 months and the mean postoperative survival for the 29 patients who died was 12.2 months. Patients with primary tumors demonstrated significantly better functional outcomes than those with metastatic disease, with mean Musculoskeletal Tumor Society functional scores of 80.2 and 66.8%, respectively (p=0.0002). Age correlated inversely with functional scores (r=-0.48; p=0.0002), while femoral resection length did not. Preoperative pathologic fracture did not appear to adversely impact final functional outcomes. The Kaplan-Meier 5-year implant survival estimate was 92.5%, with aseptic loosening as the endpoint. Both functional results and survival are increased for primary tumors versus metastatic disease following PFR. However, PFR results in excellent local disease control, reliable pain relief and good functional results in both groups, with prosthesis survival exceeding that of the patient in many cases.

Rehabilitation after total femur replacement: a report of 2 cases.

We describe the rehabilitation of 2 patients who underwent total femur replacement after neoplastic involvement of the bone. In the past, patients with cancer of the femur were generally advised to undergo a hip disarticulation or transfemoral amputation. It is now feasible to salvage the limb in selected patients, by excising the entire femur together with any contiguous soft tissue tumor and replacing it with an endoprosthesis. The surgical literature contains a number of reports on total femur replacement, which mention the rehabilitation aspects only briefly, but we found nothing on this relatively uncommon form of surgery in the rehabilitation literature. Physiotherapy techniques such as active assisted exercises, isometric exercises, and hydrotherapy are extremely useful during the early phase of rehabilitation to facilitate a graduated strengthening program. Certain exercises, such as active hip abduction or knee flexion, may not be permitted for several weeks to protect muscles that have been reattached to the prosthesis. Partial weight bearing may be required to allow incorporation of bone allograft around the prosthetic hip joint. Because of these factors patients with total femur replacement may need a longer period of rehabilitation (6-8wk) than patients with total hip or knee replacement. Patients with total femur replacement can, however, achieve full independence with an appropriate rehabilitation program.

Work status after distal femoral Kotz reconstruction for malignant tumors of bone.

OBJECTIVE: To determine the proportion of patients who experienced altered work status after reconstruction with a modular tumor prosthesis and adjuvant chemotherapy for primary sarcoma of the distal femur. DESIGN: We reviewed an institution's tumor database and patients' charts. Disability and work status data were collected preoperatively, at 1 year and 2 years postoperatively and at final follow-up. SETTING: Acute-care teaching hospital in Ontario, Canada. PARTICIPANTS: Thirty-six eligible patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Work status was plotted over time to identify unexpected deviations (based on age and preoperative status), and subjects were assigned to altered work status (defined by detrimental changes in productivity, eg, change from full-time work to not working) or expected work status (defined by ongoing work or students progressing to higher education). Disability was measured with the Toronto Extremity Salvage Score and the Musculoskeletal Tumor Society score. RESULTS: Nine patients (25%) experienced altered work status. There were no significant differences in disability ratings or demographic information between the 2 groups. Baseline job demand and living environment (rural vs urban, P=.001) were predictive by logistic regression. CONCLUSIONS: Patients with physically demanding jobs, and those living rurally, are at greatest risk for altered work status.

Deterioration of balance control after limb-saving surgery.

OBJECTIVE: Evaluation of the changes in balance control observed in patients after limb-saving surgery for malignant tumors of the lower limb. DESIGN: Case series. RESULTS: In 11 patients who underwent limb-saving surgery and 10 healthy, age-matched controls, displacement of the amplitude of the center of pressure (ACP) and velocity of the center of pressure (VCP) during normal standing and standing on a balance board were registered. Adding such constraints as standing with eyes closed and performing a Stroop task made standing more complex. During normal standing and on the balance board, both groups showed comparable ACP and VCP values. With eyes closed, both patients and controls showed a higher amplitude and velocity in the anterior-posterior direction. In the patient group, the Stroop task affected the ACP (4.5 +/- 0.8 mm) compared with normal standing (2.9 +/- 0.4 mm) and VCP (18.6 +/- 3.0 mm/sec) compared with normal standing (11.9 +/- 1.0 mm/sec). During balance board standing, the authors found a difference in the VCP for both groups whose eyes were closed and who performed under dual-task conditions (controls, 23.2 +/- 3.3 and 14.9 +/- 2.9 mm/sec; patients, 80.1 +/- 12.9 and 23.6 +/- 3.4 mm/sec). CONCLUSIONS: Although the patient group showed impressive upright standing after limb-saving surgery, upright standing become more difficult under higher visual and cognitive loads. This finding indicates that the level of postural automatism is not complete in these patients.

A functional analysis of massive knee replacement after extra-articular resections of primary bone tumors.

We performed a functional analysis of massive knee replacements after extra-articular resection of primary bone tumors. Patients did not score as highly on the Musculoskeletal Tumour Society Score and Knee Society Score (P < or = .01) as patients who had undergone intra-articular resection. Lower scores were achieved for emotional acceptance (P < or = .01), functional restriction (P < or = .05), walking distance (P < or = .05), and managing stairs (P < or = .05). These patients had a significantly greater extension lag (P < or = .01) and greater fixed flexion (P < or = .05). This functional deficit is primarily due to a compromised extensor mechanism inherent in the type of surgical resection necessary to achieve adequate removal of the tumor.

Giant cell tumor of bone: oncological and functional results of long-term follow-up.

BACKGROUND: Giant cell tumor (GCT) of bone is a rare and unpredictable lesion. Its standard treatment has ranged from surgical curettage to wide resection and varying oncological and functional results have been reported. METHODS: A retrospective review of 47 patients (17 males and 30 females) with GCT of bone was performed to evaluate the oncological and functional results. The patients were followed up for at least 5 years. The average age of the patients was 32 years (range 15-66 years). The tumor sites were distal femur in 15 cases, proximal tibia in 10, distal radius in five, spinal column in four, proximal femur in three, proximal humerus in three, proximal fibula in two, pelvis in two and others in three. Enneking's surgical stages were Stage 1 in three, Stage 2 in 34 and Stage 3 in 10 cases. In these 47 patients, 80 surgical procedures were performed. RESULTS: The rate of local recurrence was 75% in the 28 patients undergoing intralesional excision, 50% in those receiving excision and curettage and 0% in those receiving wide resection. Although there was no statistical significance, surgical stages tended to be correlated with the local recurrence rate (Stage 1, 0%; Stage 2, 53%; Stage 3, 70%). Functional evaluation was performed according to the most recent system of the Musculoskeletal Tumor Society. Functional results of the patients with extremity tumors were 28.2 (average) in those undergoing intralesional excision, 30 (average) in those receiving excision and curettage and 27.1 (average) in those receiving wide resection. Functional results were significantly correlated with the initial surgical stages (Stage 1, 30; Stage 2, 27.5; Stage 3, 24.4; Kruskal-Wallis test, P = 0.016). CONCLUSIONS: To preserve good function of the extremities and avoid local recurrence, we consider that intralesional excision with adjunctive therapy such as phenol cauterization should be employed for the treatment of benign GCT of bone.

Reconstruction of bone defect using the bone transport technique for a case of osteosarcoma of the femur.

There are few reports on skeletal reconstruction using the bone transport technique to repair bone defects caused by resections of tumors associated with osteosarcoma. We attempted to reconstruct a 23 cm bone defect after resection of an osteosarcoma of the left femur, and succeeded in gaining 17 cm by bone transport. Five years after surgery, this patient remains alive without metastasis or local recurrence.

First clinical experience with a noninvasively extendable endoprosthesis: a limb-saving procedure in children suffering from a malignant bone tumor.

A modular endoprosthetic system that can be extended noninvasively has been applied for the first time in a growing child who underwent a tumor resection in his leg. The main goal of the study was to test the extendable mechanism that noninvasively corrects leg length differences caused by growth disturbances of the affected leg. The use of this endoprosthetic system resulted in good restoration of function. Six extensions were performed resulting in 19.5 mm of prosthetic growth. Unfortunately, an ingrown toenail caused infection of the endoprosthesis, and the infection necessitated extirpation of the prosthesis 15 months postoperatively. Two months later the patient died of acute leukemia. Analysis of the endoprosthesis revealed some manufacturing shortcomings, none of which impaired the function of the endoprosthesis.

[Stabilizing procedures in tumor-induced bone defects of the pelvis and extremities]. / Stabilisierungsverfahren bei tumorbedingten Knochendefekten des Beckens und der Extremitäten.

With malignant tumors of the skeleton the same therapeutic limb-saving guidelines must apply for the proximal sections of the locomotor system--the shoulder and pelvic girdles--as for the limbs themselves, especially since amputation here can hardly be surpassed by other resectional interventions with respect to operative risk, disfigurement and functional loss. The possibilities of surgical therapy for tumorous invasion of the pelvic girdle and the extremities are considered in some detail.

Knee function after operation for malignancy of the distal femur. Quadriceps muscle mass and knee extension strength in 21 patients with hinged endoprostheses.

We evaluated quadriceps muscle mass and knee extension strength in 21 patients after resection and endoprosthetic replacement of the distal femur for malignant bone tumor. In all cases, a modular cementless, hinged prosthesis had been used. The mean follow-up period was 4 (2-9) years. Muscle mass was measured ultrasonographically, and strength isokinetically with a Cybex 6000 dynamometer. All the data for the operated side are given as percentage of the non-operated side. The average quadriceps mass was 48 (27-70) percent. The average peak torque was 31 (14-48) and 36 (18-55) percent at the speed of 30 degrees/s and 90 degrees/s, respectively. The reduction in extension strength became greater with increasing flexion. There was a moderate correlation between muscle mass and muscle strength. Most of the patients who had kept more than 40 percent of the quadriceps mass had more than 30 percent peak torque. Patients with excellent function (Enneking 1987) had more quadriceps muscle mass and higher strength than those that were merely good with the borderline at about 40 percent muscle mass.

Gait analysis in patients after Van Nes rotationplasty.

Gait was analyzed through kinetic, kinematic, and temporal-distance parameters assessment to evaluate the functional performance of ten children treated by the classical Van Nes rotationplasty (VNR). Van Nes rotationplasty is a surgical procedure, which permits the conversion of the ankle joint into a "pseudo-knee" joint. The data were compared with measurements of a normal population of ten healthy subjects. Significant differences with respect to the normal were found in stride duration, stride length, cadence, velocity, and stance-swing ratio, and in ground-reaction forces parameters, which define the propulsive phase in the prosthetic side and the acceptance phase in the sound side. There were differences in some kinematic parameters as well. Van Nes rotationplasty is acceptable from a biomechanical-functional point of view, particularly with respect to the active control of the pseudo-knee, which allows a smooth and coordinate gait pattern.

Assessment of patient function after limb-sparing surgery.

Cancer rehabilitation is becoming more of a focus for the field of physiatry due to increased longevity and the side effects of treatment. In order to investigate the rehabilitation needs of patients undergoing limb-sparing procedures, chart analysis was conducted on 17 children treated for primary bone tumors by resection and an expandable endoprosthetic replacement. Each patient underwent a course of postoperative inpatient and outpatient physical therapy and was followed over an average of 2.5 years. Gait training was relatively straightforward and in seven patients required neither orthosis nor ambulatory aid. The other ten patients walked with a knee orthosis, axillary crutches, or both. Until the time came for reoperation to lengthen the implant, a shoe lift of 1in maximum was added to compensate for the limb length discrepancy. These findings compare favorably with the more complex requirements of high proximal amputees with external prostheses, including more difficult gait training and the need for frequent adjustments, as well as prosthetic replacement as the children grow. It is clear that children undergoing limb-sparing surgery have special needs that should be addressed, including early mobilization, gait training, adjustment to repeated brief hospitalizations for lengthening, and continued follow-up to monitor their activity restriction.

Reconstruction of the proximal femur with a vascular pedicle iliac crest graft after tumour resection.

A useful method of reconstruction of the proximal femur after tumour resection is described. An anterior iliac crest bone graft with an intact vascular supply based on the deep circumflex iliac vascular bundle is used to fill the bone defect. It is swung down to the femur behind the iliopsoas muscle and locked into place in the femur. Sixteen cases of locally aggressive tumours have been resected and reconstructed by this method. Follow-up for five to eight years shows good reconstitution of the femur and hip function without recurrence.

[Experience with modular system tumor prostheses]. / Tapasztalataink modulár rendszerü tumorprotéziseinkkel.

Authors elaborated a modular tumor prosthesis by the use of which the bone segment lost after the resection of hip, femur, knee and proximal tibial tumors can be supplemented in the desired measure. The components of the prosthesis set and the field of its use are described. In the last one and half year modular tumor prostheses were inserted in 10 patients: in 6 primary bone tumors and 4 solitary metastases. One shoulder, 5 hip, 3 stiff knee and 1 tibia diaphysis supplementing modular prostheses were inserted. In spite of 2 complications the initial experiences are encouraging, and in adequate indication the possibility of retaining limb and articular function beside good functional results is given.