Rekonstruktion knöcherner Defekte in der Knochensarkomchirurgie: Tumorendoprothese vs. biologische Rekonstruktion

Megaendoprostheses in the management of malignant tumors of the lower extremities-risk factors for revision surgery

Abstract

Background

Improved oncological and surgical measures now enable curative treatment of malignant lower extremity tumors in majority of cases. Complication rates associated with surgical resection of lower extremity tumors and replacement with megaendoprostheses are high. The aim of this study was to identify risk factors that predispose to revision surgery following the use of megaimplants in curative treatment of malignant tumors of the lower extremities.

Methods

this retrospective study included patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis for tumors or metastatic lesions of the lower extremities between January 2010 and December 2020. Baseline characteristics and information on adjuvant treatment, hospitalization time, comorbidities, mobility, complications, and revision surgery were considered. Primary outcomes were revision surgery and reasons for revision. Secondary outcomes were in-hospital complications and the duration of hospitalization.

Results

Fifty-four patients (48% female, age 63 years, SD 15) were available for final analysis. Surgeries were performed at hip level in 37 patients (68.5%) and at knee level in 17 patients (31.5%). Revision for wound-related causes was performed in 12 cases (22.2%), with microbiological proof of infection in 8 cases (14.8%). Revision for hip joint instability was carried out in 4 cases (7.4%) and for disconnection between components of the megaimplant in 2 cases (3.7%). Those patients requiring a wound-related revision had undergone a longer primary surgical intervention than those who required an implant-related revision (276 vs 134 min, p = .002). Wound drains after the primary implantation remained longer in situ in patients who later required revision surgery for wound-related complications (5 vs 3 days, p = .020). An ASA > 3 was associated with an increased likelihood for in-hospital complications in general (p = .041), and in-hospital death in particular (p = .012).

Conclusions

The management of malignant tumors of the lower extremities with megaendoprostheses is associated with a high rate of wound-related complications. Swift surgical performance and early postoperative removal of wound drains minimize the risk of complications in general and the necessity of revision surgery in particular. Patients with more comorbidities were more likely to suffer in-hospital complications.

[Complication profile and revision concepts for megaprosthetic reconstruction following tumour resection at the hip]

BACKGROUND

Tumourous destruction of the periacetabular region and the proximal femur is a typical consequence of either primary malignant bone tumour manifestation or skeletal metastatic diseases. Pathological fractures of the proximal femur and periacetabular regions due to primary manifestation or metastatic disorders are frequent.

OBJECTIVES

Presentation of the most common complications of tumour endoprostheses at the hip and a description of management strategies, including therapeutic recommendations and concepts for complication avoidance.

MATERIALS AND METHODS

The current knowledge and our own experience of complication management with the use of megaprostheses around the hip are presented.

RESULTS

Compared to elective/primary total hip arthroplasty, megaprosthetic reconstructions following tumour resections have an increased rate of postoperative deep infections, dislocations, incidence of pathological and periprosthetic fractures and of deep vein thrombosis. The postoperative mortality and local tumour recurrence along with deep infections represent the most serious complications.

CONCLUSIONS

In comparison to primary arthroplasty, the risk of failure and complications following tumour-endoprosthetic replacement is increased. Precise surgical planning and careful selection and preoperative preparation of suitable patients should be performed in close interdisciplinary cooperation with final decision-making on an interdisciplinary tumour board. Wide resection and advanced reconstruction, as well as complicated palliative stabilization due to malignant bone tumour growth around the hip joint should be performed in musculoskeletal tumour centres with profound expertise in osteosynthetic and endoprosthetic reconstruction and consecutive complication management of the pelvis and the proximal femur.

[Specific intraoperative and secondary complications of biological reconstructions following extralesional tumour resections of malignant bone tumours]

BACKGROUND

The treatment of primary malignant bone tumours is interdisciplinary and individually adapted to the patient. Nowadays, limb salvage surgery is usually possible, and the subsequent reconstruction is carried out either by implantation of modular tumour megaprostheses or by biological reconstruction procedures. Special surgical and secondary complications have to be considered.

OBJECTIVES

Indication and explanation of various biological reconstruction procedures and presentation of specific peri- and postoperative complications.

MATERIALS AND METHODS

An adapted literature review and the contribution of our own therapy experiences and case studies for the presentation of biological reconstructions and their complication management was performed.

RESULTS

In biological reconstructions, autografts, allografts or a combination of autografts and allografts are used. Stabilization is achieved with screw and plate osteosyntheses. The most common secondary complications are pseudarthrosis, interponate fracture, graft necrosis and secondary malpositions.

CONCLUSION

In selected cases, particularly at the upper extremities and in dia- or metaphyseal tumour sites, biological reconstruction after extralesional tumor resection is the surgical therapy of choice. The rate of long-term revision interventions is significantly lower compared to modular tumour megaprostheses. Biological reconstructions and the treatment of specific complications have to be performed in specialized centres for musculoskeletal surgical oncology/tumor orthopedics.

Ultra-short stem anchorage in the proximal tibial epiphysis after intercalary tumor resections: analysis of reconstruction survival in four patients at a mean follow-up of 56 months

INTRODUCTION

Tumors localized in the proximal tibial meta-diaphysis often lead to osteoarticular resections.

MATERIALS AND METHODS

In this study, we retrospectively reviewed four patients who underwent intercalary tumor resection and reconstruction using an ultra-short stem in the proximal tibial epiphysis, a procedure that to our knowledge has not been reported in literature so far.

RESULTS

At the time of operation, the mean patient age was 26.2 years. Three patients were male and one was female. Patients were diagnosed with osteosarcoma in two cases, Ewing's sarcoma and malignant fibrous histiocytoma of bone in one case each. In all cases, wide tumor resections were achieved (osteotomy 3-3.5 cm below the tibia plateau joint surface, mean resection length of tibial bone 18 cm) at a mean time of operation of 198.8 min. Two superficial wound-healing disorders occurred, leading to one surgical revision in each case. One local tumor recurrence occurred 12 months after operation in a patient who discontinued his adjuvant chemotherapy. This patient died of disease, 31 months after operation. Three patients are alive with no evidence of disease at a mean follow-up of 56 months. Walking is not impaired and light sports activities have been reported in all cases. The mean MSTS score is 28/30.

CONCLUSIONS

Therefore, we report this reconstruction technique to be considered for special indications where the functional outcome can be improved by preservation of the knee joint in tumors of the proximal meta-diaphyseal tibial region.

Impacts of Tumor Location, Nature and Bone Destruction of Extremity Osteosarcoma on Selection of Limb Salvage Operative Procedure

OBJECTIVE

To study the impacts of tumor location, nature and extent of bone destruction on selection of operative protocol for extremity osteosarcoma (OS).

METHODS

The medical records of 201 patients with extremity OS treated in our institute from December 1999 to June 2014 were retrospectively reviewed. Ninety eligible patients (56 males and 34 females) of average age 20 ± 11 years (range, 4-40 years) were enrolled. Tumor locations were categorized as diaphyseal (4; diaphysis group) or juxta-articular (86); the latter being subclassified as with (51, type III, epiphysis group) or without invasion beyond the epiphyseal line or plate (35, type I and II, metaphysis group) according to MRI images. Tumor nature (osteogenic, 51; osteolytic, 39) was determined radiologically. Extent of bone destruction was quantitated according to Mirel's scoring system to obtain an "invasion score". Regular postoperative follow-up included physical examination and imaging evaluation.

RESULTS

Fifty-four patients underwent biological reconstruction and 36 mechanical reconstruction. The mean follow-up duration was 51 months (range, 6-176 months, including four deaths within 12 months). Biological reconstruction was performed more frequently in the diaphysis and metaphysis groups (31/39, 79.5%) than mechanical reconstruction (8/39, 20.5%, P < 0.05). Biological reconstruction and articular preservation were associated with more satisfactory limb function (MSTS scores: 25.0 ± 3.3 and 25.1 ± 3.6) than mechanical reconstruction and articular resection (MSTS scores: 23.4 ± 3.7 and 23.1 ± 3.4, P < 0.05). Reconstruction methods and articular preservation had no relationship with overall or tumor-free survival (P > 0.05). Osteolytic lesions were associated with more extensive bone destruction than osteogenic lesions according to invasion scores (P < 0.05). Following biological reconstruction, high invasion scores (>8) had a 13.5-fold risk of fracture compared with low scores (≤8) (P < 0.05). Twenty-one subjects had recurrences, 30 metastases and 26 died. Postoperative complications included infection (6), fracture (10), and prosthesis loosening (4). Kaplan-Meier analysis indicated 5- and 10-year survival rates of 68.9% and 62.8%, respectively, and 5- and 10-year tumor-free survival rates of 66.7% and 57.8%, respectively.

CONCLUSION

Selection of limb salvage operative protocol for extremity OS should rely on tumor location, nature and extent of bone destruction. Regardless of tumor site, mechanical reconstruction is indicated for tumors with high invasion scores (>8), whereas biological reconstruction is preferred for those with low invasion scores (≤8). Tumors sparing the epiphyseal line or plate are ideal candidates for articular preservation.

[New surgical treatment options for bone tumors]

Primary bone neoplasms can be classified into benign, locally/aggressive and rarely metastasizing and malignant tumors. Patients with benign tumors usually undergo surgical treatment in cases of local symptoms, mainly consisting of pain or functional deficits due to compression of important anatomical structures, such as nerves or blood vessels. Locally/aggressive and rarely metastasizing tumors exhibit an infiltrative growth pattern, so that surgical treatment is necessary to prevent further destruction of bone leading to local instability. Finally, the surgical treatment of malignant tumors is, with few exceptions, considered to be a prerequisite for long-term survival, either alone or in combination with systemic chemotherapy. Whereas the main objective of surgery in the treatment of benign tumors is relief of local symptoms with a minimum amount of damage to healthy tissue and minimizing the risk of local recurrence while ensuring bone stability in locally aggressive and rarely metastasizing tumors, the primary goal in the operative treatment of bone sarcomas is the resection of the tumor with clear surgical margins followed by defect reconstruction and the preservation of function. This review examines the current developments in the surgical treatment of primary bone neoplasms with respect to the management of the tumors and novel reconstructive options.