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Hovav O, Kolonko S, Zahir SF, Velli G, Chouhan P, Wagels M. Limb salvage surgery reconstructive techniques following long-bone lower limb oncological resection: a systematic review and meta-analysis. ANZ J Surg 2023; 93:2609-2620. [PMID: 36821561 DOI: 10.1111/ans.18335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
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.
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Affiliation(s)
- Oliver Hovav
- Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- The Australian Centre for Complex Integrated Surgical Solutions, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Kolonko
- Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Syeda Farah Zahir
- Princess Alexandra Hospital Library and Knowledge Centre, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Gina Velli
- Department Plastic and Reconstructive Surgery, Sunshine Coast, Sunshine Coast University Hospital, Queensland, Australia
| | - Prem Chouhan
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Department of Plastic Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Michael Wagels
- Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- The Australian Centre for Complex Integrated Surgical Solutions, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
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Huang M, Ma Z, Yu J, Lu Y, Chen G, Fan J, Li M, Ji C, Xiao X, Li J. Does joint-sparing tumor resection jeopardize oncologic and functional outcomes in non-metastatic high-grade osteosarcoma around the knee? World J Surg Oncol 2023; 21:185. [PMID: 37344861 DOI: 10.1186/s12957-023-03045-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/25/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND We previously reported joint-sparing tumor resection for osteosarcoma with epiphyseal involvement in which transepiphyseal osteotomy went through the in situ ablated epiphysis. However, we do not know whether this is a safe approach when compared with joint-sacrificed tumor resection. Our objective was to compare oncologic and functional outcomes between patients who underwent joint preservation (JP) and joint replacement (JR) tumor resection. Furthermore, we identified the risk factors of local recurrence, metastasis and survival. METHODS Eighty-nine patients with non-metastatic high-grade osteosarcoma around the knee were treated with limb-salvage surgery (JP in 47 and JR in 42). Age, gender, tumor location, pathologic fracture, plain radiographic pattern, limb diameter change, perivascular space alteration, surgical margin, local recurrence, metastasis, death, and the Musculoskeletal Tumor Society (MSTS)-93 scores were extracted from the records. Univariate analysis was performed to compare oncologic and functional outcomes. Binary logistic and cox regression models were used to identify predicted factors for local recurrence, metastasis, and survival. RESULTS Local recurrence, metastasis and overall survival were similar in the JP and JR group (p = 0.3; p = 0.211; p = 0.143). Major complications and limb survival were also similar in the JR and JP group (p = 0.14; p = 0.181). The MSTS score of 27.06 ± 1.77 in the JP group was higher than that of 25.88 ± 1.79 in the JR group (p = 0.005). The marginal margin of soft tissue compared with a wide margin was the only independent predictor of local recurrence (p = 0.006). Limb diameter increase and perivascular fat plane disappearance during neoadjuvant chemotherapy were independent predictors for metastasis (p = 0.002; p = 0.000) and worse survival (p = 0.000; p = 0.001). CONCLUSIONS Joint-sparing tumor resection with the ablative bone margin offers advantage of native joint preservation with favorable functional outcomes while not jeopardizing oncologic outcomes compared with joint-sacrificed tumor resection. Surgeon should strive to obtain adequate soft tissue surgical margin decreasing risk of local recurrence. Novel drug regimens might be reasonable options for patients with obvious limb diameter increase and perivascular fat disappearance during chemotherapy.
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Affiliation(s)
- Mengquan Huang
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Ziyang Ma
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Jie Yu
- Department of Orthopedics, 986 Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Yajie Lu
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Guojing Chen
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Jian Fan
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Minghui Li
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Chuanlei Ji
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China
| | - Xin Xiao
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China.
| | - Jing Li
- Department of Orthopedics, Xi Jing Hospital, Air Force Medical University, Shaanxi, 710032, Xi'an, People's Republic of China.
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Chen G, Li M, Xiao X, Ji C, Huang M, Wang Z, Lu Y, Li J. A classification system of joint-salvage tumor resection in osteosarcoma of the knee: A retrospective cohort study. Knee 2023; 41:221-231. [PMID: 36731182 DOI: 10.1016/j.knee.2023.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/25/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Joint-preserving surgery is possible for patients with juxta-articular osteosarcoma of the knee, even when the tumor invades the epiphysis. Oncologic and functional outcomes may vary due to the extent of tumor invasion, the amount of epiphysis preservation, and reconstruction methods. We aimed to introduce a novel classification facilitating clinical evaluation of different surgical treatments. METHODS We identified 52 patients with osteosarcoma of the knee undergoing joint-preserving tumor resection and intercalary reconstruction. We classified procedures into two types and six subtypes based on the tumor location and adjuvant treatment employed. Oncologic outcomes, limb function and complications were compared among different types. RESULTS None of the patients had a local recurrence in the preserved epiphysis apart from three (5.7 %) who had local recurrence in soft tissue. Overall survival rate of the patients was 82.7 % at 5 and 10 years. There was no difference in survival rate (P = 0.909), local recurrence (P = 0.642) between type I (tumor not invading epiphysis) and type II (tumor invading epiphysis). In addition to one skin necrosis in the 3D-printed prosthesis reconstruction and one infection in Capanna reconstruction, all complications necessitating additional surgery occurred in allograft. The Musculoskeletal Tumor Society (MSTS) scores ranged from 21 to 30 with a median of 26. There were differences in the MSTS scores among six subgroups (P = 0.015), with the highest in type Ia and the lowest in type IIc. The less of the viable epiphysis retained, the worse the knee function was at long-term follow up. CONCLUSIONS The suggested classification can guide surgical strategy and is convenient for comparison of the functional results.
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Affiliation(s)
- Guojing Chen
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Minghui Li
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Xin Xiao
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Chuanlei Ji
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Mengquan Huang
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Zhen Wang
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Yajie Lu
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China.
| | - Jing Li
- Department of Bone Oncology, Xi Jing Hospital, Air Force Medical University, Xi'an, Shaanxi, People's Republic of China.
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Raux S, Ducrot C, Marec-Bérard P, Corradini N, Claude L, Dijoud F, Picard C, Bouhamama A, Chotel F. Epiphyseal-sparing biological reconstruction of bone sarcoma in children: Focus on articular function and growth. Orthop Traumatol Surg Res 2022; 109:103540. [PMID: 36592656 DOI: 10.1016/j.otsr.2022.103540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/09/2022] [Accepted: 10/19/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Epiphyseal preservation surgery and biological reconstruction after resection of metaphyseal bone sarcoma in children is a surgical challenge which can only be justified if future joint function is maintained. HYPOTHESIS The main hypothesis of this work was that long-term function was maintained. The secondary hypotheses were that local control of the disease and growth restoration were achieved, at the cost of an acceptable number of complications. MATERIAL AND METHOD This was a retrospective study of 14 children with a median age of 8 years [2-14] at the time of surgery. The tumors (Ewing's sarcoma or osteosarcoma) were mostly situated at the knee (n=9) and hip (n=3). The reconstruction used an induced membrane (n=7) or an allograft (n=7). We studied joint function, mechanisms contributing to loss of growth, surgical complications and survival at the last follow-up. RESULTS At the median follow-up of 76 months [24-130], 9 out of 14 patients required revision for non-union, and 4 of them required a second revision. At the last follow-up, 82% of the length had been restored, due to 3 bone lengthenings and 7 contralateral epiphysiodeses. Preserved joint function was excellent with an average modified MSTS score of 28.3/30 [24-30]. No local recurrence was reported. DISCUSSION Our experience of epiphyseal preservation allows local control of the disease and very good function but at the cost of a cumbersome surgical program (12 out of 14 patients were reoperated on, with an average of 1.2 interventions per patient). The main difficulty is the growth management, most often by complex programs of alternating bone lengthening and shortening. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Sébastien Raux
- Hôpital Femme Mère Enfant, 59, boulevard Pinel, 69677 Bron, France.
| | - Coline Ducrot
- Hôpital Femme Mère Enfant, 59, boulevard Pinel, 69677 Bron, France
| | | | | | - Line Claude
- Institut d'Hématologie et Oncologie Pédiatrique, Lyon, France
| | | | - Cécile Picard
- Hôpital Femme Mère Enfant, 59, boulevard Pinel, 69677 Bron, France
| | - Amine Bouhamama
- Institut d'Hématologie et Oncologie Pédiatrique, Lyon, France
| | - Franck Chotel
- Hôpital Femme Mère Enfant, 59, boulevard Pinel, 69677 Bron, France
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He G, Dai AZ, Mustahsan VM, Shah AT, Li L, Khan JA, Bielski MR, Komatsu DE, Kao I, Khan FA. A novel method of light projection and modular jigs to improve accuracy in bone sarcoma resection. J Orthop Res 2022; 40:2522-2536. [PMID: 35245391 DOI: 10.1002/jor.25300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023]
Abstract
We developed a novel method using a combined light-registration/light-projection system along with an off-the-shelf, instant-assembly modular jig construct that could help surgeons improve bone resection accuracy during sarcoma surgery without many of the associated drawbacks of 3D printed custom jigs or computer navigation. In the novel method, the surgeon uses a light projection system to precisely align the assembled modular jig construct on the bone. In a distal femur resection model, 36 sawbones were evenly divided into 3 groups: manual-resection (MR), conventional 3D-printed custom jig resection (3DCJ), and the novel projector/modular jig (PMJ) resection. In addition to sawbones, a single cadaver experiment was also conducted to confirm feasibility of the PMJ method in a realistic operative setting. The PMJ method improved resection accuracy when compared to MR and 3DCJ, respectively: 0.98 mm versus 7.48 mm (p < 0.001) and 3.72 mm (p < 0.001) in mean corner position error; 1.66 mm versus 9.70 mm (p < 0.001) and 4.32 mm (p = 0.060) in mean maximum deviation error; 0.79°-4.78° (p < 0.001) and 1.26° (p > 0.999) in mean depth angle error. The PMJ method reduced the mean front angle error from 1.72° to 1.07° (p = 0.507) when compared to MR but was slightly worse compared to 0.61° (p = 0.013) in 3DCJ. The PMJ method never showed an error greater than 3 mm, while the maximum error of other two control groups were almost 14 mm. Similar accuracy was found with the PMJ method on the cadaver. A novel method using a light projector with modular jigs can achieve high levels of bone resection accuracy, but without many of the associated drawbacks of 3D printed jigs or computer navigation technology.
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Affiliation(s)
- Guangyu He
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Amos Z Dai
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Vamiq M Mustahsan
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Aadit T Shah
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Liming Li
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | | | - Michael R Bielski
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - David E Komatsu
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Imin Kao
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Fazel A Khan
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
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Huang S, Li H, Xing Z, Ji T, Guo W. Factors Influencing Nonunion and Fracture Following Biological Intercalary Reconstruction for Lower-Extremity Bone Tumors: A Systematic Review and Pooled Analysis. Orthop Surg 2022; 14:3261-3267. [PMID: 36263968 PMCID: PMC9732628 DOI: 10.1111/os.13546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To determine nonunion rate, fracture rate, and their risk factors following biological intercalary reconstruction for lower extremity bone tumors. METHODS A systematic review and pooled analysis were conducted. PubMed, Embase, and Wiley Cochrane Library were searched from inception up to June 01, 2020. Studies concerning biological intercalary reconstruction after resection of lower extremity bone tumors were included. Overall nonunion and fracture rates were calculated. For studies reporting patient outcomes individually with precise graft characteristics and fixation methods, the individual data were extracted. Patients with demographical and clinical characteristics, including age, sex, tumor location, graft characteristics, and fixation method, were pooled for a multivariate analysis. For each factor of interest, odds ratio (OR), 95% confidence interval (95% CI), and p-value from logistic regression were reported. RESULTS A total of 2776 articles were identified from the initial literature search and 76 studies (2052 patients) were included. Sixty-nine studies were case series and seven were comparative studies. The overall nonunion rate was 19% (382/2052; range: 0%-53%), and the overall fracture rate was 17% (344/2052; range: 0%-75%). Thirty of the 76 studies (362 patients) reported patients' characteristics individually and were thus included in the pooled multivariate analysis. Intramedullary nail fixation was associated with a significantly higher nonunion rate compared to plate fixation (OR = 2.2, 95% CI: 1.23-4.10, p = 0.009). Reconstruction with a vascularized fibula graft had a statistically non-significant lower nonunion rate than reconstruction without the graft (OR = 0.6, 95% CI: 0.34-1.07, p = 0.086). Devitalized autografts had a lower fracture risk than allografts (OR = 0.3, 95% CI: 0.14-0.64, p = 0.002), and males tended to have higher fracture risk than females (OR = 2.1, 95% CI: 1.00-4.44, p = 0.049). CONCLUSIONS Reconstruction with intramedullary nail fixation is related to an elevated risk of nonunion. Allografts and males have a higher fracture risk than devitalized autografts and females, respectively. Further high-quality comparative analyses with large sample sizes and adequate follow-up duration are needed to validate these findings.
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Affiliation(s)
- Siyi Huang
- Musculoskeletal Tumor CenterPeking University People's HospitalBeijingChina,Key Laboratory for Musculoskeletal Tumor of BeijingBeijingChina
| | - Hongfei Li
- Department of StatisticsUniversity of ConnecticutStorrsConnecticutUSA
| | - Zhili Xing
- Department of OrthopedicsPeking University International HospitalBeijingChina
| | - Tao Ji
- Musculoskeletal Tumor CenterPeking University People's HospitalBeijingChina,Key Laboratory for Musculoskeletal Tumor of BeijingBeijingChina
| | - Wei Guo
- Musculoskeletal Tumor CenterPeking University People's HospitalBeijingChina,Key Laboratory for Musculoskeletal Tumor of BeijingBeijingChina
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Crenn V, Quinette Y, Bouthors C, Missenard G, Viard B, Anract P, Boisgard S, Mascard E, Gouin F. Intercalary allograft reconstruction following femoral tumour resection: mid- and long-term results and benefits of adding a vascularised fibula autograft. World J Surg Oncol 2022; 20:195. [PMID: 35698130 PMCID: PMC9195446 DOI: 10.1186/s12957-022-02650-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 05/24/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Bone healing in femoral reconstructions using intercalary allografts can be compromised in a tumour context. There is also a high revision rate for non-union, infection, and fractures in this context. The advantages and disadvantages of an associated vascularised fibula graft (VFG) are still a matter of debate. Methods In a multicentre study, we retrospectively analysed 46 allograft reconstructions, operated on between 1984 and 2017, of which 18 were associated with a VFG (VFG+) and 28 without (VFG−), with a minimum follow-up of 2 years. We determined the cumulative probability of bone union as well as the mid- and long-term revision risks for both categories by Kaplan-Meier survival analysis and a multivariate Cox model. We also compared the MSTS scores. Results Significant differences in favour of VFG+ reconstruction were observed in the survival analyses for the probability of bone union (log-rank, p = 0.017) and in mid- and long-term revisions (log-rank, p = 0.032). No significant difference was observed for the MSTS, with a mean MSTS of 27.6 in our overall cohort (p = 0.060). The multivariate Cox model confirmed that VFG+ was the main positive factor for bone union, and it identified irradiated allografts as a major risk factor for the occurrence of mid- and long-term revisions. Conclusion Bone union was achieved earlier in both survival and Cox model analyses for the VFG+ group. It also reduced the mid- and long-term revision risk, except when an irradiated allograft was used. In case of a tumour, we thus recommend using VFG+ from a fresh-frozen allograft, as it appears to be a more reliable long-term option. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02650-x.
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Affiliation(s)
- Vincent Crenn
- Service de Chirurgie Orthopédique, CHU de Nantes, Place Alexis Ricordeau, 44000, Nantes, France. .,INSERM, UMR 1238, Phy-Os, Université de Nantes, Nantes, France.
| | - Yonis Quinette
- Service de Chirurgie Orthopédique, CHU de Nantes, Place Alexis Ricordeau, 44000, Nantes, France
| | - Charlie Bouthors
- Service de Chirurgie Orthopédique, APHP/CHU Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Gilles Missenard
- Service de Chirurgie Orthopédique, APHP/CHU Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Brice Viard
- Service de Chirurgie Orthopédique, APHP/CHU Kremlin-Bicêtre, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Philippe Anract
- Service de Chirurgie Orthopédique, AP-HP/Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Stéphane Boisgard
- Service de Chirurgie Orthopédique, CHU Gabriel Montpied, 58 rue Montalembert, 63000, Clermont-Ferrand, France
| | - Eric Mascard
- Département de Chirurgie Orthopédique Pédiatrique, APHP/Hôpital Necker, 149 rue de Sèvres, 75015, Paris, France
| | - François Gouin
- Service de Chirurgie Orthopédique, CHU de Nantes, Place Alexis Ricordeau, 44000, Nantes, France.,INSERM, UMR 1238, Phy-Os, Université de Nantes, Nantes, France.,Département de Chirurgie, Centre Léon Bérard, 28 rue Laennec, 69008, Lyon, France
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Li J, Lu Y, Chen G, Li M, Xiao X, Ji C, Wang Z, Guo Z. Cryoablation-aided joint retention surgery for epiphysis involvement in osteosarcoma compared with endoprosthetic replacement. Bone Joint J 2021; 103-B:1421-1427. [PMID: 34334045 DOI: 10.1302/0301-620x.103b8.bjj-2020-2528.r2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes. METHODS A total of 22 patients who had localized osteosarcoma with epiphyseal involvement around the knee and underwent limb salvage surgery were allocated to joint preservation (JP) group and joint arthroplasty (JA) group. Subjects were followed with radiographs, Musculoskeletal Tumor Society (MSTS) score, and clinical evaluations at one, three, and five years postoperatively. RESULTS Patients in both groups (ten in JP and 12 in JA) did not differ in local recurrence (p ≥ 0.999) and occurrence of metastases (p ≥ 0.999). Overall survival was similar in both groups (p = 0.858). Patients in the JP group had less range of motion (ROM) of the knee (p < 0.001) and lower MSTS scores (p = 0.010) compared with those of the JA group only at one year postoperatively. There was no difference between groups either at three years for ROM (p = 0.185) and MSTS score (p = 0.678) or at five years for ROM (p = 0.687) and MSTS score (p = 0.536), postoperatively. Patients in the JA group tended to have more complications (p = 0.074). Survival of primary reconstruction in the JP group was better than that of the JA group (p = 0.030). CONCLUSION Cryoablation-aided joint-sparing surgery offers native joint preservation with comparable functional recovery and more durable reconstruction without jeopardizing oncological outcomes compared with conventional limb salvage surgery. Cite this article: Bone Joint J 2021;103-B(8):1421-1427.
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Affiliation(s)
- Jing Li
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Yajie Lu
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Guojing Chen
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Minghui Li
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Xin Xiao
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Chuanlei Ji
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Zhen Wang
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
| | - Zheng Guo
- Orthopaedic Department, Xi Jing Hospital Affiliated to the Air Force Medical University of PLA, Xi'an, China
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Computer-assisted surgical planning of complex bone tumor resections improves negative margin outcomes in a sawbones model. Int J Comput Assist Radiol Surg 2021; 16:695-701. [PMID: 33725339 DOI: 10.1007/s11548-021-02337-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/25/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE Several technologies have been implemented in orthopedic surgery to improve surgical outcomes, usually focusing on more accurate execution of a surgical plan, but the development of the plan itself is also of great importance. The purpose of this study is to examine whether the use of preoperative computer planning platforms can improve the surgical plan? METHODS Eight surgeons created a preoperative surgical plan to resect a distal femur parosteal osteosarcoma in two settings: (1) Using a 2-D and 3-D CT scan only (current standard); and (2) using a computer-assisted planning platform. The plans were thereafter virtually executed using a novel surgical navigation system and a Sawbones model. This simulated model was derived from, and identical to, an actual patient scenario. The outcomes of interest were the number of positive margin cuts, and the volume of the resected specimen. RESULTS Using the surgical plan developed with computer assistance, there were 4 positive margin cuts made by 2 surgeons. In comparison, using standard planning, there were 14 positive margin cuts made by all 8 surgeons (p = 0.02). The resection volume was larger in the computer-assisted plans (96 ± 10 mm3) than in the standard plans (88 ± 7 mm3) (p = 0.055). CONCLUSIONS Computer-assisted planning significantly decreased the risk of a positive margin resection in this Sawbones tumor model used to simulate resection of a primary bone sarcoma. This proof of concept study highlights the importance of advanced surgical planning and sets the ground for developing beneficial surgical planning systems.
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Othman S, Bricker JT, Azoury SC, Elfanagely O, Weber KL, Kovach SJ. Allograft Alone vs. Allograft with Intramedullary Vascularized Fibular Graft for Lower Extremity Bone Cancer: A Systematic Review and Meta-Analysis. J Plast Reconstr Aesthet Surg 2020; 73:1221-1231. [DOI: 10.1016/j.bjps.2020.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/09/2020] [Indexed: 12/30/2022]
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11
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Sanders PTJ, Spierings JF, Albergo JI, Bus MPA, Fiocco M, Farfalli GL, van de Sande MAJ, Aponte-Tinao LA, Dijkstra PDS. Long-Term Clinical Outcomes of Intercalary Allograft Reconstruction for Lower-Extremity Bone Tumors. J Bone Joint Surg Am 2020; 102:1042-1049. [PMID: 32265356 DOI: 10.2106/jbjs.18.00893] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Improved survival rates for patients with primary bone tumors of the extremities have increased the demand for reliable and durable reconstruction techniques. Some authors have stated that, after successful ingrowth, allografts are a durable long-term solution. This hypothesis is largely based on small studies with short-to-midterm follow-up. In order to determine the durability of intercalary allograft reconstructions in the lower extremities, we evaluated the long-term clinical outcomes at a minimum of 10 years. METHODS All patients who received an intercalary allograft reconstruction in a lower extremity between 1980 and 2006 were included in this retrospective multicenter cohort study. One hundred and thirty-one patients with a median age of 19 years were included. Eighty-nine (68%) had a femoral reconstruction, and 42 (32%) had a tibial reconstruction. The most prevalent diagnoses were osteosarcoma (55%), Ewing sarcoma (17%), and chondrosarcoma (12%). The median follow-up was 14 years. A competing risk model was employed to estimate the cumulative incidences of mechanical failure and infection. Patient mortality or progression of the disease was used as a competing event. RESULTS Nonunion occurred in 21 reconstructions (16%), after a median of 16 months, and was associated with intramedullary nail-only fixation (p < 0.01) and fixation with nonbridging plate(s) (p = 0.03). Allograft fracture occurred in 25 reconstructions (19%) after a median of 42 months (range, 4 days to 21.9 years). Thirteen (52%) of the allograft fractures occurred within 5 years; 8 (32%), between 5 and 10 years; and 4 (16%), at >10 years. With failure for mechanical reasons as the end point, the cumulative incidences of reconstruction failure at 5, 10, and 15 years were 9%, 14%, and 21%, respectively. CONCLUSIONS Intercalary allograft reconstruction is an acceptable reconstructive option, mainly because of the absence of superior alternatives with a known track record. However, a considerable and continuing risk of mechanical complications should be taken into account. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- P T J Sanders
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands
| | - J F Spierings
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands
| | - J I Albergo
- Carlos E. Ottolenghi Institute of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M P A Bus
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands
| | - M Fiocco
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands.,Leiden University Mathematical Institute, Leiden, the Netherlands
| | - G L Farfalli
- Carlos E. Ottolenghi Institute of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M A J van de Sande
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands
| | - L A Aponte-Tinao
- Carlos E. Ottolenghi Institute of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P D S Dijkstra
- Departments of Orthopaedic Surgery (P.T.J.S., J.F.S., M.P.A.B., M.A.J.v.d.S., and P.D.S.D.) and Medical Statistics and Biomedical Sciences (M.F.), Leiden University Medical Center, Leiden, the Netherlands
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12
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Salunke AA, Shah J, Chauhan TS, Parmar R, Kumar A, Koyani H, Garg N, Bhole M, Merja M, Pandit J, Pandya S, Kamani M. Reconstruction with biological methods following intercalary excision of femoral diaphyseal tumors. J Orthop Surg (Hong Kong) 2020; 27:2309499018822242. [PMID: 30798734 DOI: 10.1177/2309499018822242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM The aim of this study was to assess outcomes of biological (nonvascularized fibula grafts and extracorporeal irradiated autologous bone grafts) methods used for reconstruction of intercalary defects after resection of femoral diaphyseal tumors. MATERIALS AND METHODS This study included 28 patients who had undergone intercalary resection in femoral diaphyseal tumors between 2011 and 2016. The mean follow-up period was 24 months (range 12-57 months). RESULTS The mean union time for diaphyseo-diaphyseal union was 10.5 and 11 months in nonvascularized fibula group and extracorporeal radiotherapy (ECRT) group, respectively. The mean union time for metaphyseo-diaphyseal union was 6.5 months in both nonvascularized fibula and ECRT groups. Six patients had distant metastasis, and one patient had local recurrence. The mean Musculoskeletal Tumor Society score was 28 at the last follow-up. Two patients had surgical site infection in the nonvascularized fibula group. Implant failure was found in one patient of the ECRT group requiring revision surgery. Three patients had nonunion (two from the nonvascularized fibula group and one from the ECRT group). CONCLUSION The present study indicates that the biological reconstruction modalities provide good functional outcomes in diaphyseal tumors of femur. Nonvasularized fibula and ECRT-treated autografts reconstruction provides good results, and union timing is comparable. The outcomes of the current study are promising as compared to the results in the reviewed literature. The reconstruction method depends on the resources available at the oncological center and the conversance with the method of the treating surgeon.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Mayur Kamani
- Department of Surgical Oncology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
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13
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Comparison of Pediatric Intercalary Allograft Reconstructions with and without a Free Vascularized Fibula. Plast Reconstr Surg 2018; 142:1065-1071. [DOI: 10.1097/prs.0000000000004794] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Sternheim A, Kashigar A, Daly M, Chan H, Qiu J, Weersink R, Jaffray D, Irish JC, Ferguson PC, Wunder JS. Cone-Beam Computed Tomography-Guided Navigation in Complex Osteotomies Improves Accuracy at All Competence Levels: A Study Assessing Accuracy and Reproducibility of Joint-Sparing Bone Cuts. J Bone Joint Surg Am 2018; 100:e67. [PMID: 29762285 DOI: 10.2106/jbjs.16.01304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to assess the accuracy and reproducibility of a novel cone-beam computed tomography (CBCT)-guided navigation system designed for osteotomies with joint-sparing bone cuts. METHODS Eighteen surgeons participated in this study. First, 3 expert tumor surgeons resected bone tumors in 3 Sawbones tumor models identical to actual patient scenarios. They first performed these osteotomies without navigation and then performed them using a navigation system and 3-dimensional (3D) planning tools based on CBCT imaging. The 2 sets of measurements were compared using image-based measurements from post-resection CBCT. Next, 15 residents, fellows, and orthopaedic staff surgeons were instructed on the use of the system, and their navigated resections were compared with navigated resections performed by the 3 expert tumor surgeons. RESULTS One hundred and twenty-six navigated cuts done by the orthopaedic oncologists were compared with 126 non-navigated cuts by the same surgeons. The cuts violated the tumor in 22% (6) of the 27 non-navigated resections compared with none of the 27 navigated resections. The navigated cuts were significantly more accurate in terms of entry point, pitch, and roll (p < 0.001). The variation among the 3 surgeons when they used navigation was <0.6 mm for the entry cut and, on average, 1.5° for pitch and roll. All 18 surgeons then completed a total of 144 navigated cuts. The level of experience did not result in a significant difference among groups with regard to cut accuracy. Two cuts went into the tumor. The mean distance from the planned bone cuts to the actual entry points into bone was 1.5 mm (standard deviation [SD] = 1.4 mm) for all users. The mean difference in pitch and roll between the planned and actual cuts was 3.5° (SD = 2.8°) and 3.7° (SD = 3.2°) for all users. CONCLUSIONS Even in expert hands, navigated cuts were significantly more accurate than non-navigated cuts. When the osteotomies were aided by navigation, their accuracy did not differ according to the level of professional experience. CBCT-based metrics enable intraoperative assessments of cut accuracy and reconstruction planning. CLINICAL RELEVANCE CBCT-guided navigated osteotomies can improve accuracy regardless of surgeon experience and decrease the variability among different surgeons.
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Affiliation(s)
- Amir Sternheim
- National Unit of Orthopaedic Oncology, Tel Aviv Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aidin Kashigar
- Division of Orthopaedic Surgery, Queen's University, Kingston, Ontario, Canada
| | - Michael Daly
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Harley Chan
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Jimmy Qiu
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Robert Weersink
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - David Jaffray
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Radiation Physics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Ontario Cancer Institute, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Ferguson
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jay S Wunder
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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15
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Gautam D, Malhotra R. Megaprosthesis versus Allograft Prosthesis Composite for massive skeletal defects. J Clin Orthop Trauma 2018; 9:63-80. [PMID: 29628687 PMCID: PMC5884048 DOI: 10.1016/j.jcot.2017.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/20/2017] [Indexed: 02/09/2023] Open
Abstract
Massive skeletal defects are encountered in the setting of tumors necessitating excision, failed total hip arthroplasty with periprosthetic bone loss, periprosthetic fracture, complex trauma, multiple failed osteosynthesis and infection. Reconstruction of the segmental defects poses a tremendous challenge to the orthopaedic surgeons. The goal of osseous reconstruction of these defects is to restore the bone length and function. Currently the most commonly employed methods for reconstruction are either a megaprosthesis or an Allograft Prosthesis Composite (APC). Megaprosthesis, initially created for the treatment in neoplastic pathologies are being used for the non-neoplastic pathologies as well. The longevity of these implants is an issue as majority of the patients receiving them are the survivors of oncologic issue or elderly population, both in which the life expectancy is limited. However, the early complications like instability, infection, prosthetic breakage and fixation failure have been extensively reported in several literatures. Moreover, the megaprostheses are non-biological options preventing secure fixation of the soft tissue around the implant. The Allograft Prosthesis Composites were introduced to overcome the complications of megaprosthesis. APC is made of a revision-type prosthesis cemented into the skeletal allograft to which the remaining soft tissue sleeve can be biologically fixed. APCs are preferred in young and low risk patients. Though the incidence of instability is relatively low with the composites as compared to the megaprosthesis, apart from infection, the newer complications pertaining to APCs are inevitable that includes non-union, allograft resorption, periprosthetic fracture and potential risk of disease transmission. The current review aims to give an overview on the treatment outcomes, complications and survival of both the megaprostheses and APCs at different anatomic sites in both the upper and lower limbs.
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Affiliation(s)
| | - Rajesh Malhotra
- Corresponding author at: Room No 5019, Department of Orthopedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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16
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What are the Oncologic and Functional Outcomes After Joint Salvage Resections for Juxtaarticular Osteosarcoma About the Knee? Clin Orthop Relat Res 2017; 475:2095-2104. [PMID: 28425055 PMCID: PMC5498384 DOI: 10.1007/s11999-017-5356-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Joint salvage surgery for patients with juxtaarticular osteosarcoma remains challenging, especially when the tumor invades the epiphysis. Because patients are surviving longer with current chemotherapy regimens, it is advantageous to retain native joints if possible, especially in young patients. However, the results using joint-preserving tumor resections in this context have not been well characterized. QUESTIONS/PURPOSES (1) What are the functional outcomes after limb salvage surgery at a minimum of 3 years? (2) What are the oncologic outcomes? (3) Is joint salvage surgery for epiphyseal tumors associated with an increased risk of local recurrence compared with metaphyseal tumors not invading the epiphysis? (4) What are the complications associated with joint salvage surgery? METHODS Between 2004 and 2013, we treated 117 patients with juxtaarticular osteosarcoma; of those, 43 (38%) were treated with joint salvage surgery, and 41 (95%) of the 43 patients are included in our study. The other two (5%) were lost to followup before 3 years (mean, 4.4 years; range, 3-11 years,). During the period in question, we generally performed joint salvage surgery in these patients when they had a favorable response to chemotherapy, did not have a pathologic fracture or extrusion of the tumor into the joint, and did not have a whole-epiphyseal osteolytic lesion, a large mass, or obvious neurovascular involvement. This report is a followup of an earlier study; the current study includes an additional nine patients, and additional followup of a mean of 19 months for the patients included in the earlier report. We ascertained overall survival and survival free from local recurrence which was estimated using the Kaplan-Meier method, functional status of the limb which was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system, and recorded reconstructive complications including infection, fracture, skin necrosis, and nonunion. We compared oncologic and functional outcomes between patients with (n = 28) and without tumor extension to epiphysis (n =13). We also compared oncologic and functional outcomes among patients with different adjuvant treatments including microwave ablation (n = 11), cryoablation (n = 12), and navigation-assisted osteotomy (n = 5). Complications were tallied using records from our institutional database. RESULTS The overall Kaplan-Mayer survival rate was 82% (95% CI, 104-128 months) at 5 years. The overall Kaplan-Meier survivorship from local recurrence was 91% at 5 years (95% CI, 115-133 months). Three patients had a local recurrence, but none had local recurrence in or close to the remaining epiphysis. The MSTS scores ranged from 22 to 30 points, with a median of 28. There were no differences in survival rate, local recurrence, or MSTS scores between patients with a tumor that did not invade the epiphysis and those in whom the tumor did invade the epiphysis. There were differences in MSTS scores among patients with epiphyseal tumor extension in which different adjuvant techniques, including microwave ablation, cryoablation, and navigation-assisted osteotomy, were used. Additional surgical procedures were recorded for 10 patients (24%). Osteonecrosis of the residual epiphysis was detected 13 patients (31%). CONCLUSIONS Our findings suggest it is possible to salvage joints in selected patients with juxtaarticular osteosarcoma around the knee. The patients who have a favorable response to chemotherapy are the best candidates for this approach. Future studies might explore the role of adjuvant techniques of microwave ablation and cryoablation, particularly when the tumor invades the epiphysis, and whether resections can be facilitated with navigation. LEVEL OF EVIDENCE Level IV, therapeutic study.
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17
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Panagopoulos GN, Mavrogenis AF, Mauffrey C, Lesenský J, Angelini A, Megaloikonomos PD, Igoumenou VG, Papanastassiou J, Savvidou O, Ruggieri P, Papagelopoulos PJ. Intercalary reconstructions after bone tumor resections: a review of treatments. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:737-746. [PMID: 28585185 DOI: 10.1007/s00590-017-1985-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 05/30/2017] [Indexed: 11/28/2022]
Abstract
An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.
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Affiliation(s)
- Georgios N Panagopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece.
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO, USA
| | - Jan Lesenský
- Department of Orthopaedics, First Medical Faculty, Prague Teaching Hospital, Charles University, Bulovka, Prague, Czechia
| | - Andrea Angelini
- Department of Orthopaedics and Musculoskeletal Oncology, University of Padova, Padova, Italy
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | | | - Olga Savvidou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | - Pietro Ruggieri
- Department of Orthopaedics and Musculoskeletal Oncology, University of Padova, Padova, Italy
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
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18
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Wilson RJ, Sulieman LM, VanHouten JP, Halpern JL, Schwartz HS, Devin CJ, Holt GE. Cost-utility of osteoarticular allograft versus endoprosthetic reconstruction for primary bone sarcoma of the knee: A markov analysis. J Surg Oncol 2017; 115:257-265. [PMID: 28105636 DOI: 10.1002/jso.24525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/28/2016] [Accepted: 11/18/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND The most cost-effective reconstruction after resection of bone sarcoma is unknown. The goal of this study was to compare the cost effectiveness of osteoarticular allograft to endoprosthetic reconstruction of the proximal tibia or distal femur. METHODS A Markov model was used. Revision and complication rates were taken from existing studies. Costs were based on Medicare reimbursement rates and implant prices. Health-state utilities were derived from the Health Utilities Index 3 survey with additional assumptions. Incremental cost-effectiveness ratios (ICER) were used with less than $100 000 per quality-adjusted life year (QALY) considered cost-effective. Sensitivity analyses were performed for comparison over a range of costs, utilities, complication rates, and revisions rates. RESULTS Osteoarticular allografts, and a 30% price-discounted endoprosthesis were cost-effective with ICERs of $92.59 and $6 114.77. One-way sensitivity analysis revealed discounted endoprostheses were favored if allografts cost over $21 900 or endoprostheses cost less than $51 900. Allograft reconstruction was favored over discounted endoprosthetic reconstruction if the allograft complication rate was less than 1.3%. Allografts were more cost-effective than full-price endoprostheses. CONCLUSIONS Osteoarticular allografts and price-discounted endoprosthetic reconstructions are cost-effective. Sensitivity analysis, using plausible complication and revision rates, favored the use of discounted endoprostheses over allografts. Allografts are more cost-effective than full-price endoprostheses.
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Affiliation(s)
- Robert J Wilson
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lina M Sulieman
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob P VanHouten
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L Halpern
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Herbert S Schwartz
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clinton J Devin
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger E Holt
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
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Marczak D, Kowalczewski J, Czubak J, Okoń T, Synder M, Sibiński M. Short and mid term results of revision total knee arthroplasty with Global Modular Replacement System. Indian J Orthop 2017; 51:324-329. [PMID: 28566786 PMCID: PMC5439320 DOI: 10.4103/0019-5413.205684] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The original knee megaprostheses with fixed or rotating hinge articulation were custom made and only used for reconstruction of the knee following distal femoral or proximal tibial tumor resections. The aim of the study was to analyze the short- and mid-term results of revision total knee arthroplasty with Global Modular Replacement System (GMRS) used in difficult situations not amenable to reconstruction with standard total knee replacement implants. MATERIALS AND METHODS Nine patients (9 knees) were treated with this comprehensive modular implant system, with a mean age of 73.7 years (range 56-83 years) and a mean followup of 5 years (range 3-8 years). Two patients were treated for distal femoral nonunion, five for distal femur periprosthetic fracture and two for periprosthetic joint infection. RESULTS The mean Knee Society Score: Knee and functional scores were 77.9 and 40 points, respectively. All demonstrated full extension and flexion was at least 90°. Recurrence of infection was present in one patient. No signs of loosening, dislocation, or implant failure were observed. CONCLUSIONS Based on our small series of patients that represent severe cases, GMRS provides relatively good mid-term functional results, pain relief, and good implant survivorship with a low complication rate. This salvage procedure allows elderly, infirm patients to regain early ambulatory ability.
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Affiliation(s)
- Dariusz Marczak
- Department of Orthopaedics, Postgraduate Medical Education Center, Otwock, Poland
| | - Jacek Kowalczewski
- Department of Orthopaedics, Postgraduate Medical Education Center, Otwock, Poland
| | - Jarosław Czubak
- Department of Orthopaedics, Postgraduate Medical Education Center, Otwock, Poland
| | - Tomasz Okoń
- Department of Orthopaedics, Postgraduate Medical Education Center, Otwock, Poland
| | - Marek Synder
- Department of Orthopaedics, Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland
| | - Marcin Sibiński
- Department of Orthopaedics, Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland,Address for correspondence: Dr. Marcin Sibiński, Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland. E-mail:
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20
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What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors? Clin Orthop Relat Res 2016; 474:660-8. [PMID: 25701001 PMCID: PMC4746162 DOI: 10.1007/s11999-015-4204-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After bone tumor resection, reconstruction for limb salvage surgery can be challenging because of the resultant large segmental bony defects. Structural allografts have been used to fill these voids; however, this technique is associated with high complication rates. To circumvent the complications associated with this procedure, massive bony allografts have been supplemented with an intramedullary vascularized free fibula. However, few studies have examined the outcomes using this technique in the pediatric and adolescent populations. QUESTIONS/PURPOSES The purpose of this study was to examine the revision-free survival using he Capanna technique for limb salvage for pediatric lower limb salvage. We attempted to answer the following questions: (1) What was the overall limb salvage rate along with incidence of reoperation and complications? (2) How did pediatric and adolescent patients functionally perform after this technique? (3) What was the incidence of late complications including infection and fracture? (4) What was the incidence of limb length discrepancy? METHODS Eighteen pediatric patients who underwent lower extremity limb salvage with the use of cadaveric allograft and intramedullary free fibular transfer (Capanna technique) were identified. There were nine boys males and nine girls with a mean age of 11 years (range, 5-18 years) and mean followup of 8 years (range, 2-15 years), respectively. All patients had at least 2 years followup. Three patients have not been seen in followup during the past 5-years; however, all had made it to their 5-year clinical followup. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. Time to union was recorded through an evaluation of radiographs. Mankin functional outcome and Musculoskeletal Tumor Society (MSTS) rating scale were recorded for each patient. RESULTS The overall limb salvage rate was 94%. Fourteen patients underwent an additional surgical procedure. Six patients underwent additional procedure(s) to treat a symptomatic nonunion. Seventeen of the patients had a good or excellent Mankin score with a mean MSTS rating of 93% at last followup. Six of the patients underwent a limb length modification procedure. CONCLUSIONS Use of large allografts in conjunction with intramedullary vascularized free fibulas appears to be a reliable method for the reconstruction of large bony tumors of the lower extremity in this population, although we did not directly compare this with allografts alone in our study. The use of locked plates may improve union times. The proportion of patients achieving limb preservation was high and complication rates are acceptable. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Zimel MN, Farfalli GL, Zindman AM, Riedel ER, Morris CD, Boland PJ, Healey JH. Revision Distal Femoral Arthroplasty With the Compress(®) Prosthesis Has a Low Rate of Mechanical Failure at 10 Years. Clin Orthop Relat Res 2016; 474:528-36. [PMID: 26394638 PMCID: PMC4709327 DOI: 10.1007/s11999-015-4552-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/01/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with failed distal femoral megaprostheses often have bone loss that limits reconstructive options and contributes to the high failure rate of revision surgery. The Compress(®) Compliant Pre-stress (CPS) implant can reconstruct the femur even when there is little remaining bone. It differs from traditional stemmed prostheses because it requires only 4 to 8 cm of residual bone for fixation. Given the poor long-term results of stemmed revision constructs, we sought to determine the failure rate and functional outcomes of the CPS implant in revision surgery. QUESTIONS/PURPOSES (1) What is the cumulative incidence of mechanical and other types of implant failure when used to revise failed distal femoral arthroplasties placed after oncologic resection? (2) What complications are characteristic of this prosthesis? (3) What function do patients achieve after receiving this prosthesis? METHODS We retrospectively reviewed 27 patients who experienced failure of a distal femoral prosthesis and were revised to a CPS implant from April 2000 to February 2013. Indications for use included a minimum 2.5 mm cortical thickness of the remaining proximal femur, no prior radiation, life expectancy > 10 years, and compliance with protected weightbearing for 3 months. The cumulative incidence of failure was calculated for both mechanical (loss of compression between the implant anchor plug and spindle) and other failure modes using a competing risk analysis. Failure was defined as removal of the CPS implant. Followup was a minimum of 2 years or until implant removal. Median followup for patients with successful revision arthroplasty was 90 months (range, 24-181 months). Functional outcomes were measured with the Musculoskeletal Tumor Society (MSTS) functional assessment score. RESULTS The cumulative incidence of mechanical failure was 11% (95% confidence interval [CI], 4%-33%) at both 5 and 10 years. These failures occurred early at a median of 5 months. The cumulative incidence of other failures was 18% (95% CI, 7%-45%) at 5 and 10 years, all of which were deep infection. Three patients required secondary operations for cortical insufficiency proximal to the anchor plug in bone not spanned by the CPS implant and unrelated to the prosthesis. Median MSTS score was 27 (range, 24-30). CONCLUSIONS Revision distal femoral replacement arthroplasty after a failed megaprosthesis is often difficult as a result of a lack of adequate bone. Reconstruction with the CPS implant has an 11% failure rate at 10 years. Our results are promising and demonstrate the durable fixation provided by the CPS implant. Further studies to compare the CPS prosthesis and other reconstruction options with respect to survival and functional outcomes are warranted. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Melissa N. Zimel
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065 USA
| | - German L. Farfalli
- Institute of Orthopedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | | | - Elyn R. Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Carol D. Morris
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD USA
| | - Patrick J. Boland
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065 USA
| | - John H. Healey
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065 USA ,Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, NY USA
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Avril P, Le Nail LR, Brennan MÁ, Rosset P, De Pinieux G, Layrolle P, Heymann D, Perrot P, Trichet V. Mesenchymal stem cells increase proliferation but do not change quiescent state of osteosarcoma cells: Potential implications according to the tumor resection status. J Bone Oncol 2015; 5:5-14. [PMID: 26998421 PMCID: PMC4782020 DOI: 10.1016/j.jbo.2015.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/13/2015] [Accepted: 11/30/2015] [Indexed: 12/11/2022] Open
Abstract
Conventional therapy of primary bone tumors includes surgical excision with wide resection, which leads to physical and aesthetic defects. For reconstruction of bone and joints, allografts can be supplemented with mesenchymal stem cells (MSCs). Similarly, adipose tissue transfer (ATT) is supplemented with adipose-derived stem cells (ADSCs) to improve the efficient grafting in the correction of soft tissue defects. MSC-like cells may also be used in tumor-targeted cell therapy. However, MSC may have adverse effects on sarcoma development. In the present study, human ADSCs, MSCs and pre-osteoclasts were co-injected with human MNNG-HOS osteosarcoma cells in immunodeficient mice. ADSCs and MSCs, but not the osteoclast precursors, accelerated the local proliferation of MNNG-HOS osteosarcoma cells. However, the osteolysis and the metastasis process were not exacerbated by ADSCs, MSCs, or pre-osteoclasts. In vitro proliferation of MNNG-HOS and Saos-2 osteosarcoma cells was increased up to 2-fold in the presence of ADSC-conditioned medium. In contrast, ADSC-conditioned medium did not change the dormant, quiescent state of osteosarcoma cells cultured in oncospheres. Due to the enhancing effect of ADSCs/MSCs on in vivo/in vitro proliferation of osteosarcoma cells, MSCs may not be good candidates for osteosarcoma-targeted cell therapy. Although conditioned medium of ADSCs accelerated the cell cycle of proliferating osteosarcoma cells, it did not change the quiescent state of dormant osteosarcoma cells, indicating that ADSC-secreted factors may not be involved in the risk of local recurrence.
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Affiliation(s)
- Pierre Avril
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France
| | - Louis-Romée Le Nail
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France; University Hospital, Service de Chirurgie Orthopédique et Traumatologique, Tours F-37044, France; Faculté de Médecine, Université François Rabelais, Tours F-37044, France
| | - Meadhbh Á Brennan
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France
| | - Philippe Rosset
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France; University Hospital, Service de Chirurgie Orthopédique et Traumatologique, Tours F-37044, France; Faculté de Médecine, Université François Rabelais, Tours F-37044, France
| | - Gonzague De Pinieux
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France; Faculté de Médecine, Université François Rabelais, Tours F-37044, France; University Hospital, Service d'Anatomie Pathologique, Tours F-37044, France
| | - Pierre Layrolle
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France
| | - Dominique Heymann
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France
| | - Pierre Perrot
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France; University Hospital, Service de Chirurgie Plastique et des Brûlés, Nantes F-44093, France
| | - Valérie Trichet
- INSERM, UMR 957, Equipe Labellisée LIGUE 2012, Nantes F-44035, France; Université de Nantes, Nantes Atlantique Universités, Laboratoire de Physiopathologie de la Résorption Osseuse et Thérapie des Tumeurs Osseuses Primitives, Faculté de Médecine, 1 rue Gaston Veil, Nantes F-44035, France
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Akiyama T, Kanda S, Maeda A, Endo M, Saita K. Patella dislocation following distal femoral replacement after bone tumour resection. BMJ Case Rep 2014; 2014:bcr-2014-205006. [PMID: 25073529 DOI: 10.1136/bcr-2014-205006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We report the case of a 16-year-old girl with patella dislocation following distal femur replacement for a malignant tumour. We performed a medial plication and lateral release procedure to treat her persistent patellar dislocation after distal femur replacement following malignant tumour resection. This treatment improved the patient's gait ability dramatically. A distal femur reconstruction with a total knee arthroplasty (TKA) system for tumour resection is a frequently performed procedure. The reported incidence of patella dislocation following distal femur reconstruction with a TKA is 2.3%. However, treatment procedures for patella dislocation following a distal femur replacement after malignant tumour resection have not been studied extensively. To the best of our knowledge, this is the first English case report about patella dislocation following distal femoral replacement focusing on surgical treatment. Our experience suggests that treatment for patella dislocation following distal femur reconstruction with a TKA should be considered positively.
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Affiliation(s)
- Toru Akiyama
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shotaro Kanda
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akinori Maeda
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Minoru Endo
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Bus MPA, Dijkstra PDS, van de Sande MAJ, Taminiau AHM, Schreuder HWB, Jutte PC, van der Geest ICM, Schaap GR, Bramer JAM. Intercalary allograft reconstructions following resection of primary bone tumors: a nationwide multicenter study. J Bone Joint Surg Am 2014; 96:e26. [PMID: 24553895 DOI: 10.2106/jbjs.m.00655] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Favorable reports on the use of massive allografts to reconstruct intercalary defects underline their place in limb-salvage surgery. However, little is known about optimal indications as reports on failure and complication rates in larger populations remain scarce. We evaluated the incidence of and risk factors for failure and complications, time to full weight-bearing, and optimal fixation methods for intercalary allografts after tumor resection. METHODS A retrospective study was performed in all four centers of orthopaedic oncology in the Netherlands. All consecutive patients reconstructed with intercalary (whole-circumference) allografts after tumor resection in the long bones during 1989 to 2009 were evaluated. The minimum follow-up was twenty-four months. Eighty-seven patients with a median age of seventeen years (range, 1.5 to 77.5 years) matched inclusion criteria. The most common diagnoses were osteosarcoma, Ewing sarcoma, adamantinoma, and chondrosarcoma. The median follow-up period was eighty-four months (range, twenty-five to 262 months). Ninety percent of tumors were localized in the femur or the tibia. RESULTS Fifteen percent of our patients experienced a graft-related failure. The major complications were nonunion (40%), fracture (29%), and infection (14%). Complications occurred in 76% of patients and reoperations were necessary in 70% of patients. The median time to the latest complication was thirty-two months (range, zero to 200 months). The median time to full weight-bearing was nine months (range, one to eighty months). Fifteen grafts failed, twelve of which failed in the first four years. None of the thirty-four tibial reconstructions failed. Reconstruction site, patient age, allograft length, nail-only fixation, and non-bridging osteosynthesis were the most important risk factors for complications. Adjuvant chemotherapy and irradiation had no effects on complication rates. CONCLUSIONS We report high complication rates and considerable failure rates for the use of intercalary allografts; complications primarily occurred in the first years after surgery, but some occurred much later after surgery. To reduce the number of failures, we recommend reconsidering the use of allografts for reconstructions of defects that are ≥15 cm, especially in older patients, and applying bridging osteosynthesis with use of plate fixation.
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Affiliation(s)
- M P A Bus
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer:
| | - P D S Dijkstra
- Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - M A J van de Sande
- Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - A H M Taminiau
- Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - H W B Schreuder
- Department of Orthopaedic Surgery, Radboud University Nijmegen Medical Center, Postzone 357, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - P C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - I C M van der Geest
- Department of Orthopaedic Surgery, Radboud University Nijmegen Medical Center, Postzone 357, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - G R Schaap
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer:
| | - J A M Bramer
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands. E-mail address for J.A.M. Bramer:
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Intercalary reconstructions with vascularised fibula and allograft after tumour resection in the lower limb. Sarcoma 2013; 2013:160295. [PMID: 23766665 PMCID: PMC3676952 DOI: 10.1155/2013/160295] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 04/09/2013] [Accepted: 04/28/2013] [Indexed: 11/17/2022] Open
Abstract
Reconstruction with massive bone allograft and autologous vascularised fibula combines the structural strength of the allograft and the advantages of fibula's intrinsic blood supply. We retrospectively analysed the outcome of twelve patients (4 male, 8 female) who received reconstruction with massive bone allograft and autologous vascularised fibula after tumour resection in lower limb. Mean age was 17.8 years (range 11–31 years), with following primaries: Ewing's sarcoma (n = 6), osteosarcoma (n = 4), liposarcoma grade 2 (n = 1), and adamantinoma (n = 1). Mean followup was 38.7 months (median 25.7 months; range 2–88 months). Seven tumours were located in the femur and five in the tibia. The mean length of bone defect was 18.7 cm (range 15–25 cm). None of the grafts had to be removed, but there occurred four fractures, four nonunions, and two infections. Two patients developed donor side complication, in form of flexion deformity of the big toe. The event-free survival rate was 51% at two-year followup and 39% at three- and five-year followup. As the complications were manageable, and full weight bearing was achieved in all cases, we consider the combination of massive bone allograft and autologous vascularised fibula a stable and durable reconstruction method of the diaphysis of the lower limbs.
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Abstract
BACKGROUND Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown. QUESTIONS/PURPOSES We therefore determined the survival of the Compress prosthesis (Biomet Inc, Warsaw, IN, USA) at 5 and 10 actuarial years and identified the failure modes for this form of prosthetic fixation. METHODS We retrospectively reviewed clinical and radiographic records for all 82 patients who underwent Compress knee arthroplasty from 1998 to 2008, as well as one patient who received the device elsewhere but was followed at our institution. Prosthesis survivorship and modes of failure were determined. Followup was for a minimum of 12 months or until implant removal (median, 43 months; range, 6-131 months); 28 patients were followed for more than 5 years. RESULTS We found a survivorship of 85% at 5 years and 80% at 10 years. Eight patients required prosthetic revision after interface failure due to aseptic loosening alone (n = 3) or aseptic loosening with periprosthetic fracture (n = 5). Additionally, five periprosthetic bone failures occurred that did not require revision: three patients had periprosthetic bone failure without fixation compromise and two exhibited irregular prosthetic osteointegration patterns with concomitant fracture due to mechanical insufficiency. CONCLUSIONS Compress prosthetic fixation after distal femoral tumor resection exhibits long-term survivorship. Implant failure was associated with patient nonadherence to the recommended weightbearing proscription or with bone necrosis and fracture. We conclude this is the most durable FDA-approved fixation method for distal femoral megaprostheses. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Frisoni T, Cevolani L, Giorgini A, Dozza B, Donati DM. Factors affecting outcome of massive intercalary bone allografts in the treatment of tumours of the femur. ACTA ACUST UNITED AC 2012; 94:836-41. [DOI: 10.1302/0301-620x.94b6.28680] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We retrospectively reviewed 101 consecutive patients with 114 femoral tumours treated by massive bone allograft at our institution between 1986 and 2005. There were 49 females and 52 males with a mean age of 20 years (4 to 74). At a median follow-up of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed. The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and failure of fixation were studied. The most adverse factor on the outcome was the use of intramedullary nails, followed by post-operative chemotherapy, resection length > 17 cm and age > 18 years at the time of intervention. The simultaneous use of a vascularised fibular graft to protect the allograft from mechanical complications improved the outcome, but the use of intramedullary cementing was not as successful. In order to improve the strength of the reconstruction and to advance the biology of host–graft integration, we suggest avoiding the use of intramedullary nails and titanium plates, but instead using stainless steel plates, as these gave better results. The use of a supplementary vascularised fibular graft should be strongly considered in adult patients with resection > 17 cm and in those who require post-operative chemotherapy.
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Affiliation(s)
- T. Frisoni
- Istituto Ortopedico Rizzoli, via
Pupilli 1, Bologna 40136, Italy
| | - L. Cevolani
- Istituto Ortopedico Rizzoli, via
Pupilli 1, Bologna 40136, Italy
| | - A. Giorgini
- Istituto Ortopedico Rizzoli, via
Pupilli 1, Bologna 40136, Italy
| | - B. Dozza
- Istituto Ortopedico Rizzoli, Laboratorio
di Patologia Ortopedica e Rigenerazione Tissutale Ossea, via
Pupilli 1, Bologna 40136, Italy
| | - D. M. Donati
- Istituto Ortopedico Rizzoli, via
Pupilli 1, Bologna 40136, Italy
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Treatment of resistant nonunion of supracondylar fractures femur by megaprosthesis. Knee Surg Sports Traumatol Arthrosc 2011; 19:1137-40. [PMID: 21311865 DOI: 10.1007/s00167-011-1416-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Resistant nonunion of distal femoral fractures in the elderly is a great challenge to treat because it is often associated with multiple problems like poor bone quality, arthritis, disuse osteopenia, joint contractures, and implant failure. We treated ten patients with megaprosthesis and report the outcome. METHODS Ten elderly patients of resistant nonunion of distal femoral fractures with arthritis knee were treated with megaprosthesis. The median patient age was 74 years (68-85 years). All these patients had undergone at least two prior operative procedures and were operated by us, 24-33 months following the first index surgery. Modular Resection System was used in all the patients. RESULTS Eight patients were available for follow-up. Median follow-up period was 4 years. Two patients required extended local wound care for wound skin necrosis. One patient sustained traumatic periprosthetic subtrochanteric fracture following a subsequent trauma. No thromboembolic complications were seen. All knees showed satisfactory alignment and range of motion. Postoperative, median knee society pain score, and knee society function score were 84 (80-88) and 88 (84-92) at last follow-up. CONCLUSION Megaprosthesis can be offered as a one-stage salvage procedure for difficult nonunion in distal femoral fractures associated with bone loss, osteoporosis, and secondary knee arthritis.
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Nguyen MP, Buckwalter JA, Miller BJ. Patterns of improvement following oncologic reconstructrion compared to total knee arthroplasty and revision knee arthroplasty. THE IOWA ORTHOPAEDIC JOURNAL 2011; 31:160-165. [PMID: 22096436 PMCID: PMC3215130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Limb salvage surgery for primary malignant bone tumors of the lower limbs requires complete resection of the tumor, followed by a reconstruction to restore function. In contrast to the abundant information on total knee arthroplasty, data on the recovery pattern of limb salvage surgery is largely limited. With the aim of guiding patient expectations and optimizing care, we retrospectively compared the clinical outcomes among patients following oncologic knee reconstruction, primary total knee arthroplasty, and revision total knee arthroplasty. From January, 2001 to June, 2009, we identified a cohort of 503 primary total knee arthroplasties, 55 revision knee arthroplasties, and 15 oncologic reconstructions. Outcomes were assessed by the validated Short Form-36 (SF-36) health questionnaire. We found that oncologic patients significantly improved their Physical Component Score at one and minimum two-year follow up compared to baseline (p< 0.05) with the majority of improvement (90%) made within the first year following surgery. This is a similar pattern to that observed following primary and revision total knee arthroplasty.
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Affiliation(s)
- Mai P Nguyen
- Department of Orthopaedics and Rehabilitation, University of Iowa Iowa City, IA, USA
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