Outcomes and Options for Prosthetic Reconstruction After Tumour Resection About the Knee

Evaluation of tumor-prostheses over time: Complications, functional outcome, and comparative statistical analysis after resection and reconstruction in orthopedic oncologic conditions in the lower extremities

Objectives:

Previous multicenter studies report variable outcomes and failure rates after tumor-prosthetic reconstructions. The purpose of this study was (1) to evaluate implant survival, limb survival, and functional outcome in a cohort of patients who underwent resection of primary malignancies or aggressive benign bone tumors and reconstruction with modern tumor-prostheses in the lower extremities and (2) to provide comparison to a historical cohort on previous generations of tumor-prostheses from the same center.

Methods:

A longitudinal retrospective single-center study of 72 consecutive patients (F/M = 30/42), mean age = 44 (range = 7–84) years with bone, soft tissue sarcoma adjacent to bone (n = 69), and aggressive benign bone tumors (n = 3) having surgery between 2006 and 2016 with bone resection and reconstruction with tumor-prostheses were compared to a historical cohort from1985 to 2005. Revisions were classified as major and minor revisions. Causes of failure were classified according to the Henderson classification. Fine and Gray competing risk analysis was used for assessing cumulative incidence for implant revision and limb amputation. Functional outcome was evaluated with Musculoskeletal Tumor Society Score system.

Results:

Forty-seven patients were alive at the end of the study. Mean follow-up was 6 years (range = 2–13 years). Ten-year cumulative risk of major revision was 18% (95% confidence interval = 9%–28%). Deep infection and recurrence of tumor caused most revisions in modern tumor-prostheses. Ten-year cumulative incidence of limb amputation was 11% (95% confidence interval = 3%–18%). According to the Henderson classification, the overall predominant failure mode was non-mechanical (n = 20, 51%). Mean Musculoskeletal Tumor Society Score was 20 (67%) (range = 0–30).

Conclusion:

A minimum of 2 years follow-up with modern modular tumor-prostheses demonstrated a relatively low risk of implant failure and amputation and also an acceptable functional outcome. No statistical difference of, implant survival, limb survival and functional outcome between tumor-prostheses over two time periods was observed, possibly explained by Type 2 error.

Imaging following surgery for primary appendicular bone tumours

Primary bone tumours are uncommon, with sarcomas accounting for < 0.2% of all malignancies. The survival rate of primary bone sarcomas has significantly improved due to (neo)adjuvant therapy, while improved surgical techniques and development of new prostheses have shifted the surgical focus from amputation to limb preservation in the vast majority of patients. A wide variety of surgical options are available for the treatment of primary bone tumours which depend upon histological diagnosis, their appearance at the time of presentation and response to any (neo)adjuvant therapy as required. This review is intended to help radiologists familiarise themselves with the management of primary appendicular bone tumours and expected normal postoperative appearances for the various surgical techniques, and to recognise potential complications.

Hospital Resource Utilization Associated With Endoprosthetic Reconstruction Versus Primary Arthroplasty

Endoprosthetic reconstructions of the hip and knee are currently reimbursed as primary hip and knee arthroplasty according to Current Procedural Terminology (CPT) coding guidelines. The purpose of this study was to compare hospital resources consumed by patients undergoing endoprosthetic reconstruction with those consumed by patients undergoing primary arthroplasty. The authors' hypothesis was that the former group carries more comorbidities, experiences longer length of stay (LOS), and has greater resource consumption. A retrospective review was performed of 61 patients undergoing endoprosthetic reconstruction and 745 patients undergoing primary hip or knee arthroplasty between 2015 and 2018 at a single institution. Demographic, clinical, and financial data were compared. The Charlson Comorbidity Index (CCI) was used to measure patients' health status and identify comorbidities associated with prolonged LOS through linear regression analysis. Patients who underwent endoprosthetic reconstruction had a greater than 3.5 times average LOS compared with primary arthroplasty patients: 10.81 days vs 2.94 days (P<.01). They demonstrated a higher mean CCI, higher rates of malignancy and pulmonary disease, and a wider age range. Their mean cost of care totaled $73,730.29, compared with $24,940.84 imposed by primary arthroplasty patients (P<.01). Significant predictors of LOS were malignancy status (metastatic or localized) and age younger than 50 years, with increased LOS being associated with increased cost. Patients undergoing endoprosthetic reconstruction of the hip and knee represent a fundamentally different patient population than primary arthroplasty patients based on comorbidities, variability in health status, and surgical indications. They have higher comorbidity scores and longer hospitalizations and consume more financial resources than primary arthroplasty patients. [Orthopedics. 2021;44(1):e73-e79.].

Current review of surgical management options for extremity bone sarcomas

Modern surgical management of extremity bone sarcomas is governed by limb-sparing surgery combined with adjuvant and neoadjuvant chemotherapy.

All the resection and reconstruction techniques have to achieve oncologic excision margins, with survival rates and functional results superior to amputation.

The main reconstruction techniques of bone defects resulted after resection are: modular endoprosthetic reconstruction; bone graft reconstruction; bone transport; resection arthrodesis; and rotationplasty.

Oncologic resection and modular endoprosthetic reconstruction are the generally approved surgical options adopted for the majority of cases in major specialized bone sarcoma centres.

Good basic principles, efficient multidisciplinary approach and sustained research in the field can provide a better future for the challenge posed by extremity bone sarcoma treatment.

Cite this article: EFORT Open Rev 2019;4:174-182. DOI: 10.1302/2058-5241.4.180048