Ilizarov method to correct limb length discrepancy after limb-sparing hemipelvectomy

Changes in psoas muscle size and ambulatory function after internal hemipelvectomy without reconstruction

Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes. T1-weighted MR images were evaluated at three intervals for 12 pelvic sarcoma patients following interval hemipelvectomy without reconstruction. Correlations between the measured changes and improvements in Timed Up and Go test (TUG) and gait speed outcomes were assessed both independently and using a stepwise multivariate regression model. Increased ipsilesional psoas muscle size from three months postoperatively to latest follow-up was positively correlated with gait speed improvement (r = 0.66). LLD at three months postoperatively was negatively correlated with both TUG (r = -0.71) and gait speed (r = -0.61). This study suggests that psoas muscle strengthening and minimizing initial LLD will achieve the greatest improvements in ambulatory function. LLD and change in hip musculature remain substantial prognostic factors for achieving the best clinical outcomes after internal hemipelvectomy. Changes in psoas size were correlated with the amount of functional improvement. Several patients in this study did not return to their preoperative ipsilateral psoas size, indicating that monitoring changes in psoas size could be a beneficial rehabilitation strategy.

All-Internal Limb Lengthening with Simultaneous Corrective Osteotomy After Internal Hemipelvectomy: A Case Report

CASE

A 27-year-old woman with a Grade II chondrosarcoma in the right acetabulum underwent a Type II internal hemipelvectomy with an ischiofemoral fusion. She developed a 7.0-cm functional limb-length discrepancy with adduction of the hip at rest. Four years after surgery, she underwent a corrective osteotomy and limb lengthening with a magnetic lengthening nail. Eleven years after tumor resection and a successful pregnancy, she had symmetric leg lengths and ambulated without an assistive device.

CONCLUSIONS

A magnetic lengthening nail is a viable option for correcting limb-length discrepancies after hemipelvectomy. If necessary, a simultaneous corrective proximal femoral osteotomy can be performed.

Biologic Reconstruction With a Motorized Intramedullary Bone Transport Nail After Tumor Resection

Distraction osteogenesis is an option for reconstruction of intercalary defects. The use of bone transport after tumor surgery has been limited because of concerns of pin tract infections with external fixation and the theoretical risk of causing tumor growth. The effects of chemotherapy and radiation on the regenerate and healing of the docking site are also not well studied, but the current literature has mostly favorable outcomes with no evidence of causing tumor proliferation. The Precice bone transport nail offers a noninvasive method of distraction osteogenesis, which eliminates the need for prolonged external fixation and the risk of pin tract infections. This report discusses the technique for using the Precice bone transport nail after tumor resection. Bone transport may be considered for intercalary defects after en bloc resection of sarcoma, metastatic disease, and benign aggressive bone tumors. The use of distraction osteogenesis after tumor resection is a promising technique for the biologic reconstruction of intercalary defects.

Leg Lengthening as a Means of Improving Ambulation Following an Internal Hemipelvectomy

Reconstructive surgery following an internal hemipelvectomy for a malignant pelvic tumor is difficult due to the structural complexity of the pelvis and the massive extension of the tumor. While high complication rates have been encountered in various types of reconstructive surgery, resection without reconstruction reportedly involved fewer complications. However, this method often results in limb shortening with resultant instability during walking. We reported herein leg lengthening performed to correct lower limb shortening after an internal hemipelvectomy, which improved ambulatory stability and overall QOL. An 18-year-old male patient came to our hospital to correct a lower limb discrepancy resulting from a left internal hemipelvectomy. His left pelvis and proximal femur had been resected, and the femur remained without an acetabular roof. His left lower limb was about 8 centimeters shorter. The left tibia was lengthened 8 centimeters with an external fixator. After the lengthening, the patient was able to walk without support and his gait remarkably improved. Additionally he no longer required placing a wallet in his back pocket as a pad as a means of raising the left side of his torso while sitting. Leg lengthening was a useful method of improving ambulation after an internal hemipelvectomy.

Internal hemipelvectomy with reconstruction for primary pelvic neoplasm: a systematic review

BACKGROUND

Hemipelvectomy is a major operation with significant risks including infection, prosthesis failure and fracture. This systematic review was designed to review the functional outcomes, oncologic outcomes and complications in patients who received internal hemipelvectomy and pelvic reconstruction for primary pelvic tumour.

METHODS

Searches on MEDLINE, the Cochrane Library, Embase and Google Scholar were performed to locate studies involving patients receiving internal hemipelvectomy and pelvic reconstruction using a prosthesis, implant or bone graft. All studies were either prospective or retrospective observational studies published in English.

RESULTS

This systematic review included 12 studies from 1990 to 2011 involving 217 patients from 5 to 77 years of age who had received follow-up for a period from 3 weeks to 15 years. Among the 12 studies, the mortality rate, disease-free rate and incidence of local recurrence were 10-69.2, 23.1-90.0 and 9.1-41.7%, respectively. The post-operative Musculoskeletal Tumor Society (MSTS) functional score ranged from 50 to 70 in the more recent studies. Compared with prostheses and other implants, patients who received allografts had the highest post-operative function, as shown by their MSTS scores, but also had a greater incidence of post-operative infection. On the other hand, the prosthesis group was associated with the highest percentage of fracture and dislocations, as well as other significant complications.

CONCLUSION

This comprehensive review provided informative details regarding the goals, outcomes and complications associated with this procedure and underscored the need for further investigation into the various surgical approaches currently available.

Sociooccupational and physical outcomes more than 20 years after the diagnosis of osteosarcoma in children and adolescents: limb salvage versus amputation

BACKGROUND

To the best of the authors' knowledge, there has been relatively little research published to date regarding very long-term survivors of childhood and adolescent osteosarcoma. In the current study, the authors compared the very long-term survival outcomes of patients with osteosarcoma who were treated with either limb salvage procedures or amputation.

METHODS

A total of 38 patients with osteosarcoma who survived ≥ 20 years from the time of diagnosis were divided into 2 groups according to whether they underwent amputation or limb salvage. Participants were asked to complete a questionnaire concerning their education, employment, annual income, marital status, health insurance, lifestyle, siblings, and all current and past health issues.

RESULTS

Education, employment, marital status, and health insurance were not found to differ significantly between the 2 groups of survivors, who described themselves as being similar to their siblings. Eight percent of survivors underwent secondary amputation because of complications with an endoprosthesis. The cumulative incidence of second primary neoplasms was 13%, and this finding was significantly higher in females and in survivors who underwent radiotherapy and had a genetic predisposition. The second primary malignancies were breast cancer (ductal invasive carcinoma, ductal in situ carcinoma, and leiomyosarcoma), mediastinal leiomyosarcoma, and squamocellular carcinoma of the oral cavity and the uterine cervix. Amputees required more assistive walking support than survivors who received limb salvage treatment (P<.05, chi-square test).

CONCLUSIONS

Despite the many challenges that osteosarcoma survivors face, patients who survived ≥ 20 years after their initial diagnosis reported having overall adjusted well to their physical limitations and were productive individuals.

Hemipelvectomy- only a salvage therapy?

After the first hemipelvectomy in 1891 significant advances have been made in the fields of preoperative diagnosis, surgical technique and adjuvant treatment in patients with pelvic tumors. The challenging surgical removal of these rare malignant bone or soft tissue tumors accompanied by interdisciplinary therapy is mostly the only chance of cure, but bares the risk of intensive bleeding and infection. The reconstruction after hemipelvectomy is of importance for the later outcome and quality of life for the patient. Here, plastic surgery with microvascular free flaps or local rotational flaps improved the reconstruction and reduced infection rates. Average local recurrence rates of 14% demonstrate good surgical results, but 5 year survival rates of only 50% are described for some tumor entities, showing the importance of a multimodal collaboration. On a basis of a selective literature review the history, indications, treatment options and outcome of hemipelvectomies are presented.

Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage

As the number of osteosarcoma survivors increases, the impact of quality of life and function needs to be addressed. Limb salvage is the preferred treatment when patients have treatment options; yet, the questionable long-term durability and complications of prostheses, combined with ambiguous function, leave some doubt regarding the best clinical and surgical options. Comparisons between limb salvage patients, amputees and controls also require further investigation. Amputation would leave the patients with a lifelong requirement for an external prosthetic leg associated with an overall limited walking distance. While artificial limbs are much more sophisticated than those used in the past, phantom limb sensations remain a substantial and unpredictable problem in the amputee. Complications such as stump overgrowth, bleeding, and infection, also require further elucidation. Limb salvage surgery using endoprosthesis, allografts or reconstruction is performed in approximately 85% of patients affected by osteosarcoma located in the middle and/or distal femur. One drawback in limb-salvage surgery in the long-term survivor is that endoprostheses have a limited life span with long-term prosthetic failure. The inherent high rate of reoperation remains a serious problem. Replacing a damaged, infected or severely worn-out arthroplastic joint or its intramedullary stem is difficult, especially in the long-stem cemented endoprostheses used in the 1980s. Limb lengthening procedures in patients who have not reached maturity must also be addressed. Periprosthetic infections, compared to other indications for joint reconstruction, were found to be more frequent in patients treated for neoplastic conditions and their outcome can be devastating, resulting in total loss of joint function, amputation, and systemic complications. Quality of life in terms of function, psychological outcome and endpoint achievements such as marriage and employment apparently do not differ significantly between amputee and nonamputee osteosarcoma survivors. Amputee patients nonetheless appear to have made satisfactory adjustments to their deficits with or without a functional external prosthesis. It also appeared that amputee patients had a similar psychological and quality of life outcome as limb salvage patients. There was no evidence of excessive anxiety or depression or deficits in self-esteem compared with the normal population or matched controls. A number of long-term survivors also achieved high ranking in the professional and commercial work place. These positive aspects should be recognized and emphasized to patients and their parents when discussing the outcome.

Surgical management of primary osteosarcoma

Surgical strategies for the primary tumor for patients with extremity and pelvis osteosarcoma have evolved from the ablative to limb-sparing approaches over the past three decades. Favorable oncologic and functional outcomes with contemporary tissue-conserving techniques consistently observed in skeletally mature patients have prompted the application of similar approaches to a growing number of eligible skeletally immature patients. In response to emerging long-term outcome data, current strategies have focused principally on refining the nature and scope of surgical resection to preserve uninvolved tissues, and on the adoption of novel biological and nonbiological skeletal and soft-tissue reconstruction methods to optimize function. We focus on these clinical issues and discuss current efforts to advance the surgical management of the primary tumor and address the limitations of the definitive treatment of the primary tumor, including locally recurrent disease and complications of skeletal reconstructions.