Long-Term Outcomes following Lower Extremity Sarcoma Resection and Reconstruction with Vascularized Fibula Flaps in Children:

Comparison of limb reconstruction with vascularized fibula flap versus induced membrane technique in 54 pediatric cases over 16 years

BACKGROUND

Children's bone loss of limbs represents a significant challenge for surgeons, especially given that children are growing individuals. In the pediatric population, we compared bone reconstruction using vascularized fibula flaps with the induced membrane technique. The primary purpose of this study was to evaluate the delay and quality of consolidation.

METHODS

Data from patients who underwent limb reconstruction using either the fibula flap or the induced membrane were retrospectively collected from files across two centers. Perioperative and long-term complications were documented, along with functional and aesthetic outcome.

RESULTS

Between 2004 and 2020, 31 children underwent limb reconstruction using a fibula flap, and 13 patients were treated using the induced membrane technique. The etiologies included 76% tumors, 20% congenital pseudarthroses, and 3.7% infections. The median size of the bone resection was 12.5 cm (range: 1.8 to 31 cm). The median time to consolidation after free fibula flap transfer was 10 months (range: 2 to 55 months) versus 7.5 months (range: 1 to 64 months) for the Masquelet technique (p = 0.54). Limb length inequality occurred in 52% of fibula cases and 39% of the induced membrane cases (p = 0.55).

CONCLUSIONS

Both of free fibula flap and the induced membrane technique are effective options for bone reconstructing long bones in children. These techniques yield good functional outcomes and have comparable consolidation times.

Comparing Fibula Flap Insetting Techniques for Pediatric Oncologic Extremity Reconstruction

BACKGROUND

Extremity reconstruction in skeletally immature patients presents unique challenges in terms of operative technique, bone healing, and limb function. A variety of insetting techniques have been described, with no clearly superior option. The authors hypothesized that vascularized fibula flaps placed in the intramedullary space are associated with shorter union times and better functionality compared with onlay flaps.

METHODS

In a cohort study, the authors retrospectively reviewed the medical records of all pediatric patients who underwent fibula flap extremity reconstruction at a single center from 2001 through 2018. Comorbidities, complications, and outcomes were analyzed. Complete fibula union was based on radiographic evidence of significant cortical bridging.

RESULTS

Thirty-three patients (mean age, 13.6 years; range, 2 to 18 years) underwent pedicled ( n = 7) or free ( n = 26) fibula flap reconstructions in 12 upper extremities and 21 lower extremities. Median follow-up was 69.5 months (interquartile range, 16.3 to 114.6 months). Onlay and intramedullary fibula position compared with intercalary placement (median, 13.5 and 14.6 months versus 3.4 months; P = 0.002) were associated with longer time to complete bone union. Complications including allograft fracture ( P = 0.02) and hardware removal ( P = 0.018) were also associated with longer time to complete union and eventual conversion to megaprosthesis ( P = 0.02, P = 0.038). Thirty-two patients (97%) achieved full union and a functional reconstruction.

CONCLUSIONS

Fibula flap reconstruction is safe and effective for pediatric long-bone reconstruction. Longer fibula union times were associated with onlay and intramedullary fibula placement, allograft fracture, and hardware removal.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Return to sports following lower limb musculoskeletal tumor surgery-A systematic review

BACKGROUND

Survivors of primary malignant musculoskeletal tumors often face long-term disability. Clinicians at present are unable to provide evidence-based advice about returning to sports, which is important for active patients.

PURPOSES

Identify patients returning to sports. Describe the sporting activities in which patients participate. Identify the outcome measures used to assess return to sport. Identify barriers preventing return to sports.

STUDY DESIGN

Systematic review.

METHODS

A comprehensive search strategy was used to identify relevant studies combining the following concepts: (1) Bone/Soft tissue tumor, (2) Lower limb, (3) Surgical interventions, and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors (MTB, FS, and CG).

RESULTS

Twenty-two studies were selected, published between 1985 and 2020, including 1005 patients. Fifteen of the 22 studies had valid data on return to sports, with 705 participants, of which 412 (58.4%) returned to some form of sport such as swimming and cycling, at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing surgery and amputation; none of these were able to identify a difference in sports participation or ability.

CONCLUSION

There is insufficient published research to provide guidance for patients with respect to return to sports following musculoskeletal tumors. Future prospective studies are needed to collect better pre- and post-treatment data at multiple time intervals. Validated clinical and patient sports participation outcomes such as type of sports, level, frequency, and validated sports-specific outcome scores should be recorded. In particular, more comparison between limb sparing surgery and amputation would be welcome.

Athletic children: Guidelines and monitoring in pediatric orthopedic surgery

In day-to-day practice pediatric orthopedic surgeons often come up against the question of sport. The aim of the present study was to analyze the relationship between sport and childhood, with 3 questions: (1) What are the benefits of sport for children? (2) How to manage high-level child athletes? And (3) What sports are possible after major orthopedic surgery? Sports provide many benefits for children, and are to be encouraged. Sixty minutes' moderate to intense physical activity per day benefits motor development and bone mineralization and reduces the risk of obesity. On the other hand, excessive sports activity, as encountered in high-level sport, can be harmful for the child's development. The amount of training should not exceed a certain threshold in terms of hours per week according to age. Surgical treatment of sport-related traumatic lesions does not necessarily accelerate return to sport: indications need to be reasonable, despite pressure from the patient's circle. Sports are possible after major orthopedic surgery, although return to sport tends to be delayed and the level is lower than preoperatively.

Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis

PURPOSE

To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects.

METHODS

A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality".

RESULTS

After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation.

CONCLUSIONS

This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.

Lower Limb Reconstruction Using Tibial Strut Autograft after Resection of Primary Malignant Bone Tumors in Skeletally Immature Patients

Background

Reconstruction of large bone defects in skeletally immature patients remains a surgical challenge. We report the long-term clinical outcomes of a novel surgical technique for lower limb reconstruction using the tibia as a strut autograft following resection of primary malignant bone tumors in skeletally immature patients.

Methods

We retrospectively reviewed the medical records of six patients diagnosed with lower limb primary bone sarcoma. All patients underwent tumor resection and reconstruction using tibial strut autograft. The radiological and clinical outcomes including complications at the recipient and donor sites were assessed.

Results

The mean age at presentation was ten years (range 6-15 years). Two cases had osteosarcoma and four had Ewing sarcoma. The mean length of the resected tumor and tibial autografts were 20.83 and 19.33 cm respectively. Union at both ends was achieved in five grafts while one graft achieved union only at the distal end. The mean time for union of the proximal and distal junctions was 4 and 8.8 months respectively. The mean follow-up period was 8.4 years (range 14 months-20 years). One patient developed a foot drop, and three patients underwent subsequent joint arthrodesis (2 knees and 1 ankle). The mean musculoskeletal tumor society functional score was 80.8%. Two patients had clinically significant leg-length discrepancy that needs further lengthening procedure. Four patients survived with no evidence of disease and two patients died due to their primary oncologic disease. All donor sites regenerated, with the earliest signs of new bone formation at (2-4) weeks post-operatively.

Conclusion

Reconstruction using non-vascularized‎ tibia strut autograft after resection of primary malignant lower limb bone tumors can be a viable alternative method for reconstructing large bone defects in the immature skeleton.

Reconstruction for bone tumours of the shoulder and humerus in children and adolescents

Reconstructions for paediatric bone tumours of the shoulder girdle and humerus are intended to optimize placement of the hand in space. Given the longevity of paediatric survivors of sarcoma, durability is an important planning consideration. Here, I review a subset of approaches based on anatomical site with an emphasis on function and longevity. Often, biological reconstructions that combine living bone with tendon repairs and transfers best address those goals.

Function-preserving Surgery for Femoral Sarcoma by "In Situ Preparation" Technique with a Free Flap

Resection of soft-tissue sarcomas near important tissues (major blood vessels, nerves, bones) is challenging. “In situ preparation” (ISP) technique enables the function of the affected limb to be maintained by preserving the tissue as much as possible. The technique is based on evaluation of the margin of resection of important tissues near the tumor during surgery. Postoperative fractures are known to frequently occur, however, in cases where bones were preserved and periosteum has been resected by the ISP. We present the case of a 51-year-old woman who required treatment for soft-tissue sarcoma close to the femur. During surgery, femoral periosteum was included in the tumor side and the femur was preserved by the ISP. We covered the femur using a vascularized latissimus dorsi free flap instead of periosteum. The flap survived completely, and 5 years after surgery, there has been no recurrence or postoperative complications and the lower limb is functional. This is the first reported case of successful combined use of the bone ISP and the vascularized latissimus dorsi free flap to preserve the function of the limb affected by femoral sarcoma suspected of bone infiltration.

Free Tissue Transfer with Distraction Osteogenesis and Masquelet Technique Is Effective for Limb Salvage in Patients with Gustilo Type IIIB Open Fractures

Osteocutaneous reconstruction can be challenging because of concomitant injuries and limited donor sites. There is a paucity of data on limb salvage outcomes following combined soft-tissue reconstruction and bone transport or Masquelet procedures. The authors reviewed a consecutive series of open tibia fracture patients undergoing soft-tissue reconstruction with either distraction osteogenesis or Masquelet technique. Endpoints were perioperative flap complications and bone union. Fourteen patients with Gustilo type IIIB open tibia fractures were included. Half of the group received muscle flaps and the remaining half received fasciocutaneous flaps. Ten patients (71.4 percent) underwent distraction osteogenesis and the remaining patients underwent Masquelet technique. Average bone gap length was 65.7 ± 31.3 mm (range, 20 to 120 mm). In the bone transport group, the average external fixation duration was 245 days (range, 47 to 686 days). In the Masquelet group, the average duration of the first stage of this two-stage procedure (i.e., time from cement spacer placement to bone grafting) was 95 days (range, 42 to 181 days). Bone union rate, as determined by radiographic evidence, was 85.7 percent. There was one complete flap failure (7.1 percent). One patient underwent below-knee amputation after failing bone transport and developing chronic osteomyelitis and subsequent infected nonunion. Our case series demonstrates that nonosteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85 percent and a limb salvage rate over 90 percent in patients with Gustilo type IIIB fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma

Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.

Microsurgery in musculoskeletal oncology

Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.

Vascularised fibular grafts for reconstruction of extremity bone defects after resection of bone and soft-tissue tumours : a single institutional study of 49 patients

AIMS

The aims of this study were to analyse the long-term outcome of vascularised fibular graft (VFG) reconstruction after tumour resection and to evaluate the usefulness of the method.

PATIENTS AND METHODS

We retrospectively reviewed 49 patients who had undergone resection of a sarcoma and reconstruction using a VFG between 1988 and 2015. Their mean follow-up was 98 months (5 to 317). Reconstruction was with an osteochondral graft (n = 13), intercalary graft (n = 12), inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed the oncological and functional outcome, and the rate of bony union and complications.

RESULTS

Five- and ten-year overall survival rates were 89% and 86%, respectively. Local recurrence occurred in two patients. Eight patients developed pulmonary metastases. Bone union was achieved in 44 patients (90%). Fracture occurred in six patients (12%), infection in three (6%), and nonunion in five (10%). The mean Musculoskeletal Tumor Society (MSTS) scores were as follows: osteochondral graft 70%; intercalary graft 73%; inlay graft 89%; and resection arthrodesis 83%.

CONCLUSION

Although associated with a relatively high rate of complications, each reconstruction method is useful, with a high rate of successful limb salvage and a good long-term functional outcome. Cite this article: Bone Joint J 2017;99-B:1237-43.

Reconstruction Following Tumor Resections in Skeletally Immature Patients

Reconstruction options in children after bone tumor resection are as varied as they are challenging. Advances in biologic and endoprosthetic design have led to many choices, all of which must be considered in the context of prognosis, treatment limitations, and patient/family expectations. The current experience and results of limb-sparing surgery following bone sarcoma resection in growing children are discussed, including allograft, autograft, and metallic prostheses alone and in combination, especially as they pertain to the knee. In some cases, the ablative options of amputation and rotationplasty must be seen as equal and, at times, superior choices to limb salvage.

[Secondary orthopaedic complications after childhood tumors of the musculoskeletal system]

BACKGROUND

Multidisciplinary care, modern care management, and medical progress have brought significant gains in modern survival rates for children and adolescents with tumors of the musculoskeletal system.

OBSERVATIONS

The surgical approach must rest on the consideration of the long-term orthopedic sequelae likely to be caused by the elected treatment (limb amputation versus limb conservation - reconstruction choices), as well as by adjuvant therapies, such as chemotherapy or radiotherapy. Complications due to allograft reconstructions (infections, fractures, pseudoarthritis) occur within the range of 0 to 36 months. After 36 months, allograft longevity is fair, but 10 years later, 60% of grafts are likely to have failed and been removed. Joint prostheses have overall survival rates of 75% over 10 years, and 52% over 20 years. As for allografts, infectious complications occur within the first few years, while later prosthetic replacements are mostly due to mechanical causes. Assessing the long-term evolution of biological reconstructions proves a lot more challenging, due to the lack of hindsight and available information, except for vascularized fibula grafts, which show good long-term results. Numerous medical reviews have been published that address the quality of life of children treated for malignant tumors of the musculoskeletal system. They mostly consist in comparative studies between limb conservation and limb amputation, and point to similar results overall. Such data must be taken into account when deciding on a treatment for a child or an adolescent: quality of life, the function of the affected limb, the probable need for re-operation all encourage to favor reconstructions whenever they are possible, as they come closest to normal anatomy.

CONCLUSION

Too frequently, medical knowledge remains fragmented among multiple disciplines, because of the difficulty of organizing follow-up over the very long-term. Progress can only be achieved by setting-up multidisciplinary care pathways between pediatric surgeons and surgeons treating adult patients.