Alcohol-inactivated autograft replantation with joint preservation in the management of osteosarcoma of the distal femur: a preliminary study

Resection for malignant tumors in the elbow and individualized reconstruction under assistance of 3D printing technology: A case report

RATIONALE

With a high failure rate and multiple postoperative complications, the resection for tumors in the elbow and reconstruction present a formidable challenge to orthopedic surgeons. The maturation of 3-dimension (3D) printing technology has facilitated the preoperative design, intraoperative navigation, and reconstruction of bone defects in patients with complex malignant tumors of the elbow joint. In order to improve prognosis, we explored a method of tumor resection and elbow reconstruction aided by 3D printing technology in this research.

PATIENT CONCERNS

The patient underwent nephrectomy for clear cell carcinoma of the left kidney 3 years ago. Six months ago, the patient presented with limited movement and lateral tenderness in the right elbow joint. The tumor puncture biopsy demonstrated renal clear cell carcinoma metastasis.

DIAGNOSES

Renal clear cell carcinoma with distal humerus bone metastasis.

INTERVENTIONS

Thin-layer CT scan data of the patient was acquired, and a 3D reconstruction of both upper limb bones and joints was conducted, followed by a simulation of diseased tissue excision. According to the model, individualized osteotomy guidelines and elbow prostheses were designed and manufactured. Then, prior to the completion of the actual operation, a simulation of the preoperative phase was performed.

OUTCOMES

The operation was completed without incident. At the 1-, 3-, and 6-month postoperative examinations, both the position and mobility of the prosthesis were found to be satisfactory, and no complications were observed. The hospital for special surgery score and mayo elbow performance score scores increased in comparison to the preoperative period.

LESSONS

For patients with complex tumors in the elbow joint, 3D printing technology may assist in the precise excision of the tumor and provide an individualized elbow joint prosthesis that is more precise and effective than traditional surgery. It can accomplish a satisfactory treatment effect for patients when combined with early postoperative scientific rehabilitation training, so it is a method worth promoting.

Clinical efficacy of customized modular prosthesis in the treatment of femoral shaft metastases

Purpose

To examine clinical outcomes of a specialized modular prosthesis used to fill a bone deficiency following removal of femoral shaft metastases.

Methods

Eighteen patients with femoral shaft metastases who underwent en bloc resection and implantation of a personalized modular prosthesis between December 2014 and December 2019 were retrospectively analyzed. Pain, limb function, and quality of life were evaluated using the visual analog scale (VAS), Musculoskeletal Tumor Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale. The Kaplan–Meier technique was used to analyze patient survival.

Results

The operation duration was 90–150 min (mean, 115 min), and the osteotomy length was 9–16 cm (mean, 11.72 cm). The patients were followed for 12–62 months (mean, 25.28 months). The VAS and NHP ratings were lower at 3, 6, and 12 months after surgery than before surgery, while the MSTS, ISOLS, and KPS scores were higher after surgery than they had been before. These differences were statistically significant (P<0.05). The survival period was between 7 and 62 months (mean, 20.89 months), and the rates of survival at 1-year and 2-year were 72.22% and 27.78%, respectively. Except for two patients with aseptic prosthesis loosening during the follow-up period, there were no problems.

Conclusion

En bloc excision and implantation of a personalized modular prosthesis can reduce pain and improve the ability of patients with femoral shaft metastases to perform daily activities, thereby improving their quality of life.

Study on the effect of artificial joint replacement for osteosarcoma

Osteosarcoma is one of the most prevalent primary malignant bone tumors that affects teenagers more than adults. In recent years, artificial femoral replacement has become more and more common. The use of artificial total femoral replacement surgery prevents the need for amputating the damaged limb, preserves the patient's ability to move and bear weight on the leg, lessens the severity of the psychological trauma, and significantly raises the patient's quality of life. To explore the treatment methods and therapeutic effects of artificial femoral replacement in the treatment of femoral osteosarcoma. The clinical data of 11 patients with femoral malignant tumors who underwent artificial femoral replacement from January 2019 to March 2022 were retrospectively analyzed. Among them, 7 males and 4 females, 11 to 40 years old, average 19.36 ± 9.44 years old. The disease duration is 2 to 7 months, with an average of 4.7 months. Before and 3 months after operation, the patients who had tumors were given a score on the visual analog scale, and their quality of life was also measured. At the most recent follow-up, both the Musculoskeletal Tumor Society score and the Harris hip score were analyzed. Eleven patients were followed up for 6 to 58 months, and an average of 21 months. Complications such as wound infection, joint dislocation, and nerve damage did not occur. In 1 patient, popliteal vein thrombus formation, and in 2 patients with osteosarcoma died from tumor progression. Visual analog scale score at 3 months after surgery and the quality-of-life scores were 3.68 ± 1.39 and 40.04 ± 4.31, respectively, which were significantly improved compared to before surgery (5.94 ± 1.19 and 22.42 ± 3.63, respectively, P < .05). At the last interview, Musculoskeletal Tumor Society score is scored from 18 to 29 points, average 22.5 ± 5.9 points, and Harris hip score is scored from 42 to 90 points, with an average score of 69.0 ± 14.7. Artificial total femoral replacement is an effective limb salvage operation in the treatment of osteosarcoma.

Comparative efficacy of intraoperative extracorporeal irradiated and alcohol-inactivated autograft reimplantation for the management of osteosarcomas-a multicentre retrospective study

BACKGROUND

Biologic bone reconstruction in limb salvage surgery for the treatment of malignant bone tumours has always been controversial. The various inactivation methods, their convenience and stability, the curative effects elicited and associated costs all need to be considered. This study aimed to compare the clinical efficacy of intraoperative extracorporeal irradiated reimplantation with alcohol-inactivated autograft reimplantation for limb salvage surgery in patients with osteosarcoma.

METHODS

We retrospectively analysed 28 patients with osteosarcoma, 14 patients treated with intraoperative cobalt 60 irradiation and reimplantation (group A), and 14 patients treated by alcohol-inactivated autograft reimplantation (group B). The postoperative complications and clinical efficacy of each treatment method were compared by statistical analysis.

RESULTS

The local recurrence rate was 14.3% in each group. Complete bony union was achieved in 64.3% of patients in group A and 71.4% of patients in group B. The overall 5-year survival rate was 71.4% in group A and 78.6% in group B. The mean Musculoskeletal Tumor Society (MSTS) score was 25.33 ± 4.72 (range 15-30) in group A and 24.00 ± 5.85 (range 15-30) in group B, and the mean International Society of Limb Salvage (ISOLS) score was 25.79 ± 5.13 (range 20-36) in group A and 26.14 ± 5.33 (range 20-30) in group B. P < 0.05 was considered to indicate a significant difference. The results showed that the long-term clinical efficacy did not differ significantly between the two methods.

CONCLUSIONS

In limb salvage surgery for osteosarcoma, intraoperative extracorporeal irradiation and alcohol-inactivated autograft reimplantation yielded equivalent outcomes. The alcohol-inactivated method may be a much more convenient and inexpensive way to reconstruct bone defects. Additional studies as well as more case studies are needed to fully evaluate the clinical efficacy and safety of this treatment method.

Liquid nitrogen for cryotherapy treatment for osteosarcoma of the middle femur: A case report

Background

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. Cryotherapy liquid nitrogen has been used an adjuvant treatment for tumors for some decades.

Case presentation

A 23‐year‐old male patient was admitted to our hospital, mainly due to progressive pain in his left thigh, and confirmed osteosarcoma by local biopsy. A total length of 28 cm tumor bone was completely resected at the region of above and below lesion 3 cm under the guidance of MRI. After removed part of the tumor tissue, tumor bone was dealt with liquid nitrogen for 20 minutes. Finally, the bone was fixed with intramedullary needles for reconstruction. Three months after surgery, the X‐ray examination showed poor bone growth at both distal sides of osteotomy and disuse degeneration of knee joint. The patient was performed an incision on the lateral side of the distal left thigh to secure the locking plate, and followed up every 3 months. Two years after operation, there was no sign of local recurrence.

Conclusion

Liquid nitrogen for cryotherapy may be a feasible local therapy for large lesion of osteosarcoma in middle femur.

En bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases

PURPOSE

To evaluate the short-term clinical efficacy and complications of en bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases.

METHODS

A total of 21 patients with humeral diaphyseal bone metastases treated with en bloc resection and intercalary prosthesis implantation from August 2014 to August 2019 were retrospectively analysed. The visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale were used to assess pain, limb function, and quality of life. Survival of the patients was analysed using the Kaplan-Meier method.

RESULTS

The patients were followed up for 12-57 months (mean: 22 months); the operative time was 68-114 minutes (mean: 76.24 min); the osteotomy length was 6.5-10 cm (mean: 8.02 cm); and the intra-operative blood loss was 95-125 ml (mean: 104.71 ml). At three, six and 12 months after surgery, the VAS and NHP scores were lower, whereas the MSTS, ISOLS, and KPS scores were higher than those before surgery, and the differences were statistically significant (P < 0.05). The survival time was four to 24 months (mean: 19.46 months). Thesix month and one year survival rates were 80.95% and 52.38%, respectively. During the follow-up period, no complications occurred except for aseptic prosthesis loosening in one patient.

CONCLUSIONS

En bloc resection and intercalary prosthesis implantation can reduce pain, improve limb function, prolong survival time, and improve quality of life in patients with humeral diaphyseal bone metastases.

Clinical evaluations of diaphysis malignant tumors of femur and tibia treated with microwave ablation in situ

Background

This study was designed to evaluate the clinical outcomes of patients with diaphysis malignant tumors of femur and tibia treated with microwave ablation (MWA) in situ.

Methods

Retrospective study of 32 patients with diaphysis malignant bone tumors of femur or tibia have been treated by microwave ablation. Instead of en bloc resection, hyperthermia ablation in situ was carried out followed by strengthen procedure. The patients were followed up for a period ranging from 36 to 180 months.

Results

Twenty-five patients survived over 3 years and all of the patients alive have a satisfactory functional and cosmetic limb. The postoperative survival rate of MWA group was significantly higher than the amputation group in consecutive inclusions.

Conclusions

MWA is a feasible and effective surgical method for limb salvage operation and it might offer an innovative and distinctive therapeutic alternative for diaphysis malignant bone tumors, which avoiding osteotomy or prosthesis replacement.

Level of evidence

Level IV, clinical cohort study

Efficacy of a Modified Scoring System to Facilitate Surgical Decision-making for Diaphyseal Malignancies: When is Devitalized Tumor-bearing Autograft of Value?

Objectives

To evaluate the validity of a modified scoring system (MSS) for inferring the bony quality of tumor‐bearing diaphyses and predicting the risk of reconstructive failure after devitalized bone replantation (DBR).

Methods

In this retrospective cohort study, we reviewed the records of 30 patients surgically treated for diaphyseal malignancies between 1996 and 2015. There were 18 male and 12 female subjects; the average age was 34.0 ± 24.5 years (8–82 years). Tumor locations comprised the femur (21), the humerus (4), the tibia (3), the radius (1), and the fibula (1). Histological diagnoses included osteosarcoma (13), metastases (4), Ewing sarcoma (3), chondrosarcoma (3), malignant fibrohistiocytoma (2), periosteal osteosarcoma (1), Langerhans cell sarcoma (1), lymphoma (1), rhabdomyosarcoma (1), and malignant giant cell tumor (1). All primary tumors were rated as stage IIB. Twenty patients underwent DBR. Prosthetic procedures and segmental autografting/allografting were performed in 7 and 3 cases, respectively. MSS (comprising 5 elements: pain, tumor location, bone destruction, localized dimension, and longitudinal dimension) for each patient was calculated in accordance with their preoperative presentations. Outcome measurements included oncological results, outcomes of reconstructions, complications, and functional preservation, presented using the musculoskeletal tumor society (MSTS) scale.

Results

Follow up was available in 29 cases for an average duration of 61.0 ± 49.9 months (12–152 months). Infection occurred in 2 patients (6.9%), primary nonunion in 6 (27.3%), metastases in 9 (31.9%), recurrences in 4 (13.8%), and deaths in 7 (24.1%); 1 subject underwent amputation due to recurrence following endoprosthetic replacement (3.4%). In the DBR group, fractures occurred in 4 cases (21.1%) and nonunion in 5 (25%); internal fixation was related to nonunion (nails, 44.4% vs plates, 9.1%, P = 0.02). MSS was associated with fractures of devitalized autografts (11.0 ± 1.2 vs 8.3 ± 1.8, P = 0.01); the system was efficacious in predicting chances of fractures of these grafts (P = 0.02). MSS ≥ 10 (with false positive rate ≤ 6.7%) suggested increased fracture probability (≥22.7%) after DBR; therefore, 10 was considered a cutoff value.

Conclusions

Diaphyseal malignancies with MSS ≥10 may contraindicate DBR for increased chances of reconstructive failure. In this situation, alternative procedures are advisable. Further investigations are warranted to assess the efficacy of MSS in implying the validity of DBR for diaphyseal malignancies.

Limb salvage surgery with joint preservation for malignant humeral bone tumors: operative procedures and clinical application

BACKGROUND

However, the application of limb salvage with joint preservation is controversial. The purpose of this study is to propose a selection strategy of joint-sparing operative procedures for humeral malignancies based on tumor origin, site and bone strength.

METHODS

The medical data of 28 patients with humeral malignancies treated at our institute from January 2010 to December 2016 were analyzed retrospectively. The patients had a median age of 51 years (range, 8-82 years). Bone strength scoring system was utilized to evaluated bone strength of the tumor. Four joint-sparing surgical methods were performed on selected patients. Evaluation of limb function was based on the Musculoskeletal Tumor Society scoring system. Two-sample t-test was used to compare patient group data such as bone strength score and postoperative Musculoskeletal Tumor Society score.

RESULTS

The mean follow-up period for the 7 patients with primary malignancies was 45 months (range, 15-66 months). One patient died due to recurrence and lung metastasis, while the remaining 6 patients (6/7, 85.7%) survived without recurrence. For the 21 patients with metastases, 5 survived with tumors, with an average survival time of 25.8 months (range, 9-48 months). The rest died from progression of the primary tumors. The mean bone strength score for the biological reconstruction group and non-biological reconstruction group was respectively 9.7 ± 1.3 and 12.9 ± 1.2. A significant difference between the 2 groups (p < 0.05) was found. Mean postoperative Musculoskeletal Tumor Society score was respectively 27.2 ± 1.8 and 26.1 ± 1.7 for the 2 groups. There was no significant difference between the 2 groups (p > 0.05). Non-oncological complications included fracture (1), aseptic loosening (1) and radial nerve injury (1).

CONCLUSIONS

Alcohol devitalized autograft replantation is applicable for diaphyseal humeral primary malignancies, with a good response to chemotherapy and a low bone strength score (≤10). In situ microwave ablation is suitable for diaphyseal and (or) metaphyseal low-grade malignant bone tumors or metastases with a low bone strength score (≤10). Intercalary prosthetic reconstruction is preferred for diaphyseal metastases with a high bone strength score (> 10).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The long-term outcomes following the use of inactivated autograft in the treatment of primary malignant musculoskeletal tumor

Background

Biological reconstruction surgery is a tough but alluring option for treating primary malignant musculoskeletal tumors. In this article, we evaluate the clinical outcomes of primary malignant musculoskeletal tumors treated with inactivated autograft using alcohol.

Method

In this article, we include 58 patients who had primary malignant bone tumors treated with wide resection and recycling autograft reconstruction using alcohol between January 2003 and January 2013. The outcomes were measured by recurrence, functional status, and complications. Functional status was assessed according to the Musculoskeletal Tumor Society Score (MSTSS). The Kaplan-Meier survival curve was used to evaluate the survival rate of the patient.

Result

The most common tumor was osteosarcoma (31 cases) followed by chondrosarcoma (10 cases). The tibia was the most frequently involved skeletal site (27 cases) followed by femur (26 cases). The median follow-up period was 54 months, ranging from 18 to 96 months. In 58 patients, 12 were with local recurrence (20.7 %), 16 with lung metastasis (27.6 %), and 13 with complications (22.4 %). The main complication was infection (8 cases). The autografts survived in 49 patients (84.5 %). The mean MSTSS score was 78.5 %, ranging from 47 to 98 %.

Conclusion

Recycling autograft reconstruction using alcohol had favorable clinical outcomes to some degree; however, the recurrence and complication rates seem to be high. Thus, we should apply this method with caution and choose the patients with strict surgical indication.