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Errani C, Atherley O’Meally A, Tsukamoto S, Mavrogenis AF, Tanaka Y, Manfrini M. An algorithm for surgical treatment of children with bone sarcomas of the extremities. SICOT J 2024; 10:38. [PMID: 39364963 PMCID: PMC11451188 DOI: 10.1051/sicotj/2024033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 08/02/2024] [Indexed: 10/05/2024] Open
Abstract
INTRODUCTION Limb salvage surgery in children following bone sarcoma resection is a challenging problem because of the small size of the bones, the lack of appropriate size-matched implants, and the risk of limb-length discrepancy once skeletal growth is complete, secondary to the loss of the epiphyseal plate. Although several reconstruction options are available in children with bone sarcomas, such as vascularized fibula, massive bone allograft, extracorporeal devitalized autograft, endoprosthesis, and allograft-prosthesis composite, a consensus has not been reached on the best reconstruction method. The purpose of the present study is to propose an algorithm for reconstruction after resection of bone sarcomas in children. METHODS In this review, we analyzed reports on limb reconstruction in children following treatment for bone sarcoma, to provide a comprehensive overview of the different reconstruction options in children with bone sarcomas, the outcomes, and the risks and benefits of the different surgical approaches. RESULTS Despite a high risk of complications and the necessity for limb-lengthening procedures, prosthetic or biological reconstructions seem to achieve good functional outcomes in children with bone sarcoma. The use of massive bone graft seems to be recommended for intercalary reconstructions, with a free vascularized fibular graft for long defects, while for osteoarticular reconstruction a modular or expandable prosthesis or an allograft-prosthesis composite seems to have good results. For reconstruction of the proximal humerus, modular prosthesis or allograft-prosthesis composite are more commonly used than expandable prosthesis since there are fewer functional constraints related to possible limb-length discrepancy on the upper limb compared to the lower limb. DISCUSSION We discuss the advantages and limitations of the different available surgical options for bone reconstruction following tumor resection in children and propose an algorithm of potential surgical treatments for children with bone sarcomas of the extremities.
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Affiliation(s)
- Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
| | - Ahmed Atherley O’Meally
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University 840, Shijo-cho, Kashihara Nara 634-8521 Japan
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine 41 Ventouri Street, Holargos Athens 15562 Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University 840, Shijo-cho, Kashihara Nara 634-8521 Japan
| | - Marco Manfrini
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli Via Pupilli 1 Bologna 40136 Italy
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Aiba H, Atherley O'Meally A, Aso A, Tsukamoto S, Kimura H, Murakami H, Saito S, Sakai T, Bordini B, Cosentino M, Zuccheri F, Manfrini M, Donati DM, Errani C. Malawer type I/V proximal humerus reconstruction after tumor resection: a systematic review. J Shoulder Elbow Surg 2024; 33:2096-2108. [PMID: 38642876 DOI: 10.1016/j.jse.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/08/2024] [Accepted: 03/03/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Several reconstruction methods exist for Malawer type I/V proximal humerus reconstruction after bone tumor resection; however, no consensus has been reached regarding the preferred methods. METHODS We conducted a literature search on various types of proximal humerus oncologic reconstruction methods. We collected data on postoperative functional outcomes assessed based on Musculoskeletal Tumor Society (MSTS) scores, 5-year reconstruction survival rates, and complications. We calculated each reconstruction's weighted mean based on the sample size and standard errors. Complications were categorized based on the Henderson classification. Based on these integrated data, our primary objective is to propose an optimal strategy for proximal humerus reconstruction after bone tumor resection. RESULTS We examined various reconstruction techniques, including modular prosthesis (752 patients in 21 articles), osteoarticular allograft (142 patients in 6 articles), allograft prosthesis composites (APCs) (236 patients in 12 articles), reverse shoulder total arthroplasty (141 patients in 10 articles), composite reverse shoulder total arthroplasty (33 patients in 4 articles), claviculo-pro-humero (CPH) technique (51 patients in 6 articles), and cement spacer (207 patients in 4 articles). Weighted mean MSTS scores were: modular prosthesis (73.8%), osteoarticular allograft (74.4%), APCs (79.2%), reverse shoulder total arthroplasty (77.0%), composite reverse shoulder total arthroplasty (76.1%), CPH technique (75.1%), and cement spacer (69.1%). Weighted 5-year reconstruction survival rates were modular prosthesis (85.4%), osteoarticular allograft (67.6%), APCs (85.2%), reverse shoulder total arthroplasty (84.1%), and cement spacer (88.0%). Reconstruction survival data was unavailable for composite reverse shoulder total arthroplasty and CPH technique. Major complications included shoulder joint instability: modular prosthesis (26.2%), osteoarticular allograft (41.5%), APCs (33.9%), reverse shoulder total arthroplasty (17%), composite reverse shoulder total arthroplasty (6.1%), CPH technique (2.0%), and cement spacer (8.7%). Aseptic loosening of the prosthesis occurred: modular prosthesis (3.9%) and reverse shoulder total arthroplasty (5.7%). Allograft fracture was observed in 54.9% of patients with osteoarticular allograft. CONCLUSION The complication profiles differed among reconstruction methods. Weighted mean MSTS scores exceeded 70% in all methods except cement spacer, and the 5-year reconstruction survival rate surpassed 80% for all methods except osteoarticular allograft. Proximal humerus reconstruction after bone tumor resection should consider potential complications and patients' individual factors.
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Affiliation(s)
- Hisaki Aiba
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan.
| | - Ahmed Atherley O'Meally
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Orthopaedic Surgery, Complejo Hospitalario Metropolitano CSS, Panama, Panama
| | - Ayano Aso
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Shinji Tsukamoto
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Japan
| | - Hiroaki Kimura
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Shiro Saito
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Takao Sakai
- Department of Orthopedic Surgery, Nagoya City University, Nagoya, Japan
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Monica Cosentino
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Federica Zuccheri
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Manfrini
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Maria Donati
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Clinica Ortopedica e Traumatologica III a Prevalente Indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Lin J, Song G, Huang A, Hu J, Tang Q, Lu J, Huang Y, Gong M, Zhu X, Wang J. Design and validation of a novel 3D-printed glenohumeral fusion prosthesis for the reconstruction of proximal humerus bone defects: a biomechanical study. Front Bioeng Biotechnol 2024; 12:1428446. [PMID: 39040498 PMCID: PMC11260710 DOI: 10.3389/fbioe.2024.1428446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Background All available methods for reconstruction after proximal humerus tumor resection have disadvantages, and the optimal reconstruction method remains uncertain. This study aimed to design a novel 3D-printed glenohumeral fusion prosthesis and verify its feasibility and safety using biomechanical methods. Methods We verified the feasibility and safety of the 3D-printed glenohumeral fusion prosthesis by finite element analysis and biomechanical experimentation. In the finite element analysis, three reconstruction methods were used, and displacement and von Mises stress were observed; on this basis, in the biomechanical experiment, models constructed with sawbones were classified into two groups. The force‒displacement curve of the 3D-printed prosthesis was evaluated. Results In terms of displacement, the finite element analysis showed greater overall stability for the novel prosthesis than traditional glenohumeral joint arthrodesis. There was no obvious stress concentration in the internal part of the 3D-printed glenohumeral fusion prosthesis; the stable structure bore most of the stress, and the force was well distributed. Adding lateral plate fixation improved the stability and mechanical properties of the prosthesis. Furthermore, the biomechanical results showed that without lateral plate fixation, the total displacement of the prosthesis doubled; adding lateral plate fixation could reduce and disperse strain on the glenoid. Conclusion The design of the 3D-printed glenohumeral fusion prosthesis was rational, and its stability and mechanical properties were better than those of traditional glenohumeral joint arthrodesis. Biomechanical verification demonstrated the feasibility and safety of this prosthesis, indicating its potential for proximal humerus bone defect reconstruction after tumor resection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Xiaojun Zhu
- Department of Musculoskeletal Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jin Wang
- Department of Musculoskeletal Oncology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
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El-Gammal TA, El-Sayed Ali A, Kotb MM, Saleh WR, Ragheb YF, Refai OA, Morsy MM, El-Gammal YT. Free Vascularized Proximal Fibular Epiphyseal Transfer For Hip Reconstruction Following Septic Necrosis In Children. J Pediatr Orthop 2024; 44:308-315. [PMID: 38462889 DOI: 10.1097/bpo.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Septic necrosis of the femoral head and neck in children represents a challenging problem. Several reconstructive techniques have been described but with disappointing long-term results. Vascularized epiphyseal transfer utilizing the proximal fibula have been successfully used for reconstruction of the proximal humerus and distal radius and only scarcely used for hip reconstruction. This cohort represents the largest reported series of epiphyseal transfer for hip reconstruction following septic necrosis in children. METHODS A total of 18 patients with an average age at surgery of 5.4 years were included. The average follow-up was 3.6 years (range 2.3 to 6.8 y). RESULTS Transient postoperative foot drop was observed in 4 patients. Radiographic resorption of the transferred fibula occurred in 2 cases. Longitudinal growth averaged 7.3 mm/year, and the physis width increased by an average of 2.7 mm/year. The rate of longitudinal growth was fastest after the age of 10 years (18.5 mm/y), which coincides with the pubertal growth spurt. All successful transfers had an open growth plate on final follow-up radiographs. Ten patients had limb length discrepancy of an average 2.8 cm (range 1 to 8 cm). Thirteen patients had satisfactory functional according to the criteria of Hunka et al. Three patients had unsatisfactory results; one had painful nonunion at the fibula-femur junction, and the other two had limited flexion range of 45 degrees. The average postoperative neck-shaft angle was 96.4 degrees which decreased by an average of 8 degrees at the final follow-up. Three patients underwent a valgus subtrochanteric osteotomy to correct a severe varus deformity. The final neck-shaft angle correlated significantly with the functional results where it averaged 96 degrees in the satisfactory group and 57 degrees in the unsatisfactory group. CONCLUSION Vascularized epiphyseal transfer presents a promising treatment for children with septic necrosis of the femoral head and neck in whom other methods have failed to provide satisfactory long-term results. We recommend the procedure be done before the age of 5 years for optimum results. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Department of Orthopedics, University of Louisville, Louisville, KY
| | - Amr El-Sayed Ali
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Mohamed Mostafa Kotb
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Waleed Riad Saleh
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Yasser Farouk Ragheb
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Omar Ahmed Refai
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Mohamed Mohamed Morsy
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Department of Orthopedics, University of Birmingham at Alabama, AL
| | - Yousif Tarek El-Gammal
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Kleinert-Kutz Institute of Hand and Microsurgery, Louisville, KY
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Houdek MT, Sullivan MH, Broida SE, Barlow JD, Morrey ME, Moran SL, Sanchez-Sotelo J. Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis. JBJS Rev 2024; 12:01874474-202403000-00008. [PMID: 38466801 DOI: 10.2106/jbjs.rvw.23.00217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Samuel E Broida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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Errani C, Aiba H, Atherley A, Palmas M, Kimura H, Donati DM, Manfrini M. What Is the Revision-free Survival of Resurfaced Allograft-prosthesis Composites for Proximal Humerus Reconstruction in Children With Bone Tumors? Clin Orthop Relat Res 2024; 482:00003086-990000000-01475. [PMID: 38259160 PMCID: PMC11124666 DOI: 10.1097/corr.0000000000002969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/07/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Reconstruction of the proximal humerus in children who undergo bone tumor resection is challenging because of patients' small bone size and possible limb length discrepancy at the end of skeletal growth due to loss of the physis. There are several options for proximal humerus reconstruction in children, such as clavicula pro humero, free vascularized fibula grafting, massive bone osteoarticular allografting, endoprostheses, and allograft-prosthesis composites, but no consensus exists on the best method for reconstruction. Resurfaced allograft-prosthesis composites could be an alternative surgical option, but little is known about the results of this surgical technique. QUESTIONS/PURPOSES (1) What are the complications and what is the survivorship free from reconstruction failure associated with resurfaced allograft-prosthesis composites in a small, single-center case series? (2) What Musculoskeletal Tumor Society scores do patients achieve after reconstructions with resurfaced allograft-prosthesis composites? METHODS This study was a retrospective, single-arm case analysis in a single institution. We generally considered resurfaced allograft-prosthesis composites in children with malignant bone tumors involving the metaepiphysis of the proximal humerus in whom there was no evidence of joint contamination and in whom axillary nerve preservation was possible. Between 2003 and 2021, we treated 100 children (younger than 15 years) with bone tumors of the humerus. Thirty children (30%) with diaphyseal tumors (21 children) or distal tumors (9 children) were excluded. Among the potentially eligible children, 52 were not analyzed because they were treated with other procedures such as amputation, modular prostheses, cement spacers, free vascularized fibula grafting, and massive bone osteoarticular allografts. We included 18 children (26% of the potentially eligible children) who were treated with resurfaced allograft-prosthesis composites. There were 9 boys and 9 girls, with a median age of 10 years (range 4 to 15 years) at the time of diagnosis. A long stem (≥ 6 cm) in the resurfaced allograft-prosthesis composite was used in 9 children and a short stem (< 6 cm) was used in the remaining 9. One of the 18 children had a follow-up of less than 2 years. The median follow-up of the remaining 17 children was 4.7 years (range 2 to 19 years). The children' medical records were reviewed for clinical and functional outcomes. We performed a competing risk analysis to calculate the reconstruction failure-free survival of resurfaced allograft-prosthesis composites. Reconstruction failure was defined as removal of the implant or allograft because of implant loosening or breakage and allograft fracture or resorption. We analyzed the children's postoperative complications and functional outcomes at the end of the follow-up period using the Musculoskeletal Tumor Society functional scoring system. RESULTS The competing risk analysis revealed that reconstruction failure was 25% (95% confidence interval 7% to 40%) at 3 years, reaching a plateau. Four of 18 children underwent surgical revision with a new reconstruction. The reasons for reconstruction revision were resorption of the allograft at the proximal part (2 children) and fracture of the allograft (2 children). Reconstruction revision was performed in 3 of 9 children who underwent reconstruction with a short stem and in 1 of 9 children who underwent reconstruction with a long stem. Several children had other complications that did not result in removal of the allograft. Allograft resorption was observed in 4 of 18 children, but no additional surgical treatment was performed. Shoulder instability or subluxation was observed in 4 of 18 children, but only 1 child underwent surgery with a reverse shoulder arthroplasty without removal of the resurfaced allograft-prosthesis composite. Limited elbow motion because of plate impingement was observed in 1 child who underwent surgical cutting of the protruding distal part of the plate. Incomplete radial nerve palsy after surgery occurred in 1 child, with spontaneous resolution after 2 months. Screw loosening occurred in 2 children who underwent surgery with removal of loose screws. Two children had a nonunion at the graft-host bone junction; 1 child underwent surgery with bone grafting and refixation of the graft-host bone junction, and the other child with both nonunion and plate breakage was treated with bone grafting and refixation of the graft-host bone junction with a new plate. Among 17 children who had a follow-up longer than 2 years, the median Musculoskeletal Tumor Society functional score at the last follow-up interval was 23 of 30 (range 20 to 26); 1 child was considered to have an excellent result (functional score ≥ 26), 15 children were considered to have a good result (functional score 21 to 25), and 1 child was considered to have a fair result (functional score ≤ 20). The Musculoskeletal Tumor Society functional score did not change after excluding 4 children who underwent replacement of resurfaced allograft-prosthesis composites (24 of 30 [range 20 to 26]). The median angle of flexion of the shoulder was 40° (range 20º to 90°), and the median angle of abduction was 30° (range 20º to 90°). CONCLUSION Resurfaced allograft-prosthesis composites showed a high risk of complications, but not all complications resulted in removal of the reconstructed allograft. We used this technique mainly for very young children with small bones and for older children who underwent axillary nerve preservation. Although its success may be limited owing to a high risk of complications, a resurfaced allograft-prosthesis composite could be an alternative surgical option in order to preserve the bone stock and achieve good functional outcomes in very young children. We recommend using a long-stem resurfaced allograft-prosthesis composite, which may reduce the risk of complications. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Costantino Errani
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Hisaki Aiba
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Orthopaedic Surgery, Nagoya City University, Nagoya, Japan
| | - Ahmed Atherley
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Palmas
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Hiroaki Kimura
- Department of Orthopaedic Surgery, Nagoya City University, Nagoya, Japan
| | - Davide Maria Donati
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Manfrini
- Clinica Ortopedica e Traumatologica III a prevalente indirizzo Oncologico, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Jamshidi K, Karimi A, Babaei Zarch MA, Mirzaei A. Outcomes of proximal humeral reconstruction with cemented osteoarticular allograft in pediatric patients: a retrospective cohort study. J Shoulder Elbow Surg 2023; 32:e608-e615. [PMID: 37315710 DOI: 10.1016/j.jse.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/23/2023] [Accepted: 05/06/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft. METHODS Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88 ± 31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records. RESULTS Mean active forward flexion of the shoulder was 38° ± 18°. Mean active abduction was 48° ± 18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4% ± 11.2%. The mean Toronto Extremity Salvage Score was 75.6% ± 12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal. CONCLUSION In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques.
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Affiliation(s)
- Khodamorad Jamshidi
- Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amin Karimi
- Research Development Unit, Department of Orthopedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Mohammad Ali Babaei Zarch
- Research Development Unit, Department of Orthopedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Mirzaei
- Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Beltrami G, Rajan S, Nucci AM, Galeotti A, Guido D, Campanacci D, Innocenti M. Biological Prosthesis (Hollow 3D-Printed Titanium Custom-Made Prosthesis and Bone Graft) for Humeral Reconstruction in Pediatric Oncologic Patients: Surgical Indications and Results. Bioengineering (Basel) 2023; 10:1371. [PMID: 38135962 PMCID: PMC10741201 DOI: 10.3390/bioengineering10121371] [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: 10/05/2023] [Revised: 11/08/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
This study presents the mid-term outcomes of a novel "biological prosthesis" for pediatric humerus reconstruction after major bone tumor removal. This approach involves a hollow 3D-printed titanium custom-made prosthesis combined with bone grafting. The primary aim was to preserve and revitalize the unaffected autologous proximal or distal humeral stump. Between 2017 and 2021, we treated five pediatric patients (mean age 11.2 years; range 7-17) with humeral bone sarcomas. A one-stage surgical procedure involved tumor resection and implanting a hollow 3D-printed custom-made prosthesis. In two cases, we preserved the proximal humerus; in two, the distal part; and in one, both. Graft materials included homologous bone chips in three cases and free vascularized fibular grafts in two cases. All patients were clinically and radiographically assessed after a mean follow-up of 32.2 months (range of 14-68). No significant complications were observed, and no implant revisions were needed. Osseointegration was evident in all cases within eight months post-surgery; vascular support for the remaining autologous stump was demonstrated in all cases. Our hollow 3D-printed custom-made prosthesis and bone grafting offer the potential for partial or complete articular surface preservation. This approach encourages revascularization of the epiphysis, leading to satisfactory outcomes in humerus reconstruction within the pediatric population.
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Affiliation(s)
- Giovanni Beltrami
- Department of Orthopedic, Traumatology and Paediatric Orthopaedic Oncology, Azienda Ospedaliero Universitaria IRCCS, Meyer Children Hospital, 50139 Florence, Italy
| | - Sreeraj Rajan
- Department of Orthopaedic Oncology, Aster MIMS, Calicut 673016, India
| | - Anna Maria Nucci
- Department of Orthopedic, Traumatology and Paediatric Orthopaedic Oncology, Azienda Ospedaliero Universitaria IRCCS, Meyer Children Hospital, 50139 Florence, Italy
| | - Alberto Galeotti
- Department of Orthopedic, Traumatology and Paediatric Orthopaedic Oncology, Azienda Ospedaliero Universitaria IRCCS, Meyer Children Hospital, 50139 Florence, Italy
| | - Davide Guido
- Department of Orthopedic, Traumatology and Paediatric Orthopaedic Oncology, Azienda Ospedaliero Universitaria IRCCS, Meyer Children Hospital, 50139 Florence, Italy
| | - Domenico Campanacci
- Department of Orthopedic Oncology and Reconstructive Microsurgery, CTO, 10100 Florence, Italy
| | - Marco Innocenti
- Orthoplastic Surgery Division, Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Lee CJ, Tiourin E, Khoshab N, Leis AR, Nassif NA, Misaghi A, Vyas RM. Vascularized Fibular Epiphyseal Transfer for Pediatric Limb Salvage: Review of Applications and Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5354. [PMID: 37859637 PMCID: PMC10584290 DOI: 10.1097/gox.0000000000005354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
Vascularized fibular epiphyseal transfer (VFET) offers a functional advantage in pediatric limb salvage due to the preservation of growth potential and an articular surface for remodeling. This review summarizes the available evidence on the clinical characteristics and outcomes of pediatric reconstruction applying VFET at different recipient sites and with varying techniques. VFET was used to reconstruct the proximal humerus, distal radius or ulna, proximal femur, distal fibula, calcaneus, and mandible. Although most often harvested on the anterior tibial artery, VFET has also been performed using the peroneal artery, the inferior lateral genicular artery, and a dual pedicle. Recipient site flap inset most often involved fixation with plates and/or screws as well as soft tissue reconstruction using a retained slip of biceps femoris tendon. Outcomes included limb growth, range of motion, and strength. The most common reported complications were bone flap fracture and peroneal nerve palsy. The anterior tibial artery was the most applied pedicle with reliable limb growth, but with the added risk of postoperative peroneal palsy. Bone flap fracture most often occurred at the proximal humerus and femur recipient sites. Plate fixation and the combined use of allograft had lower instances of bone flap fracture. This review highlights how the anticipated dynamic growth and remodeling this free flap offers in the long term must be weighed against its complexity and potential complications.
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Affiliation(s)
- Christine J. Lee
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Ekaterina Tiourin
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Nima Khoshab
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Amber R. Leis
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
- Division of Plastic Surgery, Children’s Hospital Orange County, Orange, Calif
| | | | - Amir Misaghi
- Division of Orthopedic Surgery, Children’s Hospital Orange County, Orange, Calif
| | - Raj M. Vyas
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
- Division of Plastic Surgery, Children’s Hospital Orange County, Orange, Calif
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10
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Du W, Zhou W, Zhou L, Wang Y, Yan C, Al-Aroomi MA, Pang P, Sun C. Donor-site morbidity of free fibula flap in pediatric patients: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 83:207-214. [PMID: 37276738 DOI: 10.1016/j.bjps.2023.04.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/01/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
The morbidity of free fibula flap (FFF) in pediatric patients has gained attention. Thus, we aimed to evaluate donor-site morbidity after FFF harvesting in pediatric patients and its relationship with age. A systematic literature search of databases for cross-sectional studies related to pediatric donor-site morbidity after FFF harvesting was performed. Two independent reviewers evaluated relevant article titles and abstracts to extract data regarding donor-site morbidity from each article. Fifteen studies were included in the meta-analysis that evaluated the rate of complications. Individual cases of ankle instability were divided into the 0-13- and 13-17-year-old groups. The Chi-square test was used to compare ankle instability between both groups. A logistic regression model was created to analyze the relationships between age and ankle instability/claw toe. Sixteen English articles published between 2007 and 2021 were included in the systematic review. Information on morbidities of 294 cases in which FFF was used was collected. The mean incidence rate of complications, instability, claw toe, and nerve injury were 19.3%, 12.9%, 5.9%, and 5.1%, respectively. Bivariate analysis showed that age was significantly correlated with the incidence of ankle instability but not with the incidence of claw toe. The Chi-square test showed that the incidence rate of ankle instability between the age groups was significantly different. Therefore, we recommend 14 years of age as a new predictive factor for ankle instability. Nevertheless, there is limited evidence in this field, and more pediatric research is needed to clarify these findings.
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Affiliation(s)
- Weidong Du
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Wanghang Zhou
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Lu Zhou
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Yao Wang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Cong Yan
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Maged Ali Al-Aroomi
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Pai Pang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
| | - Changfu Sun
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, No. 117, Nanjing Bei Street, Heping District, Shenyang, Liaoning 110002, People's Republic of China.
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11
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Chappell AG, Ramsey MD, Dabestani PJ, Ko JH. Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review. Arch Plast Surg 2023; 50:82-95. [PMID: 36755653 PMCID: PMC9902088 DOI: 10.1055/s-0042-1758639] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 08/04/2022] [Indexed: 02/09/2023] Open
Abstract
Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.
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Affiliation(s)
- Ava G. Chappell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew D. Ramsey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Parinaz J. Dabestani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Jason H. Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Address for correspondence Jason H. Ko, MD, MBA, Associate Professor, Program Director Plastic Surgery Residency, Division of Plastic and Reconstructive SurgeryDepartment of Orthopedic Surgery, Northwestern University Feinberg School of MedicineChicago, IL 60611
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12
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Feltri P, Solaro L, Errani C, Schiavon G, Candrian C, Filardo G. Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:29-48. [PMID: 34110477 DOI: 10.1007/s00402-021-03962-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Pietro Feltri
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Luca Solaro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1/10, 40136, Bologna, Italy.
| | - Costantino Errani
- Orthopaedic Service, Musculoskeletal Oncology Department, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Guglielmo Schiavon
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900, Lugano, Switzerland.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy.,Facoltà Di Scienze Biomediche, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
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13
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Kaneuchi Y, Yoshida S, Fujiwara T, Evans S, Abudu A. Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity. J Pediatr Surg 2022; 57:702-709. [PMID: 35490054 DOI: 10.1016/j.jpedsurg.2022.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/19/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Limb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation. PATIENTS AND METHODS Retrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018. RESULTS We analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3-9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010). CONCLUSION The prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yoichi Kaneuchi
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK; Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Shinichirou Yoshida
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Tomohiro Fujiwara
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Scott Evans
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Adesegun Abudu
- Department of Oncology, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
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14
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Dabestani PJ, Ramsey MD, Chappell AG, Fracol ME, Stover MD, Ko JH. Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00001. [PMID: 36240298 DOI: 10.2106/jbjs.cc.22.00286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/10/2022] [Indexed: 02/24/2023]
Abstract
CASE A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.
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Affiliation(s)
- Parinaz J Dabestani
- Division of Plastic and Reconstructive Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Matthew D Ramsey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ava G Chappell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Megan E Fracol
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael D Stover
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients. Sarcoma 2022; 2022:6240293. [PMID: 35586727 PMCID: PMC9110248 DOI: 10.1155/2022/6240293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced amputation as the gold standard and is now performed in 90–95% of upper extremity malignancies. However, many of these salvage procedures are associated with significant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized fibular flap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population. Methods Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded. Results Five patients (average age = 8.4 years; range = 5–10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n = 4) or Ewing sarcoma (n = 1). The mean follow-up was 3.7 years. Complications occurred in five patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time = 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up. Conclusion Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or augmentation of large bony defects.
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16
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Kwon KB, Chung CY, Park MS, Lee KM, Sung KH. Lengthening and deformity correction in vascularized fibular autograft for a patient with Ewing sarcoma. J Orthop Surg (Hong Kong) 2021; 29:23094990211044549. [PMID: 34654326 DOI: 10.1177/23094990211044549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report the case of a pediatric patient with Ewing's sarcoma of the tibia treated with vascularized fibular autograft where the resulting limb deformity and leg length discrepancy (LLD) were corrected using Ilizarov external fixator. A 14-year-old girl presented to our outpatient clinic with a deformity of the right proximal and distal tibia and an 11.7 cm of LLD after tumor reconstruction surgery. Deformity correction and limb lengthening were simultaneously performed using double corticotomy on the right proximal and distal tibia. One year postoperatively, the union of the right proximal tibia had progressed, but nonunion was observed at the right distal corticotomy site. To address this, osteosynthesis with tricortical iliac bone allograft was performed after the removal of the Ilizarov external fixator. After 6 months, the union of the distal tibia was confirmed, and the varus deformity of proximal and distal tibia improved. The LLD was also decreased, but the left lower limb was still longer by 3 cm. This report shows that vascularized fibular autografts can potentially be used for the gradual correction of LLD and deformities. However, for the treatment of multiple deformities in bones previously reconstructed with vascularized fibular graft, the possibility of impaired bone forming potential of the fibular graft should be considered.
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Affiliation(s)
- Ki Bum Kwon
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 65462Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Chin Youb Chung
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 65462Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Moon Seok Park
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 65462Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Kyoung Min Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 65462Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Ki Hyuk Sung
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 65462Seoul National University Bundang Hospital, Gyeonggi, Korea
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17
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Gümüştaş SA, Çevik HB, Kayahan S. An Epidemiological Study of Primary Bone Tumors of the Fibula. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:548-553. [PMID: 34692938 DOI: 10.22038/abjs.2020.47057.2299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 12/05/2020] [Indexed: 11/06/2022]
Abstract
Background Relatively low incidence has led to an under-rating of fibula tumors. This study aimed to evaluate fibula tumors as a whole and to give detailed information based on histological types according to the anatomic location of the tumors in the fibula. Methods Evaluation was made of all the primary bone tumors of the fibula recorded in our bone tumor registry and institute of pathology from 2007 to 2018. Of these, 62 cases were identified. Analysis included assessment of age, gender, tumor localization, the presenting symptoms, the duration of symptoms, and treatment methods. Results There were 48 (77.4%%) benign and 14 (22.6%) malignant tumors. The most commonly found benign tumors were non-ossifying fibroma (12/48; 25%) and aneurysmal bone cyst (12/48; 25%), and the malignant tumors were chondrosarcoma (3/14; 21.4%) and chondroblastic osteosarcoma (3/14; 21.4%). The most common location for both benign and malignant tumors (58.3%, 71.4%) are the proximal fibula, followed by the distal fibula (27.1%, 28.6%) and the diaphysis (14.6%, 0%). Six (9.7%) patients presented with pathological fibula fractures. Conclusion Fibular tumors are rarely encountered in clinical practice but are mostly benign, with malignancy determined in approximately a quarter of patients. However, as most benign tumors are asymptomatic, and therefore remain undetected, the actual proportion of malignant tumors will be much lower.
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Affiliation(s)
- Seyit Ali Gümüştaş
- University of Health Sciences, Kartal Dr. Lütfi Kırdar Research and Training Hospital, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Hüseyin Bilgehan Çevik
- University of Health Sciences, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Department of Orthopaedics and Traumatology, Ankara, Turkey
| | - Sibel Kayahan
- University of Health Sciences, Kartal Dr. Lütfi Kırdar Research and Training Hospital, Department of Orthopaedics and Traumatology, İstanbul, Turkey
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18
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Hopyan S. Reconstruction for bone tumours of the shoulder and humerus in children and adolescents. J Child Orthop 2021; 15:358-365. [PMID: 34476025 PMCID: PMC8381401 DOI: 10.1302/1863-2548.15.210131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Sevan Hopyan
- Division of Orthopaedics and Program in Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto,Division of Orthopaedics, Department of Surgery and Department of Molecular Genetics, University of Toronto,Correspondence should be sent to Sevan Hopyan, The Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8. E-mail:
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19
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Composite-Free Vascularized Fibular Epiphyseal Flap and Proximal Humeral Allograft for Proximal Humerus Reconstruction in a Pediatric Patient. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202107000-00005. [PMID: 34232929 PMCID: PMC8265871 DOI: 10.5435/jaaosglobal-d-21-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/12/2021] [Indexed: 11/25/2022]
Abstract
Tumors involving the epiphysis in children present a reconstructive challenge. A free vascularized fibula epiphyseal transfer offers a means for biological reconstruction and longitudinal growth; however, it is often complicated by graft fracture and limited shoulder motion. Here, we present a case of a composite structural allograft with free vascularized fibula epiphyseal transfer for proximal humeral reconstruction. At 27-month follow-up, there was longitudinal growth, hypertrophy of the epiphysis, shoulder function which allowed activities of daily living, and no graft fracture.
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20
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Lu Y, Xiao X, Li M, Chen G, Huang M, Ji C, Wang Z, Li J. Use of Vascularized Fibular Epiphyseal Transfer with Massive Bone Allograft for Proximal Humeral Reconstruction in Children with Bone Sarcoma. Ann Surg Oncol 2021; 28:7834-7841. [PMID: 33974195 DOI: 10.1245/s10434-021-10032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The vascularized fibula epiphyseal transfer provides a reconstructive option for longitudinal growth after oncologic resection of the proximal humerus in pediatric patients. However, postoperative fractures and poor shoulder function are common. The purpose of this review was to introduce a composite approach in oncologic reconstruction of the proximal humerus and assess its clinical outcomes. METHODS We retrospectively investigated five children (3 osteosarcoma and 2 Ewing's sarcoma) who underwent biological reconstruction with combination of vascularized fibula epiphyseal transfer and massive bone allograft after oncologic resection of the proximal humerus. The mean follow-up was 46.8 months. RESULTS All patients were alive at the last follow-up. There was no graft fracture, hardware failure, or infection. The mean time of osseous union was 2.9 months at fibula-humerus junction and 6.2 months at allograft-humerus junction. Hypertrophy and axial growth were evident in all, except one patient who has avascular necrosis of the fibula head. The mean hypertrophy index was 51.5%, and the mean growth was 4.4 mm per annum. The mean arm discrepancy was 4.6 cm. All reconstruction was in situ with the average abduction of 113° and forward flexion of 69°. The mean Musculoskeletal Tumor Society (MSTS) score was 85.4% at the final follow-up. All patients experienced dropped foot and resolved spontaneously. CONCLUSIONS The combination of vascularized fibula epiphyseal transfer with massive allograft bone provides a reliable oncologic reconstruction of proximal humerus in children. It not only offers the ability of longitudinal growth, hypertrophy, and osseous union but also diminishes reconstructive complications and improves shoulder function. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Yajie Lu
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Xin Xiao
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Minghui Li
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Guojing Chen
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Mengquan Huang
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Chuanlei Ji
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Zhen Wang
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Jing Li
- Department of Orthopedics, Xi Jing Hospital, Air force Medical University, Xi'an, Shaanxi, People's Republic of China.
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Surgical Advances in Osteosarcoma. Cancers (Basel) 2021; 13:cancers13030388. [PMID: 33494243 PMCID: PMC7864509 DOI: 10.3390/cancers13030388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Osteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development. Abstract Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.
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Zhu N, Hou J. Assessing immune infiltration and the tumor microenvironment for the diagnosis and prognosis of sarcoma. Cancer Cell Int 2020; 20:577. [PMID: 33292275 PMCID: PMC7709254 DOI: 10.1186/s12935-020-01672-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 11/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sarcomas, cancers originating from mesenchymal cells, are comprehensive tumors with poor prognoses, yet their tumorigenic mechanisms are largely unknown. In this study, we characterize infiltrating immune cells and analyze immune scores to identify the molecular mechanism of immunologic response to sarcomas. METHOD The "CIBERSORT" algorithm was used to calculate the amount of L22 immune cell infiltration in sarcomas. Then, the "ESTIMATE" algorithm was used to assess the "Estimate," "Immune," and "Stromal" scores. Weighted gene co-expression network analysis (WGCNA) was utilized to identify the significant module related to the immune therapeutic target. Gene ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed using the "clusterProfiler" package in R for annotation and visualization. RESULTS Macrophages were the most common immune cells infiltrating sarcomas. The number of CD8 T cells was negatively associated with that of M0 and M2 macrophages, and positively associated with M macrophages in sarcomas samples. The clinical parameters (disease type, gender) significantly increased with higher Estimate, Immune, and Stromal scores, and with a better prognosis. The blue module was significantly associated with CD8 T cells. Functional enrichment analysis showed that the blue module was mainly involved in chemokine signaling and the PI3K-Akt signaling pathway. CD48, P2RY10 and RASAL3 were identified and validated at the protein level. CONCLUSION Based on the immune cell infiltration and immune microenvironment, three key genes were identified, thus presenting novel molecular mechanisms of sarcoma metastasis.
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Affiliation(s)
- Naiqiang Zhu
- Department of Minimally Invasive Spinal Surgery, Affiliated Hospital of Chengde Medical College, Chengde, 067000, China
| | - Jingyi Hou
- Department of Minimally Invasive Spinal Surgery, Affiliated Hospital of Chengde Medical College, Chengde, 067000, China.
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Lu Y, Zhu H, Huang M, Zhang C, Chen G, Ji C, Wang Z, Li J. Is frozen tumour-bearing autograft with concurrent vascularized fibula an alternative to the Capanna technique for the intercalary reconstruction after resection of osteosarcoma in the lower limb? Bone Joint J 2020; 102-B:646-652. [PMID: 32349589 DOI: 10.1302/0301-620x.102b5.bjj-2019-1380.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIMS The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction. METHODS From June 2011 to January 2016 a retrospective study was carried out of patients with primary osteosarcoma of lower limbs who underwent combined biological intercalary reconstruction. Patients were categorized into two groups based on the reconstructive technique: frozen tumour-bearing autograft combined with concurrent VFG (Group 1) and the Capanna method (Group 2). Demographics, operating procedures, oncological outcomes, graft union, limb function, and postoperative complications were compared. RESULTS A total of 23 patients were identified for analysis: eight in Group 1 and 15 in Group 2. There was no difference in the demographics (age, sex, and affected site) and operating procedures (resection length, duration of surgery, and blood loss) between the two groups. No significant difference was found in local recurrence in Group 1 versus Group 2 (p = 0.585). Mean union time for the frozen autograft-host junction was 8.4 months (7.0 to 11.0), significantly earlier than for the allograft-host junction in Group 2 (mean 14.1 months (10.0 to 28.0); p < 0.001). Mean Musculoskeletal Tumor Society scores in groups 1 and 2 were 90.3% (SD 7.4%) and 88.0% (SD 9.0%), respectively, with no significant statistical difference (p = 0.535). In terms of complications, infection (n = 1, 6.7%) and delayed union (n = 2, 13.3%) occurred in Group 2, but no such complications were observed in Group 1. CONCLUSION Frozen tumour-bearing autograft in combination with VFG can be used as an alternative to the Capanna reconstruction in properly selected patients with osteosarcoma. Cite this article: Bone Joint J 2020;102-B(5):646-652.
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Affiliation(s)
- Yajie Lu
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Haodong Zhu
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Mengquan Huang
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Chunlin Zhang
- Department of Orthopaedics, Tenth People's Hospital of Tongji University, Shanghai, China
| | - Guojing Chen
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Chuanlei Ji
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Zhen Wang
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
| | - Jing Li
- Department of Orthopaedics, Xi Jing Hospital Affiliated to the Air Force Medical University, Shaanxi, China
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Takeuchi A, Yamamoto N, Hayashi K, Matsubara H, Miwa S, Igarashi K, Tsuchiya H. Joint-preservation surgery for pediatric osteosarcoma of the knee joint. Cancer Metastasis Rev 2020; 38:709-722. [PMID: 31807972 DOI: 10.1007/s10555-019-09835-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The multi-disciplinary approach involving imaging, multi-agent chemotherapy, meticulous surgical procedures, and careful postoperative care has facilitated an increase in the use of limb-sparing surgery for pediatric osteosarcoma. Osteosarcoma usually occurs around the metaphysis of the distal femur or proximal tibia and needs wide excision with the adjacent joint and replacement by a megaprosthesis. The recent advancement in imaging modalities and surgical techniques supports joint-preservation surgery (JPS), involving the preservation of the adjacent epiphysis, for select patients following careful assessment of the tumor margins and precise tumor excision. An advantage of this surgery is that it maintains the adjacent joint and preserves the growth of the residual epiphysis, which provides excellent limb function. Various reconstruction options are available, including allograft, tumor-devitalized autograft, vascularized fibula graft, distraction osteogenesis, and custom-made implants. However, several complications are inevitable with these options, such as loosening, non-union at the host-graft junction, infection, fracture, implant loosening, breakage, deformity, limb-length discrepancy related to the reconstruction methods, or patient growth in pediatric osteosarcoma. Surgeons should fully understand the advantages and disadvantages of this procedure. In this review, we discuss the concept of JPS, types of reconstruction methods, and current treatment outcomes. It is our opinion that the further analysis by multi-institutional setting is necessary to clarify long-term outcomes and establish global guidelines on the indications and surgical procedure for JPS.
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Affiliation(s)
- Akihiko Takeuchi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hidenori Matsubara
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Yao W, Cai Q, Wang J, Hou J. Mid- to long-term effects of two different biological reconstruction techniques for the treatment of humerus osteosarcoma involving caput humeri. World J Surg Oncol 2020; 18:23. [PMID: 31996228 PMCID: PMC6990589 DOI: 10.1186/s12957-020-1797-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/19/2020] [Indexed: 11/21/2022] Open
Abstract
Background The proximal humerus is one of the most common sites of primary or metastatic malignant tumors. Reconstruction of the shoulder after tumor resection is controversial and challenging. When intra-articular resection is performed, biological reconstruction (osteoarticular allograft and autologous bone implantation) may be the first choice rather than prosthetic reconstruction. Objective To observe the mid- to long-term effects of oncologic, reconstructive, and functional outcomes of two different biological reconstruction methods for resection of humerus osteosarcoma involving caput humeri. Methods This was a retrospective study of 13 consecutive patients who underwent humeral reconstruction of osteosarcoma including caput humeri using osteoarticular allograft (n = 7) and tumor bone inactivated and reimplantation (TBIR, n = 6) in our clinic between 2007 and 2017. Patients’ general information, resection and reconstruction techniques, oncological and functional outcomes, and complications were collected and evaluated. Different complications of implantations were compared and analyzed for the different biological methods. Results The study included ten males and three females with an average age of 19.15 years. The operation time was about 3.65 h with an average blood loss of 631 ml. The resection tumor bones were 13–45 cm (23.54 cm on average). The mean follow-up period was 5.27 years. The shoulder movement was 10–70° (average, 44.00°) in abduction, 0–30° (average, 14.17°) in flexion, and 0–20° (average, 11.90°) in extention at the last follow-up. The complications included fracture in four TBIR patients and two allograft patients with an average of 2.67 years postoperation. Fracture rate was higher and appeared time was earlier in TBIR patients than in allograft patients (p = 0.04); caput humeri absorption occurred in all seven allograft patients and three TBIR patients at an average of 3.10 years after surgery; severe graft bone resorption appeared in five TBIR patients and two allograft patients at an average of 2.57 years of follow-up. Conclusions Humerus biological reconstruction involving caput humeri was associated with a high complication rate and acceptable limb function in the mid to long term. New combined biological methods should be explored and adopted in the future.
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Affiliation(s)
- Weitao Yao
- Department of Bone and Soft Tumor, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, 45000, People's Republic of China.
| | - Qiqing Cai
- Department of Bone and Soft Tumor, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, 45000, People's Republic of China
| | - Jiaqiang Wang
- Department of Bone and Soft Tumor, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, 45000, People's Republic of China
| | - Jingyu Hou
- Department of Bone and Soft Tumor, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, 45000, People's Republic of China
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Tsuda Y, Tsoi K, Stevenson JD, Fujiwara T, Tillman R, Abudu A. Extendable Endoprostheses in Skeletally Immature Patients: A Study of 124 Children Surviving More Than 10 Years After Resection of Bone Sarcomas. J Bone Joint Surg Am 2020; 102:151-162. [PMID: 31714469 DOI: 10.2106/jbjs.19.00621] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Extendable endoprostheses are used to reconstruct segmental defects following resection of bone sarcomas in skeletally immature patients. However, there remains a paucity of studies with regard to long-term outcomes. METHODS We retrospectively reviewed 124 skeletally immature children who underwent an extendable endoprosthetic replacement and survived more than 10 years after the surgical procedures. Anatomical sites included the distal part of the femur (n = 66), the proximal part of the femur (n = 13), the proximal part of the tibia (n = 29), and the proximal part of the humerus (n = 16). Complications and implant survival were classified according to the modified Henderson criteria. RESULTS The mean follow-up was 24 years (range, 10 to 36 years). The mean age at the time of the extendable endoprosthetic replacement was 9 years (range, 2 to 16 years). All patients had reached skeletal maturity at the last follow-up. The 10-year endoprosthetic failure-free survival rate was 28%. A total of 243 complications occurred in 90% of patients; these complications were most frequently related to soft-tissue problems (27% of complications). The incidence of and cumulative survival with respect to each failure mode varied between anatomical sites. Soft-tissue failures occurred most frequently in the proximal part of the femur (77%; p = 0.003), and the distal part of the femur was the most frequent site of aseptic loosening (52%; p = 0.014) and structural failure (55%; p = 0.001). Excluding lengthening procedures, 105 patients (85%) underwent an additional surgical procedure, with a mean of 2.7 surgical procedures per patient (range, 0 to 7 surgical procedures per patient). The mean limb-length discrepancy at the final follow-up was 1 cm (range, 0 to 9 cm). Limb salvage was achieved in 113 patients (91%). The mean Musculoskeletal Tumor Society functional score (the percentage of a total score of 30 points) was 82% (range, 40% to 100%) in 115 patients with available data at the last follow-up. CONCLUSIONS Extendable endoprostheses are associated with a high complication rate and a need for additional surgical procedures over time. Despite this, successful limb salvage with reasonable function and small limb-length discrepancy is achievable in the long term. Our study provides benchmark data for individual anatomical sites for further improvements of outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Yusuke Tsuda
- Royal Orthopaedic Hospital, Birmingham, United Kingdom
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27
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Tsuda Y, Fujiwara T, Evans S, Kaneuchi Y, Abudu A. Extra-articular resection of shoulder joint for bone sarcomas: Oncologic and limb-salvage outcomes of 32 cases compared with shoulder disarticulation and forequarter amputation. J Surg Oncol 2020; 121:612-619. [PMID: 31919856 DOI: 10.1002/jso.25838] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 12/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to identify the overall survival (OS), surgical complications, survival of reconstruction, and functional outcome of patients who underwent extra-articular resection of the shoulder joint for primary bone sarcomas. The OS and local recurrence rates in patients who underwent an amputation were also evaluated for comparison. METHODS Thirty-two patients treated between 1988 and 2017 were studied. The tumours were located in the humerus in 22 (69%) and scapula in 10 patients (31%). The resection types were Malawer type IV in 6 (19%), type V in 21 (66%), and type VI in 5 patients (15%). Reconstruction was performed with endoprosthesis in 23 patients (72%) while excision arthroplasty with the suspension of the humerus to the clavicle was performed in 9 patients (28%). Surgical margins were wide in 16, marginal in 8, intralesional in 3, and not available in 5 patients. During the study period, 40 patients underwent a forequarter amputation and 11 patients underwent a shoulder disarticulation. RESULTS The 5-year OS for patients who underwent extra-articular resection of the shoulder joint was 42% which was not statistically different compared with that of patients who underwent amputation (5-year OS = 30%; P = .091). The 5-year survival of the reconstruction was 94%, similar for endoprosthesis and excision arthroplasty. Local recurrence and complications developed in 6 (19%) and 10 patients (31%), respectively. Failures of the reconstruction requiring revision surgery occurred in two patients (6%). Limb salvage was achieved in 30 patients (94%). The median Musculoskeletal Tumour Society functional score was 61% (interquartile range, 57%-70%) and was similar in the endoprosthesis and excision arthroplasty group. CONCLUSIONS Extra-articular resection of the shoulder joint for bone sarcomas is an effective limb-salvage method. However, local recurrence remains a principal concern.
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Affiliation(s)
- Yusuke Tsuda
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK.,Department of Orthopaedic Surgery, University of Tokyo Hospital, Tokyo, Japan
| | | | - Scott Evans
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Yoichi Kaneuchi
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Adesegun Abudu
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK
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Tsuda Y, Fujiwara T, Stevenson JD, Parry MC, Tillman R, Abudu A. The long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Bone Joint J 2020; 102-B:64-71. [DOI: 10.1302/0301-620x.102b12.bjj-2020-0124.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Methods A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11). Results The median follow-up time was 10.6 years (IQR 3.9 to 20.4). The overall implant survival at ten years was 75%. Complications occurred in 13 patients (37%). Subluxation at the proximal humerus occurred in 19 patients (54%) but only six (17%) were symptomatic. Subluxation was seen more commonly in children under the age of nine years (86%) than in those aged nine years or more (33%) (p = 0.002). Implant failure occurred in nine patients (26%): the most common cause was aseptic loosening (four patients, 11%). Lengthening of the implant was carried out in 23 patients (66%). At final follow up, three patients had a limb that was shortened by 5 cm or more. The mean Musculoskeletal Tumor Society (MSTS) functional score was 79% (73% to 90%). Conclusion Extendable endoprosthetic replacement is a reliable method of reconstructing humerus after excision of a bone sarcoma. Children who are less than nine years old have a high risk of subluxation. Cite this article: Bone Joint J 2020;102-B(1):64–71
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Affiliation(s)
- Yusuke Tsuda
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK
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What Is the Survival and Function of Modular Reverse Total Shoulder Prostheses in Patients Undergoing Tumor Resections in Whom an Innervated Deltoid Muscle Can Be Preserved? Clin Orthop Relat Res 2019; 477:2495-2507. [PMID: 31389894 PMCID: PMC6903840 DOI: 10.1097/corr.0000000000000899] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the reverse total shoulder arthroplasty (RTSA) are felt to be useful in other reconstructions where rotator cuff function is compromised, so it seemed logical that it might help in tumor reconstructions as well in patients where the deltoid muscle and its innervation can be preserved. QUESTIONS/PURPOSES In patients with a tumor of the proximal humerus that can be resected with preservation of the deltoid muscle, (1) What complications are associated with tumor resection and reconstruction with a modular RTSA? (2) What are the functional results of modular RTSA in these patients? METHODS From January 2011 to January 2018, we treated 52 patients for bone tumors of the proximal humerus. Of these, three patients were treated with forequarter amputation, 14 were treated with standard modular proximal humerus implants, seven were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. Generally, we used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. Conversely, we preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, we retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. We excluded three patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and three patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were nine men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was performed in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon (PR) and shoulder surgeon (AC). Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society score (range 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range 0 to 100). The statistical analysis was performed using Kaplan-Meier curves. RESULTS Complications occurred in five of 22 patients; there was a shoulder dislocation (Type I) in four patients and aseptic loosening (Type II) in one. Function in these patients on the outcomes scales we used was generally satisfactory; the mean Musculoskeletal Tumor Society score was 29, the mean Constant score was 61, and the mean American Shoulder and Elbow Surgeons score was 81. CONCLUSIONS Although this was a small series of patients with heterogeneous diagnoses and resection types, and we were not able to directly compare the results of this procedure with those of other available reconstructions, we found patients treated with RTSA achieved reasonable shoulder function after resection and reconstruction of a proximal humerus tumor. It may not be valuable in all tumor resections, but in patients in whom the deltoid can be partly spared, this procedure appears to reasonably restore short-term shoulder function. However, future larger studies with longer follow-up are needed to confirm these findings. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Fujiwara T, Medellin MR, Sambri A, Tsuda Y, Balko J, Sumathi V, Gregory J, Jeys L, Abudu A. Preoperative surgical risk stratification in osteosarcoma based on the proximity to the major vessels. Bone Joint J 2019; 101-B:1024-1031. [DOI: 10.1302/0301-620x.101b8.bjj-2018-0963.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels. Patients and Methods A total of 226 patients with high-grade non-metastatic osteosarcoma in the limbs were investigated. Median age at diagnosis was 15 years (4 to 67) with the ratio of male to female patients being 1.5:1. The most common site of the tumour was the femur (n = 103) followed by tibia (n = 66). The vascular proximity was categorized based on the preoperative MRI after neoadjuvant chemotherapy into four types: type 1 > 5 mm; type 2 ≤ 5 mm, > 0 mm; type 3 attached; type 4 surrounded. Results Limb salvage rate based on the proximity type was 92%, 88%, 51%, and 0% for types 1 to 4, respectively, and the overall survival at five years was 82%, 77%, 57%, and 67%, respectively (p < 0.001). Local recurrence rate in patients with limb-salvage surgery was 7%, 8%, and 22% for the types 1 to 3, respectively (p = 0.041), and local recurrence at the perivascular area was observed in 1% and 4% for type 2 and 3, respectively. The mean microscopic margin to the major vessels was 6.9 mm, 3.0 mm, and 1.4 mm for types 1 to 3, respectively. In type 3, local recurrence-free survival with limb salvage was significantly poorer compared with amputation (p = 0.025), while the latter offered no overall survival benefit. In this group of patients, factors such as good response to chemotherapy or limited vascular attachment to less than half circumference or longitudinal 10 mm reduced the risk of local recurrence. Conclusion The proximity of osteosarcoma to major blood vessels is a poor prognostic factor for local control and survival. Amputation offers better local control for tumours attached to the blood vessels but does not improve survival. Limb salvage surgery offers similar local control if the tumour attachment to blood vessels is limited. Cite this article: Bone Joint J 2019;101-B:1024–1031.
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Affiliation(s)
- T. Fujiwara
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - M. R. Medellin
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
- Oncology Department, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - A. Sambri
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
- Istituto Ortopedico Rizzoli/University of Bologna, Bologna, Italy
| | - Y. Tsuda
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
| | - J. Balko
- Department of Musculoskeletal Pathology, The Royal Orthopaedic Hospital, Birmingham, UK
| | - V. Sumathi
- Department of Musculoskeletal Pathology, The Royal Orthopaedic Hospital, Birmingham, UK
| | - J. Gregory
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
| | - L. Jeys
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
| | - A. Abudu
- Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK
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