The cost-effectiveness of limb salvage for bone tumours

Rehabilitation Treatment of a Patient With Total Humeral Endoprosthetic Replacement

Total humeral endoprosthetic replacement (THR) is a rare surgery for malignant humeral bone tumors. Studies focusing on its surgical methods and functional status are limited. Furthermore, rehabilitation treatment after THR has not been reported. Therefore, this case report aimed to investigate its postoperative rehabilitation treatment and reinstatement. A 69-year-old woman was diagnosed with chondrosarcoma of her left humerus. THR was performed the day following patient admission. The wide resection caused the loss of her left shoulder motor function. She had a left ulnar nerve disorder and carpal tunnel syndrome. Rehabilitation treatments such as joint range of motion training were initiated on postoperative day (POD) 1. We designed a shoulder abductor brace to maintain her left shoulder in an abducted and flexed position so she could use her left hand effectively. The manual muscle testing scores for elbow joint movements gradually improved. On POD47, she was transferred to a convalescent rehabilitation hospital to receive training in activities of daily living and barber work. The patient was discharged on POD107. The Disabilities of the Arm, Shoulder, and Hand score improved from 86.2 (POD7) to 17.2 (POD107). She continued outpatient rehabilitation and reinstated work on POD143. The use of a brace and seamless rehabilitation from the acute phase to convalescence and community-based rehabilitation enabled the patient with THR to return to work. This study suggests that precise assessment of the disorders and consecutive rehabilitation treatment with a brace should be considered after THR.

Application of additively manufactured 3D scaffolds for bone cancer treatment: a review

Bone cancer is a critical health problem on a global scale, and the associated huge clinical and economic burdens are still rising. Although many clinical approaches are currently used for bone cancer treatment, these methods usually affect the normal body functions and thus present significant limitations. Meanwhile, advanced materials and additive manufacturing have opened up promising avenues for the development of new strategies targeting both bone cancer treatment and post-treatment bone regeneration. This paper presents a comprehensive review of bone cancer and its current treatment methods, particularly focusing on a number of advanced strategies such as scaffolds based on advanced functional materials, drug-loaded scaffolds, and scaffolds for photothermal/magnetothermal therapy. Finally, the main research challenges and future perspectives are elaborated.

Survivorship, complications, and outcomes following distal femoral arthroplasty for non-neoplastic indications

Aims

Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

Methods

We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.

Results

Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048).

Conclusion

DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates.

Cite this article: Bone Jt Open 2022;3(3):173–181.

Hospital Resource Utilization Associated With Endoprosthetic Reconstruction Versus Primary Arthroplasty

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

Compressive osseointegration for endoprosthetic reconstruction

This review summarizes the biomechanical concepts, clinical outcomes and limitations of compressive osseointegration fixation for endoprosthetic reconstruction. Compressive osseointe - gration establishes stable fixation and integration through a novel mechanism; a Belleville washer system within the spindle applies 400-800 PSI force at the boneimplant interface. Compressive osseointegration can be used whenever standard endoprosthetic reconstruction is indicated. However, its mode of fixation allows for a shorter spindle that is less limited by the length of remaining cortical bone. Most often compressive osseointegration is used in the distal femur, proximal femur, proximal tibia, and humerus but these devices have been customized for use in less traditional locations. Aseptic mechanical failure occurs earlier than with standard endoprosthetic reconstruction, most often within the first two years. Compressive osseointegration has repeatedly been proven to be non-inferior to standard endoprosthetic reconstruction in terms of aseptic mechanical failure. No demographic, device specific, oncologic variables have been found to be associated with increased risk of aseptic mechanical failure. While multiple radiographic parameters are used to assess for aseptic mechanical failure, no suitable method of evaluation exists. The underlying pathology associated with aseptic mechanical failure demonstrates avascular bone necrosis. This is in comparison to the bone hypertrophy and ingrowth at the boneprosthetic interface that seals the endosteal canal, preventing aseptic loosening.

[Total endoprosthetic replacement of femur, humerus and tibia]

Improvements in diagnostics and effectiveness of chemotherapy have resulted in most patients with primary malignant bone tumours being candidates for limb salvage surgery. Herewith, the use of modern modular tumour endoprostheses allows for the replacement of all big joints and even entire long bones such as the femur, humerus and tibia. In this article, we focus on individual prerequisites for and challenges with performing a total endoprosthetic reconstruction of the above-mentioned anatomic structures. Additionally, data from the literature with regards to functional outcome, problems and complications are presented.

How Often Do Acetabular Erosions Occur After Bipolar Hip Endoprostheses in Patients With Malignant Tumors and Are Erosions Associated With Outcomes Scores?

BACKGROUND

Bipolar endoprosthetic replacement is an option for reconstruction of the proximal femur to restore a functional extremity and salvage the limb. However, because these patients are young, there is a theoretical risk for long-term degenerative changes of the acetabulum. Currently, there is a paucity of data concerning the proportion of patients who experience degenerative acetabulum changes after reconstruction and whether these changes are associated with Musculoskeletal Tumor Society (MSTS) scores.

QUESTIONS/PURPOSES

(1) What proportion of patients develop acetabular cartilage degeneration after bipolar hemiarthroplasty for malignant tumor-related reconstructions? (2) What is the survivorship free from revision for acetabular wear, erosions, or progressive arthritis? (3) Is there an association between the presence of acetabular erosions and lower MSTS scores?

METHODS

Between 2000 and 2015, 148 patients underwent endoprosthetic reconstruction of the proximal femur with a bipolar hemiarthroplasty for a malignant tumor and were potentially eligible for this retrospective study. Minimum followup was 1 year except for those who died or were revised earlier; of the 148, no patients were lost to followup before that time who were not known to have died; mean followup on the remainder was 79 months (range, 12-220 months), and the mean time to death after surgery for those who died was 28 months (range, 0-196 months). Over the course of the study, 93 (63%) patients died. The mean (± SD) patient age was 57 ± 17 years, and 55% (81 of 148) of the patients were men. We used magnification-corrected supine AP plain radiographs of the hip to evaluate degenerative acetabulum changes, and we used the 1993 MSTS score to assess function through chart review and a longitudinally maintained institutional database. We used a competing-risks survivorship estimator rather than Kaplan-Meier because of the high proportion of patients who had died during the surveillance period.

RESULTS

Nineteen patients (13%) developed cartilage erosion > 2 mm in the acetabulum, with two also developing protrusio after proximal femoral replacement with a bipolar endoprosthesis. Three additional patients also developed signs of protrusio. The mean acetabular wear after bipolar replacement was 1.2 mm. Patients with longer followup (p = 0.001) were at higher risk for developing acetabular wear. Six patients underwent conversion to THA to treat hip pain. At 10 years the cumulative incidence for conversion to THA for acetabular wear is 5% (95% confidence interval [CI], 0%-11%), whereas the cumulative incidence of death was 70% (95% CI, 61%-79%). There was no difference in mean MSTS scores between patients who developed > 2 mm of acetabular erosion (65% ± 25%) and those who did not (67% ± 20%; p = 0.77).

CONCLUSIONS

Wear was uncommon among patients with malignant hip tumors treated with bipolar endoprostheses, but the followup here was short, and some patients indeed developed wear and underwent wear-related revisions to THA. Patients expected to survive more than a few years should have periodic radiographic surveillance and should be followed for a longer period to get a better sense for whether the problem worsens with time, as we expect it may, among patients who survive for longer periods.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Component Fracture in the Kotz Modular Femoral Tibial Reconstruction System: An Under-Reported Complication

BACKGROUND

Primary bone tumors of the femur are commonly reconstructed using an endoprosthesis. Different modes of implant failure have been described, including structural failure; although uncommon, this may be an under-reported complication. The purpose of this study is to examine the rates and risk factors for implant fracture of the Kotz Modular Femoral Tibial Reconstruction system (KMFTR).

METHODS

Two hundred twenty-one patients (95 women and 126 men) who underwent a KMFTR reconstruction were reviewed. Twenty-seven patients (12%) sustained a prosthetic fracture. The mean time to fracture was 7 years postoperatively. The fractured component most commonly involved the distal femur (n = 21) and a screw hole in the stem (n = 12). In patients with stem fractures (n = 21), the mean intramedullary stem diameter was 12 mm and the mean extramedullary component length was 18 cm.

RESULTS

Compared to patients who did not fracture, those with a prosthetic fracture had a significantly smaller stem diameter (12 vs 14 mm, P = .001) and a significantly longer extramedullary component length (18 vs 15 cm, P = .04). There was no difference between the preoperative and postoperative Toronto Extremity Salvage Scores (P = .98), Musculoskeletal Tumor Society 87 (P = .78), or Musculoskeletal Tumor Society 93 (P = 1.0) ratings for patients with or without a prosthetic fracture.

CONCLUSION

This study shows that fracture is an under-reported complication associated with the KMFTR stem. We identified an endoprosthetic component fracture rate of 12%. Patients with smaller stem diameter and longer resection lengths were more likely to sustain a stem fracture. Subsequent revision provides a durable means of reconstruction, with no significant loss of patient function.

Limb Salvage Versus Amputation in Conventional Appendicular Osteosarcoma: a Systematic Review

The overall survivorship in patients with appendicular osteosarcoma has increased in the past few decades. However, controversies and questions about performing an amputation or a limb salvage procedure still remain. Using three peer-reviewed library databases, a systematic review of the literature was performed to evaluate all studies that have evaluated the outcomes of appendicular osteosarcoma, either with limb salvage or amputation. The mean 5-year overall survivorship was 62% for salvage and 58% for amputation (p > 0.05). At mean 6-year follow-up, the local recurrence rates were 8.2% for salvage and 3.0% for amputation (p > 0.05). Additionally, at mean 6-year follow-up, the rate for metastasis was 33% for salvage and 38% for amputation (p > 0.05). The revision rates were higher with salvage (31 vs. 28%), and there were more complications in the salvage groups (52 vs. 34%; p > 0.05). Despite the heterogeneity of studies available for review, we observed similar survival rates between the two procedures. Although there was no significant statistical difference between rates of recurrence and metastasis, the local recurrence rate and risk of complications were higher for limb salvage as compared to amputation. Cosmetic satisfaction is often higher with limb salvage, whereas long-term expense is higher with amputation. Overall, current literature supports limb salvage procedures when wide surgical margins can be achieved while still retaining a functional limb.

Periprosthetic Fractures in Megaprostheses: Algorithmic Approach to Treatment

With increases in both life expectancy and the number of patients with endoprosthetic replacements, more periprosthetic fractures are expected to occur. Periprosthetic fractures related to megaprostheses present a treatment challenge, with a high incidence (one-third of affected patients) of secondary revision as a result of prosthetic loosening, infection, nonunion, refracture, or even amputation. Efforts to improve endoprosthetic reconstruction should focus on preventing postoperative complications. Understanding the causes of complications and strategies to avoid them could lead to significant improvements in implant survival, limb function, and patient outcomes. This article presents a concise review of the current literature and an algorithmic approach to reconstruction of these complex injuries. [Orthopedics. 2017; 40(3):e387-e394.].

Staged reconstruction brachytherapy has lower overall cost in recurrent soft-tissue sarcoma

Purpose

Adjuvant brachytherapy (AB) with immediate (IR) and staged reconstruction (SR) are distinct treatment modalities available for patients with recurrent soft tissue sarcoma (STS). Although SR may offer local control and toxicity benefit, it requires additional upfront procedures, and there is no evidence that it improves overall survival. With the importance of value-based care, our goal is to identify which technique is more cost effective.

Material and methods

A retrospective review of 22 patients with recurrent extremity STS treated with resection followed by AB alone. Hospital charges were used to compare the cost between SR and IR at the time of initial treatment, at 6-month intervals following surgery, and cumulative cost comparisons at 18 months.

Results

Median follow-up was 31 months. Staged reconstruction (n = 12) was associated with an 18-month local control benefit (85% vs. 42%, p = 0.034), compared to IR (n = 10). Staged reconstruction had a longer hospital stay during initial treatment (10 vs. 3 days, p = 0.002), but at 18 months, the total hospital stay was no longer different (11 vs. 11 days). Initially, there was no difference in the cost of SR and IR. With longer follow-up, cost eventually favored SR, which was attributed primarily to the costs associated with local failure (LF). On multivariate analysis, cost of initial treatment was associated with length of hospital stay (~$4.5K per hospital day, p < 0.001), and at 18 months, the cumulative cost was ~175K lower with SR (p = 0.005) and $58K higher with LF (p = 0.02).

Conclusions

In recurrent STS, SR has a longer initial hospital stay when compared to IR. At 18 months, SR had lower rates of LF, translating to lower total costs for the patient. SR is the more cost-effective brachytherapy approach in the treatment of STS, and should be considered as healthcare transitions into value-based medicine.

Management of Bone Sarcoma

Treatment of bone sarcoma requires careful planning and involvement of an experienced multidisciplinary team. Significant advancements in systemic therapy, radiation, and surgery in recent years have contributed to improved functional and survival outcomes for patients with these difficult tumors, and emerging technologies hold promise for further advancement.

Rehabilitation Strategies and Outcomes of the Sarcoma Patient

Sarcomas are a relatively rare cancer that, depending on the location, can cause significant neuromusculoskeletal dysfunction and require rehabilitation interventions to reduce pain, restore function, and improve quality of life. This review focuses on sarcoma subtypes that frequently cause these complications: bony and soft tissue sarcomas leading to limb salvage or amputation, desmoid tumors, and malignant peripheral nerve sheath tumors. Rehabilitation approaches and outcomes are discussed, as well as considerations for childhood sarcoma survivors transitioning to adulthood.

How Often Does Spindle Failure Occur in Compressive Osseointegration Endoprostheses for Oncologic Reconstruction?

BACKGROUND

Compressive osseointegration is a promising modality for limb salvage in distal femoral oncologic tumors. However, few studies have explored short-term survival rates in a large patient cohort of distal femur compressive endoprostheses or highlighted the risk factors for spindle failures.

QUESTIONS/PURPOSES

We asked: (1) What is the frequency of compressive osseointegration spindle failure in distal femoral reconstructions? (2) What are the characteristics of rotational failure cases with distal femur compressive osseointegration endoprostheses? (3) What are the risk factors for mechanical and rotational failure of distal femur compressive osseointegration implantation? (4) What are other modalities of failure or causes of revision surgery, which affect patients undergoing distal femur compressive osseointegration implantation for oncologic reconstruction?

METHODS

Between 1996 and 2013, 127 distal femoral reconstructions with the Compress(®) prosthesis were performed in 121 patients. During that time, 116 Compress(®) prostheses were implanted for aggressive primary tumors of the distal femur and/or failure of previous oncologic reconstruction. This approach represented approximately 91% of the distal femoral reconstructions performed during that time. Of the patients with prostheses implanted, four patients (four of 116, 3%) had died, and 37 (37 of 116, 32%) were lost to followup before 24 months. The median followup was 84 months (range, 24-198 months), and 71 patients (66% of all patients) were seen within the last 3 years. A retrospective chart review was performed to determine failure modality as defined by radiographs, clinical history, and intraoperative findings. Risk factors including age, sex, BMI, resection length, and perioperative chemotherapy were analyzed to determine effect on spindle and rotational failure rates. Survival analysis was determined using the Kaplan-Meier estimator. Differences in survival between groups were analyzed using the log rank test. Risk factors were determined using Cox proportional hazard modeling.

RESULTS

Spindle survival at 5 and 10 years was 91% (95% CI, 82%-95%). Survival rates from rotational failure at 5 and 10 years were 92% (95% CI, 83%-96%); the majority of failures occurred within the first 2 years postoperatively and were the result of a twisting mechanism of injury. With the numbers available, none of the potential risk factors examined were associated with mechanical failure. The 5-year and 10-year all-cause revision-free survival rates were 57% (95% CI, 44%-67%) and 50% (95% CI, 36%-61%), respectively.

CONCLUSIONS

Distal femur compressive osseointegration is a viable method for endoprosthetic reconstruction. Rotational failure is rare with the majority occurring early. No variables were found to correlate with increased risk of mechanical failure. More research is needed to evaluate methods of preventing mechanical and rotational failures in addition to other common causes of revision such as infection in these massive endoprosthetic reconstructions.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Functional and oncologic outcome of cemented endoprosthesis for malignant proximal femoral tumors

BACKGROUND

Cemented endoprosthetic replacement is an option for reconstruction of the proximal femur to achieve limb salvage. Existing outcome studies combine benign and malignant conditions, or group endoprostheses from multiple areas into one cohort. We sought to examine a series of endoprosthetic replacements of the proximal femur for a malignant process.

METHODS

We reviewed 204 patients who underwent an endoprosthesis for a malignant process of the proximal femur with at least 2-year follow-up. Mean age was 59 years, with 55% being male. The most common pathology was metastatic disease (n = 120, 59%). Mean follow-up was 7 years (2-22 years). Mean time to death was 2 years (range 2 weeks-18 years). A bipolar component was used in 93% of patients.

RESULTS

5-year survival was 8% in patients with metastatic disease and 54% for patients with primary disease. Local recurrence and metastatic disease developed in 5 and 19 patients with a primary sarcoma. Following the procedure the mean Harris Hip and Musculoskeletal Tumor Society Scores were 75 and 18.

CONCLUSION

Patients typically succumb to their disease prior to implant failure; however, endoprosthetic replacement provides patients with an acceptable means of functional recovery with an acceptable complication profile. J. Surg. Oncol. 2016;114:501-506. © 2016 Wiley Periodicals, Inc.

Total Humeral Endoprosthetic Replacement following Excision of Malignant Bone Tumors

Humerus is a common site for malignant tumors. Advances in adjuvant therapies and reconstructive methods provide salvage of the upper limb with improved outcomes. Reports of limb salvage with total humeral replacement in extensive humeral tumors are sparse. We undertook a retrospective study of 20 patients who underwent total humeral endoprosthetic replacement as limb salvage following excision of extensile malignant tumor from 1990 to 2011. With an average followup of 42.9, functional and oncological outcomes were analyzed. Ten patients were still alive at the time of review. Mean estimated blood loss was 1131 mL and duration of surgery was 314 minutes. Deep infection was encountered in one patient requiring debridement while mechanical loosening of ulnar component was identified in one patient. Subluxation of prosthetic humeral head was noted in 3 patients. Mean active shoulder abduction was 12.5° and active flexion was 15°. Incompetence of abduction mechanism was the major determinant of poor active functional outcome. Mean elbow flexion was 103.5° with 30.5° flexion contracture in 10 patients with good and useful hand function. Average MSTS score was 71.5%. Total humeral replacement is a reliable treatment option in restoring mechanical stability and reasonable functional results without compromising patient survival, with low complication rate.

Long term outcomes of cemented endoprosthetic reconstruction for periarticular tumors of the distal femur

BACKGROUND

In order to achieve an oncological margin during limb salvage surgery for tumors of the distal femur, part or the entire knee joint is frequently sacrificed. Endoprosthetics make limb salvage possible through restoration of a functional extremity. Currently there remains a paucity of data concerning their long-term outcomes and associated risk factors for failure.

METHODS

We identified 152 patients who underwent an endoprosthetic reconstruction for an oncological process of the distal femur between 1972 and 2013. The mean follow-up was 10years. Mean age and body mass index (BMI) were 39years and 25.8 respectively. The most common pathology was osteosarcoma (n=78, 48%). Outcomes were compared to a control group of 20,643 patients undergoing total knee arthroplasty (TKA) for degenerative joint disease (DJD) during the same time period.

RESULTS

The mean five-, 10-, 15-, 20-, and 25-year revision-free survival for an endoprosthesis was 76%, 63%, 51%, 36%, and 28%. Compared to the five-, 10-, 15-, 20-, and 25-year survival of 95%, 90%, 82%, 74%, and 67% for control TKAs (p<0.0001 at all-time points). Overall limb survival was 93%, with 11 patients undergoing amputation. There was no difference in implant survival comparing modular and custom endoprostheses.

CONCLUSION

The results of this study show that given the complexity of these operations, the rate of revision surgery following endoprosthetic replacement is high. Nevertheless, the use of these modular reconstructions leads to a high rate of limb salvage (93%) over a 25-year period at our institution.

LEVEL OF EVIDENCE

Level III.

Tumor endoprosthesis revision rates increase with peri-operative chemotherapy but are reduced with the use of cemented implant fixation

Chemotherapy may reduce osseointegration of tumor endoprosthesis, while delaying chemotherapy may reduce survival. We studied the effects of chemotherapy and cemented fixation on tumor endoprosthesis survivorship with a retrospective analysis of 50 consecutive patients receiving lower limb salvage surgery. We compared rates of radiographic loosening/revision and effect of cement fixation between chemotherapy/no chemotherapy cohorts. Chemotherapy increased the total revision rate (HR = 3.8 [1-14], P = 0.033), but did not affect aseptic loosening. Cement fixation reduced revision for loosening (HR = 0.09 (0.008-0.98), P = 0.012) and showed less radiographic loosening (HR = 0.09 (0.02-0.51), P = 0.00066). Cement fixation had lower rates of revision for loosening and radiographic loosening regardless of whether chemotherapy was given. We conclude that for these implants, cement fixation provides superior results to uncemented fixation.

Mifamurtide for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection: a cost-effectiveness analysis

OBJECTIVES

Mifamurtide is an immune macrophage stimulant that when added to standard chemotherapy has demonstrated survival benefit for newly diagnosed osteosarcoma. The objectives of this study were to investigate the cost-effectiveness of adding mifamurtide to standard three- or four-agent chemotherapy for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection and the issues of obtaining robust cost-effectiveness estimates for ultra-orphan drugs, given the shortage of data.

METHODS

An economic evaluation was conducted from the perspective of the UK's National Health Service as part of the manufacturer's submission to the National Institute for Health and Care Excellence. The disease process was simplified to a transition through a series of health states, modeled by using a Markov approach. Data to inform the model were derived from patient-level data of Study INT-0133, published literature, and expert opinion. The final efficacy measure was life-years gained (LYG), and utilities were used to obtain quality-adjusted life-years (QALYs).

RESULTS

For a 60-year time frame and a discount rate of 3.5% for outcomes, patients receiving mifamurtide benefited from an average additional 1.57 years of life and 1.34 QALYs, compared with patients receiving chemotherapy alone, giving an incremental cost-effectiveness ratio (ICER) of £58,737 per LYG and £68,734 per QALY. Because treatment effects were both substantial in restoring health and sustained over a very long period, the National Institute for Health and Care Excellence changed its guidance to allow a discount of 1.5% for outcomes to be applied in these special circumstances. By using this discount factor, it was found that patients receiving mifamurtide had an average additional 2.58 years of life and 2.20 QALYs compared with patients receiving chemotherapy alone, resulting in an ICER of £35,765 per LYG and £41,933 per QALY.

CONCLUSION

Mifamurtide's ICER is cost-effective compared with that of other orphan and ultra-orphan drugs, for which prices and corresponding cost-effectiveness estimates are high.

Is the Injury Severity Score Relevant in Complex Lower Limb Trauma?

First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of trauma.

[Is routine implant removal after trauma surgery sensible?]

We present a literature review about implant removal after operative extremity and spine fracture treatment. The indication for implant removal procedures has become less frequent in recent years, but is still more common in Europe than for example in North America. The time required to perform a implant removal can easily exceed the planned amount. Implant removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the implant should be made with great care. Therefore good communication with the patient and thorough information about risks and benefits are essential.

[Cost analysis of the diagnosis and treatment of soft tissue sarcomas in reference centres]

OBJECTIVE

To determine the diagnostic and treatment costs in patients referred to a reference centre with a suspected soft tissue sarcoma.

MATERIAL AND METHODS

The study consisted of a historic cohort of 48 consecutive patients who were diagnosed with soft tissue sarcomas and treated in our centres between the years 2009 and 2011, both prior to and after performing the biopsy. The cost per procedure was taken from the official list of prices published in the year 2009. A comparative study of the data was performed using the Mann-Whitney U and Wilcoxon tests.

RESULTS

The mean cost per patient was 14,427.58€. In those referred before the biopsy, the overall mean cost was 11,818.67€, and in those referred afterwards, it was 6,456.74€ (p=.0073). There were no significant differences in the diagnostic costs between the groups. However, the mean cosy of the treatment per patient was higher in the second group (p=.0121).

DISCUSSION

The referral to centres with experienced multidisciplinary teams in this disease is a common fact highlighted in many articles, where the financial savings have also been demonstrated.

CONCLUSIONS

This study shows that, as well as improving the care aspect of the patients when they are referred to a specialist centre prior to the biopsy, there is also a lower health care cost.

Current concepts in surgical treatment of osteosarcoma

Osteosarcoma is the most common malignant primary neoplasm of bone. For an optimal oncological outcome, surgical removal of tumor is an essential component of its multidisciplinary treatment. Limb salvage surgery has long been established as the standard of care for osteosarcoma. While limb-salvaging techniques have acceptable rates of disease control, amputation remains a valid procedure in selected cases. In current orthopedic oncology practice, the focus is on optimizing the balance between preservation of form and function of the limb and adequate oncological clearance at the same time. Improving the functional outcome and longevity of reconstructive procedures also remains a challenge.

What are estimated reimbursements for lower extremity prostheses capable of surgical and nonsurgical lengthening?

BACKGROUND

Growing prostheses accommodate skeletally immature patients with bone tumors undergoing limb-preserving surgery. Early devices required surgical procedures for lengthening; recent devices lengthen without surgery. Expenses for newer expandable devices that lengthen without surgery are more than for their predecessors but overall reimbursement amounts are not known.

QUESTIONS/PURPOSES

We sought to determine reimbursement amounts associated with lengthening of growing prostheses requiring surgical and nonsurgical lengthening.

METHODS

We retrospectively reviewed 17 patients with growing prostheses requiring surgical expansion and eight patients with prostheses capable of nonsurgical expansion. Insurance documents were reviewed to determine the reimbursement for implantation, lengthening, and complications. Growth data were obtained from the literature.

RESULTS

Mean reimbursement amounts of surgical and nonsurgical lengthenings were $9950 and $272, respectively. Estimated reimbursements associated with implantation of a growing prosthesis varied depending on age, sex, and location. The largest difference was found for 4-year-old boys with distal femoral replacement where reimbursement for expansion to maturity for surgical and nonsurgical lengthening prostheses would be $379,000 and $208,000, respectively. For children requiring more than one surgical expansion, net reimbursements were lower when a noninvasive lengthening device was used. Annual per-prosthesis maintenance reimbursements to address complications for surgical and nonsurgical lengthening prostheses were $3386 and $1856, respectively.

CONCLUSIONS

This study showed that reimbursements for lengthening of growing endoprostheses capable of nonsurgical expansion may be less expensive in younger patients, particularly male patients undergoing distal femur replacement, than endoprostheses requiring surgical lengthening. Longer outcomes studies are required to see if reimbursements for complications differ between devices.

LEVEL OF EVIDENCE

Level III, economic and decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.

Proximal ulna endoprosthetic replacement for bone tumours in young patients

PURPOSE

The optimal reconstructive method after resection of malignant bone tumours of the proximal ulna is unknown.We report the outcome of endoprosthetic replacement in a young patient population.

METHODS

This was a retrospective review of four patients[three males and one female; mean age 17.5 (range 11–31)years] who underwent limb salvage with a proximal ulnar endoprosthetic replacement following excision of malignant bone tumour. Mean follow-up was 85 (range 14–194) months.

RESULTS

All patients were alive at final follow-up and reported an improvement in pain. One patient required transhumeral amputation for intralesional excision complicating a local recurrence at one month. Two patients developed fixed flexion deformities of the elbow, one of whom required radial-head excision. Mean Musculoskeletal Tumour Society (MSTS)score and Toronto Extremity Salvage Score (TESS) were 27(range 25–28) and 81 (73–88), respectively.

CONCLUSIONS

Custom-made proximal ulna endoprosthetic replacement following resection of malignant bone tumours in young patients provides a stable reconstruction option with satisfactory function and without apparent compromise in patient survival.

Total condylar unipolar expandable prosthesis for proximal tibia malignant bone tumors in early childhood

Wide resection and reconstruction of tumors of the proximal tibia in the pediatric population are challenging procedures. The use of hinged, expandable prostheses may cause early closure of the distal femoral growth plate, which may increase the risk of limb discrepancy already present in this population. Between 1991 and 2001, 2 girls and 1 boy, aged 6, 6, and 4 years, respectively, were diagnosed with osteosarcoma of the proximal tibia and treated with wide resection and reconstruction with a condylar unipolar expandable tibial prosthesis. A press-fitted technique was used for component insertion. All patients received neoadjuvant and adjuvant chemotherapy. Radiographic and functional follow-up took place at least once a year for a minimum of 4 years. Adequate pain control, limb-length equality, and acceptable function were obtained in all patients. One patient presented with significant range of motion reduction (0°- 30°) in the affected knee. Limb lengthening was performed as needed to maintain balanced limb length. All patients had a good Musculoskeletal Tumor Society category score. No complications occurred in terms of component loosening or infection. One patient died shortly after 4-year follow-up because of doxorubicin-induced leukemia. Currently used hinged, expandable prostheses can jeopardize the unaffected distal femoral growth plate. This article describes a technique of reconstruction that spares the distal femoral growth plate. Adequate limb length can be expected with acceptable functional outcome. However, it is imperative to keep in perspective the expectations of the physician, the physician's team, the patient, and the patient's family.

Infected total femoral replacements: evaluation of limb loss risk factors

A complication of total femoral replacement (TFR) is periprosthetic infection. Studies have shown that infected endoprostheses have a significant amputation rate, as high as 36.7%. This study examined possible risk factors that may attribute to unsalvageable TFRs following periprosthetic infections, including age, sex, primary vs secondary TFRs, number of irrigation and debridements, recent history of periprosthetic infection, early vs late infection, use of antibiotic cement, and the number of postoperative antibiotics. In a retrospective chart review, 10 patients who had periprosthetic infections of their TFRs were identified from our orthopedic surgical database between 2000 and 2010. Seven of 10 TFRs were unsalvageable due to infection. The 2 greatest risk factors that influenced unsalvageable TFR were age older than 50 years and recipients of secondary TFRs. All 6 patients older than 50 years had unsalvageable TFRs, whereas 1 of 4 patients younger than 50 years had an unsalvageable TFR (P<.05). Similarly, all 6 patients who received secondary TFRs had unsalvageable TFRs, whereas 1 of 4 patients who received a TFR as the primary method of treatment had an unsalvageable TFR (P<.05). No other risk factors showed statistical significance or could be identified as possible risk factors. Surgeons should educate patients who fall into high-risk categories about the benefits of early intervention, such as amputation, that could prevent additional surgeries and decrease the lengths of hospitalizations.

Quality of life in survivors of a primary bone tumour: a systematic review

Purpose. We conducted a systematic search of published literature, to assess (i) quality of life (QoL) for survivors of a bone tumour compared with the normal population; (ii) QoL implications following amputation, successful or failed limb salvage; (iii) adaptation of young children to amputation compared with older children or adolescents.

Methods. Electronic databases were searched including Medline, PsycLIT and Cinahl covering the years 1982– 1998.

Results. We identified 11 studies. Regardless of treatment, physical functioning was poor compared with population norms or healthy siblings.There was less consistent evidence regarding emotional functioning. Seven studies compared functioning in amputees and limb salvage patients.Two reported advantages in physical function for the limb salvage group, one for the amputees and the rest no differences. Evidence about social functioning or marriage is inconclusive, but there are suggestions that amputees report more job discrimination.

Discussion. The literature is inconclusive, largely because of methodological problems. These include small and non-representative samples, and lack of sensitive and appropriate measures. Specific gaps in the literature include very little work concerned with psychological outcomes for children, or for those experiencing failed limb salvage. More attention needs to be given to gender differences in emotional response to traumatic surgery.The implications of the results for helping families balance the merits of different treatments are discussed.

Megaendoprosthesis in the treatment of bone tumors in the knee and hip region

Background/Aim. For almost two decades extremity amputation has not been the only viable option for patients with from bone cancer in the region of the hip and knee. Remarkable advances in implant technology, surgical reconstructive technique and adoption of new chemotherapy protocols provide a new option for surgeons who diagnose and treat bone tumors. Megaendoprosthesis has become widely accepted alternative in limb salvage surgery of the extremities. The aim of this study was to present an outcome of the treatment of bone tumors in the knee and hip region by the use of custom made megaendoprothesis. Methods. In the period 2006-2008 we adopted new clinical practice protocols for preoperative management in candidates for tumor megaprostheses of the hip and knee including: surgical tumor staging, histopathological verification, determinants of anatomical-mechanical defect, status of soft tissues, CT evaluation of the referent measures of pelvis, femur and tibia necessary for creation of custom made endoprosthesis and surgery plan, as well as modern, less invasive surgical approach. The patients were monitored during ? 24 months after the surgery for detecting possible complications. Results. All procedures were performed without complications during and immediately after the surgery. During the follow-up period not less than 24 months we failed to record any significant complications. Conclusion. Custom made megaendoprosthesis are the method of choice in the treatment of bone tumors in the region of the hip and knee at the Orthopedics and Traumatology Clinic, Military Medical Academy, Belgrade. The greatest challenge - ensuring longevity of a prosthesis can be achieved not only by prevention of common complications of arthroplasty procedures but, certainly, with the introduction of new methods for preoperative planning - computer-assisted technique of measuring referent sizes and software solutions for the selection and design of custom-made components of an endoprosthesis.

Total femur replacement: primary procedure for treatment of malignant tumours of the femur

We present our experience of treating patients with tumours involving the whole femur with excision and total femur endoprostheses over the last 30 years (1975-2005). There were 26 consecutive patients (14 men and 12 women). Average age was 40 years (14-82 years) at the time of surgery and 21 of the patients had primary malignant bone tumours with five having the procedure for metastases. 11 patients were still alive of which nine were free of disease at the time of review at a mean follow-up of 57 months (3-348). The overall patient survival at 10 years was 37%. The survival of patients with a primary localised tumour was 50% at 10 years. Revision of the prostheses was necessary in two patients (at 110 and 274 months) because of recurrent dislocation and aseptic loosening. Amputation was necessary in two patients but long term limb survival was 92% at 10 years. Nine patients alive with no evidence of disease had a mean MSTS functional score of 72%.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is 18,002 pounds at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor

BACKGROUND

Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis.

METHODS

Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score.

RESULTS

The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction. The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp.

CONCLUSIONS

Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograft-related complication.

Primary bone osteosarcoma in the pediatric age: State of the art

The current combination treatment, chemotherapy and surgery, has significantly improved the cure rate and the survival rate of primary bone osteosarcoma. The 5-year survival rate has increased in the last 30 years from 10% to 70%. Even in patients with poor prognosis, such as those with metastases at diagnosis, the 5-year survival rate has reached 20-30% due to chemotherapy and the surgical removal of metastases and primary tumor. However, the most effective drugs are still the same as those employed over the last 20 years as front line neoadjuvant or adjuvant chemotherapy: Doxorubicin, Cisplatin, Methotrexate, Ifosfamide. No standard, second line therapy exists for those who relapse. At relapse, due to the lack of new non-cross-resistant drugs, surgery is still the main option when feasible. Other drugs have been employed in relapsed patients with poor results. This article reviews the state of the art of treatment for bone osteosarcoma in the pediatric age.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Case reports: polymethylmethacrylate lung embolus after limb-salvage surgery of the distal femur

Limb-salvage surgery for malignant tumors frequently involves reconstruction with an endoprosthesis anchored to bone by using third-generation cementing techniques. A 10-year-old boy with osteosarcoma had a pulmonary embolus caused by polymethylmethacrylate after having limb-salvage surgery that used high-pressure cementing techniques. He experienced transient postoperative chest pain, and a new wedge-shaped radiodense pulmonary lesion appeared on a computed tomography scan of the chest. A thoracotomy for resection of suspected metastatic osteosarcoma revealed a pulmonary infarct caused by cement embolization. Awareness of this potential complication should prompt investigation of possible pulmonary embolism and may prevent unnecessary thoracotomy.

Oncologic approaches to pediatric limb preservation

Preservation of limb function in the pediatric oncology patient is uniquely challenging. Treatment must be strictly prioritized in terms of the patient's life, the limb, its function, length equalization, and cosmetic appearance. At the same time, social, socioeconomic, and cultural factors must be understood and respected to achieve the most advantageous outcome for both the patient and family. Given these considerations, as well as the relative rarity of many oncologic diagnoses and the myriad of presentation scenarios, drafting generalized treatment recommendations is difficult. Instead, orthopaedic intervention in the care of children and young adults with oncologic conditions must be individualized, with the broad goal being optimization of limb function rather than rigid advocacy of limb salvage.

Limb salvage in bone sarcomas in patients younger than age 10: a 20-year experience

The authors present their experience over the last 20 years in limb salvage procedures of a consecutive series of 40 children under 10 years of age (range 2-10 years) with bone sarcomas. Nineteen were osteogenic sarcomas and 21 were Ewing sarcomas. Only one case, located in the distal phalanx of the toe, was treated by straightforward amputation. Intercalary allografts and Canadell's technique were used to preserve joints whenever possible, and prosthesis or osteoarticular allografts were used when the joint surface was involved. Survival rate in this series was 75%. There were four local recurrences. At the last follow-up (mean 11.2 years, range 5-19 years postop), 90% of the patients preserved their limbs. Eighty percent of the authors' results were excellent or good according to the Musculoskeletal Tumor Society Scale. Limb salvage is a real possibility even in young children with bone sarcomas. The age of the patient itself is not a contraindication for limb salvage.

Custom megaprosthetic replacement for proximal tibial tumours

We analysed 133 patients treated with resection and endoprosthetic proximal tibial replacement from 1988 to 2000. Mean age was 22.3 years and osteosarcoma was the most common tumour. Average follow-up was 59.4 months. An excellent functional result was achieved in 63 patients and a good result in 36. The number of patients who had no evidence of disease was 102. Twenty-four patients died due to disease. Infection was the most common complication, followed by periprosthetic fracture and aseptic loosening. The 5-year limb survival rate was 85.5%.

Risk of amputation following limb salvage surgery with endoprosthetic replacement, in a consecutive series of 1261 patients

Endoprosthetic replacements are commonly used for limb salvage following surgical excision of bone tumours. Advantages include initial reliability, rapid restoration of function and their ready availability. Potential long-term problems include loosening, infection and mechanical failure. Increasing problems may lead to the necessity for amputation; this paper assesses that risk. A total of 1,261 patients have undergone endoprosthetic replacements in our centre in the past 34 years, with a total of 6,507 patient years of follow up. A total of 112 patients have had subsequent amputation. The reasons for amputation were local recurrence in 71, infection in 38, mechanical failure in two and chronic pain in one. The proximal tibia had the greatest risk of amputation (n=38/245). The time to amputation varied from 2 days to 16 years, with a mean of 31 months. The risk of amputation decreased with time, although 10% took place after more than 5 years.

Outcome of lower extremity malignancy survivors treated with transfemoral amputation

OBJECTIVE

To determine outcomes of surviving patients who underwent transfemoral amputation as part of treatment for lower extremity malignancy at a mean 15 years postoperatively, with a minimum 2-year follow-up.

DESIGN

Retrospective, case control.

SETTING

Tertiary care university medical center.

PATIENTS

Thirty-five of 38 consecutively admitted patients free of metastatic disease managed with transfemoral amputation as part of treatment of a lower extremity bone and/or soft tissue malignancy between 1966 and 1997 at 1 institution. The control group included 35 age- and gender-matched subjects recruited from the local driver's license office.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Musculoskeletal Function Assessment (MFA), Short Form-12 General Health Status Survey (SF-12), physical performance battery, cost, and demographic data.

RESULTS

Controls showed superior scores as measured by the MFA (P < .0001), the physical component summary of the SF-12 (P = .0002), and the physical performance battery (P < .0001), but had inferior scores on the mental component summary of the SF-12 (P < .0001). With the numbers available, no differences were found between study and control subjects in terms of employment rate (P = .51), education level (P = .66), income level (P =.44), marital status (P = .79), incidence of self-reported health problems (P = .14), and alcohol (P =.42) and tobacco (P = .82) use. Ten patients were included in the cost analysis; the mean cost to obtain and maintain a lower extremity prosthesis was $4225 per year (range, 623 dollars-8517 dollars).

CONCLUSIONS

Although the decrease in physical performance was anticipated in the study group, the group differed very little from the control population in terms of employment, education level, income, marital and home status, incidence of self-reported health problems, incidence of self-reported depression, and alcohol and tobacco use. Also, the long-term cost of maintaining a lower extremity prosthesis is noted.

Ankle arthrodesis: indications and techniques

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.