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

Functional and Surgical Outcomes After Endoprosthetic Reconstruction With Expandable Prostheses in Children: A Systematic Review

Treatment of bone sarcomas in children is associated with wide tumor re-section and segmental reconstruction. The optimal surgical approach is still under debate in the literature. During the past decade, the application of expandable prostheses has gained remarkable attention because it improves patients' appearance and allows limb growth preventing leg length discrepancy. A systematic review of the literature was performed to identify studies focusing on the functional and surgical outcomes of the application of expandable endoprostheses. [Orthopedics. 2019; 42(4):184-190.].

Surgical and Functional Outcomes After Limb-Preservation Surgery for Tumor in Pediatric Patients: A Systematic Review

BACKGROUND

Limb-salvage surgery and segmental reconstruction for the treatment of lower extremity osseous tumors in the pediatric population have been described in the literature, but there is little consensus regarding the optimal surgical treatment for this patient population.

METHODS

A systematic review of the literature was performed to identify studies focusing on limb-salvage procedures in pediatric patients who were managed with one of three reconstructions with use of a metallic endoprosthesis, allograft, or allograft-prosthesis composite. Data were segregated according to the excised and reconstructed anatomical location (proximal part of the femur, total femur, distal part of the femur, proximal part of the tibia) and were collated to assess modes of failure and functional outcomes of each reconstruction type for each anatomic location.

RESULTS

Sixty articles met the inclusion criteria; all were Level-IV evidence, primarily consisting of small, retrospective case series. Infection was a primary mode of failure across all reconstruction types and locations, whereas allograft reconstructions were susceptible to structural failure as well. The rate of failure in the pediatric population correlated well with previously published results for adults. The incidence of subsequent amputation was lower in the pediatric population (5.2%) than has been reported in adults (9.5%) (p = 0.013). Meaningful growth of expandable metallic endoprostheses was reported in the literature, with an overall rate of leg-length discrepancy of 13.4% being noted at the time of the latest follow-up. The Musculoskeletal Tumor Society (MSTS) questionnaire was the most consistently used outcome measure in the literature, with average scores ranging from 71.0% to 86.8%, depending on reconstruction type and anatomic location.

CONCLUSIONS

The current state of the literature detailing the surgical and functional outcomes of segmental reconstruction for the treatment of pediatric bone tumors is limited to Level-IV evidence and is complicated by under-segregation of the data by age and anatomical location of the reconstruction. Despite these limitations, pediatric limb-salvage surgery demonstrates satisfactory initial surgical and functional outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction Following Tumor Resections in Skeletally Immature Patients

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

Reconstruction After Tumor Resection in the Growing Child

Limb preservation surgery has gained acceptance as a viable alternative to amputation for the treatment of extremity bone tumors in the growing child. There are several options for reconstructing the potential loss of a physis and the defect created by tumor excision. Metallic endoprosthesis, massive allograft, and allograft-prosthesis composites have been described in the skeletally immature population. With the development of expandable prostheses, even those far from skeletal maturity may be candidates for limb salvage. However, improvements in the literature are needed, including reporting surgical and functional outcomes in a rigorous manner, specific to age, anatomic location, and reconstruction.