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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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Tupper CJ, Reeson EA, Burdyny MR, Eaton VP, Silberstein PT. Extent of Surgery and Survival of Osteosarcoma: A Retrospective Population-Based Study. Cureus 2024; 16:e56030. [PMID: 38606239 PMCID: PMC11008610 DOI: 10.7759/cureus.56030] [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] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
Background Osteosarcoma (OSC) is the most common primary bone tumor and is often managed surgically. Few prior investigations have assessed differences in OSC survival by specific surgical techniques at a national registry level. We sought to compare survival based on surgical subtypes for OSC patients in the Surveillance, Epidemiology, and End Results (SEER) database. Methodology We searched the SEER database for malignant OSCs diagnosed between 2000 and 2019 which were surgically managed. Separate survival comparisons were made for one and five years for wide excision (local tumor destruction or resection versus partial resection) and radical excision (radical resection with limb-sparing versus limb amputation with or without girdle resection). Results A total of 4,303 patients were included, of whom 3,587 were surgically managed. There were no survival differences between local destruction and partial resection (hazard ratio = 0.826, p = 0.303). However, younger age, lower staging, and management without radiation were associated with improved survival. The radical excision comparison showed limb amputation was associated with worse survival than limb-sparing surgery (hazard ratio = 1.531, p < 0.001). Younger age, female sex, lower stage, receipt of chemotherapy, and neoadjuvant plus adjuvant chemotherapy were associated with improved survival while Black and American Indian or Alaska Native were associated with worse survival. Conclusions Our findings show that patients managed with limb-sparing radical resection survived significantly compared to limb amputation. There were no differences in survival for wide excision surgeries. The use of a combination of neoadjuvant and adjuvant chemotherapy also yields improved survival. OSC survival may be optimized with limb-sparing surgery with a combination of neoadjuvant and adjuvant chemotherapy.
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Affiliation(s)
- Connor J Tupper
- Department of Orthopaedics, Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Emily A Reeson
- Department of Orthopaedics, Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
| | - Michael R Burdyny
- Department of Orthopaedics, Creighton University School of Medicine, Omaha, USA
| | - Vincent P Eaton
- Department of Orthopaedics, Creighton University School of Medicine, Omaha, USA
| | - Peter T Silberstein
- Department of Hematology and Oncology, Creighton University School of Medicine, Omaha, USA
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Zan P, Shen J, Liu K, Wang H, Cai Z, Ma X, Sun W. Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children. Front Pediatr 2023; 11:1168637. [PMID: 37416814 PMCID: PMC10320852 DOI: 10.3389/fped.2023.1168637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/09/2023] [Indexed: 07/08/2023] Open
Abstract
Purpose To explore the application of Custom-made Semi-joint prosthesis replacement combined with Ligament Advanced Reinforcement System (LARS) ligament reconstruction for the limb salvage surgery (LSS) of malignant tumors in the distal femur and provide selections for the LSS of malignant tumors in skeletal immature children. Methods A total of 8 children with malignant tumors in the distal femur who underwent Custom-made Semi-joint prosthesis replacement combined LARS ligament reconstruction for LSS from January, 2018 until December, 2019 in our bone and soft tissue tumor center were retrospectively recruited. The prosthesis related complications, oncological prognosis and knee function were observed, and the surgical efficacy was comprehensively evaluated. Results The average follow-up time was 36.6 months (30-50 months). The average osteotomy length was 13.2 cm (8-20 cm) according to the preoperative imaging results and the length of the customized prosthesis. Two years after operation, the average MSTS-93 score was 24.4 (16-29) which indicated good limb functions. The range of motion of the knee was 0°-120°, with an maximum average of 100°. At last follow-up, the average height of the children increased by 8.4 cm (6-13 cm), and the average limb shortening was 2.7 cm (1.8-4.6 cm). One patient had wound complications in the early postoperative period, wound scab fell off to form superficial ulcer, in whom debridement and suturing were performed. One patient developed hematogenous disseminated prosthesis infection 2 years after surgery, and the prosthesis is now in situ with anti-infection treatment. One patient developed pulmonary metastasis during follow-up, and received chemotherapy and targeted therapy with lesion well controlled. At the last follow-up, there was no local tumor recurrence or prosthesis loosening. Conclusion Under the premise of appropriate case selection, customized semi-joint prosthesis replacement combined with LARS ligament reconstruction provides a new option for LSS in children with distal femur malignant tumors. LARS ligament reconstruction ensures the stability and range of motion of the knee joint, which maximally preserves the epiphysis of the tibia side and the growth function of the tibia side, reduces the complications of limb length inequality in the long term and creates conditions for limb lengthening or total joint replacement in adults.
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Affiliation(s)
| | | | | | | | | | | | - Wei Sun
- Correspondence: Xiaojun Ma Wei Sun
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4
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Pilavaki P, Gahanbani Ardakani A, Gikas P, Constantinidou A. Osteosarcoma: Current Concepts and Evolutions in Management Principles. J Clin Med 2023; 12:jcm12082785. [PMID: 37109122 PMCID: PMC10143544 DOI: 10.3390/jcm12082785] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/08/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Osteosarcoma is a rare malignancy arising from mesenchymal tissue, and represents the most common bone sarcoma. The management of osteosarcoma is challenging, and requires a multidisciplinary approach. In daily clinical practice, surgery, radiotherapy, and conventional chemotherapy constitute the therapeutic armamentarium against the disease. However, a significant number of patients with initially localized osteosarcoma will experience local or distant recurrence, and the prognosis for metastatic disease remains dismal. There is a pressing need to identify novel therapeutic strategies to better manage osteosarcoma and improve survival outcomes. In this study, we present recent advances in the therapeutic management of osteosarcoma, including surgical and medical advances. The role of immunotherapy (immune checkpoint inhibitors, adoptive cellular therapy, cancer vaccines) and other targeted therapies including tyrosine kinase inhibitors is discussed; however, additional studies are required to delineate their roles in clinical practice.
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Affiliation(s)
- Pampina Pilavaki
- Medical School, University of Cyprus, Nicosia 1678, Cyprus
- Medical Oncology, Bank of Cyprus Oncology Center, Nicosia 2006, Cyprus
| | | | - Panagiotis Gikas
- Department of Orthopaedics, Cleveland Clinic London, London SW1X 7HY, UK
| | - Anastasia Constantinidou
- Medical School, University of Cyprus, Nicosia 1678, Cyprus
- Medical Oncology, Bank of Cyprus Oncology Center, Nicosia 2006, Cyprus
- Cyprus Cancer Research Institute, Nicosia 2109, Cyprus
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5
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Skeletal Muscle Measurements in Pediatric Hematology and Oncology: Essential Components to a Comprehensive Assessment. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010114. [PMID: 36670664 PMCID: PMC9856749 DOI: 10.3390/children10010114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Abstract
Children with hematologic and oncologic health conditions are at risk of impaired skeletal muscle strength, size, and neuromuscular activation that may limit gross motor performance. A comprehensive assessment of neuromuscular function of these children is essential to identify the trajectory of changes in skeletal muscle and to prescribe therapeutic exercise and monitor its impact. Therefore, this review aims to (a) define fundamental properties of skeletal muscle; (b) highlight methods to quantify muscle strength, size, and neuromuscular activation; (c) describe mechanisms that contribute to muscle strength and gross motor performance in children; (d) recommend clinical assessment measures; and (e) illustrate comprehensive muscle assessment in children using examples of sickle cell disease and musculoskeletal sarcoma.
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6
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Yamamoto N, Araki Y, Tsuchiya H. Joint-preservation surgery for bone sarcoma in adolescents and young adults. Int J Clin Oncol 2023; 28:12-27. [PMID: 35347494 PMCID: PMC9823050 DOI: 10.1007/s10147-022-02154-4] [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: 09/13/2021] [Accepted: 03/07/2022] [Indexed: 01/11/2023]
Abstract
Bone sarcoma often occurs in childhood, as well as in adolescents and young adults (AYAs). AYAs differ from pediatric patients in that their bone is skeletally mature and the physis has almost disappeared with the completion of growth. Although AYAs spend less time outside, they often participate in sports activities, as well as driving, working, and raising a family, which are natural activities in daily living. Multidisciplinary approaches involving imaging, multi-agent chemotherapy, surgical procedures, and careful postoperative care has facilitated an increase in limb-sparing surgery for bone sarcoma. In addition, recent advances in imaging modalities and surgical techniques enables joint-preservation surgery, preserving the adjacent epiphysis, for selected patients following the careful assessment of the tumor margins and precise tumor excision. An advantage of this type of surgery is that it retains the native function of the adjacent joint, which differs from joint-prosthesis replacement, and provides excellent limb function. Various reconstruction procedures are available for joint-preserving surgery, including allograft, vascularized fibula graft, distraction osteogenesis, and tumor-devitalized autografts. However, procedure-related complications may occur, including non-union, infection, fracture, and implant failure, and surgeons should fully understand the advantages and disadvantages of these procedures. The longevity of the normal limb function for natural activities and the curative treatment without debilitation from late toxicities should be considered as a treatment goal for AYA patients. This review discusses the concept of joint-preservation surgery, types of reconstruction procedures associated with joint-preservation surgery, and current treatment outcomes.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa-city, Ishikawa 920-8641 Japan
| | - Yoshihiro Araki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa-city, Ishikawa 920-8641 Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa-city, Ishikawa 920-8641 Japan
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7
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Rock K, Addison O, Gray VL, Nelson CM, Henshaw RM, York T, Ruble K, Marchese V. Quantifying muscle strength, size, and neuromuscular activation in adolescent and young adult survivors of musculoskeletal sarcoma: Identifying correlates and responses to functional strengthening. Knee 2023; 40:270-282. [PMID: 36529045 PMCID: PMC9898163 DOI: 10.1016/j.knee.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Medical and surgical treatment for musculoskeletal sarcoma (MSS) place survivors at risk for impairments in muscle properties including muscle strength, muscle size, and neuromuscular activation. The purpose of this study was to explore muscle properties, gross motor performance, and quality of life (QoL) and the changes in response to a 6-week functional strengthening intervention (PT-STRONG) in MSS survivors of childhood cancer (CCS). METHODS Eight lower extremity MSS CCS (13-23 years old) performed baseline testing and three completed PT-STRONG. Participants completed measurements of knee extension strength using handheld dynamometry, vastus lateralis (VL) and rectus femoris (RF) muscle thickness using ultrasonography at rest, and neuromuscular activation using electromyography during strength testing and a step-up task. Participants also completed gross motor and QoL assessments. RESULTS Compared with the non-surgical limb, MSS CCS had lower surgical limb knee extension strength, VL muscle thickness, and RF step-up muscle rate of activation (RoA). Compared with normative values, MSS CCS had decreased bilateral knee extension strength, gross motor performance, and physical QoL. Positive correlations among muscle strength, muscle thickness, and gross motor performance were identified. After PT-STRONG, MSS CCS had improvements in VL muscle thickness, VL and RF RoA duing step-up, gross motor performance, and physical QoL. CONCLUSIONS Positive association between larger muscle thickness with greater knee extension strength, and higher knee extension strength with better gross motor performance indicate that comprehensive physical therapy assessment and interventions that identify and target impairments in muscle properties to guide clinical decision making should be considered for MSS CCS into survivorship.
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Affiliation(s)
- Kelly Rock
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Odessa Addison
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vicki L Gray
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christa M Nelson
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert M Henshaw
- Department of Orthopedic Oncology, Children's National Hospital, Washington, DC, USA; Department of Orthopedic Oncology, Washington Cancer Institute at Medstar Washington Hospital Center, Washington, DC, USA; Department of Clinical Orthopedic Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Teresa York
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Hematology/Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kathryn Ruble
- Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Victoria Marchese
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA.
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Origin and Therapies of Osteosarcoma. Cancers (Basel) 2022; 14:cancers14143503. [PMID: 35884563 PMCID: PMC9322921 DOI: 10.3390/cancers14143503] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 01/15/2023] Open
Abstract
Simple Summary Osteosarcoma is the most common malignant bone tumor in children, with a 5-year survival rate ranging from 70% to 20% depending on the aggressiveness of the disease. The current treatments have not evolved over the past four decades due in part to the genetic complexity of the disease and its heterogeneity. This review will summarize the current knowledge of OS origin, diagnosis and therapies. Abstract Osteosarcoma (OS) is the most frequent primary bone tumor, mainly affecting children and young adults. Despite therapeutic advances, the 5-year survival rate is 70% but drastically decreases to 20–30% for poor responders to therapies or for patients with metastasis. No real evolution of the survival rates has been observed for four decades, explained by poor knowledge of the origin, difficulties related to diagnosis and the lack of targeted therapies for this pediatric tumor. This review will describe a non-exhaustive overview of osteosarcoma disease from a clinical and biological point of view, describing the origin, diagnosis and therapies.
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Gosheger G, Schulze M, Mathilda de Vaal M, Theil C, Schneider K, Laufer A. MUTARS® Humero pro Femur Replacement: A Novel Reconstructive Procedure after Malignant Bone Tumor Resection of the Femur in Young Children. J Bone Oncol 2022; 35:100444. [PMID: 35855932 PMCID: PMC9287182 DOI: 10.1016/j.jbo.2022.100444] [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: 05/05/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022] Open
Abstract
Limb-preserving treatment in young children suffering malignant bone tumors remains challenging. MUTARS® Humero pro Femur replacement represents a salvage procedure. Distal humerus component serves as a hinged knee joint after 180° rotation. Satisfactory complication rates and functional results. Subsequent conversion to conventional tumor endoprosthesis.
Limb-preserving surgery in young children suffering malignant bone tumor of the femur is challenging due to the specific anatomical conditions. Extendable tumor endoprostheses are often oversized, while custom-made endoprostheses do not provide the intraoperatively required variability regarding reconstruction length. Allo- and autograft replacements, on the other hand, show high complication and revision rates. We report a novel reconstructive procedure after resection of malignant bone tumors of the femur in young children, and present our preliminary results of this technique.
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Noninvasive Expandable Endoprostheses From Reconstruction to Skeletal Maturity: A Surgical Technique and Lengthening Guide. J Am Acad Orthop Surg 2021; 29:998-1007. [PMID: 34543240 DOI: 10.5435/jaaos-d-21-00183] [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: 02/09/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023] Open
Abstract
Limb salvage is the benchmark for pediatric extremity bone sarcomas. However, reconstructive strategies must account for any anticipated remaining growth potential and the resultant limb inequality. Expandable endoprostheses offer the theoretical advantage of immediate weight-bearing, predictable function, and reliable maintenance of leg-length equality. The evolution of the lengthening mechanism now permits noninvasive lengthening, opposed to the multiple open procedures of the past. These design improvements have contributed to their growing popularity. Experience has indicated that these noninvasive implants more reliably achieve leg-length equality, have longer failure-free survival, and decreased complications, although some have noted gearbox and lengthening failures. Currently, no standardize technique exists for managing patients with noninvasive expandable implants from the time of reconstruction to final lengthening at skeletal maturity. This blueprint aims to provide a detailed surgical technique, lengthening schedule, and recommendations for the mitigation and management of complications to achieve successful limb salvage with noninvasive expandable endoprostheses.
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Lex JR, Adlan A, Tsoi K, Evans S, Stevenson JD. Frequency and reason for reoperation following non-invasive expandable endoprostheses: A systematic review. J Bone Oncol 2021; 31:100397. [PMID: 34712555 PMCID: PMC8529098 DOI: 10.1016/j.jbo.2021.100397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/08/2021] [Accepted: 10/03/2021] [Indexed: 11/25/2022] Open
Abstract
Implant failure is the most common reason for revision of growing prostheses. Maximum prosthesis growth with a residual LLD is the most common mode of failure. Functional outcomes are good, but 1/ 5 patients have a persistent LLD over 2 cm.
Background Non-invasive expandable endoprostheses (NIEPR) utilize an external electromagnetic field to drive an innate mechanical gearbox. This lengthens the extremity following oncological resections in children with a predicted limb length discrepancy (LLD), facilitating limb-salvage. This review was conducted to assess NIEPR implant survival rates and identify modes of implant failure unique to these prostheses. Methods Medline, EMBASE and the Cochrane Library databases were searched for all manuscripts evaluating implant survival of NIEPRs implanted into skeletally immature patients following resection of extremity sarcomas. Minimum follow-up of 12 months or implant failure was required for inclusion. Failures were classified using the latest ISOLS classification and exact implant-specific failure modality was also identified. Results 19 studies met inclusion criteria. Mean age was 10.0 years (7.7 – 11.4 years). The most common locations for NIEPR implantation were the distal femur (343, 76.7%) and proximal tibia (53, 119%). Mean follow-up was 65.3 months (19.4 – 163 months). The overall implant revision rate was 46.2% (0 – 100%); implant specific revisions included maximal prosthesis lengthening with persistent LLD (10.4%), failed extension mechanism (6.1%), implant fracture (7.7%), hinge fracture (1.4%) and bushing wear (0.9%). Persistent clinically significant (>20 mm) LLD at final follow-up was present in 19.2% (0 – 50%) of patients. The mean MSTS score was 85.1% (66.7–96.3%) at final follow-up. Conclusion Implant-related failures are the most common reason for NIEPR revision. Implant reliability appears to be improved with current designs. A sub-classification to the current classification system based on implant-specific failures for NIEPRs is proposed.
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Affiliation(s)
- Johnathan R Lex
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Amirul Adlan
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Scott Evans
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK
| | - Jonathan D Stevenson
- The Royal Orthopaedic Hospital, Oncology Department, Birmingham, West Midlands B31 2AP, UK.,Aston University Medical School, Aston University, Birmingham, UK
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12
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Haddad BI, Alisi MS, Yasin MS, Hamdan MQ, Abu Hassan Frcs FO. Lower Limb Reconstruction Using Tibial Strut Autograft after Resection of Primary Malignant Bone Tumors in Skeletally Immature Patients. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:567-577. [PMID: 34692941 DOI: 10.22038/abjs.2021.54365.2714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/13/2021] [Indexed: 11/06/2022]
Abstract
Background Reconstruction of large bone defects in skeletally immature patients remains a surgical challenge. We report the long-term clinical outcomes of a novel surgical technique for lower limb reconstruction using the tibia as a strut autograft following resection of primary malignant bone tumors in skeletally immature patients. Methods We retrospectively reviewed the medical records of six patients diagnosed with lower limb primary bone sarcoma. All patients underwent tumor resection and reconstruction using tibial strut autograft. The radiological and clinical outcomes including complications at the recipient and donor sites were assessed. Results The mean age at presentation was ten years (range 6-15 years). Two cases had osteosarcoma and four had Ewing sarcoma. The mean length of the resected tumor and tibial autografts were 20.83 and 19.33 cm respectively. Union at both ends was achieved in five grafts while one graft achieved union only at the distal end. The mean time for union of the proximal and distal junctions was 4 and 8.8 months respectively. The mean follow-up period was 8.4 years (range 14 months-20 years). One patient developed a foot drop, and three patients underwent subsequent joint arthrodesis (2 knees and 1 ankle). The mean musculoskeletal tumor society functional score was 80.8%. Two patients had clinically significant leg-length discrepancy that needs further lengthening procedure. Four patients survived with no evidence of disease and two patients died due to their primary oncologic disease. All donor sites regenerated, with the earliest signs of new bone formation at (2-4) weeks post-operatively. Conclusion Reconstruction using non-vascularized tibia strut autograft after resection of primary malignant lower limb bone tumors can be a viable alternative method for reconstructing large bone defects in the immature skeleton.
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Affiliation(s)
- Bassem I Haddad
- Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohammed S Alisi
- Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohamad S Yasin
- Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohammad Q Hamdan
- Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan
| | - Freih O Abu Hassan Frcs
- Department of Special Surgery, Division of Orthopaedics, School of Medicine, The University of Jordan, Amman, Jordan
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Araki Y, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Igarashi K, Higuchi T, Abe K, Taniguchi Y, Yonezawa H, Morinaga S, Asano Y, Tsuchiya H. Clinical outcomes of frozen autograft reconstruction for the treatment of primary bone sarcoma in adolescents and young adults. Sci Rep 2021; 11:17291. [PMID: 34453061 PMCID: PMC8397769 DOI: 10.1038/s41598-021-96162-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 07/23/2021] [Indexed: 01/31/2023] Open
Abstract
Age affects the clinical outcomes of cancer treatment, including those for bone sarcoma. Successful reconstruction using frozen autograft after excision of bone sarcoma has been reported; however, little is known about the clinical outcomes of frozen autograft reconstruction according to age. The purpose was to evaluate the clinical outcomes of the frozen autograft reconstruction focusing on skeletally mature adolescents and young adults (AYAs) that was 15 to 39 years of age. A total of 37 AYA patients with primary bone sarcoma on the appendicular skeleton were enrolled in this study. The mean follow-up period was 89 months. The graft survival (GS), overall survival (OS), recurrence-free survival (RFS), complications and the function were retrospectively evaluated using medical records. The 10-year GS, OS, and RFS rates were 76%, 84%, and 79%, respectively. Bone union was achieved with a rate of 94% within 1 year after surgery, and nonunion (n = 1) and fracture (n = 2) were infrequently observed. Graft removal was performed in 7 cases, and the most common reason for the removal was infection (n = 5). The Musculoskeletal Tumor Society score was excellent in 23 cases of the available 29 cases. Frozen autograft reconstruction for AYAs showed excellent clinical outcomes, although the long-term follow-up is required.
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Affiliation(s)
- Yoshihiro Araki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takashi Higuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kensaku Abe
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yuta Taniguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hirotaka Yonezawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Sei Morinaga
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yohei Asano
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
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Zhao X, Wu Q, Gong X, Liu J, Ma Y. Osteosarcoma: a review of current and future therapeutic approaches. Biomed Eng Online 2021; 20:24. [PMID: 33653371 PMCID: PMC7923306 DOI: 10.1186/s12938-021-00860-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/17/2021] [Indexed: 02/06/2023] Open
Abstract
Osteosarcoma (OS) is the most common primary bone malignancy that affects children and young adults. OS is characterized by a high degree of malignancy, strong invasiveness, rapid disease progression, and extremely high mortality rate; it is considered as a serious threat to the human health globally. The incidence of OS is common in the metaphysis of long tubular bones, but rare in the spine, pelvis, and sacrum areas; moreover, majority of the OS patients present with only a single lesion. OS has a bimodal distribution pattern, that is, its incidence peaks in the second decade of life and in late adulthood. We examine historical and current literature to present a succinct review of OS. In this review, we have discussed the types, clinical diagnosis, and modern and future treatment methods of OS. The purpose of this article is to inspire new ideas to develop more effective therapeutic options.
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Affiliation(s)
- Xin Zhao
- Anhui Chest Hospital, 397 Jixi Road, Hefei, 230022 China
| | - Qirui Wu
- Materials Genome Institute, Shanghai University, Shanghai, 201800 China
| | - Xiuqing Gong
- Materials Genome Institute, Shanghai University, Shanghai, 201800 China
| | - Jinfeng Liu
- Materials Genome Institute, Shanghai University, Shanghai, 201800 China
| | - Yujie Ma
- Materials Genome Institute, Shanghai University, Shanghai, 201800 China
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15
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Alder KD, Morris MT, Hao Z, Li L, Yu KE, Lee FY. Avoiding Limb-Length Discrepancy with Reconstruction of a Massive Tibial Defect Using a Bone Allograft and a Minimally Invasive Lengthening System in a Pediatric Patient: A Case Report. JBJS Case Connect 2021; 10:e0456. [PMID: 32649132 DOI: 10.2106/jbjs.cc.19.00456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 7-year-old boy was found to have Ewing sarcoma of the left tibia. The sarcoma was resected, and the defect was reconstructed using a humeral head allograft and intramedullary limb-lengthening nail. CONCLUSIONS Limb-salvage reconstruction in children can be complicated by the sacrifice of epiphyseal plates and limb-length discrepancies and thus requires techniques tailored to each case.
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Affiliation(s)
- Kareme D Alder
- 1Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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16
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Perez JR, Jose J, Mohile NV, Boden AL, Greif DN, Barrera CM, Conway S, Subhawong T, Ugarte A, Pretell-Mazzini J. Limb salvage reconstruction: Radiologic features of common reconstructive techniques and their complications. J Orthop 2020; 21:183-191. [PMID: 32256002 DOI: 10.1016/j.jor.2020.03.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/25/2020] [Indexed: 01/26/2023] Open
Abstract
Limb salvage surgery refers to orthopaedic procedures designed to resect tumors and reconstruct limbs. Improvements in managing malignant bone lesions have led to a dramatic shift in limb salvage procedures. Orthopaedic surgeons now employ four main reconstructive procedures: endoprosthesis, autograft, bulk allograft, and allograft prosthetic composite. While each approach has its advantages, each technique is associated with complications. Furthermore, knowledge of procedure specific imaging findings can lead to earlier complication diagnosis and improved clinical outcomes. The aim of this article is to review leading reconstructive options available for limb salvage surgery and present a case series illustrating the associated complications.
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Affiliation(s)
- Jose R Perez
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Jean Jose
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Neil V Mohile
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Allison L Boden
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Dylan N Greif
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Carlos M Barrera
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Sheila Conway
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Ty Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
| | - Ane Ugarte
- Hospital Universitario Donostia, Department of Radiology, Begiristain Doktorea Pasealekua #109, Gipuzkoa, 20014, Spain
| | - Juan Pretell-Mazzini
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1600 NW 10th Ave, Miami, 33136, FL, USA
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17
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Tanner L, Keppner K, Lesmeister D, Lyons K, Rock K, Sparrow J. Cancer Rehabilitation in the Pediatric and Adolescent/Young Adult Population. Semin Oncol Nurs 2020; 36:150984. [DOI: 10.1016/j.soncn.2019.150984] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Limb Salvage and Reconstruction Options in Osteosarcoma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1257:13-29. [PMID: 32483727 DOI: 10.1007/978-3-030-43032-0_2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in chemotherapy, sophisticated imaging, and surgical techniques over the last few decades have allowed limb-salvage surgery (LSS) to become the preferred surgical treatment for bone sarcomas of the extremities. The goal of LLS is to maximize limb functionality to allow for the maintenance of quality of life without compromising overall survival and tumor local recurrence rates. Today, limb-salvage procedures are performed on 80-95% of patients with extremity osteosarcoma, and the 5-year survival rate in extremity osteosarcoma patients is now 60-75%.This chapter will focus on LSS for extremity osteosarcoma. Common types of surgical reconstruction techniques including endoprostheses, intercalary or osteoarticular allografts, vascularized fibular autografts, and allograft prosthetic composites (APC), and their complications such as infection, local recurrence, graft fracture, implant failure, and nonunion will be discussed in detail. Anatomic locations of lesions discussed include the proximal femur, distal femur, proximal tibia, distal tibia, proximal humerus, distal humerus, and forearm bones.
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19
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Nelson CM, Marchese V, Rock K, Henshaw RM, Addison O. Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma. Front Pediatr 2020; 8:292. [PMID: 32612962 PMCID: PMC7308581 DOI: 10.3389/fped.2020.00292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.
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Affiliation(s)
- Christa M Nelson
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Victoria Marchese
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kelly Rock
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Robert M Henshaw
- Department of Orthopedic Oncology, MedStar Georgetown Orthopedic Institute, Washington, DC, United States.,Department of Orthopedic Oncology, Children's National Medical Center, Washington, DC, United States
| | - Odessa Addison
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, United States.,Baltimore VA GRECC, Baltimore, MD, United States
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20
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Ji T, Yang Y, Li DS, Tang XD, Guo W. Limb Salvage Using Non-hinged Endoprosthesis and Staged Correction of Leg-length Discrepancy for Children with Distal Femoral Malignant Tumors. Orthop Surg 2019; 11:819-825. [PMID: 31489784 PMCID: PMC6819186 DOI: 10.1111/os.12525] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/05/2019] [Accepted: 07/21/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Limb salvage in pediatric patients remains a challenge. We describe a staged strategy. The procedure includes: (i) tumor removal and non-hinged static endoprosthesis reconstruction; (ii) leg length discrepancy (LLD) correction by shoe lift or distraction osteogenesis; and (iii) maturity reconstruction by regular endoprosthesis. The aim of the study was to investigate the results of non-hinged static megaprosthesis reconstruction and staged LLD correction in the treatment of malignant tumors in the distal femur in children. METHODS Non-hinged megaprostheses were implanted in 12 pediatric patients with osteosarcoma in the distal femur. The prosthesis consists of a femoral component with constrained condylar knee (CCK) design, and a tibial component with a small-diameter press-fit stem and derotation fins. A posterior stabilizing polyethylene component is fixed on the tibial component. The cases were prospectively followed up with focus on the growth rate of adjacent uninvolved bone in the salvaged limb, joint stability, knee stability, function outcome, length discrepancy, and surgery-related complications. RESULTS There were five girls and seven boys included in the study, with an average age at the time of primary surgery of 10.0 years (range, 8-12 years). All the tumors were located in the distal femur. The average follow up was 76.3 months (range, 24-139 months). The Ligament Augmentation and Reconstruction System (LARS) ligament was used in two patients to enhance the soft tissue reattachment and reconstruct medial collateral ligament (MCL). Ten patients were alive at the final follow-up and two had died of lung metastases. Expected LLD was 6.7 cm (range, 3.0-13.2 cm) at initial surgery. At the final follow-up, nine patients reached skeletal maturity and the actual LLD at the femur was 5.3 cm (range, 3.0-10.1 cm), excluding 1 cm correction at initial surgery by endoprosthesis. The proximal tibia physis showed an average of 86.7% (range, 56.5%-100%) growth of the contralateral side. The mean reduction in tibial length was 1.2 cm (range, 0.5-4.7 cm). Six patients received distraction osteogenesis at a mean length of 5.4 cm (range, 3.0-9.1 cm). Range of knee movement was between 85° and 125°, with an average of 102.5°. The Musculoskeletal Tumor Society 93 score of patients alive was 80.6 (range, 60-90). CONCLUSION Non-hinged static megaprosthesis followed by LLD correction with shoe lift or staged distraction osteogenesis appears to be an alternative option to treat children with malignant bone tumors around the knee.
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Affiliation(s)
- Tao Ji
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Yi Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Da-Sen Li
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Xiao-Dong Tang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
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21
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Yoda Y, Yamaguchi SI, Hirozane T, Asano N, Seki A, Morioka H, Nakayama R, Nakamura M, Matsumoto M. Preservation of the Epiphysis and Growth Plate in the Surgical Management of Femoral Osteosarcoma in a Skeletally Immature Patient by Intercalary Resection and Biological Reconstruction: A Case Report. Case Rep Oncol 2019; 12:513-522. [PMID: 31427945 PMCID: PMC6696784 DOI: 10.1159/000501713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/18/2022] Open
Abstract
Osteosarcoma arises most frequently in the metaphysis around the knee and its management by limb salvage surgery in skeletally immature pediatric patients is extremely challenging. Common reconstructive methods such as endoprosthetic or biological reconstruction are not fully capable of dealing with durability-related and growth-related problems and their functional outcomes are not as good as those seen in adult cases. A definitive limb salvaging procedure in children that outperforms amputation or rotationplasty has not yet been established. Herein, we report a case of stage IV osteosarcoma in the femur of a 7-year-old boy that was safely managed with intercalary resection preserving the distal femoral growth plate and epiphysis, followed by biological reconstruction using a frozen tumor-devitalized autograft. Good response to preoperative chemotherapy and the diaphyseal location of the tumor enabled us to perform a tumor resection that spared the growth plate and preserved the native knee joint structure. Plate fixation over the growth plate was terminated by removing the locking screws in the epiphysis after 44 months, which restored growth capacity to some extent. At 50 months postoperatively, no recurrence or progression of the disease was observed. The patient uses an extension shoe and reports having little discomfort in his daily life despite having a restricted range of motion and limb length discrepancy. In conclusion, limb salvage with biological reconstruction in skeletally immature patients can provide an acceptable functional outcome, including minimized limb length discrepancy, if critical damage to the growth plate and articular components can be avoided.
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Affiliation(s)
- Yuhei Yoda
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Orthopaedic Surgery, National Center for Child Health and Development, Tokyo, Japan
| | | | - Toru Hirozane
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naofumi Asano
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Atsuhito Seki
- Department of Orthopaedic Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hideo Morioka
- Department of Orthopedic Surgery, Tokyo Medical Center, Tokyo, Japan
| | - Robert Nakayama
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Orthopaedic Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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22
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Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review. Clin Orthop Relat Res 2019; 477:894-902. [PMID: 30801278 PMCID: PMC6437378 DOI: 10.1097/corr.0000000000000630] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Excision of bone tumors and endoprosthetic reconstruction allow patients early weightbearing and a potential functional advantage compared with amputation. These reconstructions do not restore the limb to normal status, however, and patients are subject to complications that may result in revision or loss of the limb. Because better understanding of these complications based on current information might help the patient and surgeon in decision-making, we undertook a systematic review of studies published on this topic. QUESTIONS/PURPOSES (1) What are the primary modes and proportion of failure of tumor endoprostheses in patients undergoing reconstruction after excision of primary extremity bone sarcomas? METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library for all studies published from April 15, 1998, to April 15, 2018. Three reviewers independently reviewed studies reporting endoprosthetic reconstruction survival and events requiring revision for primary extremity bone tumors treated with endoprosthetic reconstruction for inclusion and performed independent data extraction. We excluded all studies with fewer than five patients, any systematic review/meta-analyses, and any study not reporting on primary extremity bone tumors. All discrepancies were resolved by the study's senior author. Data extracted from included studies were any reoperation event for wound dehiscence, any operative fixation for a pathologic fracture, and any revision of the primary endoprosthesis for implant wear or breakage, deep infection not amenable to prosthesis retention, or for local recurrence. We assessed the overall quality of the evidence with the Methodological Index for Non-Randomized Studies (MINORS) approach with a higher MINORS score representative of a more methodologically rigorous study with a total possible score of 16 points for noncomparative and 24 points for comparative studies. Forty-nine studies met criteria for inclusion from an initial search return of 904 studies, of which no studies were randomized controlled trials. From a total patient population of 2721, there was a mean followup of 93 months (range, 1-516 months) with loss to followup or death occurring in 447 of 2118 (21%) patients with six studies not providing loss to followup data. The mean MINORS score was 14 for prospective studies and 11 for retrospective studies. RESULTS Overall, there were 1283 reoperations among the 2721 (47%) patients. Reoperation for mechanical endoprosthetic events (soft tissue dehiscence or periarticular soft tissue instability, aseptic loosening, or implant wear/fracture) occurred in 907 of 2721 (33%) patients. Aseptic loosening occurred at a mean of 75 months (range, 1-376 months) in 212 of 315 patients (67%). Deep infection requiring removal of the initial prosthesis occurred in 247 of 2721 (9%) patients with deep infection occurring at a mean of 24 months (range, 1-372 months) in the 190 infections (77%) with time to infection data available. Local recurrence rates requiring revision or amputation occurred in 129 (5%) of all patients. There was an overall primary endoprosthesis survival rate without any surgical reintervention of 63% among reporting studies at a mean of 79 months followup. CONCLUSIONS Failures of endoprosthetic reconstructions after extremity tumor surgery are common, most often resulting from implant wear or fracture, aseptic loosening, and infection. Importantly, the aggregated data are the first to attempt to quantify the time to specific complication types within this patient population. Deep infection not amenable to endoprosthesis retention appears to occur approximately 2 years postoperatively in most patients, with aseptic loosening occurring most commonly at 75 months. Although endoprosthetic reconstruction is one of the most common forms of reconstruction after bone tumor resection, the quality of published evidence regarding this procedure is of low quality with high loss to followup and data quality limiting interstudy analysis. The quality of the evidence is low with high loss to followup and inconsistent reporting of times to reintervention events. Although the most common modes of endoprosthetic failure in this population are well known, creation of quality prospective, collaborative databases would assist in clarifying and informing important elements of the followup process for these patients. LEVEL OF EVIDENCE Level IV, therapeutic study.
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23
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Florou V, Nascimento AG, Gulia A, de Lima Lopes G. Global Health Perspective in Sarcomas and Other Rare Cancers. Am Soc Clin Oncol Educ Book 2018; 38:916-924. [PMID: 30231406 DOI: 10.1200/edbk_200589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Sarcomas, rare and heterogenous malignancies that comprise less than 1% of all cancers, have poor outcomes in the metastatic and refractory setting. Their management requires a multidisciplinary approach that consists of medical and surgical oncologists, radiation oncologists, and pathologists as well as ancillary support. In addition to systemic treatments, most patients will require surgical resection and radiation therapy, which mandates the use of the latest technologies and specialized expertise. Management guidelines have been developed in high-income countries, but their applicability in low-income countries, where resources may be limited, remains a challenge. In this article, we propose the best possible evidence-based practices specifically for income-constrained settings to overcome this challenge. In addition, we review the different methods that can be used in low-income countries to access new and expensive treatments, which often times carry prohibitive costs for these areas.
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Affiliation(s)
- Vaia Florou
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Antonio G Nascimento
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Ashish Gulia
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Gilberto de Lima Lopes
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
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24
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Wright JG. Small Simple Trials: A Strategy for Orthopaedic Randomized Trials. J Bone Joint Surg Am 2018; 100:e95. [PMID: 30020133 DOI: 10.2106/jbjs.17.01107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James G Wright
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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25
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