Objective To identify the postoperative function and short-term outcome of Global Modular Replacement System (GMRS) for reconstruction of defect after removal of tumor so as to supply information for cl inical appl ication. Methods Between March 2007 and May 2009, 30 l imb-salvage cases reconstructed with GMRS were retrospectively reviewed, including 18 males and 12 females with a median age of 25 years (range, 11-57 years). The preoperative diagnoses were osteosarcoma in 15 cases, mal ignant fibro-histiocytoma in 4, giant cell tumor in 3, chondrosarcoma in 2, and Ewing’s sarcoma and angiosarcoma in 1 respectively. The duration of symptom ranged from 1 to 15 months with an average of 5.6 months. There were 4 revision cases at mean time of 3.4 years after index surgeries. The locations were the proximal femur in 3 cases, distal femur in 22 cases, and proximal tibia in 5 cases. According to Enneking stage, 2 cases were rated as stage IB, 1 as stage IIA, and 27 as stage IIB. Four cases were compl icated by pathologic fracture. Results The average operation time was 165 minutes (range, 120-240 minutes); the mean blood loss was 448.3 mL (range, 100-1 500 mL); and the mean resection length was 14.1 cm (range, 7.5-22.5 cm). All the wounds healed by first intention. All 30 patients were followed up 10-35 months (22.3 months on average). Local recurrence occurred in 2 cases (6.7%) at 5 and 14 months respectively and distal metastasis occurred in 5 cases (16.7%) at 4-12 months (7.3 months on average) postoperatively. One patient died of multiple lung metastases at 10 months postoperatively. Twenty-nine patients survived at last follow-up, including 25 cases of tumor-free survival and 4 cases of tumor bearing survival. Aseptic loosening occurred in 2 cases (6.7%) at 1.5 years and 2 years postoperatively respectively. Deep infection occurred in 1 case (3.3%) at 1 year postoperatively. At last follow-up, the Musculoskeletal Tumor Society (MSTS) 93 scores were 4.6% ± 0.7% for pain, 3.7% ± 0.9% for function, 3.2% ± 1.3% for satisfactory degree, 4.3% ± 0.9% for orthesis, 3.7% ± 0.7% for walking, 3.3% ± 1.0% for gait; total score was 75.9% ± 14.2%. The Toronto Extremity Salvage Score (TESS) score was 87.0 ± 7.0. Conclusion Reconstruction for defect after removal of tumor with GMRS has satisfactory short-term outcome with good function recovery and low compl ication rate.
OBJECTIVE To analyze the indications for revision surgery after limb salvage procedure of malignant bone tumor and summarize the experiences in revision surgery. METHODS From January 1994 to December 1997, 8 cases were re-operated after primary limb salvage procedure. The average survival period with no-tumor occurrence was 8 years. The common causes for the revision were traumatic osteoarthritis, fracture, and bone resorption. The main difficulties in revision were soft tissue contracture and limb discrepancy from limb shortening. RESULTS In this study, there was total hip replacement in 1 case, large segmental allograft for reconstruction of distal femur in 3 cases, total knee replacement upon composite of previously transplanted allograft in 3 cases, removing of intramedullary nail and re-internally fixed with intramedullary nail in 1 cases. The isotopic bone scan before the revision showed active bone metabolism in all 4 transplanted segmental allograft. The pathologic study of the transplanted allograft after revision confirmed new bone formation in allograft. The revision procedure reduced the pain, and improved the limb function. CONCLUSION The main causes of revision surgery after limb salvage procedure of malignant bone tumor are fracture of transplanted allograft segment or devitalized tumor segment, and poor function of the affected joint. Constrained knee prostheses with rotating hinges or semi-constrained ball-axis resurfacing knee prostheses improve the function of knee joint postoperatively.
Objective To evaluate the effectiveness of soft tissue reconstruction after resection of musculoskeletal tumor and to discuss the strategy of soft tissue reconstruction. Methods Between June 2003 and December 2010, 90 patients with musculoskeletal tumor underwent tumor resection and soft tissue reconstruction. There were 59 males and 31 females with a median age of 37.2 years (range, 9-85 years), including 52 bone tumors and 38 soft tissue tumors. One stage reconstruction of soft tissue was performed after tumor resection in 75 cases; reconstruction of soft tissue was performed after debridement in 7 cases of wound dehiscence; and two stage reconstruction of soft tissue was performed after debridement and vacuum sealing drainage placement in 8 cases of infected wounds. The gastrocnemiums flap was used in 40 cases, the latissimus dorsi myocutaneous flap in 6 cases, rectus abdominis myocutaneous flap in 4 cases, gluteus maximus musculocutaneous flap in 1 case, pectoralis major muscle flap in 1 case, cross-abdominal flap in 1 case, local transfer flap in 27 cases, pedicled flaps in 5 cases, and skin grafts in 5 cases. The size of the flap ranged from 6.5 cm × 4.5 cm to 21.0 cm × 9.0 cm. Results Eighty-seven flaps survived, and incisions healed by first intention in 81 cases. In 6 cases of healing by second intention, 2 had partial flap necrosis, which was cured by dressing change; 3 had delayed healing; 1 had mild infection, which was cured after conservative treatment. Wound of donor site healed primarily, and the grafted skin survived. Seventy-three patients were followed up 10-102 months (mean, 36.1 months). Local tumor recurrence was observed in 6 patients, who received second resection at 2-27 months (mean, 8.2 months) after operation. Thirteen patients dead of primary disease at 6-34 months (mean, 19.2 months) after operation. Conclusion The defects caused by resection of musculoskeletal tumor require soft tissue reconstructions. Optimal reconstruction can enhance wound closure, decrease incidence of wound complication, preserve limb function.
ObjectiveTo investigate the effects of fibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery.
MethodsBetween July 1999 and March 2013, 76 patients with neoplasms of the proximal tibia underwent tumor resection, prosthetic replacement, and gastrocnemius medial head flap transfer. Among them, 38 patients underwent fibular head resection (group A) and 38 underwent fibular head preservation (group B). There was no significant difference in gender, age, side, tumor classification and stage, and disease duration between 2 groups (P>0.05). The complications and the position of the components were observed, and American society for bone tumors scoring system (MSTS93) was used to evaluate the joint function.
ResultsAll patients were followed up 12-150 months (mean, 87 months). Incision infection occurred in 1 patient (2.63%) of group A and 6 patients (15.79%) of group B, showing significant difference (χ2=3.934, P=0.047). Necrosis of gastrocnemius medial head flap was found in 1 patient of group A and 2 patients of group B. Prosthetic loosening and instability of the knee were observed in 4 and 2 cases of group A and in 6 and 4 cases of group B, respectively. In groups A and B, there were 3 and 5 cases of local recurrence, 7 and 6 cases of distant metastasis, and 8 and 7 deaths, respectively. According to MSTS93, the results were excellent in 23 cases, good in 10 cases, fair in 3 cases, and poor in 2 cases, with an excellent and good rate of 86.84% in group A; the results were excellent in 21 cases, good in 11 cases, fair in 3 cases, and poor in 3 cases, with an excellent and good rate of 84.21% in group B; and no significant difference was found in the excellent and good rate between 2 groups (χ2=0.106, P=0.744).
ConclusionFibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery is beneficial to intra-operative tissue coverage, and it can reduce trauma by skin transplantation and related complications. Good stability and motion of the joint can be obtained after operation.
Objective To investigate the effect of the semi-joint prosthesis replacement in treating malignant tumors around the children’s knees. Methods Five children (aged 8-12 years) with malignant tumors around the proximal end ofthe tibia underwent the semi-joint prostheses replacement from March 2000 to June 2005. All the children had been diagnosed with osteosarcoma, which was graded as ⅡB by the Enneking staging system. The pathologic changes involved the upper segment of the tibia 9-11 cm in length. Before operation all the patients underwent puncture biopsy and standard chemotherapy. The lesion extent was determined by X-ray, CT and MRI, and then the size of the prosthesis was determined. The length of the prosthesis was 1-2 cm longer than that of the excised bone. After operation the patients were given neoadjuvant chemotherapy for 2 courses and they could walk with the help of a special brace 4 weeks postoperatively. Results All the 5 patients had a successful semi-joint prosthesis replacement exceptone patient who had a skin flap necrosis, and the wound healed after a flap grafting. The remaining patients had their wounds healed by first intention. The12-36 months’ follow-up revealed that all the patients had no metastasis or recurrence of the tumor and they were living and well except one patient who died oflung metastasis 8 months after operation. Conclusion The semi-joint prosthesis replacement in the limb salvage surgery for maligant tumors around the children’s knees has advantages of avoiding a damage to the normal osteoepiphysis, stabilizing the knee joint, and facilitating elongation of the limb in future. Italso creates the condition for total knee replacement in adults.
Objective To probe a satisfactory surgical management of the limbsalvage for osteogenic malignant tumors around the knees. Methods From January1989 to December 2001, 42 patients (19 males and 18 females, aged 12-46) with osteogenic malignant tumors around the knees underwent surgical management of the limb salvage, including prosthesis replacement, allogenous bone grafting, and bone cement with adriamycin filled. Based on the pathological examination, osteosarcoma was found in 11 patients, synoviosarcoma in 4 patients, malignant fibrous histiocytoma in 3 patients, and giant cell tumor of the bone in 19 patients. All the patients underwent neoadjuvant chemotherapy for 1-2 courses before operatioexcept the patients with giant cell tumor of the bone. The patients underwent prosthesis replacement, allogenous bone grafting, bone cement with adriamycin filled, and postoperative chemotherapy. By the Enneking evaluating system, the patients were assessed on their reconstructed limb functions after the reconstructive operation for the musculoskeleta malignant tumors. Of the patients, 37 were followed up after operation. Results According to the follow-up for 3-11 years (mean, 5.6 years) in the 37 patients, 2 patients had recurrence and metastasis of the tumor, and died 3 and 4 years after operation, respectively. One patient underwent amputation of the limb for local recurrence of the tumor. One patient had amputation of the limb for the preoperative radiotherapy and the infection and necrosis of the operative wound after the limb-salvage surgery. Two patients had amputation of the limb for the rejection of the allogenous bone graft and theformation of the fistula.Thirty-one patients had good wound healing andgood functions of the limb. The results were evaluated by the Enneking evaluating system as follows: excellent in 7 patients, good in 14, fair in 10, and poor in 6. Conclusion Making an early diagnosis, recognizing the operative indication, choosing the operative method, and performing the preoperative and postoperative chemotherapy and/or radiotherapy are the keys to achieving an ideal limb-salvage surgery for osteogenic malignant tumors around the knees.
Objective
To investigate the clinical application and early results of combined epiphyseal preservation and autograft bone transfer for limb salvage in children with osteosarcoma.
Methods
Between March 2010 and March 2011, 3 children with osteosarcoma were treated with epiphyseal preservation and autograft bone transfer. There were 1 boy and 2 girls with the age of 10-14 years. The disease duration was 2 weeks to 3 months. The tumors were rated as type II according to San-Julian radiological classification and as type IIB according to Enneking surgical classification. The locations were the distal femur in 1 case and the proximal tibia in 2 cases. The surgical technique included preoperative neoadjuvant chemotherapy, excision of part of the epiphysis, preservation of subarticular epiphysis, external fixation with Ilizarov apparatus and transport osteogenesis treatment. Safe excision border was confirmed by histological examination. Postoperative observation included the wound healing, local recurrence or distant metastasis, length, speed, alignment, and regeneration of transplanted bone, the length and function of the affected limb.
Results
The postoperative histological examination proved the safe surgical margin in all 3 patients. The incision healing by first intention was obtained at distal femur in 1 case and by second intention at proximal tibia in 2 cases at 4 weeks after changes of dressing. Three patients were followed up 12, 18, and 24 months, respectively. There was no local recurrence or distant metastasis during follow-up. Two cases had pin-tract infection at 10 months after external fixation and were cured after changes of dressing and antibiotics administration. The length of transplanted osteogenisis was 18.0, 9.5, and 16.0 cm, respectively. The speed of lengthening was 2.57, 2.07, and 1.20 cm/month, respectively. One patient had alignment deviation during lengthening, which was adjusted under anaesthesia. Bony healing was achieved at 8 months after lengthening end in 2 cases and external fixation was removed; 1 patient had poor bone growth and was given retraction for promoting bone growth. At last follow-up, the length of the affected limbs was 1.0-1.5 cm shorter than that of normal limbs, but no abnormalities was observed at donor sites. The affected knee flexion reached 90° and 120° in 2 patients and poor knee function was observed in 1 patient for external fixation.
Conclusion
The combined epiphyseal preservation and transport osteogenesis technique can be used for bone defect repair by lengthening the residual bone. It is a promising limb salvage treatment for children with osteosarcoma.
ObjectiveTo investigate the application value of the Ilizarov technique for infection after the limb salvage operation of primary bone tumor.
MethodsA retrospective analysis was made on the clinical data of 6 patients with infection treated with Ilizarov technique after limb salvage operation of primary bone tumor between July 2012 and April 2015. There were 4 males and 2 females, aged 18-40 years (mean, 28 years). Tumor types included 3 cases of osteosarcoma and 3 cases of giant cell tumor of bone. Tumor located at the left distal femur in 2 cases, at the right distal femur in 1 case, at the left proximal tibia in 1 case, and at the right proximal tibia in 2 cases. Six cases had recurring infection after debridement. The patients underwent operation 2 to 5 times (mean, 3.5 times). The time from tumor resection to visiting was 8-20 months (mean, 14.3 months). During operation, the internal implant was removed; infection and necrotic tissue was removed thoroughly; and the Ilizarov external fixator was installed. After operation, gentamycin normal saline was used for 2 to 3 weeks, and the sensitive antibiotic intravenous infusion was performed at the same time. After 1 week, the osteotomy lengthening was used.
ResultsAll 6 patients were followed up for 6 to 18 months (mean, 12.2 months). Pin tract infection occurred in 1 case after operation; primary healing of incision was obtained in the other patients, and no related complications occurred. The external fixation time ranged from 6 to 16 months (mean, 11.5 months). The healing indexes ranged from 34 to 62 days/cm (mean, 52.0 days/cm). After removal of the external fixator, the knee range of motion ranged from 0 to 5° (mean, 3°) in extension, and from 120 to 130° (mean, 125°) in flexion. The American musculo-skeletal tumor society system (MSTS) function scoring was excellent in 3 patients, good in 2 patients, and fair in 1 patient, with an excellent and good rate of 83.3%. During follow-up period, there was no recurrence of infection; and no recurrence or metastasis was found in 3 patients with osteosarcoma.
ConclusionInfection can be cured by Ilizarov technique after limb salvage operation of bone tumor.
ObjectiveTo investigate the reasons and managements of implant-related complications after hinge knee replacement for tumors around the knee.
MethodsA retrospective analysis was made on the clinical data of 96 patients undergoing hinge knee replacement between January 2000 and December 2012. There were 64 males and 32 females with the mean age of 31.0 years (range, 15-72 years). The most common tumor type was osteosarcoma (72 cases), and the second was giant cell tumor (15 cases). The tumor located at the distal femurs in 52 cases and at the proximal tibias in 44 cases. Fifteen hinge and 81 rotating hinge prostheses were used. The recurrence, metastasis, and survival were recorded. The implant-related complications were observed.
ResultsThe median follow-up time was 43.5 months (range, 10-156 months). Complications were observed in 21 patients (25 implant-related complications);13 complications located at the femur and 12 complications at the tibia. The complications included aseptic loosening (8 cases), deep infection (7 cases), prosthetic breakage (4 cases), peri-prosthetic fracture (2 cases), and dislocation (4 cases). Most deep infection occurred within 12 months after operation (6/7), and most aseptic loosening after 40 months of operation (6/8). The rate of limb salvage was 90.6% (87/96) and the amputation rate was 9.4% (9/96). The overall survival rate of the prosthesis was 76.7% (5-year) and 47.2% (10-year). The 5-year survival rate was 82.9% for femoral prosthesis and 71.0% for tibial prosthesis, showing no significant difference (P=0.954).
ConclusionHinge knee prosthesis still has a high rate of complications. Deep infection is main reason to decrease short-term prosthetic survival rate, and aseptic loosening shortens the long-short prosthetic survival time.
ObjectiveTo investigate the effectiveness and technical key points of limb salvage surgery by allotransplantation of cryopreservated vascularized bone in children and adolescents with osteosarcoma.
MethodsA retrospective analysis was made on the clinical data of 21 children and adolescents with osteosarcoma receiving limb salvage surgery by allotransplantation of cryopreservated vascularized bone from their relatives between February 2004 and April 2012. There were 13 males and 8 females, aged from 7 to 16 years (mean, 12.6 years). According to Enneking stage system, 15 cases were rated as stage ⅡA and 6 cases as stage ⅡB. The tumors located at the distal femur in 10 cases, at the proximal femur in 1 case, at the proximal tibia in 8 cases, at the proximal humerus in 1 case, and at the distal radius in 1 case. Imaging examination showed that epiphyseal extension of malignant bone tumors in 7 cases. The iliac bone allograft with deep iliac vessels was obtained from their lineal consanguinity. After preservation by a twostep freezing schedule, the iliac bone allograft with deep iliac vessels was implanted into the bone defect area after tumor resection. The size of iliac bone flap was 8.0 cm×3.0 cm×2.0 cm-14.0 cm×5.0 cm×2.5 cm. Reserved joint surgery was performed on 16 cases and joint fusion surgery on 5 cases, and external fixation was used in all cases. The chemotherapy was given according to sequential high-dose methotraxate, adriamycin, and cisplatine before and after operation.
ResultsAll 21 cases were followed up from 5 months to 11 years (mean, 6.4 years). At 2 weeks after operation, the erythrocyte rosette forming cells accounted for 56.7%±3.9%, showing no significant difference when compared with that of normal control (58.3%±4.3%) (t=1.56, P=0.13), which suggested no acute rejection. At 4 weeks after operation, single photon emission computerized tomography bone scan indicated that the blood supply of bone graft was rich, and the metabolism was active. At 12 weeks after operation, the digital subtraction angiography showed the artery of iliac bone flap kept patency. X-ray films showed that malunion and non-union occurred at 5 and 6 months after operation in 1 case, respectively. The bone graft healed in the other patients, and the healing time was 3.2-6.0 months (mean, 4.4 months). At last follow-up, American Musculoskeletal Tumor Society (MSTS) score was significantly improved to 26.80±2.14 from preoperative value (17.15±1.86) (t=-4.15, P=0.00). The survival rate was 85.7% (18/21) and the recurrence rate was 9.5% (2/21).
ConclusionAllotransplantation of cryopreservated vascularized bone from the relatives provides a new method for the treatment of osteosarcoma in children and adolescents. A combination of allotransplantation and chemotherapy can achieve the ideal treatment effect. The correct cutting, preservation, and transplantation of the donor bone, and indication are the key to improve the effectiveness.
