Surgical modalities in the treatment of bone sarcoma in children

Scapulo-humeral arthrodesis using a pedicled scapular pillar graft following resection of the proximal humerus

BACKGROUND

Scapulo-humeral arthrodesis (SHA) is a proven reconstruction method in patients with proximal humerus malignancies requiring resection of the shoulder abduction apparatus (rotator cuff and deltoid muscles) or its nerve supply. Standard practice consists in using a pedicled fibular flap. We use instead a pedicled autologous bone graft harvested from the ipsilateral scapular pillar.

HYPOTHESIS

The objective of this study was to assess functional outcomes and radiological healing after SHA using a pedicled scapular pillar graft.

MATERIALS AND METHODS

We retrospectively reviewed the charts of the 12 patients managed at a single center by a single surgeon between 1994 and 2011. SHA was performed using a vascularised ipsilateral scapular pillar graft after proximal humerus resection to treat a bone malignancy. The graft was harvested from the ipsilateral scapular pillar, pedicled on the circumflex scapular artery, fitted into the remaining proximal humerus, and secured to the glenoid using screws. A humerus-scapular spine plate was added to stabilize the arthrodesis. Radiographic results were assessed on standard radiographs obtained at last follow-up. Functional outcomes were evaluated using the MusculoSkeletalTumour Society (MSTS) score and Toronto Extremity Salvage Score (TESS).

RESULTS

After a mean follow-up of 4.9 years, 87.5% of SHA junctions were healed, mean MSTS score was 71%, and mean TESS score was 70%.

DISCUSSION

The outcomes in our patients were similar to those reported after SHA using a pedicled fibular flap. However, our technique does not require microsurgery. It is simple, reproducible, and effective. Its indications of choice are intra- or extra-articular resection of the proximal humerus including the attachments of the rotator cuff and deltoid muscle tendons or the nerves supplying these muscles.

LEVEL OF EVIDENCE

Level IV (retrospective study).

Intercalary allograft reconstructions following resection of primary bone tumors: a nationwide multicenter study

BACKGROUND

Favorable reports on the use of massive allografts to reconstruct intercalary defects underline their place in limb-salvage surgery. However, little is known about optimal indications as reports on failure and complication rates in larger populations remain scarce. We evaluated the incidence of and risk factors for failure and complications, time to full weight-bearing, and optimal fixation methods for intercalary allografts after tumor resection.

METHODS

A retrospective study was performed in all four centers of orthopaedic oncology in the Netherlands. All consecutive patients reconstructed with intercalary (whole-circumference) allografts after tumor resection in the long bones during 1989 to 2009 were evaluated. The minimum follow-up was twenty-four months. Eighty-seven patients with a median age of seventeen years (range, 1.5 to 77.5 years) matched inclusion criteria. The most common diagnoses were osteosarcoma, Ewing sarcoma, adamantinoma, and chondrosarcoma. The median follow-up period was eighty-four months (range, twenty-five to 262 months). Ninety percent of tumors were localized in the femur or the tibia.

RESULTS

Fifteen percent of our patients experienced a graft-related failure. The major complications were nonunion (40%), fracture (29%), and infection (14%). Complications occurred in 76% of patients and reoperations were necessary in 70% of patients. The median time to the latest complication was thirty-two months (range, zero to 200 months). The median time to full weight-bearing was nine months (range, one to eighty months). Fifteen grafts failed, twelve of which failed in the first four years. None of the thirty-four tibial reconstructions failed. Reconstruction site, patient age, allograft length, nail-only fixation, and non-bridging osteosynthesis were the most important risk factors for complications. Adjuvant chemotherapy and irradiation had no effects on complication rates.

CONCLUSIONS

We report high complication rates and considerable failure rates for the use of intercalary allografts; complications primarily occurred in the first years after surgery, but some occurred much later after surgery. To reduce the number of failures, we recommend reconsidering the use of allografts for reconstructions of defects that are ≥15 cm, especially in older patients, and applying bridging osteosynthesis with use of plate fixation.

Results of surgical resection in pediatric pelvic tumors

Thirty nonmetastatic patients with malignant tumors of the pelvis underwent surgical resection between November 2000 and December 2009. The diagnosis included Ewing's sarcoma (22), osteogenic sarcoma (four), chondrosarcoma (two), and synovial sarcoma (two). Eighteen resections included the acetabulum and 12 did not. Twenty-seven patients were available for follow-up. Follow-up ranged from 4 to 138 months (mean 43 months). Nineteen patients are currently alive. There were two local recurrences. The overall survival was 68% at 5 years. The Musculoskeletal Tumor Society Score ranged from 22 to 29. Surgery provides good local control and oncologic outcomes with acceptable function in these patients.

Epiphysis preserving operations for the treatment of lower limb malignant bone tumors

PURPOSE

To assess two epiphyseal sparing procedures for the treatment of lower limb malignant bone tumors.

METHODS

Between January 2007 and January 2011, 15 patients, seven males and eight females with a mean age of 11.75 years (range, 7-24), underwent epiphysis preservation operations. There were ten osteosarcomas, three Ewing's sarcomas and two fibrosarcomas. Ten tumors were in the distal femur and five in the proximal tibia. Chemotherapy was administered pre- and post-surgery. A transepiphyseal resection was performed in nine patients and an epiphysis section after physeal distraction in six. The affected bones were substituted with massive allograft bone and fixed with intramedullary nails or plates and screws. Follow-up assessment included plain X-rays and MRI.

RESULTS

One patient died from lung metastases 32 months post-surgery. Surgical complications included length discrepancy between both legs of 1-3 cm in four patients, >3 cm in one patient, delayed union at the proximal allograft-host junction in two patients and at the distal junction in 13 patients. Graft bone rejection occurred in two patients, superficial infection was seen in one patient, and broken fixation and partial graft bone resorption occurred in one patient. No relapse was observed during the follow-up period. Normal knee joint flexion-extension was achieved in 14 patients. All patients were able to walk unaided 24 months after surgery.

CONCLUSIONS

Limb saving surgery with epiphyseal sparing is useful for the management of malignant bone tumors in children and adolescents, and maintains normal joint function with few complications.

Paediatric diaphyseal malignant tumors: options for reconstruction after intercalary resection

From January 2002 to June 2008, 525 malignant pediatric skeletal tumors were operated. Forty-two (8%) tumors were diaphyseal in origin. The age of the patients ranged from two to 16 years. Femur was the most common site.After resection, various methods of reconstruction were adopted based on tumor site and availability of reconstruction options. Thirty-seven patients were available for follow-up. Follow-up duration ranged from 4 months to 86 months (mean 38.3 months). Eight patients succumbed to the disease. There were three local recurrences. The Musculoskeletal Tumor Society Score ranged from 18 to 30 (mean 27). Joint-preserving intercalary resections are an oncologically safe option with gratifying functional results.

Multidisciplinary care in pediatric oncology

This paper describes the significant advances in the treatment of childhood cancer and supportive care that have occurred over the last several decades and details how these advances have led to improved survival and quality of life (QOL) for children with cancer through a multidisciplinary approach to care. Advances in the basic sciences, general medicine, cooperative research protocols, and policy guidelines have influenced and guided the multidisciplinary approach in pediatric oncology care across the spectrum from diagnosis through long-term survival. Two case studies are provided to highlight the nature and scope of multidisciplinary care in pediatric oncology care.