Umkehrplastik im operativen Behandlungsplan der prim�r malignen Knochentumoren

Modified Borggreve-Van Nes-Winkelmann rotationplasty for surgery in developing countries

BACKGROUND

Amputation is still the most common therapy for patients suffering from osteosarcoma in Myanmar, despite the fact that limb salvage surgery e.g. Borggreve-Van Nes-Winkelmann rotationplasty for malignant tumors located within the distal femur or proximal tibia is the current state-of-the-art reconstructive procedure. A safe and reliable operation technique is crucial in order to perform a complex surgical procedure like the rotationplasty in lower-middle income economies with limited infrastructure and resources. The authors present seven cases of patients with osteosarcomas that received a Borggreve-Van Nes-Winkelmann rotationplasty with an evaluation of the procedures focusing on safety and sustainability.

METHODS

From 2019 until 2020, seven young patients with osteosarcomas of the distal femur or proximal tibia were treated with Borggreve-Van Nes-Winkelmann rotationplasties in the Orthopaedic Hospital in Mandalay, Myanmar. As modification of the standard procedure the dissection and subsequent clamping of the femoral artery in order to minimize blood loss as well as the formation of an adipocutaneous flap that minimizes swelling and decreases the pressure on the vessels were successfully performed. This modified procedure resembles a safe and simplified surgical technique that is feasible under the circumstances of lower-middle income economies with good outcomes.

RESULTS

All patients showed good functional and aesthetic results. One of the seven patients needed secondary wound closure due to wound dehiscence.

CONCLUSIONS

A simplified and safe operation technique for the performance of the Van Nes-Borggreve rotationplasty was adapted to the given constraints in lower-middle income economies and proved to be successful. Trial registration All patients approved to participate in the study and have given consent to publication.

[Rotationplasty in a schoolboy for osteosarcoma: Prosthesis fitting and update]

INTRODUCTION

The classical treatment of osteosarcoma used to be ablative surgery. After the appearance of adjuvant chemotherapy, survival in these patients increased, and with it, the number of affected school age children with high growth potential. Hence, reconstructive surgeries are currently proposed instead of conventional bone resections due to greater limb preservation and better functional status than those achieved with conventional amputations.

CASE PRESENTATION

We describe a case of osteosarcoma in a 9-year-old boy with a history of retinoblastoma. The tumour involved the entire length of the left femur. He also had a lung metastasis. Given the incomplete response to neoadjuvant chemotherapy, we chose bone resection, rotation and fitting of the left lower limb and thoracoscopy to treat the lung injury. A bypass ortoprosthesis was placed for the first 6 weeks, until there was healing, bone consolidation and absence of complications, followed by a definitive orthoprosthesis for the next 4 months. At one year, the patient was able to walk independently with the use of the ortoprosthesis, swimming with a fin adapted to the stump and was had restarted cycling. At the last clinical review, at the age of 13 years, he is disease free and continues to have periodic follow-up visits in our office for adaptations to the prosthesis according to his growth.

DISCUSSION

This case highlights the various reconstructive options available and the difficulties encountered in the management of these aggressive malignant processes. Rotationplasty is a viable therapeutic option in young patients with osteosarcoma, which allows the child to participate again in premorbid daily and recreational activities.

Rotational Tibio-Pelvic Constrained Hip Arthroplasty: A Surgical Technique: A Case Report

CASE

A 25-year-old man presented with chronic bone and soft tissue infection of the right thigh following resection and radiation of epithelioid sarcoma. Multiple revisions and debridement procedures had failed to control the infection and left him unable to ambulate. We describe a modified Van Nes rotationplasty using a constrained, prosthetic hip between the tibia and pelvis following femur resection. With 18 months of follow-up, the patient was able to walk with a prosthetic device without evidence of recurrent infection.

CONCLUSIONS

We report this rotationplasty as a potential approach to avoid hip disarticulation in cases requiring extensive debridement for incurable infection.

Results of 20 consecutive patients treated with the Repiphysis expandable prosthesis for primary malignant bone

Limb-salvage for primary malignant bone tumors in pediatric patients presents a unique challenge when resection includes an active physis. Early expandable prostheses required open surgical procedures to achieve lengthening. Newer prostheses are capable of achieving expansion without open procedures through the use of an electromagnetic field. This study reports our results with 90 consecutive expansion procedures using the Repiphysis^® prosthesis. We retrospectively reviewed the records of 20 patients (22 limbs) who underwent limb-salvage using the Repiphysis^® prosthesis from 2003 to 2015. There were 9 males and 11 females with a mean age of 9 years and 9 months (6–16 years). Reconstruction included the distal femur in 11 cases, total femur in four, proximal tibia in three, proximal humerus in three, and total humerus in one. Complications were reviewed and functional scores were recorded using the MSTS/ISOLS system. Five patients had a second prosthesis implanted during the course of the study for a total of 27 prostheses. The mean follow-up was 57 (6–148) months. Four patients have not been expanded: three due to death prior to lengthening, and one patient who has not yet developed a leg length discrepancy. Ninety consecutive expansion procedures were performed in 18 limbs in 16 patients. A mean of 9 (5–20) mm was gained per expansion and 4.8 cm per patient who has undergone expansion to date. Seven patients have reached skeletal maturity and have been converted to an adult endoprosthesis. These patients averaged 8 expansions per patient and a mean of 7.4 (1.8–12.9) cm in length gained. There were 15 complications in 11 patients including one dislocation, one contracture, four cases of aseptic loosening, five structural failures (three expansion mechanism failures and two tibial fractures), three deep infections, and one case of local recurrence. The mean MSTS score was 80 % (37–97 %) and the limb retention rate was 95 %. The results of this study are comparable to previous studies involving non-invasive prostheses. This study hopefully provides additional data for clinicians to consider when faced with limb threatening sarcomas in the immature skeleton.

[Management of complications in megaprostheses]

BACKGROUND

Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty.

OBJECTIVES

The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described.

MATERIALS AND METHODS

The current knowledge and our own experience of complication management with the use of megaprostheses are presented.

RESULTS

Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups.

CONCLUSIONS

Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.

Autoclaved tumor bone for skeletal reconstruction in paediatric patients: a low cost alternative in developing countries

We reviewed in this series forty patients of pediatric age who underwent resection for malignant tumors of musculoskeletal system followed by biological reconstruction. Our surgical procedure for reconstruction included (1) wide en bloc resection of the tumor; (2) curettage of tumor from the resected bone; (3) autoclaving for 8 minutes (4) bone grafting from the fibula (both vascularized and nonvascularized fibular grafts used); (5) reimplantation of the autoclaved bone into the host bone defect and fixation with plates. Functional evaluation was done using MSTS scoring system. At final followup of at least 18 months (mean 29.2 months), 31 patients had recovered without any complications. Thirty-eight patients successfully achieved a solid bony union between the graft and recipient bone. Three patients had surgical site infection. They were managed with wound debridement and flap coverage of the defect. Local recurrence and nonunion occurred in two patients each. One patient underwent disarticulation at hip due to extensive local disease and one died of metastasis. For patients with non-union, revision procedure with bone graft and compression plates was successfully used. The use of autoclaved tumor grafts provides a limb salvage option that is inexpensive and independent of external resources and is a viable option for musculoskeletal tumor management in developing countries.

Van Nes rotationplasty as a treatment method for Ewing's sarcoma in a 14-month-old

INTRODUCTION

In recent years, the rotationplasty procedure has become popular amongst tumour surgeons as an alternative to endoprosthetic replacement or amputation. There are very few documented cases of this technique in young patients with malignancy.

PRESENTATION OF CASE

We describe an extremely rare case of Ewing's sarcoma in a 14-month-old boy that involved the entire length of the left femur. At initial presentation, pulmonary metastatic spread had occurred and there was no neurovascular involvement. Complete response to neo-adjuvant chemotherapy was achieved prior to performing the definitive surgical procedure.

DISCUSSION

This case highlights the many reconstructive options and difficulties encountered in managing such extremely young patients with aggressive malignant disease. In this case, a complete femoral excision was necessary and various treatment options were explored. These included irradiation and re-implantation, endoprosthetic replacement and manufacturing a custom growing prosthesis. Taking future functional, psychological and social implications into consideration, we performed a total femoral excision and Van Nes rotationplasty of the tibia at our institute. Histological analysis of the tumour resection showed clear tumour margins and at 1 year clinical review, the patient demonstrates good functional outcome with no evidence of disease recurrence.

CONCLUSION

Van Nes rotationplasty is a viable reconstructive option in young patients with sarcoma of the femur. We believe this to be the youngest reported case of rotationplasty in current literature.

Analysis of limb function after various reconstruction methods according to tumor location following resection of pediatric malignant bone tumors

Background

In the reconstruction of the affected limb in pediatric malignant bone tumors, since the loss of joint function affects limb-length discrepancy expected in the future, reconstruction methods that not only maximally preserve the joint function but also maintain good limb function are necessary. We analysis limb function of reconstruction methods by tumor location following resection of pediatric malignant bone tumors.

Patients and methods

We classified the tumors according to their location into 3 types by preoperative MRI, and evaluated reconstruction methods after wide resection, paying attention to whether the joint function could be preserved. The mean age of the patients was 10.6 years, Osteosarcoma was observed in 26 patients, Ewing's sarcoma in 3, and PNET(primitive neuroectodermal tumor) and chondrosarcoma (grade 1) in 1 each.

Results

Type I were those located in the diaphysis, and reconstruction was performed using a vascularized fibular graft(vascularized fibular graft). Type 2 were those located in contact with the epiphyseal line or within 1 cm from this line, and VFG was performed in 1, and distraction osteogenesis in 1. Type III were those extending from the diaphysis to the epiphysis beyond the epiphyseal line, and a Growing Kotz was mainly used in 10 patients. The mean functional assessment score was the highest for Type I (96%: n = 4) according to the type and for VFG (99%) according to the reconstruction method.

Conclusion

The final functional results were the most satisfactory for Types I and II according to tumor location. Biological reconstruction such as VFG and distraction osteogenesis without a prosthesis are so high score in the MSTS rating system. Therefore, considering the function of the affected limb, a limb reconstruction method allowing the maximal preservation of joint function should be selected after careful evaluation of the effects of chemotherapy and the location of the tumor.

Early posttraumatic rotationplasty after severe degloving and soft tissue avulsion injury: a case report

The case reported here describes early posttraumatic rotationplasty after severe degloving of the entire soft tissue sleeve from the left hemipelvis to the knee in an 80-year-old man who was knocked off his bicycle by a truck. During his treatment and rehabilitation, we observed severe complications (cerebrovascular accident, pneumonia, and spondylodiscitis). At the 2-year follow up, bony union of the rotationplasty osteotomy site was seen. The Enneking score was 10 points. The patient stated satisfaction with the outcome. At the last follow up, he was able to move around the house using his prosthesis and a walker and reported that he had been getting better at independent walking in the last 60 months, but for longer distances, he was still using a wheelchair.

Improvement of the soft socket after rotationplasty: a single case study

Rotationplasty is established as a functionally improving and partially ablative method of tumour surgery, but good clinical and functional results do not only depend on a successful surgery. Due to the changed biomechanical situation the activity level is limited by the weight bearing capacity of the rotated foot. Painful blisters and callosities may limit the use of the exo-prosthesis, because the skin is overstressed in the soft socket. A 28-year-old patient with a rotationplasty type A2 suffered from painful callosities of the rotated foot. Capacitive pressure measurements were performed as well as a gait analysis for kinematics and kinetic characteristics. Clinically a decrease of the callosities and a pain relieve was obvious and the patient learned skiing without prior knowledge. Biomechanically a decrease of the peak pressure (from 240.6-135.0 kPa) and the mean pressure (from 83.2-66.2 kPa), was observed with an increased weight bearing area. The study has shown that a modification of the heel bench can considerably improve pressure distribution. An increase of the load bearing area appears to enable the skin to compensate even intensive strain during athletic activities.

Osteosarcoma: the COSS experience

COSS, the interdisciplinary Cooperative German-Austrian-Swiss Osteosarcoma Study Group, was founded in 1977 and has since registered some 3,500 bone sarcoma patients from over 200 institutions. For the purpose of the Pediatric and Adolescent Osteosarcoma Conference in Houston, March 2008, the outcomes of 2,464 consecutive patients with high-grade central osteosarcoma, who had been diagnosed between 1980 and 2005 and had been treated on neoadjuvant COSS protocols, were reviewed. Intended treatment had included surgery and multidrug chemotherapy, with high-dose methotrexate, doxorubicin, cisplatin, and ifosfamide being used in most protocols. After a median follow-up of 7.31 years for 1,654 survivors, 5- and 10-year survival estimates were 0.748/0.695 for 2,017 patients with localized extremity tumors and 0.369/0.317 for 444 patients with axial tumors or/and primary metastases, respectively. Tumor response to preoperative chemotherapy was of independent prognostic significance. Over the years, there was a major shift from amputation towards limb-salvage. This development was least evident for patients below the age of 10. While survival expectancies improved from the first to the second half of the recruitment period, no further improvement was evident within the latter period. In the manuscript, the results described above are discussed based on the findings of the previous analyses of our group.

Bone tumors in adolescents and young adults

OPINION STATEMENT

Bone tumors, particularly osteosarcomas and members of the Ewing Sarcoma Family of Tumors (ESFT), are typical malignancies of adolescents and young adults. Current diagnostic and therapeutic guidelines for patients of all ages were developed in this specific age group. The aim of bone sarcoma therapy should be to cure the patient from both the primary tumor and all (micro-)metastatic deposits while maintaining as much (extremity) function and causing as few treatment-specific late effects as possible. Bone sarcoma therapy requires close multidisciplinary cooperation. Usually, it consists of induction chemotherapy, followed by local therapy of the primary tumor (and, if present, primary metastases) and further, adjuvant chemotherapy. Local treatment for osteosarcoma should be surgery whenever feasible. Surgery is also gaining importance in ESFT, which was long considered a domain of radiotherapy. Modern reconstructive techniques continue to expand the indications for limb salvage, particularly for patients who have not yet reached skeletal maturity. Treatment within the framework of prospective, multi-institutional trials should be considered standard of care not only for children, but also for affected adolescents and (young) adults. Such trials are essential in guaranteeing that all patients have access to appropriate care and that progress from biological studies can be translated into prognostic improvements without undue delay. The rarity of bone sarcomas increasingly requires trials to be multinational.

Current treatment for Ewing's sarcoma

Ewing's sarcoma is the second most common primary bone tumor seen in children and adolescents, and was described by James Ewing in 1921 as a diffuse endothelioma of bone. It is one of the differential diagnoses of pediatric small round blue cell tumors. This is not a single condition, but a group of morphologically and clinically closely related disorders with similar molecular biology -- expression of tumor-specific chimeric oncoproteins through balanced chromosomal translocations involving the EWS gene -- often referred to as the Ewing family of tumors. This includes Ewing's sarcoma of bone, extra-osseous Ewing's sarcoma, Askin tumor and peripheral neuroectodermal tumor. These are aggressive neoplasms with almost 25% of patients having clinically evident metastases at presentation. Ewing's sarcoma has therefore been considered as a systemic disease necessitating local as well as systemic treatment. An aggressive multidisciplinary approach has resulted in significant improvement in prognosis for patients with these tumors. Despite aggressive treatment, 20-40% of patients with localized disease and almost 80% of patients with metastatic disease at presentation succumb to the illness. Advances in understanding the molecular biology of these tumors will hopefully result in the development of novel treatment approaches. The aim of this article is to review the existing treatment methods and to highlight the more recent approaches to the treatment of this condition.

Allograft reconstruction for bone sarcoma of the tibia in the growing child

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing’s sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease.

Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction.

With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.