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Moses Li ML, Wong KC, Chiu WK, Kumta SM. Intermediate-term results and risk factors analysis of tumor endoprosthesis in paediatric patients after the resection of lower extremity bone sarcoma. J Orthop Surg (Hong Kong) 2022; 30:10225536221132403. [PMID: 36207771 DOI: 10.1177/10225536221132403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Mechanical failure of the endoprostheses is a concern in paediatric patients with primary bone sarcoma. Their long-term results are variable in the Asian population, thus we aim to investigate the outcome by assessing the mechanical failure, its risk factors and the functional results. METHODS We retrospectively reviewed 38 paediatric patients (mean 13.29, range 6-18) with primary bone sarcoma of lower extremity undergone chemotherapy and limb salvage surgery with tumor endoprosthesis between 2003 and 2016. All hospital notes were reviewed for any type of failures. Risk factors for implant loosening like stem size, remaining bone length, stem length, extracortical bone bridge ingrowth (EBBI), the ratio of resected bone length to whole bone length, bone stem ratio and custom-made versus modular were analyzed. The limb function was recorded by Musculoskeletal Tumor Society (MSTS) score. Median follow-up time was 7.42 years (3.0-15.4 years) and minimum follow-up for surviving patients was 2 years. RESULTS Endoprosthesis survivorship, according to Kaplan Meier was 94.7%, 85.4% and 66.2% at 2, 5 and 10 years respectively. Type II failure occurred in three patients (7.9%). Type III failure occurred in four patients (10.5%). Type IV failure occured in two patients (5.2%). Only EBBI independently predicted implant loosening (p = .007). Risk factors like stem size, remaining bone length, stem length, the ratio of resected bone length to whole bone length and custom-made versus modular were not associated with increase in implant loosening (p > .05). The mean stem size was 9.41 mm in asymptomatic group, comparable with 9.22 mm in the failure group (p = .79). The MSTS score was 29.62. CONCLUSIONS Our data suggests that paediatric Chinese patients with small body built had good and excellent mid-term results in implant survival and limb function respectively. EBBI is important in preventing loosening in tumor endoprosthesis. In contrast to the reported higher failure risk with stem size <12 mm, we found no increased loosening rate with smaller stem size endoprosthesis. LEVEL OF EVIDENCE Class III.
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Affiliation(s)
- Man Lung Moses Li
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
| | - Kwok Chuen Wong
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
| | - Wang Kei Chiu
- Department of Orthopaedics and Traumatology, 13621Prince of Wales Hospital, Hong Kong
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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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Long-term outcomes of non-invasive expandable endoprostheses for primary malignant tumors around the knee in skeletally-immature patients. Arch Orthop Trauma Surg 2022; 142:927-936. [PMID: 33417027 DOI: 10.1007/s00402-020-03712-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/06/2020] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Expandable endoprostheses are used to restore limb function and compensate for the sacrifice physis involved in carcinologic resection. Long-term outcomes of the last generation of knee "non-invasive" expandable endoprostheses are required. Objectives were to report on oncologic results of bone sarcoma resection around the knee with expandable endoprosthesis reconstruction and to compare the surgical outcomes of the "non-invasive" expandable endoprostheses used in our department. MATERIALS AND METHODS Retrospective study that included all children with bone sarcoma around the knee that underwent tumor resection reconstructed with non-invasive expandable prosthesis. Phenix-Repiphysis was used from 1994 to 2008 followed by Stanmore JTS non-invasive from 2008 to 2016. Survival and complications were recorded. Functional outcomes included Musculoskeletal Tumor Society (MSTS) score, knee range of motion, lower limb discrepancy (LLD). RESULTS Forty children (Sex Ratio = 1) aged a mean 8.8 years (range, 5.6-13.8) at surgery were included in the study. There were 36 osteosarcoma and 4 Ewing sarcoma that involved 33 distal femur and 7 proximal tibia. Cohort (n = 40) consisted of 28 Phenix-Repiphysis and 12 Stanmore with a mean follow-up of 9.8 ± 5.8 years and 6.1 ± 3.1 years, respectively. Postoperative infection rate was 7.5% in the cohort (3 Repiphysis). Functional results were significantly better in the Stanmore group with a mean MSTS of 87.6 ± 5.4% and knee flexion of 112 ± 38°. At last follow-up, implant survival was 100% in Stanmore group, whereas all living Phenix-Repiphysis were explanted. Mechanical failure was the primary cause for revision of Phenix-Repiphysis. Limb length equality was noted in 79% patients with Phenix-Repiphysis and 84% with Stanmore at last follow-up. CONCLUSION Chemotherapy and limb-salvage surgery yield good oncologic outcomes. Expandable endoprostheses are effective in maintaining satisfactory function and lower limb equality. With improvements made in the last generation of "non-invasive" prostheses, implants' survival has been substantially lengthened.
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Masrouha K, Abboud M, Saab R, Muwakkit SA, Khoury N, Haidar R, Saghieh S. Long-term follow-up of children treated with the Repiphysis expandable prosthesis for lower extremity bone sarcoma. J Pediatr Orthop B 2022; 31:e258-e263. [PMID: 34101677 DOI: 10.1097/bpb.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Expandable endoprostheses provide a limb salvage option for skeletally immature patients with bone sarcoma of the lower extremities. Initial reports of the Repiphysis prosthesis were encouraging; however, medium-term follow-up revealed high complication rates. We report on the long-term follow-up of a cohort of patients treated with the Repiphysis prosthesis. Eleven patients were included in the study. Data collected included sex, age at surgery, duration of follow-up, site of disease, histologic diagnosis, number of lengthening sessions, amount lengthened, postoperative complications, endoprosthetic failure, mode of endoprosthetic failure, duration from index surgery to failure and to revision, type of revision surgery and final limb-length discrepancy. The average duration of follow-up from the time of surgery was 180 months (range, 144-215 months). Fifteen Repiphysis implants were used in 11 patients. All implants failed with an average time from surgery to failure of 36 months (range, 3-72 months). Twenty-four complications were observed: one wound dehiscence, two deep infections, 18 mechanical failures, implant collapse with destruction of proximal tibia epiphysis in two and one periprosthetic proximal femur fracture with dislodgement of the stem. Despite being an option for limb salvage, the Repiphysis prosthesis has a high rate of mechanical failure and need for revision, similar to other expandable implants. The authors, therefore, recommend full disclosure of the potential short- and long-term complications and need for revision, as well as alternative treatment options if their use is considered. Level of evidence: IV (Therapeutic).
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Affiliation(s)
- Karim Masrouha
- Divisions of Pediatric Orthopedic Surgery and Orthopedic Oncology, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Miguel Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | - Raya Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | - Samar A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Children's Cancer Institute
| | | | - Rachid Haidar
- Division of Orthopedic surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Said Saghieh
- Division of Orthopedic surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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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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van der Heijden L, Farfalli GL, Balacó I, Alves C, Salom M, Lamo-Espinosa JM, San-Julián M, van de Sande MA. Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young. J Child Orthop 2021; 15:322-330. [PMID: 34476021 PMCID: PMC8381388 DOI: 10.1302/1863-2548.15.210095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/02/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible. METHODS We describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours. RESULTS Different resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life. CONCLUSION Several biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours. LEVEL OF EVIDENCE Level V Expert opinion.
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Affiliation(s)
- Lizz van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, the Netherlands,Correspondence should be sent to Lizz van der Heijden MD PhD, Department of Orthopaedic Surgery, Leiden University Medical Centre, Postal Zone J11-R70, P.O. Box 9600, 2300 RC Leiden, the Netherlands. E-mail:
| | - Germán L. Farfalli
- Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Inês Balacó
- Department of Pediatric Orthopedics – Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Alves
- Department of Pediatric Orthopedics – Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Marta Salom
- Department of Pediatric Orthopedics, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Mikel San-Julián
- Department of Orthopedic Surgery, Clinica Universidad de Navarra, Pamplona, Spain
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Zöllner SK, Amatruda JF, Bauer S, Collaud S, de Álava E, DuBois SG, Hardes J, Hartmann W, Kovar H, Metzler M, Shulman DS, Streitbürger A, Timmermann B, Toretsky JA, Uhlenbruch Y, Vieth V, Grünewald TGP, Dirksen U. Ewing Sarcoma-Diagnosis, Treatment, Clinical Challenges and Future Perspectives. J Clin Med 2021; 10:1685. [PMID: 33919988 PMCID: PMC8071040 DOI: 10.3390/jcm10081685] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 02/08/2023] Open
Abstract
Ewing sarcoma, a highly aggressive bone and soft-tissue cancer, is considered a prime example of the paradigms of a translocation-positive sarcoma: a genetically rather simple disease with a specific and neomorphic-potential therapeutic target, whose oncogenic role was irrefutably defined decades ago. This is a disease that by definition has micrometastatic disease at diagnosis and a dismal prognosis for patients with macrometastatic or recurrent disease. International collaborations have defined the current standard of care in prospective studies, delivering multiple cycles of systemic therapy combined with local treatment; both are associated with significant morbidity that may result in strong psychological and physical burden for survivors. Nevertheless, the combination of non-directed chemotherapeutics and ever-evolving local modalities nowadays achieve a realistic chance of cure for the majority of patients with Ewing sarcoma. In this review, we focus on the current standard of diagnosis and treatment while attempting to answer some of the most pressing questions in clinical practice. In addition, this review provides scientific answers to clinical phenomena and occasionally defines the resulting translational studies needed to overcome the hurdle of treatment-associated morbidities and, most importantly, non-survival.
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Affiliation(s)
- Stefan K. Zöllner
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
| | - James F. Amatruda
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA;
| | - Sebastian Bauer
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Medical Oncology, Sarcoma Center, University Hospital Essen, 45147 Essen, Germany
| | - Stéphane Collaud
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Thoracic Surgery, Ruhrlandklinik, University of Essen-Duisburg, 45239 Essen, Germany
| | - Enrique de Álava
- Institute of Biomedicine of Sevilla (IbiS), Virgen del Rocio University Hospital, CSIC, University of Sevilla, CIBERONC, 41013 Seville, Spain;
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, 41009 Seville, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Jendrik Hardes
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Wolfgang Hartmann
- Division of Translational Pathology, Gerhard-Domagk Institute of Pathology, University Hospital Münster, 48149 Münster, Germany;
- West German Cancer Center (WTZ), Network Partner Site, University Hospital Münster, 48149 Münster, Germany
| | - Heinrich Kovar
- St. Anna Children’s Cancer Research Institute and Medical University Vienna, 1090 Vienna, Austria;
| | - Markus Metzler
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - David S. Shulman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02215, USA; (S.G.D.); (D.S.S.)
| | - Arne Streitbürger
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Musculoskeletal Oncology, Sarcoma Center, 45147 Essen, Germany
| | - Beate Timmermann
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre, 45147 Essen, Germany
| | - Jeffrey A. Toretsky
- Departments of Oncology and Pediatrics, Georgetown University, Washington, DC 20057, USA;
| | - Yasmin Uhlenbruch
- St. Josefs Hospital Bochum, University Hospital, 44791 Bochum, Germany;
| | - Volker Vieth
- Department of Radiology, Klinikum Ibbenbüren, 49477 Ibbenbühren, Germany;
| | - Thomas G. P. Grünewald
- Division of Translational Pediatric Sarcoma Research, Hopp-Children’s Cancer Center Heidelberg (KiTZ), 69120 Heidelberg, Germany;
- Division of Translational Pediatric Sarcoma Research, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Core Center, 69120 Heidelberg, Germany
| | - Uta Dirksen
- Pediatrics III, University Hospital Essen, 45147 Essen, Germany;
- West German Cancer Center (WTZ), University Hospital Essen, 45147 Essen, Germany; (S.B.); (S.C.); (J.H.); (A.S.); (B.T.)
- German Cancer Consortium (DKTK), Essen/Düsseldorf, University Hospital Essen, 45147 Essen, Germany
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Surgical Advances in Osteosarcoma. Cancers (Basel) 2021; 13:cancers13030388. [PMID: 33494243 PMCID: PMC7864509 DOI: 10.3390/cancers13030388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Osteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development. Abstract Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.
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9
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Staals EL, Sambri A, Campanacci DA, Muratori F, Leithner A, Gilg MM, Gortzak Y, Van De Sande M, Dierselhuis E, Mascard E, Windhager R, Funovics P, Schinhan M, Vyrva O, Sys G, Bolshakov N, Aston W, Gikas P, Schubert T, Jeys L, Abudu A, Manfrini M, Donati DM. Expandable distal femur megaprosthesis: A European Musculoskeletal Oncology Society study on 299 cases. J Surg Oncol 2020; 122:760-765. [PMID: 32506533 DOI: 10.1002/jso.26060] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 04/25/2020] [Accepted: 05/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Expandable distal femur prostheses have become more popular over the last decades, but scientific data is limited. METHODS A retrospective study was performed, including cases treated between 1986 and 2019 in 15 European referral centers for bone sarcomas. RESULTS A total of 299 cases were included. Average follow-up was 80 months (range, 8-287 months). Mean patient age was 10 years. Most (80%) of the implants were noninvasive growers and a fixed hinge knee was used more often (64%) than a rotating hinge. Most prosthetic designs showed good (>80%) implant survival at 10 years, but repeat surgery was required for 63% of the patients. The most frequent reason for revision procedure was the completion of lengthening potential. Noninvasive expandable implants showed less risk of infection compared to invasive growers (11.8% vs 22.9% at 10 years). No difference in aseptic loosening was found between cemented and uncemented stems. CONCLUSIONS This study shows the increasing popularity of expandable distal femur prostheses, with overall good results for function and implant survival. However, repeat surgery is frequently required, especially in patients under the age of 10 years old. Infection is less frequent in noninvasive growers compared to implants that require invasive lengthening procedures.
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Affiliation(s)
| | - Andrea Sambri
- Orthopedic Surgery, AOSP Sant'Orsola-Malpighi, Bologna, Italy
| | | | - Francesco Muratori
- Orthopedic Surgery, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | | | | | - Yair Gortzak
- Orthopedic Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | | | | | - Eric Mascard
- Orthopedic Surgery, hôpital-Necker, Paris, France
| | | | | | | | - Oleg Vyrva
- Orthopedic Surgery, Sytenko Institute of Spine and Joint Pathology, Kharkiv, Ukraine
| | - Gwen Sys
- Orthopedic Surgery, Universitai Ziekenhuis Gent, Gent, Belgium
| | - Nikolay Bolshakov
- Orthopedic Surgery, National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Will Aston
- Orthopedic Surgery, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Panagiotas Gikas
- Orthopedic Surgery, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Thomas Schubert
- Orthopedic Surgery, Clinic Universitaires Saint-Luc, Brussels, Belgium
| | - Lee Jeys
- Orthopedic Surgery, Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Adesegun Abudu
- Orthopedic Surgery, Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Marco Manfrini
- Orthopedic Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Outcomes of Expandable Prostheses for Primary Bone Malignancies in Skeletally Immature Patients: A Systematic Review and Pooled Data Analysis. J Pediatr Orthop 2020; 40:e487-e497. [PMID: 32501921 DOI: 10.1097/bpo.0000000000001459] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies. RESULTS A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004). CONCLUSIONS Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies. LEVEL OF EVIDENCE Level IV-retrospective case series with pooled data.
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11
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How is the outcome of the Limb Preservation System™ for reconstruction of hip and knee? Orthop Traumatol Surg Res 2020; 106:409-415. [PMID: 31864962 DOI: 10.1016/j.otsr.2019.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite tremendous advantages in the development and application of megaprostheses in tumour and revision surgery, complications are still not infrequently observed. Only two studies investigating the outcome of the LPS™ system in the proximal femur and distal femur/proximal tibia have been published thus far. Herein, mid-term implant survival rates one of the largest cohort of patients treated with the LPS™-system are presented aiming tp answer: 1) How is the outcome of the LPS™ system in the proximal femur and distal femur/proximal tibia? 2) Which factors are associated with altered implant survival? 3) What is the cumulative risk of complications according to Henderson? HYPOTHESIS The LPS™-system is associated with high complication rates that depend on implant site, with infections being most common. PATIENTS AND METHODS Fifty-seven patients who received the LPS™-system at the proximal femur (n=31), distal femur (n=21) and proximal tibia (n=5) between 2004 and 2010 for oncological (n=40) or non-oncological (n=17) causes, were retrospectively included. Median follow-up was 5.0 years (range, 0-12.4 years). Complications were classified according to Henderson into instability/soft tissue failure (type 1), aseptic loosening (type 2), structural failure (type 3), periprosthetic infection (type 4), tumour progression (type 5). Competing-risk-analyses were applied to estimate implant survival with death as the competing event. RESULTS Twenty-six patients (45.6%) developed a complication, of whom 9 (29.0%) had a proximal femoral and 17 (65.4%) a distal femoral/proximal tibial implant. Type 4 complications were most common (n=11), followed by type 3 (n=6, including 2 yoke-fractures), type 1 and 2 (n=4 each), and type 5 (n=1). The only factor associated with the development of complications in the multivariate model was a distal femoral/proximal tibial implant (hazard-ratio: 7.418, 95% confidence-interval: 2.193-26.096, p=0.001), irrespective of reason for reconstruction and use of muscular flaps. The cumulative-incidence of failure including all complications was 34.3%, 40.7% and 67.1% at 3, 5 and 10 years, respectively. DISCUSSION The LPS™-system may be used for proximal femoral reconstructions both in the oncological and non-oncological setting. Rates of complications are higher in our cohort than reported in literature for other, comparable, megaprosthesis systems. Especially in the distal femur/proximal tibia, complication rates were high, partially attributable to the former implant design leading to fractures of the yoke-mechanism. As the implant has been remodelled after these issues became evident, there is no objection to use this megaprosthesis system today. LEVEL OF EVIDENCE IV, Observational Study.
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Coathup MJ, Ahmad S, Maempel JF, Briggs TW, Aston WJ, Skinner JA, Blunn GW. Non-invasive massive growing prostheses reduce infection in paediatric cancer patients. J Orthop Surg (Hong Kong) 2020; 27:2309499019833403. [PMID: 30827180 DOI: 10.1177/2309499019833403] [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] [Indexed: 11/15/2022] Open
Abstract
PURPOSE In this study, we asked the question of whether non-invasive (NI) extendible bone tumour implants are as reliable and reduce infection when compared with patients who received a minimally invasive (MI) extendible implant. METHODS Forty-two NI extendible bone tumour implants were investigated at a mean follow-up of 22 months (range, 1-87 months) and 63 MI implants at a mean follow-up of 49 months (range, 1-156 months). RESULTS Kaplan-Meier analysis showed that the probability of MI implant survival was 58.8% compared with 78.6% in NI patients. No significant difference between these two patient groups was found. Infection was the main reason for failure in the MI implant group where nine (35%) implants were revised. However, only one (11%) NI implant was revised for infection ( p = 0.042). None of the NI implants failed due to aseptic loosening; however, six (23%) MI implants were revised for aseptic loosening of the intramedullary stem. Four (15%) of the failed MI implants were revised due to full extension and five (56%) of failed NI implants were replaced as the implant had been fully extended where the patient still required growth. CONCLUSION Where possible, an NI massive prosthesis should be used in this patient group. Our results suggest that MI prostheses should be infrequently used due to the high incidence of infection. Lengthening of NI prostheses is painless, can be carried out in the clinic and is more cost-effective. However, further work is required to increase the amount of growth potential available in these implants.
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Affiliation(s)
- Melanie Jean Coathup
- 1 Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, The Royal National Orthopaedic Hospital, Middlesex, UK
| | - Samee Ahmad
- 1 Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, The Royal National Orthopaedic Hospital, Middlesex, UK
| | - Julian F Maempel
- 2 Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | - Gordon W Blunn
- 1 Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, The Royal National Orthopaedic Hospital, Middlesex, UK
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Tsuda Y, Fujiwara T, Stevenson JD, Parry MC, Tillman R, Abudu A. The long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Bone Joint J 2020; 102-B:64-71. [DOI: 10.1302/0301-620x.102b12.bjj-2020-0124.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Methods A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11). Results The median follow-up time was 10.6 years (IQR 3.9 to 20.4). The overall implant survival at ten years was 75%. Complications occurred in 13 patients (37%). Subluxation at the proximal humerus occurred in 19 patients (54%) but only six (17%) were symptomatic. Subluxation was seen more commonly in children under the age of nine years (86%) than in those aged nine years or more (33%) (p = 0.002). Implant failure occurred in nine patients (26%): the most common cause was aseptic loosening (four patients, 11%). Lengthening of the implant was carried out in 23 patients (66%). At final follow up, three patients had a limb that was shortened by 5 cm or more. The mean Musculoskeletal Tumor Society (MSTS) functional score was 79% (73% to 90%). Conclusion Extendable endoprosthetic replacement is a reliable method of reconstructing humerus after excision of a bone sarcoma. Children who are less than nine years old have a high risk of subluxation. Cite this article: Bone Joint J 2020;102-B(1):64–71
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Affiliation(s)
- Yusuke Tsuda
- Oncology Department, Royal Orthopaedic Hospital, Birmingham, UK
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Abstract
BACKGROUND The majority of osteoarticular defects after tumor resection in adolescent and adult patients are reconstructed using megaendoprosthetic implants. However, even infant and pre-teen children undergo reconstruction of defects using so-called growing prostheses with an increasing frequency. OBJECTIVES Presentation of current techniques, outcomes and the most common complications of megaendoprosthetic reconstruction following tumour resection. METHODS Selective literature review and discussion of current concepts and knowledge in megaendoprosthetic reconstruction against personal experience and treatment strategies. RESULTS Megaendoprosthetic reconstructions achieve good functional results and long-term limb salvage (ca. 90% of cases) in adolescent and adult patients. Still, periprosthetic infection and mechanical failure of joint components are among the most common complications observed. In infant and pre-teen children treated by reconstruction using a growing prosthesis, mandatory maintenance operations-in the process of elongating the implant-must also be considered when assessing complication risks. CONCLUSIONS Megaendoprosthetic reconstructions of osteoarticular defects are a standard procedure in adolescent and adult patients. Despite a substantial complication rate, limb salvage is achieved in a majority of patients. When using growing prostheses in younger children, one needs to be aware of additional servicing procedures that occur independently of those arising from complications.
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Abstract
Tumour endoprostheses have facilitated limb-salvage procedures in primary bone and soft tissue sarcomas, and are increasingly being used in symptomatic metastases of the long bones. The objective of the present review was to analyse articles published over the last three years on tumour endoprostheses and to summarize current knowledge on this topic. The NCBI PubMed webpage was used to identify original articles published between January 2015 and April 2018 in journals with an impact factor in the top 25.9% of the respective category (orthopaedics, multidisciplinary sciences). The following search-terms were used: tumour endoprosthesis, advances tumour endoprosthesis, tumour megaprosthesis, prosthetic reconstruction AND tumour. We identified 347 original articles, of which 53 complied with the abovementioned criteria. Articles were categorized into (1) tumour endoprostheses in the shoulder girdle, (2) tumour endoprostheses in the proximal femur, (3) tumour endoprostheses of the knee region, (4) tumour endoprostheses in the pelvis, (5) (expandable) prostheses in children and (6) long-term results of tumour endoprostheses. The topics of interest covered by the selected studies largely matched with the main research questions stated at a consensus meeting, with survival outcome of orthopaedic implants being the most commonly raised research question. As many studies reported on the risk of deep infections, research in the future should also focus on potential preventive methods in endoprosthetic tumour reconstruction.
Cite this article: EFORT Open Rev 2019;4:445-459. DOI: 10.1302/2058-5241.4.180081
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Affiliation(s)
- Maria A Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
| | - Dimosthenis Andreou
- Department of General Orthopaedics and Tumour Orthopaedics, University Hospital Muenster, Germany
| | - Per-Ulf Tunn
- Tumour Orthopaedics, HELIOS Klinikum Berlin-Buch, Germany
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
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Windhager R, Funovics P, Panotopoulos J, Hobusch G, Schinhan M. [Growing prostheses after sarcoma resection in children and adolescents]. DER ORTHOPADE 2019; 48:563-571. [PMID: 31123758 DOI: 10.1007/s00132-019-03753-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Growing prostheses are regarded as a valuable alternative to amputation and rotationplasty for the treatment of primary malignant bone and soft-tissue sarcomas in childhood. During the last three decades different devices have been introduced and technically improved from invasively to non-invasively extendable prostheses. THE CURRENT SITUATION OF STUDIES Despite the long period, only 21 peer-reviewed publications could be detected containing relevant numbers and results. In these papers, 590 patients with mean follow-up times of 81.1 months were reported who had been fitted with growing prostheses at the age of 12.6 years. Besides satisfactory functional results (78.3 out of 100 MSTS points) there was a high complication rate of 27.3% infections and 22.4% mechanical failure. COMPLICATIONS This increasing risk of infection over a long follow-up period, represents the biggest drawback of this method and, therefore, needs to be discussed extensively with the patients and parents when considering this procedure as an alternative to ablative surgery.
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Affiliation(s)
- R Windhager
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - P Funovics
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - J Panotopoulos
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - G Hobusch
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - M Schinhan
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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Sambri A, Staals E, Medellin MR, Abudu A, Gikas P, Pollock R, Briggs TWR, Donati DM, Manfrini M. Stanmore noninvasive extendible endoprosthesis in the treatment of bone sarcoma in the preadolescent. J Surg Oncol 2019; 120:176-182. [DOI: 10.1002/jso.25501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/03/2019] [Accepted: 04/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Sambri
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
| | - Eric Staals
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
| | - Manuel Ricardo Medellin
- Orthopedic OncologyRoyal Orthopaedic Hospital NHS TrustBirmingham UK
- Orthopedic OncologyInstituto Nacional de CancerologiaBogotà Colombia
| | - Adesegun Abudu
- Orthopedic OncologyRoyal Orthopaedic Hospital NHS TrustBirmingham UK
| | - Panagiotis Gikas
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | - Rob Pollock
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | - Tim WR Briggs
- Orthopedic OncologyRoyal National Orthopaedic Hospital NHS TrustLondon UK
| | | | - Marco Manfrini
- Orthopedic OncologyIRCCS Istituto Ortopedico RizzoliBologna Italy
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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: 27] [Impact Index Per Article: 5.4] [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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Medellin MR, Fujiwara T, Clark R, Jeys LM. Comparison of minimally invasive and non-invasive systems in lengthening total femoral prostheses. Bone Joint J 2018; 100-B:1640-1646. [DOI: 10.1302/0301-620x.100b12.bjj-2018-0135.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to describe, analyze, and compare the survival, functional outcome, and complications of minimally invasive (MI) and non-invasive (NI) lengthening total femoral prostheses. Patients and Methods A total of 24 lengthening total femoral prostheses, 11 MI and 13 NI, were implanted between 1991 and 2016. The characteristics, complications, and functional results were recorded. There were ten female patients and ten male patients. Their mean age at the time of surgery was 11 years (2 to 41). The mean follow-up was 13.2 years (seven months to 29.25 years). A survival analysis was performed, and the failures were classified according to the Modified Henderson System. Results The overall implant survival was 79% at five, ten, and 20 years for MI prostheses, and 84% at five years and 70% at ten years for NI prostheses. At the final follow-up, 13 prostheses did not require further surgery. The overall complication rate was 46%. The mean revision-free implant survival for MI and NI prostheses was 59 months and 49 months, respectively. There were no statistically significant differences in the overall implant survival, revision-free survival, or the distribution of complications between the two types of prosthesis. Infection rates were also comparable in the groups (9% vs 7%; p = 0.902). The rate of leg-length discrepancy was 54% in MI prostheses and 23% in NI prostheses. In those with a MI prosthesis, there was a smaller mean range of movement of the knee (0° to 62° vs 0° to 83°; p = 0.047), the flexion contracture took a longer mean time to resolve after lengthening (3.3 months vs 1.07 months; p < 0.001) and there was a lower mean Musculoskeletal Tumor Society (MSTS) score (24.7 vs 27; p = 0.295). Conclusion The survival and complications of MI and NI lengthening total femoral prostheses are comparable. However, patients with NI prosthesis have more accurate correction of leg-length discrepancy, a better range of movement of the knee and an improved overall function.
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Affiliation(s)
- M. R. Medellin
- Consultant in Orthopaedic Oncology and Reconstructive Surgery, Royal Orthopaedic Hospital, Birmingham, UK
| | - T. Fujiwara
- Consultant in Orthopaedic Oncology and Reconstructive Surgery, Royal Orthopaedic Hospital, Birmingham, UK
| | - R. Clark
- Consultant in Orthopaedic Oncology and Reconstructive Surgery, Royal Orthopaedic Hospital, Birmingham, UK
| | - L. M. Jeys
- Consultant in Orthopaedic Oncology and Reconstructive Surgery, Royal Orthopaedic Hospital, Birmingham, UK
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Tsagozis P, Parry M, Grimer R. High complication rate after extendible endoprosthetic replacement of the proximal tibia: a retrospective study of 42 consecutive children. Acta Orthop 2018; 89:678-682. [PMID: 30371124 PMCID: PMC6300744 DOI: 10.1080/17453674.2018.1534320] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The long-term outcome of reconstruction with extendible prostheses after resection of tumors the proximal tibia in children is unknown. We investigated the functional outcome, complication rate and final limb salvage rate after this procedure. Patients and methods - 42 children who had a primary extendible replacement of the proximal tibia for bone tumor with a Stanmore implant between 1992 and 2013 were identified in the department's database. All notes were reviewed to identify the oncological and functional outcomes, the incidence of complications and the rate of amputation. 20 children were alive at final follow-up. Median follow-up time was 6 years and minimum follow-up for surviving patients was 3 years. Results - The overall limb salvage rate was 35/42; amputation was needed in 7 children. 15 implants were revised with a new implant. The Musculoskeletal Tumor Society Score was 73% (40-93) at final follow-up. The overall complication rate was 32/42. Soft tissue problems were the most common mode of complication, noted in 15 children, whereas structural failure and infection occurred in 12 children each. Use of prostheses with non-invasive lengthening was associated with a higher infection rate as compared with conventional ones (4/6 vs. 8/36) and inferior limb survival. Interpretation - Extendible replacements of the proximal tibia allow for limb salvage and satisfactory late functional outcome but have a high rate of complications. The use of non-invasive lengthening implants has not shown any benefit compared with conventional designs and is, rather, associated with higher risk for infection and amputation.
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Affiliation(s)
- Panagiotis Tsagozis
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham, UK; ,Department of Orthopaedic Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden,Correspondence:
| | - Michael Parry
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham, UK;
| | - Robert Grimer
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham, UK;
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Gilg MM, Gaston CL, Jeys L, Abudu A, Tillman RM, Stevenson JD, Grimer RJ, Parry MC. The use of a non-invasive extendable prosthesis at the time of revision arthroplasty. Bone Joint J 2018; 100-B:370-377. [PMID: 29589498 DOI: 10.1302/0301-620x.100b3.bjj-2017-0651.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. Patients and Methods All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). Results The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Conclusion Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370-7.
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Affiliation(s)
- M M Gilg
- Department of Orthopedic Surgery and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - C L Gaston
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK and The Department of Orthopedics, Philippine General Hospital, Manila Taft Avenue, Manila, 1000, Philippines
| | - L Jeys
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - A Abudu
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - R M Tillman
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - J D Stevenson
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - R J Grimer
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
| | - M C Parry
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, B31 2AP, United Kingdom
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Lipshultz ER, Holt GE, Ramasamy R, Yechieli R, Lipshultz SE. Fertility, Cardiac, and Orthopedic Challenges in Survivors of Adult and Childhood Sarcoma. Am Soc Clin Oncol Educ Book 2017; 37:799-806. [PMID: 28561655 DOI: 10.1200/edbk_174708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The combination of cisplatin, doxorubicin, and methotrexate was established as the standard backbone of contemporary osteosarcoma therapy in 1986. Since then, however, further improving the survival of patients with osteosarcoma has been challenging-30% to 40% of patients with osteosarcoma still die of this disease. In addition, these patients often experience loss of fertility at a young age, short- and long-term treatment-related cardiotoxicity, and adverse orthopedic effects from surgical resection of the tumor or endoprosthetic reconstructions. Cancer treatment often markedly increases the risk of infertility later in life, causing many patients substantial distress and regret. Sperm banking and oocyte cryopreservation are standard of care and should be available to all at-risk patients. Newer techniques, such as autologous gonadal tissue transplant for prepubertal children, are being developed, and newer systemic agents have infertility risk profiles that remain undefined and warrant further study. Cost and access remain barriers to these options. The late effects of anthracycline-induced cardiotoxicity are also increasingly a problem for these patients. These effects are often progressive and can be disabling. Adding dexrazoxane to doxorubicin therapy significantly reduces the risk for most adverse cardiac outcomes without compromising the efficacy of induction chemotherapy. Limb salvage surgery remains the standard of care for treatment in the majority of patients with extremity sarcomas. Modular metal prostheses and allograft reconstructions comprised the majority of surgical procedures for limb salvage surgery. The most common mechanism of failure of these implants is infection and mechanical failure of the implant.
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Affiliation(s)
- Emma R Lipshultz
- From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center, Nashville, TN; University of Miami Miller School of Medicine, Miami, FL; Wayne State University, Children's Hospital of Michigan, Karmanos Cancer Institute, Detroit, MI
| | - Ginger E Holt
- From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center, Nashville, TN; University of Miami Miller School of Medicine, Miami, FL; Wayne State University, Children's Hospital of Michigan, Karmanos Cancer Institute, Detroit, MI
| | - Ranjith Ramasamy
- From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center, Nashville, TN; University of Miami Miller School of Medicine, Miami, FL; Wayne State University, Children's Hospital of Michigan, Karmanos Cancer Institute, Detroit, MI
| | - Raphael Yechieli
- From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center, Nashville, TN; University of Miami Miller School of Medicine, Miami, FL; Wayne State University, Children's Hospital of Michigan, Karmanos Cancer Institute, Detroit, MI
| | - Steven E Lipshultz
- From the Dana-Farber Cancer Institute, Boston, MA; Vanderbilt-Ingram Cancer Center, Nashville, TN; University of Miami Miller School of Medicine, Miami, FL; Wayne State University, Children's Hospital of Michigan, Karmanos Cancer Institute, Detroit, MI
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Bergovec M, Friesenbichler J, Scheipl S, Gilg MM, Leithner A. Extremitätenerhaltende Chirurgie bei Tumoren im Kindesalter. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0324-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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