Objective To study the clinical feasibility of the prosthetic composites of the intercalary allograft and the segmental allograft in reconstruction of the skeletal defect after the limb tumor resection. Methods Between August 1999 and December 2003, 28 patients with skeletal defects after the limb tumor resection were treated with the intercalary allograft or the segmental allograft megaprosthesis composite for reconstruction of skeletal defects. The bone involvements were observed in 16 patients with osteosarcoma, 4 patients with parosteal osteosarcoma, 5 patients with Ewing sarcoma, and 3 patients with soft tissuesarcoma. Preoperative biopsy was performed on all the patients, and the pathological result was confirmed after surgery. According to the Enneking system, 5 patients were grouped in ⅠB and 23 patients in ⅡB. The patients with osteosarcomaor Ewing sarcoma received the standard chemotherapy before and after operation.Eighteen and ten patients received the segmental allograft prosthetic compositereplacement and the intercalary allograft with the interlocking intramedullary nail fixation, respectively. The functional outcome was evaluated by the MSTS score. Results According to the follow-up for 5-48 months (average, 24 months), local recurrence was observed in 1 patient who underwent amputation eventually. Of the 28 patients, 3 developed nonunion of the allografthost junction accompanied by severe resorption and 2 developed deep infection. No allograft fracture was seen in the patients. Most of the patients achieved a good functional result with an average MSTS score of 23.4. ConclusionThe prosthetic composite replacement of the intercalary allograft and the segamental allograft can be used n the skeletal defect reconstruction after the limb tumor resection. The stablecontact in the allografthost junction and the b intramedullary internal fixation can help to reduce the complication rate of the allograft.
Objective To investigate the effect of limb salvage on treating osteosarcoma with pathological fracture. Methods From October 2002 to January 2003, 2 cases of osteosarcoma with pathological fracture were treated by limb salvage. Intraarterial chemotherapy was given by subcutaneous implantable delivery system with caffeine. Replacement with prosthesis was performed after 5 times of chemotherapy. Results Two patients were followed up for twenty-four months and 21 months respectively. No infection, aseptic loosening, local recurrence or metastasis occurred, and function recovery of joints was satisfactory. Conclusion Limb salvage can be considered in condition that primary osteosarcoma with pathological fracture can be treated by effective and comprehensive chemotherapy.
Objective To probe a satisfactory surgical management of the limbsalvage for osteogenic malignant tumors around the knees. Methods From January1989 to December 2001, 42 patients (19 males and 18 females, aged 12-46) with osteogenic malignant tumors around the knees underwent surgical management of the limb salvage, including prosthesis replacement, allogenous bone grafting, and bone cement with adriamycin filled. Based on the pathological examination, osteosarcoma was found in 11 patients, synoviosarcoma in 4 patients, malignant fibrous histiocytoma in 3 patients, and giant cell tumor of the bone in 19 patients. All the patients underwent neoadjuvant chemotherapy for 1-2 courses before operatioexcept the patients with giant cell tumor of the bone. The patients underwent prosthesis replacement, allogenous bone grafting, bone cement with adriamycin filled, and postoperative chemotherapy. By the Enneking evaluating system, the patients were assessed on their reconstructed limb functions after the reconstructive operation for the musculoskeleta malignant tumors. Of the patients, 37 were followed up after operation. Results According to the follow-up for 3-11 years (mean, 5.6 years) in the 37 patients, 2 patients had recurrence and metastasis of the tumor, and died 3 and 4 years after operation, respectively. One patient underwent amputation of the limb for local recurrence of the tumor. One patient had amputation of the limb for the preoperative radiotherapy and the infection and necrosis of the operative wound after the limb-salvage surgery. Two patients had amputation of the limb for the rejection of the allogenous bone graft and theformation of the fistula.Thirty-one patients had good wound healing andgood functions of the limb. The results were evaluated by the Enneking evaluating system as follows: excellent in 7 patients, good in 14, fair in 10, and poor in 6. Conclusion Making an early diagnosis, recognizing the operative indication, choosing the operative method, and performing the preoperative and postoperative chemotherapy and/or radiotherapy are the keys to achieving an ideal limb-salvage surgery for osteogenic malignant tumors around the knees.
ObjectiveTo investigate the effects of fibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery. MethodsBetween July 1999 and March 2013, 76 patients with neoplasms of the proximal tibia underwent tumor resection, prosthetic replacement, and gastrocnemius medial head flap transfer. Among them, 38 patients underwent fibular head resection (group A) and 38 underwent fibular head preservation (group B). There was no significant difference in gender, age, side, tumor classification and stage, and disease duration between 2 groups (P>0.05). The complications and the position of the components were observed, and American society for bone tumors scoring system (MSTS93) was used to evaluate the joint function. ResultsAll patients were followed up 12-150 months (mean, 87 months). Incision infection occurred in 1 patient (2.63%) of group A and 6 patients (15.79%) of group B, showing significant difference (χ2=3.934, P=0.047). Necrosis of gastrocnemius medial head flap was found in 1 patient of group A and 2 patients of group B. Prosthetic loosening and instability of the knee were observed in 4 and 2 cases of group A and in 6 and 4 cases of group B, respectively. In groups A and B, there were 3 and 5 cases of local recurrence, 7 and 6 cases of distant metastasis, and 8 and 7 deaths, respectively. According to MSTS93, the results were excellent in 23 cases, good in 10 cases, fair in 3 cases, and poor in 2 cases, with an excellent and good rate of 86.84% in group A; the results were excellent in 21 cases, good in 11 cases, fair in 3 cases, and poor in 3 cases, with an excellent and good rate of 84.21% in group B; and no significant difference was found in the excellent and good rate between 2 groups (χ2=0.106, P=0.744). ConclusionFibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery is beneficial to intra-operative tissue coverage, and it can reduce trauma by skin transplantation and related complications. Good stability and motion of the joint can be obtained after operation.
Objective To investigate the effect of the semi-joint prosthesis replacement in treating malignant tumors around the children’s knees. Methods Five children (aged 8-12 years) with malignant tumors around the proximal end ofthe tibia underwent the semi-joint prostheses replacement from March 2000 to June 2005. All the children had been diagnosed with osteosarcoma, which was graded as ⅡB by the Enneking staging system. The pathologic changes involved the upper segment of the tibia 9-11 cm in length. Before operation all the patients underwent puncture biopsy and standard chemotherapy. The lesion extent was determined by X-ray, CT and MRI, and then the size of the prosthesis was determined. The length of the prosthesis was 1-2 cm longer than that of the excised bone. After operation the patients were given neoadjuvant chemotherapy for 2 courses and they could walk with the help of a special brace 4 weeks postoperatively. Results All the 5 patients had a successful semi-joint prosthesis replacement exceptone patient who had a skin flap necrosis, and the wound healed after a flap grafting. The remaining patients had their wounds healed by first intention. The12-36 months’ follow-up revealed that all the patients had no metastasis or recurrence of the tumor and they were living and well except one patient who died oflung metastasis 8 months after operation. Conclusion The semi-joint prosthesis replacement in the limb salvage surgery for maligant tumors around the children’s knees has advantages of avoiding a damage to the normal osteoepiphysis, stabilizing the knee joint, and facilitating elongation of the limb in future. Italso creates the condition for total knee replacement in adults.
Objective To summarize and analyze the clinical experience and theclinical outcome of treating tumorous diseases in the proximal femur by the customized hip arthroplasty. Methods Eleven patients (7 males and4 females, aged 40-69 years) with a tumorous disease in the proximal femur received a removal ofthe proximal femur and the customized hip arthroplasty from February 1994 to November 2002. Of the 11 patients, 7 had giant cell tumor in the proximal femur, 2 had chondroblastoma, 1 had osteitis deformans, and 1 had fibrous dysplasia. Six patients received the artificial total hip replacement and 5 underwent the dipolar-cup artificial femoral head prosthesis replacement. Results The follow-upfor 1-5 years in 9 patients (2 patients lost the follow-up) revealed that afteroperation one patient with hemorrhage from the incision had been given a local compression for 5 days, and finally lost the function of the quadriceps muscle and had sensory deprivation in the anterior part of the thigh. Five years later, the patient had a quadriceps muscle power of the “0” degree, a decreased sensation, the “3” degree of the hamstring and the extension and flexion muscles of the lower limb, with lameness and crutch walking. The quadriceps muscle powertest showed that 5 patients had the “3” degree of the muscle power and 2 of them had paroxysms of pain in the upper part of the thigh, especially after a long time of standing and walking, so both of them received the dipolar-cup artificial femoral head prosthesis replacement. Three patients had the “4” degree of the quadriceps muscle power, with an extension range of the hip joint of 10°27° and an average flexion degree of 74°. According to the Harris scale, 3 patientswere assessed to be good (8089), 5 moderate (70-79), but 1 bad (lt;70). No infection, recurrence or the loosening of the prosthesis was found in all the patients during the follow-up. Conclusion The customized hip arthroplasty has a goodclinical outcome in treatment of a tumorous disease in the proximal femur. However, there is a high incidence of deficiency of the quadriceps muscle power after operation, which may be relevant to the removal of the upper attachment of the quadriceps muscle. If the attachment of the quadriceps muscle, especially the internal, external and posterior septum attachment, can be fixed in the body of the prosthesis during operation, the power of the quadriceps muscle can be enhanced and the patient can have a better therapeutic effect.
ObjectiveTo investigate the causes of the complications and prevention strategy by analyzing occurrence of prosthesis-related complications after extensible semi-joint prosthesis replacement for lower limbs osteosarcoma in children. MethodsEleven children with lower limbs osteosarcoma underwent resection of tumor and replacement of the extensible semi-joint prosthesis between May 2006 and October 2012. There were 6 boys and 5 girls, with an average age of 9.3 years (range, 7-12 years). The lesions located at the distal femur in 6 cases, at the proximal femur in 2 cases, and at the proximal tibia in 3 cases. The disease duration was 2-8 months (mean, 3.6 months). According to the Enneking stage, 3 cases were rated as stage ⅡA and 8 cases as stage ⅡB. The pulmonary CT and ECT results showed no pulmonary metastasis or multi spots before operation. All patients received preoperative chemotherapy treatment for 4 times. ResultsPrimary healing of incision was obtained in 10 cases. Infection occurred in 1 case at 1 week after operation, and was cured after symptomatic treatment. Nine patients received postoperative chemotherapy for 12 times, 2 patients for 2 times and 4 times respectively. One case died of multiple metastasis; in 3 cases of pulmonary metastasis, 2 cases died and 1 case survived after resection of metastatic lesion. Eight survival cases received a follow-up of 25-89 months (mean, 42.5 months). Loosening and dislocation of the proximal femoral prosthesis occurred in 1 case, loosening and subsidence of the distal femoral prosthesis in 1 case, subluxation in 1 case, and retraction in 1 case. The incidence of prosthesis-related complications was 50%. Lengthening operation was performed on 3 cases for 1 time, and on 1 case for 2 times. And 4 cases did not undergo lengthening operation. According to Enneking function evaluation standard after malignant tumor limb-salvage surgery, the results were excellent in 1 case, good in 3, fair in 3, and poor in 1 at last follow-up with an excellent and good rate of 50%. ConclusionThe prosthesis-related complications include loosening and subsidence, dislocation, knee instability, and retraction after extensible semi-joint prosthesis replacement for lower limbs osteosarcoma. The prosthesis-related complications can be reduced by the improvement of prosthesis design and manufacture, and the use of intraoperative bone cement, artificial mesh, and postoperative restrictive brace.
OBJECTIVE To analyze the indications for revision surgery after limb salvage procedure of malignant bone tumor and summarize the experiences in revision surgery. METHODS From January 1994 to December 1997, 8 cases were re-operated after primary limb salvage procedure. The average survival period with no-tumor occurrence was 8 years. The common causes for the revision were traumatic osteoarthritis, fracture, and bone resorption. The main difficulties in revision were soft tissue contracture and limb discrepancy from limb shortening. RESULTS In this study, there was total hip replacement in 1 case, large segmental allograft for reconstruction of distal femur in 3 cases, total knee replacement upon composite of previously transplanted allograft in 3 cases, removing of intramedullary nail and re-internally fixed with intramedullary nail in 1 cases. The isotopic bone scan before the revision showed active bone metabolism in all 4 transplanted segmental allograft. The pathologic study of the transplanted allograft after revision confirmed new bone formation in allograft. The revision procedure reduced the pain, and improved the limb function. CONCLUSION The main causes of revision surgery after limb salvage procedure of malignant bone tumor are fracture of transplanted allograft segment or devitalized tumor segment, and poor function of the affected joint. Constrained knee prostheses with rotating hinges or semi-constrained ball-axis resurfacing knee prostheses improve the function of knee joint postoperatively.
Objective To investigate the clinical application and early results of combined epiphyseal preservation and autograft bone transfer for limb salvage in children with osteosarcoma. Methods Between March 2010 and March 2011, 3 children with osteosarcoma were treated with epiphyseal preservation and autograft bone transfer. There were 1 boy and 2 girls with the age of 10-14 years. The disease duration was 2 weeks to 3 months. The tumors were rated as type II according to San-Julian radiological classification and as type IIB according to Enneking surgical classification. The locations were the distal femur in 1 case and the proximal tibia in 2 cases. The surgical technique included preoperative neoadjuvant chemotherapy, excision of part of the epiphysis, preservation of subarticular epiphysis, external fixation with Ilizarov apparatus and transport osteogenesis treatment. Safe excision border was confirmed by histological examination. Postoperative observation included the wound healing, local recurrence or distant metastasis, length, speed, alignment, and regeneration of transplanted bone, the length and function of the affected limb. Results The postoperative histological examination proved the safe surgical margin in all 3 patients. The incision healing by first intention was obtained at distal femur in 1 case and by second intention at proximal tibia in 2 cases at 4 weeks after changes of dressing. Three patients were followed up 12, 18, and 24 months, respectively. There was no local recurrence or distant metastasis during follow-up. Two cases had pin-tract infection at 10 months after external fixation and were cured after changes of dressing and antibiotics administration. The length of transplanted osteogenisis was 18.0, 9.5, and 16.0 cm, respectively. The speed of lengthening was 2.57, 2.07, and 1.20 cm/month, respectively. One patient had alignment deviation during lengthening, which was adjusted under anaesthesia. Bony healing was achieved at 8 months after lengthening end in 2 cases and external fixation was removed; 1 patient had poor bone growth and was given retraction for promoting bone growth. At last follow-up, the length of the affected limbs was 1.0-1.5 cm shorter than that of normal limbs, but no abnormalities was observed at donor sites. The affected knee flexion reached 90° and 120° in 2 patients and poor knee function was observed in 1 patient for external fixation. Conclusion The combined epiphyseal preservation and transport osteogenesis technique can be used for bone defect repair by lengthening the residual bone. It is a promising limb salvage treatment for children with osteosarcoma.
ObjectiveTo investigate the application value of the Ilizarov technique for infection after the limb salvage operation of primary bone tumor. MethodsA retrospective analysis was made on the clinical data of 6 patients with infection treated with Ilizarov technique after limb salvage operation of primary bone tumor between July 2012 and April 2015. There were 4 males and 2 females, aged 18-40 years (mean, 28 years). Tumor types included 3 cases of osteosarcoma and 3 cases of giant cell tumor of bone. Tumor located at the left distal femur in 2 cases, at the right distal femur in 1 case, at the left proximal tibia in 1 case, and at the right proximal tibia in 2 cases. Six cases had recurring infection after debridement. The patients underwent operation 2 to 5 times (mean, 3.5 times). The time from tumor resection to visiting was 8-20 months (mean, 14.3 months). During operation, the internal implant was removed; infection and necrotic tissue was removed thoroughly; and the Ilizarov external fixator was installed. After operation, gentamycin normal saline was used for 2 to 3 weeks, and the sensitive antibiotic intravenous infusion was performed at the same time. After 1 week, the osteotomy lengthening was used. ResultsAll 6 patients were followed up for 6 to 18 months (mean, 12.2 months). Pin tract infection occurred in 1 case after operation; primary healing of incision was obtained in the other patients, and no related complications occurred. The external fixation time ranged from 6 to 16 months (mean, 11.5 months). The healing indexes ranged from 34 to 62 days/cm (mean, 52.0 days/cm). After removal of the external fixator, the knee range of motion ranged from 0 to 5° (mean, 3°) in extension, and from 120 to 130° (mean, 125°) in flexion. The American musculo-skeletal tumor society system (MSTS) function scoring was excellent in 3 patients, good in 2 patients, and fair in 1 patient, with an excellent and good rate of 83.3%. During follow-up period, there was no recurrence of infection; and no recurrence or metastasis was found in 3 patients with osteosarcoma. ConclusionInfection can be cured by Ilizarov technique after limb salvage operation of bone tumor.