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.
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.
ObjectiveTo investigate the effectiveness and technical key points of limb salvage surgery by allotransplantation of cryopreservated vascularized bone in children and adolescents with osteosarcoma. MethodsA retrospective analysis was made on the clinical data of 21 children and adolescents with osteosarcoma receiving limb salvage surgery by allotransplantation of cryopreservated vascularized bone from their relatives between February 2004 and April 2012. There were 13 males and 8 females, aged from 7 to 16 years (mean, 12.6 years). According to Enneking stage system, 15 cases were rated as stage ⅡA and 6 cases as stage ⅡB. The tumors located at the distal femur in 10 cases, at the proximal femur in 1 case, at the proximal tibia in 8 cases, at the proximal humerus in 1 case, and at the distal radius in 1 case. Imaging examination showed that epiphyseal extension of malignant bone tumors in 7 cases. The iliac bone allograft with deep iliac vessels was obtained from their lineal consanguinity. After preservation by a twostep freezing schedule, the iliac bone allograft with deep iliac vessels was implanted into the bone defect area after tumor resection. The size of iliac bone flap was 8.0 cm×3.0 cm×2.0 cm-14.0 cm×5.0 cm×2.5 cm. Reserved joint surgery was performed on 16 cases and joint fusion surgery on 5 cases, and external fixation was used in all cases. The chemotherapy was given according to sequential high-dose methotraxate, adriamycin, and cisplatine before and after operation. ResultsAll 21 cases were followed up from 5 months to 11 years (mean, 6.4 years). At 2 weeks after operation, the erythrocyte rosette forming cells accounted for 56.7%±3.9%, showing no significant difference when compared with that of normal control (58.3%±4.3%) (t=1.56, P=0.13), which suggested no acute rejection. At 4 weeks after operation, single photon emission computerized tomography bone scan indicated that the blood supply of bone graft was rich, and the metabolism was active. At 12 weeks after operation, the digital subtraction angiography showed the artery of iliac bone flap kept patency. X-ray films showed that malunion and non-union occurred at 5 and 6 months after operation in 1 case, respectively. The bone graft healed in the other patients, and the healing time was 3.2-6.0 months (mean, 4.4 months). At last follow-up, American Musculoskeletal Tumor Society (MSTS) score was significantly improved to 26.80±2.14 from preoperative value (17.15±1.86) (t=-4.15, P=0.00). The survival rate was 85.7% (18/21) and the recurrence rate was 9.5% (2/21). ConclusionAllotransplantation of cryopreservated vascularized bone from the relatives provides a new method for the treatment of osteosarcoma in children and adolescents. A combination of allotransplantation and chemotherapy can achieve the ideal treatment effect. The correct cutting, preservation, and transplantation of the donor bone, and indication are the key to improve the effectiveness.
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.
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.
ObjectiveTo investigate the procedure and effectiveness of total femoral replacement for treating femur malignant tumor.MethodsThe clinical data of 9 patients with femoral malignant tumors who underwent total femoral replacement between July 2013 and March 2017 were retrospectively analyzed. There were 5 males and 4 females, aged 16-75 years with an average of 44.8 years. The disease duration ranged from 2 to 6 months with an average of 3.5 months. There were 5 cases of osteosarcoma (3 cases were staged as Enneking ⅡB, 2 cases were staged as Enneking Ⅲ), 1 case of malignant fibrosarcoma (staged as Enneking ⅡB), 1 case of chondrosarcoma (staged as Enneking ⅠB), 2 cases of femoral muti-metastasis of lung cancer with pathological fracture. The visual analogue scale (VAS) score and the quality of life (QOL) score of the tumor patients were evaluated before operation and at 3 months after operation. The Musculoskeletal Tumor Society (MSTS) score and Harris hip score (HHS) were evaluated at last follow-up.ResultsNine patients were followed up 11-58 months, with an average of 21 months. No complication such as wound infection, joint dislocation, and nerve injury occurred. One patient developed popliteal vein thrombosis, and 2 patients with osteosarcoma died of tumor progression. The VAS score and QOL score at 3 months after operation were 3.2±1.2 and 40.6±5.4 respectively, which were significantly improved when compared with preoperative ones (5.9±0.8 and 22.3±4.2 respectively) (t=11.314, P=0.000; t=–7.794, P=0.000). At last follow-up, the MSTS score was 15-29 with an average of 21.1, and the HHS score was 44-90 with an average of 66.5.ConclusionTotal femoral replacement is an effective limb salvage procedure for the treatment of femoral malignant tumors, which can effectively restore the weight-bearing and walking function, relieve pain, and improve the quality of life.
ObjectiveTo assess the effectiveness of the pasteurized tumor-bearing bone replantation in treatment of primary malignant bone tumor of extremities.Methods Between February 2012 and June 2016, 13 patients with primary malignant bone tumor of extremities were treated with pasteurized tumor-bearing bone replantation after extensive excision. There were 8 males and 5 females, aged from 11 to 27 years, with an average of 17.4 years. Tumors were located at the mid-upper humerus in 2 cases, the mid-upper femur in 2 cases, the mid-lower femur in 6 cases, the mid-upper tibia in 2 cases, and the middle tibia in 1 case. According to Enneking staging system, 3 patients were classified as stage ⅠB, 5 patients as stage ⅡA, and 5 patients as stage ⅡB. There were 11 cases of osteosarcoma and 2 cases of chondrosarcoma. The disease duration ranged from 3 to 8 months, with an average of 4.8 months. The length of the tumor-bearing bone ranged from 8 to 16 cm, with an average of 12.5 cm. Postoperative follow-up was conducted regularly to evaluate the status of inactivated bone and complications. The limb function was assessed by the Musculoskeletal Tumor Society 93 (MSTS-93) scoring system.ResultsAll 13 patients were followed up 26-79 months, with an average of 50.5 months. Eleven patients survived without tumors. Two patients had local soft tissue recurrence and underwent amputation, 1 had lung metastasis after amputation and died. All patients had no complications of bone resorption, shortening, and internal fixation disorder. The nonunion of osteotomy occurred in 4 cases. Among them, 3 cases were successfully healed after autologous iliac bone grafting, and 1 case was treated conservatively. The healing time of metaphyseal osteotomy end was 10-15 months (mean, 12.6 months), the healing rate was 90.9% (10/11); the healing time of diaphyseal osteotomy end was 12-21 months (mean, 17.0 months), the healing rate was 72.7% (8/11); and the total healing rate of osteotomy end was 81.8% (18/22). One case had inactivated bone fracture and 1 case had incision dehiscence and infection after operation. At last follow-up, the MSTS-93 score of affected limb ranged from 21 to 28, with an average of 25.3.ConclusionThe procedure of the pasteurized tumor-bearing bone replantation is an effective, simple, and economic way in repair of massive segmental bone defect to save limb function for primary malignant bone tumor of extremities.
ObjectiveTo summarize the experience in the treatment of infection after limb salvage surgery for malignant tumor around knee joint, and explore the risk factor related to infection after limb salvage surgery.MethodsA clinical data of 212 patients with malignant tumor around the knee joint underwent limb salvage surgery between January 2008 and December 2017 were retrospectively analyzed. Among them, 14 cases had infection after limb salvage surgery. Two cases of acute infection were treated with sensitive antibiotics; 12 cases of chronic infection were treated with debridement and antibiotic bone cement occupying device implantation in the first stage, and prosthesis revision (8 cases), knee joint fusion (2 cases), or amputation (2 cases) in the second stage after infection control. The age, gender, preoperative chemotherapy cycle, bone marrow suppression, serum albumin, hemoglobin, operation time, postoperative drainage time, and blood transfusion volume were analyzed to screen the risk factors related to infection after limb salvage surgery. The infection and tumor recurrence were observed, and the limb function was evaluated by Enneking scoring system.ResultsThe univariate analysis showed that the preoperative chemotherapy cycle, bone marrow suppression, operation time, and postoperative drainage time were the influencing factors of postoperative infection (P<0.05). Multivariate analysis showed that the operation time, preoperative chemotherapy cycle, and postoperative drainage time were risk factors of postoperative infection (P<0.05). Among the 14 patients, 1 patient died of traffic accident at 6 months after the second stage operation, and 13 patients were followed up 12.2-48.0 months (mean, 19.9 months). Two cases of acute infection cured. Among the 11 patients with chronic infection, 2 cases of subluxation of the antibiotic bone cement occupying device after the first stage operation occurred; 9 cases of infection cured and 2 cases recurred. At 12 months after operation, except 1 case died by accident, the Enneking scores of the other 13 patients were 12-26, with an average of 20. At last follow-up, 1 case of lung metastasis was still alive, and no tumor metastasis or recurrence was found in the rest.ConclusionThe time of limb salvage surgery, preoperative chemotherapy cycle, and drainage time after limb salvage surgery are the risk factors of infection after limb salvage surgery. Early etiological examination and drug sensitivity test is the key to the treatment of infection. One-stage debridement combined with antibiotic bone cement occupying device can effectively cure infection and save patients’ limbs.