Resection Of Malignant Bone Tumors Research Articles

Research on three-dimensional printing technology based on three-dimensional multimodality imaging to assist the operation of malignant bone tumors of limbs

To explore the role and effectiveness of three-dimensional (3D) printing technology based on 3D multimodality imaging in surgical treatment of malignant bone tumors of limbs. The clinical data of 15 patients with malignant bone tumors of the limbs who met the selection criteria between January 2016 and January 2019 were retrospectively analyzed. There were 6 males and 9 females, with a median age of 34 years (range, 17-73 years). There were 5 cases of osteosarcoma, 3 cases of chondrosarcoma, 2 cases of Ewing sarcoma, 1 case of hemangiosarcoma, 1 case of ameloblastoma, and 3 cases of metastatic carcinoma. The tumors were located in the humerus in 5 cases, ulna in 2 cases, femur in 3 cases, and tibia in 5 cases. The disease duration was 2-8 months (median, 4 months). Preoperative 3D multimodality imaging was administered first, based on which computer-assisted preoperative planning was performed, 3D printed personalized special instruments and prostheses were designed, and in vitro simulation of surgery was conducted, successively. Two cases underwent knee arthroplasty, 2 had semi-shoulder arthroplasty, 2 had proximal ulna arthroplasty, and 9 had joint-preserving surgery. Surgical margins, operation time, intraoperative blood loss, surgical complications, Musculoskeletal Tumor Society (MSTS) score, and oncological outcome were collected and analyzed. All 15 patients completed the operation according to the preoperative plan, and the surgical margins were all obtained wide resection margins. The operation time was 80-240 minutes, with a median of 150 minutes. The intraoperative blood loss was 100-400 mL, with a median of 200 mL. There was no significant limitation of limb function due to important blood vessels or nerves injury during operation. One case of superficial infection of the incision was cured after dressing change, and the incisions of the other patients healed by first intention. All patients were followed up 6-48 months, with a median of 24 months. Two of the patients died of lung metastasis at 6 and 24 months after operation, respectively. No local recurrence, prosthesis dislocation, or prosthesis loosening occurred during follow-up. At last follow-up, the MSTS score ranged from 23 to 30, with an average of 25. 3D printing tecnology, based on 3D multimodality imaging, facilitates precise resection and reconstruction for malignant bone tumors of limbs, resulting in improved oncological and functional outcome.

Preoperative arterial embolization and wound complications after resection of malignant bone tumor in the pelvis: a nationwide database study.

Massive intraoperative blood loss is common in pelvic malignant bone tumor surgery, and preoperative arterial embolization may be used in selected cases. Preoperative arterial embolization reportedly increases wound complications in pelvic fracture surgery, but little evidence is available regarding pelvic bone tumor surgery. Using a Japanese nationwide database (Diagnosis Procedure Combination database), we searched for patients who underwent pelvic malignant bone tumor surgery between July 2010 and March 2018. The primary endpoint was wound complications, defined as any wound requiring re-operation, negative pressure wound therapy or both. Univariate analyses (the chi-squared test for categorical variables, the unpaired t-test for continuous variables) and multivariate logistic regression analyses were performed to examine the association between preoperative arterial embolization and wound complications. Among the 266 eligible patients, 43 (16%, 43/266) underwent embolization and 69 (26%, 69/266) developed wound complications. In the univariate analyses, preoperative arterial embolization (P<0.001), duration of anesthesia (P<0.001), the volume of blood transfusion (P<0.001) and duration of indwelling drain tube (P<0.001) were associated with wound complications. In the multivariate logistic regression analysis, preoperative arterial embolization was significantly associated with wound complications (odds ratio, 3.92; 95% confidence interval, 1.80-8.56; P=0.001). Preoperative arterial embolization may be associated with increased wound complications after pelvic malignant tumor surgery.

MUTARS® Humero pro Femur replacement: A novel reconstructive procedure after malignant bone tumor resection of the femur in young children

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.

New special approach for shoulder stability after Malawer type IVB shoulder girdle resection: A case report.

Introduction and importanceScapular prostheses are useful in shoulder stability after shoulder girdle resection for malignant bone tumors; however, they are difficult to obtain in Japan. Therefore, other methods must be considered, depending on the extent of resection. We report a case in which a clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis were used to ensure shoulder stability and preserve stable upper limb function.Case presentationA 56-year-old man presented with a large mass and edema over the entire right scapula, which caused severe pain, limited the shoulder's range of motion, and impaired function of the entire upper extremity. Clinical imaging and pathological findings indicated a diagnosis of conventional chondrosarcoma. Using the Malawer technique type IVB, we resected the shoulder girdle and secured shoulder stability with a clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis. To evaluate the patient, we obtained his Musculoskeletal Tumor Society (MSTS) and Disabilities of Arm, Shoulder, and Hand (DASH) scores 3 months postoperatively.Clinical discussionTo preserve the function of the patient's elbow and hand, the stability of his shoulder was important. We could achieve this stability by using a prosthesis available in Japan. The patient's MSTT and DASH scores improved remarkably.ConclusionA clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis can be used to ensure shoulder stability after scapular girdle resection and can preserve or improve upper limb function.

Personalized 3D-printed guide in malignant bone tumor resection and following reconstruction – 17 cases in pelvic and extremities

IntroductionCustomized accurate tumor resection and individualized reconstruction is a challenging in treatment of malignant bone tumor. Three-dimensional (3D)-printing technique is now widely used in the resection and following reconstruction of malignant bone tumor, which included but not limited to tumor model, osteotomy guide and customized implant. MethodsWe retrospectively reviewed 17 patients, who underwent limb salvage surgery by using 3D-printed guide at a single center between August 2014 and October 2019. The median duration of follow-up was 26.5 months. Osteosarcoma (41.2%) were the predominant diagnoses. The functional outcomes were assessed by Musculoskeletal Tumor Society (MSTS) functional score. We also analyzed survival status, intraoperative data (blood loss, operation time and resection length), reconstruction method, margin outcomes and complications. ResultsWe totally performed 93 guided osteotomies on affected bone and allograft bone in 17 patients. Reconstruction in 12 cases was performed with biological technique: allograft combined with autograft was used in 7 cases. 11 of 12 (91.7%) cases showed a good bone healing in both allograft and autograft. 1 of 12 (8.3%) cases had allograft necrosis. Additional intra-operative extracorporeal radiation was performed in 3 pelvic cases for reconstruction. 63 of 64 (98%) osteotomies achieved wide resection and negative margin. All the cases had successful limb salvage result without amputation. At the latest follow up, the mean MSTS Score was 24 (range: 13–30), 12 patients alive with no evidence of disease, 1 patient alive with disease, 5 patients had died of disease and 5 years overall survival is 73.3%. The most common complications are wound healing disorder in 4 cases (23.5%) and infection in 3 cases (17.6%). ConclusionThe 3D-printed resection guide was easy to use and showed promise in the field of orthopedic oncology. It can not only used in primary malignant bone tumor personalized resection but also in shaping structural bone allograft in biological reconstruction, which can achieve a safety surgical margin and individualized resection at the same time.

Humeral Stress Shielding Following Cementless Megaprosthesis Of The Proximal Humerus - A Risk For Aseptic Loosening?

We aimed at investigating the frequency and extent of stress shielding after proximal humeral replacement with cementless megaprosthesis after resection of malignant bone tumors, as well as possible risk factors for stress shielding. We also evaluated its possible influence on implant survival and functional outcome.

When Your Ankle Becomes a Knee - Long-Term Functional Outcome and Quality of Life with a Rotationplasty after Resection of Malignant Limb Tumors.

Increasing numbers of patients surviving malignant bone tumors around the knee joint have led to an increasing importance to investigate long-term results. This study assessed the long-term results of rotationplasty after resection of malignant bone tumors regarding functional outcome and quality of life to allow better comparison with other treatment options in bone cancer treatment. 60 participants who underwent rotationplasty due to bone cancer took part in this multicentric questionnaire-based study. The long-term functional outcome was measured by the Musculoskeletal tumor society score (MSTS) and the Tegner activity level scale. The health-related quality of life (HRQL) was assessed by using the Short Form Health Survey (SF-36). Patients treated with rotationplasty (median follow-up of 22 years, range 10-47 years) regained a high level of activity (median MSTS score of 24). Even a return to high level sports was possible (mean Tegner activity level scale of 4). Duration of follow-up did not influence the functional outcome. HRQL scores were comparable to the general German population. Concerns of psychological problems due to the unusual appearance of the rotated foot have not been confirmed. Rotationplasty can be a good alternative to endoprosthetic replacement or amputation, either as primary surgery or as a salvage procedure. Especially for growing children and very active patients rotationplasty should be considered.

Risk factors and outcomes for failure of biological reconstruction after resection of primary malignant bone tumors in the extremities

Biological reconstruction is widely used to reconstruct bone defects after resection of bone tumors in the extremities. This study aimed to identify risk factors for failure and to compare outcomes of the allograft, nonvascularized autograft, and recycled frozen autograft reconstruction after resection of primary malignant bone tumors in the extremities. A retrospective study was performed at a single center between January 1994 and December 2017. Ninety patients with primary malignant bone tumors of the extremities were treated with tumor resection and reconstruction using one of three bone graft methods: nonvascularized autograft (n = 27), allograft (n = 34), and recycled frozen autograft (n = 29). The median time for follow-up was 59.2 months (range 24–240.6 months). Overall failure of biological reconstruction occurred in 53 of 90 patients (58.9%). The allograft group had the highest complication rates (n = 21, 61.8%), followed by the recycled frozen autograft (n = 17, 58.6%) and nonvascularized autograft (n = 15, 55. 6%) groups. There was no statistically significant difference among these three groups (p = 0.89). The mean MSTS score was 22.6 ± 3.4 in the nonvascularized autograft group, 23.4 ± 2.6 in the allograft group, and 24.1 ± 3.3 in the recycled frozen autograft group. There was no significant difference among the groups (p = 0.24). After bivariate and multivariable analyses, patient age, sex, tumor location, graft length, methods, and type of reconstruction had no effects on the failure of biological reconstruction. Biological reconstruction using allograft, nonvascularized autograft, and recycled frozen autograft provide favorable functional outcomes despite high complication rates. This comparative study found no significant difference in functional outcomes or complication rates among the different types of reconstruction.

Bases anatomiques du gluteus maximus et application comme lambeau pédiculé de couverture pour les résections de tumeurs du bassin

The resection of malignant bone tumors of the pelvis causes significant loss of substances making covering procedures difficult. The gluteus maximus pedicled flap allows some reconstructions, but its use in vascular sacrifice is not clearly established. The objective of our study was to study its vascularization in order to assess the possibility of vascular sacrifice during carcinological resection of a pelvic tumor.We first performed a vascular mapping of the gluteus maximus muscle using 3-dimensional (3D) models from CT angiography in patients with Leriche syndrome. These models were compared to a cadaveric dissection of 2 injected muscles. A second 3D modeling from postoperative scans was performed in patients who had a gluteus maximus flap after pelvic carcinological surgery.Ten patients with Leriche syndrome had a 3D model from their scanners. Three distinct arterial systems were identified. Seven patients had a flap from the gluteus maximus muscle, including 3 cases of an Inverted pedicled Hemi Gluteus maximus flap (HGI). According to the modeling, the richness of the vascular network would allow the sacrifice of the superior gluteal pedicle without compromising the viability of this flap.Our study made it possible to confirm the richness of the vascular network of the gluteus maximus muscle and to consider the theoretical possibility of sacrificing the superior gluteal pedicle without endangering an HGI pedicled muscle flap.

Wide Resection of Primary Malignant Bone Tumors of the Hand in Children and Reconstruction Using Nonvascularized Fibular Bone Graft: Case Series and Literature Review

Primary malignant bone tumors of the hand are rare in children. Resection and reconstruction of the digit are challenging and have been described in case reports. This retrospective study describes the functional and oncologic outcomes of resection and reconstruction using a nonvascularized fibular bone graft in a cohort of children. A total of 5 children were included. The mean age at diagnosis was 7.6 years (range, 1.6-12 years). Histologic diagnosis showed Ewing sarcoma in 3 and osteosarcoma in 2 patients. Four tumors were located in the metacarpal bones of the fingers, and 1 was located in the thumb. Four patients were treated with chemotherapy. All the patients were treated with wide resection and a cement spacer. This was followed by second stage reconstruction using a nonvascularized fibular bone graft. In tumors of the fingers, carpometacarpal joint fusion with a neighboring carpal bone was performed, whereas a pseudoarthrosis was created between the graft and the base of the proximal phalanx. In the thumb's case, the opposite was done, with fusion at the metacarpophalangeal joint and a pseudoarthrosis at the carpometacarpal joint. The mean follow-up duration was 5.5 years (range, 2-9 years). Surgical margins were negative in all the patients. At their latest follow-up visit, none of the patients developed systemic or local recurrence. Two complications required a revision surgery, one due to graft subluxation and the other due to nonunion. At their final follow-up examination, the mean total arc of movement was 80° (range, 60°-100°), and all the patients were able to resume their grasping and writing capabilities. The resection and reconstruction of primary malignant bone tumors of the metacarpals using a nonvascularized fibular bone graft in children can preserve the cosmesis and function of the digit without jeopardizing oncologic outcomes. Therapeutic V.

3D Printed Multi-Functional Scaffolds Based on Poly(ε-Caprolactone) and Hydroxyapatite Composites.

3D Printed biodegradable polymeric scaffolds are critical to repair a bone defect, which can provide the individual porous and network microenvironments for cell attachment and bone tissue regeneration. Biodegradable PCL/HA composites were prepared with the blending of poly(ε-caprolactone) (PCL) and hydroxyapatite nanoparticles (HA). Subsequently, the PCL/HA scaffolds were produced by the melting deposition-forming method using PCL/HA composites as the raw materials in this work. Through a serial of in vitro assessments, it was found that the PCL/HA composites possessed good biodegradability, low cell cytotoxicity, and good biocompatibility, which can improve the cell proliferation of osteoblast cells MC3T3-E1. Meanwhile, in vivo experiments were carried out for the rats with skull defects and rabbits with bone defects. It was observed that the PCL/HA scaffolds allowed the adhesion and penetration of bone cells, which enabled the growth of bone cells and bone tissue regeneration. With a composite design to load an anticancer drug (doxorubicin, DOX) and achieve sustained drug release performance, the multifunctional 3D printed PCL/HA/DOX scaffolds can enhance bone repair and be expected to inhibit probably the tumor cells after malignant bone tumor resection. Therefore, this work signifies that PCL/HA composites can be used as the potential biodegradable scaffolds for bone repairing.

Lower Limb Reconstruction Using Tibial Strut Autograft after Resection of Primary Malignant Bone Tumors in Skeletally Immature Patients.

Reconstruction of large bone defects in skeletally immature patients remains a surgical challenge. We report the long-term clinical outcomes of a novel surgical technique for lower limb reconstruction using the tibia as a strut autograft following resection of primary malignant bone tumors in skeletally immature patients. We retrospectively reviewed the medical records of six patients diagnosed with lower limb primary bone sarcoma. All patients underwent tumor resection and reconstruction using tibial strut autograft. The radiological and clinical outcomes including complications at the recipient and donor sites were assessed. The mean age at presentation was ten years (range 6-15 years). Two cases had osteosarcoma and four had Ewing sarcoma. The mean length of the resected tumor and tibial autografts were 20.83 and 19.33 cm respectively. Union at both ends was achieved in five grafts while one graft achieved union only at the distal end. The mean time for union of the proximal and distal junctions was 4 and 8.8 months respectively. The mean follow-up period was 8.4 years (range 14 months-20 years). One patient developed a foot drop, and three patients underwent subsequent joint arthrodesis (2 knees and 1 ankle). The mean musculoskeletal tumor society functional score was 80.8%. Two patients had clinically significant leg-length discrepancy that needs further lengthening procedure. Four patients survived with no evidence of disease and two patients died due to their primary oncologic disease. All donor sites regenerated, with the earliest signs of new bone formation at (2-4) weeks post-operatively. Reconstruction using non-vascularized‎ tibia strut autograft after resection of primary malignant lower limb bone tumors can be a viable alternative method for reconstructing large bone defects in the immature skeleton.

Outcome of Surgical Resection of Primary Malignant and Aggressive Benign Metacarpal Bone Tumors.

Primary bone tumors of the hand are relatively rare. Different treatment options have been described in case reports. In this study, the authors present the diagnostic methods and treatment strategies that they used. The goal of this study is to present the oncologic and functional outcomes of surgical resection of primary malignant and aggressive benign metacarpal bone tumors. This retrospective study included 7 patients with primary malignant and aggressive benign bone tumors of the metacarpals who underwent surgical resection with or without metacarpal reconstruction between 2000 and 2017, with a minimum follow-up of 2 years. Clinical and radiologic evaluations were reviewed, and functional evaluation was performed with the Musculoskeletal Tumor Society scoring system. Seven patients (6 female; 1 male), with a mean age of 30.9±11.3 years, were included in the study. Six tumors were de novo, whereas 1 was recurrent. After resection, 5 patients had metacarpal reconstruction. Nonvascularized fibula was used for 3 patients, extracorporeal freezing of the metacarpal using liquid nitrogen was used for 1 patient, and metacarpal shift was used for 1 patient. Mean follow-up was 52.6±26.7 months. At the final follow-up, mean Musculoskeletal Tumor Society score was 27.4±1.6, and no local recurrence was documented. One patient had chest metastasis after 8 years of follow-up. The results show that surgical resection of primary malignant and aggressive benign tumors of the metacarpal bones can achieve satisfactory functional and oncologic outcomes. [Orthopedics. 2021;44(5):e633-e638.].

The Bateman-Type Soft Tissue Reconstruction around Proximal or Total Humeral Megaprostheses in Patients with Primary Malignant Bone Tumors-Functional Outcome and Endoprosthetic Complications.

Simple SummaryThe soft tissue reconstruction around proximal or total humeral megaprostheses following limb-sparing resection of a primary malignant bone tumor can be a challenge. A surgical technique to overcome these challenges is the Bateman-type soft tissue reconstruction, which is performed as a lateral acromion and trapezoid transfer aiming to improve soft tissue coverage and postoperative function. However, the functional outcome and the endoprosthetic complications of this procedure have hardly been evaluated. Our study shows that the Bateman-type reconstruction is a feasible treatment option, but the postoperative functional outcome is overall limited although good to excellent functional results can be achieved in individual patients. The risk for revision surgery is high within the first year, but remains low thereafter.We aimed to evaluate the functional outcome and endoprosthetic complications following the Bateman-type soft tissue reconstruction around proximal or total humeral replacements in patients undergoing resection of a primary malignant bone tumor. Between September 2001 and December 2018, a total of 102 patients underwent resection of a primary malignant bone tumor and subsequent reconstruction with a modular humeral megaprosthesis in our department. Fifteen (15%) of these patients underwent a Bateman-type soft tissue reconstruction and were included in this retrospective study. The median Musculoskeletal Tumor Society (MSTS) score was 21, the median Toronto Extremity Salvage Score (TESS) was 70, and the median American Shoulder and Elbow Surgeons (ASES) score was 72. Fifty-three percent (8/15) of all patients required a revision surgery after a median time of 6 months. There were 2 soft tissue failures, 3 infections and 3 tumor recurrences. The revision-free implant survivorship amounted to 53% (95% confidence interval (CI) 28–81) after 1 year and 47% (95% CI 22–73) at last follow-up. The Bateman-type reconstruction is a feasible option for soft tissue reconstruction but functional outcome is overall limited and the risk for revision surgery within the first postoperative year is high.

The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience.

Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety.

Reverse shoulder arthroplasty and synthetic mesh for reconstruction of the shoulder joint after malignant bone tumor resection

Abstract Introduction: A wide resection of malignant tumor including the deltoid insertion in the proximal humerus significantly worsens shoulder function. There are several reports about the reconstruction of the shoulder joint using reverse shoulder arthroplasty (RSA) after tumor resection. However, there have been no reports of reconstruction using RSA and a polypropylene mesh in combination with the modified L’Episcopo procedure. Patient concerns: An 83-year-old man complained of pain in his right shoulder. Diagnosis: The patient was diagnosed with dedifferentiated chondrosarcoma in the proximal humerus based on pathological assessment. Interventions: We excised the tumor with the proximal humerus including the deltoid attachment and reconstructed it with deltoid muscle by suturing it to polypropylene mesh covering the implant stem. We then performed a tendon transfer with the latissimus dorsi and teres major muscles in place of dissected posterior rotator cuffs as a modified L’Episcopo procedure. Outcomes: The pathological diagnosis confirmed a negative margin. His shoulder function improved at the 1-year follow-up. Conclusion: Reconstruction of the deltoid insertion using a polypropylene mesh surrounding the stem of an internal prosthesis during RSA is an easy technique and achieves relatively favorable shoulder function.

Rehabilitation of periscapular malignant soft-tissue tumors after partial scapulectomy, wide resection and split-thickness skin grafting: A case report

Abstract Background: Wide resection of malignant bone and soft-tissue tumors of the extremities may impair the functions of the affected limbs. Partial scaplectomy affects shoulder movements, resulting in disabilities

Retrospective Clinical Evaluation of Negative-Pressure Wound Therapy for Infection Prevention Following Malignant Pelvic Bone Tumor Resection Reconstruction.

To evaluate the clinical outcomes of negative-pressure wound therapy (NPWT) for infection prevention following pelvic reconstruction after malignant bone tumor resection. The study involved 82 patients who underwent pelvic reconstruction following en-bloc resection of malignant bone tumors between January 2003 and January 2016. Forty patients were treated with NPWT via implantation of vacuum-sealing drainage (VSD) materials into the pelvic cavity to prevent infection and wound problems (VSD group), and the remaining 42 patients underwent conventional treatment (control group). Study authors compared the inpatient length of stay, antibiotic use, drainage volume, time to wound closure, and infection rates between groups. Investigators also conducted cell cultures of the wound cavity washing fluid and hematoxylin-eosin staining for VSD materials to find recurrent tumor cells. In the VSD group, one patient (2.5%) had a superficial wound problem. In the control group, 18 patients (42.9%) had deep infection or wound problems. The VSD group had a significantly decreased infection rate, duration of antibiotic administration and inpatient stay, as well as increased wound healing compared with the control group (P < .05). Further, no tumor cells were observed in the VSD material or the wound cavity washing fluid. The application of NPWT with VSD material may be an effective and reliable method for preventing infection in patients who undergo pelvic reconstruction following malignant tumor resection.

Do irradiated osteo-articular recycled tumor autografts still hold promise for biological joint reconstruction? Our experience with acetabular and proximal ulna ECRT

BackgroundJoint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options. Questions/purposes(1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft? Methods19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50–60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status. ResultsMSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms. ConclusionsExtracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement. Level of evidenceLevel IV, Therapeutic Study.

Extracorporeal irradiation: biological reconstruction following tumor resection with a large bone defect

Reconstruction of massive segmental bone defects is a crucial point of limb salvage surgeries after malignant bone tumor resections. Megaendoprostheses implantation is a commonly used method for adult patients, but hardly usable for children below 12 years old, because of the small size of the host bone and multiple mechanic complications. Extracorporeal irradiation and allograft reimplantation (ECRT, ECI) are promising methods for these young children for limb salvage, reducing the number of prostheses revisions, reoperations. In Hungary, we performed limb salvage surgery for malignant bone tumor in 12 cases in children under 12 years old, using extracorporeally irradiated autografts as biological reconstruction. All cases were primary bone tumors (Ewing's sarcoma: 7, osteosarcoma: 4, chondrosarcoma: 1). The average age of our patients was 9 (3-12) years, the average follow-up was 32.5 (2-73) months. At follow-up, we performed physical examination, X-ray, and other imaging methods if they were necessary. Our results were compared to international publications. We observed no local recurrence, but in one case we had to perform above-knee amputation, due to a skip metastasis in the proximal tibia. The complication rates were similar to those reported in other papers. Septic complications were treated in two cases (16.7%). Total union of the resection lines was observed at 3-9 months in 60% of all cases. Reoperations were performed due to nonunion, or allograft fracture/partly desorganization in 3 cases, twice with new allograft, and with prostheses in one case. The subjective opinion of our patients is positive, they walk with full weightbearing, some of them do even light sporting activities. We found extracorporeal irradiation a useful and safe method for children under 12 years old for biological reconstruction after malignant bone tumor resection. Complication rate stays under the rate of growing prostheses complications, in optimal cases further radical, and extensive surgeries may be avoided. In the case of major complications, megaendoprostheses implantation later on is still an option as salvage procedure with limb salvage. Orv Hetil. 2020; 161(45): 1914-1919.