Musculoskeletal Tumor Society Functional Score Research Articles

Extended Intralesional Treatment versus Resection of Low-grade Chondrosarcomas

The need for segmental resection versus intralesional treatment of low-grade chondrosarcomas of the appendicular skeleton remains controversial. We hypothesized extended intralesional treatment would equally control malignant disease but with improved functional outcomes and decreased postoperative complications. We retrospectively reviewed 31 patients with 32 Grade I intracompartmental chondrosarcomas of the long bones of the appendicular skeleton treated with either resection (15 lesions) or extended intralesional curetting (17) at a minimum followup of 2 years (median, 55 months; range, 24-203 months). Lesions were larger and median followup was longer in the resection cohort. One local recurrence developed in each treatment cohort and neither transitioned to a higher grade of tumor. No patient had metastases develop or died of disease. The mean final Musculoskeletal Tumor Society functional scores were greater after extended intralesional versus resection treatment (29.5 versus 25.1). Complications were observed more frequently after resection and reconstruction (seven of 15) as compared with extended intralesional treatment (one of 17). Extended intralesional treatment of Grade I intracompartmental chondrosarcomas of the long bones of the appendicular skeleton therefore appears safe with improved functional scores and decreased complications versus segmental resection and reconstruction. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Conservative Treatment of Campanacci Grade III Proximal Humerus Giant Cell Tumors

Management of large giant cell tumors of the proximal humerus is controversial because wide resection with reconstruction results in a poor functional outcome for most patients. We retrospectively reviewed the cases of six patients with Campanacci Grade III giant cell tumors of the proximal humerus to determine the feasibility of avoiding en bloc resections for large giant cell tumors in this location. We evacuated the tumor through curettage and then used burring (unless the remaining cavity was thinned and at risk for fracture) and phenolization, followed by packing of the defect with allograft cancellous bone. The mean age of the patients at surgery was 30 years, and the minimum followup was 2.5 years (mean, 5.6 years; range, 2.5-9.7 years). One of the six patients had local recurrence 1.2 years postoperatively and was treated with repeat intralesional surgery with no additional recurrence 5 years later. No other patient required additional treatment, had pulmonary metastases develop, or had progression to osteoarthritis. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score functional scores at last followup were 26 of 30 (range, 21-30) and 95% (range, 90%-100%), respectively. These functional scores are higher than reported scores for patients with segmental resection and reconstruction of the proximal humerus. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Consequences and Prevention of Inadvertent Internal Fixation of Primary Osseous Sarcomas

The evaluation and treatment of aggressive bone tumors continue to be diagnostic and therapeutic challenges for orthopaedic surgeons. Despite compelling data regarding the hazards of biopsy, incomplete preoperative evaluation, inappropriate biopsy techniques, and premature surgical interventions continue to compromise optimal treatment of primary bone sarcomas. We retrospectively identified eight patients who had internal fixation of a primary bone sarcoma before referral to an orthopaedic oncology service. Six of the eight patients subsequently underwent amputations and two patients underwent limb salvage for local disease control. Biopsy techniques from referring institutions were highly variable, with only two of seven rendering an accurate diagnosis. The average Musculoskeletal Tumor Society functional score was 10.6 and four of eight patients were disease-free and alive at a minimum followup of 8 months (mean, 26.9 months; range, 8-80 months). Implant violation of primary bone malignancies was associated with frequent high-level amputation for local disease control and low Musculoskeletal Tumor Society functional scores. Common errors in the initial evaluation and treatment included inadequate attention to patient history, incomplete radiographic evaluation, and improper biopsy and surgical techniques, which violated compartmental boundaries. Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Trabecular Metal Endoprosthetic Limb Salvage Reconstruction of the Lower Limb

Currently, porous tantalum (trabecular metal) implants are widely accepted and frequently used for primary and revision hip and knee replacement surgery. This study examines the results of porous tantalum endoprostheses used to reconstruct large skeletal defects following resection of bone tumors. Seven custom tantalum implants were used to reconstruct 7 patients following resection for skeletal sarcomas in the femur and proximal tibia. Patient ages ranged from 13 to 71, with a mean of 34 years. Minimum patient follow-up was 6 years. The average Musculoskeletal Tumor Society functional evaluation score was 95 % of normal. There were no infections, hardware failures, or adverse events. One implant was revised 98 months post insertion because of fibrosis, loss of motion and loosening. In this small clinical series, the use of porous tantalum for limb salvage reconstruction is shown to be safe, to successfully provide osteointegration and soft tissue ingrowth, and to facilitate return of limb girdle muscle function.

Proximal Humerus Reconstructions for Tumors

The optimal method for reconstructing the proximal humerus in patients with tumors is controversial. To determine functional outcomes and complication rates after different types of reconstructions, we reviewed a consecutive series of 49 patients who underwent proximal humerus resection and osteoarticular allograft (17 patients), allograft-prosthetic composite (16), or endoprosthetic (16) reconstruction. Operative indications included primary malignancies (24 patients), metastatic disease (19), and benign aggressive disease (six). Implant revision was more common after osteoarticular reconstruction (five of 17) than after allograft-prosthetic composite (one of 16) or endoprosthetic (zero of 16) reconstructions. At a minimum followup of 24 months (median, 98 months; range, 24-214 months) in surviving patients, Musculoskeletal Tumor Society functional scores averaged 79% for the allograft-prosthetic composite, 71% for the osteoarticular allograft, and 69% for the endoprosthetic reconstruction cohorts. Shoulder instability was associated with abductor mechanism compromise and was more common after endoprosthetic reconstruction. Allograft fractures occurred in 53% of patients receiving osteoarticular allografts. We recommend allograft-prosthetic composite reconstruction for younger patients with primary tumors of bone and endoprosthetic reconstruction for older patients with metastatic disease. Because of the unacceptable complication rate, we do not recommend osteoarticular allograft reconstruction for routine use in the proximal humerus. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Endoprosthetic replacement for primary tumours around the knee

In developing countries locally-made low-cost prostheses are mainly used in limb-salvage surgery to alleviate the economic burden. We retrospectively collected data on 104 patients treated by limb-salvage surgery between July 1997 and July 2005. We used a locally-designed and fabricated stainless-steel endoprosthesis in each case. Oncological and functional outcomes were evaluated at a mean follow-up of 47 months (12 to 118). A total of 73 patients (70.2%) were free from disease, nine (8.7%) were alive with disease, 19 (18.2%) had died from their disease and three (2.9%) from unrelated causes. According to the Musculoskeletal Tumor Society scoring system, the mean functional score was 76.3% (SD 17.8). The five-year survival for the implant was 70.5%. There were nine cases (8.7%) of infection, seven early and two late, seven (6.7%) of breakage of the prosthesis, three (2.9%) of aseptic loosening and two (1.9%) of failure of the polyethylene bushing. Multivariate analysis showed that a proximal tibial prosthesis and a resection length of 14 cm or more were significant negative prognostic factors. Our survival rates and Musculoskeletal Tumor Society functional scores are similar to those reported in the literature. Although longer follow-up is needed to confirm our results, we believe that a low-cost custom-made endoprosthesis is a cost-effective and reliable reconstructive option for limb salvage in developing countries.

Oncological and functional results following operation for giant cell tumour of bone

Objective Giant cell tumours(GCT) represent one of the most common benign tumours of bone. However, despite its benign nature they are aggressive lesions that have a tendency to recur. This study aims to report experience with the treatment of GCTs, and reviews the relationship between surgical management and clinical outcome. Methods A retrospective review was performed with 70 patients (32 males and 38 females) who presented to our institution between 1991 and 2001 with GCT of bone. An evaluation of the oncological and functional results was conducted and patients were divided into three groups according to the treatment method; Group I: (46 patients) intralesional curettage and adjuvant therapy and packing with filling materials. Group II: (18 patients) en-bloc resection and arthrodesis or reconstruction. Group III: (6 patients) amputation. Results The mean follow-up period was 10 years (range, 5-15 years). The overall rate of local recurrence was 14%, 22% in Group I, and only 4% in Group II and Group III. According to the Musculoskeletal Tumour Society(MSTS) score for functional outcome, the mean overall score for Group I was 27.9 (out of 30), 15.9 for Group II. Of note, the 9 patients within Group II who received endoprosthetic reconstruction, the mean overall MSTS functional score was 25.5. Conclusion Intralesional curettage with adjuvant therapies and filling agents is often associated with a relatively high recurrence rate, however joint function is well preserved. Patients with more extensive, biologically aggressive, and/or recurrent tumours are best treated with en-bloc resection.

Reconstruction of type II pelvic resection with a new peri-acetabular reconstruction endoprosthesis

We report our early experience with a new peri-acetabular reconstruction endoprosthesis used for pelvic reconstruction after tumour resection. The outcome of 21 patients who underwent limb salvage following type II pelvic resection and reconstruction using the peri-acetabular reconstruction prosthesis between 2000 and 2006 was retrospectively reviewed. This prosthesis was designed to use the remaining part of the ilium to support a horizontally placed acetabular component secured with internal fixation and bone cement. Into this device a constrained acetabular liner is positioned which is articulates with a conventional femoral component to which a modular extension and modular head are attached. The mean follow-up was 20.5 months (1 to 77). The most common complications were deep infection, superficial wound infections, and dislocation. The mean musculoskeletal tumor society functional outcome score for the survivors was 20.1(11 to 27). We recommend the use of the peri-acetabular reconstruction prosthesis for reconstruction of large defects after type II pelvic resection, as this design has a greater inherent stability over other available prostheses.

The Clinical Results of En Bloc Proximal Fibula Resection for the Treatment of Fibular Head Tumor

Purpose: We retrospectively reviewed cases of en bloc resection of the proximal fibula for the treatment of tumor arising from the fibular head. Materals and Methods: Between April 1996 and August 2006, 10 patients who underwent en bloc proximal fibular resection and were followed for at least 12 months were included in this study. The mean age was 27.1 years (range, 5-60 years) and the mean follow-up duration was 64.7 months (range, 12.7-140.6 months). The type of en bloc resection was classified according to the Malawer’s resection criteria and the postoperative clinical results were evaluated according to the range of motion, knee joint stability and Musculoskeletal Tumor Society (MSTS) functional scoring system. Results: All patients were able to move the knee joint from 0° extension to 145o flexion except one patient with flexion contracture of 5o. Grade 1 lateral instability of the knee joint was present in two patients. The average MSTS function score was 92.6% (range, 73-100%). There was one patient with lung metastasis who was underwent lobectomy, but there were no patients with local recurrence. Conclusion: En bloc resection of the proximal fibula for the treatment of tumors arising from the fibular head is a useful therapeutic method that preserves the knee stability and promotes good functional outcome

Reconstruction with pasteurized autograft for distal tibial tumor

Primary malignant tumors of the distal tibia are rare. With advances in various treatment modalities, limb salvage for tumors of the distal tibia has been indicated for selected cases. This study examined whether the results of a pasteurized autologous bone graft are comparable to other reconstruction methods with regard to the graft survival and the functional outcome. Between 1992 and 2003, nine patients with malignant tumors of the distal tibia were subjected to the reconstruction with a recycled pasteurized autograft. The ultimate graft survival, union time, complications, and functional results were analyzed retrospectively. One out of the nine autografts was removed after 15 months, due to non-union. Seven complications occurred in six patients, which included superficial infections (two cases), deep infections (one case), non-union (two cases), and fracture (two cases). None of the patients required a secondary below the knee amputation during the follow-up period. The average musculoskeletal tumor society (MSTS) functional score was 26/30 (86.7%). The reconstruction with a pasteurized autograft is a simple and easily method for treating distal tibial malignancies. Moreover, vascularized fibula transfer might be considered a good ancillary procedure for resolving graft-related complications.

Reconstruction of Musculoskeletal Defects Following Oncologic Resection in 76 Patients

Between 1990 and 2002, 76 patients underwent 102 muscle flap reconstructions for extremity sarcomas. The patients had radical resection with immediate reconstruction. Reconstructions were performed by the Musculoskeletal Oncology and Plastic Surgery services. The mean age of our patients was 39.1 years. Patients were studied for a mean of 25.4 months. There were 79 pedicle flaps and 23 free flaps. Complications occurred in 23.7% of patients, including wound necroses, seromas, postoperative bleeding, postoperative infections, and flap loss. Five patients required a secondary flap procedure. The overall flap survival rate was 98%. Three patients had local recurrences. Sixteen patients (21.1%) have died of their disease. Five patients are alive with metastases. In 54 patients, Musculoskeletal Tumor Society (MSTS) functional evaluation scores averaged 27.1 (range, 12-30). In this large series of patients, we have demonstrated that, although minor complications are common, functional limbs can be salvaged following oncologic resection from the extremities.

Arthrodèse d’épaule avec fibula vascularisée après résection tumorale de l’extrémité supérieure de l’humérus: Shoulder arthrodesis with vascularized fibular graft after tumor resection of the proximal humerus

Purpose of the study Resection of malignant tumors of the proximal humerus often requires dissection of the rotator cuffs and the deltoid muscle. There is no consensus on the ideal method for shoulder reconstruction. We report the functional outcome in a homogeneous series of eight patients treated by arthrodesis using a vascularized free fibular flap. Material and methods Eight patients were included in this study. All had an aggressive tumor of the upper humerus. Tumor resection was associated with a rotator cuff and deltoid muscle resection in all patients. All patients then underwent shoulder arthrodesis using a free vascularized fibular flap fixed with a plate. Clinical and radiological evaluation was available for six patients at mean 28 months. The Musculoskeletal Tumor Society function score was used to assess overall function of the upper limb. The cosmetic outcome and radiographic bone healing as well as hypertrophy of the fibular graft were noted. Results Active abduction and active flexion were 82° on average. All patients could bring their hand to the mouth. Circumduction was possible but limited in amplitude. The mean function score was 26.5/30 with an excellent functional outcome in all patients. The cosmetic outcome was considered poor by all patients. Radiographically, bone healing was achieved at last follow-up in all patients but there was one case of failed fusion between the fibular graft and the scapula which required secondary iliac grafting. Mean fibular graft hypertrophy was 32.8% at last follow-up. Discussion and conclusion Two reconstruction methods have been described for patients who require tumor resection of the upper humerus: reconstruction with preservation of glenohumeral joint function and shoulder arthrodesis. Many techniques have been described for each method. It is however difficult to compare the different series reported in the literature because rotator cuff and deltoid muscle resection was not systematically performed and reconstruction methods varied between patients. An analysis of the literature shows that preservation of motion of the scapular glenoid joint can give good functional results when the rotator cuff and deltoid muscle can be preserved. If they cannot, results favor shoulder arthrodesis which provides the patient with very satisfactory upper limb function. Use of a vascularized fibular flap has provided very good arthrodesis results. The patient must however be informed of the probable poor final cosmetic result.

Intralesional Curettage for Grades II and III Giant Cell Tumors of Bone

Grade III Campanacci lesions are traditionally treated with wide resections based on their postulated aggressiveness and potential for local recurrence and metastasis. The purpose of this study was to determine if there was a difference in local recurrence rates of Grade II and III lesions treated with intralesional curettage, burring, phenol cauterization, and polymethylmethacrylate application. Sixty-three patients (26 Campanacci Grade II and 37 Grade III lesions) met the inclusion criteria. No pathologic fractures, including intraarticular fractures, were included in this study. Followup averaged 108 months (range, 25-259 months). The overall local recurrence rate was 6% (4 of 63 patients), with no observed difference between Grade II and III lesions. The average Musculoskeletal Tumor Society functional score was 27.9/30 (93%). The mean range of motion of the adjacent joint was 97%. Patients with radiographic signs of osteoarthritis before treatment did not show substantial progression, and only one patient developed radiographic signs of degenerative arthritis postoperatively. Our distal metastatic rate was 3.2%. These data support the use of intralesional curettage and burring with adjuvant phenol and polymethylmethacrylate even in Grade III lesions, in the absence of pathologic fracture, regardless of the presence or extent of extraosseous extension. Therapeutic study, Level III-1 (retrospective cohort). See the Guidelines for Authors for a complete description of levels of evidence.

Chondroblastoma of bone

We undertook this retrospective study to determine the rate of recurrence and functional outcome after intralesional curettage for chondroblastoma of bone. The factors associated with aggressive behaviour of the tumour were also analysed. We reviewed 53 patients with histologically-proven chondroblastoma who were treated by intralesional curettage in our unit between 1974 and 2000. They were followed up for at least two years to a maximum of 27 years. Seven (13.2%) had a histologically-proven local recurrence. Three underwent a second intralesional curettage and had no further recurrence. Two had endoprosthetic replacement of the proximal humerus and two underwent below-knee amputation after aggressive local recurrence. One patient had the rare malignant metastatic chondroblastoma and eventually died. The mean Musculoskeletal Tumour Society functional score of the survivors was 94.2%. We conclude that meticulous intralesional curettage alone can achieve low rates of local recurrence and excellent long-term function.

Free Vascularized Fibula Grafts in Limb-Salvage Surgery

The authors review the outcome of a consecutive series of 24 free vascularized fibular grafts performed as part of a limb-salvage procedure following tumor excision. There were 15 women and nine men with a mean age of 26 years (range: 6 to 52 years). The minimum follow-up was 12 months. The mean length of the graft was 13.1 cm. (range: 4.5 to 25 cm). Fifteen grafts were used in the upper limb, eight in the lower limb, and one in the pelvis. Bony union was achieved in 21/24 patients at a mean of 9.3 months. Complications occurred in 13/24 patients of whom 11 required a second operation. Four patients died of metastatic disease. The mean Musculoskeletal Tumor Society (MSTS) functional score in the remaining 20 was 84.5 percent, with 16 patients having a good or excellent outcome. Free vascularized fibula grafts offer a reliable method of reconstruction after excision of bone tumors. Although the incidence of complications appears high, they are relatively easy to correct, bony union is achieved in the majority, and functional outcome is good.

Treatment of benign bone lesions with an injectable calcium sulfate-based bone graft substitute.

The treatment of benign bone lesions can be challenging due to the limited quantity of autogenous graft available for harvest and grafting of the defect. The use of an injectable calcium bone graft substitute, Minimally-Invasive Injectable Graft (MIIG) (Wright Medical Technology, Inc, Arlington, Tenn), material for treatment of these bone lesions is advantageous. Calcium sulfate has a long-standing history in the treatment of bone voids secondary to trauma, infection, or neoplastic processes. Minimally-Invasive Injectable Graft injectable calcium sulfate graft may be injected into surgically created osseous defects or bone defects secondary to traumatic injury. After hardening, the paste acts as a temporary intraosseous support through which internal fixation may be placed. Fifteen patients with benign space-occupying lesions were treated with curettage and grafting with an injectable, surgical-grade, calcium sulfate bone graft substitute. Bone healing was assessed postoperatively and defined as resorption of the bone graft substitute material and replacement with new bone formation. The grafted defects in 14 of the 15 patients showed complete incorporation of the graft material at an average of 8 weeks. One patient required incision and drainage for a deep infection 5 weeks postoperatively. The average follow-up was 6 months (range: 3-15 months), and Musculoskeletal Tumor Society functional outcome scores averaged 83%. This injectable, minimally invasive graft material is easy to use, provides a temporary structural support when grafting bone defects, and results in predictable rapid bone healing.

Early multicenter experience with a noninvasive expandable prosthesis.

A noninvasive expandable prosthesis for skeletally immature children after limb salvage surgery has been developed. Between 1998 and 2001, 18 Phenix prostheses were implanted in 15 pediatric patients who had been diagnosed and treated for osteosarcoma about the knee. Of the 15 original prostheses, 10 were implanted at the time of primary tumor resection and five were revisions from an endoprosthetic modular knee system. Sixty expansions of the 18 prostheses were done, with all but two done as outpatient procedures. An average 8.5 mm was obtained per lengthening (range, 1-30 mm). The average followup was 21.5 months (range, 12-33 months) and the latest Musculoskeletal Tumor Society functional scores averaged 90%. Eight revisions were required for stem fracture or loosening. There was one amputation because of a postoperative arterial thrombosis. The principle of the Phenix prosthesis involves storage of energy in a spring compressed by a locking system. Lengthening is achieved via exposure to an electromagnetic field that allows controlled release of the spring. This is a unique expandable custom prosthesis that offers many benefits in maintaining limb length equality in growing patients. Although the early experience is promising, additional data are required regarding the long-term structural integrity of the prosthesis. We are optimistic that this technology will prove beneficial, not only for patients with malignant bone tumors but in applications requiring serial limb length equalizations or for spinal deformities.

Complex segmental elbow reconstruction after tumor resection.

Twenty-three patients were reviewed retrospectively to determine their oncologic and functional outcomes after resection of 15 primary or eight metastatic tumors about the elbow between 1985 and 2000. The indications for resection were dictated by the histologic features of the tumor, location of the lesion, and extent of bone destruction. A total humeral reconstruction was done in 12 patients. Of this group, an endoprosthesis was used in seven patients and a total humeral allograft with a proximal humeral prosthesis and osteoarticular elbow reconstruction (allograft-prosthetic composite) was used in five patients. Eleven additional patients had a segmental total elbow replacement after resection of the distal humerus or proximal ulna. Local disease control was achieved in 17 patients (74%). Fourteen patients presented with (48%) or had (13%) distant metastasis develop, but only eight (35%) died of their disease. Periprosthetic lysis or allograft resorption was present in five patients (22%), and two (18%) humeral components of total elbow prostheses required revision for loosening. The mean Musculoskeletal Tumor Society functional score was 23 of 30 points (77%) in the 12 living patients followed up for a mean of 46 months (range, 24-124 months). It was 83% in patients with a segmental total elbow reconstruction and 71% in patients with a total humeral reconstruction. Aggressive limb salvage of the humerus or elbow or both provides a satisfactory functional outcome without jeopardizing overall survival.

Extensible Endoprostheses for Bone Tumors of the Proximal Femur in Children

Between 1983 and 1996, nine children were treated with extensible endoprosthetic replacements of the proximal femur after resection of primary bone tumors. Four patients died of their disease. The remaining five patients were observed for an average follow-up period of 7.6 years. In these five patients, the authors performed an average of 10.2 operations per patient, including five lengthenings and a mean total extension of 69.7 mm per patient. Acetabular loosening and hip dislocations were the most frequent complications. Only two patients have not had a revision or a major complication. Despite this, four children are alive with a functioning lower limb and a mean Musculoskeletal Tumor Society functional score of 77.6%. Extensible endoprosthesis of the proximal femur is a viable alternative to hip disarticulation and in selected children offers an opportunity for near-normal development of the lower limb by allowing equalization of limb length and the ability to walk without the use of mobility aids.

Allograft reconstruction after resection of malignant tumors of the scapula.

The oncologic and functional outcomes of six patients who had scapular allograft reconstruction after scapulectomy for malignant tumors were reviewed. Five patients had Stage IIB and one patient had Stage IB tumors. Total scapulectomy was done in five patients, and partial scapulectomy (glenoid and neck) was done in one patient. Frozen glycerolized scapular allografts were implanted and fixed with plates and screws. The scapular muscles were reattached to the allograft. Tendon reconstruction to replace the excised muscles was done in two patients. The patients were followed up for an average of 3.8 years (range, 2-6 years). Cosmesis, elbow, and hand function were good in all patients. There were no infections, nonunions, or shoulder dislocations. One patient fractured the body of the allograft after a fall. One patient had local recurrence and had scapulectomy 5 years postoperatively. Two patients died 3 and 5 years postoperatively with lung metastases but with functioning grafts. The mean functional result using the Musculoskeletal Tumor Society functional score was 82 (range, 77-87). In this series, scapular allograft reconstruction restored cosmesis, shoulder stability, and function. Preservation or reconstruction of rotator cuff muscles is recommended.