Underwent Limb Salvage Surgery Research Articles

Mesenchymal chondrosarcoma of the foot salvaged by sensate chimeric anterolateral thigh free flap

Mesenchymal chondrosarcoma is a rare, aggressive sarcoma of bone or soft tissue with a high risk of hematogenous spread, leading to significant morbidity and mortality. Surgical resection is the standard treatment for localized cases. Addressing the limited data, we present a case of localized mesenchymal chondrosarcoma in the foot, where upfront surgery risked sacrificing the medial longitudinal arch crucial for weight-bearing. The patient received neoadjuvant chemotherapy and underwent limb salvage surgery using a sensate chimeric anterolateral thigh flap to preserve functionality.

Metal Ion Release in Cancer Patients Following Megaprosthesis Salvage Surgery

BackgroundMegaprostheses contain many more modular components than conventional total hip and knee arthroplasty, which may lead to higher serum levels of metal ions. The aim of this study was to determine serum concentrations of titanium, chromium, and cobalt ions in cancer patients after limb salvage surgery with a megaprosthesis. MethodsA retrospective, descriptive cohort analysis consisting of patients who underwent cancer-related limb salvage surgery with a megaprosthesis at our hospital between 2010 and 2020 was conducted. Baseline and follow-up data were extracted from clinical and surgical records. Blood samples were prospectively obtained. Descriptive statistics were used for the analysis. ResultsA total of 71 patients underwent limb salvage surgery during the study period. Of these, 22 (10 women, 12 men) were included in the study. The mean age was 52 years (range, 21 to 80). Most cases (n = 16; 72.7%) involved the femur. Most patients (n = 14, 63.6%) underwent total knee megaprosthesis surgery. Implant revision surgery was required in 45% of cases (n = 10), with a mean interval of 4.32 years between the initial and revision surgeries. The mean follow-up time after revision surgery was 4.05 years. High levels of chromium were observed in 22.7% of patients (n = 5). High cobalt levels were found in 68.2% (n = 15) of patients, with toxic levels in 9.1% (n = 2). Titanium levels were high in 77.3% (n = 17) of cases and toxic in 22.7% (n = 5). Postoperative chemotherapy was significantly associated with titanium levels (P = .017). No correlation was observed between metal ion levels and time from primary or revision surgery or time from the first to revision surgery. ConclusionsThis study shows that cancer-related limb salvage surgery with megaprosthesis is associated with metal ion levels that exceed established safe thresholds. Compared to conventional hip arthroplasty, a higher proportion of the patients in this cohort presented elevated levels of metal ions. Level of evidenceIII.

Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review.

Peri-megaprosthetic joint infections (PJI) in tumor surgery are complex and challenging complications that significantly impact the outcomes of the patients. The occurrence of PJI poses a substantial threat to the success of these operations. This review aims to identify and summarize the risk factors associated with PJI in tumor surgery with megaprosthetic reconstruction as well as to determine the overall risk of PJI in limb salvage surgery. A thorough examination of published literature, scrutinizing the incidence of PJI in tumor prostheses after limb salvage surgery was done. Research studies that documented the incidence of PJI in tumor patients who underwent limb salvage surgery, and explored the risk factors associated with the occurrence of PJI were deemed eligible. A total of 15 studies were included in the analysis and underwent comprehensive examination. After the exploration of key parameters, several significant risk factors for PJI concerning the type of implant coating, surgical site characteristics, patient demographics, and procedural factors were recorded. The findings underscore the need for a nuanced approach in managing tumor patients undergoing limb salvage surgery and megaprosthetic reconstruction, with emphasis on individualized risk assessments and individualized preventive strategies.

Forequarter Amputation for Malignant Tumours: Tale of Sustained Relevance or Telltale Sign of Doom?

Forequarter amputation (interscapulothoracic amputation) includes surgical removal of an upper limb and the shoulder girdle, including the scapula and a portion of the clavicle. We aim to report about our recent experience of having to resort to this mutilating surgery and the clinicopathological variables in that context. The study was done at a cancer centre in Northeast India. It was an ambispective study design, where the patient cohort who underwent FQA was identified retrospectively from the operative register of major surgeries for the time period 1st June 2020 to 31st May 2022 (24 months), and these patients were followed up prospectively from 1st June 2022 to 31st May 2023 (1 year). The study variables were obtained from the electronic medical records (EMR), the physical case files and the hospital-based cancer registry (HBCR). There were 7 patients who underwent forequarter amputation (FQA) during the two years, and in the same period, 15 patients underwent limb salvage surgery for tumours around the shoulder girdle. This translates to a FQA rate of 31.8%. The male:female ratio of the patients was 3:4. The median age of the patients was 32 years (range 19 to 59 years). The histologies included osteosarcoma (2), chondrosarcoma (2), Ewing's sarcoma (2) and hidradenocarcinoma (1). None of these patients had any distant metastatic disease. Four patients had local disease progression on neoadjuvant chemotherapy. Three of the patients had emergency surgery as a life-saving procedure on account of bleeding from their ulcerated tumours. Two patients had disease which was recurrent and unsalvageable due to the encasement of the neurovascular bundle. The median follow-up was 8 months (range 4 to 18 months). Five patients had distant recurrence with pulmonary metastases (100%) and bone secondaries (14.3%) within a range of 3 to 8 months. None of the patients had any local recurrence. Two patients are on follow-up without any evidence of disease (17 and 18 months respectively). Forequarter amputation is the surgical option when tumours around the shoulder girdle are not amenable to limb-sparing procedures by virtue of their disease extent. These cancers are usually aggressive leading to early distant metastasis.

Resurfacing the defect from wide excision of a malignant peripheral nerve sheath tumor based on a thoracodorsal artery perforator free flap: a case report

Malignant peripheral nerve sheath tumors (MPNSTs) are rare, aggressive soft tissue sarcomas with a high rate of recurrence and metastasis. Limb salvage surgery with free flap reconstruction is a viable option for selected patients with MPNSTs, but careful consideration should be given to the risk of recurrence. This case report describes a 26-year-old male patient with a recurrent, aggressive, high-grade MPNST who underwent limb salvage surgery with thoracodorsal artery perforator free flap reconstruction. Despite the surgical intervention, local recurrence of the MPNST was detected, and below-knee amputation was ultimately recommended. This case highlights the importance of early, definitive treatment decision-making in cases of aggressive, high-grade MPNSTs. Close postoperative monitoring and early detection of recurrence are crucial for achieving optimal outcomes in patients with MPNSTs undergoing limb salvage surgery with free flap reconstruction.

Are Pathologic Fractures in Patients With Osteosarcoma Associated With Worse Survival Outcomes? A Systematic Review and Meta-analysis.

Pathologic fractures occur in 5% to 10% of patients with osteosarcoma, and prior studies have suggested they are prognostically important. However, because they represent an uncommon event in the setting of an already rare disease, most studies fail to reach conclusive findings, and there is no agreement about how best to treat pathologic fractures. (1) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer overall survivorship? (2) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer local recurrence-free survival or metastasis-free survival? (3) Is the surgical approach (amputation or limb salvage) associated with differences in local recurrence rates in patients with osteosarcoma with pathologic fractures? This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our study was registered in PROSPERO (ID: 380459). A search of the PubMed and Embase databases resulted in 625 and 747 titles, respectively. After application of the inclusion and exclusion criteria, 21 articles were finally included. Quality assessment of all studies was performed using the Newcastle-Ottawa Quality Assessment Scale. The Risk of Bias In Non-Randomized Studies of Interventions tool was used in the 11 articles that evaluated the effect of an intervention (amputation or limb salvage) on local recurrence rates. The relative risk (RR) was calculated to compare outcomes in patients with osteosarcoma with pathologic fractures and those without. Heterogeneity among studies was calculated using the I 2 statistic. The pooled RR was calculated using the fixed-effects or random-effects model depending on study heterogeneity. The fragility index and the ratio between the fragility index and the total number of participants for each outcome was additionally calculated to assess the robustness of our results. A total of 7604 patients with osteosarcoma, 12% of whom (885) had pathologic fractures, were included in our analysis. Pathologic fractures in patients with osteosarcoma were associated with lower 3-year (RR 1.53 [95% CI 1.29 to 1.82]; p < 0.001) and 5-year overall survival (RR 1.27 [95% CI 1.16 to 1.40]; p < 0.001). No difference in recurrence rates was found between patients with osteosarcoma with pathologic fractures and those without (RR 1.22 [95% CI 0.91 to 1.64]; p = 0.18). However, having a pathologic fracture was associated with an increased risk of developing metastasis (RR 1.33 [95% CI 1.08 to 1.63]; p = 0.01). Treatment with limb salvage surgery was not associated with a higher rate of local recurrence (RR 1.58 [95% CI 0.88 to 2.85]; p = 0.13). In light of these findings, surgeons should be aware that after appropriate case selection, patients with osteosarcoma and pathologic fractures undergoing limb salvage surgery may have similar rates of local recurrence to those undergoing amputation. Therefore, a pathologic fracture may no longer be an absolute contraindication for limb salvage surgery. Future studies adjusting for potential confounders such as tumor size, tumor location, and response to neoadjuvant therapy would provide further insight into the effect of pathologic fractures on our assessed outcomes. Level III, therapeutic study.

Cancer-Specific Survival after Limb Salvage versus Amputation in Children and Adolescents with Osteosarcoma: A Population-Based Analysis with Propensity Score Matching.

The study aims to identify whether osteosarcoma patients of children and young adults will benefit from a survival profit from the choice of the operation method. The National Cancer Institute SEER database from 2000 to 2018 was selected for a retrospective analysis of 1630 children and young adults with a primary diagnosis of osteosarcoma, 1222 who underwent limb-preserving surgery, and 408 who underwent amputation. Confounders were controlled for by propensity score matching (PSM), cancer-specific survival (CSS) was analyzed using the Kaplan-Meier method, and univariate and multivariate Cox regression was used to analyze the factors influencing the prognosis of children and young osteosarcoma patients after surgery. A nomogram plot predicted 1-, 3-, and 5- survival rate in osteosarcoma. The model's accuracy was validated by the area under the ROC and calibration curves. After PSM, multifactor Cox regression analysis found AJCC Stage III-IV (CSS : HR = 5.26, 95% CI 1.95-14.18, p=0. 001; HR = 5.54, 95% CI 2.56-12.01, p < 0. 001. Limb salvage surgery (CSS : HR = 0.58, 95% CI 0.44-0.77, p < 0. 001) has independent impact factors for CSS prognosis. The survival curve before and after PSM showed that patients with osteosarcoma of children and young adults who underwent limb salvage surgery had a survival benefit compared with those who underwent amputation surgery. Gender, chemotherapy, histology, primary tumor site, stage, and surgical modality were modeled in a total of six variables in the nomogram. The model exhibited good predictive performance. The AUC were 0.823, 0.74, and 0.757 for training set at 1, 3, and 5 years, respectively. The AUC of validation set 0.666, 0.722, and 0.699 at 1, 3, and 5 years, respectively. The model also predicted CSS with good fidelity for both datasets. This model was significantly superior to the 8th edition of the AJCC TNM staging system, with a better net benefit in predicting CSS in children and young adults with osteosarcoma. Limb salvage surgery is an option for children and young adults with osteosarcoma and cancer-specific survival rates can be improved by receiving limb salvage surgery.

Functional results after reconstruction with modular tumor endoprostheses in patients with malignant bone tumors

The functional outcome in patients after limb salvage surgery, and in particular reconstructions with modular tumor endoprostheses, has been the subject of many international series, but only a few publications mention the functionality in a Bulgarian patient group. The aim of the present study was to analyze the functional outcome in a Bulgarian group of patients with malignant bone tumors that underwent resection and reconstruction with modular tumor endoprostheses. Our series consists of 14 patients with malignant bone tumors who underwent limb salvage surgery and reconstruction with modular tumor endoprostheses between February 2012 and January 2021. Staging was done using the AJCC staging system for bone sarcoma. The MSTS score system was used to evaluate the functional results. The mean follow-up time was 38.5 months (range, 8 to 96). The mean MSTS score for our series was 70%. Distant metastases were found in 4 (28%) patients. Local recurrence occurred in 3 (21%) patients. The most severe late complication was a mechanical failure of the expanding mechanism in 1 patient. Reconstruction with modular tumor endoprostheses offer superb functionality and improved life quality in patients with primary malignant bone tumors.

Our Experience with the Modular Universal Tumour and Revision System in Pediatric Patients with Ewing's Sarcoma – Report of Six Cases

Ewing’s sarcoma (ES) usually affects patients between 10 and 19 years of age and has a rapid progression. The main goal of surgical treatment is to remove the tumour with at least wide margins, limb salvage being achievable in most cases. In recent years, modular tumour endoprostheses have become one of the main methods used in children. From August 2012 to May 2019, six patients with histologically diagnosed ES underwent limb salvage surgery and reconstruction with a MUTARS® type endoprosthesis. The mean age of the patients is 12.6 years (from 8 to 16). For the reconstruction in all six patients we used MUTARS® type endoprostheses, two of which were expandable (MUTARS® Xpand) (33.33%). The average follow-up period was 40 months. The longest follow-up was 96 months. The average MSTS score one month after operative treatment and rehabilitation was 62% (18/30) and the average MSTS score after 12 months was 72% (21/30). Mechanical failure of the expanding mechanism was the main complication we encountered in our series. In conclusion limb salvage surgeries and reconstruction with modular tumour endoprostheses give patients with Ewing’s sarcoma not only a chance for a disease-free life, but a potentially functional limb.

Whole Blood Titanium Concentration after Limb Salvage Surgery with Three-Dimensional-Printed Ti6Al4V Implants.

Three-dimensional (3D)-printed customized implants can be fabricated and utilized for all bones with massive bone defects. The main safety issues with 3D-printed implants made of Ti6Al4V alloy are related to the release of metal debris and residual powder. In this study, we investigated the perioperative titanium concentrations in whole blood and peri-implant fluid samples of patients who underwent limb salvage surgery with a 3D-printed Ti6Al4V implant. Nineteen patients who underwent limb salvage surgery with 3D-printed Ti6Al4V implants were divided into two groups: the serial samples group and the follow-up group. To observe metal distribution and clearance in the body, serial samples of blood and peri-implant fluid from the surgical drain were prospectively collected for five patients in the serial samples group. For the remaining 14 patients who were followed up for more than a year, blood samples were collected only once. In the serial samples group, the mean baseline titanium concentration was 0.78 µg/L (range, 0.1-2.2 µg/L): 3 patients showed peak concentration before the third postoperative month, while 2 patients still showed an increasing pattern at this point. Total titanium mass in the surgical drain showed a wash-out phenomenon in a week, with a significant uniform decrease (p = 0.04). In 14 patients in the follow-up group, the mean titanium concentration in the whole blood was 10.8 µg/L (range, 0.3-36.6 µg/L). For the 14 patients with a long-term follow-up, the aluminum and vanadium concentrations were all negligible. Whole blood titanium concentrations were higher after surgery using 3D-printed implants than after that using conventional orthopedic implants, but markedly lower than in patients with implant failure. None of the patients developed serious clinical adverse effects during follow-up.

What has changed in the last 25 years in osteosarcoma treatment? A single center experience.

Osteosarcoma is the most common type of primary malignant bone tumor in the extremities. The main purpose of this study was to determine clinical features, prognostic factors, and treatment results of patients with osteosarcoma at our center. We retrospectively analyzed the medical records of children with osteosarcoma between the years 1994-2020. 79 patients were identified (54.4% male, 45.6% female). The most common primary site was the femur (62%). Twenty-six of them (32.9%) had lung metastasis at diagnosis. The patients were treated between 1995- 2013 according to the Mayo Pilot II Study protocol, while the others were treated with the EURAMOS protocol between the years 2013-2020. Sixty-nine patients underwent limb salvage surgery as a local treatment, whereas seven underwent amputation. The median follow-up time was 53 months (2.5-265 months). The event-free survival (EFS) and overall survival (OS) rates at 5 years were 52.1% and 61.5%. The 5-year EFS and OS rates were 69.4% and 80% in females; 37.1% and 45.5% in males (p=0.008/p=0.001). The 5-year EFS and OS rates of the patients without metastasis were 63.2% and 66.3%; with metastasis 28.8% and 51.8% (p=0.002/p=0.05). For good-responders, the 5-year EFS and OS rates were 80.2% and 89.1%; while for poor-responders, 35% and 46.7% (p=0.001). Mifamurtide was used in addition to chemotherapy as of the year 2016 (n=16). The 5-year EFS and OS rates were 78.8% and 91.7%, respectively for the mifamurtide group; 55.1% and 45.9%, respectively for the non-mifamurtide group (p=0.015, p=0.027). Metastasis at diagnosis and poor response to preoperative chemotherapy were the most important predictors of survival. Females had a better outcome than males. In our study group, the mifamurtide group`s survival rates were significantly higher. Further large studies are needed to validate the efficacy of mifamurtide.

Calcanectomy in primary high-grade sarcomas: Foot salvage without the need for any reconstruction

The calcaneum is a rare site for primary bone sarcomas. Calcanectomy is not considered for high-grade malignancies due to anticipated issues with obtaining negative margins, providing adequate soft-tissue coverage, and preserving satisfactory function. A below-knee amputation overcomes these difficulties and is very functional and, thus, the preferred local control option. The aim of this study is to evaluate the role of total calcanectomy, without any formal reconstruction, in high-grade calcaneal sarcomas. Over 14 years, three patients with high-grade calcaneal sarcomas underwent limb salvage surgery as opposed to amputation for their primary malignancy. Total calcanectomy was undertaken using a Cincinnati incision. No formal “calcaneal” reconstruction was undertaken after resection, essentially leaving the patient with an excision arthroplasty through the subtalar joint. The Achilles tendon was reattached to the posterior talus. Negative resection margins were achieved in all cases with the primary wound closure. Two patients are alive with no evidence of disease at 15 and 10 years. The third patient, at over 1 year postoperatively, has no evidence of local disease recurrence but has had metastasectomy for documented pulmonary metastases at the presentation. The average musculoskeletal tumor society score was 85.5%, and the average Toronto extremity salvage score was 88.5%. In our experience, even high-grade malignancies at this unusual site are potentially amenable to limb salvage. Our results show that perhaps ablative surgery should not be considered inevitable. Good functional outcomes can be achieved without reconstruction, thus minimizing potential “construct”-related morbidities.

Application of three-dimensional printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors

To investigate the clinical application and effectiveness of three-dimensional (3D) printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors. The clinical data of 10 adolescent patients with femoral primary malignant tumor who met the selection criteria and underwent limb salvage surgery with 3D printed customized prosthesis with preserved epiphysis and articular surface between January 2020 and October 2021 were retrospectively analyzed. There were 6 males and 4 females with an average age of 12.5 years ranging from 7 to 18 years. There were 8 cases of osteosarcoma and 2 cases of Ewing's sarcoma. Enneking stage was Ⅱb. The length of the lesions ranged from 76 to 240 mm, with an average of 138.0 mm. The length of osteotomy (i. e. length of customized prosthesis) ranged from 130 to 275 mm, with an average of 198.5 mm; the distance between distal osteotomy end and epiphyseal line ranged from 0 to 15 mm, with an average of 8.8 mm; the bone defect after osteotomy accounted for 37.36% to 79.02% of the total length of the lesion bone, with a mean of 49.43%. The operation time, intraoperative blood loss, complications, tumor outcome (refered to RESIST1.1 solid tumor efficacy evaluation criteria), and limb length discrepancy were recorded. The Musculoskeletal Cancer Society (MSTS) 93 score was used to evaluate the function at 6 months after operation, and visual analogue scale (VAS) score was used to evaluate the pain before and after operation. The operation was successfully performed in all the 10 patients, and the postoperative pathological results were consistent with the preoperative pathological results. The operation time was 165-440 minutes, with an average of 263 minutes; and the intraoperative blood loss was 100-800 mL, with an average of 350 mL. All patients were followed up 7-26 months, with an average of 11.8 months. No tumor was found on the osteotomy surface; the customized prosthesis were firmly installed and closely matched with the retained articular surface. The tumor outcome of neoadjuvant chemotherapy was stable in 4 cases and partial remission in 6 cases. No local recurrence or distant metastasis was found in 9 cases after postoperative adjuvant chemotherapy; pulmonary metastasis was found in 1 case at 12 months after operation. Two patients had local incision fat liquefaction, superficial infection, and delayed healing at 14 days after operation; 1 patient had local bone absorption at the contact surface of the prosthesis, and the screw and prosthesis did not loosen at 7 months after operation; the other patients had good incision healing, with no infection, prosthesis loosening, fracture, or other complications. At 6 months after operation, the MSTS93 score was 19-28, with an average of 24.1; 8 cases were excellent and 2 cases were good. The VAS score was 0.9±1.0, which significantly improved when compared with before operation (5.9±1.0) ( t=23.717, P<0.001). The height of the patients increased by 1-12 cm, with an average of 4.6 cm. At last follow-up, 4 patients had limb length discrepancy, with a length difference of 1 cm in 2 cases and 2 cm in 2 cases. The application of 3D printed customized prosthesis in the resection and reconstruction of adolescents femoral primary malignant tumors can achieve the purpose of preserving epiphysis and articular surface, and obtain good effectiveness.

Tourniquet use in patients undergoing tumour resection and endoprosthetic reconstruction of the knee.

The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee. We retrieved data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial; specifically, differences in baseline characteristics, surgical details, and postoperative functional outcomes between patients who had undergone surgery under tourniquet and those who had not. A linear regression model was created to evaluate the impact of tourniquet use on postoperative Toronto Extremity Salvage Scores (TESSs) while controlling for confounding variables. A negative-binomial regression model was constructed to explore predictors of postoperative length of stay (LOS). Of the 604 patients enrolled in the PARITY trial, 421 had tumours around the knee joint, of whom 225 (53%) underwent surgery under tourniquet. The tourniquet group was younger (p = 0.014), more likely to undergo surgery for a tumour of the tibia, and had shorter operating times by a mean of 50 minutes (95% confidence interval 30 to 72; p < 0.001). The adjusted linear regression model found that the use of a tourniquet, a shorter operating time, and a higher baseline TESS independently predicted better function at both three- and six-month follow-up. The negative-binomial regression model showed that tourniquet use, shorter operating time, younger age, and intraoperative tranexamic acid administration independently predicted a shorter LOS in hospital. The results of this study show that in patients undergoing resection of a tumour around the knee and endoprosthetic reconstruction, the use of an intraoperative tourniquet is associated with a shorter operating time, a reduced length of stay in hospital, and a better early functional outcome.Cite this article: Bone Joint J2022;104-B(10):1168-1173.

Role of anlotinib in the treatment of early advanced osteosarcoma of limbs in children.

e23509 Background: The prognosis of advanced or early advanced osteosarcoma during neoadjuvant chemotherapy is unfavorable. Many patients can only accept brutal amputation without a new and reliable limb rescue solution. There are no clinical data on the efficacy and safety of anlotinib in the treatment of osteosarcoma in children and adolescents. We investigate the efficacy of anotinib plus first-line chemotherapy (platinum + doxorubicin liposome/ifosfamide) in the treatment of early advanced osteosarcoma in children and adolescents. Methods: Early advanced osteosarcoma in this study was defined as pathologically identified osteosarcoma that progressed within 6 months after radical surgery, with neoadjuvant chemotherapy or adjuvant chemotherapy. 11 cases of limb osteosarcoma with Enneking stage IIB (8 cases in the lower femur and 3 cases in the upper tibia), aged 8-15 years, were selected from February 2018 to December 2021. After 1 cycle of first-line neoadjuvant chemotherapy, patients locally advanced received anlotinib (12mg/d) combined with first-line chemotherapy for 1-2 cycles. The tumor shrinkage rate, limb salvage rate, disease-free survival time (DFS), progression-free survival time (PFS), disease control rate (DCR), and safety were analyzed. Results: 9 patients had locally advanced during neoadjuvant chemotherapy. After 2 cycles of anlotinib combined with first-line chemotherapy, the tumor shrunked and was well demarcated from surrounding tissue. All patients underwent limb salvage surgery Postoperative chemotherapy lasted for 4-6 cycles, with a median DFS of 12 months. 2 patients who developed recurrence or metastasis after radical surgery continued to complete at least 8 cycles of standard first-line chemotherapy combined with anlotinib, PFS showed separately 6 months and 8 months. The tumor shrinkage rate was 54.55% and the DCR was 72.73%. The adverse reactions associated with anlotinib were epistaxis (8 cases, 72.72%) and oral ulcer (1 case, 9.09%), which were controlled immediately after withdrawal. Conclusions: Combination of anlotinib with first-line chemotherapy can shrink the tumor, improve limb salvage rate for children with early advanced osteosarcoma, and delay disease progression for children with recurrence and metastasis after radical surgery. The toxicity of anlotinib combined with first-line chemotherapy were tolerated which is expected to be a new approach for the treatment of early advanced osteosarcoma.

Early Clinical Outcome of Limb Salvage Surgery of Osteosarcoma in the Lower Extremity Using Liquid Nitrogen

Background. Osteosarcoma in the lower extremity has become a challenge for orthopedic surgeons to manage because surgeons need to preserve the affected joint's functions and retain stability as physiologic as possible. Thus, limb salvage surgery may be the treatment of choice. One of the techniques using liquid nitrogen provides better functionality and efficacy in preventing recurrence.&#x0D; Methods. From October 2020 to October 2021, 7 patients with primary musculoskeletal sarcoma underwent limb salvage surgery (LSS) by wide resection of the tumor and reconstruction using recycled Autograft treated with liquid nitrogen. The resected bone was dipped in liquid nitrogen for 15 min and thawed at room temperature for 15 min. The recycled bone was re-implanted into its original site and stabilized with internal fixation, and some of them followed with arthroplasty.&#x0D; Results. Average age was 14.14 years old. The most common site was the distal femur which was found in 3 cases (42,8%). During the 6-months-follow-up period, all patients had a good function (mean functional MSTS score of 90%) with one case of local recurrence in the re-implanted bone and one case of infection. No metastasis was reported in any patient.&#x0D; Conclusion. Satisfying functional results were recorded in all subjects treated with cryosurgery in Dr. Mohammad Hoesin General Hospital Palembang with equal results with studies around the world.

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.

Early Complications after Limb Salvage Procedures: Prospective Cross Sectional Study

ABSTRACT Introduction: Sarcomas are tumors that are mesenchymal in origin involving bone and soft tissues occurring in all age groups. Giant cell tumor, although benign, is locally aggressive and can also destroy the bone. Amputation was once considered primary treatment but now with advancements in diagnostic imaging modalities, surgical procedures and adjuvant therapies, limb salvage surgeries have become the preferred treatment modality. The primary objective of our study was to determine the incidence of early complications occurring within the first thirty days in patients who underwent limb salvage surgery at our hospital. The secondary objective was to assess the association of these complications with patient-related factors, surgical modality, tumor characteristics and neoadjuvant therapy. Methodology: All the patients with bone or soft tissue sarcoma and aggressive giant cell tumors of the extremities who underwent wide excision and limb salvage surgery from February 2020 to December 2021 were included in this study. Data were collected prospectively on follow-up visits in the clinic for one month. Data were compiled and analyzed using SPSS version 22. A p-value of &lt;0.05 was considered significant throughout the study. Results: A total of 60 patients were included in this study. The mean age of the patients was 39.90 years. Bone and soft tissue tumors were found in 35 and 25 patients respectively. A total of 13 patients experienced postoperative complications within 30 days of surgery. The association of these postoperative complications with gender distribution, prior comorbid conditions, type of tumor, anatomical location of the tumor and neoadjuvant therapy was found to be statistically insignificant. Conclusion: The most frequently occurring postoperative complications are wound-related and the incidence of these complications is independent of the proposed risk factors. Research registry number: Researchregistry4695. Highlights

Early outcomes of limb salvage surgery with mega-prosthesis

Objective: To determine the early outcomes of limb salvage surgery with mega prosthesis. Methods: This retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&amp;RC) from 1st January 2017 till 31st January 2020. Data like demographics, histopathology, functional and survival outcomes were retrieved from the Hospital Information System. Musculoskeletal Tumor Society (MSTS) score was used to evaluate the functional outcomes after the surgery. For survival analyses, Kaplan-Meier curve was applied. Prosthesis joint infection, amputation rate, metastasis, mortality rate, and recurrence were also recorded. Results: This study included 43 patients who underwent limb salvage surgery with endoprosthesis reconstruction at SKMCH&amp;RC. The mean age at the time of diagnosis was (26.5±15.8) years. Patients with distal femoral replacement had the highest MSTS scores (81.45±9.70) while those with proximal humerus replacement has the lowest MSTS scores (56.8±11.2). There was a strong association between site of tumor and MSTS (F=3.30, P=0.017). We also found a correlation between surgical site infection and MSTS scores (r=0.484, P=0.001). Patients with recurrence also had significantly lower MSTS scores (P&lt;0.05). The cumulative survival rate at the end of two-year follow-up was (71.4±17.1)% in proximal femur tumor patients, (88.0±7.8)% in distal femur tumor patients, and (50.0±3.5)% in proximal humerus tumor patients. Besides, patients with Ewing sarcoma had the highest survival rate (97.5±11.0)% while patients with chondrosarcoma had the lowest survival rate (77.8±13.9)%. Conclusions: Limb salvage surgery with mega-prosthesis can be performed with satisfactory functional and survival outcomes, but further studies are needed to compare it with other limb salvage methods. This study can be used as a reference for future studies.

Functional Outcomes of Limb Salvage Surgery in Patients with Giant Cell Tumor of Bone of the Lower Extremities: A Retrospective Study

Giant cell tumor of the bone (GCTB) is a benign, locally aggressive neoplasm that is relatively rare, with a propensity to result in progressive bone destruction, and is associated with a high risk of recurrence. There is no widely held consensus regarding its ideal treatment. Worldwide, there are varying techniques ranging from intralesional curettage to resection of the lesion, supplemented with combinations of numerous adjuncts and fillers, depending on the resected amount and integrity of bone, as well as the preference of the surgeon. This was a cross-sectional study that included 20 patients who underwent limb salvage surgery for giant cell tumor of the bone of the lower extremities from January 2009 to February 2020 at two tertiary hospitals. The mean follow-up period was 37.3 months (SD=2.84). The extended curettage (EC) group had a mean Musculoskeletal Tumor Rating Scale (MSTS) score of 28.18 (SD=7.51) which is considered as an excellent outcome, while the resection (RS) group had an mean MSTS score of 19.67 (SD=11.02), which is considered as a good outcome. EC resulted to a total of eight complications (47%), while RS had one complication (33%). Prevalence of recurrence was noted to be 11.75% among those who underwent EC, while no recurrence was noted among those in the RS group. Use of bone cement as a filler was noted to have less recurrence as compared with the use of bone grafts, however were both were noted to result in excellent functional outcomes. Despite the prevalence of complications and recurrence of GCTB of the salvaged extremity in those who underwent EC, there is still report of excellent functionality. It is hence important to disclose all these possible outcomes and to stress the importance of compliance to follow-up for monitoring of these events.