Underwent Limb Salvage Research Articles

The correlation of prognostic factors and clinical outcomes in patients with osteosarcoma – An observational study

Context: Osteosarcoma is characterized by the production of malignant osteoid. It arises typically in the adolescent age group. Aims: The purpose of this study is to analyze the impact of various prognostic factors on survival in osteosarcoma patient admitted in our institution. Settings and Design: Retrospective observational study of 10 years duration from 2007 to 2017 Methods and Materials: There were 66 patients in the records. As a part of the staging work up, CT and MRI of the local part and CECT CHEST were performed . All patients received adriamycin and cisplatin with or without Ifosfamide, and PCVE regimen. Statistical analysis used: IBM SPSS Statistics version 20. Survival and percentage of necrosis was correlated by Spearman Rank correlation. Results: Sixty six patients were included in this study. The median survival of patient who underwent limb salvage surgery (LSS) was 28 months and that of patient underwent amputation was 17 months. No statistically significant survival advantage present between the two group (p=0.68). There is a statistically significant difference in percentage of necrosis in patient who receive neoadjuvant chemotherapy if ifosfamide is added to the regime (p=0.006). Spearman Rank correlation revealed that there was a strong positive Correlation (0.418) between the percentage of necrosis and survival. The correlation was statistically significant (p = 0.02). Conclusions: LSS in osteosarcoma is a safe alternative to amputation. Response to chemotherapy, with regards to necrosis correlates well with survival, thus clearly emphasizing the role of chemotherapy in the management of these tumors. Keywords: OSTEOSARCOMA, Limb salvage surgery, Amputation.

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report.

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report.

Functional results of various reconstruction techniques in primary malignant bone tumors

Abstract Introduction: The aim of the study was to report the clinical and functional outcomes in patients undergoing limb salvage with various reconstruction techniques in primary malignant bone tumor. Materials and methods: This study was performed between 2011 and 2018 on 52 patients with primary malignant bone tumors admitted to the Department of Orthopaedics and Traumatology of University Emergency Hospital, Bucharest. All the patients underwent surgical treatment (resection-reconstruction technique) followed by oncologic therapy. The mean follow-up was 3 years and 8 months and the minimum follow-up was 12 months. Results: The best results were obtained in patients in whom resection of the tumor followed by reconstruction was possible, without affecting the adjacent joint through arthrodesis or arthroplasty. These patients had an average MSTS score of 75.2%. The patients who underwent reconstruction procedures by endoprosthesis also had good results with an average MSTS score of 72.3%, while patients with arthrodesis obtained rather modest results – the average MSTS score being 67.3%. When taking into consideration the location of tumors, the best MSTS scores were obtained in patients with tumors of the distal radius – 80%, followed by femoral and humeral diaphysis – 75.6%, distal femur – 75.2%, proximal femur – 73.3%, proximal humerus – 72.3%, tibial diaphysis – 72.2%, distal tibia – 70% and proximal tibia 68.7%. Conclusions: The orthopedist must judiciously chose the surgical technique, taking into consideration the anatomical particularities and the needs of the patient. Given the functional results and the emotional acceptability, reconstruction with tumor prosthesis represents the first option.

Predictors of Survival in Children with Osteogenic Sarcoma Undergoing Limb Salvage Surgery: Experience from a Tertiary Cancer Center in Rural India

Abstract Context: Osteogenic Sarcoma (OGS) is the fifth most common malignancy among adolescents aged 15–19. With multimodality therapy, the long-term survival has improved from 16% in the prechemotherapy era to around 70% in the postchemotherapy era. Aim: This study aims to determine the clinical profile and survival of children with OGS being treated with limb-salvage surgery (LSS). Subjects and Methods: This is a retrospective analysis of all cases of OGS (age ≤ 19) who underwent LSS at our center between June 2009 and February 2017. Baseline characteristics were noted and multivariate analysis was performed for various variables to identify predictors of survival. Results: Among 44 cases studied majority were boys (n = 27). Ninety-three percentage (n = 41) were adolescents. Stage 2 disease was 75% and Stage 3 disease was 25%. The estimated 3-year overall survival (OS) was 69% (95% confidence interval [CI] 55–86) and the estimated 3-year event-free survival (EFS) was 55% (95% CI = 41–74). OS was significantly improved in patients with >90% necrosis postneoadjuvant chemotherapy (NACT) when compared with <90% necrosis (3-year OS = 88% vs. 51%,P= 0.01) and in patients who received ≤4 cycles NACT versus >4 cycles (78% vs. 60%,P= 0.04). EFS was significantly better in patients without lung metastasis at presentation (61% vs. 29%,P= 0.04), Stage 2 disease (59% vs. 38%,P= 0.04) and >90% necrosis in the tumor post-NACT (69% vs. 35%,P= 0.02). Conclusion: Significant response to NACT predicted improved OS and EFS in children with OGS treated with LSS.

Limb sparing surgery with vascular reconstruction for nonrhabdomyosarcoma soft tissue sarcoma in infants: A novel solution using allogenic vein graft from the parent

Surgery continues to remain an integral component of treatment, especially for nonrhabdomyosarcoma soft tissue sarcoma as compared to rhabdomyosarcoma owing to their general insensitivity to chemotherapy. A key determinant of outcomes, particularly for extremity tumors includes complete tumor resection with negative margins; however, a significant limitation for limb salvage surgery is the adherence of sarcomas to vital vascular structures. Hitherto, vascular involvement constituted an adequate reason for amputation. However, modern reconstructive techniques and availability of prosthetic grafts in addition to autologous venous grafts have rendered limb salvage surgery possible in a substantial majority of patients. Vascular resection and reconstruction for extremity soft tissue sarcoma in children have not been used routinely for reasons like the small-caliber of native vessels, limited options for conduits and rapid somatic growth. The situation is inconceivable in infants owing to the contemporaneous diminutive caliber of the vessels.We report two infants with lower extremity nonrhabdomyosarcoma soft tissue sarcoma who underwent limb salvage surgery with resection of femoral vessels following which vascular reconstruction was successfully performed using the great saphenous vein allograft harvested from the father.

Limb Preservation Using Vascular Reconstruction in Patients with Large Extremity Soft Tissue Sarcomas: Results of Multi-Modality Therapy

Management of extremity sarcoma has shifted from amputation to limb salvage surgery with improvements in surgical techniques and multimodality treatment protocols. For tumors involving major neurovascular bundles, it has not been accepted as a routine practice uniformly due to fear of oncological outcomes, postoperative morbidity, and lack of expertise in microvascular surgery. We analyzed our experience of limb salvage surgery with vascular reconstruction for extremity sarcomas. Retrospective analysis of patients with extremity sarcomas undergoing limb salvage surgery through vascular reconstruction was done. The feasibility, surgical, oncological, and functional outcomes of these patients was studied. Out of 176 patients undergoing limb preserving surgery for extremity sarcoma, limb salvage using vascular resection and reconstruction was done in 14 patients. Mean age of these 14 patients was 35.4 years (19–49). Arterial reconstruction was done in 7 patients, venous in 5, and in 2 patients both arterial and venous reconstructions were performed. All the 14 patients had tumor-free margins, and none had immediate post-operative graft failure requiring amputation. Post radiation graft exposure occurred in one patient. Involvement of major vascular bundle in extremity sarcomas should not always be considered a contraindication for limb preservation. Optimal oncological outcome with preserved limb function can be achieved by arteriovenous reconstructive procedures. In places with limited resources, autologous grafts are preferred because of constraints of availability and cost.

Predictors and Survival of Patients with Osteosarcoma After Limb Salvage versus Amputation: A Population‐Based Analysis with Propensity Score Matching

Conflicting findings have been reported concerning the survival of patients treated with limb salvage and amputation for osteosarcoma. This study aimed to identify predictors associated with surgery types and survival difference. Patients with osteosarcoma were selected from the Surveillance Epidemiology and End Results database (1975-2016). Multivariable logistic regression analysis was conducted, and a nomogram was further established. Propensity score matching (PSM)-adjusted Kaplan-Meier curves, log-rank tests, Cox proportional hazards regression analysis were performed to compare overall survival (OS) and cancer-specific survival (CSS). Among 3363 patients with osteosarcoma, 2447 and 916 underwent limb salvage and amputation. Predictors associated with amputation in the nomogram included age, gender, primary tumor site, tumor grade, tumor stage, tumor size and radiotherapy. Totally 900 pairs of patients treated with limb salvage and amputation were matched after PSM. Limb salvage was significantly associated with improved OS (HR, 0.773; 95% CI, 0.670-0.892; p < 0.001) and CSS (HR, 0.795; 95% CI, 0.681-0.927; p = 0.003) in PSM-adjusted cohort after adjusting for related variables. The significant treatment effect of limb salvage was consistent within most subgroups. Among patients treated with surgery for osteosarcoma, age between 41 and 60, age ≥ 61, pelvis as the primary site, high tumor grade (III/IV), regional and distant tumor stage, tumor size ≥ 92mm and radiotherapy were independent prognostic factors in PSM cohort. Limb salvage exhibits significant benefit on OS and CSS compared with amputation for osteosarcoma. Predicators and survival differences should be given full consideration for the treatment of osteosarcoma.

Limb Salvage Using Liquid Nitrogen-Treated Tumour-Bearing Autograft: A Single Institutional Experience of 10 Patients.

Many reconstruction methods have evolved to offer limb salvage surgery (LSS) to patients with musculoskeletal sarcomas. It can be achieved using endoprosthesis or biological reconstruction methods like allograft or autograft or a combination of both. In carefully selected patients, resected bone can be recycled and reimplanted after sterilisation using methods like irradiation, autoclaving, pasteurisation or liquid nitrogen. From 2010 to 2016, 10 patients with primary musculoskeletal sarcoma underwent limb salvage surgery (LSS) by wide resection of the tumour and reconstruction using recycled autograft treated with liquid nitrogen. Intercalary resection was carried out in six patients and intra-articular in four. The resected bone was dipped in liquid nitrogen for 25min, thawed at room temperature for 15min followed by dipping in vancomycin-mixed saline for 10min. The recycled bone was re-implanted into its original site and stabilised with internal fixation. At a mean follow-up period of 39.6months (range 6-97months), all patients had a good function (mean functional score of 80%) with no evidence of local recurrence in the re-implanted bone or otherwise. Union was achieved at 15 of the 16 osteotomy sites with a mean union time of 5.2months (range 4-7months) without any additional surgical interventions. In none of the patient, augmentation with vascularised/non-vascularised fibula was done. No complication like fracture of the autograft, implant failure or deep/superficial infection was reported in any patient. Recycled tumour-bearing autograft after treatment with liquid nitrogen is an anatomical, cost-effective, relatively simpler and reliable technique for reconstruction of bone defect after resection in selective primary musculoskeletal sarcoma patients.

Survival analysis of osteosarcoma patients: A 15-year experience.

Management of osteosarcoma has evolved considerably for the past two decades and there have been changes of practices especially pertaining to chemotherapy regime. This is a review of our cases in the past 15 years. This is a retrospective survival analysis study of 128 patients treated at University Malaya Medical Centre (UMMC) from 1997 to 2011. There were 80 (62.5%) male and 48 (37.5%) female patients with the median age being 15 (5-59). Majority had osteosarcoma of extremities (94.5%). More than 60% patients developed metastasis throughout the course of treatment with 39% presenting with lung metastasis. Osteoblastic osteosarcoma was the commonest subtype (65.6%). Of the 109 patients treated surgically, 84 patients (65.6%) underwent limb salvage surgery while the rest underwent amputation. Seventy-one per cent of patients completed treatment with local recurrence rate of 22.7%. The 5-year and 10-year survival rates were 56.31% (95% CI: 46.20, 65.24) and 22.33% (95% CI: 14.86, 30.76), respectively. The 5-year event-free survival was 52.94% (95% CI: 41.83, 62.87). In multivariate analysis, the independent prognostic factors were presence of metastasis and completion of treatment for both 5-year and 10-year overall survival. Good histological response was only significant for multivariate analysis at 5 years. Patients with metastasis had a hazard ratio of 20.4 at 5 years and 3.26 at 10 years. Overall survival rate for osteosarcoma patients at our centre was comparably higher than other centres in the region. Two independent risk factors for survival are metastatic status and completion of treatment. A standardized chemotherapy regime is essential for long-term survival.

Management of Local Soft Tissue Recurrent Osteosarcoma After Wide Resection and Reconstruction with Megaprosthesis: A Case Report

Introduction: Limb salvage surgery involves all of the surgical methods to achieve the eradication of a malignant neoplasm and restoration of the limb with a satisfactory oncologic, functional, and cosmetic outcome. Rates of local recurrence are 4% to 10%. There is a chance of local recurrence from the contamination of biopsy path. Neoadjuvant chemotherapy has a guarding effect on managing neoplasm infiltration at the biopsy location.Case Presentation: An 18 year old male experienced a new painless lump at his right anterior thigh with size about 5 cm in diameter since 5 months ago. Previously, he underwent limb salvage surgery with megaprosthesis about 6 months ago due to osteosarcoma at his right distal femur. He also got neoadjuvant and adjuvant chemotherapy for 6 cycles. Mass removal was done and 1.5 cm mass in diameter was found within quadriceps muscle with a soft consistency and well-defined border from the previous biopsy site that had not been resected. The specimen result was osteosarcoma surrounded by tumor-free tissue. Postoperatively, he still had the same range of motion function as before.Conclusions: We need to consider the previously contaminated biopsy path that could lead to local recurrence. Factors that affect the prediction of the recurrent disease are the disease-free time period, location of recurrence and histological response to therapy and the capability to achieve total surgical removal. Tumor removal followed by the local radiation and chemotherapy is the preferred treatment for recurrence.

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction.

Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle.Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions.Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate.Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success.Level of Evidence: Prognostic Level IV.

Comparison of MRI and Histopathology with regard to Intramedullary Extent of Disease in Bone Sarcomas

In today's era, limb salvage surgery is the procedure of choice and current standard of care in appropriately selected patients of bone sarcomas. For adequate oncologic clearance, preoperative evaluation of the extent of tumor is mandatory. The present study was done to compare measurements of bone sarcomas (osteosarcoma, Ewing's sarcoma, and chondrosarcoma) as determined by magnetic resonance imaging (MRI) with the histopathological extent seen on resected specimens. We prospectively evaluated 100 consecutive patients with a diagnosis of bone sarcoma who underwent limb salvage surgery between May 2014 and December 2014. The maximum longitudinal (cranio-caudal) dimension of tumor on the noncontrast T1-WI sequence of MRI (irrespective of whether it was pre/postchemotherapy) was compared with the gross dimensions of the tumor on histopathology. The arithmetic mean difference, Wilcoxon signed-rank test, and Spearman's correlation analysis were used to test the differences and correlation between groups. Mean tumor size on MRI based on the largest extent on MRI was 12.1 ± 4.85 cm (mean ± standard deviation), while it was 10.77 ± 4.6 cm (mean ± standard deviation) on histopathology. In 79 cases, MRI overestimated the extent of disease; the mean was 1.79 cm with a standard deviation of 1.56 cm. When the disease extent was underestimated on MRI (13 cases), the mean was 0.58 cm with a standard deviation of 0.43 cm. In 8 cases (osteosarcoma (7), Ewing's sarcoma (1)), MRI measurement was equal to histopathology. The Spearman correlation analysis showed a high correlation of tumor length on histopathology with the MRI for all patients (R = 0.948, P < 0.0001). We thus conclude that MRI is accurate in delineating the extent of bone sarcomas. A margin of 2 cm from the maximum tumor extent is adequate to ensure appropriate surgical resection.

Outcomes of Expandable Prostheses for Primary Bone Malignancies in Skeletally Immature Patients: A Systematic Review and Pooled Data Analysis.

Osteosarcoma and other primary bone malignancies are relatively common in skeletally immature patients. Current literature features case series with disparate complication rates, making it difficult for surgeons to educate patients on outcomes after limb salvage with expandable prostheses. This study aims to provide an update on complication rates, mortality, and functional outcomes in patients who undergo limb salvage with expandable prostheses for primary bone malignancies. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive PubMed/Medline and Cochrane search of peer-reviewed published literature from 1997 to 2017 was performed, yielding a total of 1350 studies. After multiple rounds of review for inclusion and exclusion criteria, 28 retrospective studies were included. All were level IV evidence of case series and retrospective studies. Overall, this included 634 total patients and 292 patients with individual patient data. The primary outcomes studied were complication rates, mortality, and Musculoskeletal Tumor Society (MSTS) functional score. Secondary outcomes included complication rate subtypes, number of lengthening procedures, mean amount lengthened, and prevalence of limb length discrepancies. A total of 292 patients with individual patient data averaged 10.1 years at the surgery and had a mean follow-up of 67 months. Two hundred sixteen patients (74%) had tumors of the distal femur. MSTS scores averaged 80.3 and overall mortality was 22%. Patients with distal femur tumors averaged 4.4 lengthening procedures and 43 mm lengthened. Leg length discrepancy (LLD) was 36% overall, which increased with longer periods of follow-up (P<0.001). Overall complication and revision rate was 43%, increasing to 59% in patients with 5 to 10 years of follow-up, and 89% in patients with >10 years of follow-up. Minimally invasive prostheses had lower rates of complications than noninvasive prostheses (P=0.024), specifically mechanical complications (P=0.028), mostly because of increased rates of lengthening and device failure in the noninvasive models (21% vs. 4%, P=0.0004). Despite its limitations, which include entirely heterogenous and retrospective case series data, this systematic review provides clinicians with pooled summary data representing the largest summary of outcomes after reconstruction with expandable prostheses to date. This analysis can assist surgeons to better understand and educate their patients and their families on functional outcomes, mortality, and complication rates after limb-sparing reconstruction with expandable prostheses for primary bone malignancies. Level IV-retrospective case series with pooled data.

Malignant distal femur tumors management in children, low cost innovations with affordable care in a tertiary care hospital, a cross sectional study.

IntroductionMalignant musculoskeletal tumors in children are mostly comprised of Osteosarcoma and Ewing's sarcoma and distal femur is the most common site for primary bone tumors. This study examined the surgical management outcomes of pediatric patients (<18 years) presented in our setup with malignant distal femur tumors.MethodologyWe retrospectively reviewed the medical records of patients diagnosed with malignant sarcomas of distal femur and younger than 18 years of age who underwent limb salvage surgery during June 2009–June2017.ResultsThere were 31 pediatric patients who had distal femur malignant tumors and out of them 20 patients were selected who underwent limb salvage as a primary surgery. The mean age (range) of patients was 11.90 (6–17) years. Seventeen had osteosarcoma and three had Ewing's sarcoma. In surgery all patients were offered reconstruction. Post-operative complications were observed in (50%) patients while other 50% patients had no complications. Wound infection, flap necrosis, broken plates with non-union and recurrence of disease were the reported complications. Revision surgery was performed in 10 patients out of 20 patients.ConclusionSalvage was the primary option in our surgery and revision surgery was performed in the cases due to complications. Small sample size was the limitation of the study.

Reconstructive Challenges of Proximal Ulnar Bone Tumors: Our Experience with Biological Osteoarticular Reconstruction Using Extracorporeal Irradiation and Reimplantation.

Introduction Limb salvage surgery following proximal ulna resection poses a challenge in reconstruction of the complex elbow anatomy. Various reconstruction methods described offer inadequate restoration of function and stability. Following resection of proximal ulna tumors, we aimed to restore the joint using the resected osteochondral segment of proximal ulna treated with extracorporeal irradiation and reimplantation. Questions/Purposes (1) Does irradiated osteoarticular autograft reconstruction for proximal ulna allow anatomical joint restoration and what are the oncological and functional outcomes? (2) Is there evidence of graft-related complications or osteoarthritis at a minimum of 2 years follow-up with irradiated osteoarticular autografts for the proximal ulna? (3) How does our method of reconstruction fare as compared to reported reconstruction options in the literature? Materials and Methods. 3 patients with primary bone tumors involving the proximal ulna underwent limb salvage surgery with en bloc resection and reconstruction using the resected bone after treating it with extracorporeal irradiation of 50 Gy. Minimum follow-up of 2 years was considered for assessment of final outcomes. Radiographs were assessed for bony recurrence, union across osteotomy junction, and signs of joint arthritis. Functional outcome measures included range of movement, muscle power testing, and functional and disability scores. Results 2 complete and 1 partial olecranon involving proximal ulnar resections were performed for three cases of Ewing's sarcoma in 2 males and 1 female. Follow-up ranged from 28 to 42 months, and all patients continue to remain disease free. All 3 patients have achieved full range of flexion-extension and pronosupination movement in comparison to the contralateral side. Muscle power for flexion and extension was 5/5. MSTS score: 100% (30/30); MEPS score: 100; and DASH score: zero were achieved for all patients. Union across osteotomy junctions at median follow-up of 8 months without need for intervention/bone grafting was achieved. No complications related to joint laxity/subluxation, infection, graft fracture, or implant failure was noted. None of the patients have clinical or radiological signs of joint arthritis across the irradiated articulation. Conclusion Biological restoration of elbow anatomy using osteoarticular irradiated graft for proximal ulna reconstruction offers great joint stability and functional outcomes. Although the potential risks of infection and graft failure need to be considered, reconstruction with the size-matched radiated autograft eliminates donor site morbidity, offers a low-cost alternative to endoprosthesis, and provides outcomes superior to any other methods of reconstruction as analyzed from the literature.

Clinical Outcomes with the Intrepid Dynamic Exoskeletal Orthosis: A Retrospective Analysis.

Severe lower limb injuries have a negative impact on many aspects of an individual's life. One rehabilitative option for patients who have undergone limb salvage is the Intrepid Dynamic Exoskeletal Orthosis (IDEO). The IDEO is a custom-made dynamic response device which is used to restore function for patients with a wide variety of injuries. Clinical outcomes were routinely collected on patients fit with IDEOs at the Center for the Intrepid, Brooke Army Medical Center. The purpose of this retrospective study was to analyze the clinical outcomes collection process and the patient outcomes collected as part of routine clinical care. The Brooke Army Medical Center IRB approved this study and granted waivers of informed consent and HIPAA authorization. Electronic medical records were reviewed over an 18-month period from July 2014 to January 2016. Records were examined to obtain the date of IDEO delivery, date of outcomes form completion, responses on the forms, and to verify diagnosis or injury. Data gathered included wear time, IDEO comfort, pain with and without the IDEO, Lower Extremity Functional Scale scores with and without the IDEO, and global rating of change questions for everyday activities and high impact activities. Wilcoxon signed-ranked tests were used to compare pain and function with vs. without the IDEO. During the 18-month period, new IDEOs were delivered to 156 unique patients. Outcomes forms were collected as part of routine clinical care from 90 of these 156 patients (58%). An additional nine forms were collected from patients who received their IDEOs prior to July 2014. In all, 99 outcomes forms were collected. Mean follow-up time from IDEO delivery to outcomes form completion was 35 ± 31 days for the original 90 patients. The most common patient diagnoses were fracture, nerve injury, arthritis, and fusion. Responses on the forms indicated that patients were generally comfortable wearing their IDEOs (8.3 ± 1.3 on a 0-10 scale) and wore them most of the day (10.7 ± 3.4 hours per day). Improvement in pain (from 5.2 ± 2.9 to 1.7 ± 1.6 points on a 0-10 scale) and Lower Extremity Functional Scale scores (from 29.7 ± 16.6 to 59.5 ± 13.6 points) with the IDEO were both more than the minimal clinically important difference and were statistically significant (p < 0.001). This descriptive retrospective study demonstrated that it was feasible to collect clinical outcomes data which were relevant for characterizing the effects of IDEO use and enabled quantification of improvements in self-reported function and walking pain with the IDEO. Due to the retrospective nature of this study, limitations include missing data and the lack of any performance measures to complement the self-reported data. Clinical outcomes collection continues as a routine part of clinical care and there remains an ongoing aim to collect information on all patients to obtain an accurate assessment of devices and services and ultimately better serve our patients.

Growing Without Pain: The Noninvasive Expandable Prosthesis is Boon for Children with Bone Cancer, as well as Their Surgeons!

Background:Orthopedic oncology has evolved over the past few decades to favor limb salvage over amputations. The noninvasive expandable prosthesis can be lengthened with an externally applied magnetic field eliminating the pain, stiffness, as well as the risk of infection. We present the largest series in Indian experience with this implant over the last 8 years while analyzing its benefit to the surgeons and the patients, but are we able to justify the cost effectiveness?Materials and Methods:Eighteen implants were used in 16 patients with nonmetastatic primary bone sarcoma from May 2006 to June 2015. All implants were manufactured by Stanmore implants worldwide based in London, UK. Lengthening was done in the outpatient department during the followup visits using an external electromagnetic coil. The function was assessed using the musculoskeletal tumor society (MSTS) score.Results:The patients had a mean age of 10.25 years at the time of surgery. The mean followup was 49.56 months. Twelve patients are alive at a followup after surgery. The prostheses were lengthened by a mean of 31.64 mm and average lengthening per session was 4.18 mm. The mean MSTS score was 28.83. Two revisions for jammed mechanism and two patients had a successful two-stage revision for delayed infection.Conclusion:The noninvasive expandable prosthesis is an ideal implant for children undergoing limb salvage surgery for bone sarcoma who are expected to have more than 3 cm of limb length discrepancy at maturity. The initial high cost compared to a minimally invasive expandable implant can be recovered as there is no additional cost of lengthening. The small amounts of lengthening at more frequent intervals is more physiological as compared with the minimally invasive type where more lengthening is done to minimize the number of procedures. While the functional and oncological outcomes are comparable, this implant allows limb lengths to be maintained without pain, functional compromise or risk of infection.

Biological reconstruction of the bone defects with free fibula flap after resections of extremity located bone tumors: Clinical and radiological short-term results

<br><b>Background:</b> Recently, limb salvage surgery is a preferred method in orthopedic oncology and extremity-located bone tumors treated by limb salvage surgery have a 90%–95% success rate. The aim of the study is functional and radiological evaluations of the undergone biological reconstruction with free fibula flap (FFF) after tumor surgery and the effects of the defect size on the functional results. <b>Subjects and Methods:</b> Between 2005 and 2010, 13 patients (7M/6F) who underwent limb salvage surgery for benign/malignant bone tumors were included in study. Diagnoses included five osteosarcomas, six Ewing's sarcomas, one high-grade chondrosarcoma, and one aneurysmal bone cyst. Diaphyseal and metaphyseal regions of femur (7), humerus (3), tibia (2), and radius (1) were reconstructed. FFF was combined with a strut femoral allograft in seven cases. Postoperatively, partial weight-bearing allowed at postoperative 3 month and increased gradually. The mean follow-up was 25 months (12–60) and evaluated by extremity function scoring of Musculoskeletal Tumor Society (MSTS) and radiologically. <b>Results:</b> On the 6^th month, in 92.3% of patients (12/13), evident union, and on the 12^th month, in all of the patients, evident union and bone flap hypertrophy were observed. The mean MSTS score was measured 77.58% (46.66–100). As the resection size increased, the MSTS scores were significantly decreased (<i>P</i> = 0.027<i>)</i>; as the bone flap size increased, there were relatively low MSTS scores (<i>P</i> = 0.440<i>)</i>. On the patients without bone flap hypertrophy on 6^th month, the bone flap size was measured relatively higher (<i>P</i> = 0.069) and the operation duration was relatively higher (<i>P</i> = 0.100). As the operation duration increased, there were relatively lower MSTS scores (<i>P</i> = 0.062). In cases where allograft and VFG combined (7/9 patients) had higher MSTS scores than the ones, only FFF was used (<i>P</i> = 0.621). <b>Conclusions:</b> Limb salvage surgery improves the life quality without worsening the prognosis and is a method that should be preferred. The biologic reconstruction of the defects with FFF, following extremity located musculoskeletal tumor resections have positive effects on functional outcomes.<br>

The Correlation of Surgical Margins and Outcome Of Soft Tissue Sarcomas of The Extremities and Trunk in Hospital Sultan Ismail, Johor Bahru

Introduction: Patients with soft tissue sarcoma are treated following the standardized guidelines, however it is not guaranteed patient will remain free from local recurrence (LR) and metastasis. This study was conducted to determine the association between microscopic marginal status with local recurrence, metastasis and the survival of the patient. Materials and Methods: This retrospective study was conducted from January 2015 to December 2017 in Hospital Sultan Ismail, Johor Bahru. All patients underwent complete standadized resection of the tumour and had been follow up for 5 years. An operating and follow-up records of 70 cases who fulfill the inclusion and exclusion criteria were collected and analysed using Pearson chi square test and Kaplan-Meier curves. Results: Of the 70 patients, 52 were males and 18 were females. The age of the patients were between 16 and 73 years with the means age of 48.8 years old. Sixty eight patients underwent limb salvage surgery and 2 had amputation. 42 of them had positive post-operative microscopic surgical margin (PMSM) while 28 were negative. Local recurrence was noted in 28 and metastasis in 30 patients. Patient who had PMSM has higher risk to get local recurrence and metastasis compared to patient with negative margin (p-value &lt;0.001). The overall median survival was 23 months. Overall survival rates for 3 years was 80% and for 5 years was 65%. Conclusion: In our study, patient with positive post-operative microscopic surgical margin had higher possibility to develop local recurrence, metastases and decrease overall survival rate.

Developing Surgical Oncology Services in Resource Constrained Settings: Results of a Systematic and Motivated Approach

Background: General surgeons trained in surgical oncology and working in a general service hospital can offer and provide a wide variety of oncological services although significant limitations exist compared with a true tertiary cancer care center in developed high income countries. Providing optimal and standard of care surgical oncology services is truly demanding and limitations in ancillary and support services can potentially limit the quality of care provided in resource constrained settings like ours. Aim: The aim of this study was to analyze the patterns of care, surgical outcomes in terms of morbidity and mortality, quality of resection in terms of margins and nodal yield over a period of 08 weeks in a general service hospital with resource constrained setting and with two trained and motivated surgical oncologists. Methods: Data of 22 patients with solid organ cancers who underwent major operative treatment both curative and palliative under the surgical oncology services were analyzed retrospectively. All patients were evaluated clinically, imaging as required and pathologic tissue diagnosis of cancer obtained as was possible and after adequate preoperative preparation were operated upon. Results: Four patients of carcinoma rectum underwent low anterior resection with diverting ileostomy, one patient with rectal cancer had APR with permanent end colostomy, two patients underwent total thyroidectomy for papillary thyroid cancer, eight patients underwent modified radical mastectomy for carcinoma breast, two patients had optimal cytoreductive surgery for carcinoma ovary -one patient upfront and another as interval cytoreduction, two cases of soft tissue tumor underwent limb salvage surgery, one case of carcinoma stomach underwent subtotal gastrectomy, one case of carcinoma cecum underwent classic right radical hemicolectomy. Two patients underwent emergency exploration for acute abdomen who were otherwise metastatic for palliation. All but one case received neoadjuvant therapy prior to surgery in carcinoma rectum, one case of carcinoma ovary and carcinoma breast were operated after neoadjuvant chemotherapy. Overall there was only one margin positive resection after low anterior resection who was operated upfront due to impending obstruction. The average nodal yield in all cases of colorectal carcinomas and breast cancer cases were as per current NCCN standards. Morbidities included seroma collection in 3 patients, minor surgical site infection in 2 patients, peristomal allergy in two patients, there were no deaths in elective cases. Conclusion: Providing quality surgical oncology services in a resource constrained general service hospital is challenging. Through an aggressive, well planned and motivated approach with a good surgical oncology training background and with available resources it is possible to achieve a varied spectrum, quality care and an improved and sustainable healthcare oncology systems for better outcomes even in these settings.