Aim

While the association of surgery and radiation therapy in high grade Soft Tissue Sarcoma (STS) of extremities is considered the “golden standard”, there is not international agreement regarding type, timing, overall dose of radiation, and size, site and histology of tumours to be irradiated. A similar consideration is about low grade STS. The aim of our paper is critically reconsider our experience, trough a retrospective analysis of 15 years experience. This in order to propose a perspective protocol of treatment of high and low grade STS, in order to minimize the late complication rate.

Knee extensor mechanism reconstruction after excision for bone or soft tissue tumors is a challenging procedure. When a resection of the patellar bone-tendon apparatus is required, an omologous graft can be used for its reconstruction to avoid knee arthrodesis and preserve a functional knee. Since 1996 we performed such a procedure in 15 cases in 14 patients. In 4 cases (Group 1) excision and reconstruction involved only the patella and the attached tendons together with the involved soft tissues. In the remaining 11 cases (Group 2) an extrarticular en-bloc knee resection was accomplished and reconstruction was obtained by a megaprosthesis to replace the distal femur and a composite allograft-prosthesis to replace proximal tibia and the extensor apparatus. One of the en-bloc knee resections was performed in a patient who had previously had an isolated extensor apparatus replacement, which was later converted to a complete knee resection and substitution after a local relapse.

A free flap (anterolateral thigh) was used in 4 patients.

Histotypes were as follows:

Group 1: pleomorphic sarcoma 2, synovial sarcoma 1, myxofibrosarcoma 1.

One patient in group 2 was lost at follow-up after a few months. In the remaining patients follow-up ranged from 7 to 132 months.

In Group 1 two local and one distant (groin lymphnodes in one of the two patients affected by local recurrence) relapses occurred, in Group 2 one local and 4 distant relapses (lung) occurred. One of these latter distant relapses affected the patient at the beginning in Group 1 and later converted to Group 2.

Besides recurrences, 4 patients in Group 2 were affected by local complications:

one deep infection;

Active extension was initially obtained in all patients and, when local complications did not occur, it was stable with time. Extension lag ranged from 0 to 30°. Maximum flexion ranged from 80 to 110°. Patients could walk without brace nor aids.

Allograft reconstruction after extensor apparatus excision, either alone or combined to a total knee resection, can be an efficacious option in the treatment of sarcomas of the knee.

The treatment of bone metastases is usually palliative and aims to achieve adequate control of pain, to prevent and resolve compression of the cord in lesions of the spine and to anticipate or stabilise pathological fractures in the appendicular skeleton. In selected cases the complete resection of an isolated bone metastasis may improve the survival of the patient. During recent decades, the life expectancy of patients affected with metastatic carcinoma has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution.

From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures seemed relatively high. However in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure.