The aim of this study was to analyse the gait
pattern, muscle force and functional outcome of patients who had undergone
replacement of the proximal tibia for tumour and alloplastic reconstruction
of the extensor mechanism using the patellar-loop technique. Between February 1998 and December 2009, we carried out wide
local excision of a primary sarcoma of the proximal tibia, proximal
tibial replacement and reconstruction of the extensor mechanism
using the patellar-loop technique in 18 patients. Of these, nine
were available for evaluation after a mean of 11.6 years (0.5 to
21.6). The strength of the knee extensors was measured using an
Isobex machine and gait analysis was undertaken in our gait assessment
laboratory. Functional outcome was assessed using the American Knee
Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores. The gait pattern of the patients differed in ground contact time,
flexion heel strike, maximal flexion loading response and total
sagittal plane excursion. The mean maximum active flexion was 91°
(30° to 110°). The overall mean extensor lag was 1° (0° to 5°).
The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that
in the non-operated leg (p <
0.001). The mean functional scores
were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional
score). In summary, the results show that reconstruction of the extensor
mechanism using this technique gives good biomechanical and functional
results. The patients’ gait pattern is close to normal, except for
a somewhat stiff knee gait pattern. The strength of the extensor
mechanism is reduced, but sufficient for walking. Cite this article:
We report our early experience with the use of
a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction
of the hemipelvis after resection of a primary malignant peri-acetabular
tumour involving the sacroiliac joint. We retrospectively reviewed the outcome of 17 patients who had
undergone resection of a pelvic tumour and reconstruction with this
prosthesis between July 2002 and July 2010. One patient had a type I+II+III+IV resection (ilium + peri-acetabulum
+ pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium
+ acetabulum + sacrum). The outcome was assessed at a mean follow-up
of 33 months (15 to 59). One patient was alive with disease, 11
were alive without disease and five had died of disease. The overall
five-year survival rate was 62.4%. Six patients had a local recurrence.
The mean Musculoskeletal Tumour Society score was 58% (33 to 77).
Deep infection occurred in two patients, problems with wound healing
in five and dislocation in one. For patients with a primary malignant peri-acetabular sarcoma
involving the sacroiliac joint, we believe that this new prosthesis
is a viable option for reconstruction of the bony defect left following
resection of the tumour. It results in a satisfactory functional
outcome with an acceptable rate of complications. Cite this article:
The aims of this study were to analyse the long-term outcome
of vascularised fibular graft (VFG) reconstruction after tumour
resection and to evaluate the usefulness of the method. We retrospectively reviewed 49 patients who had undergone resection
of a sarcoma and reconstruction using a VFG between 1988 and 2015.
Their mean follow-up was 98 months (5 to 317). Reconstruction was
with an osteochondral graft (n = 13), intercalary graft (n = 12),
inlay graft (n = 4), or resection arthrodesis (n = 20). We analysed
the oncological and functional outcome, and the rate of bony union
and complications.Aims
Patients and Methods
We determined the efficacy of a devitalised autograft
(n = 13) and allograft (n = 16) cortical strut bone graft combined
with long-stem endoprosthetic reconstruction in the treatment of
massive tumours of the lower limb. A total of 29 patients (18 men:11
women, mean age 20.1 years (12 to 45) with a ratio of length of
resection to that of the whole prosthesis of >
50% were treated
between May 2003 and May 2012. The mean follow-up was 47 months
(15 to 132). The stem of the prosthesis was introduced through bone
graft struts filled with cement, then cemented into the residual
bone. Bone healing was achieved in 23 patients (86%). The mean Musculoskeletal
Tumour Society functional score was 85% (57 to 97). The five-year
survival rate of the endoprostheses was 81% (95% confidence intervals
67.3 to 92.3). The mean length of devitalised autografts and allografts
was 8.6 cm (5 to 15), which increased the ratio of the the length
of the stem of the prosthesis to that of the whole length of the
prosthesis from a theoretical 35% to an actual 55%. Cortical strut bone grafting and long-stem endoprosthetic reconstruction
is an option for treating massive segmental defects following resection
of a tumour in the lower limb. Patients can regain good function
with a low incidence of aseptic loosening. The strut graft and the
residual bone together serve as a satisfactory bony environment
for a revision prosthesis, if required, once union is achieved. Cite this article:
In patients with a tumour affecting the distal
ulna it is difficult to preserve the function of the wrist following extensive
local resection. We report the outcome of 12 patients (nine female,
three male) who underwent excision of the distal ulna without local
soft-tissue reconstruction. In six patients, an aggressive benign
tumour was present and six had a malignant tumour. At a mean follow-up
of 64 months (15 to 132) the mean Musculoskeletal Tumour score was
64% (40% to 93%) and the mean DASH score was 35 (10 to 80). The
radiological appearances were satisfactory in most patients. Local
recurrence occurred in one patient with benign disease and two with
malignant disease. The functional outcome was thus satisfactory
at a mean follow-up in excess of five years, with a relatively low
rate of complications. The authors conclude that complex reconstructive
soft-tissue procedures may not be needed in these patients. Cite this article:
Giant cell tumours (GCTs) of the small bones
of the hands and feet are rare. Small case series have been published but
there is no consensus about ideal treatment. We performed a systematic
review, initially screening 775 titles, and included 12 papers comprising
91 patients with GCT of the small bones of the hands and feet. The
rate of recurrence across these publications was found to be 72%
(18 of 25) in those treated with isolated curettage, 13% (2 of 15)
in those treated with curettage plus adjuvants, 15% (6 of 41) in
those treated by resection and 10% (1 of 10) in those treated by
amputation. We then retrospectively analysed 30 patients treated for GCT
of the small bones of the hands and feet between 1987 and 2010 in
five specialised centres. The primary treatment was curettage in
six, curettage with adjuvants (phenol or liquid nitrogen with or
without polymethylmethacrylate (PMMA)) in 18 and resection in six.
We evaluated the rate of complications and recurrence as well as
the factors that influenced their functional outcome. At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence
was 50% (n = 3) in those patients treated with isolated curettage,
22% (n = 4) in those treated with curettage plus adjuvants and 17%
(n = 1) in those treated with resection (p = 0.404). The only complication
was pain in one patient, which resolved after surgical removal of remnants
of PMMA. We could not identify any individual factors associated
with a higher rate of complications or recurrence. The mean post-operative
Musculoskeletal Tumor Society scores were slightly higher after
intra-lesional treatment including isolated curettage and curettage
plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to
30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted
in the cure for all patients and is therefore a reasonable treatment
for both primary and recurrent GCT of the small bones of the hands
and feet. Cite this article:
Atypical cartilaginous tumours are usually treated
by curettage. The purpose of this study was to show that radiofrequency
ablation was an effective alternative treatment. We enrolled 20 patients (two male, 18 female, mean age 56 years
(36 to 72) in a proof-of-principle study. After inclusion, biopsy
and radiofrequency ablation were performed, followed three months
later by curettage and adjuvant phenolisation. The primary endpoint
was the proportional necrosis in the retrieved material. Secondary endpoints
were correlation with the findings on gadolinium enhanced MRI, functional
outcome and complications. Our results show that 95% to 100% necrosis was obtained in 14
of the 20 patients. MRI had a 91% sensitivity and 67% specificity
for detecting residual tumour after curettage. The mean functional
outcome (MSTS) score six weeks after radiofrequency ablation was
27.1 (23 to 30) compared with 18.1 (12 to 25) after curettage (p
<
0.001). No complications occurred after ablation, while two
patients developed a pathological fracture after curettage. We have shown that radiofrequency ablation is capable of completely
eradicating cartilaginous tumour cells in selective cases. MRI has
a 91% sensitivity for detecting any residual tumour. Radiofrequency
ablation can be performed on an outpatient basis allowing a rapid
return to normal activities. If it can be made more effective, it
has the potential to provide better local control, while improving
functional outcome. Cite this article:
We retrospectively reviewed the outcomes of 33
consecutive patients who had undergone an extra-articular, total or
partial scapulectomy for a malignant tumour of the shoulder girdle
between 1 July 2001 and 30 September 2013. Of these, 26 had tumours
which originated in the scapula or the adjacent soft tissue and
underwent a classic Tikhoff–Linberg procedure, while seven with
tumours arising from the proximal humerus were treated with a modified
Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement
System for soft-tissue reconstruction in nine patients, but not
in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6
(95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to
19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95%
CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients
who had undergone a LARS soft-tissue reconstruction had a mean score
of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5
to 19.0) for those who did not. The Tikhoff–Linberg procedure is a useful method for wide resection
of a malignant tumour of the shoulder girdle which helps to preserve
hand and elbow function. The method of soft-tissue reconstruction
has no effect on functional outcome. Cite this article:
The aims of this retrospective study were to report the feasibility
of using 3D-printing technology for patients with a pelvic tumour
who underwent reconstruction. A total of 35 patients underwent resection of a pelvic tumour
and reconstruction using 3D-printed endoprostheses between September
2013 and December 2015. According to Enneking’s classification of
bone defects, there were three Type I lesions, 12 Type II+III lesions,
five Type I+II lesions, two Type I+II+III lesions, ten type I+II+IV
lesions and three type I+II+III+IV lesions. A total of three patients
underwent reconstruction using an iliac prosthesis, 12 using a standard
hemipelvic prosthesis and 20 using a screw-rod connected hemipelvic
prosthesis.Aims
Patients and Methods
Pigmented villonodular synovitis (PVNS) is a
rare benign disease of the synovium of joints and tendon sheaths, which
may be locally aggressive. We present 18 patients with diffuse-type
PVNS of the foot and ankle followed for a mean of 5.1 years (2 to
11.8). There were seven men and 11 women, with a mean age of 42
years (18 to 73). A total of 13 patients underwent open or arthroscopic
synovectomy, without post-operative radiotherapy. One had surgery
at the referring unit before presentation with residual tibiotalar
PVNS. The four patients who were managed non-operatively remain
symptomatically controlled and under clinical and radiological surveillance.
At final follow-up the mean Musculoskeletal Tumour Society score
was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto
Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American
Academy of Orthopaedic Surgeons foot and ankle score was 89 (95%
CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically
without further intervention six years after surgery. Targeted synovectomy
without adjuvant radiotherapy can result in excellent outcomes,
without recurrence. Asymptomatic patients can be successfully managed
non-operatively. This is the first series to report clinical outcome
scores for patients with diffuse-type PVNS of the foot and ankle. Cite this article:
We investigated the functional outcome in patients
who underwent reverse shoulder replacement (RSR) after removal of
a tumour of the proximal humerus. A total of 16 patients (ten women
and six men) underwent this procedure between 1998 and 2011 in our
hospital. Five patients died and one was lost to follow-up. Ten
patients were available for review at a mean follow-up of 46 months
(12 to 136). Eight patients had a primary and two patients a secondary
bone tumour. At final follow up the mean range of active movement was: abduction
78° (30° to 150°); flexion 98° (45° to 180°); external rotation
32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal
Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity
Salvage Score was 70% (30% to 91%). Two patients had a superficial
infection and one had a deep infection and underwent a two-stage
revision procedure. In two patients there was loosening of the RSR;
one dislocated twice. All patients had some degree of atrophy or
pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus
gives acceptable results. Cite this article:
Endoprosthetic replacement of the distal tibia and ankle joint for a primary bone tumour is a rarely attempted and technically challenging procedure. We report the outcome of six patients treated between 1981 and 2007. There were four males and two females, with a mean age of 43.5 years (15 to 75), and a mean follow-up of 9.6 years (1 to 27). No patient developed a local recurrence or metastasis. Two of the six went on to have a below-knee amputation for persistent infection after a mean 16 months (1 to 31). The four patients who retained their endoprosthesis had a mean musculoskeletal tumour society score of 70% and a mean Toronto extremity salvage score of 71%. All were pain free and able to perform most activities of daily living in comfort. A custom-made endoprosthetic replacement of the distal tibia and ankle joint is a viable treatment option for carefully selected patients with a primary bone tumour. Patients should, however, be informed of the risk of infection and the potential need for amputation if this cannot be controlled.
Peri-acetabular tumour resections and their subsequent
reconstruction are among the most challenging procedures in orthopaedic
oncology. Despite the fact that a number of different pelvic endoprostheses
have been introduced, rates of complication remain high and long-term
results are mostly lacking. In this retrospective study, we aimed to evaluate the outcome
of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis
after a type 2 or type 2/3 internal hemipelvectomy. A total of 19 patients (11M:8F) with a mean age of 48 years (14
to 72) were included, most of whom had been treated for a primary
bone tumour (n = 16) between 2003 and 2009. After a mean follow-up
of 39 months (28 days to 8.7 years) seven patients had died. After
a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive,
of whom 11 were disease-free. Complications occurred in 15 patients.
Three had recurrent dislocations and three experienced aseptic loosening.
There were no mechanical failures. Infection occurred in nine patients,
six of whom required removal of the prosthesis. Two patients underwent
hindquarter amputation for local recurrence. The implant survival rate at five years was 50% for all reasons,
and 61% for non-oncological reasons. The mean Musculoskeletal Tumor
Society score at final follow-up was 49% (13 to 87). Based on these poor results, we advise caution if using the pedestal
cup for reconstruction of a peri-acetabular tumour resection. Cite this article:
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
The aim of this study was to evaluate the functional
and oncological outcome of extracorporeally irradiated autografts
used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone
tumour of the pelvis. There were 13 males and five females with
a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic
sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a
mean follow-up of 51.6 months (4 to 185), nine patients had died
with metastatic disease while nine were free from disease. Local
recurrence occurred in three patients all of whom eventually died of
their disease. Deep infection occurred in three patients and required
removal of their graft in two while the third underwent a hindquarter
amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the
16 patients who could be followed-up for at least 12 months was
77% (50 to 90). Those 15 patients who completed the Toronto Extremity
Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid
method of reconstruction after an internal hemipelvectomy. It has
an acceptable morbidity and a functional outcome that compares favourably
with other available reconstructive techniques. Cite this article:
We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 ( Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.