The aim of this study was to define the incidence
of venous thromboembolism (VTE) and risk factors for the development
of deep-vein thrombosis (DVT) after the resection of a musculoskeletal
tumour. A total of 94 patients who underwent resection of a musculoskeletal
tumour between January 2003 and December 2005 were prospectively
studied. There were 42 men and 52 women with a mean age of 54.4
years (18 to 86). All patients wore intermittent pneumatic compression
devices and graduated compression stockings. Ultrasound examination
of the lower limbs was conducted to screen for DVT between the fifth
and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic
(2%). One patient (1%) had a fatal pulmonary embolism. Patients
aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic)
after resection of a musculoskeletal tumour with mechanical prophylaxis
was high. It seems that both mechanical and anticoagulant prophylaxis
is needed to prevent VTE in patients who have undergone the resection
of a musculoskeletal tumour. Cite this article:
Guidelines for the management of patients with metastatic bone
disease (MBD) have been available to the orthopaedic community for
more than a decade, with little improvement in service provision
to this increasingly large patient group. Improvements in adjuvant
and neo-adjuvant treatments have increased both the number and overall
survival of patients living with MBD. As a consequence the incidence
of complications of MBD presenting to surgeons has increased and
is set to increase further. The British Orthopaedic Oncology Society
(BOOS) are to publish more revised detailed guidelines on what represents
‘best practice’ in managing patients with MBD. This article is designed
to coincide with and publicise new BOOS guidelines and once again
champion the cause of patients with MBD. A series of short cases highlight common errors frequently being
made in managing patients with MBD despite the availability of guidelines.Objectives
Methods
We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modfied 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients.
We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular
A total of 157 hindquarter amputations were carried
out in our institution during the last 30 years. We have investigated
the reasons why this procedure is still required and the outcome.
This operation was used as treatment for 13% of all pelvic bone
sarcomas. It was curative in 140 and palliative in 17, usually to
relieve pain. There were 90 primary procedures (57%) with the remaining
67 following the failure of previous operations to control the disease
locally. The indication for amputation in primary disease was for
large tumours for which limb-salvage surgery was no longer feasible.
The peri-operative mortality was 1.3% (n = 2) and major complications
of wound healing or infection arose in 71 (45%) patients. The survival
at five years after hindquarter amputation with the intent to cure
was 45%, and at ten years 38%. Local recurrence occurred in 23 patients
(15%). Phantom pain was a significant problem, and only 20% used
their prosthesis regularly. Functional scores were a mean of 57%.
With careful patient selection the oncological results and functional outcomes
of hindquarter amputation justify its continued use. Cite this article:
We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation.
Rarely, the extent of a malignant bone tumour
may necessitate resection of the complete humerus to achieve adequate
oncological clearance. We present our experience with reconstruction
in such cases using a total humeral endoprosthesis (THER) in 20
patients (12 male and eight female) with a mean age of 22 years
(6 to 59). We assessed the complications, the oncological and functional
outcomes and implant survival. Surgery was performed between June
2001 and October 2009. The diagnosis included osteosarcoma in nine,
Ewing’s sarcoma in eight and chondrosarcoma in three. One patient
was lost to follow-up. The mean follow-up was 41 months (10 to 120)
for all patients and 56 months (25 to 120) in survivors. There were
five local recurrences (26.3%) and 11 patients were alive at time
of last follow-up, with overall survival for all patients being
52% (95% confidence interval (CI) 23.8 to 74) at five years. The
mean Musculoskeletal Tumor Society score for the survivors was 22
(73%; 16 to 23). The implant survival was 95% (95% CI 69.5 to 99.3)
at five years. The use of a THER in the treatment of malignant tumours of bone
is oncologically safe; it gives consistent and predictable results
with low rates of complication.
We report our early experience with the use of a non-invasive distal femoral expandable endoprosthesis in seven skeletally immature patients with osteosarcoma of the distal femur. The patients had a mean age of 12.1 years (9 to 15) at the time of surgery. The prosthesis was lengthened at appropriate intervals in outpatient clinics, without anaesthesia, using the principle of electromagnetic induction. The patients were functionally evaluated using the Musculoskeletal Tumour Society scoring system. The mean follow-up was 20.2 months (14 to 30). The prostheses were lengthened by a mean of 25 mm (4.25 to 55) and maintained a mean knee flexion of 110° (100° to 120°). The mean Musculoskeletal Tumour Society score was 68% (11 to 29). Complications developed in two patients; one developed a flexion deformity of 25° at the knee joint, which was subsequently overcome and one died of disseminated disease. The early results from patients treated with this device have been encouraging. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality.
The purpose of this study was to assess the outcome
of 15 patients (mean age 13.6 years (7 to 25)) with a primary sarcoma
of the tibial diaphysis who had undergone excision of the affected
segment that was then irradiated (90 Gy) and reimplanted with an
ipsilateral vascularised fibular graft within it. The mean follow-up was 57 months (22 to 99). The mean time to
full weight-bearing was 23 weeks (9 to 57) and to complete radiological
union 42.1 weeks (33 to 55). Of the 15 patients, seven required
a further operation, four to obtain skin cover. The mean Musculoskeletal
Society Tumor Society functional score at final follow-up was 27
out of 30 once union was complete. The functional results were comparable
with those of allograft reconstruction and had a similar rate of
complication. We believe this to be a satisfactory method of biological reconstruction
of the tibial diaphysis in selected patients.
We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.
There is little information about the management
of peri-prosthetic fracture of the humerus after total shoulder replacement
(TSR). This is a retrospective review of 22 patients who underwent
a revision of their original shoulder replacement for peri-prosthetic
fracture of the humerus with bone loss and/or loose components.
There were 20 women and two men with a mean age of 75 years (61
to 90) and a mean follow-up 42 months (12 to 91): 16 of these had
undergone a previous revision TSR. Of the 22 patients, 12 were treated
with a long-stemmed humeral component that bypassed the fracture.
All their fractures united after a mean of 27 weeks (13 to 94).
Eight patients underwent resection of the proximal humerus with
endoprosthetic replacement to the level of the fracture. Two patients
were managed with a clam-shell prosthesis that retained the original
components. The mean Oxford shoulder score (OSS) of the original
TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean
OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival
using re-intervention for any reason as the endpoint was 91% (95%
confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at
one and five years, respectively. There were two revisions for dislocation of the humeral head,
one open reduction for modular humeral component dissociation, one
internal fixation for nonunion, one trimming of a prominent screw
and one re-cementation for aseptic loosening complicated by infection,
ultimately requiring excision arthroplasty. Two patients sustained
nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated
with bone loss and/or loose components is a salvage procedure that
can provide a stable platform for elbow and hand function. Good
rates of union can be achieved using a stem that bypasses the fracture.
There is a high rate of complications and function is not as good as
with the original replacement.
We reviewed our initial seven-year experience
with a non-invasive extendible prosthesis in 34 children with primary bone
tumours. The distal femur was replaced in 25 cases, total femur
in five, proximal femur in one and proximal tibia in three. The
mean follow-up was 44 months (15 to 86) and 27 patients (79%) remain
alive. The prostheses were lengthened by an electromagnetic induction
mechanism in an outpatient setting and a mean extension of 32 mm
(4 to 80) was achieved without anaesthesia. There were lengthening
complications in two children: failed lengthening in one and the
formation of scar tissue in the other. Deep infection developed
in six patients (18%) and local recurrence in three. A total of
11 patients required further surgery to the leg. Amputation was
necessary in five patients (20%) and a two-stage revision in another.
There were no cases of loosening, but two patients had implant breakage
and required revision. The mean Musculoskeletal Tumor Society functional
score was 85% (60% to 100%) at last known follow-up. These early
results demonstrate that the non-invasive extendible prosthesis
allows successful lengthening without surgical intervention, but
the high incidence of infection is a cause for concern.
Between 1992 and 1999, we treated 350 patients with skeletal metastases. A multivariable analysis of the patients was conducted using the Cox proportional hazards model. We identified five significant prognostic factors for survival, namely, the site of the primary lesion, the performance status (Eastern Cooperative Oncology Group status 3 or 4), the presence of visceral or cerebral metastases, any previous chemotherapy, and multiple skeletal metastases. The score for each significant factor was derived from the corresponding estimated regression coefficients (natural logarithm of the hazard ratio). The prognostic score was calculated by adding all the scores for individual factors. The rate of survival was 31% at six months and 11% at one year for the patients with a prognostic score of 6 or more. By contrast, patients with a prognostic score of 2 or less had a rate of survival of 98% at six months and 89% at one year. This scoring system can be used to determine the optimal treatment for patients with pathological fractures or epidural compression.
Pathological fractures in children can occur
as a result of a variety of conditions, ranging from metabolic diseases and
infection to tumours. Fractures through benign and malignant bone
tumours should be recognised and managed appropriately by the treating
orthopaedic surgeon. The most common benign bone tumours that cause pathological
fractures in children are unicameral bone cysts, aneurysmal bone
cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological
fractures through a primary bone malignancy are rare, these should
be recognised quickly in order to achieve better outcomes. A thorough
history, physical examination and review of plain radiographs are
crucial to determine the cause and guide treatment. In most benign
cases the fracture will heal and the lesion can be addressed at
the time of the fracture, or after the fracture is healed. A step-wise
and multidisciplinary approach is necessary in caring for paediatric
patients with malignancies. Pathological fractures do not have to
be treated by amputation; these fractures can heal and limb salvage
can be performed when indicated.
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5 to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6 mm (3.5 to 161.5),
requiring a mean of 11.3 extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11 patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
The aim of this study was to define the treatment
criteria for patients with recurrent chondrosarcoma. We reviewed the
data of 77 patients to examine the influence of factors such as
the intention of treatment (curative/palliative), extent of surgery,
resection margins, status of disease at the time of local recurrence
and the grade of the tumour. A total of 70 patients underwent surgery
for recurrent chondrosarcoma. In seven patients surgery was not
a viable option. Metastatic disease occurred in 41 patients, appearing
synchronously with the local recurrence in 56% of cases. For patients
without metastasis at the time of local recurrence, the overall
survival at a mean follow-up after recurrence of 67 months (0 to
289) was 74% (5 of 27) compared with 19% (13 of 50) for patients
with metastasis at or before the development of the recurrence.
Neither the type/extent of surgery, site of tumour, nor the resection margins
for the recurrent tumour significantly influenced the overall survival. With limited survival for patients with metastatic disease at
the time of local recurrence (0% for patients with grade III and
de-differentiated chondrosarcoma), palliative treatment, including
local radiation therapy and debulking procedures, should be discussed
with the patients to avoid long hospitalisation and functional deficits. For
patients without metastasis at the time of local recurrence, the
overall survival of 74% justifies an aggressive approach including
wide resection margins and extensive reconstruction.
Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.
Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI. Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one. Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome.
We identified eight patients of 2900 with a primary malignant bone tumour who had coexisting neurofibromatosis type 1. This was a much higher incidence than would be expected by chance. The patients had a mean age of 22.4 years (9 to 54): five were male. Two patients subsequently developed a second bone sarcoma, one of which was radiation induced. Four of the primary tumours were osteosarcomas, four were spindle-cell sarcomas and one a Ewing’s sarcoma. All the patients were treated with chemotherapy and surgery: six of the eight appear to be cured. This study suggests a possible relationship between neurofibromatosis type 1 and the development of a bone sarcoma, the increased risk being estimated at eight times that of the normal population. We recommend that further research into this possible link should be considered.