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Surgery in malignant bone tumors
Curr Probl Cancer 37 (2013) 192–197
Contents lists available at ScienceDirect
Curr Probl Cancer journal homepage: www.elsevier.com/locate/cpcancer
Surgery in malignant bone tumors Steven Gitelis, MD, Christopher O. Bayne, MD, Jonathan M. Frank, MD, Yale Filingham, MD, Paul M. Kent, MD, FAAP
Introduction Limb preservation is now the standard method of treatment for most bone sarcomas.1-4 Limb-salvage operations have been shown to have similar recurrence rates to amputation.5,6 A recent study by Schrager et al.7 of pediatric patients with ES and OS showed a 35% greater mortality rate with amputation compared with limb salvage. The success of limb salvage is the result of several advances in the evaluation, diagnosis, and treatment of pediatric bone sarcomas. These include imaging modalities such as magnetic resonance imaging that allow for precise mapping of the tumor, effective chemotherapy, and reconstructive options that allow for a functional limb.1-3 Treatment typically includes preoperative chemotherapy, surgical resection with or without reconstruction, and postoperative chemotherapy.8
Management of pediatric bone sarcomas When a child presents with OS or ES, the initial step is staging and biopsy.9 This is followed by neoadjuvant chemotherapy.10,11 The drugs for OS and ES differ, but the overall goal is to eradicate the tumor locally, treat metastatic disease, and potentially make the child a candidate for a limb preservation operation. In addition to chemotherapy, ES can be treated with surgery or radiation. Although radiation is often the treatment for lesions occurring in the spine and pelvis, the preferred treatment is surgical removal.12 This is because of the risks of secondary malignancy and morbidity associated with radiation treatment.13 The treatment of OS includes chemotherapy and resection. Patients with ES and those with OS are treated postoperatively with adjuvant chemotherapy as well.
Operative treatment Historically, surgical treatment of ES and OS was amputation, and it may still be necessary for a nonreconstructable limb.8 This may be owing to neurovascular involvement, pathologic fracture with contamination of surrounding tissue, or local recurrence.14 New reconstructive options allow many of these previously unsalvageable limbs to be preserved. 0147-0272/$ - see front matter & 2013 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.currproblcancer.2013.07.006
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When compared with adult sarcomas, the treatment of pediatric bone sarcomas includes an added level of complexity. The management of these tumors requires consideration of how treatment would affect remaining bone growth. Although some sarcomas are located in the middle of the bone, most bone sarcomas in children are located around growth plates.4 For example, most cases of pediatric OS occur around the knee, often affecting the distal femoral and proximal tibial physes.15,16 Effective limb salvage requires removal of the cancer with wide margins at the expense of these critical growth plates. These growth plates account for nearly five-eighths of an inch per year of future growth and can lead to significant limb-length inequality.17,18 As an example, a high-grade intramedullary OS in the lower end of the femur in a 10-year-old child, if treated with limb salvage, would likely lead to nearly a 4-in limb-length inequality—a discrepancy that most would find unacceptable. Sarcomas that occur proximal or distal to the physis are less problematic. An example is a diaphyseal ES occurring in the midshaft of the femur or tibia. This can often be treated with a midbone resection followed by reconstruction and preservation of the growth plates. Despite these difficulties, techniques such as expandable pediatric implants, rotationplasty, intercalary allografts, free tissue transfer with growth plate, and physeal distraction are making limb salvage in children a reasonable option.
Endoprosthetic treatment One new promising limb-salvage procedure involves tumor excision and knee reconstruction with a prosthesis that can be expanded to account for the loss of physeal growth (Fig 1A-C). These knee devices are bendable and restore the function of the knee joint, but are also
Fig. 1. Antero-posterior radiograph of a 9-year-old with osteosarcoma of the distal femur. (B) Antero-posterior radiograph after distal femur resection and reconstruction with an expandable prosthesis. (C) Lateral radiograph of expandable knee prosthesis.
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expandable by either an open or closed mechanism.19-22 The closed mechanism is particularly innovative, as the additional surgical procedures required for the open expansion carry the risk of possible nerve damage, infection, or ankylosis.21,22 The devices expandable by closed means contain a mechanism that can be activated by an externally applied electromagnetic field. The limb can thus be lengthened 1 cm at a time without the need for an incision. This can be repeated monthly or as needed to mirror the growth of the contralateral limb. This type of pediatric device would serve the patient during the years of skeletal growth, but ultimately would need to be revised to an adult prosthesis, which is more functional and durable.20
Rotationplasty Another option for a sarcoma around the knee is a rotationplasty (Fig 1A-D). In addition to tumor resection, the knee joint is removed while maintaining the neurovascular structures that supply the residual limb. The ankle joint is then brought up to the level of the resected bone and rotated 1801. The ankle joint then serves functionally as a knee and the foot as a leg stump. The patient can be fitted with a prosthesis assembled on the foot with its retained sensitivity. This is an extremely functional and durable operation, although because of its appearance, it is a challenging choice for the parents.23-26
Intercalary allograft ES of the diaphysis of a long bone is initially treated with chemotherapy. The large soft tissue mass that is commonly present regresses into the bone. At this point, a decision must be made whether to proceed with irradiation of the affected bone or to resect the sarcoma. Irradiation has several problems. First, there is an increased risk of local recurrence in comparison with surgery. Second, irradiation damages the bone and the adjacent growth plate, which may lead to pathologic fracture and limb-length inequality. Finally, radiation can lead to a postradiation sarcoma—a devastating complication. For these reasons, surgery is currently the preferred treatment modality. If clean margins can be achieved with resection of the midportion of the tibia or femur, then an intercalary allograft can be used (Fig 2A–D). This can be supplemented with a vascularized tissue transfer involving the insertion of a frozen bone allograft (in association with a vascularized fibula graft) into the gap, which is then fixed in place with a rigid internal device.27-30 For cases in which the sarcoma involves the metaphysis of the lower femur or upper tibia with absolutely no tumor involvement of the epiphysis, a resection of the metaphysis can be performed through the growth plate, thus preserving the knee joint. An intercalary allograft is then used to bridge the gap between the epiphysis and the diaphysis. Rigid internal fixation can be difficult because of the limited amount of bone left in the epiphysis. If this procedure is successful, the patient maintains the knee joint and thus has excellent function. Healing of the host bone-allograft junction can take 8-12 months, but once this occurs, the patient may resume most activities. The most commonly reported complications are fracture of the allograft, infection, and nonunion. Infection has been reported in up to 18% of cases with the risk being higher in tibial reconstructions owing to the thin soft tissue coverage.31-33 The risk of infection is also increased for patients undergoing adjuvant therapy. There is an increased risk of nonunion for femoral reconstruction, host bone-allograft interface gaps 4 1 mm, and for patients undergoing adjuvant chemotherapy.31-33 Allograft fracture can occur at any time after implantation, with a 16% incidence within the first 3 years and 20% at 6-12 years.27
Free tissue transfer Another new and exciting surgical reconstructive option in children is the use of a free tissue transfer with growth plate, most commonly, the fibula. This can be used as a reconstructive
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Fig. 2. (A) Antero-posterior radiograph (11 year old), Ewing's sarcoma of tibial diaphysis after chemotherapy. (B) Anteroposterior radiograph after intercalary resection with reconstruction with bone allograft. Note the healing at the allograft/ host bone junction.
option for the proximal humerus. As this requires microvascular anastomosis of the graft to the recipient site blood supply, it can be a very lengthy and challenging operation.34 A vascularized fibular autograft can also be used in conjunction with an allograft to increase bulk and strength. Usually, the vascularized autograft is placed on top of the dead allograft to restore bone viability and to aid in healing at the allograft-host bone junction, similar to an intercalated allograft.
Physeal distraction In patients with sarcomas involving the metaphysis of long bones, physeal distraction may be utilized to save the joint during resection of the tumor. First described by Canadell et al.,35 this technique consists of 3 phases. The physis is first distracted at a rate of 1-2 mm/d. This can be
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done concurrently while the patient is receiving adjuvant chemotherapy. Then, the en bloc resection of the tumor is performed, but without exposing the metaphyseal surface of the physis. Once the pathology shows negative margins, an intercalated graft is placed. For a patient to be considered a candidate for this procedure, the tumor must be located in the metaphysis, the physis must still be open, and it must be proven that the tumor does not cross the physis. Physeal distraction has been shown to be adequate for local control while preserving limb function.36
Conclusion Historically, pediatric bone sarcomas were treated with amputation. Limb salvage for pediatric bone sarcomas is becoming increasingly popular, partly because of the excellent oncological and functional outcomes. Numerous reconstructive options are now available with several modifications to improve outcomes. Currently, many of these patients can be managed with limb preservation, which is an exciting and attractive alternative to the patient and family that may improve overall quality of life. References 1. Bacci G, Balladelli A, Palmerini E, et al. Neoadjuvant chemotherapy for osteosarcoma of the extremities in preadolescent patients: the Rizzoli Institute experience. J Pediatr Hematol Oncol 2008;30:908–12. 2. Federman N, Bernthal N, Eilber FC, et al. The multidisciplinary management of osteosarcoma. Curr Treat Options Oncol 2009;10:82–93. 3. Sakamoto A, Iwamoto Y. Current status and perspectives regarding the treatment of osteo-sarcoma: chemotherapy. Rev Recent Clin Trials 2008;3:228–31. 4. Wittig JC, Bickels J, Priebat D, et al. Osteosarcoma: a multidisciplinary approach to diagnosis and treatment. Am Fam Physician 2002;65:1123–32. 5. Rougraff BT, Simon MA, Kneisl JS, et al. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study. J Bone Joint Surg Am 1994;76:649–56. 6. Simon MA, Aschliman MA, Thomas N, et al. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. 1986. J Bone Joint Surg Am 2005;87:2822. 7. Schrager J, Patzer RE, Mink PJ, et al. Survival outcomes of pediatric osteosarcoma and Ewing's sarcoma: a comparison of surgery type within the SEER database, 1988-2007. J Registry Manage 2011;38:153–61. 8. Messerschmitt PJ, Garcia RM, Abdul-Karim FW, et al. Osteosarcoma. J Am Acad Orthop Surg 2009;17:515–27. 9. Arndt CA, Rose PS, Folpe AL, et al. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc 2012;87:475–87. (PMID: 22560526). 10. Grier HE, Krailo MD, Tarbell NJ, et al. Addition of ifosfamide and etoposide to standard chemotherapy for Ewing's sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694–701. 11. Myers CA, Register BC, Lertwanich P, et al. Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study. Am J Sports Med 2011;39(Suppl):85S–91S. 12. La TH, Meyers PA, Wexler LH, et al. Radiation therapy for Ewing's sarcoma: results from Memorial Sloan-Kettering in the modern era. Int J Radiat Oncol Biol Phys 2006;64:544–50. 13. Fuchs B, Valenzuela RG, Inwards C, et al. Complications in long-term survivors of Ewing sarcoma. Cancer 2003;98: 2687–92. 14. Gupta A, Meswania J, Pollock R, et al. Non-invasive distal femoral expandable endoprosthesis for limb-salvage surgery in paediatric tumours. J Bone Joint Surg Br 2006;88:649–54. 15. Carrle D, Bielack SS. Current strategies of chemotherapy in osteosarcoma. Int Orthop 2006;30:445–51. 16. Bielack SS, Kempf-Bielack B, Delling G, et al. Prognostic factors in high grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002;20:776–90. 17. Anderson M, Green WT, Messner MB. Growth and predictions of growth in the lower extremities. J Bone Joint Surg Am 1963;45-A:1–14. 18. Westh RN, Menelaus MB. A simple calculation for the timing of epiphysial arrest: a further report. J Bone Joint Surg Br 1981;63-B:117–19. 19. Baumgart R, Lenze U. Expandable endoprostheses in malignant bone tumors in children: indications and limitations. Recent Results Cancer Res 2009;179:59–73. 20. Gitelis S, Neel MD, Wilkins RM, et al. The use of a closed expandable prosthesis for pediatric sarcomas. La Chirurgia degli organi di movimento 2003;88:327–33. 21. Lewis MM. The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer 1986;57:499–502. 22. Schindler OS, Cannon SR, Briggs TW, et al. Use of extendable total femoral replacements in children with malignant bone tumors. Clin Orthop Relat Res 1998:157–70.
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23. Forni C, Gaudenzi N, Zoli M, et al. Living with rotationplasty—quality of life in rotationplasty patients from childhood to adulthood. J Surg Oncol 2012;105:331–6. 24. Rodl RW, Pohlmann U, Gosheger G, et al. Rotationplasty quality of life after 10 years in 22 patients. Acta Orthop Scand 2002;73:85–8. 25. Lane JM, Christ GH, Khan SN, et al. Rehabilitation for limb salvage patients: kinesiological parameters and psychological assessment. Cancer 2001;92:1013–19. 26. Veenstra KM, Sprangers MA, van der Eyken JW, et al. Quality of life in survivors with a Van Ness-Borggreve rotationplasty after bone tumour resection. J Surg Oncol 2000;73:192–7. 27. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive technique for intercalary defects of long bones: the association of massive allograft with vascularized fibular autograft. Long-term results and comparison with alternative techniques. Orthop Clin North Am 2007;38:51–60. (vi). 28. Ceruso M, Falcone C, Innocenti M, et al. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir 2001;33:277–82. 29. Chang DW, Weber KL. Use of a vascularized fibula bone flap and intercalary allograft for diaphyseal reconstruction after resection of primary extremity bone sarcomas. Plast Reconstr Surg 2005;116:1918–25. 30. Moran SL, Shin AY, Bishop AT. The use of massive bone allograft with intramedullary free fibular flap for limb salvage in a pediatric and adolescent population. Plast Reconstr Surg 2006;118:413–19. 31. Donati D, Capanna R, Campanacci D, et al. The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study. Chir Organi Mov 1993;78:81–94. 32. Muscolo DL, Ayerza MA, Aponte-Tinao L, et al. Intercalary femur and tibia segmental allografts provide an acceptable alternative in reconstructing tumor resections. Clin Orthop Relat Res 2004:97–102. 33. Ortiz-Cruz E, Gebhardt MC, Jennings LC, et al. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am 1997;79:97–106. 34. Bowen CV, Singer S. Bernard O'Brien: the microsurgical transfer of immature bone. Microsurgery 1994;15:733–7. 35. Canadell J, Forriol F, Cara JA. Removal of metaphyseal bone tumours with preservation of the epiphysis. Physeal distraction before excision. J Bone Joint Surg Br 1994;76:127–32. 36. Betz M, Dumont CE, Fuchs B, et al. Physeal distraction for joint preservation in malignant metaphyseal bone tumors in children. Clin Orthop Relat Res 2011;470:1749–54.
Contents lists available at ScienceDirect
Curr Probl Cancer journal homepage: www.elsevier.com/locate/cpcancer
Surgery in malignant bone tumors Steven Gitelis, MD, Christopher O. Bayne, MD, Jonathan M. Frank, MD, Yale Filingham, MD, Paul M. Kent, MD, FAAP
Introduction Limb preservation is now the standard method of treatment for most bone sarcomas.1-4 Limb-salvage operations have been shown to have similar recurrence rates to amputation.5,6 A recent study by Schrager et al.7 of pediatric patients with ES and OS showed a 35% greater mortality rate with amputation compared with limb salvage. The success of limb salvage is the result of several advances in the evaluation, diagnosis, and treatment of pediatric bone sarcomas. These include imaging modalities such as magnetic resonance imaging that allow for precise mapping of the tumor, effective chemotherapy, and reconstructive options that allow for a functional limb.1-3 Treatment typically includes preoperative chemotherapy, surgical resection with or without reconstruction, and postoperative chemotherapy.8
Management of pediatric bone sarcomas When a child presents with OS or ES, the initial step is staging and biopsy.9 This is followed by neoadjuvant chemotherapy.10,11 The drugs for OS and ES differ, but the overall goal is to eradicate the tumor locally, treat metastatic disease, and potentially make the child a candidate for a limb preservation operation. In addition to chemotherapy, ES can be treated with surgery or radiation. Although radiation is often the treatment for lesions occurring in the spine and pelvis, the preferred treatment is surgical removal.12 This is because of the risks of secondary malignancy and morbidity associated with radiation treatment.13 The treatment of OS includes chemotherapy and resection. Patients with ES and those with OS are treated postoperatively with adjuvant chemotherapy as well.
Operative treatment Historically, surgical treatment of ES and OS was amputation, and it may still be necessary for a nonreconstructable limb.8 This may be owing to neurovascular involvement, pathologic fracture with contamination of surrounding tissue, or local recurrence.14 New reconstructive options allow many of these previously unsalvageable limbs to be preserved. 0147-0272/$ - see front matter & 2013 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.currproblcancer.2013.07.006
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When compared with adult sarcomas, the treatment of pediatric bone sarcomas includes an added level of complexity. The management of these tumors requires consideration of how treatment would affect remaining bone growth. Although some sarcomas are located in the middle of the bone, most bone sarcomas in children are located around growth plates.4 For example, most cases of pediatric OS occur around the knee, often affecting the distal femoral and proximal tibial physes.15,16 Effective limb salvage requires removal of the cancer with wide margins at the expense of these critical growth plates. These growth plates account for nearly five-eighths of an inch per year of future growth and can lead to significant limb-length inequality.17,18 As an example, a high-grade intramedullary OS in the lower end of the femur in a 10-year-old child, if treated with limb salvage, would likely lead to nearly a 4-in limb-length inequality—a discrepancy that most would find unacceptable. Sarcomas that occur proximal or distal to the physis are less problematic. An example is a diaphyseal ES occurring in the midshaft of the femur or tibia. This can often be treated with a midbone resection followed by reconstruction and preservation of the growth plates. Despite these difficulties, techniques such as expandable pediatric implants, rotationplasty, intercalary allografts, free tissue transfer with growth plate, and physeal distraction are making limb salvage in children a reasonable option.
Endoprosthetic treatment One new promising limb-salvage procedure involves tumor excision and knee reconstruction with a prosthesis that can be expanded to account for the loss of physeal growth (Fig 1A-C). These knee devices are bendable and restore the function of the knee joint, but are also
Fig. 1. Antero-posterior radiograph of a 9-year-old with osteosarcoma of the distal femur. (B) Antero-posterior radiograph after distal femur resection and reconstruction with an expandable prosthesis. (C) Lateral radiograph of expandable knee prosthesis.
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expandable by either an open or closed mechanism.19-22 The closed mechanism is particularly innovative, as the additional surgical procedures required for the open expansion carry the risk of possible nerve damage, infection, or ankylosis.21,22 The devices expandable by closed means contain a mechanism that can be activated by an externally applied electromagnetic field. The limb can thus be lengthened 1 cm at a time without the need for an incision. This can be repeated monthly or as needed to mirror the growth of the contralateral limb. This type of pediatric device would serve the patient during the years of skeletal growth, but ultimately would need to be revised to an adult prosthesis, which is more functional and durable.20
Rotationplasty Another option for a sarcoma around the knee is a rotationplasty (Fig 1A-D). In addition to tumor resection, the knee joint is removed while maintaining the neurovascular structures that supply the residual limb. The ankle joint is then brought up to the level of the resected bone and rotated 1801. The ankle joint then serves functionally as a knee and the foot as a leg stump. The patient can be fitted with a prosthesis assembled on the foot with its retained sensitivity. This is an extremely functional and durable operation, although because of its appearance, it is a challenging choice for the parents.23-26
Intercalary allograft ES of the diaphysis of a long bone is initially treated with chemotherapy. The large soft tissue mass that is commonly present regresses into the bone. At this point, a decision must be made whether to proceed with irradiation of the affected bone or to resect the sarcoma. Irradiation has several problems. First, there is an increased risk of local recurrence in comparison with surgery. Second, irradiation damages the bone and the adjacent growth plate, which may lead to pathologic fracture and limb-length inequality. Finally, radiation can lead to a postradiation sarcoma—a devastating complication. For these reasons, surgery is currently the preferred treatment modality. If clean margins can be achieved with resection of the midportion of the tibia or femur, then an intercalary allograft can be used (Fig 2A–D). This can be supplemented with a vascularized tissue transfer involving the insertion of a frozen bone allograft (in association with a vascularized fibula graft) into the gap, which is then fixed in place with a rigid internal device.27-30 For cases in which the sarcoma involves the metaphysis of the lower femur or upper tibia with absolutely no tumor involvement of the epiphysis, a resection of the metaphysis can be performed through the growth plate, thus preserving the knee joint. An intercalary allograft is then used to bridge the gap between the epiphysis and the diaphysis. Rigid internal fixation can be difficult because of the limited amount of bone left in the epiphysis. If this procedure is successful, the patient maintains the knee joint and thus has excellent function. Healing of the host bone-allograft junction can take 8-12 months, but once this occurs, the patient may resume most activities. The most commonly reported complications are fracture of the allograft, infection, and nonunion. Infection has been reported in up to 18% of cases with the risk being higher in tibial reconstructions owing to the thin soft tissue coverage.31-33 The risk of infection is also increased for patients undergoing adjuvant therapy. There is an increased risk of nonunion for femoral reconstruction, host bone-allograft interface gaps 4 1 mm, and for patients undergoing adjuvant chemotherapy.31-33 Allograft fracture can occur at any time after implantation, with a 16% incidence within the first 3 years and 20% at 6-12 years.27
Free tissue transfer Another new and exciting surgical reconstructive option in children is the use of a free tissue transfer with growth plate, most commonly, the fibula. This can be used as a reconstructive
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Fig. 2. (A) Antero-posterior radiograph (11 year old), Ewing's sarcoma of tibial diaphysis after chemotherapy. (B) Anteroposterior radiograph after intercalary resection with reconstruction with bone allograft. Note the healing at the allograft/ host bone junction.
option for the proximal humerus. As this requires microvascular anastomosis of the graft to the recipient site blood supply, it can be a very lengthy and challenging operation.34 A vascularized fibular autograft can also be used in conjunction with an allograft to increase bulk and strength. Usually, the vascularized autograft is placed on top of the dead allograft to restore bone viability and to aid in healing at the allograft-host bone junction, similar to an intercalated allograft.
Physeal distraction In patients with sarcomas involving the metaphysis of long bones, physeal distraction may be utilized to save the joint during resection of the tumor. First described by Canadell et al.,35 this technique consists of 3 phases. The physis is first distracted at a rate of 1-2 mm/d. This can be
196
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done concurrently while the patient is receiving adjuvant chemotherapy. Then, the en bloc resection of the tumor is performed, but without exposing the metaphyseal surface of the physis. Once the pathology shows negative margins, an intercalated graft is placed. For a patient to be considered a candidate for this procedure, the tumor must be located in the metaphysis, the physis must still be open, and it must be proven that the tumor does not cross the physis. Physeal distraction has been shown to be adequate for local control while preserving limb function.36
Conclusion Historically, pediatric bone sarcomas were treated with amputation. Limb salvage for pediatric bone sarcomas is becoming increasingly popular, partly because of the excellent oncological and functional outcomes. Numerous reconstructive options are now available with several modifications to improve outcomes. Currently, many of these patients can be managed with limb preservation, which is an exciting and attractive alternative to the patient and family that may improve overall quality of life. References 1. Bacci G, Balladelli A, Palmerini E, et al. Neoadjuvant chemotherapy for osteosarcoma of the extremities in preadolescent patients: the Rizzoli Institute experience. J Pediatr Hematol Oncol 2008;30:908–12. 2. Federman N, Bernthal N, Eilber FC, et al. The multidisciplinary management of osteosarcoma. Curr Treat Options Oncol 2009;10:82–93. 3. Sakamoto A, Iwamoto Y. Current status and perspectives regarding the treatment of osteo-sarcoma: chemotherapy. Rev Recent Clin Trials 2008;3:228–31. 4. Wittig JC, Bickels J, Priebat D, et al. Osteosarcoma: a multidisciplinary approach to diagnosis and treatment. Am Fam Physician 2002;65:1123–32. 5. Rougraff BT, Simon MA, Kneisl JS, et al. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study. J Bone Joint Surg Am 1994;76:649–56. 6. Simon MA, Aschliman MA, Thomas N, et al. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. 1986. J Bone Joint Surg Am 2005;87:2822. 7. Schrager J, Patzer RE, Mink PJ, et al. Survival outcomes of pediatric osteosarcoma and Ewing's sarcoma: a comparison of surgery type within the SEER database, 1988-2007. J Registry Manage 2011;38:153–61. 8. Messerschmitt PJ, Garcia RM, Abdul-Karim FW, et al. Osteosarcoma. J Am Acad Orthop Surg 2009;17:515–27. 9. Arndt CA, Rose PS, Folpe AL, et al. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc 2012;87:475–87. (PMID: 22560526). 10. Grier HE, Krailo MD, Tarbell NJ, et al. Addition of ifosfamide and etoposide to standard chemotherapy for Ewing's sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694–701. 11. Myers CA, Register BC, Lertwanich P, et al. Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study. Am J Sports Med 2011;39(Suppl):85S–91S. 12. La TH, Meyers PA, Wexler LH, et al. Radiation therapy for Ewing's sarcoma: results from Memorial Sloan-Kettering in the modern era. Int J Radiat Oncol Biol Phys 2006;64:544–50. 13. Fuchs B, Valenzuela RG, Inwards C, et al. Complications in long-term survivors of Ewing sarcoma. Cancer 2003;98: 2687–92. 14. Gupta A, Meswania J, Pollock R, et al. Non-invasive distal femoral expandable endoprosthesis for limb-salvage surgery in paediatric tumours. J Bone Joint Surg Br 2006;88:649–54. 15. Carrle D, Bielack SS. Current strategies of chemotherapy in osteosarcoma. Int Orthop 2006;30:445–51. 16. Bielack SS, Kempf-Bielack B, Delling G, et al. Prognostic factors in high grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002;20:776–90. 17. Anderson M, Green WT, Messner MB. Growth and predictions of growth in the lower extremities. J Bone Joint Surg Am 1963;45-A:1–14. 18. Westh RN, Menelaus MB. A simple calculation for the timing of epiphysial arrest: a further report. J Bone Joint Surg Br 1981;63-B:117–19. 19. Baumgart R, Lenze U. Expandable endoprostheses in malignant bone tumors in children: indications and limitations. Recent Results Cancer Res 2009;179:59–73. 20. Gitelis S, Neel MD, Wilkins RM, et al. The use of a closed expandable prosthesis for pediatric sarcomas. La Chirurgia degli organi di movimento 2003;88:327–33. 21. Lewis MM. The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer 1986;57:499–502. 22. Schindler OS, Cannon SR, Briggs TW, et al. Use of extendable total femoral replacements in children with malignant bone tumors. Clin Orthop Relat Res 1998:157–70.
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23. Forni C, Gaudenzi N, Zoli M, et al. Living with rotationplasty—quality of life in rotationplasty patients from childhood to adulthood. J Surg Oncol 2012;105:331–6. 24. Rodl RW, Pohlmann U, Gosheger G, et al. Rotationplasty quality of life after 10 years in 22 patients. Acta Orthop Scand 2002;73:85–8. 25. Lane JM, Christ GH, Khan SN, et al. Rehabilitation for limb salvage patients: kinesiological parameters and psychological assessment. Cancer 2001;92:1013–19. 26. Veenstra KM, Sprangers MA, van der Eyken JW, et al. Quality of life in survivors with a Van Ness-Borggreve rotationplasty after bone tumour resection. J Surg Oncol 2000;73:192–7. 27. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive technique for intercalary defects of long bones: the association of massive allograft with vascularized fibular autograft. Long-term results and comparison with alternative techniques. Orthop Clin North Am 2007;38:51–60. (vi). 28. Ceruso M, Falcone C, Innocenti M, et al. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir 2001;33:277–82. 29. Chang DW, Weber KL. Use of a vascularized fibula bone flap and intercalary allograft for diaphyseal reconstruction after resection of primary extremity bone sarcomas. Plast Reconstr Surg 2005;116:1918–25. 30. Moran SL, Shin AY, Bishop AT. The use of massive bone allograft with intramedullary free fibular flap for limb salvage in a pediatric and adolescent population. Plast Reconstr Surg 2006;118:413–19. 31. Donati D, Capanna R, Campanacci D, et al. The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study. Chir Organi Mov 1993;78:81–94. 32. Muscolo DL, Ayerza MA, Aponte-Tinao L, et al. Intercalary femur and tibia segmental allografts provide an acceptable alternative in reconstructing tumor resections. Clin Orthop Relat Res 2004:97–102. 33. Ortiz-Cruz E, Gebhardt MC, Jennings LC, et al. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am 1997;79:97–106. 34. Bowen CV, Singer S. Bernard O'Brien: the microsurgical transfer of immature bone. Microsurgery 1994;15:733–7. 35. Canadell J, Forriol F, Cara JA. Removal of metaphyseal bone tumours with preservation of the epiphysis. Physeal distraction before excision. J Bone Joint Surg Br 1994;76:127–32. 36. Betz M, Dumont CE, Fuchs B, et al. Physeal distraction for joint preservation in malignant metaphyseal bone tumors in children. Clin Orthop Relat Res 2011;470:1749–54.