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SECTION 4
LONG-TERM SURVIVORS (>10 YEARS): PREDICTION, QUALITY OF LIFE, COMPLICATIONS
ORAL PRESENTATIONS
ID 102
Limb salvage in malignant proximal humeral tumors
A.H.M. Taminiau, J.W.A. Swen
Leiden University Medical Centre, Leiden, Netherlands
Introduction: Results of prosthesis and osteoarticular allografts. Limb salvage procedures in primary bone tumors of the proximal humerus, if oncological adequate, offer attractive prospects regarding function of shoulder elbow and hand.
Material and Methods: From 1984-2005 184 patient were operated for proximal humeral malignancies. 55 had reconstructive shoulder joint surgery: chondrosarcoma (16), Ewing sarcoma (7), grawitz (2), MFH (3), osteochondroma (1), GCT (8), fibr. dysplasia (1), histiocytoma (1), NHL (1). Patient gender: male (32), female (23). Mean-age 45y (14-91y). Mean follow-up 8y (3m-21y).
Results: Resections were reconstructed with prosthesis and allografts (12), prosthesis (17), intercalary allografts (14) and osteoarticular allografts (1). 20 patients received neo-adjuvant chemotherapy or radiotherapy; osteosarcoma (9), Ewing sarcoma (6), MFH (3), NHL (1). 12 patients have died. 16 patients had a recurrence or metastasis. Procedures were complicated by infections (7), pseudarthrosis (3), luxations (2), bone resorption (1), and osteolysis round the stem (1). All could be treated with revision operations. No amputations were performed due to complications. Procedures with intercalary allografts had all good function. Pseudarthrosis (3) was successfully treated with bone grafts. Infections (3) in osteoarticular reconstruction as well as in prosthetic infections were revised after treatment of the infection. Allograft-prosthesis and osteoarticular allografts had all but one stable joints, restricted motion in abduction and elevation and good hand/elbow function.
Conclusions: Limb salvage in humeral bone tumors is an acceptable procedure. Despite complications of allografts all upper limbs could be saved. The functional outcome shows restricted but stable shoulder functions.
ID 280
Clinical analysis of infectious complications after endoprosthetic replacement in primary and metastatic bone tumours
V.A. Sokolovskii, N.V. Dmitrieva, D.V. Nisichenko,
S.A. Saravanan, M.N. Orehov, A.V. Sokolovskii N.N. Blokhin Russian Cancer Research Center,
Moscow, Russian Federation
Aim: To analyze the infectious complications after endopros-thetic replacement in patients with primary and metastatic bone tumours.
Materials and Methods: Between 1992 and 2004, 275 patients who underwent segmental bone resection with subsequent endoprosthetic replacement for primary and metastatic tumours, were analyzed retrospectively. Infectious complications were manifested in 39/325 (12%) patients. There were 27 men, 12 women, between the age group of 13 to 53 years. The mean age was 23.1 years. We observed the infectious complications in 34/275 (12.36%) patients after the endoprosthetic replacement for the primary and metastatic bone tumours and in 5/50 (10%) patients after the revisional endoprosthetic replacement. Histological diagnosis included: 19 — Osteosarcoma, 6 — Malignant fibro histiocytoma, 2 each — Ewing's tumour & Paraosteal sarcoma, 4 — Periosteal sarcoma, 1 each — Chondrosarcoma & Giant cell tumour and 3 — Metastatic bone tumours.
Results: Infectious complications observed in the following: after humeral replacement — 2 patients, after femoral resection with subsequent endoprosthetic replacement — 14 patients, after tibial resection with subsequent endoprosthetic replacement — 14 patients, after total hip replacement — 7 patients, after total femoral replacement — 2 patients. Neoadjuvant and/or adjuvant polychemotherapy was carried out in 31/38 (81.6%) patients. Early, late and delayed infection was observed in the following order: 23/39( 59%), 14/39 (35.9%) & 2/39 (5.1%). Identification of the pathogen-sensitivity to antibiotics was carried out on the semi-automatic microbiological analyzer ATB-expression (Bio-merieux). In all 39 patients antibiotic treatment was carried out for 2 or more weeks depending on the pathogen. Besides that, in 21 patients (75%) diffe-
rent operative interventions were performed: removal of endoprosthesis — 1/39 (2.6%) patient, revisional endoprosthetic replacement — 6/39 (15.4%) patients, amputation of extremities — 18/39 (46.1%) patients, removal of endoprosthesis with installation of cement spacer 3/39 (7.7%). In 11/39 (28.2%) patients, infections were treated only conservatively. Conclusion: We observed the infectious complications very frequently (21.5%) after the tibial resection with endoprosthetic knee replacement (Fisher's exact criteria р<0.05). As an independent method of treatment, antibiotic therapy was effective only in 28.2% of patients.
ID 100
Endoprosthetic reconstruction for orthopaedic oncology:
A minimum of 10 year follow up
L.M. Jeys, A. Kulkani, RJ. Grimer, S.R. Carter,
R.M. Tillman, A.A. Abudu
Royal Orthopaedic Hospital, Birmingham, UK
Introduction: Endoprosthetic replacement (EPR) is the limb salvage treatment of choice following resection of bone tumours in the UK, having been used for 39 years in our institution. This study investigates the fate of the reconstruction in the long term.
Material and Methods: Between 1966 and 1995 776 patients underwent EPRs. Growing endoprostheses were excluded as they invariably require revision to adult prostheses, leaving 667 replacements. Insufficient data was available in 6 cases, leaving 661 patients in the study. Information was reviewed concerning the diagnosis, implant and patient survival, subsequent surgery, complications and functional outcome. Kaplan-Meier survival analysis was used for implant survival with end points defined as revision for mechanical failure (aseptic loosening, implant fracture, instability, avascular necrosis, periprosthetic fracture, pain and stiffness) and revision for any cause (infection, local recurrence and mechanical failure).
Results: Patient survival was 52.7% at 10 years and 45.7% at 20 years. For those patients who survived their original disease, the mean follow up was 15 years (range 10-35 years). 227 (34%) patients underwent revision surgery, 75 patients for infection (33%), 36 patients for locally recurrent disease (16%) and mechanical failure in 116 patients (51%). With revision for mechanical failure as the end-point, implant survival was 75% at 10 years and 52% at 20 years. With revision any cause as an end-point implant survival was 58% at 10 years and 38% at 20 years. There was a significant difference between survival of implant between implantation sites, with the proximal humeral implant survival being the best and tibial reconstructions being the worst.
Conclusions: Our results are comparable with other series of long term follow up. We feel the results justify the long term use of endoprostheses in the reconstruction of limbs following excision of tumours.
ID 208
Osteosarcoma of the pelvis: outcome of surgical treatment
B. Fuchs1, N. Hoekzema2, FH. Sim1
1 Balgrist University Hospital, Zurich, Switzerland
2 Mayo Clinic, Rochester, United States
Introduction: Pelvic osteosarcomas belong to the most challenging tumors fort the orthopedic surgeon to treat. To better define patient and tumor characteristics as well as therapy results, the outcome of patients with osteosarcoma of the pelvis whose treatment strategy included surgical resection of the tumor at one single large institution was analyzed. Material and Methods: 48 patients were retrospectively analyzed. At the time of diagnosis, the mean age was 36 (11-66) years. Most of the osteosarcomas were located in the ilium (18), and acetabulum (12). 20 patients underwent internal hemipel-vectomy. In 29 patients, a wide surgical margin was achieved. Results: At the mean follow-up of 5.6 (0.2-21) years, 20 patients (42%) were alive without disease. The 5- and 10-year survival was 48% and 42%, respectively. 15 patients (31%) developed local recurrences at a mean of 17 (2-63) months. The 5-and 10-year recurrence free-survival was 56% and 43%, respectively. No patient with local recurrence was alive. Local recurrence was directly related to margin, but not to tumor size and location. 27 patients (56%) developed subsequent metastasis at a mean of 16 months. Patients who developed metastasis at diagnosis faired worse compared to those who developed metastasis subsequently. The metastasis-free survival at 5- and 10-years was 52% and 42%, respectively. Conclusions: The survival of patients with pelvic osteosarcoma does still not compare with extremity osteosarcoma. Margin is related to local recurrence; if there was local recurrence, the patient ultimately died. Metastasis may develop independent of local surgical control, and the outlook for these patients is particularly bad if present at diagnosis.
ID 139
Composite prosthesis in proximal tibia reconstruction: artificial and biological components outcome
G.G. Perrucchini, P.A. Daolio, S. Mapelli Istituto Ortopedico Gaetano Pini, Milano, Italy
Introduction: The Authors (AA.) reviewed all reconstructions of the proximal tibia performed in their Oncology-Orthopa-edics Department in Milan with a composite prosthesis, with adequate follow-up. The review focuses on the artificial-biological assembly outcome.
Material and Methods: 15 knee prosthesis assembled with an allograft to replace the articular segment of the proximal tibia were implanted between 1995 and 2002 in Istituto Ortopedico Gaetano Pini in Milan. The AA. consider the continuous series starting from the first implant in 1995 and they stop files revision at December 2002 in order to have a considerable follow up. All prosthesis were products of the same manufacturer whereas allografts were provided from two different European Bone Banks. In the youngest patient's case only the tibial front of the knee was replaced with the composite prosthesis to obtain a new knee, leaving the original femoral side articulating with the new tibial prosthetic surface.
Results: Twelve of fifteen implants are still in place. Two patients died of disease: an adult died of osteosarcoma, during the adjuvant chemotherapy period; a girl, 14 years of age, died of osteosarcoma too, in three years from the diagnosis. One more device failed, due to the recurrence of a leiomiosar-coma treated by an amputation above the knee. Of the group of 12 surviving prosthesis, one patient had a new surgery to replace the previous allograft that fractured. One other patient needed an implement with autograft at allograft-host junction, fifteen months after the primary surgery. One patient's knee developed invasive ossification of soft tissues with consequent complete loss of motion.
Conclusions: 15 composite prosthesis implanted, 12 surviving of the disease. Two patient underwent a new operation due to a complication (1 fracture of the allograft and 1 nonunion). Only one patient obtained poor functional result, because of peri-prosthetic ossifications. The Authors consider such implant a good device to recover the knee after oncological resection of the proximal tibia.
ID 22
Quality of life and coping in sarcoma patients
Z. Shmuelv
Weizman Hospital, Tel Aviv, Israel
Introduction: It has often been claimed that quality of life depends on the kind of coping that patients use. The purpose of the study was to assess the relations between overall quality of life and coping efficacy in three major domains. Material and Methods: The participants were 20 patients diagnosed with sarcoma within the past 6 months. They included 12 women and 8 men. Their mean age was 32.5 years. They were administered on one page two questionnaires (both developed by Kreitler & Kreitler in the Psychooncology Unit of the Tel-Aviv Medical Center): the multidimensional quality of life questionnaire (revised version) that includes 22 items to which the patient is asked to respond by checking one of 4 response alternatives (a lot, moderate, a little, not at all); and the coping questionnaire (short version) that include 22 items to which the patient has to respond by checking how true each was (very true, true, not true, not all true). The coping questionnaire provided three scores: emotional coping, cognitive coping and behavioral coping. Results: The results showed that the high scores of overall quality of life were obtained by patients who scored highest on emotional coping. The second best kind of coping was the behavioral and the last the cognitive.
Conclusions: The findings suggest that in order to improve quality of life it is important to focus on emotional coping.
ID 24
The long term follow-up results of massive endo-prothesis of TMTS
Erler Kaan, Demiral Baht, Qigek Ilke, Özdemir Tane, Basbozrurt Must
Gülhane Military Medical Academy, Ankara, Turkey
Introduction: Considering patient survival and functional advances, limb salvage surgery has been performed in our department with the proper indications Massive endo-
prosthetic reconstruction of the limbs after the limb salvage surgery for the benign aggressive and malignant tumors has been indicated and performed for 47 cases in our department. We presented our clinical ten-years-results of the massive endoprosthesis of TMTS from the year of 1990 to 1997. Material and Methods: Five cases with benign aggressive bone tumors and forty-two cases with malignant bone tumors were reconstructed with TMTS after the primer en-bloc resection surgery. Thirty-seven patients were diagnosed as osteosarcoma. Lesions were located in distal femoral for 21 cases, in proximal femoral for 3 cases, in femoral diaphysis for 4 cases, in proximal tibial for 7 cases and in proximal humeral for one case. The other case had both distal femoral and proximal tibial lesion. Two patients were diagnosed as chondrosarcoma. One of them had lesion in distal femoral and the other one had lesion in proximal femoral. The two cases with tumor in distal femoral were diagnosed as leyomyosarcoma and lymphoma. The mean age was 23 (11-66). The mean length of en bloc excision was 11 cm (7-48 cm).
Results: We didn't notice acute vascular injury, venous thrombosis and pulmonary embolism during peroperative and postoperative periods in all patients. Common peroneal nerve sacri-fication was performed in two patients because of involvement. Femoral stems in five cases and tibial stems in three cases were revised because of aseptic loosening. One cases who had local recurrence was treated with high above knee amputation. ECF was applied in other two cases for distraction osteogenesis. Conclusions: TMTS has been used for massive endoprosthetic reconstruction after en-bloc resections. Our 10-years-follow-up of TMTS reconstruction revealed that aseptic loosening was the main problem for the revisions free from the local recurrence rates. Despite its early and late complications, the functional advances for the patients' daily life improving with the massive prothesis was undeniable.
POSTER SESSION
ID 192
Instabilty of the endoprosthesis in bone tumors.
A retrospective analysis
V.A. Sokolovskiy. S.A. Saravanan, M.N. Orehov,
D.V. Nisichenko. A.A. Amiraslanov
N.N. Blokhin Russian Cancer Research Center, Moscow, Russian Federation
Introduction: To analyze the frequency and the reasons of the instability of the endoprosthesis after endoprosthetic replacement of major joints in bone tumours.
Material and Methods: From 1992 — 2004, 275 endoprosthetic replacements (142 men & 133 women) of major joints were performed. The median age was 27.3 years (10 to 80 years). 34 (12.3%) out of 275 patients had instability of the endoprosthesis after primary endoprosthetic replacement, and in 5 patients, instability of the endoprosthesis was observed after revisional endoprosthetic replacement. Totally, instability of the endoprosthesis was diagnosed in 44 (16%) patients out of 275 operative interventions. We analyzed the instability of the endoprosthesis in various joints after endoprosthetic replacement. These are the following: 2/31 (6.4%) cases at the humeral joint, 2/44 (4.2%) cases at the hip joint, 11/65 (16.9%) had instability of the endoprosthesis after proximal tibial resection, 28/170
За
(16.4%) had instability of the endoprosthesis after distal femoral resection and 1/15 (6.6%) had instability of the endoperosthesis after total endoprosthetic replacement of femur. The Retrospective analysis of cases has shown, that the reasons of instability were the following: Aseptic loosening of the stem of the endo-pros-thesis in 12/44 (27.3%) cases, destruction of the endoprosthesis in 17/44 (38.6%) cases, migration of the endoprosthesis in 6/44 (13.6%) cases, destruction of the plastic bush in 7/44 (15.9%) cases and periprosthetic fracture in 2/44 (4.5%) cases. Results: The time required for the development of instability of the endoprosthesis ranged from 6 days to 12.5 years. The mean required time was 26.1 months. Instability of the endoprosthesis most often seen (16.9%) after proximal tibial resection and less often seen after proximal femoral resection with endoprosthetic replacement (4.2%).
Conclusions: The most frequent reason (38.6%) resulting instability of the endoprosthesis was destruction (wear & tear) of the endoprosthesis.
ID 116
Resection arthrodeses of knee after tumor resection -different surgical techniques
Z.A. Matejovsky, Z. Matejovsky, I. Kofranek Orthopedic Clinic Bulovka, Prague, Czech Republic
Introduction: Purpose of this study is to evaluate long term results of different techniques of resection arthrodeses (RA) for bone tumors around the knee.
Material and Methods: From 1975 until 1995 we performed 77 RA. Patients were evaluated according to the oncological outcome, functional and psychological compliance and complications. Possibility for conversion into endoprosthesis is discussed together with present rare indications for RA. Results: Most patients (57) had an osteosarcoma. Surgical techniques were fibular grafts with bone chips, massive allograft fixed with rod or plate, split ipsilateral femur or tibia autograft combined with bone chips and temporary cement spacers. From 5 fibular grafts only one survives with good functional results. Massive allografts did better when fixed with plates as valgus and slight flexion could be achieved. Standard long nails showed higher rates of fracture failures. Chemotherapy and especially irradiation increases the infection rate mainly in the tibia. Initial use of cement spacers is an option. Best results were achieved by splitting and rotating half of the ipsilateral bone, adding bone chips and stabilizing with plate. Complications were osteosynthesis failures, bone graft resorption, fracture or non union, infection and local recurrence. Conversion into endoprostheses is feasible in cases of mechanical failures. Salvage of an infected tumor endoprosthesis through arthrodesis is also possible. Conclusions: RA after tumor resection has high risk of complications that can be improved through a correct surgical technique. Graft incorporation defends on adjuvant treatment, age of patient, type of graft and osteosynthesis. If healed, RA enables a stable and fully weight-bearing extremity with good long term results. Indication for RA has greatly decreased with the improvement of large tumor endoprostheses, but it still keeps its indication in small children or cases were lack of soft tissue doesn't enable the use of nonconstrained or semi-constrained endoprostheses.
ID 18
Long term survival (> 10 years) of patients with osteosarcoma and multiple synchronous metastases
G.U. Exner1, S. Bielack1, B. Kempf-Bielack1,
A.R. von Hochstetter2, Th. Schneider2
1 Olgahospital, Stuttgart, Germany
2 Pathologie Enge, Zurich, Switzerland
Introduction: Few patients with osteosarcoma and multiple synchronous metastases survive longer than 10 years after first diagnosis. We have been able to follow 9 patients from the COSS study who survived for more than 10 years with multilocular metastastic disease at diagnosis. Two of the patients were treated in our institution. We feel it is important to realize that some patients with multiple synchronous metastases may survive for long time.
Material and Methods: Patients registered in the COSS study with osteosarcomas and involvement of at least 3 sites were included. Skip lesions and multiple lesion in one lung lobe were excluded as each compartment was considered one site. The diagnosis of multilocular OSA was assumed, if at least at 2 sites histology proved typical OSA. There were 7 male and 2 female patients. Average age at primary tumor biopsy averaged 20.2 years and ranged from 7.5 to
44.7 years. Primary tumor site was the distal femur in five patients, proximal femur in one patient, femur metaphysis in one patient proximal femur and pelvis in one patient and multiple pelvic locations in one patient. All patients had synchronous pulmonary metastases. Five patients had multiple metastases in both lungs, one patient showed one metastasis in each lung, one patient had one metastasis in each lung and metastases in the 9th rip on each side, one patient showed two metastases in the right lung and one metastasis in the left acetabulum and one patient showed multiple metastases in both lungs with one additional metastasis in the 11th thoracic vertebra, the right femur, the right iliac bone and the right pubic bone.
Results: Two patients were lost to follow up after complete remission was stated. They averaged 15.6 years without relapse before they were lost to follow up. Complete remission was achieved in four patients with an average of 16.2 years without relapse. One patient with initially diffuse synchronous lung metastases is alive without complete remission after 15.6 years but is currently treated with high dose MTX because of metastases in the 11th thoracic vertebra and one rib. One patient with multiple synchronous pulmonary metastases and multiple skeletal metastases now reach 10.1 years without additional secondary metastases. One patient died 14.4 years after osteosarcoma with multiple synchronous pulmonary metastases was diagnosed for the first time. Conclusions: Long term survival (over 10 years) of OSA patients with progressive disease have not been specifically addressed in the literature. In metastatic disease frequently a short term life expectancy is assumed. However even in progressive tumor disease prognosis has been improved with treatment and support to maintain quality of life. The data presented herein are not intended to give the impression of a generally good long term prognosis but should indicate that some patients may survive for long term. We have no clear factors to explain the slow progress in some patients. Aspects may be stable psychology allowing the patient to repeatedly undergo
f/u examinations and consequently managing problems, even so this may be only symptomatic or locally curative.
ID 122
Long term functional outcome and quality of life after treatment for extremity bone sarcoma
L.H. Aksnes1, K. Sundby Hall1, G. Folleres1, H.F.C. Bauer2,
H. Lernedal2, C. Allert2, N.L. Jebsen3
1 The Norwegian Radium Hospital, Rikshospitalet-Radiumhospitalet trust, Oslo, Norway
2 The Karolinska Hospital, Stockholm, Sweden
3 Haukeland Hospital, Bergen, Norway
Introduction: The purposee of this study was to evaluate the functional outcome and the quality of life (QoL) in survivors of extremity localized osteosacoma and Ewing sarcoma (EBTSs) min 5 y after treatment.
Material and Methods: One hundred and thirty three (75 males) EBTSs (>15 y of age) are included in this study. The function was evaluated according to Enneking's system and Toronto Extremity Salvage Score (TESS) and QoL by Short Form 36 (SF-36) in addition to demographic data. SF-36 findings have been compared to an age and gender adjusted norm data. Results: The median age at follow up was 29 y (15-57). Median time since diagnosis was 13 y (6-25). For 98 EBTSs the follow-up was > 10 y. Limb sparing surgery was performed in 60%. Fifty two percent were married/cohabitant, and 42% had completed a college/university degree. Sixty seven percent were working full or part time, and 19% were studying. The median Enneking score was 70% (17-100), and the median TESS 89% (43-100). The amputated had significant lower Enneking score, and those being amputated > 10 years ago had a significant lower score than the other amputated. No significant differences were seen in TESS. The EBTSs had lower scores in all the physical dimensions of SF-36 compared to their norm sample (p<0.001). The males had also significant lower scores in two of the mental dimensions (Social Functioning, p = 0.04 and Role Emotional, p = 0.008). There were no differences between the amputated and the limb sparing EBTSs except in physical functioning (p = 0.003). Conclusions: The EBTSs are doing well, but have a reduced physical functioning compared to the norm. Being amputated > 10 y ago gives a lower Enneking score, but do not influence the TESS and SF-36.
ID 54
Third primary osteosarcoma in a 22-year interval
A. Leithner1, W. Ertl1, R.Windhager1, T. Bauernhofer2,
E. Spuller3, K. Bodo3
1 Department of Orthopedic Surgery, Medical University Graz, Austria
2 Division of Oncology, Department of Medicine, Medical University Graz, Austria
3 Institute of Pathology, Medical University Graz, Austria
Introduction: Only few reports on patients who develop metachronous skeletal osteosarcoma exist. In these patients a metachronous osteosarcoma subsequently developed in another site without evidence of pulmonary metastases.
Material and Methods: We report an extremely rare case of a patient with a third primary osteosarcoma resulting in a rotationplasty on one and a tumorendoprosthesis on his other lower extremity.
Results: In 1983, an 18-year old male Caucasian received a rotationplasty due to a G3 osteosarcoma of his left distal femur, followed by an adjuvant therapy (Rosen T10 protocol). Ten years later, in 1993, a second primary G3 osteosarcoma of his twelfth thoracal vertebral body was detected. An en bloc resection was performed, followed by adjuvant chemotherapy. In July 2005, 12 years after his last operation, the patient was admitted to our department due to swelling and pain in his distal right femur. A biopsy was taken, again showing a G3 osteosarcoma. Staging revealed no metastases. After neoadjuvant chemotherapy a wide resection and reconstruction with a tumorendoprosthesis was performed. As a complication 2 months after the final operations the patient fell due to difficult weight bearing in combination with his rotationplasty and an open luxation of the operated knee occurred. At the moment, 3 months after the last resection the patient is free of recurrence or metastases and is still receiving chemotherapy.
Conclusions: The precise etiology of conventional osteosarcoma still remains unclear. In cases like the one described a genetic component is obvious. As the patient did not give his content for a genetic analysis yet, the identification of the genetic factor remains elusive. Rare cases like this, however, strengthen the need for a further molecular research leading to a better understanding of the factors causing osteosarcoma.
ID 103
Long time follow-up Kotz prostheses
A.H.M. Taminiau, P.D.S. Dijkstra
Leiden University Medical Centre, Leiden, Netherlands
Introduction: The files of the patients treated between 1984 and 1994 who received Kotz modular prosthesis for reconstruction after resection of primary bone tumors are analyzed. Material and Methods: 27 patients (17 male, 10 female) age 14-76 mean 37,1 years. Diagnosis osteosarcoma 11, chondrosarcoma 7, Ewing 4, MFH 3, synoviosarcoma 1, GCT 1. The used Kotz prosthetic device was: femur distal 16, proximal 7, tibia proximal 3.
Results: Oncological results: 8 Patients died (tumor related 7, other cause 1). There was one local recurrence. One patient had progressive recurrent disease (GCT to osteosarcoma). All 19 other are alive tumor free. Three amputations were performed; two for infection and one for local recurrence Of the 19 long term survivors: 5 patients had no complication except for osteolysis around the stem and have still their prosthesis functioning. 5 had revision of the system towards a Mutars modular prosthesis. One of these because of fracture of the bone, one due to breaking the stem of the prosthesis. Prosthetic complications: bushes revision 4, acetabular cup revisions 2, loosening of the stem requiring cementation 2, fracture solved by revision of the Kotz prosthesis 1, infection 2 treated by amputation and rotation plasty. Conclusions: The Kotz modular system prosthesis at longer follow up requires often second surgical procedures what is a problem as patients tent to survive longer.
ID 104
Treatment and recurrence of primary aneurysmal bone cysts
A.H.M. Taminiau, J. Vogel, P.D.S. Dijkstra,
P.C.W. Hogendoorn, E. van der Linden
Leiden University Medical Centre, Leiden, Netherlands
Introduction: Aneurysmal bone cyst is a vascular benign but destructive lesion of bone, often situated in or near the epiphyseal plate. Recurrence rates vary among different treatment options from 0-59%. Purpose of this research was to identify the therapy with the lowest recurrence rate, shortest in-hospital stay and least complications, especially considering growth disturbance.
Material and Methods: From 81 patients were diagnosed with primary aneurysmal bone cyst between 1980 and 2006 in the Leiden University Medical Center. Curettage, golden standard treatment, was compared to embolization, excision, injection with Ethibloc, autologous bone marrow, and methylprednisolone (Depo medrol®). Embolization with a Sel-dinger procedure can be performed either as treatment or as pre-operative adjuvans to curettage. Embolization is the treatment of choice for aneurysmal bone cysts in the spine and pelvis. Complications are rare. En bloc excision is common treatment for aneurysmal bone cysts in expendible bones. After excision, autologous or allogenic bone graft is sometimes required. Recurrence after en bloc excision is rare. For aneurysmal bone cysts in or near the epiphyseal plate, excision is not suitable because of induced growth disturbance. Injection of aneurysmal bone cysts with Ethibloc (solution of zein in alcohol) is a novel treatment option. It stimulates formation of bone inside the aneurysmal bone cyst. Injections with Ethibloc are suitable for long bones, pelvis or spine. Results: Major complications hardly ever occur, but fatal Ethibloc injection in the spine has been reported once. Minor side effects include fever, temporary local pain and temporary self-healed inflammatory reaction in the first two weeks. Injections with methylprednisolone (5) was used on small scale in previous years but have a high recurrence rate (100%) and is abandoned. Embolisation (13) had a recurrence rate of 45%. Curettage (42) had a recurrence rate of 40.5%. Injection with Ethibloc (21) had the lowest recurrence rate14%, but is used only for three years.
Conclusions: Our first treatment of choice is injection with Ethibloc. If impossible embolisation is a good alternative. Curettage can be seen as the last resort, as it is the most invasive therapy.
ID 162
Post operative complications after total hip replacement in proximal femoral tumors
V.A. Sokolovski, V.P. Voloshin, M.D. Aliev, V.S. Zubikov,
S.A. Saravanan, D.V. Nisichenko
N.N. Blokhin Russian Cancer Research Center,
Moscow, Russian Federation
Introduction:To analyze the post operative complications after total hip replacement in proximal femoral tumors. Material and Methods: We retrospectively reviewed 50 patients who undergone total hip replacement for proximal
femoral tumors between 1994 and 2005. The histological diagnoses included 14 - metastases, 10 - osteosarcoma, 8 -chondrosarcoma, 4 - Ewing's sarcoma, 4 - giant cell tumor,
3 - malignant fibrous histiocytoma, 2 paraosteal and 2 periosteal osteosarcoma, and 1 each from primary neuroectodermal tumor, myeloid disease, and aneurysmal bone cyst. The follow-up ranged from 1 — 9 years (mean follow-up 5 years). Results: Out of 50, 10 (20%) patients had delayed post operative periprosthetic infection. In 5 patients, dislocation of the endoprosthesis, in 2 patients haematoma were occurred in the early post operative period. The dislocation was reduced with satisfactory functional results. Instability of endoprosthesis was observed in 6 patients and required revisional total or partial hip replacement. Local recurrence of the tumor occurred in 2 patients and 2 patients necessitated exatriculation of the hip joint. 3 patients showed evidence of lung metastases. One patient was died of myocardial infarction in the early post operative period. There was no evidence of disease in 32 patients.
Conclusions: In our experience, periprosthetic infection was the commonest complication observed and S.aureus was the commonest pathogen identified. Special care was taken to reconstruct the abductors and Psoas muscle to the endoprosthesis to increase the stability of the artificial hip joint. Though the complication rate is very high, there is no doubt that endoprosthetic replacement of the proximal femur provides a good functional and oncological outcome when compared with the various other reconstructive surgeries.
ID 262
Is hindquarter amputation justifiable:
the Royal National Orthopaedic Hospital experience
G.Y. Sheshappanavar, J.M. Jagiello, P.K. Jaiswal,
O.M. Stokes, S.R. Cannon
Royal National Orthopaedic Hospital, London, UK
Background: Advances in adjuvant and neoadjuvant therapies have rendered many tumours that previously necessitated amputation amenable to limb salvage procedures. However, a significant proportion of tumours are still treated by hindquarter amputation in an attempt to cure the patient, or to reduce the tumour load. This tends to be lengthy, mutilating and is associated with high morbidity and poor survivorship. Aims: To review the survivorship, quality of life and functional assessment following hindquarter amputations performed in this centre in the last 10 years.
Material and Methods: This was a retrospective study of 51 consecutive patients who had hindquarter amputations for tumours between 1996 to 2006. Available patients were evaluated using contemporary functional outcome assessments (Musculoskeletal Society Tumour Score, Toronto Extremity Salvage Score, SF36).
Results: Fifty-one patients (31 males, 20 females) had palliative (8) or curative hindquarter amputations (43) for chondrosarcoma (18), malignant fibrous histiocytoma (6), osteosarcoma (4) and other sarcoma subtypes (23). The mean age was
50.7 years (range 24-78). The mean duration of symptoms until referral was 5.2 months, the mean time from referral to tissue diagnosis was 16.2 days (range 2-80) and the time from confirmed histological diagnosis to surgery was 39.2 days (range 2190) on average. Significant complications included phantom
limb pain (15), wound problems (24), urinary problems (6), cardiopulmonary events (5) and erectile dysfunction (3). 33 of the 51 patients have passed away, with a mean survival postoperatively of 10.7 months (range 2-43), with carcinomatosis the main cause of death. The mean cumulative survival following hindquarter amputation in this hospital is 17.3 months.
Conclusions: Patients with no metastasis and clear margins at amputation had a better cumulative survival rate. Therefore the decision to proceed for hindquarter amputation to achieve a curative resection is justified but has to be weighed up against the associated significant complications, morbidity and functional deterioration.
