Kristen L. Kellar-Graney

Distal femur resection with endoprosthetic reconstruction: a long-term followup study.

The distal femur is a common site for primary and metastatic bone tumors and therefore, it is a frequent site in which limb-sparing surgery is done. Between 1980 and 1998, the authors treated 110 consecutive patients who had distal femur resection and endoprosthetic reconstruction. There were 61 males and 49 females who ranged in age from 10 to 80 years. Diagnoses included 99 malignant tumors of bone, nine benign-aggressive lesions, and two nonneoplastic conditions that had caused massive bone loss and articular surface destruction. Reconstruction was done with 73 modular prostheses, 27 custom-made prostheses, and 10 expandable prostheses. Twenty-six gastrocnemius flaps were used for soft tissue reconstruction. All patients were followed up for a minimum of 2 years. Function was estimated to be good or excellent in 94 patients (85.4%), moderate in nine patients (8.2%), and poor in seven patients (6.4%). Complications included six deep wound infections (5.4%), six aseptic loosenings (5.4%), six prosthetic polyethylene component failures (5.4%), and local recurrence in five of 93 patients (5.4%) who had a primary bone sarcoma. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction is a safe and reliable technique of functional limb sparing that provides good function and local tumor control in most patients.

Osteosarcoma of the proximal humerus : long-term results with limb-sparing surgery

The purpose of the current study was to analyze the long-term oncologic and functional results and complications associated with limb-sparing surgery and endoprosthetic reconstruction for 23 patients with osteosarcoma of the proximal humerus. There was one Stage IIA lesion, 18 Stage IIB lesions, and four Stage III lesions in this study group. Twenty-two patients were treated with an extraarticular resection that included the deltoid and rotator cuff and one patient was treated with an intraarticular resection that spared the shoulder abductors. In all these patients, the proximal humerus was reconstructed with a cemented endoprosthetic replacement that was stabilized via a technique of static suspension (Dacron tapes) and dynamic suspension (muscle transfers). At latest followup (median, 10 years), 15 patients (65%) were alive without evidence of disease. There were no local recurrences. Prosthetic survival was 100% for the 15 survivors. The Musculoskeletal Tumor Society upper extremity functional score ranged from 24 to 27 (80%–90%). All shoulders were stable and pain-free. Elbow and hand function were preserved in all patients. The most common complication was a transient neurapraxia (n = 8). En bloc extraarticular resection and endoprosthetic reconstruction is a safe and reliable method of limb-sparing surgery for patients with high-grade extracompartmental osteosarcoma of the proximal humerus.

Constrained total scapula reconstruction after resection of a high-grade sarcoma

Patients with high-grade sarcomas arising from the scapula or periscapular soft tissues traditionally have been treated with either a total scapulectomy or a wide, en bloc, extraarticular scapular resection, termed the Tikhoff-Linberg resection. The major challenge after such resections is to restore shoulder girdle stability while preserving a functional hand and elbow. The current authors describe three patients who had an extraarticular, total scapula resection (modified Tikhoff-Linberg) for a high-grade sarcoma. Each patient had reconstruction with a constrained (rotator cuff-substituting) total scapula prosthesis in an effort to optimally restore the normal muscle force couples of both glenohumeral and scapulothoracic mechanisms. At latest followup, the Musculoskeletal Tumor Society functional score was 24 to 27 of 30 (80%–90%). All patients had a stable, painless shoulder and functional hand and elbow. Forward flexion and abduction ranged from 25° to 40°. Glenohumeral rotation (internal rotation, T6; external rotation −10°) below shoulder level, shoulder extension, and adduction were preserved. Protraction, retraction, elevation, and abduction of the scapula were restored and contributed to shoulder motion and upper extremity stabilization. There were no complications. Total scapula reconstruction with a constrained total scapula prosthesis is a safe and reliable method for reconstructing the shoulder girdle after resection of select high-grade sarcomas. The authors emphasize the clinical indications, prosthetic design, surgical technique, and early functional results.

Sciatic nerve resection: is that truly an indication for amputation?

En bloc resection of the sciatic nerve with an adjacent bone or soft tissue tumor has been assumed to be associated with a poor functional outcome and, therefore, was considered an indication for amputation. Although many surgical oncologists today challenge this assumption and do limb-sparing resection in these patients, a report of the functional outcome of a series of patients who had this procedure has not been published. Between 1991 and 1999, the authors treated 15 patients who had resection of the sciatic nerve. There were 10 females and five males, ranging in age from 2 to 73 years. Diagnoses included 11 high-grade soft tissue sarcomas, one primary bone sarcoma, and three metastatic bone tumors. Four lesions were located in the pelvis, one in the buttock, and 10 in the posterior thigh. At the most recent followup, 14 patients were ambulatory, seven of whom required a walking aid. Because of peroneal nerve palsy, all patients required a short-leg brace. However, overall function was determined to be good in 11, moderate in three, and poor in one patient. None had a pressure sore of the foot and none required a secondary amputation. Good function is achieved in most patients who have sciatic nerve resection. Therefore, the necessity to resect the sciatic nerve is not an indication for amputation.

Utilitarian shoulder approach for malignant tumor resection.

Malignant tumors involving the shoulder girdle can arise from four distinct locations: the proximal humerus, scapula, periscapular muscles, and axillary structures. This article describes a utilitarian shoulder approach that can be used to resect these tumors.

Tumors of the Musculoskeletal System

Both benign and malignant tumors (neoplasms) may arise from any mesenchymal soft tissue or bony tissue of the extremities, pelvis, shoulder girdle, or the axial skeleton. All tumors arise from one of the different histological types of tissue that comprise the musculoskeletal system: bone (osteoid forming tumors), cartilage (chondroid forming tumors), muscle, and the fibrous connective tissue (soft-tissue tumors). Only rarely do tumors arise from the arteries or nerves.

Limb-Sparing Surgery for High-Grade Sarcomas of the Proximal Humerus

The shoulder girdle is the third most frequent site for high-grade extremity sarcomas, and the proximal humerus is the most commonly affected bone (1,2). Osteosarcoma, chondrosarcoma, and Ewing’s sarcoma are the most common primary tumors arising in this location (3–6). These tumors usually originate in the metaphyseal region and present with extraosseous extension (Enneking stage IIB). Before 1970 most patients with high-grade spindlecell sarcomas (e.g., osteosarcomas, chondrosarcomas) involving the proximal humerus were treated with a forequarter amputation (2). In 1977 Marcove et al. (7) were the first to report limb-sparing treatment for high-grade sarcomas arising in this location. These authors reported performing an en bloc extra-articular resection that included the proximal humerus, glenoid, overlying rotator cuff, lateral two thirds of the clavicle, deltoid, coracobrachialis, and proximal biceps (long head) (Fig. 1). Local tumor control and survival rates were similar to those achieved with forequarter amputation. Resection, however, preserved a functional hand and elbow. These early oncologic results were confirmed by other surgeons, and limb-sparing surgery for high-grade sarcomas of the proximal humerus became standard treatment (5,6,8–17). In the early experience with limb-sparing surgery, no attempt was made to reconstruct the shoulder girdle and extremities were left flail after resection (7,9,11). Patients complained of unstable extremities, poor lifting ability, and poor cosmesis. Traction neuropraxia inevitably developed, leading to pain, weakness, and sensory deficits in the hand. Patients ultimately needed to wear an external orthosis for support. In an effort to maintain shoulder motion and extremity length, and improve stability, surgeons often used an intramedullary rod as a functional spacer (12). The rod was secured into the remaining humerus and fastened proximally to a clavicle or a rib. Instability was still a problem, and hardware failure, pain, and erosion through the chest wall or skin occurred frequently. To ensure shoulder stability, other surgeons advocated arthrodesis of the remaining humerus to the scapula using either a cadaver allograft alone or an allograft plus free fibula construct (14). This method required prolonged postoperative immobilization in a shoulder spica cast and frequently failed secondary to fracture, nonunion, and infection. In addition, donor site morbidity associated with free fibula transfer was not uncommon. When a successful arthrodesis occurred, motion (rotation) below the shoulder level where most activities are performed was limited. As the popularity of limb-sparing surgery for shoulder girdle sarcomas grew, the extent of resection necessary for various tumors, particularly the indications for an extra-articular resection, remained a matter of debate. The best method for reconstruction was also under considerable discussion. In response, Malawer et al. (3–6) developed a surgical classification system based on tumor location, extent, grade, and pathologic type (Fig. 2). Address correspondence and reprint requests to Dr. Martin M. Malawer, Department of Orthopedic Oncology, 110 Irving Street N.W., Washington, DC 20010, USA. E-mail: mmalawer1@aol.com Techniques in Shoulder & Elbow Surgery 2(1):54–69, 2001