Skip to main content

Advertisement

Log in

Limb salvage in the skeletally immature patient

  • Published:
Current Oncology Reports Aims and scope Submit manuscript

Abstract

The most common tumors of bone, osteosarcoma and Ewing sarcoma, commonly occur in the skeletally immature patient. Historically, amputation was the procedure of choice; however, improved oncologic outcome and technical advances in limb salvage surgery have made limb salvage therapy a feasible and valuable treatment option. Nevertheless, depending on the extent of the lesion within the long bone, it may be difficult to spare the physis, and hence, in the skeletally immature patient, resection of a sarcoma of bone can create a limb-length discrepancy and gait abnormalities. This article reviews the limb salvage options available for the skeletally immature patient who requires reconstruction of a segmental long bone defect.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Benjamin R, Chawla S, Murray J, et al.: Preoperative chemotherapy for osteosarcoma: a treatment approach facilitating limb salvage with major prognostic indications. In Adjuvant Therapy of Cancer, vol 4. Edited by Jones S, Salmon S. Philadelphia: Grune and Stratton; 1984; 601–610.

    Google Scholar 

  2. Klein MJ, Kenan S, Lewis MM: Osteosarcoma: clinical and pathological considerations. Orthop Clin North Am 1989, 20:327–345.

    PubMed  CAS  Google Scholar 

  3. Rosen G, Marcove RC, Huvos AG, et al.: Primary osteogenic sarcoma: eight-year experience with adjuvant chemotherapy. J Cancer Res Clin Oncol 1983, 106:55–67.

    Article  PubMed  Google Scholar 

  4. Simon MA, Aschliman MA, Thomas N, Mankin HJ: Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am 1986, 68:1331–1337. A retrospective multi-institutional study of 227 patients with osteosarcoma of the distal end of the femur was done to compare rates of local recurrence, metastasis, and survival. Three cohorts of patients who had had either a limb-sparing procedure, an above-the-knee amputation, or disarticulation of the hip were compared. The Kaplan-Meier estimates of the percentage of patients who survived and the percentage of patients without recurrent disease showed no difference among the three surgical groups (Mantel-Cox test statistic: P=0.8) after a median follow-up of 5 and a half years. Compared with above-theknee amputation or disarticulation of the hip, the use of a limb salvage procedure for osteosarcoma of the distal end of the femur did not shorten the disease-free interval or compromise long-term survival.

    PubMed  CAS  Google Scholar 

  5. Whelan JS: Osteosarcoma. Eur J Cancer 1997, 33:1611–1618. A complete review of osteosarcoma including recent advances in molecular biology and chemotherapy.

    Article  PubMed  CAS  Google Scholar 

  6. Dominkus M, Krepler P, Schwameis E, et al.: Growth prediction in extendable tumor prostheses in children. Clin Orthop Relat Res 2001, 390:212–220.

    Article  PubMed  Google Scholar 

  7. Anderson MS, Green WT, Messner MB: Growth and predictions of growth in the lower extremities. J Bone Joint Surg Am 1963, 45-A:1–14.

    Google Scholar 

  8. Moseley CF: A straight-line graph for leg-length discrepancies. J Bone Joint Surg Am 1977, 59:174–179.

    PubMed  CAS  Google Scholar 

  9. Moseley CF: A straight line graph for leg length discrepancies. Clin Orthop 1978, 136:33–40.

    PubMed  Google Scholar 

  10. Little D, Nigo L, Aiona M: Deficiencies of current methods for timing of epiphysiodesis. J Pediatr Orthop 1996, 16:173–179.

    PubMed  CAS  Google Scholar 

  11. Menelaus MB: Correction of leg length discrepancy by epiphysial arrest. J Bone Joint Surg Br 1966, 48:336–339.

    PubMed  CAS  Google Scholar 

  12. Menelaus M: The Anstey Giles lecture. Opening and closing the growth plate. Aust N Z J Surg 1981, 51:518–527.

    PubMed  CAS  Google Scholar 

  13. Kaufman K, Miller L, Sutherland D: Gait asymmetry in patients with limb-length inequality. J Pediatr Orthop 1996, 16:144–150. This study investigated 20 subjects with documented limb-length inequalities to determine the magnitude of discrepancies that result in gait abnormalities. The contact time, first and second force peaks, and loading and unloading rates of the vertical ground-reaction force were measured for both limbs. These parameters were predictive for quantification of gait asymmetry. The asymmetry of these parameters increased as the limb-length inequality increased. In general, a limb-length inequality of greater than 2.0 cm (3.7%) resulted in gait asymmetry that was greater than that observed in the normal population.

    PubMed  CAS  Google Scholar 

  14. Horton G, Olney B: Epiphysiodesis of the lower extremity: results of percutaneous technique. J Pediatr Orthop 1996, 16:180–182.

    PubMed  CAS  Google Scholar 

  15. Scales JT, Sneath RS, Wright KWJ: Design and clinical use of extending prosthesis. In Limb Salvage in Musculoskeletal Oncology. Edited by Enneking WF. New York: Churchill Livingstone; 1987:52–61.

    Google Scholar 

  16. Kenan S, Lewis MM: Limb salvage in pediatric surgery: the use of the expandable prosthesis. Orthop Clin North Am 1991, 22:121–131. The concept of an expandable adjustable prosthesis to address the problem of leg-length discrepancy is examined.

    PubMed  CAS  Google Scholar 

  17. Kenan S, Bloom N, Lewis MM: Limb-sparing surgery in skeletally immature patients with osteosarcoma: the use of an expandable prosthesis. Clin Orthop Relat Res 1991, 270:223–230.

    PubMed  Google Scholar 

  18. Eckardt JJ, Safran MR, Eilber FR, et al.: Expandable endoprosthetic reconstruction of the skeletally immature after malignant bone tumor resection. Clin Orthop Relat Res 1993, 297:188–202.

    PubMed  Google Scholar 

  19. Eckardt JJ, Kabo JM, Kelley CM, et al.: Expandable endoprosthesis reconstruction in skeletally immature patients with tumors. Clin Orthop 2000, 1(373):51–61. Expandable endoprotheses were used for limb reconstruction after resection of malignant bone tumors in skeletally immature patients. Fifty percent of the patients underwent 32 expansion procedures, to a maximum of 9 cm.

    Google Scholar 

  20. Ward WG Sr, Yang RS, Eckardt JJ: Endoprosthetic bone reconstruction following malignant tumor resection in skeletally immature patients. Orthop Clin North Am 1996, 27:493–502.

    PubMed  CAS  Google Scholar 

  21. Dominkus M, Windhager R, Kotz R: Treatment of malignant bone tumors in young children-complications and revisions. Acta Orthop Scand 1997, 276(Suppl 4):4.

    Google Scholar 

  22. Schiller C, Windhager R, Fellinger EJ, et al.: Extendable tumour endoprostheses for the leg in children. J Bone Joint Surg Br 1995, 77:608–614. Report of six children reconstructed with extendable prostheses. The mean length gained was 13.15 cm (4.5 to 19.5), requiring 53 planned procedures. Seven revision operations were necessary for complications. Functional evaluation showed excellent and good results in all cases. Stress shielding at the site of anchorage of the prosthesis was more pronounced than in adults. Expandable prostheses required more operations that were needed solely for lengthening.

    PubMed  CAS  Google Scholar 

  23. Gitelis S, Neel MD, Wilkins RM, et al.: The use of a closed expandable prosthesis for pediatric sarcomas. Chir Organi Mov 2003, 88:327–333. A review of their experience with a noninvasive expandable prosthesis for skeletally immature patients following limb salvage for malignant tumors above the knee. The functional results were excellent, similar to conventional modular devices. Complications were salvageable.

    PubMed  CAS  Google Scholar 

  24. Wilkins RM, Soubeiran A: The Phoenix expandable prosthesis: early American experience. Clin Orthop Relat Res 2001, 382:51–58.

    Article  PubMed  Google Scholar 

  25. Borggreve J: Kniegelenssersatz durch das in der Beinlngsachse um 1800 gedrehte Fussgelenk. Arch Orthop Unfall-Chir 1930, 28:175–178.

    Article  Google Scholar 

  26. Van Nes CP: Rotation-plasty for congenital defects of the femur: making use of the ankle of the shortened limb to control the knee loint of a prosthesis. J Bone Joint Surg Am 1950, 32:12–16.

    Google Scholar 

  27. Hanlon M, Krajbich JI: Rotationplasty in skeletally immature patients. Long-term followup results. Clin Orthop Relat Res 1999, 1(358):75–82.

    Google Scholar 

  28. Heeg M, Torode IP: Rotationplasty of the lower limb for childhood osteosarcoma of the femur. Aust N Z J Surg 1998, 68:643–646.

    PubMed  CAS  Google Scholar 

  29. Hillmann A, Rosenbaum D, Gosheger G, et al.: Rotationplasty type B IIIa according to Winkelmann: electromyography and gait analysis. Clin Orthop Relat Res 2001, 384:224–231.

    Article  PubMed  Google Scholar 

  30. Merkel KD, Gebhardt M, Springfield DS: Rotationplasty as a reconstructive operation after tumor resection. Clin Orthop Relat Res 1991, 270:231–236.

    PubMed  Google Scholar 

  31. Cammisa FP,Jr., Glasser DB, Otis JC, et al.: The Van Nes tibial rotationplasty: a functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur. J Bone Joint Surg Am 1990, 72:1541–1547. The results of functional testing showed that patients with rotationplasties performed and those who had endoprosthetic replacement were better than those who had above-the-knee amputation. Rotationplasty can therefore be a favorable alternative to amputation or endoprosthetic replacement, either as a primary or as a salvage procedure.

    PubMed  Google Scholar 

  32. Gottsauner-Wolf F, Kotz R, Knahr K, et al.: Rotationplasty for limb salvage in the treatment of malignant tumors at the knee: a follow-up study of seventy patients. J Bone Joint Surg Am 1991, 73:1365–1375.

    PubMed  CAS  Google Scholar 

  33. Hoffman C, Hillmann A, Krakau H, et al.: Functional results and quality of life measurements in patients with multimodal treatment of a primary bone tumor located in the distal femur: rotationplasty versus endoprosthetic replacement. Med Pediatr Oncol 1998, 31:202–203.

    Google Scholar 

  34. McClenaghan BA, Krajbich JI, Pirone AM, et al.: Comparative assessment of gait after limb-salvage procedures. J Bone Joint Surg Am 1989, 71:1178–1182.

    PubMed  CAS  Google Scholar 

  35. Winkelmann WW: Type-B-IIIa hip rotationplasty: an alternative operation for the treatment of malignant tumors of the femur in early childhood. J Bone Joint Surg Am 2000, 82:814–828.

    PubMed  CAS  Google Scholar 

  36. Murray MP, Jacobs PA, Gore DR, et al.: Functional performance after tibial rotationplasty. J Bone Joint Surg Am 1985, 67-A:392–399.

    Google Scholar 

  37. Steenhoff JR, Daanen HA, Taminiau AH: Functional analysis of patients who have had a modified Van Nes rotationplasty. J Bone Joint Surg Am 1993, 75:1451–1456.

    PubMed  CAS  Google Scholar 

  38. Kotz R, Salzer M: Rotation-plasty for childhood osteosarcoma of the distal part of the femur. J Bone Joint Surg Am 1982, 64:959–969.

    PubMed  CAS  Google Scholar 

  39. Kapukaya A, Subasi M, Kandiya E, et al.: Limb reconstruction with the callus distraction method after bone tumor resection. Arch Orthop Trauma Surg 2000, 120:215–218.

    Article  PubMed  CAS  Google Scholar 

  40. Nakatsuka Y, Ozaki T, Kawai A, et al.: Reconstruction of bony defect after resection of a high grade osteosarcoma using bone transport: a case report. Presented at the International Symposium on Limb Salvage, Singapore, 1993.

  41. Tsuchiya H, Tomita K, Minematsu K, et al.: Limb salvage using distraction osteogenesis: a classification of the technique. J Bone Joint Surg Br 1997, 79:403–411.

    Article  PubMed  CAS  Google Scholar 

  42. Knothe UR, Springfield DS: A novel surgical procedure for bridging of massive bone defects. World J Surg Oncol 2005, 3:7.

    Article  PubMed  Google Scholar 

  43. Kumta SM, Chow TC, Griffith J, et al.: Classifying the location of osteosarcoma with reference to the epiphyseal plate helps determine the optimal skeletal resection in limb salvage procedures. Arch Orthop Trauma Surg 1999, 119:327–331. Classifying the location of osteosarcoma with reference to the epiphyseal plate helps determine the optimal skeletal resection in limb salvage procedures.

    Article  PubMed  CAS  Google Scholar 

  44. Donati D, Di Liddo M, Zavatta M, et al.: Massive bone allograft reconstruction in high-grade osteosarcoma. Clin Orthop Relat Res 2000, 377:186–194. Functional results with allografts in patients with high-grade osteosarcoma were good or excellent in 74%. The nonunion rates were 49%, and the fracture rate was 27%.

    Article  PubMed  Google Scholar 

  45. San Julian Aranguren M, Leyes M, Mora G, Canadell J: Consolidation of massive bone allografts in limb-preserving operations for bone tumours. Int Orthop 1995, 19:377–382.

    Article  PubMed  CAS  Google Scholar 

  46. 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, 426:97–102. The oncologic and functional survival of intercalary femur and tibia segmental allografts implanted after segmental resection was examined. Infection, fracture, and nonunion rates were determined.

    Article  PubMed  Google Scholar 

  47. Sorger JI, Hornicek FJ, Zavatta M, et al.: Allograft fractures revisited. Clin Orthop Relat Res 2001, 382:66–74.

    Article  PubMed  Google Scholar 

  48. Berrey BH Jr, Lord CF, Gebhardt MC, Mankin HJ: Fractures of allografts: frequency, treatment, and end-results. J Bone Joint Surg Am 1990, 72:825–833.

    PubMed  Google Scholar 

  49. Lord CF, Gebhardt MC, Tomford WW, Mankin HJ: Infection in bone allografts: incidence, nature, and treatment. J Bone Joint Surg Am 1988, 70:369–376.

    PubMed  CAS  Google Scholar 

  50. Gerrand CH, Griffin AM, Davis AM, et al.: Large segment allograft survival is improved with intramedullary cement. J Surg Oncol 2003, 84:198–208.

    Article  PubMed  Google Scholar 

  51. Gebhardt MC, Flugstad DI, Springfield DS, Mankin HJ: The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. Clin Orthop Relat Res 1991, 270:181–196. Bone allografts used to reconstruct the bony defects following tumor resection offer many advantages, including joint reconstruction and incorporation of the graft to the host bone in these relatively young patients. The results of 53 patients 30 years of age or younger were assessed to determine functional outcome. The authors concluded that allografts can be used for limb reconstruction in patients with high-grade osteosarcoma who receive aggressive adjuvant chemotherapy. The functional results are comparable with those from other methods of reconstruction, and once incorporated by the host, offer the advantage of longevity, compared with metallic implants.

    PubMed  Google Scholar 

  52. Dick H, Strauch R: Infection of massive bone allografts. Clin Orthop Relat Res 1994, 306:46–53.

    PubMed  Google Scholar 

  53. Mankin HJ, Gebhardt MC, Jennings LC, et al.: Long-term results of allograft replacement in the management of bone tumors. Clin Orthop Relat Res 1996, 324:86–97.

    Article  PubMed  Google Scholar 

  54. Hornicek FJ, Gebhardt MC, Tomford WW, et al.: Factors affecting nonunion of the allograft-host junction. Clin Orthop Relat Res 2001, 382:87–98.

    Article  PubMed  Google Scholar 

  55. Innocenti M, Delcroix L, Manfrini M, et al.: Vascularized proximal fibular epiphyseal transfer for distal radial reconstruction. J Bone Joint Surg Am 2004, 86-A:1504–1511.

    PubMed  Google Scholar 

  56. Innocenti M, Ceruso M, Manfrini M, et al.: Free vascularized growth-plate transfer after bone tumor resection in children. J Reconstr Microsurg 1998, 14:137–143.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lewis, V.O. Limb salvage in the skeletally immature patient. Curr Oncol Rep 7, 285–292 (2005). https://doi.org/10.1007/s11912-005-0052-7

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11912-005-0052-7

Keywords

Navigation