The Journal of the Korean bone and joint tumor society (대한골관절종양학회지)

The Korean Musculoskeletal Tumor Society (대한근골격종양학회)
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Limb Salvage Surgery with Tumor Prosthesis for the Malignant Bone Tumors Involving the Proximal Femur

대퇴골 근위부 악성 골종양 환자에서 종양 대치물을 이용한 사지 구제술

  • Chun, Young Soo (Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University) ;
  • Baek, Jong Hun (Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University) ;
  • Lee, Seung Hyuk (Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University) ;
  • Lee, Chung Hwan (Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University) ;
  • Han, Chung Soo (Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University)
  • 전영수 (경희대학교 의과대학 정형외과학교실) ;
  • 백종훈 (경희대학교 의과대학 정형외과학교실) ;
  • 이승혁 (경희대학교 의과대학 정형외과학교실) ;
  • 이충환 (경희대학교 의과대학 정형외과학교실) ;
  • 한정수 (경희대학교 의과대학 정형외과학교실)
  • Received : 2014.03.31
  • Accepted : 2014.06.03
  • Published : 2014.06.30
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Abstract

Purpose: As well as patient survival, the restoration of postoperative function such as ambulation is important in limb salvage operations for treatment of malignant bone tumors involving the proximal femur. The authors analyzed clinical outcomes of limb salvage operations using tumor prostheses for metastatic or primary malignant bone tumors in the proximal femur. Materials and Methods: From February 2005 to January 2014, 20 cases (19 patients) with malignant bone tumor involving the proximal femur with pain or complicated pathologic fracture were treated with segmental resection and limb salvage operations with tumor prostheses. Mean age was 63.1 years (range 35-86). Fourteen patients were male and six ones were female. The mean follow-up period was 20 months (1-94 months). There were 15 cases of metastatic bone tumor, 4 cases of osteosarcoma, and 1 case of multiple myeloma. The primary tumors of the metastatic bone tumors included 4 lung cancers, 3 hepatocellular carcinomas, and 3 renal cell carcinomas. Other primary tumors were breast cancer, thyroid cancer, colon cancer, prostate cancer, and malignant spindle cell tumor, each in 1 case. Modular tumor prostheses were used in all cases; (Kotz's$^{(R)}$ Modular Tumor prosthesis (Howmedica, Rutherford, New Jersey) in 3 cases, MUTARS$^{(R)}$ proximal femur system (Implantcast, Munster, Germany) in 17 cases). Perioperative pain was assessed with Visual Analogue Scales (VAS). Postoperative functional outcome was assessed with Musculoskeletal Tumor Society (MSTS) grading system. Results: Out of 20 cases (19 patients), 11 cases (10 patients) survived at the last follow-up. Average postoperative survival of the 9 deceased patients was 10.1 months (1-38 months). VAS score improved from pre-operative average of 8.40 (5-10) to 1.35 (0-3) after operation. Average postoperative MSTS function score was 19.65 (65.50%, 7-28). The associated complications were 2 local recurrences, 3 hematomas, 3 infections, 2 scrotal swellings, and 1 dislocation. There was no case of periprosthetic fracture or loosening. Conclusion: Limb salvage operation with tumor prosthesis is an appropriate treatment for early pain reduction and functional restoration in malignant bone tumors in the proximal femur with pain an/or complicated pathologic fractures.

목적: 대퇴골 근위부에 발생한 악성 골 종양의 치료로 사지 구제술을 시행하는 경우 환자의 생존과 더불어 술 후 보행 등의 기능회복이 중요하다. 대퇴골 근위부의 악성 골 종양에 의한 통증 또는 병적 골절이 발생한 환자에 대하여 종양 대치물을 이용한 사지 구제술 시행 후 임상 결과에 대해서 분석하였다. 대상 및 방법: 2005년 2월부터 2014년 1월까지 대퇴골 근위부 악성 골 종양을 진단 받고 통증 또는 병적 골절이 발생하여 대퇴골 근위부 절제술 및 종양 대치물을 이용한 사지 구제술을 시행한 20예(19명)를 대상으로 하였다. 평균 연령은 63.1세(범위 35-86세)였으며 남자가 14예, 여자가 6예였다. 평균 추시 기간은 20개월(1-94개월)이었고, 전이성 골 종양 15예, 골육종 4예, 다발성 골수종 1예였으며, 전이성 병변의 원발 암은 폐암 4예, 간암 3예, 신장암 3예였고, 유방암, 갑상선암, 대장암, 전립선암, 악성 방추 세포암이 각각 1예씩 이었다. 사용된 종양 대치물은 모두 조립형 종양 대치물로 Kotz's$^{(R)}$ Modular Tumor prosthesis (Howmedica, Rutherford, New Jersey)가 3예에서 사용되었고, MUTARS$^{(R)}$ proximal femur system (Implantcast, Munster, Germany)이 17예에서 사용되었다. 수술 전 후의 동통 정도를 Visual Analogue Scales(VAS)로 평가하였으며, 술 후 하지의 기능적 평가를 위해 Musculoskeletal Tumor Society score(MSTS) grading system 을 이용하였다. 결과: 최종 추시 시 20예(19명) 중 11예(10명)가 생존하고 9예(9명)가 사망하였으며 사망한 환자의 술 후 평균 생존기간은 10.1개월(1-38개월) 이었다. VAS 점수는 술 전 평균 8.40점(5-10점)에서 술 후 평균 1.35점(0-3점)으로 호전 되었고, 수술 후 MSTS 기능적 평가는 평균 19.65점(65.50%) (7-28점)이었다. 수술과 관련된 합병증으로는 국소 재발 2예, 혈종 3예, 감염 3예, 음낭 종창 2예, 탈구 1예였고 치환물 주위 골절이나 해리는 없었다. 결론: 대퇴골 근위부에 발생한 악성 골 종양에 의한 통증 또는 병적 골절이 발생한 경우 종양 대치물을 이용한 사지 구제술은 조기의 통증 감소 및 기능 회복을 위한 적절한 치료로 생각된다.

Keywords

References

  1. Bell RS. Treatment of axial skeleton bone metastases. Clin Orthop Relat Res. 2003;(415 Suppl):S198-200.
  2. Menendez LR, Ahlmann ER, Kermani C, Gotha H. Endoprosthetic reconstruction for neoplasms of the proximal femur. Clin Orthop Relat Res. 2006;450:46-51. https://doi.org/10.1097/01.blo.0000229332.91158.05
  3. Sung KS, Chang MJ. Tumor prosthetic replacement for the metastatic bone tumors involving the proximal femur. J Korean Bone & Joint Tumor Soc. 2007;13:48-53.
  4. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limbsalvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68:1331-7. https://doi.org/10.2106/00004623-198668090-00005
  5. Eckardt JJ, Eilber FR, Dorey FJ, Mirra JM. The UCLA experience in limb salvage surgery for malignant tumors. Orthopedics. 1985;8:612-21.
  6. Donati D, Giacomini S, Gozzi E, Mercuri M. Proximal femur reconstruction by an allograft prosthesis composite. Clin Orthop Relat Res. 2002;(394):192-200.
  7. Damron TA, Sim FH. Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. Instr Course Lect. 2000;49:461-70.
  8. Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res. 1983;(178):297-302.
  9. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;(286):241-6.
  10. Lin PP, Mirza AN, Lewis VO, et al. Patient survival after surgery for osseous metastases from renal cell carcinoma. J Bone Joint Surg Am. 2007;89:1794-801. https://doi.org/10.2106/JBJS.F.00603
  11. Rompe JD, Eysel P, Hopf C, Heine J. Metastatic instability at the proximal end of the femur. Comparison of endoprosthetic replacement and plate osteosynthesis. Arch Orthop Trauma Surg. 1994;113:260-4. https://doi.org/10.1007/BF00443814
  12. Wedin R, Bauer HC. Surgical treatment of skeletal metastatic lesions of the proximal femur: endoprosthesis or reconstruction nail? J Bone Joint Surg Br. 2005;87:1653-7. https://doi.org/10.2106/JBJS.D.03005eth
  13. Wedin R, Bauer HC, Wersäll P. Failures after operation for skeletal metastatic lesions of long bones. Clin Orthop Relat Res. 1999;(358):128-39.
  14. Yazawa Y, Frassica FJ, Chao EY, Pritchard DJ, Sim FH, Shives TC. Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures. Clin Orthop Relat Res. 1990;(251):213-9.
  15. Steensma M, Healey JH. Trends in the surgical treatment of pathologic proximal femur fractures among Musculoskeletal Tumor Society members. Clin Orthop Relat Res. 2013;471:2000-6. https://doi.org/10.1007/s11999-012-2724-6
  16. Farid Y, Lin PP, Lewis VO, Yasko AW. Endoprosthetic and allograft-prosthetic composite reconstruction of the proximal femur for bone neoplasms. Clin Orthop Relat Res. 2006;442:223-9. https://doi.org/10.1097/01.blo.0000181491.39048.fe
  17. McGoveran BM, Davis AM, Gross AE, Bell RS. Evaluation of the allograft-prosthesis composite technique for proximal femoral reconstruction after resection of a primary bone tumour. Can J Surg. 1999;42:37-45.
  18. Zehr RJ, Enneking WF, Scarborough MT. Allograft-prosthesis composite versus megaprosthesis in proximal femoral recon-struction. Clin Orthop Relat Res. 1996;(322):207-23.
  19. Bickels J, Meller I, Henshaw RM, Malawer MM. Reconstruction of hip stability after proximal and total femur resections. Clin Orthop Relat Res. 2000;(375):218-30.
  20. Holzer G, Windhager R, Kotz R. One-stage revision surgery for infected megaprostheses. J Bone Joint Surg Br. 1997;79:31-5. https://doi.org/10.1302/0301-620X.79B1.7139
  21. Donati D, Zavatta M, Gozzi E, Giacomini S, Campanacci L, Mercuri M. Modular prosthetic replacement of the proximal femur after resection of a bone tumour a long-term follow-up. J Bone Joint Surg Br. 2001;83:1156-60. https://doi.org/10.1302/0301-620X.83B8.12165
  22. Finstein JL, King JJ, Fox EJ, Ogilvie CM, Lackman RD. Bipolar proximal femoral replacement prostheses for musculoskeletal neoplasms. Clin Orthop Relat Res. 2007;459:66-75. https://doi.org/10.1097/BLO.0b013e31804f5474
  23. Potter BK, Chow VE, Adams SC, Letson GD, Temple HT. Endoprosthetic proximal femur replacement: metastatic versus primary tumors. Surg Oncol. 2009;18:343-9. https://doi.org/10.1016/j.suronc.2008.08.007
  24. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Joint Surg Br. 1994;76:178-86.
  25. Lee SH, Oh JH, Lee KS, Yoo KH, Kim HS. Infection after prosthetic reconstruction in limb salvage surgery. Int Orthop. 2002;26:179-84. https://doi.org/10.1007/s00264-001-0328-y
  26. McDonald DJ, Capanna R, Gherlinzoni F, et al. Influence of chemotherapy on perioperative complications in limb salvage surgery for bone tumors. Cancer. 1990;65:1509-16. https://doi.org/10.1002/1097-0142(19900401)65:7<1509::AID-CNCR2820650710>3.0.CO;2-I