Clinical Orthopaedics and Related Research®

, Volume 470, Issue 6, pp 1749–1754

Physeal Distraction for Joint Preservation in Malignant Metaphyseal Bone Tumors in Children

  • Michael Betz
  • Charles E. Dumont
  • Bruno Fuchs
  • G. Ulrich Exner
Clinical Research



Physeal distraction facilitates metaphyseal bone tumor resection in children and preserves the adjacent joint. The technique was first described by Cañadell. Tumor resection procedures allowing limb-sparing reconstruction have been used increasingly in recent years without compromising oncologic principles.


We report our results with Cañadell’s technique by assessing tumor control, functional outcome, and complications.


Six consecutive children with primary malignant metaphyseal bone tumors underwent physeal distraction as a part of tumor resection. Tumor location was the distal femur in four patients, the proximal humerus in one patient, and the proximal tibia in one patient. The functional outcome was evaluated after a minimum of 18 months (median, 62 months; range, 18–136 months) using the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS).


At latest followup, five patients were alive and disease-free and one had died from metastatic disease. All tumor resections resulted in local control; there were no local recurrencies. The mean MSTS score was 79% (range, 53%–97%) and corresponding mean TESS was 83% (range, 71%–92%). In one case, postoperative infection required amputation of the proximal lower leg. All physeal distractions were successful except for one patient in whom distraction resulted in rupturing into the tumor. This situation was salvaged by transepiphyseal resection.


We consider Cañadell’s technique a useful tool in the armamentarium to treat children with malignant tumors that are in close proximity to an open physis.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Abudu A, Grimer R, Tillman R, Carter S. The use of prostheses in skeletally immature patients. Orthop Clin North Am. 2006;37:75–84.PubMedCrossRefGoogle Scholar
  2. 2.
    Aksnes LH, Bauer HC, Jebsen NL, Folleras G, Allert C. Haugen GS, Hall KS. Limb- sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients. J Bone Joint Surg Br. 2008;90:786–794.PubMedCrossRefGoogle Scholar
  3. 3.
    Avedian RS, Haydon RC, Peabody TD. Multiplanar osteotomy with limited wide margins: a tissue preserving surgical technique for high-grade bone sarcomas. Clin Orthop Relat Res. 2010;468:2754–2764.PubMedCrossRefGoogle Scholar
  4. 4.
    Ayerza MA, Farfalli GL, Aponte-Tinao L, Musculo DL. Does increased rate of limb- sparing surgery affect survival in osteosarcoma? Clin Orthop Relat Res. 2010;468:2854–2859.PubMedCrossRefGoogle Scholar
  5. 5.
    Bielack S, Kempf-Bielack B, Schwenzer D, Birkfellner T, Delling G, Ewerbeck V, Exner GU, Fuchs N, Göbel U, Graf N, Heise U, Helmke K, von Hochstetter AR, Jürgens H, Maas R, Münchow N, Salzer-Kuntschik M, Treuner J, Veltmann U, Werner M, Winkelmann W, Zoubek A, Kotz R. [Neoadjuvant therapy for localized osteosarcoma of extremities: results from the Cooperative osteosarcoma study group COSS of 925 patients] [in German]. Klin Pädiatr. 1999;211:260–270.PubMedGoogle Scholar
  6. 6.
    Campanacci L, Manfrini M, Colangeli M, Alí N, Mercuri M. Long-term results in children with massive bone osteoarticular allografts of the knee for high-grade osteosarcoma. J Pediatr Orthop. 2010;30:919–927.PubMedCrossRefGoogle Scholar
  7. 7.
    Cañadell J, de Pablos J. Breaking bony bridges by physeal distraction: a new approach. Int Orthop. 1985;9:223–229.PubMedCrossRefGoogle Scholar
  8. 8.
    Cañadell 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;76:127–132.PubMedGoogle Scholar
  9. 9.
    Cañadell J, San-Julian M. Pediatric Bone Sarcomas. Berlin, Germany: Springer; 2009.Google Scholar
  10. 10.
    Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res. 1996;5:508–516.PubMedCrossRefGoogle Scholar
  11. 11.
    de Pablos J, Cañadell J. [Elongation of the lower extremities: experience at the University Clinic of Navarre][in Spanish]. Rev Med Univ Navarra. 1987;31:43–52.PubMedGoogle Scholar
  12. 12.
    de Pablos J, Villas C, Cañadell J. Bone lengthening by physial distraction: an experimental study. Int Orthop. 1986;10:163–170.PubMedCrossRefGoogle Scholar
  13. 13.
    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 muskuloskeletal system. Clin Orthop Relat Res. 1993;286:241–246.PubMedGoogle Scholar
  14. 14.
    Juergens C, Weston C, Lewis I, Whelan J, Paulussen M, Oberlin O, Michon J, Zoubek A, Juergens H, Craft A. Safety assessment of intensive induction with vincristine, ifosfamide, doxorubicin, and etoposide (VIDE) in the treatment of Ewing tumors in the EURO-E.W.I.N.G. 99 clinical trial. Pediatr Blood Cancer. 2006;47:22–29.PubMedCrossRefGoogle Scholar
  15. 15.
    McDonald DJ, Scott SM, Eckardt JJ. Tibial turn-up for long distal femoral bone loss. Clin Orthop Relat Res. 2001;383:214–220.PubMedCrossRefGoogle Scholar
  16. 16.
    Mercuri M, Capanna R, Manfrini M, Bacci G, Picci P, Ruggieri P, Ferruzzi A, Ferraro A, Donati D, Biagini R, et al. The management of malignant bone tumors in children and adolescents. Clin Orthop Relat Res. 1991;264:156–168.PubMedGoogle Scholar
  17. 17.
    Muscolo DL, Ayerza M, Aponte-Tinao L, Ranalletta M. Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee. J Bone Joint Surg Am. 2005;87(suppl 1):226–236.PubMedCrossRefGoogle Scholar
  18. 18.
    Muscolo DL, Ayerza MA, Aponte-Tinao LA, Ranalletta M. Use of distal femoral osteoarticular allografts in limb salvage surgery: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 pt 2):305–321.PubMedCrossRefGoogle Scholar
  19. 19.
    Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am. 1963;45:587–622.Google Scholar
  20. 20.
    San-Julian M, Aquerreta JD, Benito A, Cañadell J. Indications for epiphyseal preservation in metaphyseal malignant bone tumors of children: relationship between image methods and histological findings. J Pediatr Orthop. 1999;19:543–548.PubMedGoogle Scholar
  21. 21.
    The European and American Osteosarcoma Study Group. EURAMOS I trial. Available at: Accessed November 14, 2010.

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Michael Betz
    • 1
  • Charles E. Dumont
    • 2
  • Bruno Fuchs
    • 1
  • G. Ulrich Exner
    • 2
  1. 1.University of Zurich, BalgristZurichSwitzerland
  2. 2.Orthopädie Zentrum ZürichZurichSwitzerland

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