Functional, Psychosocial and Professional Outcomes in Long-Term Survivors of Lower-Extremity Osteosarcomas: Amputation Versus Limb Salvage

  • Giulia Ottaviani
  • Rhonda S. Robert
  • Winston W. Huh
  • Norman Jaffe
Chapter
First Online:
Part of the Cancer Treatment and Research book series (CTAR, volume 152)

Abstract

As the number of osteosarcoma survivors increases, the impact of quality of life and function needs to be addressed. Limb salvage is the preferred treatment when patients have treatment options; yet, the questionable long-term durability and complications of prostheses, combined with ambiguous function, leave some doubt regarding the best clinical and surgical options. Comparisons between limb salvage patients, amputees and controls also require further investigation. Amputation would leave the patients with a lifelong requirement for an external prosthetic leg associated with an overall limited walking distance. While artificial limbs are much more sophisticated than those used in the past, phantom limb sensations remain a substantial and unpredictable problem in the amputee. Complications such as stump overgrowth, bleeding, and infection, also require further elucidation. Limb salvage surgery using endoprosthesis, allografts or reconstruction is performed in approximately 85% of patients affected by osteosarcoma located in the middle and/or distal femur. One drawback in limb-salvage surgery in the long-term survivor is that endoprostheses have a limited life span with long-term prosthetic failure. The inherent high rate of reoperation remains a serious problem. Replacing a damaged, infected or severely worn-out arthroplastic joint or its intramedullary stem is difficult, especially in the long-stem cemented endoprostheses used in the 1980s. Limb lengthening procedures in patients who have not reached maturity must also be addressed. Periprosthetic infections, compared to other indications for joint reconstruction, were found to be more frequent in patients treated for neoplastic conditions and their outcome can be devastating, resulting in total loss of joint function, amputation, and systemic complications. Quality of life in terms of function, psychological outcome and endpoint achievements such as marriage and employment apparently do not differ significantly between amputee and nonamputee osteosarcoma survivors. Amputee patients nonetheless appear to have made satisfactory adjustments to their deficits with or without a functional external prosthesis. It also appeared that amputee patients had a similar psychological and quality of life outcome as limb salvage patients. There was no evidence of excessive anxiety or depression or deficits in self-esteem compared with the normal population or matched controls. A number of long-term survivors also achieved high ranking in the professional and commercial work place. These positive aspects should be recognized and emphasized to patients and their parents when discussing the outcome.

Keywords

Aseptic Loosening Limb Salvage Slip Capital Femoral Epiphysis MSTS Score Initial Hospitalization Cost 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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Notes

Acknowledgements

Dr. Giulia Ottaviani, is the scientific coordinator of the project “Quality of life in long-term osteosarcoma survivors”, Joint Mobility Projects for the Exchange of Researchers, joint declaration after the ninth biennial review meeting on scientific and technological cooperation between the Republic of Italy and the United States of America, Washington, DC, Ministry for Foreign Affairs (MAE), 2008–2010.

References

  1. 1.
    Marcove RC, Miké V, Hajek JV, et al. Osteogenic sarcoma under the age of twenty-one. A review of one hundred and forty-five operative cases. J Bone Joint Surg Am. 1970;52:411-423.PubMedGoogle Scholar
  2. 2.
    Hudson M, Jaffe MR, Jaffe N, et al. Pediatric osteosarcoma: therapeutic strategies, results and prognostic factors derived from a 10-year experience. J Clin Oncol. 1990;8:1988-1997.PubMedGoogle Scholar
  3. 3.
    Mascarenhas L, Siegel S, Spector L, et al. Malignant bone tumors. In: Bleyer A, O’Leary M, Barr R, et al, eds. Cancer epidemiology in older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975–2000 (NIH Pub. No. 06-5767). Bethesda, MD: National Cancer Institute; 2006:97-110. Available at: http://seer.cancer.gov/publications/aya/8_bone.pdf. Accessed January 2009
  4. 4.
    Longhi A, Ferrari S, Bacci G, et al. Long-term follow-up of patients with doxorubicin-induced cardiac toxicity after chemotherapy for osteosarcoma. Anticancer Drugs. 2007;18:737-744.CrossRefPubMedGoogle Scholar
  5. 5.
    Berrak SG, Ewer MS, Jaffe N, et al. Doxorubicin cardiotoxicity in children: reduced incidence of cardiac dysfunction associated with continuous-infusion schedules. Oncol Rep. 2001;8:611-614.PubMedGoogle Scholar
  6. 6.
    Ruiz L, Gilden J, Jaffe N, et al. Auditory function in pediatric osteosarcoma patients treated with multiple doses of cis-diamminedichloroplatinum(II). Cancer Res. 1989;49:742-744.PubMedGoogle Scholar
  7. 7.
    Ried H, Zietz H, Jaffe N. Late effects of cancer treatment in children. Pediatr Dent. 1995;17:273-284.PubMedGoogle Scholar
  8. 8.
    Mansky P, Arai A, Stratton P, et al. Treatment late effects in long-term survivors of pediatric sarcoma. Pediatr Blood Cancer. 2007;48:192-199.CrossRefPubMedGoogle Scholar
  9. 9.
    Paulides M, Kremers A, Stohr W, et al. Prospective longitudinal evaluation of doxorubicin-induced cardiomyopathy in sarcoma patients: a report of the late effects study surveillance system (LESS). Pediatr Blood Cancer. 2006;46:489-495.CrossRefPubMedGoogle Scholar
  10. 10.
    Vassilopoulou-Sellin R, Brosnan P, Delpassand A, et al. Osteopenia in young adult survivors of childhood cancer. Med Pediatr Oncol. 1999;32:272-278.CrossRefPubMedGoogle Scholar
  11. 11.
    Jaffe N. Metachronous skeletal osteosarcoma after therapy. J Clin Oncol. 2004;22:1524.CrossRefPubMedGoogle Scholar
  12. 12.
    Jaffe N, Pearson P, Yasko AW, et al. Single and multiple metachronous osteosarcoma tumors after therapy. Cancer. 2003;98:2457-2466.CrossRefPubMedGoogle Scholar
  13. 13.
    Inskip PD, Ries LAG, Cohen RJ, et al. New malignancies following childhood cancer. In: Curtis RE, Freedman DM, Ron E, et al, eds. New malignancies among cancer survivors: SEER cancer registries, 1973-2000 (NIH Publ. No. 05-5302). Bethesda, MD: National Cancer Institute; 2006. Available at: http://seer.cancer.gov/publications/mpmono/Ch18_Childhood.pdf. Accessed January 2009
  14. 14.
    Simon MA, Aschliman MA, Thomas N, et al. Limb salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986;68:1331-1337.PubMedGoogle Scholar
  15. 15.
    Ottaviani G, Randelli P, Catagni MA. Segmental cement extraction system (SEG-CES) and the Ilizarov method in limb salvage procedure after total knee cemented prosthesis removal in a former osteosarcoma patient. Knee Surg Sports Traumatol Arthrosc. 2005;13:557-563.CrossRefPubMedGoogle Scholar
  16. 16.
    Ruggieri P, De Cristofaro R, Picci P, et al. Complications and surgical indications in 144 cases of nonmetastatic osteosarcoma of the extremities treated with neoadjuvant chemotherapy. Clin Orthop Relat Res. 1993;295:226-238.PubMedGoogle Scholar
  17. 17.
    Lindner NJ, Ramm O, Hillmann A, et al. Limb salvage and outcome of osteosarcoma: the University of Muenster experience. Clin Orthop Relat Res. 1999;358:83-89.CrossRefPubMedGoogle Scholar
  18. 18.
    Davis AM, Devlin M, Griffin AM, et al. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study. Arch Phys Med Rehabil. 1999;80:615-618.CrossRefPubMedGoogle Scholar
  19. 19.
    Renard AJ, Veth RP, Schreuder HW, et al. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol. 2000;73:198-205.CrossRefPubMedGoogle Scholar
  20. 20.
    Marulanda GA, Henderson ER, Johnson DA, et al. Orthopedic surgery options for the treatment of primary osteosarcoma. Cancer Control. 2008;15:13-20.PubMedGoogle Scholar
  21. 21.
    Krajbich JI. Lower-limb deficiencies and amputations in children. J Am Acad Orthop Surg. 1998;6:358-367.PubMedGoogle Scholar
  22. 22.
    Wilkins KL, McGrath PJ, Finley GA, et al. Phantom pain sensations and phantom limb pain in child and adolescent amputees. Pain. 1998;7:46-53.Google Scholar
  23. 23.
    Nagarajan R, Clohisy DR, Neglia JP, et al. Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing’s sarcoma: the Childhood Cancer Survivor Study. Br J Cancer. 2004;91:1858-1865.CrossRefPubMedGoogle Scholar
  24. 24.
    Futani H, Minamizaki T, Nishimoto Y, et al. Long-term follow-up after limb salvage in skeletally immature children with a primary malignant tumor of the distal end of the femur. J Bone Joint Surg Am. 2006;88:595-603.CrossRefPubMedGoogle Scholar
  25. 25.
    Tunn PU, Schmidt-Peter P, Pomraenke D, Hohenberger P. Osteosarcoma in children: long-term functional analysis. Clin Orthop Relat Res. 2004;421:212-217.CrossRefPubMedGoogle Scholar
  26. 26.
    Refaat Y, Gunnoe J, Hornicek FJ, Mankin HJ. Comparison of quality of life after amputation or limb salvage. Clin Orthop Relat Res. 2002;397:298-305.CrossRefPubMedGoogle Scholar
  27. 27.
    Van der Windt DA, Pieterson I, van der Eijken JW, et al. Energy expenditure during walking in subjects with tibial rotationplasty, above-knee amputation, or hip disarticulation. Arch Phys Med Rehabil. 1992;73:1174-1180.PubMedGoogle Scholar
  28. 28.
    Hann SB, Park HJ, Kim HS, et al. Surgical treatment of malignant and aggressive bone tumors around the knee by segmental resection and rotationplasty. Yonsei Med J. 2003;44:485-492.Google Scholar
  29. 29.
    Sawamura C, Hornicek FJ, Gebhardt MC. Complications and risk factors for failure of rotationplasty: review of 25 patients. Clin Orthop Relat Res. 2008;466:1302-1308.CrossRefPubMedGoogle Scholar
  30. 30.
    Aksnes LH, Bauer HC, Jebsen NL, et al. 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.CrossRefPubMedGoogle Scholar
  31. 31.
    Kumta SM, Cheng JC, Li CK, et al. Scope and limitations of limb-sparing surgery in childhood sarcomas. J Pediatr Orthop. 2002;22:244-248.CrossRefPubMedGoogle Scholar
  32. 32.
    Grimer RJ. Surgical options for children with osteosarcoma. Lancet Oncol. 2005;6:85-92.CrossRefPubMedGoogle Scholar
  33. 33.
    Link MP, Gebhardt MC, Meyers PA. Osteosarcoma. In: Pizzo PA, Poplack DG, eds. Principles and practices of pediatric oncology. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006:1074-1115.Google Scholar
  34. 34.
    Ghert MA, Abudu A, Driver N, et al. The indications for and the prognostic significance of amputation as the primary surgical procedure for localized soft tissue sarcoma of the extremity. Ann Surg Oncol. 2005;12:10-17.CrossRefPubMedGoogle Scholar
  35. 35.
    Bondurant FJ, Cotler HB, Buckle R, et al. The medical and economic impact of severely injured lower extremities. J Trauma. 1988;28:1270-1273.CrossRefPubMedGoogle Scholar
  36. 36.
    Hansen ST Jr. Overview of the severely traumatized lower limb. Reconstruction versus amputation. Clin Orthop Relat Res. 1989;243:17-19.PubMedGoogle Scholar
  37. 37.
    MacKenzie EJ, Bosse MJ, Castillo RC, et al. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am. 2004;86:1636-1645.PubMedGoogle Scholar
  38. 38.
    Geertzen JH, Bosmans JC, van der Schans CP, et al. Claimed walking distance of lower limb amputees. Disabil Rehabil. 2005;27:101-104.CrossRefPubMedGoogle Scholar
  39. 39.
    Catagni MA, Camagni M, Combi A, et al. Treatment of massive tibial bone loss by fibula transport with the Ilizarov frame. Clin Orthop Relat Res. 2006;448:208-216.CrossRefPubMedGoogle Scholar
  40. 40.
    Grimer RJ, Taminiau AM, Cannon SR, et al. Surgical outcomes in osteosarcoma. J Bone Joint Surg Br. 2002;84:395-400.CrossRefPubMedGoogle Scholar
  41. 41.
    Rougraff BT, Simon MA, Kneils JS, et al. Limb salvage procedure compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study. J Bone Joint Surg Am. 1994;76:649-656.PubMedGoogle Scholar
  42. 42.
    Pritchard DJ. Surgical management of osteosarcoma. In: Unni KK, ed. Bone tumors. New York: Churchill Livingstone; 1988:135-148.Google Scholar
  43. 43.
    Jeys LM, Grimer RJ, Carter SR, et al. Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am. 2005;87:842-849.CrossRefPubMedGoogle Scholar
  44. 44.
    Zeegen EN, Aponte-Tinao LA, Hornicek FJ, et al. Survivorship analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat Res. 2004;420:239-250.CrossRefPubMedGoogle Scholar
  45. 45.
    Ottaviani G, Catagni MA, Matturri L. Massive metallosis due to metal-on-metal impingement in substitutive long stemmed knee prosthesis. Histopathology. 2005;46:237-238.CrossRefPubMedGoogle Scholar
  46. 46.
    Wiedel JD. Salvage of infected total knee fusion: the last option. Clin Orthop Relat Res. 2002;404:139-142.CrossRefPubMedGoogle Scholar
  47. 47.
    Marcove RC. The surgery of Tumors and Bone Cartilage. New York: Grune and Stratton; 1981.Google Scholar
  48. 48.
    Catagni MA. Treatment of tibial nonunions. In: Bianchi Maiocchi A, ed. Treatment of fractures, nonunions and bone loss of the tibia with the Ilizarov method. Milan, Italy: Il Quadratino; 1998:97-158.Google Scholar
  49. 49.
    Catagni MA, Ottaviani G, Camagni M. Treatment of massive tibial bone loss due to chronic draining osteomyelitis: fibula transport using the Ilizarov frame. Orthopedics. 2007;30:608-611.PubMedGoogle Scholar
  50. 50.
    Catagni MA, Ottaviani G. Ilizarov method to correct limb length discrepancy after limb-sparing hemipelvectomy. J Pediatr Orthop B. 2008;17:293-298.Google Scholar
  51. 51.
    Jeys LM, Grimer RJ, Carter SR, et al. Post operative infection and increased survival in osteosarcoma patients: are they associated? Ann Surg Oncol. 2007;14:2887-2895.CrossRefPubMedGoogle Scholar
  52. 52.
    Nagarajan R, Neglia JP, Clohisy DR, et al. Limb salvage and amputation in survivors of pediatric lower-extremity bone tumors: what are the long-term implications? J Clin Oncol. 2002;20:4493-4501.CrossRefPubMedGoogle Scholar
  53. 53.
    de Visser E, Deckers JA, Veth RP, et al. Deterioration of balance control after limb-saving surgery. Am J Phys Med Rehabil. 2001;80:358-365.CrossRefPubMedGoogle Scholar
  54. 54.
    Jeys LM, Grimer RJ, Carter SR, et al. Risk of amputation following limb salvage surgery with endoprosthetic replacement, in a consecutive series of 1261 patients. Int Orthop. 2003;27:160-163.PubMedGoogle Scholar
  55. 55.
    Kim HS, Jahng JS, Han DY, et al. Immediate ipsilateral fibular transfer in a large tibial defect using a ring fixator. A case report. Int Orthop. 1998;22:321-324.CrossRefPubMedGoogle Scholar
  56. 56.
    Williams MO. Long-term cost comparison of major limb salvage using Ilizarov method versus amputation. Clin Orthop Relat Res. 1994;301:156-161.PubMedGoogle Scholar
  57. 57.
    Greenberg DB, Goorin A, Gebhardt MC, et al. Quality of life in osteosarcoma survivors. Oncology (Williston Park). 1994;8:19-25.Google Scholar
  58. 58.
    Sugarbaker PH, Barofsky I, Rosenberg SA, et al. Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery. 1982;91:17-23.PubMedGoogle Scholar
  59. 59.
    Postma A, Kingma A, De Ruiter J, et al. Quality of life in bone tumor patients comparing limb salvage and amputation of the lower extremity. J Surg Oncol. 1992;51:47-51.CrossRefPubMedGoogle Scholar
  60. 60.
    Nagarajan R, Neglia JP, Clohisy DR, et al. Education, employment, insurance, and marital status among 694 survivors of pediatric lower extremity bone tumors: a report from the childhood cancer survivor study. Cancer. 2003;97:2554-2564.CrossRefPubMedGoogle Scholar
  61. 61.
    Jaffe N, Zietz H. Amputee skiers: lofty ambassadors in the rehabilitation of cancer. Pediatr Hematol Oncol. 2004;21:557-562.CrossRefPubMedGoogle Scholar
  62. 62.
    Huh WW, Jaffe N, Ottaviani G. Adult survivors of childhood cancer and unemployment: a metaanalysis. Cancer. 2006;107:2958-2959.CrossRefPubMedGoogle Scholar
  63. 63.
    Yonemoto T, Ishii T, Takeuchi Y, et al. Education and employment in long-term survivors of high-grade osteosarcoma: a Japanese single-center experience. Oncology. 2008;72:274-278.CrossRefGoogle Scholar
  64. 64.
    de Boer AG, Verbeek JH, van Dijk FJ. Adult survivors of childhood cancer and unemployment: a metaanalysis. Cancer. 2006;107:1-11.CrossRefPubMedGoogle Scholar
  65. 65.
    Eiser C, Hill JJ, Vance YH. Examining the psychological consequences of surviving childhood cancer: systematic review as a research method in pediatric psychology. J Pediatr Psychol. 2000;25:449-460.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Giulia Ottaviani
    • 1
  • Rhonda S. Robert
  • Winston W. Huh
  • Norman Jaffe
  1. 1.Children’s Cancer Hospital, The University of Texas M.D. Anderson Cancer CenterHoustonUSA

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