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Die endoprothetische Versorgung an den Extremitäten bei Kindern nach Resektion primär maligner Knochentumoren

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Zusammenfassung

Mit der Verlängerung der Überlebenszeit nach adäquater Therapie primär maligner Knochentumoren stieg auch der Anspruch auf eine langfristig haltbare Rekonstruktion nach Tumorresektion. Aufgrund des noch vorhandenen Wachstumspotentials bedeutet das im Falle der Erkrankung von Kindern auch die Notwendigkeit eines "Mitwachsens" der erhaltenen, rekonstruierten Extremität.

Prinzipiell kann man die Techniken der Extremitätenerhaltung in biologische und endoprothetische Versorgungen trennen. Die Vorteile der endoprothetischen Versorgung liegen in der wesentlich kürzeren Rehabilitation und sofortigen Verwendbarkeit der Extremität. Ein "Mitwachsen" der Extremität ist durch die Verwendung von Wachstumsprothesen möglich, die bei Wachstumsabschluss gegen definitive Prothesen gewechselt werden. Die häufigsten Komplikationen sind Infektion, Lockerung und "stress shielding" um die Verankerung der Prothese.

An unserer Klinik wurden zwischen 1975 und 2000 55 Patienten <10 Jahren behandelt, die an einen primär malignen Knochentumor erkrankt waren. Das Operationsalter betrug im Durchschnitt 7,9 (4,2–10) Jahre. Die Diagnose lautete Osteosarkom in 36 Fällen und Ewing-Sarkom in 19 Fällen. Bei 49 Patienten war die untere Extremität betroffen, in 6 Fällen die obere Extremität. Die chirurgische Versorgung erfolgte in 34 Fällen (61,8%) endoprothetisch. An 7 Patienten (12,7%) wurde eine Umkehrplastik durchgeführt, in 4 Fällen (7,3%) erfolgte eine Amputation; 7 Patienten wurden mit einer autologen Rekonstruktion versorgt, 3 Patienten erhielten eine andere Therapie.

Nach einem mittleren Nachbeobachtungszeitraum von 114,4 (24–285) Monaten beträgt die Überlebensrate 76,5%, wobei die Osteosarkompatienten mit 83,3% besser abschnitten als Ewing-Sarkompatienten mit 63,2%.

Die endoprothetische Versorgung ist auch bei Kindern <10 Jahren möglich. Die für den Patienten adäquate Rekonstruktion muss individuell nach Abklärung der jeweiligen Ziele und Erwartungen gefunden werden.

Abstract

In recent years, significant progress has been made in the treatment of primary malignant bone tumors. The surgeon is confronted with increasing demand for limb-sparing surgery by patients and parents alike. In the skeletally immature, resection of the growing physis will ultimately result in leg length discrepancies and functional impairment. An adequate reconstruction therefore calls for the compensation of the expected growth deficit to achieve symmetry and an optimized function of the extremity.

Between 1975 and 2000, 55 patients (24 female, 31 male) were referred and treated at our institution. All patients were not older than 10 years (4.2–10, mean: 7.9 years).

Histological diagnosis was Ewing's tumors (n=19) and osteosarcoma (n=36). Localization in the extremities was predominantly in the lower extremity with 63.6% around the knee joint (distal femur and proximal tibia).

Surgical treatment was performed in all patients. Endoprosthetic reconstruction was performed in 34 patients (lower extremity n=30, 29 Howmedica Modular Reconstruction System, HMRS, 1 Pafford prosthesis; upper extremity n=4, 4 HMRS); in another case of humeral tumor involvement a resection replantation procedure was carried out. The other patients received a rotationplasty (n=7), a biologic reconstruction (n=6), resection replantation of the humerus (n=1), no reconstruction (n=3), or had to be amputated (n=4).

After a mean follow-up of 114 months (24–256 months) 11 patients had died. Even in young children endoprosthetic reconstruction with relatively early mobilization and high quality of life can be a very successful method for limb salvage.

Optimal reconstructive results following resection of primary malignant bone tumors in children are reached when indications and limitations of each method are carefully considered on an individual basis taking into account the patients' expectations.

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Authors and Affiliations

  1. Universitätsklinik für Orthopädie, Wien, Österreich

    P. Krepler, M. Dominkus, C. D. Toma & R. Kotz

  2. Universitätsklinik für Orthopädie, Währinger Gürtel 18–20, 1090, Wien, Österreich

    P. Krepler

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  1. P. Krepler
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Krepler, P., Dominkus, M., Toma, C.D. et al. Die endoprothetische Versorgung an den Extremitäten bei Kindern nach Resektion primär maligner Knochentumoren. Orthopäde 32, 1013–1019 (2003). https://doi.org/10.1007/s00132-003-0553-8

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