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Similar Survival but Better Function for Patients after Limb Salvage versus Amputation for Distal Tibia Osteosarcoma

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Amputation has been the standard surgical treatment for distal tibia osteosarcoma. Advances in surgery and chemotherapy have made limb salvage possible. However, it is unclear whether limb salvage offers any improvement in function without compromising survival.

Questions/Purposes

We therefore compared the survival, local recurrence, function, and complications of patients with distal tibia osteosarcoma treated with limb salvage or amputation.

Methods

We retrospectively reviewed 42 patients with distal tibia osteosarcoma treated from 1985 to 2010. Nineteen patients had amputations and 23 had limb salvage and allograft reconstructions. We graded the histology using Broders classification, and staged patients using the Musculoskeletal Tumor Society (MSTS) and American Joint Committee on Cancer (AJCC) systems. The tumor grades tended to be higher in the group of patients who had amputations. We determined survival, local recurrence, MSTS function, and complications. The minimum followup was 8 months (median, 60 months; range, 8–288 months).

Results

The survival of patients who had limb salvage was similar to that of patients who had amputations: 84% at 120 and 240 months versus 74%, respectively. The incidence of local recurrence was similar: three of 23 patients who had limb salvage versus no patients who had amputations. The mean MSTS functional score tended to be higher in patients who had limb salvage compared with those who had amputations: 76% (range, 30%–93%) versus 71% (range, 50%–87%), respectively. The incidence of complications was similar.

Conclusion

Patients treated with either limb salvage or amputation experience similar survival, local recurrence, and complications, but better function is achievable for patients treated with limb salvage versus amputation. Local recurrence and complications are more common in patients with limb salvage.

Level of Evidence

Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Abudu A, Grimer RJ, Tillman RM, Carter SR. Endoprosthetic replacement of the distal tibia and ankle joint for aggressive bone tumours. Int Orthop. 1999;23:291–294.

    Article  PubMed  CAS  Google Scholar 

  2. Aksnes LH, Bauer HC, Jebsen NL, Follerås 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.

    Article  PubMed  CAS  Google Scholar 

  3. Barrera M, Teall T, Barr R, Silva M, Greenberg M. Health related quality of life in adolescent and young adult survivors of lower extremity bone tumors. Pediatr Blood Cancer. 2012;58:265–273.

    Article  PubMed  Google Scholar 

  4. Boardman DL, Liu SH. Contribution of the anterolateral joint capsule to the mechanical stability of the ankle. Clin Orthop Relat Res. 1997;341:224–232.

    Article  PubMed  Google Scholar 

  5. Broders AC. Squamous-cell epithelioma of the skin: a study of 256 cases. Ann Surg. 1921;73:141–160.

    Article  PubMed  CAS  Google Scholar 

  6. Buchner M, Bernd L, Zahlten-Hinguranage A, Sabo D. [Bone and soft-tissue tumors of the foot and ankle][in German]. Chirurg. 2005;76:391–397.

    Google Scholar 

  7. Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle: a gait study of the knee and ankle. J Bone Joint Surg Am. 1987;69:1052–1062.

    PubMed  CAS  Google Scholar 

  8. Campanacci DA, Scoccianti G, Beltrami G, Mugnaini M, Capanna R. Ankle arthrodesis with bone graft after distal tibia resection for bone tumors. Foot Ankle Int. 2008;29:1031–1037.

    Article  PubMed  Google Scholar 

  9. Campanacci M. Bone and Soft Tissue Tumors: Clinical Features, Imaging, Pathology and Treatment. New York, NY: Springer Verlag; 1999:1–70.

    Google Scholar 

  10. Casadei R, Ruggieri P, Giuseppe T, Biagini R, Mercuri M. Ankle resection arthrodesis in patients with bone tumors. Foot Ankle Int. 1994;15:242–249.

    PubMed  CAS  Google Scholar 

  11. Cass JR, Settles H. Ankle instability: in vitro kinematics in response to axial load. Foot Ankle. 1994;15:134–140.

    PubMed  CAS  Google Scholar 

  12. Davis AM, Devlin M, Griffin AM, Wunder JS, Bell RS. 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.

    Article  PubMed  CAS  Google Scholar 

  13. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.

    Article  PubMed  Google Scholar 

  14. Ebeid W, Amin S, Abdelmegid A, Refaat Y, Ghoneimy A. Reconstruction of distal tibial defects following resection of malignant tumours by pedicled vascularised fibular grafts. Acta Orthop Belg. 2007;73:354–359.

    PubMed  Google Scholar 

  15. Eiser C, Darlington AS, Stride CB, Grimer R. Quality of life implications as a consequence of surgery: limb salvage, primary and secondary amputation. Sarcoma. 2001;5:189–195.

    Article  PubMed  CAS  Google Scholar 

  16. Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res. 1986;204:9–24.

    PubMed  Google Scholar 

  17. Enneking WF. Modification of the system for the functional evaluation of surgical management of musculoskeletal tumors. In: Enneking WF, ed. Limb Salvage in Musculoskeletal Oncology (Bristol-Myers/Zimmer Orthopedic Symposium). London, England: Churchill Livingstone; 1987:626–639.

  18. 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;286:241–246.

    PubMed  Google Scholar 

  19. Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, Morrow M. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer; 2002;221–228.

    Google Scholar 

  20. Hatori M, Ayoub KS, Grimer RJ, Carter SR, Tillman RM. The two-stage ipsilateral fibular transfer for tibial defect following tumour excision. Sarcoma. 2000;4:27–30.

    Article  PubMed  CAS  Google Scholar 

  21. Hintermann B. Medial ankle instability. Foot Ankle Clin. 2003;8:723–738.

    Article  PubMed  Google Scholar 

  22. Hintermann B, Sommer C, Nigg BM. The influence of ligament transection on tibial and calcaneal rotation with loading and dorsi-plantarflexion. Foot Ankle Int. 1995;16:567–571.

    PubMed  CAS  Google Scholar 

  23. Hsu RW, Wood MB, Sim FH, Chao EY. Free vascularised fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br. 1997;79:36–42.

    Article  PubMed  Google Scholar 

  24. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457–481.

    Google Scholar 

  25. King HA, Watkins TB Jr, Samuelson KM. Analysis of foot position in ankle arthrodesis and its influence on gait. Foot Ankle. 1980;1:44–49.

    PubMed  CAS  Google Scholar 

  26. Kitaoka HB, Patzer GL. Arthrodesis for the treatment of arthrosis of the ankle and osteonecrosis of the talus. J Bone Joint Surg Am. 1998;80:370–379.

    Article  PubMed  CAS  Google Scholar 

  27. Laitinen M, Hardes J, Ahrens H, Gebert C, Leidinger B, Langer M, Winkelmann W, Gosheger G. Treatment of primary malignant bone tumours of the distal tibia. Int Orthop. 2005;29:255–259.

    Article  PubMed  CAS  Google Scholar 

  28. Lee SH, Kim HS, Park YB, Rhie TY, Lee HK. Prosthetic reconstruction for tumours of the distal tibia and fibula. J Bone Joint Surg Br. 1999;81:803–807.

    Article  PubMed  CAS  Google Scholar 

  29. Malawer MM, Helman LJ, O’Sullivan B. Sarcomas of bone. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. Vol 2, Ed 7. Philadelphia, PA: Lippincott Williams & Wilkins, 2004:1794–1893.

  30. Milner CE, Soames RW. The medial collateral ligaments of the human ankle joint: anatomical variations. Foot Ankle Int. 1998;19:289–292.

    PubMed  CAS  Google Scholar 

  31. Musculo DL, Ayerza MA, Aponte-Tinao L, Ranalletta M, Abalo E. Intercalary femur and tibia segmental allografts provide an acceptable alternative in reconstructing tumor resections. Clin Orthop Relat Res. 2004;426:97–102.

    Article  Google Scholar 

  32. Natarajan MV, Annamalai K, Williams S, Selvaraj R, Rajagopal TS. Limb salvage in distal tibial osteosarcoma using a custom mega prosthesis. Int Orthop. 2000;24:282–284.

    Article  PubMed  CAS  Google Scholar 

  33. Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treat Res. 2009;152:3–13.

    Article  PubMed  Google Scholar 

  34. Papagelopoulos PJ, Savvidou OD, Mavrogenis AF, Galanis EC, Shaughnessy WJ, Unni KK, Sim FH. Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors. Clin Orthop Relat Res. 2005;437:209–218.

    Article  PubMed  Google Scholar 

  35. Picci P, Sangiorgi L, Rougraff BT, Neff JR, Casadei R, Campanacci M. Relationship of chemotherapy-induced necrosis and surgical margins to local recurrence in osteosarcoma. J Clin Oncol. 1994;12:2699–2705.

    PubMed  CAS  Google Scholar 

  36. Puri A, Subin BS, Agarwal MG. Fibular centralisation for the reconstruction of defects of the tibial diaphysis and distal metaphysis after excision of bone tumours. J Bone Joint Surg Br. 2009;91:234–239.

    Article  PubMed  CAS  Google Scholar 

  37. Ramseier LE, Malinin TI, Temple HT, Mnaymneh WA, Exner GU. Allograft reconstruction for bone sarcoma of the tibia in the growing child. J Bone Joint Surg Br. 2006;88:95–99.

    PubMed  CAS  Google Scholar 

  38. Resnick D, Kransdorf MJ. Bone and Joint Imaging. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2005.

    Google Scholar 

  39. Shalaby S, Shalaby H, Bassiony A. Limb salvage for osteosarcoma of the distal tibia with resection arthrodesis, autogenous fibular graft and Ilizarov external fixator. J Bone Joint Surg Br. 2006;88:1642–1646.

    Article  PubMed  CAS  Google Scholar 

  40. Shekkeris AS, Hanna SA, Sewell MD, Spiegelberg BG, Aston WJ, Blunn GW, Cannon SR, Briggs TW. Endoprosthetic reconstruction of the distal tibia and ankle joint after resection of primary bone tumours. J Bone Joint Surg Br. 2009;91:1378–1382.

    Article  PubMed  CAS  Google Scholar 

  41. Shmookler B, Bickels J, Jelinek J, Sugarbaker P, Malawer MM. Bone and Soft-tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamentals of Surgical Treatment. In: Malawer MM, Sugarbaker PH, eds. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Dordrecht, The Netherlands: Kluwer Academic Publishers; 2001:3–36.

    Google Scholar 

  42. Simon MA. Limb salvage for osteosarcoma in the 1980s. Clin Orthop Relat Res. 1991;270:264–270.

    PubMed  Google Scholar 

  43. Sommer C, Hintermann B, Nigg BM, van den Bogert AJ. Influence of ankle ligaments on tibial rotation: an in vitro study. Foot Ankle Int. 1996;17:79–84.

    PubMed  CAS  Google Scholar 

  44. Stéphane S, Eric M, Philippe W, Félix DJ, Raphael S. Resection arthrodesis of the ankle for aggressive tumors of the distal tibia in children. J Pediatr Orthop. 2009;29:811–816.

    Article  PubMed  Google Scholar 

  45. Sugarbaker P, Bickels J, Malawer MM. Below-knee Amputation. In: Malawer MM, Sugarbaker PH, eds. Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Dordrecht, The Netherlands: Kluwer Academic Publishers; 2001:363–370.

    Google Scholar 

  46. Yan TQ, Guo W, Yang RL, Sun X, Qu HY. [The survival and functional outcome of primary bone sarcomas in distal lower extremity][in Chinese]. Zhonghua Wai Ke Za Zhi. 2010;48:1550–1555.

    Google Scholar 

  47. Zahlten-Hinguranage A, Bernd L, Sabo D. [Amputation or limb salvage? Assessing quality of life after tumor operations of the lower extremity][in German]. Orthopade. 2003;32:1020–1027.

    Article  PubMed  CAS  Google Scholar 

  48. Zeytoonjian T, Mankin HJ, Gebhardt MC, Hornicek FJ. Distal lower extremity sarcomas: frequency of occurrence and patient survival rate. Foot Ankle Int. 2004;25:325–330.

    PubMed  Google Scholar 

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Acknowledgment

We thank Eugenio Rimondi MD, radiologist, for evaluation of the imaging of the patients.

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Authors and Affiliations

  1. Department of Orthopaedics, Orthopaedic Oncology Service, Istituto Ortopedico Rizzoli, University of Bologna, Via Di Barbiano 1/10, 40136, Bologna, Italy

    Andreas F. Mavrogenis MD, Caterina Novella Abati MD, Carlo Romagnoli MD & Pietro Ruggieri MD, PhD

Authors
  1. Andreas F. Mavrogenis MD
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  2. Caterina Novella Abati MD
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  3. Carlo Romagnoli MD
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  4. Pietro Ruggieri MD, PhD
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Corresponding author

Correspondence to Pietro Ruggieri MD, PhD.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution has approved the reporting of these cases and that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the Istituto Ortopedico Rizzoli, Bologna, Italy.

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Mavrogenis, A.F., Abati, C.N., Romagnoli, C. et al. Similar Survival but Better Function for Patients after Limb Salvage versus Amputation for Distal Tibia Osteosarcoma. Clin Orthop Relat Res 470, 1735–1748 (2012). https://doi.org/10.1007/s11999-011-2238-7

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  • DOI: https://doi.org/10.1007/s11999-011-2238-7

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