|
Eduvest � Journal
of Universal Studies Volume 3 Number 1, January, 2023 p- ISSN
2775-3735- e-ISSN 2775-3727 |
||
|
|
|
|
|
FUNCTIONAL OUTCOME OF LIMB
SALVAGE SURGERY WITH MEGAPROSTHESIS IN PRIMARY BONE TUMOUR ARROUND KNEE |
|
|
|
Misbahuddin, Mujaddid
Idulhaq Universitas
Muhammadiyah Surakarta, Indonesia Email: [email protected],
[email protected] |
|
|
|
ABSTRACT |
|
|
|
The
knee is the most frequent site of primary bone tumour.
A majority of the tumours arising in the knee can
be treated with limb salvage surgery and result in good functional outcomes.
We evaluated functional outcomes for patients who underwent surgery for
resection and megaprosthesis replacement for
primary tumours around the knee. We used the
Musculoskeletal Tumour Society Scoring System
(MSTS) for functional evaluations to compare differences between distal femur
and proximal tibia placements. This study was an observational analysis study
with cross sectional approach in primary bone tumor knee region which has
been done limb salvage surgery. The study sample included 11 cases of distal
femur and 6 cases of proximal tibia megaprosthesis
replacement. Primary tumours were classified as
follows: 5 osteosarcoma, 12 giant cell tumour
(GCT). The Patients was subjected to a physical examination to complete MSTS
score and then commpared data were obtained.
Functional outcomes, as measured by MSTS functional assessment were good to
excellent in a majority of study patients. This study shows an unsignificant
differences functional outcome using MSTS Score between resection tumour in distal femur and proximal tibia (p >0.05).
There were no differences in functional outcomes when comparing distal femur megaprostheses with proximal tibia megaprostheses |
|
|
|
KEYWORDS |
Primary Bone
tumor, MSTS score, limb salvage, megaprosthesis |
|
|
|
This
work is licensed under a Creative Commons Attribution-ShareAlike
4.0 International |
|
INTRODUCTION
Management
of tumors in extremities has undergone many changes in recent years. Since the
reconstruction of the femur was first introduced by Buchanan in 1950.1 The Limb
salvage method at the time was controversial where the current standard of
therapy was amputation. When first introduced with the limb salvage method, a
high recurrence rate has been reported. Although in its development in the
mid-20th century the provision of "adjuvant" therapy can reduce the
recurrence rate.
Developments
in diagnostic imaging, adjuvant and neoadjuvant chemotherapy and the
development of surgical techniques have increased survival rates in the 5 years
after endoproshetic installation from 20% to 85% in
the last 3 decades.
For
more than 3 decades, the focus of experts has changed from the previous
controversy in the use of the limb salvage method to become the main therapy in
an effort to improve functional and oncological outcomes with. Megaprosthesis has many benefits, among which patients can
mobilize immediately with full weight bearing, which is important because
according to the data there are 25% of patients living less than 2 years after
surgery.
In
addition, costs can be reduced.4.5.10,16 Although in general there are
complications after surgery, such as infection, aseptic loosening, prosthetic
dislocation, joint stiffness or contracture, can give a bad outcome, and the
possibility of revision, until the final choice with amputations .5,8,14 In
this case we would like to describe some of the treatments of patients with
bone tumors that have been reconstructed with megaprotesa
for the past 5 years
RESEARCH
METHOD
�This research is an observational analytic
study with cross sectional approach. Sampling was carried out in outpatient
polyclinic and medical records section of Prof. orthopedic hospital Dr. R. Soeharso, Surakarta in the period January 2013 - May 2018.
The sample used was a musculoskeletal tumor patient who had performed limb
salvage with megaprothesis.
Criteria for inclusion of patients
diagnosed with primary bone tumors in the distal femur and proximal tibia that
have been carried out wide excision and reconstruction with megaprostheis.
Patients have radiology, anatomical pathology, and blood laboratory data so
that they diagnose primary musculoskeletal tumors.3 through interviews and
physical examinations included in the MSTS scoring sheet for proximal tibia and
distal femur.
Assessment of clinical outcomes of each
limb salvage surgery by megaprosthesis in tumor
resection of the distal femur or proximal tibia using MSTS scores. T-test was
conducted to determine the effect of each type of action on postoperative
clinical outcomes (level of significance: p <0.05).
The total number of samples obtained were
17 patients, 7 women and 10 male patients with a sample age range of 16 years
to 58 years. There were tumors in the proximal tibia of 6 patients, and tumors
in the distal femur of 11 patients who had undergone limb salvage with megaprosthesis. There are two types of primary tumors,
osteosarcoma in 5 patients and giant tumor cells in 12 patients
RESULTS
AND DISCUSSION
The total number of samples obtained
were 17 patients, 7 women and 10 male patients with a sample age range of 16
years to 58 years. There were tumors in the proximal tibia of 6 patients, and
tumors in the distal femur of 11 patients who had undergone limb salvage with megaprosthesis. There are two types of primary tumors,
osteosarcoma in 5 patients and giant tumor cells in 12 patients.
The clinical outcomes were quite good
at both locations, with a mean MSTS postoperative score at a mean proximal
tibia of 70.55% and a postoperative MSTS score at an average distal femur
(mean) of 71.18%. No significant difference was found in limb salvage with megaprosthesis in the distal femur or proximal tibia.
Namely with a T score of 0.777.
In detail, the MSTS score can be
analyzed consisting of 5 components, namely the pain in the distal femur has an
average (mean) of 4.54 when compared with the proximal tibia of 4.16, so there
is no significant difference after the treatment, namely the T value of 0.239.
The mean (mean) for the function score is the distal femur of 3.90 and the
proximal tibia is 4.16. so that when compared statistically there is no
significant difference in the T-score of 0.236. Emotionally, according to MSTS,
the mean obtained at distal femur was 3.72 while the proximal tibia was 3.16,
from the T test results found 0.75 so it was mentioned not significant. For the
aid component when mobilizing (support) the outcome of the MSTS score in distal
femur patients was 2.63 compared to the proximal tibia 3.33. Where can it be
concluded that the patient after having done Limb salvage with megaprosthesis still uses braching
or crutches. And there is no significant difference because the T test score is
0.294.
Most patients after surgery have
little limitation in walking distance. That is, the average MSTS score is 3.45
on the distal femur. The gait component is obtained at the distal femur of 3.00
compared to the proximal tibia of 3.00. Where only looks minor gait on cosmetic
appearance when the patient walks. And there is no significant difference
between the distal femur and the proximal tibia, because the T test value is
1.00.
DISCUSSION
The knee is an area that often occurs
primary bone tumors and most are in the distal femur. Osteosarcoma is the
primary tumor most often affects the knee.4,6 As for giant cell tumors are
progressive tumors that require extensive resection to meet local control as
therapy, and most are giant cell tumors that have been diagnosed at grade
III.10, 19 Limb salvage is a procedure that is often performed when a tumor
hits the knee. Amputation can be performed if the tumor affects many soft
compartments and soft tissue and neurovascular structures and is considered to
pose a high risk of recurrence.6,15 At present megaprosthesis
is a new method used to restore knee joint function after extensive
resection.3,17
Reconstruction with megaprosthesis in tumors located in the distal femur is
expected to be able to direct support on the legs, can restore knee joint
motion, and the patient can return to normal activities. Most clinical outcomes
have good results with knee joint movements for daily activities are also
good.6,14
For proximal tibia it is more
difficult to do extensive resection and also for reconstruction, because of the
presence of large neurovascular around the proximal tibia, and for soft tissue
closure after surgery.10,15 The clinical outcome for reconstruction in proximal
tibia when compared with distal femoral reconstruction is worse. Because there
is a greater risk of infection and frequent revision operations and survival
rates on the prosthesis of the proximal tibia are shorter than those of the
distal femur.
�
Table 1
Figure 1
Photograph showing proximal tibia endoprosthesis
reconstruction with medial gastrocnemius flap
Figure
2
30
years age man with GCT on right distal femur, after limb salvage with megaprosthesis
CONCLUSION
The knee is an area that often
occurs primary bone tumors and most are in the distal femur. Osteosarcoma is
the most common primary tumor affecting the knee. As for giant tumor cells, it
is a progressive type of tumor that requires extensive resection to fulfill
local control as a therapy, and most are giant tumor cells that have been
diagnosed at grade III. Limb salvage is a procedure that is often performed
when a tumor hits the knee. Amputation can be done if the tumor affects many
soft compartments and soft tissue and neurovascular structures and is
considered to pose a high risk of recurrence. At present, megaprosthesis
is a new method to restore knee joint function after extensive resection
REFERENCES
Gkavardina Anthippi,
The Use of Megaprostheses for Reconstruction of Large Skeletal Defect in The
Extremities: A Critical Review. The Open Orthopaedics Journal, 2014. 384-389.
Canale, Beaty. Campbell’s
Operative Orthopaedic, 12th Ed. Chapter 19 : Principle Surgery,
Amputation versus Limb Salvage. Elsevier-Mosby. Philadelphia, USA. 2013. (2) :
785-793.
Martin m. Malawer.
Operative Technique in Orthopaedic Surgical Oncology, 3rd Ed.
Overview of Endoprosthetic Reconstruction,
kluwer Academic: Publishers, 2012. 34-36.
Fauzi Ahmad et all.
Megaprosthesis Limb Salvage Surgery: Outcome and Challanges in
Treating Advanced Bone Tumour Cases in Vast Archipelago in Indonesia. A Case
Series. International Journal of Surgery Open. Jakarta. 2018.
Jacob Bickels.
Operative Technique in Orthopaedic Surgical Oncology, 3rd Ed. Chapter 25.
Proximal and Total Femur Resection with Endoprosthetic Reconstrustion. Clin
Orthop Relat Res. 2014.
Ajay Puri. Indian Journal of
Plastic Surgery. Limb Salvage in Musculoskeletal Oncology: Recent
Advances. Wolter Kluwer Publication. India. 2018.
Badr Ennaciri. Knee
Megaprothesis: A Salvage Solution For Severe Open And Complex Distal
Femoral Fracture Associated With An Ipsilateral Brachial Plexus Injury (A Case
Report With Literature Review). Pan African Medical journal. 2015
Jutta Gamper.
Efficacy Of Different Revision Procedure For Infected Megaprostheses In
Musculoskeletal Tumour Surgery Of The Lower Limb. United States. Journal Pone.
2018
Subbiah Shanmugam.
Complications And Survival Outcome Following Custom Mega Prosthesis
Reconstruction For Bone Tumour-A Single Institution-15 Years Study.
International Journal Of Scientific Research. India. 2016
Nichola Lovecchio.
Squat exercise to estimate knee megaprosthesis rehabilitation: a pilot study.
The society of physical therapy science. IPEC inc. Italy. 2015
Calori G.M.
Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues
to consider. Injury international journal. Italy. 2014
Kask G. Functional
outcome after lower extremity soft tissue sarcoma treatment: a pilot study
based on translated and culturally adapted measures. Scandinavian journal of
Surgery. Finland. 2018
Casper Saebye.
Factors associated with reduced functional outcome and quality of life in
patients having limb-sparing surgery for soft tissue sarcomas a national
multicenter study of 128 patients. Acta Oncologica. Denmark. 2017
Wangsiyuan Teng.
Bone combined cement grafting in giant cell tumor around the knee reduces
mechanical failure. Department of Orthopedics, Hospital of Zhejiang University
School of Medicine, China. 2018
Stein J Janssen.
The Discrepancy between Patient and Clinician Reported Function in Extremity
Bone Metastases. Department of Orthopaedic Surgery, Massachusetts General
Hospital. USA. 2016
Dinesh Kadam. Limb
salvage surgery. A J Institute of Medical Sciences and A J Hospital and
Research Centre, India. 2013
Abhijeet Ashok Salunke.
Wide resection versus curettage in giant cell tumor with pathological fracture?
A systematic review and meta-analysis. Journal of Clinical Orthopaedics and
Trauma. Pramukswami Medical College, Karamsad, Gujarat, India. 2017