Survival, Recurrence, and Function After Epiphyseal Preservation and Allograft Reconstruction in Osteosarcoma of the Knee

Abstract

Background Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed. Questions/purposes We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection. MethodsWe analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system. Results Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup.

Knee joint preservation surgery in osteosarcoma using tumour-bearing bone treated with liquid nitrogen

“…Aponte-Tinao reported long-term results of allograft reconstruction in 35 osteosarcomas of the knee [15]. In this series, 18 patients achieved normal knee function; however, complications treated with additional surgical procedures were recorded for 19 patients, including fractures and three non-unions.…”

“…Such biological reconstruction uses materials such as allogeneic bone [6,15], distracted autologous bone [7,16], fibular bone [2,17,18], and treated autologous bone [19][20][21].…”

“…Massive bone allografts are still the mainstream of biological reconstruction [6,15]. Aponte-Tinao reported long-term results of allograft reconstruction in 35 osteosarcomas of the knee [15].…”

CORR Insights®: Survival, Recurrence, and Function After Epiphyseal Preservation and Allograft Reconstruction in Osteosarcoma of the Knee

“…Aponte-Tinao et al have analyzed their experience with intercalary epiphyseal-sparing surgery around the knee, a technique devised to preserve the native joint in order to maximize limb function and durability, in a selected group of 35 patients with favorable clinical-radiographic profile of response to chemotherapy [2]. Rationale for maintaining the native joint it is not only improved functionality, as the result of preserved proprioception and adequate range of motion, but also to obviate long-term prosthetic failure.…”

“…Although surgical margin and histological response to preoperative chemotherapy are well documented as the main risk factors in this setting [16], our understanding of the pathogenesis and impact on survival of this complex problem is largely incomplete. There are three fundamental issues, inherently related, that affect local recurrence and have important implications regarding whether the technological and surgical advances reported by Aponte-Tinao and colleagues [2] should be employed:…”