Skip to main content
SpringerLink
Log in

Limb salvage surgery for primary bone sarcoma of the lower extremities: Long-term consequences of endoprosthetic reconstructions

  • Original Articles
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background: Adjuvant chemotherapy and endoprosthetic replacement for bone sarcomas of the lower extremity is well established. The specific long-term consequences of these endoprosthetic reconstructions for the patient's affected limb are unknown.

Method: The oncologic results and the survival of the endoprostheses were reviewed in 32 patients with primary bone sarcoma of the femur or proximal tibia. There were 26 high-grade sarcomas, and 6 low-grade sarcomas. A proximal femoral endoprosthesis was used for reconstruction in 4 patients, a total or push-through femoral endoprosthesis in 11 patients, a distal femoral endoprosthesis in 15 patients, and a proximal tibial endoprosthesis in two patients.

Results: Median survival was 10 years (range, 1.1 to 18.9 years) for patients with high-grade sarcoma, and 8.1 years (range, 7.1 to 10 years) for patients with low-grade sarcomas. Distant metastases developed in seven patients (22%), all with stage IIB sarcoma, with concomitant local recurrence in 3 patients (9%). Five-year overall and disease-free survival rates for high-grade sarcomas were 81% and 73%, respectively. The overall endoprosthetic survival rate was 87% at 5 years, 80% at 10 years, and 56% at 15 years. Median follow-up of the original endoprostheses was 8.3 years (range, 0.6 to 18.7 years). Endoprosthesis-related complications occurred in 13 patients (41%); most complications were mechanical failures. The highest complication rate was found in distal femoral replacements (60%); amputation was necessary in both patients treated with a proximal tibial endoprosthesis. Five endoprostheses (16%) were revised. An amputation of the involved limb was performed in four patients (13%): in two patients because of local recurrence and in the other two patients because of infection. For patients alive at follow-up, the median functional Enneking evaluation score was 22 points (range, 12 to 28 points), with the highest functional scores in patients with a distal femoral endoprosthesis, and the lowest functional scores in patients with total or push-through femoral replacements.

Conclusion: Endoprosthetic reconstructions gave satisfying functional results in most patients after long-term survival. However, the proximal tibial and distal femoral endoprosthesis are particularly at risk for long-term endoprosthetic complications requiring additional surgical procedures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Ham SJ, Hoekstra HJ, van der Graaf WTA, Kamps WA, Molenaar WM, Schraffordt Koops H. The value of high-dose methotrexate-based neoadjuvant chemotherapy in malignant fibrous histiocytoma of bone.J Clin Oncol 1996;14:490–6.

    CAS  PubMed  Google Scholar 

  2. Eilber F, Giuliano A, Eckardt J, et al. Adjuvant chemotherapy for osteosarcoma: a randomized prospective trial.J Clin Oncol 1987;5:21–6.

    CAS  PubMed  Google Scholar 

  3. Link MP, Goorin AM, Miser AW, et al. The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity.N Engl J Med 1986;314:1600–6.

    CAS  PubMed  Google Scholar 

  4. Rosen G, Murphy ML, Huvos AG, Gutierrez M, Marcove RC. Chemotherapy, en bloc resection, and prosthetic bone replacement in the treatment of osteogenic sarcoma.Cancer 1976;37:1–11.

    CAS  PubMed  Google Scholar 

  5. Rosen G, Marcove RC, Caparros B, et al. Primary osteogenic sarcoma. The rationale for preoperative chemotherapy and delayed surgery.Cancer 1979;43:2163–77.

    CAS  PubMed  Google Scholar 

  6. Rosen G, Caparros B, Huvos AG, et al. Preoperative chemotherapy for osteogenic sarcoma: selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy.Cancer 1982;49:1221–30.

    CAS  PubMed  Google Scholar 

  7. Bacci G, Picci P, Ferrari S, et al. Primary chemotherapy and delayed surgery for nonmetastatic osteosarcoma of the extremities. Results in 164 patients preoperatively treated with high doses of methotrexate followed by cisplatin and doxorubicin.Cancer 1993;72:3227–38.

    CAS  PubMed  Google Scholar 

  8. Link MP, Goorin AM, Horowitz M, et al. Adjuvant chemotherapy of high-grade osteosarcoma of the extremity. Updated results of the multi-institutional osteosarcoma study.Clin Orthop 1991;270:8–14.

    PubMed  Google Scholar 

  9. Meyers PA, Heller G, Healey J, et al. Chemotherapy for nonmetastatic osteogenic sarcoma: The Memorial Sloan-Kettering experience.J Clin Oncol 1992;10:5–15.

    CAS  PubMed  Google Scholar 

  10. Springfield DS, Schmidt R, Graham-Pole J, Marcus RB, Spanier SS, Enneking WF. Surgical treatment for osteosarcoma.J Bone Joint Surg [Am] 1988;70:1124–30.

    CAS  Google Scholar 

  11. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur.J Bone Joint Surg [Am] 1986;68:1331–7.

    CAS  Google Scholar 

  12. Horowitz SM, Glasser DB, Lane JM, Healey JH. Prosthetic and extremity survivorship after limb salvage for sarcoma. How long do the reconstructions last?Clin Orthop 1993;293:280–6.

    PubMed  Google Scholar 

  13. Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage 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;76:649–56.

    CAS  Google Scholar 

  14. Ivins JC, Taylor WF, Golenzer H. A multi-institutional cooperative study of osteosarcoma. Partial report with emphasis on survival after limb salvage. In: Yamamuro T, ed.New Developments for Limb Salvage in Musculoskeletal Tumors. Tokyo: Springer-Verlag, 1989:61–9.

    Google Scholar 

  15. Simon MA. Limb salvage for osteosarcoma.J Bone Joint Surg [Am] 1988;70:307–310.

    CAS  Google Scholar 

  16. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur.J Bone Joint Surg [Br] 1994;76:178–186.

    CAS  Google Scholar 

  17. Unwin PS, Cannon SR, Grimer RJ, Kemp HBS, Sneath RS, Walker PS. Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb.J Bone Joint Surg [Br] 1996;78:5–13.

    CAS  Google Scholar 

  18. Ward WG, Eckardt JJ, Johnston-Jones KS, et al. Five to ten year results of custom endoprosthetic replacement for tumors of the distal femur. In: Brown KLB, ed.Complications of Limb Salvage. Prevention, Management, and Outcome. Montreal: International Society of Limb Salvage, 1991:483–91.

    Google Scholar 

  19. Enneking WF. A system for staging musculoskeletal neoplasms.Clin Orthop 1986;204:9–24.

    PubMed  Google Scholar 

  20. Huvos AG, Rosen G, Marcove RC. Primary osteogenic sarcoma. Pathologic aspects in 20 patients after treatment with chemotherapy, en bloc resection and prosthetic bone replacement.Arch Pathol Lab Med 1977;101:14–18.

    CAS  PubMed  Google Scholar 

  21. van Oven MW, Molenaar WM, Freling NJM, et al. Dedifferentiated parosteal osteosarcoma of the femur with aneuploidy and lung metastases.Cancer 1989;63:807–11.

    PubMed  Google Scholar 

  22. Veth RPH, Nielsen HKL, Oldhoff J, et al. The treatment of primary tumors of the femur with chemotherapy (if indicated), resection and reconstruction with an endoprosthesis.J Surg Oncol 1985;30:252–8.

    CAS  PubMed  Google Scholar 

  23. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma.Clin Orthop 1980;153:106–120.

    PubMed  Google Scholar 

  24. Veth RPH, Nielsen HKL, Oldhoff J, et al. Megaprostheses in the treatment of primary malignant and metastatic tumors in the hip region.J Surg Oncol 1989;40:214–8.

    CAS  PubMed  Google Scholar 

  25. Steinbrink K, Nieder E. Total femoral replacement and the saddle prosthesis. In: Coombs R, Friedlaender G, eds.Bone Tumour Management. London: Butterworths, 1987:159–65.

    Google Scholar 

  26. Nielsen HKL, Veth RPH, Oldhoff J, et al. Functional results of prosthetic replacement in patients with primary tumors of the distal femur. In: Enneking WF, ed.Limb Salvage in Musculoskeletal Oncology. New York: Churchill Livingstone, 1987:424–6.

    Google Scholar 

  27. Steinbrink K, Engelbrecht E, Fenelon GCC. The total femoral prosthesis. A preliminary report.J Bone Joint Surg [Br] 1982;64:305–15.

    CAS  Google Scholar 

  28. Enneking WF, Dunham W, Gebhardt MC, Malawer M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system.Clin Orthop 1993;286:241–6.

    PubMed  Google Scholar 

  29. Kaplan E, Meier P. Non-parametric estimation from incomplete observations.J Am Stat Assoc 1958;8:423–46.

    Google Scholar 

  30. 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;12:2699–705.

    CAS  PubMed  Google Scholar 

  31. Ward WG, Mikaelian K, Dorey F, et al. Pulmonary metastases of stage IIB extremity osteosarcoma and subsequent pulmonary metastases.J Clin Oncol 1994;12:1849–58.

    CAS  PubMed  Google Scholar 

  32. Unni KK. Chondrosarcoma. In: Unni KK, ed.Dahlin's Bone Tumors. General Aspects and Data on 11,087 Cases.5th edition. Philadelphia: Lippincott-Raven Publishers, 1996:71–108.

    Google Scholar 

  33. Springfield DS, Gebhardt MC, McGuire MH. Chondrosarcoma: a review.J Bone Joint Surg [Am] 1996;78:141–9.

    Google Scholar 

  34. Eckardt JJ, Eilber FR, Rosen G, et al. Limb salvage versus amputation for malignant tumors other than osteogenic sarcoma. In: Yamamuro T, ed.New Developments for Limb Salvage in Musculoskeletal Tumors. Tokyo: Springer-Verlag, 1989:73–81.

    Google Scholar 

  35. Malawer MM, Chou LB. Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas.J Bone Joint Surg [Am] 1995;77:1154–65.

    CAS  Google Scholar 

  36. Eckardt JJ, Eilber FR, Grant TG, Dorey FJ, Mirra JM. The UCLA experience in the management of stage IIB osteosarcoma: 1972–1983. In: Enneking WF, ed.Limb Salvage in Musculoskeletal Oncology. New York: Churchill Livingstone, 1987:314–26.

    Google Scholar 

  37. Cannon SR. Massive prostheses for malignant bone tumours of the limbs.J Bone Joint Surg [Br] 1997;79:497–506.

    Article  CAS  Google Scholar 

  38. Dobbs HS, Scales JT, Wilson JN, Kemp HBS, Burrows HJ, Sneath RS. Endoprosthetic replacement of the proximal femur and acetabulum. A survival analysis.J Bone Joint Surg [Br] 1981;63:219–24.

    Google Scholar 

  39. Capanna R, Ruggieri P, Decristofaro R, et al. Complications, their treatment and outcome in 257 cementless megaprostheses. In: Brown KLB, ed.Complications of Limb Salvage. Prevention, Management and Outcome. Montreal: International Society of Limb Salvage, 1991:147–50.

    Google Scholar 

  40. Eckardt JJ, Eilber FR, Rosen G, et al. Endoprosthetic replacement for stage IIB osteosarcoma.Clin Orthop 1991;270:202–13.

    PubMed  Google Scholar 

  41. Marcove RC, Lewis MM, Rosen G, Huvos AG. Total femur and total knee replacement. A preliminary report.Clin Orthop 1977;126:148–52.

    Google Scholar 

  42. Nerubay J, Katznelson A, Rubinstein Z, Morag B, Bubis JJ. Total femoral replacement.Clin Orthop 1988;229:143–8.

    PubMed  Google Scholar 

  43. Ward WG, Dorey F, Eckardt JJ. Total femoral endoprosthetic reconstruction.Clin Orthop 1995;316:195–206.

    PubMed  Google Scholar 

  44. Johnson ME, Mankin HJ. Reconstructions after resections of tumors involving the proximal femur.Orthop Clin North Am 1991;22:87–103.

    CAS  PubMed  Google Scholar 

  45. Toni A, Subdanese A, Capanna R, Guerra A, Giunti A, Campanacci M. Custom-made prosthesis: the Italian experience. In: Enneking WF, ed.Limb Salvage in Musculoskeletal Oncology. New York: Churchill Livingstone, 1987:207–10.

    Google Scholar 

  46. Bradish CF, Kemp HBS, Scales JT, Wilson JN. Distal femoral replacement by custom-made prostheses. Clinical follow-up and survivorship analysis.J Bone Joint Surg [Br] 1987;69:276–84.

    CAS  Google Scholar 

  47. Sim FH, Beauchamp CP, Chao YS. Reconstruction of musculoskeletal defects about the knee for tumor.Clin Orthop 1987;221:188–201.

    PubMed  Google Scholar 

  48. Roberts P, Chan D, Grimer RJ, Sneath RS, Scales JT. Prosthetic replacement of the distal femur for primary bone tumours.J Bone Joint Surg [Br] 1991;73:762–9.

    CAS  Google Scholar 

  49. Johnston JO, Harris TJ, Alexander CE, Alexander HA. Limb salvage procedure for neoplasms about the knee by spherocentric total knee arthroplasty and autogenous autoclaved bone grafting.Clin Orthop 1983;181:137–45.

    PubMed  Google Scholar 

  50. Horowitz SM, Lane JM, Healey JH. Soft-tissue management with prosthetic replacement for sarcomas around the knee.Clin Orthop 1992;275:226–31.

    PubMed  Google Scholar 

  51. Horowitz SM, Lane JM, Otis JC, Healey JH. Prosthetic arthroplasty of the knee after resection of a sarcoma in the proximal end of the tibia. A report of sixteen cases.J Bone Joint Surg [Am] 1991;73:286–93.

    CAS  Google Scholar 

  52. Eckardt JJ, Matthews II JG, Eilber FR. Endoprosthetic reconstruction after bone tumor resections of the proximal tibia.Orthop Clin North Am 1991;149–60.

  53. Malawer MM, McHale KA. Limb-sparing surgery for high-grade malignant tumors of the proximal tibia. Surgical technique and a method of extensor mechanism reconstruction.Clin Orthop 1989;239:231–48.

    PubMed  Google Scholar 

  54. Verkerke GJ, Schraffordt Koops H, Veth RPH, et al. Development and test of an extendable endoprosthesis for bone reconstruction in the leg.Int J Artif Organs 1994;17:155–62.

    CAS  PubMed  Google Scholar 

  55. Eckardt JJ, Safran MR, Eilber FR, Rosen G, Kabo JM. Expandable endoprosthetic reconstruction of the skeletally immature after malignant bone tumor resection.Clin Orthop 1993;297:188–202.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. the Department of Orthopaedics, Groningen University Hospital, Groningen, The Netherlands

    S. John Ham MD, René P. H. Veth MD, PhD & Jim R. van Horn MD, PhD

  2. the Department of Pathology, Groningen University Hospital, Groningen, The Netherlands

    Willemina M. Molenaar MD, PhD

  3. Dept. of Surgical Oncology, Groningen University Hospital, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands

    Heimen Schraffordt Koops MD, PhD & Harald J. Hoekstra MD, PhD

Authors
  1. S. John Ham MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Heimen Schraffordt Koops MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. René P. H. Veth MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jim R. van Horn MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Willemina M. Molenaar MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Harald J. Hoekstra MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ham, S.J., Koops, H.S., Veth, R.P.H. et al. Limb salvage surgery for primary bone sarcoma of the lower extremities: Long-term consequences of endoprosthetic reconstructions. Annals of Surgical Oncology 5, 423–436 (1998). https://doi.org/10.1007/BF02303861

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02303861

Key Words

Search

Navigation