The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 6

Scientific Articles | March 21, 2012

Outcome of Lower-Limb Preservation with an Expandable Endoprosthesis After Bone Tumor Resection in Children

Eric R. Henderson, MD¹; Andrew M. Pepper, MD¹; German Marulanda, MD¹; Odion T. Binitie, MD¹; David Cheong, MD²; G. Douglas Letson, MD²

¹ Department of Orthopaedic Surgery, University of South Florida, MDF 5th Floor, 13220 USF Laurel Drive, Tampa, FL 33612. E-mail address for E.R. Henderson: eric.r.henderson@gmail.com
² Sarcoma Program, H. Lee Moffitt Cancer and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612

View Disclosures and Other Information

Disclosure statement for author(s): PDF

Investigation performed at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, and All Children's Hospital, St. Petersburg, FloridaA commentary by Albert J. Aboulafia, MD, MBA, and James Wilkerson, MD, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Mar 21;94(6):537-547. doi: 10.2106/JBJS.I.01575

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Background:

The optimal treatment of malignant pediatric lower-extremity bone tumors is controversial. Expandable endoprostheses allow limb preservation, but the revision rate and limited function are considered barriers to their use. This study investigated the functional, emotional, and oncologic outcomes of thirty-eight patients treated with an expandable endoprosthesis.

Methods:

A retrospective chart review was performed, and surviving patients were asked to complete the Musculoskeletal Tumor Society (MSTS) outcomes instrument and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional data including the range of hip and knee motion, limb-length discrepancy, and total lengthening were also obtained.

Results:

Thirty-eight patients were treated with an expandable endoprosthesis, and twenty-six of these patients were alive at the time of the study. The mean global MSTS score was 26.1, and the mean global PODCI score was 85.8. The mean emotional acceptance and happiness subscores were high. The mean sagittal-plane hip motion in patients who had undergone replacement of the proximal aspect of the femur was 103°. The mean knee motion in patients who had undergone replacement of the proximal aspect of the femur, the distal aspect of the femur, or the proximal aspect of the tibia was 127°, 97°, and 107°, respectively. The mean lengthening at the time of skeletal maturity was 4.5 cm, and the mean limb-length discrepancy was 0.7 cm. Forty-two percent of the patients experienced complications, with ten patients requiring prosthesis revision and two of these patients requiring amputation.

Conclusions:

Current technology does not offer a single best reconstruction option for children. Previous studies and the present series have indicated that physical and emotional functioning in patients treated with an expandable endoprosthesis are good but that complication rates remain high. Amputation and rotationplasty are alternative treatments if patients and their families are amenable to these procedures. The literature supports no single superior treatment among these three options with regard to physical or emotional health.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Effective chemotherapeutic agents and advances in endoprosthesis design have made limb preservation surgery possible for many patients with a malignant bone tumor^1,2. Limb reconstruction following tumor resection in adult patients requires reestablishment of limb length, alignment, and soft-tissue stability; limb reconstruction in children also requires allowance for additional growth³. Scales created the first prosthesis design capable of lengthening in 1976⁴, and several subsequent modifications have yielded prostheses capable of lengthening through less invasive methods³.

The optimal reconstruction technique for young patients with a malignant bone tumor remains controversial. Some surgeons support amputation or rotationplasty followed by use of an external prosthesis, whereas others have adopted the use of expandable endoprostheses^5,6. Neel and Springfield have debated this issue, with Springfield citing superior outcomes after amputation and Neel citing better outcomes after endoprosthesis use, but the arguments were mainly anecdotal⁵. Limited numbers of these three procedures are performed annually, and data to suggest a single superior treatment are lacking.

The present study involved a retrospective review of thirty-eight children who received an expandable endoprosthesis after tumor resection at one institution. To our knowledge, it represents the largest such series in the United States. The purpose of the study was to assess the outcomes of patients treated with this surgical procedure in order to facilitate evidence-based decision-making for the treatment of malignant pediatric lower-extremity bone tumors.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

After institutional review board approval was obtained, we queried our database to identify patients who had received an expandable endoprosthesis. Surgical implantation of an expandable endoprosthesis at our institution was indicated primarily for skeletally immature patients who were expected to have >2 cm of residual growth of the affected extremity and were undergoing resection of a malignant bone tumor that did not involve essential neurovascular structures. Patients who had received an expandable endoprosthesis for a nononcologic condition were excluded from the study.

Patient Management

Thirty-nine primary expandable endoprostheses were implanted at our institution by two surgeons (G.D.L. and D.C.) between August 1996 and May 2009. Surgical procedures about the hip, femoral shaft, and distal aspect of the femur were performed through a lateral approach. The proximal aspect of the tibia was accessed through a medial approach, and the distal aspect of the tibia was accessed through an anterior approach.

Cement fixation was used at all bone-prosthesis interfaces. Eighteen patients received prostheses manufactured by Stryker Orthopaedics (Mahwah, New Jersey), twelve patients received prostheses manufactured by Biomet (Warsaw, Indiana), and nine patients received prostheses manufactured by Stanmore Implants (Elstree, United Kingdom). One of the Stanmore prostheses was implanted for a nononcologic condition, and this patient was excluded from the study. Nineteen (50%) of the remaining thirty-eight patients were boys and nineteen were girls. The mean age of the patients at the time of surgery was 10.4 years (range, four to fifteen years). Thirty-one of the patients had been diagnosed with osteosarcoma and seven with Ewing sarcoma. One of the boys with Ewing sarcoma had previously been treated with intercalary resection at another institution and subsequently received the expandable endoprosthesis at our institution at the age of fifteen years because of a 6-cm limb-length discrepancy. All patients with osteosarcoma and Ewing sarcoma were treated with neoadjuvant and adjuvant chemotherapy. The mean duration of follow-up in the patients who were alive at the time of the study was forty-eight months (range, twenty-three to 146 months).

Data Collection

Clinical data were obtained through a chart review. The survival of patients who could not be contacted was determined by accessing the Social Security Death Index⁷. Functional data were obtained through telephone conversations, mailed surveys, and clinic visits. Limb preservation failures were classified into five types as described previously⁸.

Physical function and emotional acceptance were assessed with two outcomes instruments, the Musculoskeletal Tumor Society (MSTS) scoring system⁹ and the Pediatric Outcomes Data Collection Instrument (PODCI)¹⁰. The MSTS scoring system is a physician-administered survey with six domains that are each scored from zero to five, with five indicating an optimal result and zero indicating a failure. The PODCI is a survey with five domains that is completed by the patient and/or the patient's parents. Each domain and the global score are reported on a scale of zero to 100, with 100 indicating an optimal result and zero indicating a failure.

Additional outcomes included the range of hip and/or knee motion, the number of lengthenings, the total distance by which the prosthesis was lengthened, the limb-length discrepancy at the most recent follow-up visit, and complications. Hip and knee motion were measured with use of a standard goniometer. Limb length was measured between the anterior superior iliac spine and the medial malleolus by one of the two surgeons or a physician assistant with use of a tape measure. Prosthesis expansion was measured with use of calibrated radiographs. Skeletal maturity was determined by assessing radiographs of the adjacent and contralateral physes.

Description of the Prostheses

Expansion of the Biomet prosthesis requires a surgical procedure performed with the patient under general anesthesia. The prosthesis is expanded in 1-cm increments, and a metal spacer is inserted and secured with a locking clip to maintain the desired length (Fig. 1).

Fig. 1

Lateral radiograph showing an expandable distal femoral endoprosthesis manufactured by Biomet.

View Large | Download Slide(.ppt)
Add to My JBJS

Lengthening of the Stryker minimally invasive segmental prosthesis is performed percutaneously with the patient under general anesthesia. A screwdriver is used to actuate the lengthening mechanism (Fig. 2).

Fig. 2

Anteroposterior radiograph showing an expandable distal femoral endoprosthesis manufactured by Stryker.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 3

Anteroposterior radiograph showing an expandable distal femoral endoprosthesis manufactured by Stanmore Implants.

View Large | Download Slide(.ppt)
Add to My JBJS

The Stanmore Juvenile Tumour System prosthesis has received 510k approval from the United States Food and Drug Administration (Fig. 3). The lengthening mechanism is activated by an external electromagnetic coil through which the patient's extremity has been inserted. The external coil is portable and the patient is awake during the procedure, which can be performed in a clinic setting (Fig. 4).

Fig. 4

Photograph showing a child undergoing noninvasive lengthening of an expandable Stanmore distal femoral endoprosthesis.

View Large | Download Slide(.ppt)
Add to My JBJS

Statistical Analysis

Statistical analysis was performed with use of SPSS software (SPSS, Chicago, Illinois). Mean values are reported with standard deviations and were compared with use of the Student t test. Categorical data were analyzed with use of the Fisher exact test (two-tailed). A p value of 0.05 was considered significant.

Source of Funding

No outside financial support was received for this study.

Results

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

All of the expandable prostheses were implanted in the lower extremity. The primary surgical procedure involved replacement of the proximal aspect of the femur in three patients (with one Stryker and two Stanmore prostheses), total replacement of the femur in three patients (with three Stryker prostheses), replacement of the distal aspect of the femur in twenty-five patients (with eight Biomet, eleven Stryker, and six Stanmore prostheses), replacement of the proximal aspect of the tibia in five patients (with two Biomet and three Stryker prostheses), and replacement of the distal aspect of the tibia in two patients (with two Biomet prostheses).

Survival

Twelve patients (32%) died during the course of the study; eleven of these patients had been diagnosed with osteosarcoma and one with Ewing sarcoma. All of these patients died of metastatic disease, at a mean of twenty-eight months (range, four to seventy-four months) after the initial resection and reconstruction.

Global Function

MSTS scores were obtained for seventeen of the twenty-six surviving patients (Table I). The mean global score (and standard deviation) was 26.1 (87.1%) ± 2.0, and the range was 23 to 29. The mean global MSTS score was 23.7 (79%) ± 1.2 (range, 23 to 25) for patients with a proximal femoral replacement, 26.4 (87.9%) ± 1.7 (range, 24 to 29) for patients with a distal femoral replacement, and 26.7 (89%) ± 1.2 (range, 26 to 28) for patients with a proximal tibial replacement.

View Larger

TABLE I MSTS Scores of Patients with an Expandable Endoprosthesis*

			MSTS Score
Manufacturer	Patient	Location‡	Pain	Function	Emotional Acceptance	Use of Supports	Walking Ability	Gait	Global
Biomet
	4	DFR	4	4	5	5	4	3	25 (83%)
	8	DFR	2	2	5	5	5	5	24 (80%)
	9	PTR	3	4	5	5	4	5	26 (87%)
	Mean†		3.0 ± 1.0	3.3 ± 1.2	5.0 ± 0.0	5.0 ± 0.0	4.3 ± 0.6	4.3 ± 1.2	25.0 (83%) ± 1.0
Stryker
	15	DFR	2	4	4	5	5	4	24 (80%)
	16	TFR	5	5	5	5	5	4	29 (97%)
	18	DFR	5	4	5	5	5	5	29 (97%)
	23	PFR	4	3	4	5	3	4	23 (77%)
	25	PTR	4	4	5	5	5	5	28 (93%)
	28	PTR	4	4	4	5	5	4	26 (87%)
	Mean†		4.0 ± 1.1	4.0 ± 0.6	4.5 ± 0.5	5.0 ± 0.0	4.7 ± 0.8	4.3 ± 0.5	26.5 (88%) ± 2.6
Stanmore
	32	DFR	5	4	4	5	5	4	27 (90%)
	34	DFR	4	4	4	5	5	4	26 (87%)
	35	DFR	5	5	5	5	5	4	29 (97%)
	36	PFR	3	4	5	4	4	3	23 (77%)
	37	DFR	5	4	5	5	5	3	27 (90%)
	38	PFR	5	3	5	5	4	3	25 (83%)
	39	DFR	4	4	4	5	5	4	26 (87%)
	40	DFR	4	4	5	5	5	4	27 (90%)
	Mean†		4.4 ± 0.7	4.0 ± 0.5	4.6 ± 0.5	4.9 ± 0.4	4.8 ± 0.5	3.6 ± 0.5	26.3 (88%) ± 1.8
All	Mean†		4.0 ± 1.0	3.9 ± 0.7	4.6 ± 0.5	4.9 ± 0.2	4.6 ± 0.6	4.0 ± 0.7	26.1 (87%) ± 2.0

*MSTS = Musculoskeletal Tumor Society.
†Values are given as the mean and the standard deviation.
‡PFR = proximal femoral replacement, TFR = total femoral replacement, DFR = distal femoral replacement, and PTR = proximal tibial replacement.

Add to My JBJS

TABLE I MSTS Scores of Patients with an Expandable Endoprosthesis*

			MSTS Score
Manufacturer	Patient	Location‡	Pain	Function	Emotional Acceptance	Use of Supports	Walking Ability	Gait	Global
Biomet
	4	DFR	4	4	5	5	4	3	25 (83%)
	8	DFR	2	2	5	5	5	5	24 (80%)
	9	PTR	3	4	5	5	4	5	26 (87%)
	Mean†		3.0 ± 1.0	3.3 ± 1.2	5.0 ± 0.0	5.0 ± 0.0	4.3 ± 0.6	4.3 ± 1.2	25.0 (83%) ± 1.0
Stryker
	15	DFR	2	4	4	5	5	4	24 (80%)
	16	TFR	5	5	5	5	5	4	29 (97%)
	18	DFR	5	4	5	5	5	5	29 (97%)
	23	PFR	4	3	4	5	3	4	23 (77%)
	25	PTR	4	4	5	5	5	5	28 (93%)
	28	PTR	4	4	4	5	5	4	26 (87%)
	Mean†		4.0 ± 1.1	4.0 ± 0.6	4.5 ± 0.5	5.0 ± 0.0	4.7 ± 0.8	4.3 ± 0.5	26.5 (88%) ± 2.6
Stanmore
	32	DFR	5	4	4	5	5	4	27 (90%)
	34	DFR	4	4	4	5	5	4	26 (87%)
	35	DFR	5	5	5	5	5	4	29 (97%)
	36	PFR	3	4	5	4	4	3	23 (77%)
	37	DFR	5	4	5	5	5	3	27 (90%)
	38	PFR	5	3	5	5	4	3	25 (83%)
	39	DFR	4	4	4	5	5	4	26 (87%)
	40	DFR	4	4	5	5	5	4	27 (90%)
	Mean†		4.4 ± 0.7	4.0 ± 0.5	4.6 ± 0.5	4.9 ± 0.4	4.8 ± 0.5	3.6 ± 0.5	26.3 (88%) ± 1.8
All	Mean†		4.0 ± 1.0	3.9 ± 0.7	4.6 ± 0.5	4.9 ± 0.2	4.6 ± 0.6	4.0 ± 0.7	26.1 (87%) ± 2.0

The PODCI was completed by fifteen patients (Table II). The mean global score was 85.8 ± 8.0. The mean global PODCI score was 79.0 ± 5.6 for patients with a proximal femoral replacement, 86.3 ± 8.5 for patients with a distal femoral replacement, and 88.8 ± 1.1 for patients with a proximal tibial replacement. The global MSTS and PODCI scores did not differ significantly according to prosthesis manufacturer or location.

View Larger

TABLE II PODCI Scores of Patients with an Expandable Endoprosthesis*

			PODCI Score
Manufacturer	Patient	Location†	Upper Extremity	Transfer and Basic Mobility	Sports and Physical Function	Pain and Comfort	Happiness	Global
Biomet
	4	DFR	100	94	48	41	100	71
	8	DFR	100	100	49	100	85	87
	9	PTR	100	98.5	82	77	92.5	89.5
	Mean		100	97.5	59.7	72.7	92.5	82.5
Stryker
	16	TFR	100	98.5	59	100	95	95.5
	18	DFR	100	100	72.5	71	90	85.5
	23	PFR	100	92	62	87.5	62.5	85.5
	28	PTR	100	95.5	68.5	87.5	100	88
	Mean		100	96.5	65.5	86.5	86.9	88.6
Stanmore
	32	DFR	100	91	78	93	100	91
	34	DFR	96	97	83	61	95	84
	35	DFR	100	95.5	85	94.5	100	93
	36	PFR	100	87	56	61	85	75.5
	37	DFR	90	91	78	45	55	76
	38	PFR	98	96.5	53	58	82.5	76
	39	DFR	100	100	97	93	100	98
	40	DFR	100	98.5	80.5	85.5	100	91
	Mean		98.0	94.6	76.2	73.9	89.7	85.6
All	Mean		98.9	95.7	70.1	77.0	89.5	85.8

*PODCI = Pediatric Outcomes Data Collection Instrument.
†PFR = proximal femoral replacement, TFR = total femoral replacement, DFR = distal femoral replacement, and PTR = proximal tibial replacement.

Add to My JBJS

TABLE II PODCI Scores of Patients with an Expandable Endoprosthesis*

			PODCI Score
Manufacturer	Patient	Location†	Upper Extremity	Transfer and Basic Mobility	Sports and Physical Function	Pain and Comfort	Happiness	Global
Biomet
	4	DFR	100	94	48	41	100	71
	8	DFR	100	100	49	100	85	87
	9	PTR	100	98.5	82	77	92.5	89.5
	Mean		100	97.5	59.7	72.7	92.5	82.5
Stryker
	16	TFR	100	98.5	59	100	95	95.5
	18	DFR	100	100	72.5	71	90	85.5
	23	PFR	100	92	62	87.5	62.5	85.5
	28	PTR	100	95.5	68.5	87.5	100	88
	Mean		100	96.5	65.5	86.5	86.9	88.6
Stanmore
	32	DFR	100	91	78	93	100	91
	34	DFR	96	97	83	61	95	84
	35	DFR	100	95.5	85	94.5	100	93
	36	PFR	100	87	56	61	85	75.5
	37	DFR	90	91	78	45	55	76
	38	PFR	98	96.5	53	58	82.5	76
	39	DFR	100	100	97	93	100	98
	40	DFR	100	98.5	80.5	85.5	100	91
	Mean		98.0	94.6	76.2	73.9	89.7	85.6
All	Mean		98.9	95.7	70.1	77.0	89.5	85.8

Physical Capacity

The mean scores for the four MSTS functional domains (function, use of supports, walking ability, and gait) were 3.9 ± 0.7, 4.9 ± 0.2, 4.6 ± 0.6, and 4.0 ± 0.7, respectively. The score for the function domain was the lowest score for any MSTS domain. The mean scores for the PODCI physical activity domains (upper extremity function, transfer and basic mobility, and sports and physical function) were 98.9 ± 2.7, 95.7 ± 3.9, and 70.1 ± 14.9, respectively. The mean score for the sports and physical function domain was the lowest for any PODCI domain. The scores for the physical capacity domains did not differ according to prosthesis manufacturer or location.

Emotional Acceptance

The mean score for the MSTS emotional acceptance domain was 4.6 ± 0.5, and the mean score for the PODCI happiness domain was 89.5 ± 14.0. The emotional acceptance and happiness scores did not differ significantly according to prosthesis manufacturer or location.

Pain

The mean score for the MSTS pain domain was 4.0 ± 1.0, indicating that most patients experienced mild discomfort during daily activities that sometimes required non-narcotic pain medication. The mean score for the PODCI pain and comfort domain was 77.0 ± 19.6. The pain scores did not differ significantly according to prosthesis manufacturer or location.

Motion

Joint motion data were available for three proximal femoral replacements, twelve distal femoral replacements, and three proximal tibial replacements. Mean hip motion in the three patients with a proximal femoral replacement was from 6.7° ± 12° of extension to 97° ± 12° of flexion, resulting in a net range of motion of 103° ± 23°. Mean knee motion in the three patients with a proximal femoral replacement was from full extension (0.0° ± 0.0°) to 127° ± 12° of flexion, resulting in a net range of motion of 127° ± 12°. Mean knee motion in the twelve patients with a distal femoral replacement was from a 1.0° ± 4.5° loss of full extension to 98° ± 36° of flexion, resulting in a net range of motion of 97° ± 36°. Mean knee motion in the three patients with a proximal tibial replacement was from 2.0° ± 1.7° of hyperextension to 105° ± 18° of flexion, resulting in a net range of motion of 107° ± 20°. Joint motion did not differ significantly according to prosthesis manufacturer or location.

Limb Lengthening

Fifteen patients in this series had reached skeletal maturity and completed the prosthesis lengthening process at the time of the latest follow-up. The mean lengthening in these patients was 4.5 cm (Table III). The mean lengthening was 3.8 cm (range, 2 to 8 cm) in the patients with a Biomet segmental prosthesis, 3.4 cm (range, 2 to 7 cm) in the patients with a Stryker minimally invasive prosthesis, and 8.8 cm (range, 4.5 to 13 cm) in the patients with a noninvasive Stanmore prosthesis.

View Larger

TABLE III Lengthening in Skeletally Mature Patients with an Expandable Endoprosthesis

Manufacturer	Patient	Location*	Total Lengthening (cm)	No. of Expansions	Limb-Length Discrepancy (cm)
Biomet
	4	DFR	8	4	2
	6	DTR	2	1	2
	8	DFR	8	4	2
	9	PTR	2	1	0
	10	DTR	2	1	0
	11	PTR	2	2	2
	12	DFR	6	4	2
	Mean		3.8		1.4
Stryker
	15	DFR	4	3	0
	16	TFR	7	7	0
	18	DFR	3.2	3	0
	20	DFR	2	2	0
	23	PFR	2	1	0
	25	PTR	2	1	0
	Mean		3.4		0.0
Stanmore
	32	DFR	4.5	11	0
	34	DFR	13	>20	0
	Mean		8.8		0.0
All	Mean		4.5		0.7

*PFR = proximal femoral replacement, TFR = total femoral replacement, DFR = distal femoral replacement, PTR = proximal tibial replacement, and DTR = distal tibial replacement.

Add to My JBJS

TABLE III Lengthening in Skeletally Mature Patients with an Expandable Endoprosthesis

Manufacturer	Patient	Location*	Total Lengthening (cm)	No. of Expansions	Limb-Length Discrepancy (cm)
Biomet
	4	DFR	8	4	2
	6	DTR	2	1	2
	8	DFR	8	4	2
	9	PTR	2	1	0
	10	DTR	2	1	0
	11	PTR	2	2	2
	12	DFR	6	4	2
	Mean		3.8		1.4
Stryker
	15	DFR	4	3	0
	16	TFR	7	7	0
	18	DFR	3.2	3	0
	20	DFR	2	2	0
	23	PFR	2	1	0
	25	PTR	2	1	0
	Mean		3.4		0.0
Stanmore
	32	DFR	4.5	11	0
	34	DFR	13	>20	0
	Mean		8.8		0.0
All	Mean		4.5		0.7

*PFR = proximal femoral replacement, TFR = total femoral replacement, DFR = distal femoral replacement, PTR = proximal tibial replacement, and DTR = distal tibial replacement.

One patient with a total femoral replacement had reached skeletal maturity and had undergone 7.0 cm of expansion. The eight skeletally mature patients with a distal femoral replacement had undergone a mean of 6.1 cm (range, 2 to 13 cm) of lengthening. The three skeletally mature patients with a proximal tibial replacement and the two skeletally mature patients with a distal tibial replacement had all undergone 2.0 cm of lengthening. Only one patient with a proximal femoral replacement had reached skeletal maturity and full lengthening; this patient had been eight years old at the time of the surgery, and she had required 2 cm of lengthening. The remaining patients with a proximal femoral replacement had undergone a mean of 2.7 cm (range, 1.0 to 3.6 cm) of lengthening and were continuing to undergoing lengthening. The mean limb-length discrepancy for all skeletally mature patients in the study was 0.7 ± 1.0 cm (range, 0 to 2 cm) at the time of the latest follow-up.

Adverse Events

Sixteen patients (42%) experienced one or more complications (Table IV). Five patients had developed a superficial infection without sequelae. There were four Type-1 (soft-tissue) failures, four Type-2 (aseptic loosening) failures, two Type-3 (structural) failures, and three Type-4 (infection) failures. There were no Type-5 (disease progression) failures. Ten patients (26%) required prosthesis revision, and two patients (including one of the ten patients who underwent a prosthesis revision) eventually required amputation. One patient required two revision procedures and two required three procedures. Two of the three deep infections were treated successfully with prosthesis revision and the third required amputation. Physeal arrest occurred in two patients; one of these patients developed a varus deformity that was treated with physeal bar resection, and the other developed varus and recurvatum that was treated with revision. Three patients with a distal femoral replacement underwent exchange of the prosthesis because the lengthening mechanism had reached its limit and the patient experienced additional growth; one of these patients had undergone the initial surgery at four years of age and required two revisions to permit additional growth.

View Larger

TABLE IV Adverse Events in Patients with an Expandable Endoprosthesis

Manufacturer	Patient	Age at Surgery (yr)	Sex	Location*	Diagnosis†	Adverse Event (Treatment)‡
Biomet
	1	6	M	DFR	OSA	Type-4 failure (revision, amputation)
	4	12	M	DFR	OSA	EXT (revision to identical prosthesis); Type-2 failure (revision to Stryker expandable prosthesis); Type-3 failure (revision to Stryker GMRS total femoral prosthesis)
	7	15	M	DFR	OSA	Type-1 failure (patellar tendon repair); Type-1 failure (quadriceps tendon repair)
	8	8	F	DFR	OSA	WD (wound revision); PA (revision to Stryker GMRS prosthesis to correct deformity)
	9	12	F	PTR	OSA	WD (wound revision); SI (oral antibiotics)
	11	12	F	PTR	OSA	Type-2 failure (revision to identical prosthesis)
	12	6	F	DFR	OSA	Type-4 failure (revision to identical prosthesis)
Stryker
	16	11	M	TFR	EWS	Type-4 failure (revision to identical prosthesis); Type-3 failure (revision to identical prosthesis)
	18	11	F	DFR	OSA	SI (oral antibiotics); Type-2 failure (revision to identical prosthesis); WD (wound revision)
	24	6	F	PTR	OSA	Type-1 failure (wound revision, amputation)
	25	14	F	PTR	OSA	Type-1 failure (patellar tendon tensioning); Type-2 failure (revision to identical prosthesis)
	26	4	F	DFR	EWS	PA (bar excision); FC (lysis of adhesions, revision to custom expandable, fixed-extension prosthesis); EXT; EXT (revision to Stanmore prosthesis)
	27	12	F	TFA	OSA	SI (oral antibiotics); seroma (evacuation)
Stanmore
	32	7	M	DFR	EWS	EXT (revision to identical prosthesis)
	35	11	M	DFR	OSA	SI (oral antibiotics)
	38	15	M	PFR	EWS	SI (oral antibiotics)

*PFR = proximal femoral replacement, TFR = total femoral replacement, DFR = distal femoral replacement, and PTR = proximal tibial replacement.
†OSA = osteosarcoma, and EWS = Ewing sarcoma.
‡Endoprosthesis failure types: Type 1 = soft-tissue failure, Type 2 = aseptic loosening, Type 3 = structural failure, and Type 4 = infection. Expandable endoprosthesis-specific complications: EXT = extension mechanism exceeded, and PA = physeal arrest. Other adverse events: SI = superficial infection, WD = wound dehiscence, and FC = flexion contracture. GMRS = Global Modular Replacement System.

Add to My JBJS

TABLE IV Adverse Events in Patients with an Expandable Endoprosthesis

Manufacturer	Patient	Age at Surgery (yr)	Sex	Location*	Diagnosis†	Adverse Event (Treatment)‡
Biomet
	1	6	M	DFR	OSA	Type-4 failure (revision, amputation)
	4	12	M	DFR	OSA	EXT (revision to identical prosthesis); Type-2 failure (revision to Stryker expandable prosthesis); Type-3 failure (revision to Stryker GMRS total femoral prosthesis)
	7	15	M	DFR	OSA	Type-1 failure (patellar tendon repair); Type-1 failure (quadriceps tendon repair)
	8	8	F	DFR	OSA	WD (wound revision); PA (revision to Stryker GMRS prosthesis to correct deformity)
	9	12	F	PTR	OSA	WD (wound revision); SI (oral antibiotics)
	11	12	F	PTR	OSA	Type-2 failure (revision to identical prosthesis)
	12	6	F	DFR	OSA	Type-4 failure (revision to identical prosthesis)
Stryker
	16	11	M	TFR	EWS	Type-4 failure (revision to identical prosthesis); Type-3 failure (revision to identical prosthesis)
	18	11	F	DFR	OSA	SI (oral antibiotics); Type-2 failure (revision to identical prosthesis); WD (wound revision)
	24	6	F	PTR	OSA	Type-1 failure (wound revision, amputation)
	25	14	F	PTR	OSA	Type-1 failure (patellar tendon tensioning); Type-2 failure (revision to identical prosthesis)
	26	4	F	DFR	EWS	PA (bar excision); FC (lysis of adhesions, revision to custom expandable, fixed-extension prosthesis); EXT; EXT (revision to Stanmore prosthesis)
	27	12	F	TFA	OSA	SI (oral antibiotics); seroma (evacuation)
Stanmore
	32	7	M	DFR	EWS	EXT (revision to identical prosthesis)
	35	11	M	DFR	OSA	SI (oral antibiotics)
	38	15	M	PFR	EWS	SI (oral antibiotics)

Four (22%) of the eighteen patients with a Stryker prosthesis and five (42%) of the twelve patients with a Biomet prosthesis underwent revision. No revisions for failure had occurred in the patients with a Stanmore prosthesis at the time of the latest follow-up; however, one of the prostheses required exchange to permit additional lengthening. The revision rate did not differ significantly among the three different prostheses.

Two patients (5%), one with a proximal tibial replacement and one with a distal femoral replacement, required amputation. One of these patients experienced a Type-4 failure (infection) and staged revision was unsuccessful; the other patient experienced a Type-1 failure (wound dehiscence) resulting in a deep infection that was refractory to treatment. No amputations were required for tumor progression.

Discussion

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Simon suggested that justifying limb preservation surgery rather than amputation for the treatment of a malignant bone tumor required that preservation provide better function and quality of life without a reduction in survival or an increase in morbidity¹¹. Because the two techniques result in equivalent mortality when they are performed in appropriate situations^1,2, the debate regarding the choice between limb preservation and amputation has primarily involved comparative analysis of the failure rate, function, and the amorphous quantity called “quality of life.” The results of the present study indicated that limb preservation surgery involving an expandable endoprosthesis fulfills the criteria of Simon and corroborates data from previous reports.

Physical Capacity

Multiple investigators have reported the functional results of limb preservation with an expandable endoprosthesis in a pediatric cohort without a corresponding control group^12-30. Physical performance measures were favorable overall; the MSTS score was the most frequently reported measure, with mean scores ranging from 66% to 90%. However, details regarding patient activity restrictions are missing from these reports. Neel et al. reported the highest mean MSTS score of 90%²⁵; eight revisions were performed in seven of eighteen patients with an expandable endoprosthesis, and six of the revisions were due to device breakage associated with the patient's activity level^5,25.

Lower functional capacity and greater activity restriction form the foundation of the argument against limb preservation^5,31. Van Nes published his rotationplasty technique for reconstruction after distal femoral resection in 1948 without substantive functional data³². Since then, several investigators have reported on the results of the rotationplasty technique in limited series^6,33-43. Murray et al. performed a detailed assessment of function after rotationplasty in two patients³⁷. Although both children in their report could participate in recreational play, competitive activity was limited. Gottsauner-Wolf et al. reported on the largest series of rotationplasties and indicated that results were good, but no outcomes instrument was used³⁵. Hanlon and Krajbich reported that all surviving members of a series of fourteen patients who had undergone rotationplasty had excellent or good MSTS scores⁴². Winkelmann reported a median MSTS score of 75 (range, 60 to 82) in a series of eight patients who had undergone rotationplasty^39-41 Hillmann et al. reported equivalent outcomes in their large series comparing limb preservation with rotationplasty⁴⁴.

Direct comparisons between limb preservation and amputation have been reported, with most authors reporting higher function scores after limb preservation^1,45-51. Aksnes et al. reported MSTS, Toronto Extremity Salvage Score (TESS), and Short Form-36 (SF-36) values for 118 patients who underwent amputation or limb preservation⁴⁵. The mean MSTS score was significantly higher in the patients treated with limb preservation surgery, and the TESS scores of the two groups were equivalent. Similar findings have been reported by other authors^31,48,50,51. In the largest comparison of this type, Rougraff et al. reported significantly better function after limb preservation than after amputation¹.

Comparisons of limb preservation, rotationplasty, and amputation outcomes have also been reported. Hopyan et al., whose series included five rotationplasties, reported superior results after limb preservation for all outcome measures except the SF-36 and the amount of time spent upright³¹. Ginsberg et al. reported better results after limb preservation compared with all other treatments except below-the-knee amputation; the difference between limb preservation and below-the-knee amputation was not significant⁵¹. Cammisa et al. reported similar findings, with limb preservation and rotationplasty both having superior results compared with above-the-knee amputation³³.

Other investigators have attempted to assess physical capacity with use of physiological testing^52-55. Otis et al. reported on twenty-six patients treated with either an endoprosthesis or above-the-knee amputation; the energy cost during walking was lower in the patients with an endoprosthesis⁵⁴. In a larger study, McClenaghan et al. reported rotationplasty to result in a lower energy cost than amputation, but no patients with limb preservation were studied⁵³. Harris et al. reported no difference in energy cost when amputation, arthrodesis, and limb preservation were compared; no patients with rotationplasty were included⁵².

Emotional Health and Appearance

The incidence of primary malignant bone tumors peaks during early adolescence⁵⁶, a time when feelings of social scrutiny and an emphasis on physical appearance are highest^57,58. Diagnosis of a malignant bone tumor during adolescence places patients at greater risk of social alienation than diagnosis at an earlier or a later age⁵⁹. Several investigators have reported on the emotional functioning of patients after limb preservation, rotationplasty, and amputation. Zahlten-Hinguranage et al. reported a similar quality of life after limb preservation and after amputation but noted that patients treated with limb preservation surgery defined their quality of life primarily through their physical abilities, whereas patients treated with amputation tended to associate quality of life with perceived social acceptability⁶⁰. Other authors have also reported similar quality of life in patients treated with limb preservation surgery and with amputation^46,61,62. Yonemoto et al. reported higher social functioning in the patients who had been treated with limb preservation surgery⁶³. Harris et al. and Postma et al. both reported superior results in the patients treated with limb preservation surgery^52,64, and Postma et al. concluded that higher social functioning due to improved cosmesis may justify limb preservation in spite of higher reoperation rates and physical complaints⁶⁴. Other authors have reported good psychological health after amputation but recommended education and support for the patient and family^65,66. Patients treated with rotationplasty may also have good outcomes, but up to one-half of patients in previous studies reported negative feelings regarding their body image and difficulty with social and intimate interactions⁴³. Only Sugarbaker et al. reported a lower quality of life in the patients who had undergone limb preservation surgery⁶⁷.

The emotional acceptance and happiness scores reported by patients in the present study demonstrated high overall patient satisfaction with the outcome. There was no correlation between the occurrence of complications and emotional satisfaction. Frances et al. reported similar findings in patients treated with limb preservation surgery and assessed with use of the PODCI⁶⁸. Although adjustment to an amputation performed during adolescence has been shown to be good later in life, the immediate emotional health and social functioning of the adolescent patient should also be considered when planning treatment.

Limb Length

The considerable cost of expandable prostheses limits their widespread use, and surgeons should consider alternative means of treating limb-length discrepancies. A discrepancy of ≤2 cm can be addressed during surgery or accommodated through shoe modification. Contralateral epiphysiodesis can be considered for anticipated discrepancies of 2 to 4 cm⁶⁹, and surgical lengthening may be considered for larger discrepancies⁷⁰.

Preemptive strategies for addressing limb-length discrepancies require accurate prediction of future growth; in the setting of pediatric limb preservation, this becomes problematic¹⁷. Dominkus et al. reported that the patients in their series required a mean expansion that was 24.3% greater than the expansion anticipated after careful preoperative assessment of growth potential¹⁷. Effecting a permanent solution at the time of the initial surgery may therefore lead to a discrepancy of unforeseen proportions. For this reason, it is our practice to treat pediatric patients with an expected limb-length discrepancy of >2 cm (based on normal growth patterns⁷¹) with an expandable prosthesis. However, one patient in our study who was treated with a proximal femoral replacement at eight years of age and reached skeletal maturity required only 2 cm of lengthening and could have been treated with a traditional, static endoprosthesis. Although we do assess skeletal maturity on the basis of the appearance of the physes on radiographs, our practice is to base lengthening decisions on limb-length measurements made in the clinic.

Adverse Events

Complications associated with limb preservation are frequent. Abudu et al. reported complications in 48% of 176 patients treated during a thirty-year period¹². The complication rate in the present series was similar to those in previous reports^12-30. Twenty-six percent of all primary endoprostheses in the present series, representing 38% of the primary endoprostheses in the surviving patients, had been revised. Three patients (including one patient who also underwent revision because of physeal arrest) required revision to permit additional lengthening. Expansion-specific failures are not accounted for in the current classification system of endoprosthesis failure⁸. If revision indications specific to the lengthening process are excluded, the failure rate of primary prostheses due to traditional failure modes was 21%, which is comparable with the failure rate reported in adult patients⁸. The revision rate for failures specific to the expandable nature of the endoprostheses was 8%, which we believe is a reasonable tradeoff for the lengthening capability of these devices.

Three patients developed a deep infection; two were treated successfully with revision and one required amputation. All three deep infections occurred after a surgical lengthening procedure. No deep infections had occurred in the patients with a Stanmore prosthesis by the time of the final follow-up, although this subgroup had the shortest duration of follow-up. Superior durability for rotationplasty compared with endoprosthesis reconstruction has been claimed³³, but the evidence is not overwhelming. Hanlon and Krajbich reported the occurrence of three major complications in a group of fourteen patients treated with rotationplasty⁴². Gottsauner-Wolf et al., however, reported a fracture rate of 10% in their series of patients treated with rotationplasty³⁵, which is slightly higher than the rate reported by Abudu et al. for patients treated with limb preservation surgery¹². The durability of external prostheses used after both amputation and rotationplasty is limited, and over time the financial cost of regular replacement of these devices has been shown to exceed the costs incurred after limb preservation surgery despite the high reoperation rate associated with endoprosthesis use⁷².

Summary

This study has several limitations. It involved a retrospective review of a small number of patients without a control group. Limited follow-up restricted data collection, as several patients had died as a result of their disease and others could not be reached to arrange clinic visits. Also, the study involved three different prostheses because it spanned a thirteen-year time period during which prosthesis design changed substantially. Further study of such prostheses is needed, but the limited number of patients receiving these devices, the obvious barriers to performing a blinded functional assessment, and strong patient and family biases regarding treatment preferences preclude large, randomized, blinded trials comparing the outcome of limb preservation surgery with alternative methods.

In summary, our study indicated that expandable endoprostheses provided a reliable option for treatment of bone sarcoma involving the lower extremity in pediatric patients. When considering amputation as an alternative to limb preservation, the level of amputation is important but complete resection of the sarcoma is essential. Treatment of a tumor in the proximal aspect of the lower extremity with limb preservation has a high success rate and avoids the poor function that follows amputation; however, there is substantially less functional disparity between limb preservation and amputation for the treatment of a tumor in the distal portion of the extremity⁵¹. Rotationplasty followed by use of an external prosthesis also remains a viable option for certain patients⁵. The development of nonsurgical lengthening technology (e.g., the Stanmore prosthesis used during the later stages of the present study) may decrease the rate of failure due to infection. At present, we believe that planning of treatment for a malignant lower-extremity bone tumor requires a full and objective discussion with the patient and family that involves functional and cosmetic expectations as well as the potential complications of the various treatments that are available.

Acknowledgements

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Note: The authors acknowledge the efforts of Dave Johnson, PA-C, and Rebecca Martin, PA-C, in bringing this investigation to fruition.

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.

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.

Marulanda GA; Henderson ER; Palumbo BT; Alexander GE; Cheong D; Letson GD. Use of extendable prostheses: a limb-salvaging alternative for patients with malignant bone tumors. Expert Rev Med Devices. 2008;5:467-74.

Scales JT; Sneath RS. The extending prosthesis. In: Coombs R; Friedlaender G, editors. Bone tumour management. London: Butterworth-Heinemann; 1987. p 168-77.

Neel MD; Springfield DS. The growing skeleton - expandable endoprostheses vs. amputations. Presented at the American Academy of Orthopaedic Surgeons Annual Meeting - Specialty Day. 2010 Mar 13; New Orleans.

Badhwar R; Agarwal M. Rotationplasty as a limb salvage procedure for malignant bone tumours. Int Orthop. 1998;22:122-5.

Social Security Death Index. http://ssdi.rootsweb.ancestry.com/cgi-bin/ssdi.cgi.2010. Accessed 2010 Oct 10.

Henderson ER; Groundland JS; Pala E; Dennis JA; Wooten R; Cheong D; Windhager R; Kotz RI; Mercuri M; Funovics PT; Hornicek FJ; Temple HT; Ruggieri P; Letson GD. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011;93:418-29.

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;286:241-6.

Daltroy LH; Liang MH; Fossel AH; Goldberg MJ. The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 1998;18:561-71.

Simon MA. Limb salvage for osteosarcoma in the 1980s. Clin Orthop Relat Res. 1991;270:264-70.

Abudu A; Grimer R; Tillman R; Carter S. The use of prostheses in skeletally immature patients. Orthop Clin North Am. 2006;37:75-84.

Arkader A; Viola DC; Morris CD; Boland PJ; Healey JH. Coaxial extendible knee equalizes limb length in children with osteogenic sarcoma. Clin Orthop Relat Res. 2007;459:60-5.

Belthur MV; Grimer RJ; Suneja R; Carter SR; Tillman RM. Extensible endoprostheses for bone tumors of the proximal femur in children. J Pediatr Orthop. 2003;23:230-5.

Cool WP; Carter SR; Grimer RJ; Tillman RM; Walker PS. Growth after extendible endoprosthetic replacement of the distal femur. J Bone Joint Surg Br. 1997;79:938-42.

Delepine G; Delepine N; Desbois JC; Goutallier D. Expanding prostheses in conservative surgery for lower limb sarcoma. Int Orthop. 1998;22:27-31.

Dominkus M; Krepler P; Schwameis E; Windhager R; Kotz R. Growth prediction in extendable tumor prostheses in children. Clin Orthop Relat Res. 2001;390:212-20.

Eckardt JJ; Kabo JM; Kelley CM; Ward WG Sr; Asavamongkolkul A; Wirganowicz PZ; Yang RS; Eilber FR. Expandable endoprosthesis reconstruction in skeletally immature patients with tumors. Clin Orthop Relat Res. 2000;373:51-61.

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

Gitelis S; Neel MD; Wilkins RM; Rao BN; Kelly CM; Yao TK. The use of a closed expandable prosthesis for pediatric sarcomas. Chir Organi Mov. 2003;88:327-33.

Gupta A; Meswania J; Blunn G; Cannon SR; Briggs TW. Stanmore non-invasive growing arthrodesis endoprosthesis in the reconstruction of complicated total knee arthroplasty: a case report. Knee. 2006;13:247-51.

Gupta A; Meswania J; Pollock R; Cannon SR; Briggs TW; Taylor S; Blunn G. Non-invasive distal femoral expandable endoprosthesis for limb-salvage surgery in paediatric tumours. J Bone Joint Surg Br. 2006;88:649-54.

Kenan S; Bloom N; Lewis MM. Limb-sparing surgery in skeletally immature patients with osteosarcoma. The use of an expandable prosthesis. Clin Orthop Relat Res. 1991;270:223-30.

Lewis MM. The use of an expandable and adjustable prosthesis in the treatment of childhood malignant bone tumors of the extremity. Cancer. 1986;57:499-502.

Neel MD; Wilkins RM; Rao BN; Kelly CM. Early multicenter experience with a noninvasive expandable prosthesis. Clin Orthop Relat Res. 2003;415:72-81.

Schiller C; Windhager R; Fellinger EJ; Salzer-Kuntschik M; Kaider A; Kotz R. Extendable tumour endoprostheses for the leg in children. J Bone Joint Surg Br. 1995;77:608-14.

Schindler OS; Cannon SR; Briggs TW; Blunn GW. Stanmore custom-made extendible distal femoral replacements. Clinical experience in children with primary malignant bone tumours. J Bone Joint Surg Br. 1997;79:927-37.

Schindler OS; Cannon SR; Briggs TW; Blunn GW; Grimer RJ; Walker PS. Use of extendable total femoral replacements in children with malignant bone tumors. Clin Orthop Relat Res. 1998;357:157-70.

Unwin PS; Walker PS. Extendible endoprostheses for the skeletally immature. Clin Orthop Relat Res. 1996;322:179-93.

Wilkins RM; Soubeiran A. The Phenix expandable prosthesis: early American experience. Clin Orthop Relat Res. 2001;382:51-8.

Hopyan S; Tan JW; Graham HK; Torode IP. Function and upright time following limb salvage, amputation, and rotationplasty for pediatric sarcoma of bone. J Pediatr Orthop. 2006;26:405-8.

Van Nes CP. Transplantation of the tibia and fibula to replace the femur following resection. “Turn-up-plasty” of the leg. J Bone Joint Surg Am. 1948;30:854-8.

Cammisa FP Jr; Glasser DB; Otis JC; Kroll MA; Lane JM; Healey JH. The Van Nes tibial rotationplasty. A functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur. J Bone Joint Surg Am. 1990;72:1541-7.

de Bari A; Krajbich JI; Langer F; Hamilton EL; Hubbard S. Modified Van Nes rotationplasty for osteosarcoma of the proximal tibia in children. J Bone Joint Surg Br. 1990;72:1065-9.

Gottsauner-Wolf F; Kotz R; Knahr K; Kristen H; Ritschl P; Salzer M. Rotationplasty for limb salvage in the treatment of malignant tumors at the knee. A follow-up study of seventy patients. J Bone Joint Surg Am. 1991;73:1365-75.

Kotz R; Salzer M. Rotation-plasty for childhood osteosarcoma of the distal part of the femur. J Bone Joint Surg Am. 1982;64:959-69.

Murray MP; Jacobs PA; Gore DR; Gardner GM; Mollinger LA. Functional performance after tibial rotationplasty. J Bone Joint Surg Am. 1985;67:392-9.

Van Nes C. Transplantation of the tibia and fibula to replace the femur following resection. “Turn-up plasty of the leg”. J Bone Joint Surg Am. 1964;46:1353-5.

Winkelmann W. [Modification of hip rotation plasty in malignant femoral tumors of the middle/distal third]. Z Orthop Ihre Grenzgeb. 1986;124:633-5. German.

Winkelmann W. Hip rotationplasty for malignant tumors of the proximal part of the femur. J Bone Joint Surg Am. 1986;68:362-9.

Winkelmann WW. Type-B-IIIa hip rotationplasty: an alternative operation for the treatment of malignant tumors of the femur in early childhood. J Bone Joint Surg Am. 2000;82:814-28.

Hanlon M; Krajbich JI. Rotationplasty in skeletally immature patients. Long-term followup results. Clin Orthop Relat Res. 1999;358:75-82.

Veenstra KM; Sprangers MA; van der Eyken JW; Taminiau AH. Quality of life in survivors with a Van Ness-Borggreve rotationplasty after bone tumour resection. J Surg Oncol. 2000;73:192-7.

Hillmann A; Hoffmann C; Gosheger G; Krakau H; Winkelmann W. Malignant tumor of the distal part of the femur or the proximal part of the tibia: endoprosthetic replacement or rotationplasty. Functional outcome and quality-of-life measurements. J Bone Joint Surg Am. 1999;81:462-8.

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;90:786-94.

Nagarajan R; Clohisy DR; Neglia JP; Yasui Y; Mitby PA; Sklar C; Finklestein JZ; Greenberg M; Reaman GH; Zeltzer L; Robison LL. Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing's sarcoma: the Childhood Cancer Survivor Study. Br J Cancer. 2004;91:1858-65.

Nagarajan R; Neglia JP; Clohisy DR; Robison LL. Limb salvage and amputation in survivors of pediatric lower-extremity bone tumors: what are the long-term implications?J Clin Oncol. 2002;20:4493-501.

Pardasaney PK; Sullivan PE; Portney LG; Mankin HJ. Advantage of limb salvage over amputation for proximal lower extremity tumors. Clin Orthop Relat Res. 2006;444:201-8.

Rao BN; Champion JE; Pratt CB; Carnesale P; Dilawari R; Fleming I; Green A; Austin B; Wrenn E; Kumar M. Limb salvage procedures for children with osteosarcoma: an alternative to amputation. J Pediatr Surg. 1983;18:901-8.

Renard AJ; Veth RP; Schreuder HW; van Loon CJ; Koops HS; van Horn JR. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol. 2000;73:198-205.

Ginsberg JP; Rai SN; Carlson CA; Meadows AT; Hinds PS; Spearing EM; Zhang L; Callaway L; Neel MD; Rao BN; Marchese VG. A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma. Pediatr Blood Cancer. 2007;49:964-9.

Harris IE; Leff AR; Gitelis S; Simon MA. Function after amputation, arthrodesis, or arthroplasty for tumors about the knee. J Bone Joint Surg Am. 1990;72:1477-85.

McClenaghan BA; Krajbich JI; Pirone AM; Koheil R; Longmuir P. Comparative assessment of gait after limb-salvage procedures. J Bone Joint Surg Am. 1989;71:1178-82.

Otis JC; Lane JM; Kroll MA. Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation. J Bone Joint Surg Am. 1985;67:606-11.

Song KM; Halliday SE; Little DG. The effect of limb-length discrepancy on gait. J Bone Joint Surg Am. 1997;79:1690-8.

Mirabello L; Troisi RJ; Savage SA. Osteosarcoma incidence and survival rates from 1973 to 2004: data from the Surveillance, Epidemiology, and End Results Program. Cancer. 2009;115:1531-43.

Eccles JS; Midgley C; Wigfield A; Buchanan CM; Reuman D; Flanagan C; Iver DM. Development during adolescence. The impact of stage-environment fit on young adolescents’ experiences in schools and in families. Am Psychol. 1993;48:90-101.

Rutter M; Graham P; Chadwick OF; Yule W. Adolescent turmoil: fact or fiction?J Child Psychol Psychiatry. 1976;17:35-56.

Felder-Puig R; Formann AK; Mildner A; Bretschneider W; Bucher B; Windhager R; Zoubek A; Puig S; Topf R. Quality of life and psychosocial adjustment of young patients after treatment of bone cancer. Cancer. 1998;83:69-75.

Zahlten-Hinguranage A; Bernd L; Ewerbeck V; Sabo D. Equal quality of life after limb-sparing or ablative surgery for lower extremity sarcomas. Br J Cancer. 2004;91:1012-4.

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;5:189-95.

Hudson MM; Tyc VL; Cremer LK; Luo X; Li H; Rao BN; Meyer WH; Crom DB; Pratt CB. Patient satisfaction after limb-sparing surgery and amputation for pediatric malignant bone tumors. J Pediatr Oncol Nurs. 1998;15:60-71.

Yonemoto T; Ishii T; Takeuchi Y; Kimura K; Hagiwara Y; Iwata S; Tatezaki S. Evaluation of quality of life (QOL) in long-term survivors of high-grade osteosarcoma: a Japanese single center experience. Anticancer Res. 2007;27:3621-4.

Postma A; Kingma A; De Ruiter JH; Schraffordt Koops H; Veth RP; Goëken LN; Kamps WA. Quality of life in bone tumor patients comparing limb salvage and amputation of the lower extremity. J Surg Oncol. 1992;51:47-51.

Tebbi CK; Petrilli AS; Richards ME. Adjustment to amputation among adolescent oncology patients. Am J Pediatr Hematol Oncol. 1989;11:276-80.

Tyc VL. Psychosocial adaptation of children and adolescents with limb deficiencies: a review. Clin Psychol Rev. 1992;12:275-91.

Sugarbaker PH; Barofsky I; Rosenberg SA; Gianola FJ. Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery. 1982;91:17-23.

Frances JM; Morris CD; Arkader A; Nikolic ZG; Healey JH. What is quality of life in children with bone sarcoma?Clin Orthop Relat Res. 2007;459:34-9.

Stanitski DF. Limb-length inequality: assessment and treatment options. J Am Acad Orthop Surg. 1999;7:143-53.

González-Herranz P; Burgos-Flores J; Ocete-Guzmán JG; López-Mondejar JA; Amaya S. The management of limb-length discrepancies in children after treatment of osteosarcoma and Ewing's sarcoma. J Pediatr Orthop. 1995;15:561-5.

Paley D; Bhave A; Herzenberg JE; Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82:1432-46.

Grimer RJ; Carter SR; Pynsent PB. The cost-effectiveness of limb salvage for bone tumours. J Bone Joint Surg Br. 1997;79:558-61.

Topics

bone neoplasms ; femur ; limb salvage ; prosthesis implantation ; tibia ; leg ; expandable prosthesis

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Outcome of Lower-Limb Preservation with an Expandable Endoprosthesis After Bone Tumor Resection in Children'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Outcome of Lower-Limb Preservation with an Expandable Endoprosthesis After Bone Tumor Resection in Children'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Eric R. Henderson, Andrew M. Pepper, German Marulanda, Odion T. Binitie, David Cheong, G. Douglas Letson; Outcome of Lower-Limb Preservation with an Expandable Endoprosthesis After Bone Tumor Resection in Children. The Journal of Bone & Joint Surgery. 2012 Mar;94(6):537-547.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment