Transcript Diapositiva 1

12th Annual CTOS Meeting 2006
POST-OPERATIVE INFECTION AND INCREASED PATIENT
SURVIVAL IN OSTEOSARCOMA : IS THERE A LINK?
Lee Jeys, Rob Grimer, Simon Carter, Roger Tillman, Seggy Abudu, ROH, Birmingham, UK
• Several known prognostic factors for osteosarcoma
• Lascelles showed increased survival in dogs with postoperative infection
• Between 1966 & 2001 a consecutive series of 1264
patients underwent reconstruction for bone tumours
• Reconstructions for metastases and benign excluded
• Landmark analysis
– Infections after 12 months excluded
– Patients dying with 12 months excluded
– Left 868 patients in study group
12th Annual CTOS Meeting 2006
• 89/868 patients (10.3%) endured a deep infection within
12 months of EPR implantation
• For osteosarcoma 10 year survival with no infection =
53.6% but with infection = 73.5% (p = 0.017).
• Only significant with the diagnosis of osteosarcoma
• Independent prognostic factor on cox regression analysis
with other known factors with a HR=0.25
• No difference in percentage necrosis between groups,
therefore, not due to more effective chemotherapy
• Coley’s toxins (Streptococcus & Klebsiella) used
historically
• Supporting evidence for other tumours
12th Annual CTOS Meeting 2006
12th Annual CTOS Meeting 2006
• 89/868 patients (10.3%) endured a deep infection within
12 months of EPR implantation
• For osteosarcoma 10 year survival with no infection =
53.6% but with infection = 73.5% (p = 0.017).
• Only significant with the diagnosis of osteosarcoma
• Independent prognostic factor on cox regression analysis
with other known factors with a HR=0.25
• No difference in percentage necrosis between groups,
therefore, not due to more effective chemotherapy
• Coley’s toxins (Streptococcus & Klebsiella) used
historically
• Supporting evidence for other tumours
12th Annual CTOS Meeting 2006
Determinants of Local Recurrence in Patients Undergoing Limb
Sparing Surgery for Osteosarcoma of the Proximal Humerus
Patrick Lin, Giri Gupta, Valerae Lewis, Christopher Cannon, Alan Yasko, UofTexas MDACC
• Aim
– Determine factors affecting local
recurrence at proximal humerus
• Preservation of deltoid muscle
• Background
– Routine resection of deltoid
muscle has been advocated by
some authors
– Loss of deltoid could result in
significant functional deficit,
especially with newer forms of
shoulder reconstruction
• Reverse shoulder prosthesis
• Allograft-prosthetic composite
• Methods
– 26 patients
• stage IIA or IIB OSA
• 12 females, 14 males
• Mean 19 yrs (range 7-47)
– Treatment
• Pre-op: DOX + IA-CDDP x 4
• Limb-sparing surgery
• Post-op chemotherapy
based upon tumor necrosis
12th Annual CTOS Meeting 2006
Local Recurrence in Osteosarcoma of the Proximal Humerus
•
Results
– 3/26 patients (11.5%) developed LR
– 2 in sub-deltoid area
• Tumor necrosis 50% & 70%
• Both patients developed Mets & LR
• Both patients died
– 1 adjacent to chest wall (not sub-deltoid)
– Pathologic fracture
– 92% tumor necrosis
– Alive 8 years after excision of LR
•
Conclusions
– Local recurrence may depend on several
factors, including margins, response to
chemotherapy, and pathologic fracture
– Routine resection of the deltoid muscle does
not appear to be warranted
12th Annual CTOS Meeting 2006
Radiation Induced Pathologic Fractures After Surgery
for Soft Tissue Sarcomas
Kevan Saidi, Anthony Griffin, Peter Ferguson, Robert Bell, Jay Wunder, Mount Sinai Hospital, Toronto
Aim of Study:
• Determine healing rates of radiation induced fractures
• Determine results of surgical management
• Fracture Fixation vs Endoprosthetic Replacement
Background:
• Previous studies established risk factors for fracture
• Helmstedter (CORR 2001) - prophylactic IM nail with periosteal stripping
• Lin (CORR 1998) - Consider primary arthroplasty in proximal & distal femur
Methods:
• Retrospective review 1986 to present
• 32 patients with 34 fractures (2 acetabular fractures - 1o THA)
12th Annual CTOS Meeting 2006
Radiation Induced Pathologic Fractures After Surgery for Soft Tissue Sarcomas
Results:
11 of 34 Fractures Healed (32%)
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Femur: 25% (3/12) proximal 12% (1/8) diaphysis 50% (1/2) distal healed
Tibia: 100% (2/2) proximal
33% (1/3) diaphysis
Others: 60% (3/5) patella, metatarsals
•
•
5/16 (31%) healed after periosteal stripping
4/9 (44%) Men & 7/23 (30%) Women Healed
•
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2/8 (25%) healed after 50 Gy
9/24 (38%) healed after 66 Gy
•
Risk Factors For Fracture (Holt, JBJS 2005):
4.5 yrs
5 yrs
• Females > 50, High Dose Radiation (60 or 66 Gy), Proximal 2/3 Femur
OR x 2
Conclusion:
• Fractures of the proximal 2/3 of the femur and the tibia diaphysis are at
high risk of non-union
• Primary endoprosthetic replacement should be considered when treating
pathologic radiation induced fractures of the proximal femur
12th Annual CTOS Meeting 2006
EXTRACORPOREALLY IRRADIATED
AUTOGRAFTS IN LIMB SALVAGE SURGERY
How it can solve difficult reconstruction problems
Hazem Wafa, MD; Robert Grimer, FRCS; Simon Carter, FRCS;
Roger Tillman, FRCS; Adesgun Abudu; FRCS (orth)
The Royal Orthopaedic Hospital, Birmingham, UK
12th Annual CTOS Meeting 2006
Aim of the study:
To evaluate the oncological and functional outcome of extracorporeally
irradiated autografts as a reconstructive technique in limb salvage surgery.
Material:
• 28 patients (17 females, 11 males).
• Median age 16 years (range 7-66).
• 11 Ewing’s sarcoma, 8 osteogenic sarcoma, 4 parosteal osteosarcoma,
3 chondrosarcoma, 1 angiosarcoma, and 1 adamantinoma.
• 14 pelvis, 6 tibia, 3 humerus, 2 scapula, 1 femur, 1 ulna, 1 metacarpal
Methods:
• Wide en-bloc resection of the lesion.
• Removal of soft tissues and tumor off the excised bone segment.
• Wrap in two layers with Vancomycin and pack in a sealed box.
• Extracorporeal irradiation with 90 Gy (35 minutes).
• Reimplantation of the irradiated autograft.
• Primary hip replacement was used in 7 cases, pedicled vascularized fibular
graft in 4, PMMA in 2, and non-vascularized fibula in 1.
12th Annual CTOS Meeting 2006
Results:
• The average follow-up 33.9 months.
• 19 patients were alive (67.9%), 17 NED and 2 AWD.
• Local recurrence in 3 cases (10.7%), all occurred in the soft tissues.
• The average time to union was 7.7 months.
• Deep infection developed in 2 cases (7.1%) necessitating graft removal.
• Fracture of the graft occurred in 2 cases, graft resorption in 2, and
non-union at 2 sites.
• The mean MSTS functional score was 25.5 / 35
Conclusions:
• Extracorporeal irradiation and re-implantation of bone is an excellent
technique which can solve difficult reconstruction problems in appropriatel
selected patients.
• This technique does not carry an increased risk of local recurrence and
the overall results are comparable to other reconstructive techniques.