Rev. bras. ortop. vol.51 número5

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Functional

assessment

of

endoprosthesis

in

the

treatment

of

bone

tumors

夽

Denis

Kiyoshi

Fukumothi,

Hiran

Pupo,

Luciano

Augusto

Reganin

∗

_,

Silvia

Raquel

Fricke

Matte,

Bruno

Spagnuolo

de

Lima,

Carlos

Augusto

de

Mattos

PontifíciaUniversidadeCatólicadeCampinas(PUC-Campinas),HospitaleMaternidadeCelsoPierro,Servic¸odeOrtopediae Traumatologia,Campinas,SP,Brazil

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Articlehistory:

Received20October2015 Accepted7January2016 Availableonline30August2016

Keywords: Boneneoplasms

Reconstructivesurgicalprocedures Jointprosthesis

Limbsalvage

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Objectives: Evaluatethefunctionalgradeofthesepatientsandtoidentifythetypesof com-plicationsfoundthatinfluencedtheaveragelifespanofendoprosthesesthefunctionsof theoperatedlimb.

Methods:Weanalyzed14post-operativecasesofendoprosthesis,patientswithmalignant bonetumorsandaggressivebenignbonetumorssubmittedtosurgerybetween2004and 2014.TheevaluationsystemusedwasproposedbyEnneking,recommendedbythe Muscu-loskeletalTumorSociety(MSTS),inadditiontotheradiologicevaluation.

Results:Endoprosthesisareexcellentchoicesforthetreatmentofbonetumorswithlimb preservation inrelationtopain,strength, andpatient’s emotionalacceptance. Another factorforgoodresultsistheimmediateweight-bearingcapacity,generatingagreater inde-pendence.

Conclusion: Theauthorsconcludethatallpatientsclassifiedthetherapyasexcellent/good, regardlessofthetypeofprosthesisused,extentofinjury,and/ortypeoftumorresection performed.

Avaliac¸ão

funcional

das

endopróteses

no

tratamento

de

tumores

ósseos

Palavras-chave: Neoplasiasósseas Procedimentoscirúrgicos reconstrutivos

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e

s

u

m

o

Objetivo:Avaliarograufuncionaldessespacienteseidentificarostiposdecomplicac¸ões encontradasequeinfluenciaramnasobrevidadasendoprótesesenafunc¸ãodomembro operado.

Métodos:Foramanalisados14pós-operatóriosdeendoprótesesempacientesportadoresde tumoresósseosmalignosebenignosagressivoscomcirurgiaentre2004e2014.Osistema

夽

StudycarriedoutatthePontifíciaUniversidadeCatólicadeCampinas(PUC-Campinas),HospitaleMaternidadeCelsoPierro,Servic¸o deOrtopediaeTraumatologia,Campinas,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](L.A.Reganin). http://dx.doi.org/10.1016/j.rboe.2016.08.012

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Prótesearticular Salvamentodemembro

deavaliac¸ãofoiopropostoporEnneking,preconizadopelaMusculoskeletalTumorSociety (MSTS),alémdaavaliac¸ãoradiográfica.

Resultados: Asendoprótesessãoótimasopçõesnotratamentode tumoresósseoscom preservaçãodomembro,emrelaçãoàdor,forçaeaceitaçãoemocionaldopaciente.Outro fator parabonsresultados éa capacidadedesuportede pesoimediato,quegerauma independênciamaior.

Conclusão:Todosospacientesclassificaramaterapiacomoexcelente/boa,indiferentemente dotipodeprótese,extensãodalesão,tipodetumoreressecc¸ãofeita.

Introduction

Withadvancesinprotocolsandtreatmentofcancerpatients andconsequentincreaseinsurvival,thenumberofpatients with bone metastases has increased, as well as the inci-dence of complications.1–4 _One _of_the _{complications} _often foundinthesepatientsarepathologicalfractures,especiallyin thelowerlimbs,whichinvariablyaffectthemeta-epiphyseal regionoftheboneandrequiresjointreconstruction.Regarding primarybonetumors,thesehavealsohadbetteroutcomes afteruseofmultidrugtherapy,resultinginlimbsalvage pos-sibility;that,inmostcases,isonlyobtainedwithlargebony resections,leadingtotheneedforreconstructionofthisbone segment, which in most cases can be attained with non-conventionalendoprosthesis.

Metastatic bone disease is the most common bone

malignancy,1_primarily_affecting_the_axial_skeleton,_pelvis_and femur.5,6 _Metastatic_involvement_of_the_lower_limbs_is asso-ciatedwithagreater number ofpathologicalfractures and promotesincreasedmorbidity/mortalityduetoprolonged bedrest,increasedriskofpneumoniaandthromboembolic events.6_Under_these_{circumstances,}_replacement_of_the_bone segment can be attained with an endoprosthesis, which rapidlyrehabilitatesthispatient,whobecomesanambulatory patient.1,7–9

Regardingprimarybonetumors,osteosarcomaandEwing’s sarcoma,aswellasgiantcelltumors(GCT)ofthebone,also occurmoreofteninthelower limbs,withthedistalfemur andproximaltibiabeingthepreferredlocations,affectingthe jointregionwhileresultingintheneedforjointreplacement. Asintheupperlimbs,thesetumorsnotinfrequentlyaffect theproximalhumerus.2,7

For primarymalignant and aggressivebenign tumors, a wide resection to achieve necessary safety margin results in largebony resections and, therefore, the need for local reconstruction.8,10

Amongthe techniquesbased on limbsalvage principle, onethat has been recommended fortreating bone metas-tases in the lower limbs and the proximal humerus, due tobetterresponseandeffectiveness,islesionresectionand replacementoftheresectedsegmentbyanunconventional endoprosthesis,5,11,12_the_method_of_choice_in_our_service.

For malignant primary bone tumors (osteosarcoma,

Ewing’s sarcoma, chondrosarcoma) and aggressive benign tumors (Enneking’s B3) obtaining a broad or radical mar-gin invariably results in large meta-epiphyseal bone loss,

requiringbiologicalorprostheticreconstruction.13_Large_bone resectionsoccurringduringsurgicalrevisionsofconventional arthroplastiesareanotherconditionthatrequirestheuseof endoprostheses.

Insuchcases,thebiological reconstructionscanbe per-formed with autologous bone graft, free or vascularized, homologous graft (tissue bank) or other autograft meth-ods.Althoughmorenatural,biologicalreconstructionshows severelimitationsinmostcases.13

Prosthetic reconstructions are performed with non-conventionalendoprostheses,whichreplacebonesandjoints. Theyareofeasyaccess,providesanatomicalreconstructionof thelimb,functionallyandfast,resultinginearlyambulation recovery.However,theyalsohaveahighnumberof compli-cationswithinshort-andlong-termfollow-up.Postoperative complicationsofbonetumorresectionsandreplacementof the resected segment by an endoprosthesis are: infection, aseptic implant loosening, periprosthetic fracture, implant fractureandtumorrecurrence.1,7,14

Thesecomplicationscanberesponsibleforthefunctional impairmentoftheaffectedlimb,implantlossandeventhe amputationoftheaffectedlimb.

Thepurposeofthisstudyistoidentifythetypesof com-plicationsfoundthatinfluencedtheaveragelifespanofthe endoprostheses and function of the operated limb of our patients, according tothe functional analysisofthe MSTS. These datacanbeusedtoimprove implantmanufacturing and surgicaltechniques,astheimprovementoforthopedic implants and techniques usedin bonedefect replacement afterneoplasticresectioniscrucialtoachievegreater dura-bility,withfewercomplicationsand increasedfunctionality oftheoperatedlimb.5,12–15

Material

and

methods

Thisisaretrospectivestudywith14patientswithmalignant andaggressivebenign(Enneking’sB3)tumors,whorequired reconstructive surgerywithnon-conventional endoprosthe-sis.Patientswithincompletemedicalrecordsthatwouldnot allowassessmentandthosewhodiedorweretransferredto anotherservicebeforecompletingoneyearoffollow-upwere excluded.PatientswhodidnotsignanInformedConsentForm werealsoexcluded.

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Table1–Patientdata.

Patient Gender Age Surgery Site Primarytumor Amputation

1 M 41 2004 Knee GCT No

2 M 52 2008 Hip Chondrosarcoma No

3 F 61 2008 Knee Chondrosarcoma Yes

4 F 66 2008 Knee Chondrosarcoma No

5 M 58 2010 Knee Chondrosarcoma Yes

6 F 81 2011 Knee Metastasis No

7 F 28 2012 Knee GCT No

8 F 60 2013 Knee Metastasis–Breast No

9 F 74 2013 Knee Chondrosarcoma Yes

10 M 65 2014 Shoulder Chondrosarcoma No

11 F 56 2014 Hip Metastasis–Kidney No

12 M 19 2014 Knee EwingSarcoma No

13 F 49 2014 Knee MultipleMyeloma No

14 F 31 2014 Knee GCT No

Fig.1–Preoperativeradiographiesofoneofthestudy patients,diagnosedwithGCTintheleftdistalfemur.

locatedinthe shoulder, two (14%)inthe hip and 11 (78%) intheknee(Fig.1).Consideringtumortype,one(7%)wasa myeloma,one(7%)anEwing’stumor,three(21%)werebone metastasesandsix(42%)werechondrosarcomas.Allsurgeries

wereperformedbetween2004and2014(Fig.2).Threepatients underwent amputation due to late complications of the endoprosthesisprimaryprocedure.Thesedataareshownin Table1.

Functional assessment was performed according to the classification recommended by Enneking, adopted by the Musculoskeletal Tumor Society (MSTS), whose parameters aremobility,pain,function,emotionalacceptance,supports, walking,gait,rangeofmotion(ROM)andstrength.Each func-tionalassessmentparameterwasevaluatedwithsixscoring levels,withthehighestscorebeingfiveandthelowest,zero. Radiographicimagingwasalsoevaluatedregardingthe endo-prosthesisstability,asshowninTable2.

UsingtheRandExcelsoftwareprograms,theexploratory data analysiswas carried out with11 patients(threewere excludedfromthedataanalysisduetoamputation) submit-tedtoendoprosthesistreatment.Thisworkaimstoevaluate whethertheendoprosthesisisaneffectivetreatment.Using aQQplotofthemeanscores,theassumptionofnormalityof scoreswasconfirmed,thatis,asthepointsareclosetothe line,thet-testcanbeusedtocomparethemeansofthedata, asshowninTable3andFig.3.

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Table2–Questionnaireresults.

Patient Pain Function Emotionalacceptance Supports Walking Gait Strength ROM

1 3 5 4 6 5 4 6 2

2 6 5 6 2 4 3 6 5

3 – – – – – – – –

4 4 4 6 1 3 2 4 6

5 – – – – – – – –

6 6 2 6 2 3 2 6 3

7 6 5 4 6 6 4 6 5

8 6 2 6 1 2 2 6 6

9 – – – – – – – –

10 4 1 4 6 – – 0 0

11 4 3 5 1 3 2 6 4

12 5 5 4 6 5 5 6 4

13 4 3 2 3 4 3 6 5

14 3 3 6 6 6 2 6 2

–0.5 –1.0 –1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

0.0 Theoretical quantiles

Sample quantiles

1.5 1.0 0.5

Fig.3–Q–Qplotofthemeantotalscores.

Results

Thescorevalueforeachpatientmayvary fromeightto48 andthemeanvalueobtainedwas32.Halfofthepatientswho answeredthequestionnairehadascorebetween30and36. Thelowestobservedscorewas15andthehighestwas42.

Intheoverallanalysisoftheendoprosthesiseffectiveness andafterestablishingthatmeanscoreshigherthanthreeis consideredagoodresultandusingStudent’st-test (compari-sonofmeans)todeterminethemeanscores,apvalue=0.002 wasobtained,astatisticallysignificantresult.

Allvariableswerealsoanalyzedseparately,usingthesame Student’stmethod,consideringaresponsehigherthanthree asatisfactoryresult.Theresultsrangedfrom0.005pto0.8. Pain, emotional acceptance and strength were statistically

Table3–Meanoftotalscoresofquestionsperpatient.

Patient Meanofscores

1 4.375

2 4.625

4 3.75

6 3.75

7 5.25

8 3.875

10 1.875

11 3.5

12 5

13 3.75

14 4.25

significantandshowedapvalue<0.05.Asforfunction, sup-ports,walking,gaitandROM,theyallshowedapvalue>0.05. Regardingradiographies,allprostheseswerestable,with no apparentsigns ofloosening orinfection, exceptforthe patients who underwent amputation due to postoperative complications or tumor recurrence. All radiographies were performedinthesameservice.

Discussion

Thecurrentliteratureisscarceregardingfunctionalresults after limb salvage surgery inpatients with malignant and aggressive benign tumors, most likelydue to the rarity of primarybonetumors.Inrecentdecades,treatmentofbone tumors went through changes, since the previously pre-ferred treatment for most cases was amputation. In the beginningofthiscentury,limbsalvagesurgerybecame pre-dominantamongsurgeons,andamputationsbecomeonlyan option,orthetreatmentofcomplicationsafterlimbsalvage surgeries.15,16

InastudycarriedoutatCentroInfantilBoldrinipublished in2008,authorscomparedtwogroupsofpatientswithbone sarcomasinthedistalendofthefemur,onewithtotaland anotherwithpartialendoprostheses,therewasnoinfluence ontheoverallfunctionaloutcomeandastatistically signifi-cantdifferencewasobservedonlyregardingstability.17

In general, non-conventional endoprostheses are excel-lent devicesinthe reconstruction oflarge boneresections; however, theyhavemechanical limitations,which mustbe consideredbeforetheirindication.

Thisstudyagreeswiththecurrentliteratureandobtained thesameresults,showingthattheendoprosthesisisan excel-lentoptioninthetreatmentofbonetumorswithlimbsalvage, especiallyinrelationtopain,strengthandpatientemotional acceptance,accordingtotheresultsshowninTable4.During the interview, all patients emphasized emotional improve-mentaftersurgery,mainlyduetopainimprovement.Another factor thatcontributestothe goodresultsdemonstratedin this study is the immediate load-bearing capacity, which resultsingreaterpatientindependence.

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Table4–Resultsoftests,theirefficacyandrespective

p-value.

Resultsofthemeancomparisontest

Variable Effective p-Value

Pain Yes 0.001

Function No 0.150

Emotionalacceptance Yes 0.005

Supports No 0.200

Walking No 0.100

Gait No 0.800

Strength Yes 0.001

ROM No 0.090

Total Yes 0.002

resectionduringsurgery.Thislossofmusclemassalso wors-ensambulationcapacityandincreasestheneedforassistance duringgait.Asaconsequenceoflimbdeterioration,limb func-tionbecomeslimited,whichagaindemonstratestheresults showninthisstudy.

Conclusion

Allpatientsclassifiedthetherapyasexcellent/good, regard-lessoftheprosthesistype,lesionextension,tumortypeand resectionperformed.

Mostpatientswithbonetumorswithlimbsalvage indi-cationhadalifeprognosisbelowthatfoundinthegeneral population,so theearlyreturn toeverydayactivities, inde-pendenceandambulationcapacityarethetreatmentgoals, makingendoprosthesisaviableandeffectiveoptionforthese patients.

Despitethelimitedstudysample,theresultsobtainedfrom the questionnairesupportthe current literature.Giventhe limitationofpatientsthatareadequateforthissampleand thefactthatitisacurrentissue,webelievethatthe endo-prosthesisiscurrentlyanexcellentchoice.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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