Paget's sarcoma: limb salvage by custom mega prosthesis: four case reports

Of 4 Paget's sarcoma patients (age range, 55-68 years) underwent limb salvage surgery by custom mega prosthesis, 3 had lesions in the upper extremity and one in the proximal femur. Three of the patients were at stage IIB of the disease, according to Enneking's system of staging musculoskeletal tumours. All 4 patients underwent wide resection with a mean length of 152.5 mm. The defects were reconstructed with custom-made prostheses: proximal humeral prostheses in 2 of the patients, total elbow prosthesis in one, and total hip prosthesis in one. During a mean postoperative follow-up period of 40 months, one died of disseminated disease 14 months after surgery; one remained disease-free; 2 had local recurrence and required amputation, of whom one died of disseminated disease one year after amputation, the other had no further evidence of the disease. We report the functional outcomes of the 2 patients who were alive at the latest follow-up. The 2-year patient survival rate was 50%.     

Leg-length inequality in children treated by Syme's amputation

We have reviewed the results of amputation through the ankle in the management of 37 children with congenital leg-length discrepancy, followed up for a mean of 7.6 years after operation. In general good function was achieved and 18 patients considered their activities to be unrestricted. The main factor affecting the functional result was the underlying condition for which operation had been performed. Although heel pad migration, scar rotation and os calcis remnants were seen, these could be accommodated by the prosthesis. Syme's amputation is tolerated well in the younger child and, in patients with a predicted leg-length discrepancy of over 15 cm associated with an abnormal foot, we recommend the operation as a primary procedure between the ages of 18 months and two years.     

Through-knee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation

During a 10-year period 104 patients (mean age 72 years) had 106 through-knee amputations. Indications for surgery were: limb gangrene, 67 (64 per cent); ischaemic ulceration, 22 (21 per cent); rest pain, 9; knee contractures, 6. Thirty patients had had previous unsuccessful vascular reconstructive surgery and five had had a failed femoral embolectomy. The through-knee disarticulation used lateral skin flaps. The mortality was 21 (20 per cent). Of the 83 survivors, 59 (71 per cent) underwent uncomplicated primary wound healing; 36 (43 per cent) of the survivors were unsuitable for rehabilitation on a prosthesis. The remaining 47 (57 per cent) were walking before discharge 30-130 days (mean 68 days) after amputation. Through-knee amputation is a rapid, relatively bloodless, amputation and is a useful debridement procedure. The many surgical and functional advantages, in conjunction with the recent reports of better rehabilitation compared with the above-knee or Gritti-Stokes amputation, suggests that the through-knee amputation deserves greater consideration.     

Tikhoff-Linberg procedure for bone and soft tissue tumors of the shoulder girdle

OBJECTIVE: To evaluate complications and the oncological and intermediate-term functional results in patients with bone and soft tissue tumors of the shoulder girdle who were managed with interscapulothoracic resection (Tikhoff-Linberg procedure). DESIGN: Case series of 19 consecutive patients during a 10-year period at a mean follow-up of 6.3 years (range, 1-11 years). SETTING: University hospital; referral center for musculoskeletal tumor surgery. PATIENTS: The initial diagnosis in this consecutive series of patients with shoulder girdle tumors requiring the Tikhoff-Linberg procedure was chondrosarcoma in 7 patients, Ewing sarcoma in 3 patients, malignant fibrous histiocytoma in 3 patients, solitary metastasis of thyroid carcinoma in 2 patients, osteosarcoma, synovial sarcoma, angiosarcoma, ancd neurofibrosarcoma in 1 patient each. According to the Musculoskeletal Tumor Society staging system, there were 6 in surgical stage IB, 10 in stage IIB, and 3 in stage III. Nine tumors involved the proximal humerus, 8 were located in the scapula or surrounding soft tissues, 1 in the lateral clavicle, and 1 in the acromioclavicular joint. INTERVENTIONS: For reconstruction of the proximal humerus after en bloc tumor resection an isoelastic cemented shoulder tumor prosthesis was inserted in every patient to restore arm length. MAIN OUTCOME MEASURES: Complications, and oncological and intermediate-term functional results. RESULTS: Twelve patients were alive with no evidence of disease. One of these patients died of nontumorous disease 2 years after surgery. One patient is alive with pulmonary metastases after 12 months. Six patients died of metastases at a mean (SD) interval of 18 months (range, 3-35 months) postoperatively. Two of these patients had additional local recurrence. A deep infection necessitated the explantation of the prosthesis in 1 patient. The mean functional score and SD according to the rating system of the Musculoskeletal Tumor Society was 72%+/-14% (range, 33%-87%) for the 12 surviving patients evaluated. Major complications (1 infection and 2 local recurrences) that may be attributed to the procedure occurred in 3 of the 19 patients. CONCLUSION: Despite an overall complication rate of 74% the Tikhoff-Linberg procedure proved to be a valuable surgical procedure for extended tumors of the shoulder girdle for functional and oncological outcome and is superior to forequarter amputation.     

膝周围恶性肿瘤的保肢手术治疗

目的为膝周围恶性肿瘤保留肢体寻求更好的治疗方法和较理想的效果。方法1989年1月～2001年12月对42例膝周围恶性肿瘤行保肢手术治疗，37例获随访。其中男19例，女18例。年龄12～46岁。经病理检查证实为骨肉瘤11例，滑膜肉瘤4例，恶性纤维组织细胞瘤3例，骨巨细胞瘤19例。除骨巨细胞瘤外，余18例术前均行1～2个疗程的新辅助化疗。行假体置换术、异体骨块移植术、骨水泥阿霉素充填术等，术后辅以化疗。术后参照Enneking肢体肌肉骨骼肿瘤外科治疗重建术后功能评估标准进行评价。结果37例获随访3～11年，平均5．6年。2例分别于术后3、4年肿瘤复发远处转移死亡；1例因肿瘤局部复发而行截肢术；1例因术前放疗，保肢术后伤口发生坏死并感染而行截肢术；2例对异体大块骨移植产生排斥反应致伤口窦道形成而行截肢手术。31例伤口愈合良好，按Enneking肢体肌肉骨骼肿瘤外科治疗重建术后功能评估标准进行评定，优7例，良14例，中10例，差6例。结论膝周围恶性肿瘤的早期诊断、手术适应证的掌握、手术方法的选择以及手术前后的化疗或放疗是达到理想疗效的关键。     

肿瘤型人工关节重建下肢骨肉瘤切除后的骨缺损

目的总结应用肿瘤型人工关节重建下肢骨肉瘤切除后骨缺损的效果及并发症。方法1997年7月~2004年7月共对167例下肢骨肉瘤实施广泛性切除后人工假体重建保肢术,100例获得随访。其中男56例,女44例。年龄13~57岁。股骨近端5例,股骨远端57例,胫骨近端38例。Enneking分期A期3例,B期85例,期12例。使用国产假体71例,进口假体29例。17例患者采用灭活肿瘤骨结合人工假体复合重建缺损,21例采用异体骨人工关节复合体,余62例采用人工假体进行重建。所有成骨肉瘤患者术前均行1~2个疗程规范化疗,术后3~5个疗程化疗。术后采用MSTS保肢评分系统对随访患者进行功能评价。结果所有患者获随访1~8年,中位随访时间3.5年。人工关节3年生存率为81.8%,5年生存率为65%。6例假体折断,13例假体迟发性感染,2例假体松动,5例移植物与宿主骨接合处不愈合,2例异体骨吸收,2例假体下沉,1例骨折。7例于术后6个月~2年内肿瘤局部复发,其中软组织肿瘤复发4例,接受肿瘤再切除治疗;另3例接受截肢手术。患者MSTS评分平均为23.30±5.17。肢体功能优62例,良27例,中7例,差4例,优良率为89%。结论与其他保肢重建方法比较,肿瘤型人工关节能保留最好的关节功能。但并发症发生率仍较高,人工关节的设计及加工有待于进一步改进。     

儿童股骨远端骨肉瘤保留骨骺的定制肿瘤型假体重建术

 目的 介绍儿童股骨远端骨肉瘤保留骨骺的定制肿瘤型假体重建术,并探讨其工作原理、手术操作技巧、早期临床疗效以及并发症的防治。方法 2012年8月至2013年7月期间,应用肿瘤瘤段骨切除、保留骨骺的定制肿瘤型假体重建术治疗股骨远端骨肉瘤的儿童患者3例,均为男性,年龄8岁、9岁和15岁。术前给予新辅助化疗1~2周期,化疗结束后根据X线、CT 和MR等检查结果评价化疗疗效,对于化疗效果好且符合保留骨骺手术条件者采用此术式治疗。首先通过CT、MRI确定病变范围,根据影像学检查结果利用计算机辅助定制保留骨骺的肿瘤型假体以及模具,待假体定制完毕后行肿瘤瘤段骨切除、保留骨骺的定制肿瘤型假体重建术,术后指导患者进行功能锻炼,切口愈合1周后给予术后的规范化化疗,并进行长期随访。 结果 3例患者手术时间分别为3 h、4 h和6 h,术中出血量分别为300 ml、500 ml和2 200 ml。对3例患者术后随访时间 为12~24个月,根据美国骨肿瘤学会评分系统（Musculoskeletal Tumor Society,MSTS）,术后3个月功能评分分别为24分、26分和13分,短期随访显示患者肢体功能良好。1例患者出现假体感染,经保守治疗（抗炎补液、切口换药等）无效后行大腿截肢术,余2例患者未出现假体松动等其他并发症。2例患者双下肢长度相差均< 2 cm。结论 通过严格掌握保留骨骺保肢手术的适应证,配合术前及术后的新辅助化疗,保留骨骺的定制肿瘤型假体重建术为儿童股骨远端骨肉瘤的保肢治疗提供了新的选择方案,其疗效安全、可靠,且具有手术操作简单、手术时间短、术后恢复快等优点,但长期疗效尚需进一步观察。     

The value of stump split skin grafting following amputation for trauma in adult upper and lower limb amputees

One hundred and twenty adult patients were reviewed in whom split skin grafts were applied to the stump following traumatic amputation of the upper limb (44 amputees) or lower limb (76 amputees). The average follow-up period was seven and a half years after initial amputation. There was delay in prosthetic fitting in all patients. Approximately one third of patients complained of occasional minor ulceration, controlled by removing the prosthesis for a few days or modification of the prosthesis. Further revision surgery, including excision of the grafted skin often combined with proximal bone resection, but not removal of the proximal joint, was necessary in 29% of below-elbow amputees and approximately 50% of below and above-knee amputees. At the above-elbow level, use of skin grafts allowed prosthetic fitting because of preservation of sufficient length of the stump. Despite the fact that revision surgery may often be necessary, split skin grafting has a definite place in the early management of the stump following traumatic limb amputation in the adult. Preservation of stump length with the knee or elbow joint allows easier rehabilitation and lower energy expenditure when using the prosthesis. Partial foot amputation, when combined with skin grafting usually requires subsequent revision to a more proximal level to obtain a satisfactory result.     

Syme amputation in heel defects

The main advantage of Syme's amputation is the end-bearing stump. A defective heel pad often leads to below-knee amputation. The question of interest is whether an atypical cutaneous flap also provides a covering for the stump adaptable to weight-bearing. Thirteen patients with heel pad ulcers or tumors who could not be attended to with a classic Syme's amputation were operated on in a modified fashion. Skin from the dorsum of the foot or a medial flap was used for covering the stump. Two patients underwent transtibial amputation. The remaining 11 patients received a covering for the end of the stump composed of tissue thick and bulky enough for weight-bearing in a prosthesis typical for a Syme stump. The results show that a transtibial amputation can be prevented by atypical soft-tissue coverage of a Syme stump with satisfactory results regarding function and cosmetics.     

Syme's amputation in adults: a long-term review

A retrospective study was undertaken in two patient populations to establish the failure rate of Syme's amputation. Failure was defined as an amputation requiring revision to a more proximal level. For traumatic lesions of the foot the failure rate was 29% and for dysvascular lesions it was 41%. The long-term functional results in 55 patients who underwent Syme's amputation for traumatic, dysvascular or congenital lesions were studied. Overall, 73% had good function. The ideal Syme's stump, where the fat pad is centred securely over the distal tibia, was noted in only 22% of patients. The authors conclude that, in the past, technical details may have been overemphasized, because in this study the functional results of Syme's amputation were more dependent on prosthetic fitting. This type of amputation is not recommended for patients with dysvascular lesions because of the high failure rate.     

Lower limb proximal amputation for a tumour: a retrospective study of 12 patients

OBJECTIVE: To analyse survival, prosthetic fitting and functional status after trans-femoral amputation or hip disarticulation for a primitive tumour. METHODS: Retrospective study of all patients admitted since 1985. RESULTS: Mean age at amputation was 55. Causes of amputation were osteosarcoma in 50%. Eight (8) patients had initial conservative surgery. Local recurrence was never observed. Nine (9) developed metastasis and required further hospitalisation. Fifty percent (50%) of patients died. Inpatient rehabilitation started 14 days after amputation (7-27), and was of a mean duration of 32 days. Prosthetic fitting was performed 13 days after admission (7 days when a liner was used). Further improvement of the prosthesis was performed in 10 patients. Among the patients who died, 5 had gone home, 4 were wearing their prosthesis all day long and 2 walked indoors with no additional support at discharge. Three (3) patients lived less than 2 months at home. Among the patients who did survive, all went home, 5 were wearing their prosthesis all day long and 2 walked indoors without aid at discharge. Two (2) patients practised sport and 4 drove. All the patients who were active have gone back to work. CONCLUSIONS: Gain due to prosthesis provision is undebatable. Good functional results can be obtained with adapted materials. Initial problems due to the synchronisation of treatments are resolved with multidisciplinary care. All patients should have a rapid and short hospitalisation in a rehabilitation unit and receive a first, simple prosthesis that can be further adapted.     

Major amputation in a defined population: incidence, mortality and results of treatment

Medical records of all patients, from a defined population of 88,000 inhabitants, who underwent major lower limb amputation during 1980-82 were retrospectively scrutinized. The records showed 131 amputations were performed in 106 patients at the district hospital and 22 amputations on 17 patients at the local university hospital, referral centre, altogether 57 men and 66 women. This gave an amputation incidence of 46 per 10(5) inhabitants per year. Of the amputees 47 per cent were older than 80 years. Only two patients underwent reconstructive vascular surgery (at the university hospital) before surgery. Final amputation level was above-knee in 61 per cent of the patients treated at the district hospital. Mortality rates at 30 days and 2 years after the amputation were 23 and 56 per cent, respectively, and the age-corrected survival after 2 years was 55 per cent. For patients who came from and eventually returned to their own homes the mean hospital stay amounted to 184 days (postoperative deaths excluded). After amputation 26 patients were trained to wear a prosthesis and 16 of these used the prosthesis 2 years after amputation. The present study underlines the need for prospective and parallel studies of vascular surgery and amputation as well as analyses of the risk factors involved in lower limb ischaemia in defined populations.     

人工全膝关节置换术后感染的治疗

目的：探讨人工全膝关节置换术后感染的治疗方法及效果。方法：6例TKA术后感染患者。感染发生时间为TKA术后1个月－11年,2例为早期感染,4例迟发性感染,平均4年2月。其中骨关节炎4例,类风湿性关节炎2例。单纯清创、抗感染治疗3例;清创、一期假体再置术1例;清创、二期假体再置换术1例;关节融合术1例。结果：在3例单纯清创、抗感染治疗中,1例经5次清创后痊愈,1例2次清创后感染未控制,改行关节融合术,1例3次清创,感染未愈;2例关节再置换术病例痊愈,功能恢复满意;2例关节融合术后痊愈。所有病例平均随访4年,除1例失去随访外,其余感染均未复发。结论：对全膝关节置换术后感染可行的治疗包括：单纯清创、抗感染治疗;清创、一期或二期假体再置换术;关节融合术等方法。每种方法都有其适应证,应根据患者的具体病情采用合适的治疗方法。     

Kotz modular femur and tibia replacement: 28 tumor cases followed for 3 (1-8) years

In the period 1984-1991, 33 lower limb reconstructions were performed with an uncemented Kotz modular femur tibia reconstruction (KMFTR) prosthesis after resection of 32 malignant bone tumors and 1 benign giant cell tumor. Tumor localization was proximal femur in 12, distal femur in 17, and proximal tibia in 4. The mean age of the patients was 38 years. 28 patients with a minimum follow-up of 1 year were studied after 3 (1-8) years. 7 patients were reoperated because of complications. Good or excellent results were obtained in 6 of the 10 proximal and 13 of the 14 distal femur reconstructions. In 2 of the 4 patients undergoing combined distal femur and proximal tibia resection, a deep infection developed, and above-knee amputation was performed. One local recurrence occurred after proximal femur resection.     

Outcome of infected total knee arthroplasty

The results of 44 cases of deep infection after total knee arthroplasty were reviewed. The average age of the patients was 62 years (range, 31–81 years), and all had positive bacterial cultures from deep aspiration or tissue biopsy. Osteitis was revealed in 22 cases. One case was initially treated with antibiotics only, 27 cases were treated with surgical debridement and antibiotics, and 16 cases had immediate removal of the prosthesis. In 21 cases, failed debridement was followed by removal of the prosthesis. Revision arthroplasty was attempted in 15 of the 37 cases in which the prosthesis was removed; the infection was cured in 11 cases. A total of 25 cases that underwent removal of the prosthesis had an arthrodesis performed, and 4 ultimately underwent amputation. In no case of osteitis was the infection cured merely by dedridement and antibiotics, and the index prostheses were retained mainly in cases in which osteitis did not develop.     

Rehabilitation of the bilateral amputee

One hundred sixteen patients with bilateral amputation as a result of severe ischemia were reviewed to evaluate their rehabilitation potential. Seventy patients were male and 46 were female; ages ranged from 31 to 92 years (mean 68 years). The operative mortality rate after the second amputation was 9.5% (11 of 116 patients). The time from the first to second amputation ranged from zero to 144 months (mean 23 months). Follow-up from 1 to 14 years was available on all patients. Sixty percent of the patients surviving the postoperative period were alive at 2 years and 40% at 5 years. Of the 105 patients available for follow-up, only 27 (26%) were able to use bilateral prostheses. Twenty-three (85%) of these patients were ambulatory after their first amputation. Four patients not walking after their first amputation became ambulatory after their second. All four had bilateral below-knee amputations. Of the 78 patients unable to use a bilateral prosthesis, 68 (87%) were able to function independently and 10 became bedridden. Successful prosthetic rehabilitation in the bilateral amputee appears primarily dependent on the use of a prosthesis after the first amputation. The acceptable long-term survival and the number of patients who became independent in their activities justify an aggressive approach to the rehabilitation of the bilateral amputee.     

Primary survival and prosthetic fitting of lower limb amputees

During the period 1984-1985 amputation of the lower limb at a level potentially requiring a prosthesis was performed on 577 patients in 16 operative units. The mean age was 75.7 years for females and 68.1 for males. The most common site of the amputation was above the knee (49.9%). The majority of amputations (93.8%) were performed for vascular diseases and diabetes. Survival figures showed that 25.5% of amputees died within 2 months of amputation, 60.7% were alive after one year and 43.2% after two years. Out of a total of 577 patients, 26.9% were fitted with a prosthesis. Out of below-knee and above-knee amputees surviving over 2 months, 61.5% and 27.2% respectively were fitted with a prosthesis. There were markedly fewer prosthetic fittings in the over-60 age group. Diabetic patients of both sexes were fitted with a prosthesis more often than arterio-sclerotic patients. Among tumour patients 82.4% received a prosthesis. In the study area more emphasis must be put on the concept of preserving the knee joint and preoperative assessment of vascular patients for selection of amputation level. Every effort must be made to avoid delay in the postoperative mobilization and rehabilitation. Prosthetic fitting of amputees could be improved by better liaison between surgical unit and specialized rehabilitation unit and by closer team approach of amputee care.     

Function of children with myelodysplasia and lower extremity amputations

This is a retrospective study of the functional status of children who underwent a lower extremity amputation for complications of myelodysplasia. With a computerized surgical database, 12 children with myelodysplasia who underwent an amputation at the Boyd level or above at a single children's referral hospital between 1983 and 2001 were identified. Four patients could not be contacted, but the remaining 8 patients were evaluated through chart review and interview to assess the impact of the amputation on their function. With a mean follow-up time of 9 years (range, 5-15 years), all 6 of the patients with a below-knee or Boyd amputation continued to ambulate using a prosthesis. Most patients occasionally reported having ulcers on their residual limb, but these cases were easily managed and did not result in amputation revisions.The only patient in this series with an above-knee amputation and the only patient with a knee disarticulation were exclusively wheelchair ambulators and no longer owned a prosthesis. This study supports the notion that children with myelodysplasia can have amputations and successfully wear a prosthesis to maintain their ambulation.     

Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions

This article reports an analysis of 75 consecutive lower limb amputees who developed painful neuroma requiring surgical excision after lower limb amputation following landmine explosions. This retrospective study analyses the results of 75 patients who were treated for painful neuroma after lower limb amputation following landmine explosions between the years 2000 and 2006. The average time period from use of prosthesis to start of symptoms suggesting neuroma was 9.6 months. The average time period from start of pain symptoms to neuroma surgery was 7.8 months. All clinically proven neuromas were surgically resected. In the mean follow-up of 2.8 years, all patients were satisfied with the end results and all were free of any pain symptoms. Painful stump with clinical diagnostic findings of neuroma described above may be regarded as neuroma without requiring any further imaging modalities and is an indication for surgery if conservative measures fail.     

A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease

BACKGROUND: Through-knee amputation provides a longer lever arm and improved muscle control of the limb compared with above-knee amputation. Through-knee amputation also allows use of a total end-bearing prosthesis, which avoids the ischial pressure and suspension belts required of the above-knee amputation prosthesis. Several reports in the European literature tout the superiority of the through-knee amputation over the above-knee amputation in the patient with vascular disease. Through-knee amputation has received little attention in the United States, however, owing to the belief that the long flaps necessary to close a standard through-knee amputation are associated with an unacceptable rate of wound problems and offer no functional ambulatory advantage to above-knee amputation. We reviewed our experience with a modified technique of through-knee amputation in a group of patients with severe lower extremity ischemia who were not candidates for below-knee amputation to determine the incidence of wound complications and their functional outcome. METHODS: Since 1996, 12 patients with severe lower extremity arterial insufficiency have undergone through-knee amputation utilizing a technique designed to limit flap length and facilitate the fit of a suction prosthesis. Two patients died of myocardial infarction in the immediate postoperative period and were excluded from the study. In the remaining 10 patients (1 man, 9 women; mean age 63 years (range 40 to 86), the below-knee amputation level was precluded because of gangrene or nonhealing wounds of the mid leg in 5 patients, failure of a previous below-knee amputation attempt in 4 patients, and severe ischemia that would compromise below-knee amputation healing in 1 patient. Nine patients had at least one failed vascular reconstruction procedure. RESULTS: Mean follow-up is 25 months (range 6 to 41). Six (60%) patients had primary healing of their amputations. Two (20%) patients had delayed healing (6 weeks and 8 weeks). Two (20%) patients developed wound infections, which required amputation revision to the above-knee level. Seven (70%) patients were fitted with a suction socket prosthesis and are fully ambulatory. One patient healed but has not ambulated because of ischemia and subsequent ulceration of the contralateral limb. CONCLUSIONS: These data show that through-knee amputation is associated with an acceptable primary healing rate (80%) and satisfactory functional outcomes (70% ambulation) in a high-risk vascular population. The functional advantages of through-knee amputation over above-knee amputation make it the preferred alternative for patients with vascular disease.