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My Child Has:
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Bone Tumors: Surgical Treatment Options
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Tumors of the distal (lower end) femur destroy the bone near the knee and the tumor may spread to the adjacent muscle (quadriceps), blood vessels (femoral and popliteal artery and vein) and nerves (sciatic, tibial and peroneal). The tumor may extend into the knee joint in very aggressive lesions.
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Amputation through the upper thigh (above knee amputation) is the standard means of treating distal femoral osteosarcomas. A cast is applied in the operating room which permits a temporary artificial leg (prosthesis)to be applied during the first few post-operative days for walking. Crutches are used for several weeks. As the swelling decreases (10 to 14 days) the patient is fitted for a plastic, temporary socket and prosthesis, which is used for 3 to 4 months until the stump is healed sufficiently to accept a permanent artificial leg.
The advantages of an amputation are that it is a simple operation with minimal chances of surgical complication and it definitively removes the local tumor. The functional outcome is good with the modern prostheses available today and with "immediate-fit" prostheses applied in the operating room. Although the patient will probably have a limp with above-the-knee amputations, the procedure is functional and stable. He/she will be able to walk, climb stairs, swim (with the prosthesis on or off) and participate in many sports such as skiing, basketball, baseball, and tennis although running will be limited. The functional limitations are left to the imagination and determination of the patient.
The average hospital stay for an amputation is about 7 to 10 days. In the lower limb, ambulation with a physical therapist begins on the second postoperative day and a temporary prosthesis is fitted at 10 to 14 days. The stump will need to be "shrunk" by wrapping it with elastic bandage ace wraps to diminish the amount of edema (swelling). There are a variety of upper and lower extremity prostheses from which to choose,depending upon the particular needs of the patient, and they are usually fit within 3 to 6 months after the amputation if the swelling has resolved sufficiently. Patients with lower extremity amputations require the use of crutches for about 3 to 6 months.
There are disadvantages to having an amputation. No one wants to lose a limb if it can be prevented. The emotional adjustment resulting from the loss of a limb and the associated change in body image can be difficult. It takes time and patience to become accustomed to using a prosthesis which must, in lower limb amputees, be used for any walking activities(including going to the bathroom at night). Some amputees have the sensation that the hand or foot is still present ("phantom pain"). The severity and duration of "phantom pain" depends on the individual and it is often treated successfully with medications until it resolves completely. The sensation may be intermittently painful soon after the operation but this discomfort usually subsides in a few weeks.
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There are many alternative techniques to reconstruct a leg following surgical removal of the tumor. Each procedure has its own particular advantages, disadvantages and indications for a given patient or situation. It should be remembered that the primary goal is to completely and safely remove the tumor. An amputation may be necessary following any of these procedures if there is evidence of residual tumor after the surgery.
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At times, the preoperative x-ray studies will show that it is possible to remove the tumor and save the upper end of the tibia and enough of the quadriceps muscle to make knee extension (straightening) possible. In this case, the lower end of the femur can be replaced by a bone transplant with a joint surface (osteoarticular allograft). The bones are joined by metal plates and screws, or a rod, and the patient's muscles and joint ligaments are reattached to the transplant to form a working joint.
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There is a variation on this theme: if the joint cannot be safely preserved, allograft can be used to replace the bone in conjunction with an artificial (metal and plastic) knee joint. The expected function of each of these reconstructions is about the same.
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The advantages of these limb-sparing procedures are that nearly normal anatomy is restored while knee motion is preserved (although usually not completely) and normal walking and stair climbing is possible. The appearance is almost normal except for some muscle loss and a long scar. Some participation in non-contact sports is usually possible after the graft has healed. For the bone transplants, crutches and a cast or special brace are used for 6 to 12 months until the transplant has healed adequately and the joint is stable. The brace has plastic and metal parts and is held in place with velcro straps.
The disadvantages to these resection procedures are related to the complexity of the operative procedure. They are very difficult surgical procedures and there is a possibility of injury to a major blood vessel or nerve. Because of the severity of the chemotherapy (when employed), there is an increased chance of an infection or wound problem which, if severe, could result in an amputation. Bone transplants carry the theoretical risk of transfer of disease such as bacterial infections, hepatitis and AIDS but the bones and donors are carefully screened and the actual risk is extremely low. The incidence of true "rejection" of the graft is low.
It is important to remember that even without postoperative complications the reconstructions do not restore the limb to normal functioning performance. There will be some muscle weakness, joint instability, and potential for fracture or non-union (failure of the transplant to knit to the patient's bone) of the graft. Patients are usually placed on postoperative antibiotics for three months following the transplant surgery to counteract the increased risk of infections which threaten the bone graft. Competitive athletics are not recommended and therefore amputations may be preferable in high-performance athletes.
The ultimate function and duration of these reconstructions is still not definitely known as compared to amputation. However, we feel that a bone transplant offers a very good chance at achieving a nearly normal, functional limb for patients who present with a "resectable" tumor.
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An artificial metallic implant can be manufactured to replace the entire end of the femur and the knee joint. The rod portion of the implant fits into the hollow marrow cavity inside the patient's femur, and is usually secured with bone cement. The patient's tibia is trimmed to accept a tibial piece affixed to the femur. The two parts join to make a knee joint which is a combination of metal and plastic.
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The advantages and expected function are the same as those for articular allografts. Since the metallic implants are cemented in place, braces are usually not needed and recovery is usually faster than with an allograft.
The disadvantages are related to the fact that metallic implants never become permanently incorporated by the bone and therefore they are subject to loosening, breakage, and erosion requiring subsequent complex revision operations. Latent infections are also possible and may require amputation. Athletic activities are usually limited as for allografts
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An arthrodesis is a joint fusion (permanent stiffening of a joint). It is another procedure designed to reconstruct the defect created from removing the end of the femur and the joint. A section of bone graft (obtained from another site in the same patient or from a bone bank) is used to bridge the gap between the femur and tibia (knitting the bones at both ends) and is held in place by metal plates, screws or rods. Since forward motion of the leg comes from hip flexor muscles, it is possible to remove the entire quadriceps without losing leg function.
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Because of the fusion of the bone graft at both ends, the patient's leg bends only at the hip and ankle. The advantages are that the appearance is nearly normal and walking and running are possible with only a minimal limp. Once the bones heal, this reconstruction becomes very stable and is probably the most durable of the limb-sparing reconstructions allowing for participation in, non-contact sports such as swimming,running, basketball, soccer, and tennis. It avoids the need to use a prosthesis and after the grafts have healed, about one year, bracing is no longer necessary.
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The main disadvantages are related to having a stiff knee. Sitting in small places such as movie theaters and on public transportation is often difficult because of the outstretched knee. Stair climbing is possible but usually only one step at a time is negotiable. There are restrictions in activities such as bicycling because of the straight leg. The complications are similar to the other reconstructions: infection, nonunion, fracture, skin healing problems, and transfer of disease if allografts are used.
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The purpose of the "rotation-plasty" is to make use of the patient's healthy leg, foot, and ankle (below the tumor) when the mid-section of the leg is removed for bone cancer. The procedure removes the section of the extremity that is involved with the tumor (an "intercalary amputation") while keeping the main nerves to the lower leg intact and functioning.
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The word "rotation" refers to the fact that the lower leg is reattached to the thigh with the foot and ankle facing backwards. In this position the ankle is the same level as the opposite knee, and bends in the same direction as the knee, serving as a substitute for it.
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The patient's foot fits down inside a prosthesis and functions much the same as below-the-knee amputation. Through physical therapy instruction the patient learns to use the foot and ankle as a knee.
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The concept of a rotation-plasty is at first difficult to accept because the appearance is quite unusual. However, when inserted into a prosthesis the appearance is similar to any other amputation. The advantages are that the stump is longer and has an actively movable "knee" joint which makes the functional result more like a below-the-knee amputation than an above-the-knee amputation. In very small children (less than 10 to 12 years of age), other types of reconstruction lead to lack of growth and ultimate shortening of the operated leg. The rotation-plasty can compensate for leg length because the prosthesis can be lengthened as the patient grows. It is also very durable since no artificial implants are used except a metal plate which joins the leg to the thigh. Most sports are possible including running sports such as baseball and soccer with a slight limp; and running can be nearly normal. Even sports where knee motion is important such as bicycling and horseback riding are possible. The complication rate is low and there is no phantom pain since the nerves are not cut for this procedure.
The disadvantages are mainly those of physical appearance and patient acceptance. However, for those patients who are still growing (less than 10 to 12 years of age) and are interested in maximizing functional mobility and sports participation rather than cosmetic appearance, it is a very good reconstructive option and one deserving of serious consideration.
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The advantage for amputation is assurance that the local tumor is completely removed. Prosthetic fitting is possible soon after the operation but the function is not as good as with other amputations. Walking with a prosthesis requires stamina and physical energy but with determination, patients can get about quite well. Athletics are limited but skiing and other modified sports activities can be achieved.
The disadvantages are due mainly to the level of amputation. With no active hip or knee control the use of a prosthesis is very challenging but with modern artificial legs independent walking is certainly possible. The issue of phantom limb pain is the same as for above-the-knee amputations.
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Since many tumors at this site are "resectable" there is a fair amount of experience with replacing the upper femur and hip joint with a femoral allograft. Muscles can be reattached to the bone allowing reasonably normal hip function. If the ball part of the femur does not fit the patient's socket, or the socket is involved with tumor, a standard artificial hip (metal and plastic hip prosthesis) can be inserted into the allograft to replace the hip joint.
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The advantages are that this reconstruction recreates the normal anatomy very closely so that postoperative function is much like that of a hip replacement for arthritis. There is no phantom pain or need for braces or prostheses. Initially, crutches, and a cane thereafter, are necessary until the bone graft has healed and the muscles are strong enough to function without aids. Walking and stair climbing are usually close to normal and non-contact sports such as bicycling and swimming are possible. Running and contact sports are not advised.
The disadvantages are that it is a large surgical procedure with an increased risk of complications such as wound healing problems, infection, fracture, or nonunion (failure to heal) of the allograft to the normal bone. The chance for a local recurrence is probably higher than with amputation although it is still quite low. The allograft concerns are the same as those at other sites. Fortunately the incidence of complications is quite low and, if successful, this procedure offers an excellent functional reconstruction for tumors in this location.
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An alternative to the allograft is to replace the part of the femur involved with tumor with a metal prosthesis and hip joint. The recovery and expected function is about the same as with the allograft. The advantages are that it avoids the bone transplant and the need to wait for healing. The prosthesis is usually cemented in place. The disadvantages are that muscles cannot be reattached to the metal so that active motion of the hip is usually not as complete. There is also the potential for breakage of the implant or loosening of the cement. In young patients the allograft may be a more durable solution.
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Malignant tumors below the knee usually have a muscle layer between the tumor and the nerves and blood vessels which makes resections in this location somewhat safer than those above the knee. The peroneal nerve which comes around the top of the fibula (the smaller, outermost of the two bones of the lower leg) and controls the muscles that lift the foot and toes, may be injured or purposely resected during removal of proximal tibial tumors. If this nerve is damaged or removed during the operation, a subsequent surgical procedure to transfer a muscle in the area usually resolves this problem.
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An above the knee amputation is the standard method of treatment for proximal tibial malignant tumors. The functional result is much better since this resection can be performed at a lower level than for tumors above the knee. However, there is still no active (muscle powered) motion of the artificial knee. The procedure, recovery, physical therapy, and functional result are the same as amputations for femoral tumors.
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The options for osteoarticular allografts, metallic prostheses, and arthrodesis are the same as for femoral tumors. The advantages, disadvantages and complications are also identical. An allograft (bone transplant) has the advantage of being able to restore knee extension which is not possible with metallic replacements.
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