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Journal of Bone and Soft Tissue Tumors (JBST) is the official Journal of The Indian Musculo Skeletal Oncology Society
Resection and Arthrodesis of the Knee Joint by Different Modalities for Aggressive Giant Cell Tumors of Bone
Volume 3 | Issue 1 | May- Aug 2017 | Page 17-21 | Y. J. Mahale, Shubham Mishra, Sagar Chinchole
Authors: Y. J. Mahale [1], Shubham Mishra [1], Sagar Chinchole [1].
[1]Departmnet of Orthopedics, ACPM Medical College, Dhule, Maharashtra, India,
Address of Correspondence
Dr. Shubham Mishra,
ACPM medical college ,
Dept of orthopaedics, room no 604,
pg boys hostel ,saakri road dhule, 424001
Email : shaggyurfrnd28@gmail.com
Abstract
Purpose: The aim is to evaluate the functional outcomes inCampanacci Grade 3 giant cell tumor (GCT)of distal femur and proximal tibia treated with wide resection and arthrodesis with different implants used such as long intramedullary interlocking nail(n=11),long Kuntscher nail(n=2), and DCP plate(n=3) andto compare the outcomes and functional results of arthrodesis with arthroplasty which were done elsewere.GCTis a aggressive benign bone tumor[1]seen in young patients with a normal life expectancy. Campanacci Grade 3 tumors and recurrent tumors require wide resection[1,2].Arthrodesis is an alternativeoptions for reconstruction in Campanacci Grade 3,though Arthroplasty is ideal option for campannci Grade 3 tumors.
Methods: Criteria included 16 patients of Campanacci Grade 3 GCT in which 14 male and 2 female around aged between 20and 60 years with a mean age of 30 years underwent resection and arthrodesis of the knee for GCTs of bone involving the distal femur(n=7) or proximal tibia(n= 9).After wide resection,2 struts were fashioned from the harvested fibula of thesame side and inserted into medullary canal at the resected ends of the tibia and femur.Cancellous bone grafts were taken from thesame side of theiliac crest.Hemicylindrical graft was taken from anteriorpart of either distal femur or proximal tibia. A long intramedullary interlocking nail was inserted inretrograde fashion through piriformis fossa to distal tibia.Cancellous bone grafts[2,3]were placed transversely along the struts and circumferentially over the host-graft junctions.For other patients, long Kuntscher nail and DCP plate with K-wirewere used.Results of arthrodesis were evaluated those in which long intramedullary interlocking nail(n=11), long Kuntscher nail(n=2),and DCP (n=3).Outcomes and complications were evaluated and compared with those of endoprosthetic arthroplasty reported elsewhere.
Results: Patients were followed up for a mean of 12 years. All patients were ofCampanacciGrade 3.The mean size of tumors was 12-10-7cm.All patients achieved arthrodesis with intramedullary interlocking nail, Kuntscher nail,and plating.A total number of patient (n=16).The mean bone union time was 12-14 weeks. There was no loss of alignment,loosening, and no implant breakage. The mean musculoskeletal tumor society[5] score was 27(87%of full score). The complications were evaluated in which patients were having skin necrosis(n=3),skin infection (n=2),and peroneal nerve injury(n=1).
Conclusions: In aggressiveCampanacciGrade 3 GCT around theknee joint,arthrodesis [6,7]withlong intramedullary interlocking nail provides good results. Longintramedullary interlocking nailing in arthrodesisprovides high fusion rates, minimal shortening,and rotational stability as compared to plate fixation. Arthrodesis is acost-effective method as compared to arthroplasty in economically constrained population of developing nations and shows good functional outcomes with acceptable morbidity.
Keywords: Giant cell tumor, arthrodesis, intramedullary interlocking nail, hemicylindrical graft, fibula transposition, bone transplantation.
References
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A Case Series on Osteochondroma of Scapula
Volume 3 | Issue 1 | May- Aug 2017 | Page 14-16 | Rohit Santhanam, Mohan Ganesan
Authors: Rohit Santhanam [1], Mohan Ganesan [1].
[1]Department of Orthopaedics, Kilpauk Medical College and Hospital, Kilpauk, Chennai, Tamil Nadu, India,
Address of Correspondence
Dr. Rohit Santhanam,
11/8 Roja street , brindavan nagar, koyambedu,
Chennai – 600092,Tamil Nadu, India.
Email: drrohitsanthanam@gmail.com
Abstract
Background: Osteochondroma is the most common primary bone tumor. It commonly occurs in young people and the growth of the tumor ceases with maturity. The most common site is in long bones, namely, femur, tibia,and humerus.Osteochondroma of flat bones especially is a rarity. These tumors can arise from both the dorsal and the ventral surface. Snapping scapula syndrome is attributed to the variants arising from the ventral surface. We have evaluated five cases involving scapula and treated them successfully.
Materials and Methods: Five cases of osteochondroma were evaluated, treated, and followed up after thorough evaluation clinically and radiographically.
Observation: All the five cases were treated successfully after thorough evaluation with no signs of recurrence. Patients had symptomatic relief and snapping scapula syndrome was relieved once the tumorwas removed with theexcellent functional outcome.
Keywords: Osteochondroma, scapula, snapping scapula syndrome.
References
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Current Concepts in Imaging of Giant Cell Tumor of Bone
Volume 3 | Issue 1 | May – Aug 2017 | Page 3-7 | Khushboo Pilania, Bhavin Jankharia
Authors: Khushboo Pilania [1], Bhavin Jankharia [1].
[1]Consultant Radiologists, Picture This by Jankharia, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Bhavin Jankharia,
Bhaveshwar Vihar, 383 S V P Rd,
Mumbai – 400004, Maharashtra, India.
E-mail: bhavin@jankharia.com
Abstract
Giant cell tumor(GCT) of bone is a tumor of giant cell proliferation that usually affects men and women in the thirdand fourthdecades. Typical cases have straight-forward imaging appearances. Atypical cases may resemble many other benign and sometimes malignant lesions. Plain radiographs and magnetic resonance imaging (MRI) are the mainstay of diagnosis, followed by biopsy and histology.Positron emission tomography/computed tomography (CT) has a limited role to play.Aneurysmal bone cyst transformation within GCTs is known. This may change the imaging appearance. GCTs may be multifocal, locally aggressive, and may metastasize to nodes and lungs.Treatment with drugs like denosumab also changes the appearance on radiographs and MRI. Post-operative imaging can be a challenge, and picking up recurrence also requires high-quality radiographs, MRIs, and CT scans.
Keywords: Giant cell tumor, giant cell tumor, bone neoplasm, computed tomography scan, magnetic resonance imaging, plain radiograph.
References
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Intralesional Curettage technique for Giant cell tumor of bone – current concepts and evidence
Volume 3 | Issue 1 | May- Aug 2017 | Page 7-12 | Manish Agarwal
Authors: Manish Agarwal [1]
[1]Department of Surgical Oncology, P.D Hinduja Hospital & Medical Research Centre, Veer SavarkarMarg, Mahim, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Manish Agarwal,
P.D Hinduja Hospital & Medical Research Centre,
Veer SavarkarMarg, Mahim, Mumbai – 400 016, Maharashtra, India.
E-mail: mgagarwal@gmail.com
Abstract
Intralesionalsurgery is the most favored kind of surgery for giant-cell tumors of the bone. A good surgical technique helps minimize the risk of local recurrence. A good exposure followed by meticulous curetting aided by a high-speed burr is the backbone of this surgery. The role of chemical and thermal adjuvants is discussed with the evidence. The best way to reconstruct the cavity after curettage has been hotly debated. This article discusses the role of bone, cement, as well as a combination “sandwich” technique.
Keywords: Intralesional surgery, curettage, giant-cell tumor, adjuvant, “sandwich” reconstruction.
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29. Frassica FJ, Gorski JP, Pritchard DJ, Sim FH, Chao EY. A comparative analysis of subchondral replacement with polymethylmethacrylate or autogenous bone grafts in dogs [Internet]. Clin Orthop Relat Res. 1993. p. 378–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8339507
30. Von Steyern F V., Kristiansson I, Jonsson K, Mannfolk P, Heinegard D, Rydholm A. Giant-cell tumour of the knee: The condition of the cartilage after treatment by curettage and cementing. J Bone Jt Surg – Br Vol . 2007;89–B(3):361–5.
31. Tejwani SG, Hame SL, Eckardt JJ. Subchondral giant-cell tumor of the proximal tibia: Arthroscopic treatment for accelerated articular cartilage and meniscal degeneration in two patients. Arthrosc – J Arthrosc Relat Surg. 2004;20(6):644–9.
32. Chen TH, Su YP, Chen WM. Giant cell tumors of the knee: Subchondral bone integrity affects the outcome. Int Orthop. 2005;29(1):30–4.
33. Buecker PJ, Gebhardt MC. Are Fibula Strut Allografts a Reliable Alternative for Periarticular Reconstruction after Curettage for Bone Tumors? Clin Orthop Relat Res [Internet]. 2007;461(Aug):170–4.
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Osteofibrous Dysplasia – an update
Volume 2 | Issue 2 | May-Aug 2016 | Page 23-25 | Pankaj Panda1, Ashish Gulia1
Authors: Pankaj Panda[1], Ashish Gulia[1]
[1]Orthopedic Oncology Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai
Address of Correspondence
Dr Ashish Gulia, MS (Ortho), Mch (Surgical Oncology)
Associate Professor, Orthopedic Oncology, Dept. of Surgical Oncology, Tata Memorial Hospital, Mumbai – 400012, India.
Email: aashishgulia@gmail.com
Abstract
Introduction: Osteofibrous dysplasia (OFD) is a rare, benign, self-limiting, fibro-osseous lesion occurring in long bones especially of lower limbs. Patients typically presents with painless swelling with or without anterior bowing of tibia .The diagnosis can be confirmed by peculiar radiological feature of well defined intracortical lytic lesion with variable degree of osteolysis and osteosclerosis. Admantinoma is close differential of this lesion . Most cases regress spontaneously by puberty , surgical intervention is required only for progressive lesions or in case of pathological fracture .
Keywords: Osteofibrous Dysplasia , Management
Introduction
Osteofibrous dysplasia (OFD) is a rare, benign, self-limiting, fibro-osseous lesion occurring in long bones especially of lower limbs. It is also called as Kempson-Campanacci lesion or cortical fibrous dysplasia. The prominence of the osteoblasts led Kempson in 1966 to describe the entity as ossifying fibroma of the long bones [2]. In 1976, Campanacci, gave the term “osteofibrous dysplasia of the tibia and fibula” in reference to its histological features, developmental origin and anatomic location [1].
Etiopathogenesis – Exact etiology is not known. A few of the cases are known to have occurred in families. It has also been reported that OFD may act as a precursor of adamantinoma which is supported by occurrence of OFD like adamantinomas. The evidence for this is limited and most of the cases are considered to be arising spontaneously.
Incidence – OFD is a rare benign self-limiting tumor, which accounts for about 0.2% of all primary bone tumors [3]. These lesions are mainly seen in the first two decades of life. It is very uncommon after skeletal maturity with any gender predilection [4].
Site – It is invariably a disorder of the tibia and fibula. The lesion usually has its epicenter in anterior cortex of tibia. Tibial mid-diaphysis and proximal metaphysis are affected the most. Ipsilateral or contra lateral fibula may be involved. Even though most of the lesions are confined to a limited portion of the bone a few may grow rapidly and involve almost entire bone. Isolated fibular involvement is rare. Forearm bones (radius and ulna) are other uncommon sites of affection [5].
Clinical features – The typical presentation is painless swelling with or without anterior bowing of the tibia. Pain is only present in about one third of the cases and is usually due to pathological fracture. About a third of the cases are detected incidentally [6].
Radiological Features:
Radiograph – The lesion appears as a well defined intracortical lytic lesion, with variable degree of osteolysis and osteosclerosis located in the anterior cortex of the tibia. These lesions may present as a single focus or multiple elongated foci interspersed with reactive bone. The overlying cortical shell presents itself in a wavy pattern giving it a “saw tooth appearance”. Most of the lesions are associated with anterior tibial bowing and buttress type of benign periosteal reaction. Aggressive lesions may involve entire diaphysis and metaphysic and may have associated pathological fractures [7, 8].
Computed Tomography – It is helpful in assessing exact extent of the lesion, cortical involvement, periosteal reaction and pathological fractures and acts as an adjuvant to MRI in the overall assessment of the lesion.
Magnetic resonance imaging – MRI helps in delineating the cortical based lesion and to assess its medullary or soft tissue extension. The lesion demonstrates mixed signals on T1 and high intensity lesions on T2 weighted images. MRI is helpful in surgical planning and differentiating OFD from adamantinoma [9].
Pathology:
On gross examination, a typical specimen appears as a whitish or yellowish solid lesion with surrounding gritty bony architecture. The cortex may be expanded and thinned out deficient at places with intact periosteum. Lesions may show medullary extension, which is usually demarcated by a sclerotic rim [10].
Microscopically, OFD demonstrates a zonal architecture with loose fibrous tissue containing spicules of woven bone in the centre which is lined by a layer of lamellar bone lined by prominent osteoblasts at the periphery. This shows a progressive maturation of the bone trabeculae from a central zone of delicate trabecular bone in a vascular fibrous stroma, to an outer zone of lamellar bone. The fibrous component in most cases contains cells which react positively for pan-cytokeratin. Desmosomes, tonofilaments, and microfilaments are seen on electron microscopy [2, 11].
Differential Diagnosis:
Several tumor and tumor like lesions can mimic Osteofibrous dysplasisas on radiographs [12]. The differential diagnoses are that of a cortical, lytic, expansile lesion. Adamantinoma is the most closest differential diagnosis as both lesions are very similar clinico- radiologically and even on histopathology. Adamantinomas are more aggressive lesions and may lead to local and distant recurrences. These commonly involve the medullary cavity, but there is usually cortical infiltration, break and soft tissue component. Other differentials include Fibrous dysplasia, Nonossifying fibroma, Aneurysmal bone cyst, Chondromyxoid fibroma, Langerhans cell histiocytosis, Osteomyelitis and Hemangioendothelioma [13]. A thorough clinico-pathological correlation substantiated with characteristic radiological findings is very essential for a definitive diagnosis of OFD.
Treatment:
According to the case series on OFDs from the Rizzoli Institute in Milan and the Mayo Clinic, these lesions, owing to their benign nature, seldom progress during childhood and undergo spontaneous regression at puberty, thus can be carefully observed with serial plain radiographs and clinical evaluation at regular intervals. If associated with significant or progressive bowing then conservative treatment in the form of bracing may be helpful to minimize deformity and prevent pathological fracture [5, 14].
Surgical intervention is mainly required in extensive cases with progressive deformity or for pathologic fracture. Extraperiosteal “shark-bite” excision is the most widely considered surgical option for OFDs. The resultant defects may be reconstructed with auto or allo-strut grafts. Other surgical interventions may include curettage bone grafting and internal fixation after correction of deformity. [9].
Prognosis – OFD has a very good prognosis. Most of the lesion even though they grow in first decade of life get stablised during the second decade and heal by spontaneous resolution. Deformities may persist for a longer time and may remodel slowly. Aggressive lesions may have severe deformity or pathological fracture, which usually heal well with surgical intervention. Excisions are mostly curative. A few lesions may progress to OFD like adamantinoma or adamantinoma and require aggressive treatment accordingly [3, 6].
References
1. Campanacci M, Olmi R. Ossifying fibroma of the long bones. A light and electron microscopic study. Arch Pathol. 1966 Sep;82(3):218-33
2. Kempson RL.Ossifying fibroma of the long bones. A light and electron microscopic study. Arch Pathol. 1966 Sep;82(3):218-33.
3. Most MJ, Sim FH, Inwards CY. Osteofibrous dysplasia and adamantinoma. J Am Acad Orthop Surg 2010;18:358-66.
4. Hahn SB, Kim SH, Cho NH, Choi CJ, Kim BS, Kang HJ. Treatment of osteofibrous dysplasia and associated lesions. Yonsei Med J. 2007 Jun 30;48(3):502-10.
5. Park YK, Unni KK, McLeod RA, Pritchard DJ. Osteofibrous dysplasia: clinicopathologic study of 80 cases. Hum Pathol. 1993 Dec;24(12):1339-47.
6. Gleason BC, Liegl-Atzwanger B, Kozakewich HP, Connolly S, Gebhardt MC, Fletcher JA, Perez-Atayde AR. Osteofibrous dysplasia and adamantinoma in children and adolescents: a clinicopathologic reappraisal. Am J Surg Pathol. 2008 Mar;32(3):363-76..
7. Levine SM, Lambiase RE, Petchprapa CN. Cortical lesions of the tibia: characteristic appearances at conventional radiography. RadioGraphics 2003;23:157-77.
8. Greenspan A. Malignant bone tumors II. In: Orthopedic imaging: a practical approach. 5th ed. Philadelphia, USA: Lippincott Williams & Wilkins; 2011. p. 754.
9. Khanna M, Delaney D, Tirabosco R, Saifuddin A. Osteofibrous dysplasia, osteofibrous dysplasia-like adamantinoma and adamantinoma: correlation of radiological imaging features with surgical histology and assessment of the use of radiology in contributing to needle biopsy diagnosis. Skeletal Radiol 2008;37:1077-1084
10. Fitzpatrick KA, Taljanovic MS, Speer DP, Graham AR, Jacobson JA, Barnes GR, HunterTB.Imaging findings of fibrous dysplasia with histopathologic and intraoperative correlation. AJR Am J Roentgenol. 2004 Jun;182(6):1389-98.
11. Kahn L. Adamantinoma, osteofibrous dysplasia and differentiated adamantinoma. Skeletal Radiol 2003;32:245-58.
12. Levine SM, Lambiase RE, Petchprapa CN. Cortical lesions of the tibia:characteristic appearances at conventional radiography. RadioGraphics 2003;23:157-77.
13. Izquierdo FM, Ramos LR, Sánchez-Herráez S, Hernández T, de Alava E, Hazelbag HM. Dedifferentiated classic adamantinoma of the tibia: a report of a case with eventual complete revertant mesenchymal phenotype. Am J Surg Pathol. 2010 Sep;34(9):1388-92.
14. Campanacci M, Laus M. Osteofibrous dysplasia of the tibia and fibula. J Bone Jt Surg Am 1981;69(A):367-75.
Dr. Paramanandam V
Dr. Anuradha A Daptardar
Dr. Ashish Gulia
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Rehabilitation following Limb-Salvage Surgery in Sarcoma
Volume 2 | Issue 2 | May-Aug 2016 | Page 19-22 | Vincent S Paramanandam1, Anuradha A Daptardar1, Ashish Gulia2
Authors: Vincent S Paramanandam[1], Anuradha A Daptardar[1], Ashish Gulia[2]
[1]Physiotherapy Department, Tata Memorial Hospital, Mumbai
[2]Orthopedic Oncology Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai.
Address of Correspondence
Dr. Paramanandam V
Technichal Officer C, Physiotherapy Department, Tata Memorial Hospital, Mumbai
Email: vinsu24@gmail.com
Abstract
Introduction: Limb salvage after tumor resection has become a norm in today’s era. There are number of biological and non biological reconstruction options available for the reconstruction of these bone defects. The success story of these surgical procedures is mainly based on their excellent functional outcome. Post surgical rehabilitation plays an important role in achieving optimal functional outcome and good quality of life. The rehabilitation protocol following limb salvage surgery is complex and it differs with type of reconstruction procedure. Present articles discusses in detail the various rehabilitation protocols required to achieve above goals.
Keywords:
Introduction
Until 1970, amputation was the primary surgical treatment offered to bone and soft tissue sarcomas. However, from that time the treatment options have evolved dramatically and now approximately 90% of these cases undergo Limb Salvage Surgery (LSS)[1]. LSS has become the main line of treatment option for bone and soft tissue sarcomas along with adjuvant and/or neo adjuvant treatment modalities (Chemotherapy/ radiotherapy). The overall survival rate has been estimated as 55%-65%, based on the age of diagnosis, and it is considered to be comparable to that of amputation.
LSS is considered to be less invasive, provides better function and quality of life than amputation [2]. Moreover, it has been proposed that patients’ acceptability of LSS is high in view of the fact that it restores the body image better than amputation[3]. Nevertheless, LSS, unlike amputation, is associated with more peri-operative complications, prolonged hospital stay and requires repeated surgeries due to various reasons such as infection and prosthetic failure. LSS demands high surgical skills, whereas, amputation is a simple surgical procedure. Additionally, recent progress in prosthetic limbs, for example microprocessor based joints and endo-skeletal prosthetic reconstructions, have improved the functional outcome and cosmetic outlook following amputation [4].
A systematic review conducted by Bekkering et al [5] reported that the quality of life outcome from current available evidence is inconclusive in supporting LSS or amputation. Another recent systematic review and meta-analysis concluded that both surgical procedures provides similar functional recovery and quality of life [6].Despite the fact that early physical rehabilitation is the key to achieve good functional outcome and quality of life after LSS, rehabilitation techniques following LSS is largely neither tested nor documented in detail [7]. Lack of adequate early rehabilitation measures following LSS could be one of the rationales for conflicting interests reported by various studies examining the quality of life in LSS vs amputation.Hence, we have attempted to summarise basic principles and site specific considerations one must utilise to develop individual case specific rehabilitation protocol.
Common rehabilitation principles in LSS
In a recent paper, Shehadeh et al. [7] attempted to standardize the rehabilitation protocol for LSS following high grade bone and soft tissue sarcomas. They reported that following a standardized rehabilitation protocol produced improved functional outcome in group of 59 patients with LSS. Their conclusion, however, is based on small observational study with heterogeneous population who received different type of LSS for different anatomical sites. Following set protocol in LSS, unlike general orthopaedic procedure, will be counterproductive. In general orthopaedic procedures, more or less,
specific anatomical structures are involved with minimal damage to the bone, joint and
soft tissue structures. In contrast, in LSS
following sarcomas, these structures are
extensively resected and may not be
identical between two individuals
undergoing similar procedures for a particular site. For example, resection length for distal end of femur osteogenic sarcoma may depend on the extent of disease in two individuals [4].
Following are common rehabilitation prospectives that need to be considered to formulate comprehensive rehabilitation protocol for LSS.
Bone and joint reconstructions: Stability and mobility following LSS largely depends on the bone and joint structure loss and the type of reconstruction. For example, megaprosthetic distal femur replacement with cementing will allow the patient to be ambulated full weight bearing (FWB), whereas, if it is a bone graft , like in most of biological reconstructions, weight bearing needs to be delayed till the osteosynthesis is confirmed by radiographical evaluation.
Neuromuscular loss: Oncology resection demands large resections, which will also include a part of uninvolved soft tissue cover as surgical margin. Large resection may require additional rotational or free flaps for soft tissue coverage. In addition, nearby neuro-vascular bundle may need to be excised or repaired, hence, complete evaluation of neuro-motor loss would be necessary to plan the dynamic strength training and external support requirements.
Skin involvement: Donor sites of free flaps often receive split thickness skin graft which may hinder the early mobilisation of nearby joint. Moreover, scar development following open biopsy and LSS may need special attention from the rehabilitation team to prevent any future functional loss.
External supports: Temporary or permanent external support in the form of static or dynamic splinting may be required to provide support to the limb. To exemplify, prophylactic use of abduction brace along with derotation boot to prevent hip dislocation following proximal femur replacement and dynamic cock-up splint for radial nerve palsy needs to be the integral part of rehabilitation service.
Oncology treatments: Deranged blood count often hinders with the intensity of rehabilitation; hence, it prolongs the overall rehabilitation(8). Radiation induced fibrosis could cause severe restrictions in the joint range of motion. Thus, rehabilitation professionals must plan around the chemotherapy cycles and add prophylactic measures to prevent any impending radiation induced joint and soft tissue dysfunction.
Multidisciplinary approach: Limb salvage surgery is complex and demands close concordance in treatment specific outcomes between various health professional working in the rehabilitation team. This team may comprise team of surgeons, medical oncologists, radiation therapists, nurses, physiotherapists, occupational therapists, prosthetics orthotics and medical social workers. Prehabilitation, rehabilitation even before starting the primary cancer therapy and surgery, such as crutch muscles strengthening, would be greatly beneficial in post-treatment functional outcome. Although in the field of LSS evidence of prehabilitation is lacking, there are considerable evidence to show beneficial effects in overall rehabilitation following cancer therapies [9–11].
Rehabilitation prescriptions and follow-up: Rehabilitation protocol for LSS must be tailor made considering the general principles and site specific modification, hence specific and also progressive. However, some negative effects of adjuvant therapies, such as the deranged blood counts and infection, may alter the course of rehabilitation process. Thus, frequent follow-up and close monitoring may be required during adjuvant therapy till they are functionally independent.
Rehabilitation consideration for specific sites
Site specific rehabilitation principles following LSS have been presented below for few common sites.
Mega prosthetic replacement for distal femoral resection:
Distal femur is the commonest site for primary high grade sarcoma and giant cell tumors. Overall strengthening other than the affected site, in all possibility, should begin preoperatively. Limb elevation and ankle toe movement should be encouraged from post operative day one to prevent deep vein thrombosis. Cemented and semiconstrained(allows rotations and flexion/extension) knee joint endoprosthetic replacement permits early joint mobilization and FWB walking. Unlike other centres [4,7], in our centre knee joint mobilisation starts from day one with the help of continuous passive motion units (Figure1) and active assisted methods within the pain tolerance level unless tight suturing. Close communication between the surgical team and the rehabilitation team helps in personalising the rehabilitation protocol as per the patients’ requirements. With adequate pain relief through appropriate medical management, active exercises could be started from day one to three. Full weight bearing walking could be started from day one initially with walker and later without any support if patient could effectively extend the knee “locking the knee”. Prior to ambulation, one leg standing and spot marching must be encouraged with appropriate support. After acute inflammation subsides slow progressive muscle strengthening exercises must be encouraged with the goal of achieving 900knee flexion, complete knee extension and muscle strength equivalent to the contra lateral lower limb by end of three months. Active passive motion devices, such as the one shown in Figure 2, may help in joint mobilisation and strengthening. Summary of rehabilitation protocol is tabulated in Table 1.
Figure 1: Continuous passive motion
Figure 2: Active passive motion unit
Table 1: Rehabilitation protocol following LSS
Mega prosthetic replacement for proximal tibial resection:
Proximal tibia and knee joint is the second most common site for primary high grade sarcoma and giant cell tumors. It is indeed a challenging location for rehabilitation in view of the fact that the extensor mechanism have to be reconstructed in these cases [4]. In most of the cases a gastrocnemius flap is done to provide a dynamic anchorage and direct anchorage to prosthesis provide a static attachment to help reattaching extensor mechanism to proximal tibial prosthesis. Protecting the extensor mechanism reconstruction till it attaches through fibrosis along with the surrounding soft tissue structures are crucial to prevent quadriceps lag. Hence, knee bending and quadriceps strengthening will be delayed for six weeks until then the knee is protected with the help of long knee brace. Re-attached gastrocnemius flap could lead to protective muscle spasm of plantar flexors and if not mobilised early it may create plantar flexors contracture. Thus, achieving/maintaining dorsi flexion of the ankle joint in the early post operative period is crucial for appropriate weight bearing.
Table 2: Rehabilitation protocol following Mega prosthetic replacement for proximal tibial resection
Mobilisation of knee joint and quadriceps strengthening could be started after six weeks; however, therapist must consider that immobilisation of the knee joint in long knee brace leads to severe restriction of patella mobility. Unless adequate patella mobility is achieved, especially the medial lateral movement, knee flexion exercises could prevent smooth gliding of patella over the femoral condyle. This will increase strain on the reconstructed patella ligament. Therefore, our institute follows a unique mobilisation protocol following proximal tibia and knee replacement which is depicted in the Table 2. In few cases quadriceps lag could be evident due to patella tendon overstretch/avulsion, this could be due to improper patella mobilisation or forceful knee bending. Figure 3 a, b and c depicts the patella tendon overstretch.
Figure 3: a) Patella position following proximal tiabia and knee joint replacement b) Patellar tendon stretch after 3months c) Patella mal position (over ride) on patient.
Mega prosthetic replacement for proximal and total femoral resection:
Resection of proximal femur and prosthetic replacement may be done for proximal femur tumor or as a part of total femoral resection and reconstruction. Partial or complete loss of joint capsule and dynamic stabilisers of hip joint during tumor resection may leave the hip joint vulnerable to dislocation. This may get potentiated with certain combination movements, if these joint movements are allowed beyond a certain limit. This restriction largely depends upon the surgical approach. Postero-lateral approach being most common in the LSS of this site, hip rotations, especially internal rotation and, flexion more than 600 and adduction of the hip joint needs to be prevented up to 6 weeks [4,7]. These movement restrictions could be achieved using hip abduction pillow/brace and de-rotation splint. Before the patient gets discharged from the hospital, training them for bed transfer, supine to standing, standing to supine and sitting in a chair/commode becomes paramount important in the early phase of
rehabilitation. Knee joint mobilisation must be started early either by the edge of bed with hip joint well supported or in side lying with pillows between legs. Any restriction of knee joint range would adversely affect the overall function since hip joint function of the ipsilateral leg has already been compromised. Early FWB ambulation could be started from post operative day one initially with walker, then with walking stick. Later most of them would be trained to walk without any walking aid. Total femoral resections may require more intense rehabilitation with additional emphasis on knee strengthening as discussed earlier (Table 2). Patients may life long need to use walking aids in view of the fact that large motor loss in these cases.
Mega prosthetic replacement for proximal humeral resections:
Proximal humerus and the shoulder girdle are the third common place for primary bone sarcomas [4]. Despite endoprosthetic replacements for functional shoulder girdle structures, such as reverse glenoid prosthesis, are available, lack of muscular structures post excision and damage to the axillary nerve often prevent their use. Frequently, the proximal end of the humerus is replaced with the endoprosthesis and suspended by the remaining muscles and soft tissue structures by suturing around the proximal end of the prosthesis. The objective of the procedure is to achieve a stable shoulder to facilitate good elbow and hand function.
To prevent the weight of the endoprosthesis and the limb acting on the newly formed pseudo joint, shoulder sling and elbow pouch are provided for 4 – 6 weeks. Early post operative rehabilitation consists of elbow and hand range of motion (ROM) and strengthening exercises within pain limit. Again these exercises must be performed in supine position only to avoid undue stress on the shoulder. After six weeks, shoulder joint limited ROM exercise in the form of pendular movements and vigorous strengthening of shoulder girdle, elbow and hand complex should be commenced. Additionally, postural correction must be included in the rehabilitation program.
Biological reconstructions
Wherever feasible, biological reconstructions are preferred over endoprosthetic implants in order to provide a stable and permanent solution for reconstruction of defects after tumor resection. However, rehabilitation following biological reconstructions needs careful considerations regarding weight bearing and joint mobilization. Utmost importance to surgical notes and communication with operative surgeon is of prime importance. Early joint mobilisation is the key to prevent joint stiffness and functional loss; nevertheless, often protective functional braces may be required to prevent damage. For example, curettage and bone grafting of the lower end of femur close to the joint demands hinge knee brace to avoid varus and valgus stress. Strengthening exercises also could be started early with functional knee brace (Fig. 4).
Figure 4: Hinge knee brace following bone graft.
Patients are taught to walk non-weight bearing with brace generally from post operative day one with the help of axillary crutches up to 8 weeks. Once, osteosynthesis is confirmed through radiological evaluation, progressive weight bearing walking could be started. FWB walking and complete joint range and strength are expected to be achieved by the end of 3 months to 4 months.
conclusion
Although limb salvage surgery for primary malignant tumours have achieved commendable advancement in surgical techniques and endo-prosthetic design and manufacturing, without optimal and timely peri and post-operative physical rehabilitation, achieving the desired quality of life outcome may not be feasible. This paper has highlighted few important rehabilitation principles and we have summarised rehabilitation protocol for specific area. Most of the oncology resection and reconstruction vary from one individual to another even in one particular site and needs tailor made rehabilitation protocol; nevertheless, this summary will be a guide for necessary foundation to design individual rehabilitation program.
References
1. Chopra BK. Health related quality of life studies in Indian patients after limb salvage surgery: Need of the hour. Med J Armed Forces India. 2013 Jul;69(3):209–10.
2. Ottaviani G, Robert RS, Huh WW, Palla S, Jaffe N. Sociooccupational and physical outcomes more than 20 years after the diagnosis of osteosarcoma in children and adolescents. Cancer. 2013;119(20):3727–36.
3. Frieden RA, Ryniker D, Kenan S, Lewis MM. Assessment of patient function after limb-sparing surgery. Arch Phys Med Rehabil. 1993 Jan;74(1):38–43 6p.
4. Oren R, Zagury A, Katzir O, Kollender Y, Meller I. Principles of rehabilitation after limb-sparing surgery for cancer. In: Musculoskeletal Cancer Surgery [Internet]. Springer; 2001 [cited 2014 Sep 3]. p. 583–93. Available from: http://link.springer.com/chapter/10.1007/0-306-48407-2_36
5. Bekkering WP, Vliet Vlieland TPM, Fiocco M, Koopman HM, Schoones JW, Nelissen RGHH, et al. Quality of life, functional ability and physical activity after different surgical interventions for bone cancer of the leg: A systematic review. SurgOncol. 2012 Jun;21(2):e39–47.
6. Mei J, Zhu X-Z, Wang Z-Y, Cai X-S. Functional outcomes and quality of life in patients with osteosarcoma treated with amputation versus limb-salvage surgery: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2014 Nov;134(11):1507–16.
7. Shehadeh A, Dahleh ME, Salem A, Sarhan Y, Sultan I, Henshaw RM, et al. Standardization of rehabilitation after limb salvage surgery for sarcomas improves patients’ outcome. HematolOncol Stem Cell Ther. 2013 Sep;6(3–4):105–11.
8. Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvão DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010 Jul;42(7):1409–26.
9. Singh F, Newton RU, Galvão DA, Spry N, Baker MK. A systematic review of pre-surgical exercise intervention studies with cancer patients. SurgOncol. 2013 Jun;22(2):92–104.
10. Silver JK. Cancer Prehabilitation and its Role in Improving Health Outcomes and Reducing Health Care Costs. SeminOncolNurs. 2015 Feb;31(1):13–30.
11. Silver JK. Cancer prehabilitation and its role in improving health outcomes and reducing health care costs. SeminOncolNurs. 2015 Feb;31(1):13–30.
Dr. Paramanandam V
Dr. Anuradha A Daptardar
Dr. Ashish Gulia
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