Review Article
Management of infection following reconstruction in bone tumors

https://doi.org/10.1016/j.jcot.2015.04.005Get rights and content

Abstract

Limb salvage surgery in bone tumors has evolved in recent years and includes all of the surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. This dramatic change came about as the result of three important developments, i.e. effective chemotherapy, improved precision imaging techniques and advances in reconstructive surgery. Reconstruction with a modular custom-made oncological endoprosthesis (megaprosthesis) has become a common procedure nowadays. These large foreign bodies make infection a common and feared complication. However, the occurrence of complications may be multifactorial, including a poor nutritional and compromised immune status due to chemotherapy and/or radiotherapy, a lengthy operation, extensive dissection and resection of soft tissues, inadequate soft-tissue coverage, a longer exposure of the wound resulting in infection, etc. Management of postoperative infection in these cases remains a challenge. This article analyses the current literature available for these cases and summarizes the cause and different available methods of treatment.

Introduction

Over the last 30 years, limb salvage surgery has evolved and the technique has been proven safe and effective in most cases.1 Limb salvage surgery includes all of the surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. Today, up to 85% of sarcomas in the extremities are treated with limb salvage surgery. This dramatic change came about as the result of three important developments, i.e. effective chemotherapy, improved precision imaging techniques, and advances in reconstructive surgery.2 Options for skeletal reconstruction include modular endoprostheses, osteoarticular or bulk allografts, allograft-prosthetic composites, vascularized bone grafts, arthrodesis, expandable prostheses, rotationplasty, and limb-lengthening techniques. Reconstruction with a modular custom-made oncological endoprosthesis (Megaprosthesis) has become a common procedure nowadays.3, 4, 5, 6, 7 This procedure provides a durable and functional limb immediately after the operation, achieving immediate rigid fixation, and allowing early initiation of a postoperative rehabilitation program. Therefore, increasing numbers of patients are undergoing megaprosthesis reconstruction after resection of a malignant bone tumor and some other nonmalignant conditions. Complications common to all types of limb salvage surgeries are neurovascular injuries, local tumor recurrence, deep wound infections, and soft-tissue healing problems.8, 9, 10, 11 The occurrence of complications may be multifactorial,12 including a poor nutritional and compromised immune status due to chemotherapy and/or radiotherapy, a lengthy operation, extensive dissection and resection of soft tissues, inadequate soft-tissue coverage, a longer exposure of the wound resulting in infection, etc. Early general complications include wound necrosis, infection, joint contracture, joint stiffness, joint instability, neuropraxia, vascular injury, etc. Infection is one of the most-common complications of limb salvage operations, and the management of postoperative infection remains a challenge.

Section snippets

Significance of chemotherapy

In the early 1970s, new anti-neoplastic drugs such as adriamycin and methotrexate were introduced, and remarkable improvements in the prognosis for some sarcomas were seen.13, 14 Neo-Adjuvant or “assisted” chemotherapy is now used for most bone sarcomas prior to surgery.15, 16, 17, 18, 19 Chemotherapy causes tumor necrosis, which allows for safer removal. In addition, chemotherapy causes the tumor to develop a rind or margin and in some cases shrink, helping the surgeon to completely resect the

Conflicts of interest

The authors have none to declare.

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