Review ArticleManagement of infection following reconstruction in bone tumors
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.
References (93)
- et al.
Results of multidisciplinary limb salvage in 240 consecutive bone sarcomas
Biomed Pharmacother
(1990) - et al.
Chemotherapy in osteosarcoma. Basis for application and antagonism to implementation: early controversies surrounding its implementation [Review]
Hemotol Oncol
(1995) - et al.
Limb salvage surgery and adjuvant radiotherapy for soft tissue sarcomas of the forearm and hand
J Hand Surgery
(1997) - et al.
Local control and function after twice-a-day radiotherapy for Ewing's sarcoma of bone
Int J Radiat Oncol Biol Phys
(1991) - et al.
Local control and functional results after twice-daily radiotherapy for Ewing's sarcoma of the extremities
Int J Radiat Oncol Biol Phys
(1996) - et al.
The role of radiation therapy in the management of non-metastatic Ewing's sarcoma of bone. Report of the intergroup Ewing's sarcoma study
Int J Radiat Oncol Biol Phys
(1981) - et al.
Combined therapy of localized Ewing's sarcoma of bone: analysis of results in 100 patients
Int J Radiat Oncol Biol Phys
(1990) - et al.
A multidisciplinary study investigating radiotherapy in Ewing's sarcoma: end results of POG #8346
Int J Radiat Oncol Biol Phys
(1998) - et al.
Salvaging the limb salvage: management of complications following endoprosthetic reconstruction for tumours around the knee
Eur J Surg Oncol
(2007) - et al.
Two-stage revision of infected uncemented lower extremity tumor endoprostheses
J Arthroplasty
(2007)
Advances in the treatment of sarcomas of the extremity. Current status of limb salvage
Cancer
The management of IIB osteosarcoma: experience from 1976 to 1985
Clin Orthop
Modular prosthetic system for segmental bone and joint replacement after tumor resection
Orthopedics
A modular femur tibia reconstruction system
Orthopaedics
Segmental replacement of long bones using titaniium fiber metal composite following tumor resection
Clin Orthop
Prosthetic replacement of the distal femur for primary bone tumors
J Bone Joint Surg [Br]
Segmental total knee arthroplasty after distal femoral resection for tumor
Clin Orthop
Endoprosthetic reconstruction for malignant bone tumors and nontumorous conditions of bone
Endoprosthetic reconstruction for limb salvage surgery
Biomed Eng Appl Basis Commun
Endoprosthesis-related complications after limb-salvage operation of malignant bone tumors around the knee
Biomed Eng Appl Basis Commun
The treatment of malignant bone tumors by conservative surgery
Recent Results Cancer Res
Neoadjuvant chemotherapy for nonmetastatic osteosarcoma of the extremities
Clin Orthop
Limb salvage operations for patients with malignant bone tumors in the extremities
Tzu Chi Med J
Presurgical chemotherapy compared with immediate surgery and adjuvant chemotherapy for nonmetastatic osteosarcoma: Pediatric Oncology Group Study POG-8651
J Clin Oncol
Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols
J Clin Oncol
The effect of adjuvant chemotherapy on relapse free survival in patients with osteosarcoma of the extremity
N Engl J Med
A comparison of two short intensive adjuvant chemotherapy regimens in operable osteosarcoma of limbs in children and young adults
J Clin Orthop
Influence of chemotherapy on perioperative complications in limb salvage surgery for bone tumors
Cancer
Neoadjuvant chemotherapy for breast carcinoma: multidisciplinary considerations of benefits and risks
Cancer
The role of radiotherapy in the treatment of bone and soft-tissue sarcomas musculoskeletal cancer surgery
Malawer Chapter
Radiation therapy in the mulimodal management of Ewing's sarcoma of bone. Report of the intergroup Ewing's sarcoma study
Natl Cancer Inst Monogr
Preoperative radiation therapy of high malignancy grade soft tissue sarcoma: a preliminary investigation
Acta Radiol Oncol
Influence of surgical margins on outcome in patients with preoperatively irradiated extremity soft tissue sarcomas
Cancer
Preoperative regional therapy for extremity sarcoma. A tricenter update
Cancer
Tolerance of normal tissues to therapeutic radiation
Reports Radiother Oncol
The risks and benefits of radiotherapy with massive endoprosthetic replacement
J Bone Joint Surg Br
Dose tolerance limits and dose volume histogram evaluation for stereotactic body radiotherapy
J Appl Clin Med Phys
Peri-Prosthetic Infection in the Orthopedic Tumor Patient
JISRF Reconstructive Rev
Incidence and outcome after infection of megaprostheses
Hip Int
Complications and their management following limb-salvage with total knee replacement
Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma
J Surg Oncol
Endoprosthetic reconstruction in 250 patients with sarcoma
Clin Orthop Relat Res
Endoprosthetic replacement for primary tumours around the knee: experience from Peking University
J Bone Joint Sur Br
Endoprosthetic replacement for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis
J Bone Joint Surg Am
Endoprosthetic replacement of the proximal humerus. Long-term results
J Bone Joint Surg Br
Infected tumor prostheses
Orthopaedics
Cited by (38)
Doxorubicin loaded cerium substituted hydroxyapatite nanoparticles: A promising new therapeutic approach for bone regeneration, doxorubicin delivery, and cancer treatment
2024, International Journal of PharmaceuticsMelt-derived copper-doped ferrimagnetic glass-ceramic for tumor treatment
2021, Ceramics InternationalCitation Excerpt :Moreover, glasses and glass-ceramics composition can be easily modified by introducing ions with therapeutic effect [31–33], both during the materials synthesis (e.g. as precursors during the melt and quenching or sol-gel process) [34–36] or after the materials synthesis (e.g. by means of ion exchange technique) [37–39]. A common problem connected to the surgery of bone tumors is the development of infections [40,41], especially in patients already immunocompromised due to radio and chemotherapies. For this reason, the authors modified a bioactive and ferrimagnetic glass-ceramic by introducing elements with antimicrobial effect.
Intralesional curettage versus prosthetic replacement for bone tumors — a finite element analysis case of limb salvage simulation in biomechanics
2021, Computer Methods and Programs in BiomedicineCitation Excerpt :These biomechanical performance generated from pre-surgical designs indicates that “prosthetic replacement” may decrease mechanical failure and revision comparable to “intralesional curettage”. Actually, reconstruction with modular customized oncological megaprostheses has become a common procedure nowadays, because wider resection takes advantages of rapid recovery, early weight bearing and lower recurrence, even if smaller resection margins of intralesional curettage allow for preservation of the growth plate and larger areas for endoprosthetic fixation [2,14]. The primary objective of surgical therapy is complete excision of tumors (giant cell or chondrosarcoma tumor, etc.), a secondary goal is conservation of the limb, and the last resort is amputation [6].
USP1 inhibitor ML323 enhances osteogenic potential of human dental pulp stem cells
2020, Biochemical and Biophysical Research CommunicationsCitation Excerpt :Therefore, DPSCs are good sources of studying the role of LHX8 in osteodifferentiation. Craniofacial bone defects caused by osteomyelitis, malignancy, or traumatic conditions require bone reconstruction [11,12]. Autologous bone grafting is the traditional approach for reconstruction [13].
Evaluation of Absolute Neutrophil Count in the Perioperative Setting of Sarcoma Resection
2024, Advances in Orthopedics