Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol.

BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.

Compliance and satisfaction with intensive physiotherapy treatment during chemotherapy in patients with bone tumours and evaluation of related prognostic factors: An observational study.

The purpose of this study was to evaluate compliance and satisfaction of adult patients to intensive rehabilitation treatment during chemotherapy cycles after surgery for bone-musculoskeletal tumours, as well as to identify possible predictive factors. An observational, prognostic, prospective study was conducted. The study enrolled 27 patients who previously had undergone modular knee prosthesis surgery in the period between October 2014 and October 2015. The outcome was compliance to intensive rehabilitation treatment during hospitalisations in the chemotherapy unit and patient satisfaction 6 months' post-surgery. The variables taken into account were linked to the patient's characteristics, to the oncological pathology and to the chemotherapy treatment administered. Patients' compliance was 100% (range, 61-100). The presence of surgery complications (29.6%) produced 5% loss in compliance to treatment; likewise, chemotherapy treatment with prevalent use of ifosfamide reduced compliance to rehabilitation by 6%. The mean patient satisfaction score was 7.9 in the Likert scale from 0 to 10. Intensive physiotherapy starting during chemotherapy administration is a feasible treatment for bone tumour patients that have shown to be able to positively adhere to it. Rehabilitation treatments, within chemotherapy wards, should therefore be promoted according to satisfaction level as reported by patient.

Comprehensive Treatment and Rehabilitation of Patients With Osteosarcoma of the Mandible.

OBJECTIVE: The article studies state-of-the art physical therapeutic techniques as a high degree of relevance to minimize invalidation and improve quality of life for patients with dental osteosarcoma. MATERIALS AND METHODS: A randomized controlled clinical trial was conducted in 21 patients with osteogenic sarcoma of mandible (C41.1). There were 10 patients in the experimental group and 11 patients in the control group. RESULTS: A comprehensive treatment and rehabilitation program for patients with osteosarcoma of mandible was developed. The first part of the program comprised 3 basic phases: preop chemotherapy, surgery, and postop rehabilitation. The surgical treatment further included resection of an affected part of the mandible and primary repair of the defect with jaw fragments and an autoimplant joined together with the help of positioning devices. The postop rehabilitation included postop chemotherapy and mesodiencephalic modulation (MDM). The second part of the program comprised preop examination, modeling, using stereolytic 3-dimensional models of the mandible, corrective surgeries, including implantation into the autoimplant-a fragment of patient's fibula, and building of a removable titanium alloy-based denture. MDM sessions were administered after each invasive intervention. CONCLUSIONS: Higher psychological and physical well-being was observed in the experimental group as compared with the control group (P < 0.01) in 2 weeks after the first surgery and 2 months after scheduled corrective surgeries, which finished in denture installation.

Limb salvage in osteosarcoma using autoclaved tumor-bearing bone.

BACKGROUND: Tumor prostheses currently give the best short- and medium-term results for limb-salvage reconstruction procedures in the treatment of bone tumors. However, in developing countries, the cost of a tumor prosthesis is beyond the reach of much of the population. We report the use of autoclaved tumor-bearing bone in 10 patients, as an affordable alternative to the use of prostheses. METHODS: This is a case series of 10 patients (mean age 19 years) with osteosarcoma who were treated at our hospital from 1998 to 2008, and followed up for a mean of 35 months (range 14 to 8). The femur was involved in six cases, the humerus in three cases, and the ulna in one case. The mean length of the autoclaved bone was 150 mm (range 60-210). RESULTS: Bone union occurred in seven patients over an mean duration of 12 months (range 8-17). Three patients had non-union. Two of these had associated implant failure, with one of them also developing chronic infection, and the third is still being followed up. Two other patients had local recurrence. CONCLUSION: The use of autoclaved tumor grafts provides an inexpensive limb-salvage option without sacrificing appropriate oncologic principles. A painless and stable limb is achievable, and the use of this technique can be further refined.

Custom-made endoprosthetic total humerus reconstruction for musculoskeletal tumours.

PURPOSE: We analysed 11 patients with malignant musculoskeletal tumours of the humerus who underwent limb salvage surgery with total humeral custom endoprosthesis from 1990 to 2009. METHODS: There were six male and five female patients, with a mean age of 17 years. The most common diagnosis was osteosarcoma. The average follow-up period was 66 months, with the maximum being 180 months. Functional and oncological outcomes were analysed. RESULTS: The one and five year cumulative survival (Kaplan-Meier method) rates were 90.9% and 77.9 %. The average Musculoskeletal Tumour Society Score (MSTS) was 80%. Two patients died due to metastasis. One patient had a forequarter amputation for local recurrence. The procedure provides fast recovery and relatively good restoration of elbow function, whereas active shoulder movements remain limited CONCLUSION: Total humeral custom endoprosthetic replacement represents a viable treatment option in indicated patients, providing reliable and reasonable function of the upper limb, with a low complication rate.

Prosthetic rehabilitation of a maxillectomy with a two-piece hollow bulb obturator. A clinical report.

Extensive bilateral midfacial defects involving the upper jaw, palate, and sinus present a formidable reconstructive challenge. A combination of total and subtotal maxillectomy is, in general, a rare surgical procedure that affects the cosmetic, functional, and psychological aspects of a patient's life. Prosthetic restoration has become the preferred method for the rehabilitation of such conditions. The use of magnets is an efficient means of providing combined prostheses with retention, quality, and stability. This clinical report describes the rehabilitation of a total and subtotal maxillectomy patient with a two-piece hollow bulb obturator retained with the help of magnets and a retention clasp.

Quality of life in young patients after bone tumor surgery around the knee joint and comparison with healthy controls.

BACKGROUND: This study aimed to compare the health related quality of life (HRQoL) of children and adolescents after malignant bone tumor surgery of the leg with healthy controls. PROCEDURE: Patients between 8 and 25 years old were cross-sectional recruited. Patients under 16 years of age received the TNO (Netherlands Organization for Applied Scientific Research) and AZL (Leiden University Medical Center) Children's Quality of Life Questionnaire (TACQOL), patients aged 16 years and older received the TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL) and the Short Form-36 (SF-36). Three age- and sex-matched normative random samples, drawn from large, nationwide studies, were used for the comparison with healthy controls. Patients were interviewed regarding their most important problems related to the disease and its treatment. RESULTS: Eighty-one patients with a mean age of 16.9 years (SD 4.2) were included (41 female). Limb sparing surgery was executed in 38 patients, ablative surgery in 43 patients. In comparison with healthy controls, patients had significantly poorer HRQoL within the domains autonomy and motor function of the TACQOL, gross motor function, cognitive functioning, daily functioning and sexuality of the TAAQOL, and physical functioning, role physical, general health, and the physical and mental component summary scales of the SF-36. Patients reported limitations in physical activities, participation in sports, and cosmetic aspects as the most detrimental consequences of their disease and its treatment. CONCLUSION: In children and adolescents who underwent surgery for a malignant tumor of the leg physical, functioning was significantly impaired as compared to healthy controls.

Team Approach: Rehabilitation Strategies for Patients After Osteosarcoma Reconstructive Surgery.

The multimodal treatment of osteosarcoma with chemotherapy, surgical resection, and reconstruction has improved outcomes after a limb-salvage surgical procedure. Physical rehabilitation considerations after surgical resection vary, depending on the location of the tumor. Physical medicine and rehabilitation physicians incorporate lymphedema specialists, orthotists, and prosthetists to help to improve limb function. Beyond physical rehabilitation, psychological or behavioral interventions and nutritional rehabilitation are necessary to maximize a patient's return to function.

The role of physical therapy and occupational therapy in the rehabilitation of pediatric and adolescent patients with osteosarcoma.

The approach to rehabilitation of patients with osteosarcoma has evolved with the many advances in the medical treatment and surgical management of this pediatric and adolescent cancer. In the past, amputation (often radical amputation) was the standard method for treating patients with extremity sarcomas, and rehabilitation was geared toward providing either functional training for patients who had not had limb replacement or prosthetic training for those who had received prostheses. Currently, limb-sparing procedures combined with adjuvant chemotherapy (and occasionally radiotherapy) are used to treat most patients with this disease. In addition, physical-therapy and occupational-therapy interventions are now tailored to address the multiple physical and psychosocial difficulties these patients will face for the remainder of their lives. Integral parts of the interdisciplinary team, practitioners of these disciplines, provide services that enable patients to achieve their highest functional status to permit them to return to their role in society and hence enjoy dignity and improved quality of life.

Maxillofacial rehabilitation of a 7-year-old boy with osteosarcoma of the mandible using a free fibula flap and implant-supported prosthesis: a clinical report.

This clinical report describes the multidisciplinary approach in the maxillofacial rehabilitation of a 7-year-old boy diagnosed with osteosarcoma of the mandible. Following surgical resection of the left half of the mandible from the angle to the parasymphyseal region, a free osseocutaneous flap from the fibula was used to successfully reconstruct the mandible. Dental implants were subsequently placed, and an implant-supported, removable mandibular resection prosthesis was fabricated. Prosthodontic planning and treatment considerations in a growing child with a reconstructed mandible are discussed.

"So, are you back to work yet?" Re-conceptualizing 'work' and 'return to work' in the context of primary bone cancer.

People with primary bone cancer typically are young (usual age-at-onset 16-35 years old) and undergo arduous treatments. The current standard of care (tumour resection and limb reconstruction with or without chemotherapy) results in survival rates in excess of 60%, but also results in significant disability at a time when patients are choosing career paths, establishing their independence and embarking on new roles. To date, the nature of the relationship between experiences of osteosarcoma illness and experiences of vocation has remained unclear. This study sought to examine this relationship using qualitative narrative methodology. In-depth audiotaped interviews were conducted with 14 osteosarcoma survivors (8 men, 6 women) who were being treated at Mount Sinai Hospital, Toronto, Canada. Interview transcripts were analyzed for story typology and thematic content via constant comparison. Respondents reported engaging in three types of 'work': 'illness work', 'identity work' and 'vocational work'. Osteosarcoma illness represented a crisis for respondents, one which necessitated considerable illness work. Illness work was portrayed as all-consuming, whereby respondents were forced to stop vocational work for considerable periods. The illness crisis also precipitated 'identity work'. Respondents recounted a transformative process, of 'becoming other' to whom they had been prior to illness. As a result, respondents told of re-entering the vocational sphere with a different sense of themselves from when they left it. When patients return for surgical follow up, clinicians routinely ask, "So, are you back to work yet?" expecting simple 'yes/no' answers. This study suggests that the answer is instead highly complex, and that patients could be seen as having been 'working' all along. This study offers a re-conceptualization of 'work' and 'return to work' in the context of osteosarcoma, with implications for clinical and return-to-work practices.

Reconstruction of type II pelvic resection with a new peri-acetabular reconstruction endoprosthesis.

We report our early experience with a new peri-acetabular reconstruction endoprosthesis used for pelvic reconstruction after tumour resection. The outcome of 21 patients who underwent limb salvage following type II pelvic resection and reconstruction using the peri-acetabular reconstruction prosthesis between 2000 and 2006 was retrospectively reviewed. This prosthesis was designed to use the remaining part of the ilium to support a horizontally placed acetabular component secured with internal fixation and bone cement. Into this device a constrained acetabular liner is positioned which is articulates with a conventional femoral component to which a modular extension and modular head are attached. The mean follow-up was 20.5 months (1 to 77). The most common complications were deep infection, superficial wound infections, and dislocation. The mean musculoskeletal tumor society functional outcome score for the survivors was 20.1(11 to 27). We recommend the use of the peri-acetabular reconstruction prosthesis for reconstruction of large defects after type II pelvic resection, as this design has a greater inherent stability over other available prostheses.

Endoprosthetic reconstruction for malignant bone and soft-tissue tumors.

BACKGROUND: Nowadays, the results of the management of malignant bone and soft-tissue tumors have been dramatically improved because of the advance in imaging, chemotherapy, radiation therapy, and surgical techniques. Patients can have longer survival times with limb-salvage surgery. Several techniques of reconstruction have been advocated and gained more popularity following malignant tumor resection by using allograft, tumor prostheses, composite allograft prosthesis, or arthrodesis. OBJECTIVE: To report the preliminary results of 32 endoprosthetic reconstructions following malignant bone and soft-tissue tumor resection. The oncologic results, functional outcomes, and complications from the surgery were assessed in the present study. MATERIAL AND METHOD: Since September 1988, the authors have performed 188 limb-salvage surgical operations for the treatment of musculoskeletal tumors at Siriraj Hospital. From March 1994 to July 2006, 32 endoprosthetic reconstructions were performed on 30 patients following malignant bone or soft-tissue tumor removal. There were 16 males and 14 females with a mean age of 28 years (range 10-73). The diagnosis was conventional osteosarcoma in 16 patients, parosteal osteosarcoma in two patients, chondrosarcoma in two patients, leiomyosarcoma in two patients, failed allograft in two patients and one patient each of periosteal osteosarcoma, Ewing's sarcoma, Gorham's disease, synovial sarcoma, malignant fibrous histiocytoma, metastatic renal cell carcinoma, and prosthetic loosening. Wide excision was performed with a mean length of 18.5 cm (range 10-41). Five proximal femurs, 17 distal femurs, 1 total femur 3 proximal tibias, 1 intercalary tibia, 4 proximal humerus and 1 distal humerus were used for reconstruction. Modular replacement systems (MRS, Stryker/Howmedica/Osteonics) were the most common prostheses used in the present series. RESULTS: The mean follow-up time was 26 months (range 6-128.7). Sixteen patients are continuously free of the disease, two are alive with the disease, two had no evidence of the disease, nine died of the disease, and one patient died from complication of hypertension. The mean Musculoskeletal Tumor Society functional analysis for upper extremity reconstruction was 93% (range 86.7-100) and for lower extremity was 89% (range 63.3-100). Two patients (6.7%) were determined to be a failure. Revision due to aseptic loosening was performed in one patient (3.3%) and one hip disarticulation was done related to local recurrence (3.3%). One patient with sciatic nerve palsy and two seromas was found and successfully treated in the present study. CONCLUSION: Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb-salvage for patients with malignant bone and soft-tissue tumors. Most patients in the present report had good to excellent functions following surgery and few complications occurred in the present report.

Rotationplasty in adult cancer patients: what is the rehab strategy and what results can be expected? A case study.

BACKGROUND AND AIM: Rotationplasty is an important and demanding challenge for physiotherapists. The aim of this paper is to describe the functional outcome achieved by a patient undergoing rotationplasty in adult age following osteosarcoma. Case description and Methods: The patient was followed throughout the rehabilitation course and the results achieved were recorded at 6, 9 and 12 months after surgery. Findings and outcomes: The results progressively improved in terms of function, functional performance and quality of life. The MSTS and TESS scales showed an improvement respectively of 20 and 23 percentage points, reaching levels of 80% and 87%. The quality of life perceived by the patient increased in the three assessments, the mental health score at one-year follow-up is higher than that expected for the population. CONCLUSIONS: Rotationplasty, even in adult age, produces good results and in the treatment of tumours in adults this operation should be taken into consideration. Clinical relevance Rotationplasty in adult age following osteosarcoma combined with a rehabilitation program enabled a patient to reach a successful outcome in terms of functional performance and quality of life.

Resection of the ilium in patients with a sarcoma: should the pelvic ring be reconstructed?

AIMS: The aim of the study was to investigate the controversial issue of whether the pelvic ring should be reconstructed following resection of the sarcomas of the ilium. PATIENTS AND METHODS: From our database, we identified 64 patients who underwent excision of a tumour involving the ilium between 1976 and 2015. A total of 35 underwent complete resection, of whom 24 were reconstructed with a non-vascularised fibula graft, and four with extracorporeal irradiation and reimplantation. A total of 29 patients had a partial resection. The mean follow-up was 9.2 years (1.1 to 25.6). Functional outcomes were assessed using the Toronto Extremity Salvation Score (TESS) at final follow-up. In all, 32 patients (50%) had a chondrosarcoma. RESULTS: The mean TESS for all patients was 71.6% (17% to 100%). The mean TESS for those who underwent total resection with reconstruction was 72.0% (17% to 100%) and without reconstruction it was 53.3% (20% to 90%) and for those who underwent partial resection it was 76.3% (31.3% to 100%). The rate of local recurrence was 42.2% and this was more common in those treated by partial resection (p = 0.048). The risk of local recurrence was related to the margin achieved at resection. CONCLUSIONS: Given the high rate of local recurrence following excision of a tumour from the ilium, obtaining wide surgical margins should be a priority even if this requires more aggressive surgery. In young patients, where late recurrence may occur, more radical complete resection should be considered. When total resection of the ilium is considered, reconstruction should also be considered as it confers a higher functional outcome than total resection without reconstruction. Cite this article: Bone Joint J 2017;99-B:538-43.

Ankle ligament reconstruction after wide resection of the osteosarcoma of the distal fibula: a case report.

BACKGROUND: Restoration of the lateral ankle after distal fibulectomy is a difficult reconstructive procedure. Many surgical techniques have been proposed. This report shows another fibular reconstructive option with promising outcome. CASE PRESENTATION: We report the case of a 30-year-old woman who presented with a solitary mass located in the lateral aspect of the ankle. The mass had grown rapidly for 2 months and caused increasing pain. Physical examination showed a 3.0 cm diameter tender, nonmobile hard mass in the lateral malleolus. Radiographs showed an osteolytic lesion involving the lateral cortex at the distal fibula. After incisional biopsy, pathologic examination found a well-differentiated intramedullary osteosarcoma. Neoadjuvant chemotherapy with doxorubicin was provided for 3 months prior to definitive surgical treatment. Magnetic resonance imaging showed persistent tumor in the biopsy site. After distal fibulectomy and wide resection, split tibialis posterior tendon transfer to the remaining peroneus brevis restored the stability of the ankle. The pain resolved within 3 months. The ankle was stable and no recurrence of the cancer was found at a 7 year follow-up. CONCLUSION: Reconstruction following distal fibulectomy and surrounding soft tissue resection responds favorably to split tibialis posterior transfer to the remaining peroneus brevis suggesting that this technique can provide a good and functional outcome.

Functional outcomes after endoprosthetic knee reconstruction following resection of osteosarcoma near the knee.

PURPOSE: The aims of this study were to evaluate outcomes of osteosarcoma patients who underwent wide resection and endoprosthetic knee reconstruction, to compare with their own sound sides and controls, and to assess the interrelationships among these parameters. METHOD: Twenty patients and 20 matched controls were recruited. Strength and range of motion (ROM) of the knee, gait and Enneking functional score were measured. RESULTS: The results revealed the operated knees were significantly weaker than sound knees and controls (p < 0.05). The ROM of operated knees, sound knees and controls were 106.2 degrees +/- 13.0 degrees, 134.1 degrees +/- 7.5 degrees, and 137.7 degrees +/- 7.0 degrees respectively (p < 0.05). Patients' and controls' walking velocity were 54 +/- 12 m/min, and 72 +/- 6 m/min (p < 0.05). Their Enneking score was 21.6 +/- 2.8 (72% of total score, 30). The ratio of extensor strength of operated/sound knee and isometric hamstring/quadriceps ratio of operated knee were significantly correlated to the difference of stance-phase duration of bilateral sides (p < 0.05). In addition, the ratio of isometric flexor strength was significantly correlated to Enneking score (p < 0.05). CONCLUSIONS: The patients achieved an acceptable recovery in strength and gait in spite of some functional limitation.

[Rehabilitation pathway after knee arthroplasty with mega prosthesis in osteosarcoma]. / Il percorso riabilitativo del paziente sottoposto a intervento di protesi da grandi resezioni di ginocchio per neoplasia scheletrica.

INTRODUCTION: The knee is the most frequent location for osteosarcoma (60%). Until 30 years ago patients with osteosarcoma were treated with an amputation of the affected limb; today 85% of these cases are treated with a "Limb Salvage" procedure, through replacement of the affected bone with a mega prosthesis implant. AIM: To measure functional recovery of patients with a knee mega-prosthesis and how rehabilitation impacts on quality of life (QOL); another aim is to define rehabilitation guidelines to manage these patients in the rehabilitation pathway. METHODS: A sample of outpatients with knee mega-prosthesis were selected in the follow-up orthopedic oncology surgery between march and may 2013. We measured the functional outcome using the multidimensional standardized Musculoskeletal Tumor Society scale (MSTS) that gives a score (0-5) for each of 7 items: pain, range of motion, stability, deformity, strength, functional activity, emotional acceptance. RESULTS: The sample included 28 outpatients. The median MSTS score was 29 (min 19, max 33) equal to 83%. Only 14 patients (50%) followed a correct rehabilitation path after surgery. DISCUSSION: 21 cases got "excellent" outcomes and 3 "good" (based on MSTS classification). In few cases (n 4) the outcome was "fairly good", related to necessity of a prosthesis surgical revision based on instability of implant (because of usage). Quadricep strength is the item that most affects the final score. There is a statistically significant correlation between high scores and patients who have recently undergone surgery. We found higher scores in patients that followed a physiotherapy program after surgery: the difference was statistically significant. CONCLUSIONS: Mega-prosthesis implants give satisfactory functional outcomes. These outcomes keep high score in time. It is recommended to follow the guidelines described in the purposed rehabilitation program.

An amputee visitor program as an adjunct to rehabilitation of the lower limb amputee.

Based on evaluation of the rehabilitative needs of patients who have had a leg amputated because of cancer, an amputee visitor program was developed. The visitor is a cancer amputee who has successfully completed rehabilitation. About 5 days after a patient's amputation, the visitor sees the patient, telling of personal experiences, answering the patient's questions, and showing the prosthesis. The visitor later evaluates the visit on a data collection sheet. From 1 to 6 months after the visit, the patient and, if possible, a relative are interviewed to determine their long-term reaction to the program. During a 30-month period, 65 new patients were seen and evaluated by two visitors. Sixty (92%) responded favorably to the visit. In follow-up interviews with 36 patients, 33 (92%) said the visit substantially improved their outlook. In summary, our data indicate that the amputee visitor contributes significantly to rehabilitation.