Limb function and quality of life after various reconstruction methods according to tumor location following resection of osteosarcoma in distal femur

Abstract

Background: We tried to compare the functional and psychosocial outcomes after various reconstruction methods according to tumor location following resection of osteosarcoma in distal femur.

Methods: We retrospectively reviewed 51 patients who underwent limb-salvage surgery of osteosarcoma in distal femur in our institution, 30 males and 21 females with an average age of 21 years (range 13-51 years). We classified osteosarcoma in distal femur into 3 types, and organized affected limb reconstruction methods after wide resection. MSTS and QOL scores were used to analyze the functional and psychological outcomes.

Results: After a mean follow-up of 43 months (12-225 months), there is no difference on functional results and QOL scores among three reconstruction groups (p > 0.05) and among three types groups (p > 0.05). No difference could be noticed on tumor-free survival and total survival among three reconstruction groups (p > 0.05) and three type groups (p > 0.05). In ≤2-year, better functional scores could be found in prosthesis group, rather than the other two inactivated-bone groups (p < 0.05).

Conclusions: Biological reconstruction with alcohol-inactivated autograft replantation could avoid prosthesis related complications and achieved comparable results with prosthesis following resection of osteosarcoma in distal femur. Different reconstruction options could be chosen according to tumor location, such as the distance to Insall line.

Figure 1

Classification of tumor location according to preoperative MRI. Type I (a), tumors located in the diaphysis at a distance of ≥ 1 cm from the Insall line. Type II (b), tumors located in contact with the Insall line or within 1 cm from this line. Type III (c), tumors extended from the diaphysis to the epiphysis beyond the Insall line.

Figure 2

A 20-year-old male patient with osteosarcoma in left distal femur was treated with alcohol-inactivated autograft replantation with articulation preservation. a Preoperative MRI showed intramedullary low mixed signal in T1 in distal femur. The lowest boarding of tumor lies 2cm over Insall line which was classified as Type I. b-d Postoperative X-ray at 1 week, 3 months and 6 months. e and f 16 months and 20 monthes after operation, X-ray showed bone callus in diaphysis, and bony healing in conjunction between host bone and inactivated bone. g 35 months after operation, X-ray showed fully bony healing and good joint space. At the end of follow-up, he has returned to normal work with 33 in MSTS score and 53 in QOL.

Figure 3

A 15-year-old female patient with osteosarcoma in right distal femur was treated with alcohol-inactivated autograft replantation with articulation preservation. a. Preoperative MRI showed intramedullary high and low mixed signal in distal femur. The tumor lies near Insall line which was classified as Type II. b. Preoperative X-ray showed osteolytic bone destruction in distal femur, in accompany with severe bone destruction in lateral cortical bone, local soft tissue mass and periosteal reaction. c. Postoperative X-ray showed significantly reduced osteolytic bone destruction in distal femur, in accompany with local soft tissue mass disappearance and restoration of the continuity of the lateral periosteum. d. Two months after operation, X-ray showed bone callus in diaphysis, and bony healing in conjunction between host bone and inactivated bone. e. 110 months after operation, X-ray showed fully bony healing and good joint space.

Figure 4

A 15-year-old male patient with osteosarcoma in left distal femur was treated with alcohol-inactivated autograft replantation with articulation preservation. a. Preoperative MRI showed intramedullary high and low mixed signal in distal femur. The lowest boarding of tumor lies 2cm over Insall line which was classified as Type I. b. Preoperative X-ray showed osteolytic bone destruction in distal femur, in accompany with severe bone destruction in lateral cortical bone, local soft tissue mass and periosteal reaction. c. Postoperative X-ray showed significantly reduced osteolytic bone destruction in distal femur, in accompany with local soft tissue mass disappearance and restoration of the continuity of the lateral periosteum. d. Two weeks after operation, X-ray showed reposition of inactivated bone with outside cortical allograft bone bridging. e. Nine months after operation, X-ray showed diaphysis fracture and bony healing in conjunction between host bone and inactivated bone. f. 30 months after reoperation, X-ray showed fully bony healing and good joint space.

Figure 5

A 17-year-old female patient with osteosarcoma in left distal femur was treated with prosthesis replacement. a 8 years after operation, bone lose and prosthesis loosening could be found on X-ray. Physical examination demonstrated 6 cm limb length discrepancy with 26 in MSTS score and 44 in QOL. b After prosthesis revision, the left lower limb alignment restored and 3 cm limb length discrepancy remained.

Figure 6

Kaplan-Meier survival curves showing survival by 3 reconstructions (a) and by 3 types (b) in patients following resection of osteosarcoma in distal femur. There is no difference on tumor-free survival and total survival among three reconstruction groups (p < 0.01) and three type groups (p < 0.01).