Periosteal preservation: a new technique in resection of bone high-grade malignant tumors in children-about eleven cases

Abstract

Objective: The purpose of this study was to describe a surgical technique of bone resection with periosteal preservation and reconstruction in patients with high-grade bone malignant tumors and to determine its effect on local recurrences, and time and quality of bone union in bone autografting reconstruction.

Patients and methods: We retrospectively reviewed 11 cases of high-grade malignant bone tumors in children aged 4 to 16 years, who were treated with chemotherapy and tumor resection while preserving partially the adjacent periosteum. Tumors were located in the lower limb in eight cases; three tumors were in the humerus. The mean length of the bone defect after resection was 15.8 cm (range, 6-34.5 cm). Reconstruction was provided by non-vascularized autograft in eight cases (lower limb) and polymethyl methacrylate spacer in three cases (upper limb). Patients were followed up for a mean of 71 months.

Results: At the last follow-up, no patients had local recurrence. Three patients were dead because of metastasis. Bone union was good in time and quality in all children who had bone autografting. In cases of PMMA reconstruction, there was periosteal bone formation around the spacer. According to the MSTS functional score, patients with lower limb localizations had a mean score of 27.75 points and patients with upper limb localizations had a score of 24/30.

Conclusion: Preservation of the periosteum in bone resection for malignant tumors could be a good adjuvant alternative for bone reconstruction, without increasing the risk of local recurrence. However, patients must be carefully selected.

Keywords: Bone sarcoma; Children; Limb preservation; Periosteum; Surgery.

Fig. 1

Ewing sarcoma of the proximal tibia in an 8-year-old boy. MR images show an extra-compartmental involvement and a partially circumferential (medial) respect for the CPU. Footnotes: arrows: axial edges; chevrons: level of the periosteal section

Fig. 2

A Ewing sarcoma of the distal right fibula with purely intraosseous second localization in the homolateral proximal tibia in a 9-year-old boy. B Subperiosteal resection of the tibial localization with the previous site of biopsy. Tripod reconstruction was performed with non-vascularized autografts (2 fibulas and one tibia cortical). The distal fibula tumor was removed (at the same surgical time) (footnote: star: periosteum preserved). C Gross specimen with posterior and medial aspects. Proximal tibia without its periosteum and only the previous site of biopsy was resected with the tumor (footnote: star: anterior tibial tuberosity). D Serial radiographs showing rapid bone consolidation and good reconstruction. E Good functional result at 3-year follow-up. Little lower limb discrepancy. MSST=28/30

Fig. 3

A Osteosarcoma of the distal left femur in a 13-year-old boy. B Tumor resection by lateral approach with medial periosteal preservation. Reconstruction was performed with two non-vascularized fibula autografts. Only the medial fibula autograft was recovered by the preserved periosteum (footnote: arrows: section line of the periosteum, stars: periosteum preserved). C Gross specimen with medial half of femur without its periosteum. D Serial radiographs showing rapid bone consolidation and good reconstruction, particularly of the medial aspect. We note the difference between the anatomical results of the two non-vascularized fibula autografts: better union and bone integration of the medial fibula which was recovered by the preserved periosteum. E Good functional result at 3-year follow-up with 4.5-cm limb discrepancy and left genu valgum. MSST=28/30

Fig. 4

A Pandiaphyseal extension of bone recurrence of a previously treated clear cell renal tumor. Type 2 subperiosteal resection. B Periosteal bone reconstruction around the PMMA permitting its good fixation