Distal Femur Resection With Endoprosthetic Reconstruction

1 CLINICAL ORTHOPAEDICS AND RELATED RESEARCHN umber 400, pp. 225 235 2002 Lippincott Williams & Wilkins, Distal Femur is a common site for primaryand metastatic bone tumors and therefore, it isa frequent site in which limb-sparing surgery isdone. Between 1980 and 1998, the authors treated110 consecutive patients who had Distal femurresection and Endoprosthetic were 61 males and 49 females who rangedin age from 10 to 80 years. Diagnoses included99 malignant tumors of bone, nine benign-aggressive lesions, and two nonneoplastic condi-tions that had caused massive bone loss and ar-ticular surface destruction. Reconstruction wasdone with 73 modular prostheses, 27 custom-made prostheses, and 10 expandable gastrocnemius flaps were used forsoft tissue Reconstruction . All patients were fol-lowed up for a minimum of 2 years. Functionwas estimated to be good or excellent in 94 pa-tients ( ), moderate in nine patients ( ),and poor in seven patients ( ).

2 Complica-tions included six deep wound infections ( ),six aseptic loosenings ( ), six prosthetic poly-ethylene component failures ( ), and localrecurrence in five of 93 patients ( ) who hada primary bone sarcoma. The limb salvage ratewas 96%. Distal Femur Endoprosthetic recon-struction is a safe and reliable technique of func-tional limb sparing that provides good functionand local tumor control in most Distal Femur is a common anatomic loca-tion for primary and metastatic bone ,7 These tumors traditionally were treated with re-section arthrodesis or amputation of the extrem-ity, with unfavorable functional and psycho-logic ,27 Improved survival amongpatients with sarcomas made these drawbackseven more pronounced and stimulated the in-vestigation of a less aggressive surgical ap-proach. Simon et al26compared the results oflimb-sparing resections with those of amputa-tion in 227 patients who had an osteosarcoma ofthe Distal Femur .

3 They concluded that doing alimb-sparing procedure in lieu of amputationdid not shorten the disease-free interval or com- Distal Femur Resection WithEndoprosthetic ReconstructionA Long-Term Followup StudyJacob Bickels, MD*; James C. Wittig, MD*; Yehuda Kollender, MD**; Robert M. Henshaw, MD*; Kristen L. Kellar-Graney, BS*; Issac Meller, MD**; and Martin M. Malawer, MD*From the * Department of Orthopedic Oncology, Wash-ington Cancer Institute, Washington Hospital Center,George Washington University, Washington DC; and**The National Unit of Orthopedic Oncology, Tel-AvivSourasky Medical Center, Sackler Faculty of Medicine,Tel-Aviv University, Tel-Aviv, requests to Martin M. Malawer, MD, Departmentof Orthopedic Oncology, Washington Cancer Institute,Washington Hospital Center, 110 Irving Street, NW,Washington, DC : May 7, : September 18, : October 11, the long-term survival of these and function, however, weremuch better, with preservation of knee motionand ability to use of induction chemotherapy, coupledwith advances in imaging and surgical tech-niques, now make it possible to do Distal femurendoprosthetic Reconstruction in 90% to 95% ofpatients with primary bone sarcoma of ,13,19,20,23,25,28 Grimer et al11showed that alimb-sparing Resection with Endoprosthetic re-construction clearly is more cost-effective thanamputation.

4 The reason for this finding is thatmost patients with primary bone sarcoma areyoung and active. If treated by amputation, theyprobably will require a sophisticated artificiallimb that has to be replaced at regular intervals,and may include the use of an artificial sportlimb, swimming limb, and spare limb. In addi-tion, most patients will have stump problemsdevelop that will necessitate recasting of experience with Distal fe-mur Endoprosthetic Reconstruction led to its usein the treatment of metastatic bone tumors andnononcologic ,18,29 Between 1980and 1998, the authors did Distal Femur resectionwith Endoprosthetic reconstructions in 110 con-secutive patients. The current study was done attwo oncology centers, using the same techniqueof Resection and Reconstruction . On the basis ofthis long-term experience, principles of distalfemur Resection with Endoprosthetic recon-struction with emphasis on surgical anatomy,surgical technique, and functional and onco-logic outcomes are AND METHODSB etween 1980 and 1998, 110 consecutive patientshad Distal Femur Resection with Endoprosthetic re-construction.

5 Patients were treated at two institu-tions; all participating surgeons were trained to-gether and used the same techniques of Resection andreconstruction. There were 61 males and 49 femaleswho ranged in age from 10 to 80 years (median, ). Nineteen patients were younger than 12years. Ninety-three patients had primary bone sarco-mas, five patients had other primary malignant tu-mors of bone, and one patient had metastatic carci-noma to the Distal Femur . Nine patients had benign-aggressive lesions, and two patients had massivebone loss and destruction of the articular surface at-tributable to nonneoplastic diagnoses. Table 1 showsthe histopathologic diagnoses and surgical classifi-cation of the patients in this staging studies were done beforesurgery for all patients with primary bone studies included plain radiography, com-puted tomography (CT), and magnetic resonanceimaging (MRI) of the entire thigh, knee, and attention was given to tumor extentthrough the Distal Femur , the anatomic location andextent of cortical breakthrough, and magnitude ofsoft tissue extension and its relation to the poplitealvessels.

6 When posterior cortical breakthrough waspresent, angiography also was done to evaluatemore accurately the patency of the popliteal vesselsand their relation to the TechniqueDistal Femur Resection with Endoprosthetic recon-struction has three steps: tumor Resection , endopros-thetic Reconstruction , and soft tissue ,12,19 Each step is ResectionThe patient is placed in the supine position on theoperating table, and a long medial incision is incision begins in the midthigh, crosses theknee along the medial parapatellar area and distalto the tibial tubercle, and then slightly curves pos-terior to the pes muscles. The biopsy site is in-cluded, with a 2-cm margin in all directions. Thisincision enables wide exposure of the Distal 1 2of thefemur, sartorial canal, knee, popliteal fossa, andproximal 1 2of the tibia. Distal extension of the in-cision allows the use of a gastrocnemius flap, ifnecessary. The popliteal space is approached by de-taching and retracting the medial hamstrings.

7 Thisexposes the popliteal vessels and sciatic interval between the popliteal vessels andthe posterior Femur then is developed by ligationand transection of the geniculate vessels. The dis-tal Femur is approached via the interval between therectus femoris and vastus medialis, leaving the in-tact vastus intermedius over the Distal Femur . Aportion of the vastus medialis is left over the me-dial soft tissue extension of the tumor. Alterna-tively, a portion of the vastus lateralis is left over alateral soft tissue extension. The joint capsule thenis opened longitudinally along its anteromedialClinical Orthopaedics226 Bickels et aland Related ResearchNumber 400 July, 2002 Distal Femur Resection with Endoprosthetic Reconstruction227border and ligaments and menisci are Femur osteotomy is done at the appropriatelocation as determined by the preoperative imagingstudies (Fig 1). In general, 3 to 4 cm beyond thepoint of proximal tumor extension is appropriatefor primary sarcomas; 1 to 2 cm is sufficient formetastatic carcinomas.

8 A tibial osteotomy then isdone to allow the introduction of the prosthetic tib-ial component. It is done in the same manner as astandard knee arthroplasty; approximately 1 cm ofbone is removed. The osteotomy is perpendicularto the long axis of the 1. Histopathologic Diagnoses and Surgical Staging of 110 Patients TreatedWith Distal Femur Endoprosthetic ReconstructionEnneking s Surgical Number ofClassification10 Histologic DiagnosesPatientsIAIBIIAIIBIIBP rimary bone sarcomasOsteosarcoma74 51671 Chondrosarcoma5 1 4 Malignant fibrous histiocytoma5 23 Ewing s sarcoma4 4 Pleomorphic sarcoma2 2 Primitive neuroectodermal tumor1 1 Synovial cell sarcoma1 1 Leiomyosarcoma of bone1 1 Other primary malignant Lymphoma of bone4 NANANANANA tumors of boneMultiple myeloma1 NANANANANAM etastatic lesionsMalignant melanoma1 NANANANANAB enign-aggressive tumorsGiant-cell tumor8 NANANANANAS ynovial chondromatosis1 NANANANANAN onneoplastic diagnosesOsteoarthritis1 NANANANANAO steoporosis1 NANANANANAT otal110 6383 NA nonapplicableFig Distal Femur osteotomy isshown.

9 An intact layer of the vastus in-termedius muscle is left over thespecimen. Reprinted from Malawer 30 Distal Femoral Resectionwith Endoprosthetic Reconstruction In Malawer MM, Sugarbaker PH Mus-culoskeletal Cancer Surgery: Treat-ment of Sarcomas and Allied Academic Publishers Dordrecht2001. Page 475 Endoprosthetic ReconstructionSince their introduction in the mid1980s, modularprostheses were used preferably for Reconstruction (Fig 2). Custom-made prostheses were used only incases requiring unusual stem length or diameter. Ex-pandable prostheses were used in patients youngerthan 12 years. The largest possible stem diameterwas used. The canal was reamed 2 mm larger thanthe chosen stem diameter. Trial articulation initiallywas done; the device used for this step in the proce-dure includes a femoral stem, body, condyle compo-nents, axle and polyethylene bushings, and tibialbearing and plug definitive modular prosthesis then is assem-bled (Fig 3).

10 Exact orientation of the prosthesis is es-sential. Based on the linea aspera and tibial tuberos-ity as the remaining anatomic guidelines, the femo-ral and tibial components are placed in line withboth. The cementing technique involved pulsatilelavage, use of an intramedullary cement restrictor,reduction of the cement by centrifugation, use of ce-ment gun, and pressurization of the cement. Patellarresurfacing is not done routinely because most pa-tients who have this procedure are young and with -out significant degenerative changes in the Tissue ReconstructionSpecial attention is given to covering the prosthesiscompletely with muscle tissue. The remaining vastusmedialis is sutured to the rectus femoris. The sarto-Clinical Orthopaedics228 Bickels et aland Related ResearchFig 2.(A) Schematics (Reprinted from Malawer M. Chapter 30 Distal Femoral Resection with Endopros-thetic Reconstruction In Malawer MM, Sugarbaker PH Musculoskeletal Cancer Surgery: Treatment of Sar-comas and Allied Academic Publishers Dordrecht 2001.)