SURGICAL TREATMENT OF PATIENTS WITH ONCO-PATHOLOGY

TRANSOSSEOUS COMPRESSION-DISTRACTION OSTEOSYNTHESIS IN ORTHOPAEDIC REHABILITATION OF PATIENTS WITH PRIMARY TUMORS OF LONG TUBULAR BONES

I.I.Balaev

Regional oncological clinic of Kurgan (Head doctor is T.I. Sirotskaya)

"In surgical treatment

of bone tumors

the following major principles

should be followed:

radical character of the surgery�,

ablasticity�, limb saving�

without disturbance of its function"

Academician N.N.Trapeznikov

Primary bone tumors are rather rare and constitute 1-4% in the general structure of all oncological diseases of a human. But considering severity of the deformity it is one of the most difficult for diagnostics and treatment part of clinical oncology. In majority of cases they appear in children and young people and 70-80% of them are located in long tubular bones. Nowadays surgical, radial and medical methods are used for treatment of bone tumors considering their histo-genesis. However, for the majority of patients surgical method of treatment is the main and takes the most important place in the complex treatment. In benign tumors it is the only one which is effective.

Crippling (amputation, disarticulation) surgeries and saving (resection) surgeries are used in a surgical method of treatment of bone tumors depending on indications. A new and advanced scientific and practical trend in modern oncology and restorative surgery is saving surgeries. These surgeries combine elimination of a pathologic process and adequate substitution of the appeared after surgery bone defect ensuring limb function. Among modern methods of reconstructive and restorative surgery in long bone defects of various size and location transosseous osteosynthesis has large advantages concerning completeness of defect substitution and rational reconstruction of an injured limb. It is rather interesting that being wide-spread in orthopaedics and traumatology the method of transosseous compression-distraction osteosynthesis was previously not used in oncology notwithstanding the wide use of saving surgeries for bone tumor treatment in oncological clinic. Only in the latter decade reports appeared about the use of the method of transosseous compression-distraction osteosynthesis for surgical treatment of primary tumors of long tubular bones. However those works were based on comparatively small experience with transosseous osteosynthesis for this problem and reflect only some clinical aspects and results of its application. That information doesn't allow objective deep comparative evaluation of the techniques, their variants and specify differential indications to their application considering detailed specificity of treatment of benign and malignant bone tumors. So, it's impossible to get from the existing works any concrete recommendations on application of transosseous osteosynthesis in bone oncology. We have large clinical experience of successful application of transosseous osteosynthesis according to Ilizarov for rehabilitation of patients with primary tumors of long tubular bones. So many-factor summarizing, detailed systematization of clinical facts with developing detailed differential recommendations on application of particular techniques and their variants in restorative treatment of this severe bone pathology is highly topical.

The material is based on analysis of 72 patients with primary tumors of tubular bones treated by transosseous osteosynthesis. 76.2% of patients were under 30 years old. 28.9% were children and adolescents. According to histologic structure 47 (65.2%) patients had benign tumors: giant cell tumor - 38 (52.7%) patients, chondroma - 4 (5.5%), chondroblastoma - 2 (2.8%), chondromyxoid fibroma - 2 (2.8%), desmoplastic fibroma - 1 (1.4%). 25 (34.8%) patients had malignant tumors: osteogenic sarcoma - 11 (15.3%) patients, juxtacortical osteosarcoma - 2 (2.8%), malignant fibrous histocitoma - 7 (9.7%), reticulosarcoma - 2 (2.8%), Ewing's sarcoma - 1 (1.4%), fibrosarcoma - 1 (1.4%), adamantinoma of long bones - 1 (1.4%). 20 patients with benign tumor had femur involved, 22 - tibia, 5 - humerus and radius. 5 patients with malignant tumors had femur involved, 16 - tibia, 1- a metatarsal bone, and 3 - humerus. The most typical location of the tumor was epimetaphysis. Bones forming knee joint were most frequently involved (39 patients (54.1%)).

Distribution of the patients with malignant tumors depending on the surgical degree of the disease according Enneking W.F., et al is represented in Table 1.

Table 1 shows that in 15 (60.0%) patients the size of the tumor was beyond the limits of a single anatomic structure, the tumor was highly malignant, and 2 patients had regional or remote metastasis. It made limb-saving surgeries in this group of patients difficult and worsened remote prognosis of treatment.

Considering indications 19 (76.0%) patients with malignant bone tumors (osteogenic sarcoma - 11, malignant fibrous histocitoma - 5, reticulosarcoma - 2, Ewing's sarcoma - 1) had neoadjuvant chemotherapy according to techniques developed at RONC, and 3 patients in pre-surgical period received also radial therapy with total focal dose 36 gray. Efficacy of the chemotherapy and radial treatment in pre-surgical period was evaluated according to a degree of medical pathomorphism of a tumor according to the scheme represented by Huvos A.G., et al. 9 (47.3%) patients had 3 degree of medical pathomorphism of a tumor, 10 (52.7%) - 1-2 degree.

Post-resection bone defects were from 5 to 27 cm. For their substitution the following procedures were used: mono- and poly-local lengthening of bone fragments, adjacent segments and inter-bone synostozation, a developed variant of free autoplasty combined with transosseous osteosynthesis for juxta-articular location of a benign tumor and free autoplasty by a tubular fragment of a fibular for substitution of a total and subtotal humeral defect in a malignant tumor. New technical solutions were suggested for optimization of conditions and increase of the efficacy of reconstructive and restorative treatment. They are protected by author certificates (author certificate 1168229) and 2 applications for a patent of the RF (the application 93052252, priority of November 16, 1993; application 94006637, priority of March 22, 1994).

Dynamics of reparative osteogenesis in the treatment period was studied by methods of osteoscintigraphy and two-photon absorbtion measurement (Fig. 1). It showed improvement of metabolism in bone tissue during substitution of post-resection defects by distraction regenerate formation. Mineralization of regenerates is quicker after removal of a benign tumor then after removal of a malignant tumor. Such tendency is noted during 1-3 month of distraction. By the end of distraction and the beginning of fixation the process of mineralization gets similar.

Analysis of the treatment outcomes varied, considering generally accepted oncological principles and according to criteria of anatomic and functional rehabilitation.

In the group of patients (47) with benign tumors there were no recurrences. Survival of the patients (25) with malignant tumors agreed with the middle statistical data of the world's literature and was 68.4% of patients - during 3 years and 46.6% of patients - during 5 years. Evaluation of anatomic and functional outcomes of the orthopaedic rehabilitation showed that the techniques were effective in 94.6% of patients who concluded the treatment.

2 clinical cases illustrate efficacy of the developed techniques of treatment.

Case 1. Male patient, 5 years old was admitted to Kurgan regional oncological clinic. He complained of a tumor and ache after physical activity in the lower third of the right femur. A year before palpation disclosed a tumor in the lower third of the right femur. Radiography and trepanobiopsy showed a juxtacortical osteosarcoma. At a local clinic the patient had 1 course of poly-chemotherapy (adrimicin, vincristin, cyclophosphan, sarcolysin) and distance gamma-therapy with a summed focal dose 36 gray. Parents of the patient refused a suggested amputation.

In the lower third of the right femur a bone tumor originating from the femur with the size 4x4 cm was discovered at admittance. There was also a moderate muscular atrophy of the femur and the tibia. The range of motions in the knee joint was limited because of limited flexion 90 degrees. The X-rays (Fig.2) showed a destruction focus with a lobate structure and round shape tight-fitting to the cortical bone layer in the distal metadiaphysis of the right femur. The size of the new growth was 3.5x1.5 cm. Diagnosis: juxtacortical osteosarcoma in the distal metadiaphysis of the right femur. The second histologic study of the micropreparations from the tumor trepanobiopsy confirmed the stated diagnosis of a juxtacortical osteosarcoma. The decision was made to do a segmental resection of the distal metadiaphysis of the right femur and to correct the surgical defect using a technique of monolocal consecutive compression-distraction osteosynthesis.

The surgery was accomplished as it had been planned with peridural anesthesia. The defect of the distal metadiaphysis of the right femur after the surgery was 5 cm. Histologic study of the preparation from the removed tumor showed juxtacortical osteosarcoma (Fig. 3). The post-surgical period was smooth. Stable compression was created and supported during 12 days at the junction of the lower margin of the proximal femoral fragment and the upper margin of the distal fragment. Then distraction was done at the junction of the bone fragments. It lasted 75 days till the surgical bone defect was corrected (Fig. 4, 5). The following fixation of the limb in a frame lasted 8 months. Restoration of the anatomical integrity and length of the femur preserving growth plates was achieved. Examination 5 years later showed no recurrence of the tumor. The patient ambulated without an additional support, studied at school (Fig. 6).

Case 2. Female patient, 11 years old was admitted to Kurgan regional oncological clinic with complaints of a periodic ache and tumor in the left tibia. Examination showed an elastic tumor on the anterior surface of the left lower-leg in projection of the proximal tibial metaepiphysis. The tumor was painful by palpation with the size 4x3 cm. The range of motions in the knee joint is limited because of flexion. Moderate atrophy of the femoral and tibial muscles. The X-ray (Fig. 7) revealed a focus of bone tissue destruction with the size 5x3 cm in the left proximal tibial metaepiphysis consisting of osteosclerotic foci. On the anterior surface there was a periosteal Kodman shelf. Diagnosis: osteogenic sarcoma of the left tibial proximal metaepiphysis. Biopsy data confirmed the clinical and radiographic diagnosis of an osteogenic sarcoma. Considering the morphological structure of the tumor, its location and size, the age of the patient the decision was made to do a neoadjuvant chemotherapy and limb-saving surgery including segmental resection of the proximal articular end of the tibia. The surgical defect was corrected by lengthening of the distal fragment creating a tibia-femoral synostosis using the technique of bilocal consecutive distraction-compression osteosynthesis. The patient had 2 courses of intravenous infusion of adriblastin with a total dose 200 mg in a 3 weeks' interval. The treatment led to elimination of pain, decrease of the soft tissue tumor component. 2 weeks later the surgery was accomplished according to the plan with a peridural anesthesia. The post-surgical defect length of the proximal articular end of the left tibia was 13 cm. Histologic study of the preparation showed an osteogenic sarcoma, an osteoplastic variant, medical pathomorphosis of the tumor of the 3d degree (Fig. 8). Post-surgical period was without complications. A week later the osteotomed split of the distal tibial fragment was transported down to the site of the surgical defect. The distraction lasted for 4 months till the contact of the transported split with the lower part of the femur was achieved. The subsequent fixation in a frame lasted for 8 months (Fig. 9). Supportability of the limb was restored with creation of tibia-femoral synostosis. Simultaneously with the defect correction 7 courses of post-surgical chemotherapy in the pre-surgical mode were done. The total dose of adriblastin including the pre-surgical chemotherapy was 920 mg. 2 years later in the process of growth the patient got a growth lag of the operated limb 5 cm. The limb shortening was corrected by a tibial lengthening at a single level. The patient was examined 10 years after the surgery. She had no complaints, ambulated freely without an additional support. Radiographs (Fig. 10) showed tibial integrity, tibia-femoral synostosis, and no recurrence of the tumor.

Both the clinical cases illustrate the application of the method in children-patients with a non-finished skeletal formation. According to the data of Russian and foreign authors it is a contraindication for limb-saving surgeries because in these cases using classical methods of plasty (auto-, alloplasty, endoprosthesis) leads to a considerable growth lag of the involved limb and its functional disability.

Thus, our experience of transosseous osteosynthesis application for treatment of patients with primary bone tumors showed that the method was highly effective, allowed correction of posttraumatic bone defects and optimal limb reconstruction not only in adults but in children with a non-completed skeletal formation. For patients with a bone sarcoma considering indications the method is advisable after a preliminary stage including radical and ablastic tumor resection with a considerable complex of neoadjuvant chemotherapy. When resecting benign tumors rehabilitation measures on anatomic and functional restoration of the operated limb should be fulfilled in one stage.

Table 1

Distribution of patients with bone sarcomas regarding a surgical stage of the disease