Limb salvage surgery with endoprosthesis reconstruction in management of locally advanced primary bone tumours: a functional outcome evaluation

Shashank Kumar Sinha, Arijit Das, Ayon Das, Sanjib Ghosh


Background: Endoprosthetic reconstruction using a custom-made metallic mega-endoprosthesis is one of the common modalities for limb salvage operation. The new promising advance of material science, design and fabrication of the endoprosthesis enable an immediate rehabilitation program and provide a durable and functional limb. The aim of the study was to evaluate the efficacy and functional outcome in patients with primary bone tumours treated by limb salvage surgery using endoprosthetic replacement.

Methods: A total of 14 patients with primary bone tumour in major large joints of the body, selected between January 2019 to August 2020, were managed by limb salvage surgery via endoprosthetic replacement. This was a prospective study conducted at a Tertiary care Government Hospital in Kolkata, and all patients were followed up to a minimum of 1.5 years. The evaluation system used was proposed by Enneking, recommended by the musculoskeletal tumour society in addition to the radiologic evaluation.

Results: At final follow-up, the mean musculoskeletal tumour society score was 89.71±3.58. The mean Knee Society Score of 9 patients was 85.55±3.64 and mean Harris hip score of 2 patients and Oxford shoulder score of 4 patients were 90.5 and 41.67 respectively by the end of 1.5 years. 12 (85.7%) patients did not have any complications. None of the cases had implant loosening or breakage, periprosthetic fracture, tumour recurrence or amputation.

Conclusions: Endoprosthesis are excellent choices for the treatment of bone tumours with limb preservation in relation to pain, strength, and patient’s emotional acceptance as they reconstruct a limb with an acceptable oncologic, functional, and cosmetic result providing immediate weight-bearing capacity and generating a greater independence.


Bone tumour, Limb salvage, Endoprosthetic reconstruction, Amputation, Joint prosthesis, Functional outcome

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Franchi A. Epidemiology and classification of bone tumors. Clinical Cases in mineral and bone metabolism. 2012;9(2): 92.

Kropej D, Schiller C, Ritschl P, Salzer-Kuntschik M, Kotz R. The management of IIB osteosarcoma: experience from 1976 to 1985. Clin Orthop Relat Res. 1991;40-4.

Aksnes LH, Bauer HCF, Jebsen NL, et al. Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients. J Bone Joint Surg. 2008;90:786-94.

Bacci G, Ferrari S, Bertoni F. Long-term outcome for patients with nonmetastatic osteosarcoma of the extremity treated at the istituto ortopedico rizzoli according to the istituto ortopedico rizzoli/osteo-sarcoma-2 protocol: an updated report. J Clin Oncol. 2000;18:4016-27.

Ferrari S, Smeland S, Mercuri M. Neoadjuvant chemotherapy with highdose Ifosfamide, high-dose methotrexate, cisplatin, and doxorubicin for patients with localized osteosarcoma of the extremity: a joint study by the Italian and Scandinavian Sarcoma Groups. J Clin Oncol. 2005;23:8845-52.

Grimer RJ. Surgical options for children with osteosarcoma. Lancet Oncol. 2005;6:85-92.

Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long- term oncological, functional, and quality-of-life study. J Bone Joint Surg. 1994;76-A:649-56.

Link MP, Goorin AM, Miser AW, Green AA, Pratt CB, Belasco JB, et al. The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity. N Engl J Med. 1986;314:1600-6.

Meyers PA, Heller G, Vlamis V. Osteosarcoma of the extremities: chemotherapy experience at Memorial Sloan-Kettering. Cancer Treat Res. 1993; 62:309-22.

Marcove RC, Rosen G. En bloc resections for osteogenic sarcoma. Cancer. 1980;45(12): 3040-4.

Mankin HJ, Gebhardt MC, Jennings LC, Springfield DS, Tomford WW. Long-term results of allograft replacement in the management of bone tumors. Clin Orthopaed Related Res. 1996;324:86-97.

Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. J Bone Joint Surg. 1986;68-A: 1331-7.

Jeys LM, Grimer RJ, Carter SR, Tillman RM. Risk of amputation following limb salvage surgery with endoprosthetic replacement, in a consecutive series of 1261 patients. Int Orthop. 2003;27:160-3.

Uyttendaele D, De Schryver A, Claessens H. Limb conservation in primary bone tumours by resection, extracorporeal irradiation and re-implantation. J Bone Joint Surg. 1988;70-B:348-53.

Malawer MM. Distal femoral resection for sarcomas of bone. In: Sugarbaker PH, Malawer MM, eds. Musculoskeletal surgery for cancer. New York: Thieme Medical Publishers; 1992: 243-59.

Refaat Y, Gunnoe J, Hornicek FJ, Mankin HJ. Comparison of quality of life after amputation or limb salvage. Clin Orthop Relat Res. 2002;397:298-305.

Bacci G, Picci P, Ferrari S. Primary chemotherapy and delayed surgery for nonmetastatic osteosarcoma of the extremities. Results in 164 patients preoperatively treated with high doses of methotrexate followed by cisplatin and doxorubicin. Cancer. 1993;72:3227-38.

Capanna R, van Horn JR, Biagini R. Reconstruction after resection of the distal fibula for bone tumor. Acta Orthop Scand. 1986;57:290-4.

Eckardt JJ, Eilber FR, Dorey FJ, Mirra JM. The UCLA experience in limb salvage surgery for malignant tumors. Orthopedics. 1985;8:612-21.

Zeegen EN, Aponte-Tinao LA, Hornicek FJ, Gebhardt MC, Mankin HJ. Survivorship analysis of 141 modular metallic endoprostheses at early followup. Clin Orthop Relat Res. 2004;420:239-50.

Sharma S, Turcotte RE, Isler MH, Wong C. Experience with cemented large segment endoprostheses for tumors. Clin Orthop Relat Res. 2007;459459:54-9.

Turcotte RE. Endoprosthetic replacements for bone tumors: review of the most recent literature. Curr Opin Orthop. 2007;18:572-8.

Hamed KAA, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Tsuchiya H. Epiphyseal sparing and reconstruction by frozen bone autograft after malignant bone tumor resection in children. Sarcoma. 2015;2015:45-9.

Li J, Wang Z, Ji C, Chen G, Liu D, Zhu H. What are the oncologic and functional outcomes after joint salvage resections for juxtaarticular osteosarcoma about the knee?. Clin Orthopaed Related Res. 2017;475(8):2095-104.

Muratori F, Totti F, D'Arienzo A, Scorianz M, Scoccianti G, Beltrami G, et al. Biological intercalary reconstruction with bone grafts after joint-sparing resection of the lower limb: is this an effective and durable solution for joint preservation?. Surg Technol Int. 2018;32:346-5.

Eiser C, Darlington AS, Stride CB, Grimer R. Quality of life implications as a consequence of surgery: Limb salvage, primary and secondary amputation. Sarcoma. 2001;5:189-95.

Han G, Bi WZ, Xu M, Jia JP, Wang Y. Amputation versus limb-salvage surgery in patients with osteosarcoma: A meta-analysis. World J Surg. 2016; 40:2016-27.

Asavamongkolkul A, Waikakul S, Phimolsarnti R, Kiatisevi P, Wangsaturaka P. Endoprosthetic reconstruction for malignant bone and soft-tissue tumors. J Med Assoc Thai. 2007;90:706-17.

Torbert JT, Fox EJ, Hosalkar HS, Ogilvie CM, Lackman RD. Endoprosthetic reconstructions: results of long-term followup of 139 patients. Clin Orthop Relat Res. 2005;438:51-9.

Futani H, Minamizaki T, Nishimoto Y, Abe S, Yabe H, Ueda T. Long-term follow-up after limb salvage in skeletally immature children with a primary malignant tumor of the distal end of the femur. J Bone Joint Surg Am 2006;88:595-603.

Palumbo BT, Henderson ER, Groundland JS. Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques. Cancer Control. 2011;18: 160-70.