We conducted a retrospective study of 61 patients, suffering from osteosarcoma, who presented to the CMJAH tumour Unit between 2007 and 2011. The average time to presentation to the unit, post-onset of symptoms, was 4.5 months. Most patients, 43/61 (70%), presented initially to a hospital or clinic; only 3/61patients (5%) presented first to traditional healers and 15/61 (25%) to a GP. 16 patients (26%) came from other South African provinces and 3 patients (5%) were international. 3 Patients (5%) presented with a pathological fracture. 3/61 (5%) patients were HIV positive, 8 unknown and the rest were HIV negative. A standard osteosarcoma work-up was performed. 4 patients (7%) were Enneking Stage 2A, 41 patients (67%) were Stage 2B and 16 patients (26%) presented with metastases (Stage 3). Biopsy was performed on average of 3 weeks post-presentation (delay largely due to MRI). Surgery was undertaken in 46 patients (75%), with the aim of achieving wide local resection margins: 13 (21%) limb salvage procedures and 33 (79%) limb ablations were performed. 4 patients refused further treatment. 54/57 patients (95%) underwent chemotherapy and, of these, 44 (81%) underwent a neo-adjuvant chemotherapy protocol and 2 patients (4%) received post-adjuvant chemotherapy only. 19/61 patients (31%) defaulted follow-up: of these 19 patients, 15 (79%) were amputees, 1 (5%) was a limb salvage patient and 4 (16%) were un-operated. Two patients developed local recurrence: 1 was treated with amputation & the other with further excision. Palliative Radiotherapy was administered to 2 patients. In March 2013, 41 patients were contactable. Of these, 17/41 (41%) were alive and of the surviving 17 patients, 9 (81%) were limb salvage patients and 6 (38%) were amputees. Of the 12 patients, who had initially presented with metastases, only I patient (8%) was alive. Only 1 of the 3 patients, who initially presented with pathological fracture, was traceable and alive. NO DISCLOSURESIntroduction
Results
The benefits of the Lautenbach suction-instillation have been recognised as an adjunct to the eradication of bone and joint infection. With the wide acceptance of external suction dressings as a means of accelerating wound healing and evacuating exudates, there are advantages to a system which combines these benefits for deep cavities with the direct infusion of antibiotics to increase local tissue concentrations. This is particularly useful in the extensive tissue defects encountered with wide excision of musculoskeletal tumours and reconstruction with mega prostheses or bulk allograft (with many patients undergoing adjuvant chemo- and radiotherapy), and also in complex orthopaedic trauma cases with tissue loss. These situations are associated with a reported infection incidence of up to 40%. The results of use of the Lautenbach suction-instillation system were studied prospectively in 100 patients over a 7 year period. Sixty cases followed wide excision of musculoskeletal tumours and 40 were caused by complex trauma. Due to logistics, many tumour cases were managed post-operatively in a septic orthopaedic ward. Immediate soft tissue cover was achieved in all tumour cases, utilising flaps where necessary, but cover was delayed for up to 3 weeks in some trauma cases. One late infection (2 years post-op) in a bulk allograft reconstructed sarcoma patient and 1 trauma infection were noted. Both were successfully eradicated with a secondary debridement & Lautenbach suction-instillation.Materials.
Results.
It has become standard practice in our unit to treat large giant cell tumours with intralesional curettage, burring, a locking plate and adjuvant liquid nitrogen & PMMA cementation. 24 patients have been treated in this fashion over the past 7 years. We have had 2 recurrences to date, both recent. These 2 cases of large Campanacci type 2 & 3 giant cell tumour of the distal femur & proximal tibia, successfully treated with megaprosthetic replacement are reported. One patient had lung metastases, which appeared stable and were being closely monitored for progress. Histopathology had been reviewed and giant-cell rich osteosarcoma definitely excluded. Osteoclastic inhibitory chemotherapy was instituted 6 weeks post-op.
Giant cell tumours of bone involving the lower limb are characteristically close to the knee joint and pose a challenge in their treatment with respect to functional outcome, risk of recurrence and complications. Various treatment modalities exist, but it is widely accepted that intra-lesional curettage followed by local adjuvants and cementation of the defect may protect the integrity of the nearby joint and maintain function and stability. Many studies have reported on the use of various adjuvants and different methods of filling the defect left by intralesional curettage as well as fixation of impending or simultaneous pathological fractures with plate and screws. Up to 12 weeks, or more, of non weight bearing has been advised post-op, particularly in the larger lesions. We have encountered no evidence of the use of locking plates in augmenting reconstruction with PMA bone cement, particularly when a large lesion, displaying a very thin cortical envelope is encountered, and where there may be concern for knee strength and stability post-op. We surmised that the addition of such a rigid construct would be of benefit in aiding a faster rehabilitation. At our institution we have treated 3 patients in this manner: two patients had large giant cell tumours of the proximal tibia and one involving the distal femur. They were treated with intralesional curettage, liquid nitrogen, and bone cementation but in all three cases, we augmented the cement filler with a locking plate. Although we have a limited sample size, and our mean follow-up is only 12 months, it has been our experience that this approach may provide an immediately stable knee, rapid rehabilitation with return to full weight bearing within 4–6 weeks and very good post-operative function by 3 months post-op, with few complications.
