Reconstruction of bone defects after resection of osteosarcoma in children with artificial hemi-knee prosthesis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SHEN Rongkai ^1,2 , CHEN Meng ^1,2 , CHEN Fei ^1,2 , SONG Yaoguang ^1,2 ,  ZHU Xia ^1,2

1. Department of Bone Oncology, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350004, P. R. China;
2. Department of Orthopedics, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou Fujian, 350004, P. R. China;

Corresponding author：

ZHU Xia, Email: zhuhouy5399@fjmu.edu.cn

Keywords：

Osteosarcoma; artificial semi-knee prosthesis; limb salvage surgery; limb length discrepancy

DOI：

10.7507/1002-1892.202503035

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Objective To explore the effectiveness of artificial hemi-knee prosthesis reconstruction for bone defects after resection of pediatric osteosarcoma. Methods A retrospective analysis was conducted on the clinical data of 18 children with osteosarcoma who met the selection criteria and were treated between January 2016 and December 2019. There were 11 males and 7 females, aged 6-10 years (mean, 8.9 years). Osteosarcoma located in the distal femur in 11 cases and the proximal tibia in 7 cases. Among them, 12 cases were conventional osteosarcoma and 6 cases were small cell osteosarcoma, with a disease duration of 1-9 months (mean, 3.1 months). All patients received 2 cycles of preoperative chemotherapy with doxorubicin, cisplatin, and ifosfamide. After en bloc tumor segment resection, bone defects were reconstructed using custom-made artificial hemi-knee prostheses. Rehabilitation training was initiated at 8 weeks postoperatively under the protection of a knee immobilizer brace, combined with 4 cycles of adjuvant chemotherapy. During follow-up, lower limb growth length and limb shortening (compared with the healthy side) were measured, and limb function was evaluated using the Musculoskeletal Tumor Society-93 (MSTS-93) scoring system. Results All surgeries were successfully completed, with an operation time of 2.0-3.1 hours (mean, 2.4 hours) and intraoperative blood loss of 180-320 mL (mean, 230.0 mL). Incisional edge necrosis occurred in 1 case at 10 days postoperatively, while the incisions of the remaining 17 patients healed by first intention. One case developed periprosthetic infection caused by Staphylococcus aureus at 1 week postoperatively, which was cured after symptomatic treatment. All 18 patients were followed up 60-96 months (mean, 74.2 months). No local tumor recurrence was observed during follow-up. Imaging examinations showed prosthesis loosening in 2 cases, while the prosthesis of other patients were well-positioned. At last follow-up, the knee joint range of motion was 80°-120° (mean, 106.7°). The MSTS-93 score was 16-29 (mean, 24.7), with 12 cases rated as excellent, 5 good, and 1 fair. The patients’ height increased by 12.8-20.0 cm (mean, 15.5 cm), the lower limb growth length was 6.0-13.0 cm (mean, 9.7 cm), and limb shortening was 1.8-4.6 cm (mean, 3.1 cm). There was no significant difference in MSTS-93 scores, lower limb growth length, or limb shortening between the distal femur group and the proximal tibia group (P>0.05). Conclusion Artificial hemi-knee prosthesis reconstruction can preserve the adjacent normal epiphysis of the knee joint, maximize limb growth potential, and reduce adult limb length discrepancy, making it a suitable reconstruction option for children with knee osteosarcoma.

Citation： SHEN Rongkai, CHEN Meng, CHEN Fei, SONG Yaoguang, ZHU Xia. Reconstruction of bone defects after resection of osteosarcoma in children with artificial hemi-knee prosthesis. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(7): 824-830. doi: 10.7507/1002-1892.202503035 Copy

1.	Zhao X, Wu Q, Gong X, et al. Osteosarcoma: a review of current and future therapeutic approaches. Biomed Eng Online, 2021, 20(1): 24. doi: 10.1186/s12938-021-00860-0.
2.	Grimer RJ. Surgical options for children with osteosarcoma. Lancet Oncol, 2005, 6(2): 85-92.
3.	Aponte-Tinao L, Ayerza MA, Muscolo DL, et al. Survival, recurrence, and function after epiphyseal preservation and allograft reconstruction in osteosarcoma of the knee. Clin Orthop Relat Res, 2015, 473(5): 1789-1796.
4.	Kim Y, Jeon DG, Cho WH, et al. Clinical outcomes of endoprosthetic reconstruction for proximal femoral resection. Jpn J Clin Oncol, 2021, 51(8): 1248-1252.
5.	Becktell K, Chen Y, Yasui Y, et al. Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS). Pediatr Blood Cancer, 2024, 71(10): e31189. doi: 10.1002/pbc.31189.
6.	No authors listed]. Osteosarcoma. Nat Rev Dis Primers, 2022, 8(1): 76. doi: 10.1038/s41572-022-00411-4.
7.	Kang S, Lee JS, Park J, et al. Staged lengthening and reconstruction for children with a leg-length discrepancy after excision of an osteosarcoma around the knee. Bone Joint J, 2017, 99-B(3): 401-408.
8.	Wang J, Tang J, Tan X, et al. Amputation predisposes to higher cancer-specific mortality than limb salvage surgery in pediatric patients with osteosarcoma of the limbs: A propensity matching analysis. Front Surg, 2022, 9: 817051. doi: 10.3389/fsurg.2022.817051.
9.	Kaneuchi Y, Yoshida S, Fujiwara T, et al. Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity. J Pediatr Surg, 2022, 57(11): 702-709.
10.	Kapukaya R, Karaali E, Çiloğlu O, et al. Epiphysis salvage reconstruction and associated complications following tumor resections in skeletally immature patients. Indian J Surg Oncol, 2021, 12(1): 164-171.
11.	Sambri A, Staals E, Medellin MR, et al. Stanmore noninvasive extendible endoprosthesis in the treatment of bone sarcoma in the preadolescent. J Surg Oncol, 2019, 120(2): 176-182.
12.	Lex JR, Adlan A, Tsoi K, et al. Frequency and reason for reoperation following non-invasive expandable endoprostheses: A systematic review. J Bone Oncol, 2021, 31: 100397. doi: 10.1016/j.jbo.2021.100397.
13.	Dukan R, Mascard E, Langlais T, et al. Long-term outcomes of non-invasive expandable endoprostheses for primary malignant tumors around the knee in skeletally-immature patients. Arch Orthop Trauma Surg, 2022, 142(6): 927-936.
14.	Gosheger G, Schulze M, Mathilda de Vaal M, et al. MUTARS^® Humero pro Femur replacement: A novel reconstructive procedure after malignant bone tumor resection of the femur in young children. J Bone Oncol, 2022, 35: 100444. doi: 10.1016/j.jbo.2022.100444.
15.	Ji T, Yang Y, Li DS, et al. Limb salvage using non-hinged endoprosthesis and staged correction of leg-length discrepancy for children with distal femoral malignant tumors. Orthop Surg, 2019, 11(5): 819-825.
16.	Li Y, Xu H, Yang Y, et al. Survival and functional outcomes after hemiarthroplasty in children with proximal tibial osteosarcoma. J Orthop Surg Res, 2024, 19(1): 619. doi: 10.1186/s13018-024-05103-1.
17.	Xu H, Li Y, Yu F, et al. An innovative staged prosthetic lengthening reconstruction strategy for osteosarcoma-related leg discrepancy. Sci Rep, 2024, 14(1): 717. doi: 10.1038/s41598-023-50422-8.
18.	Grinberg SZ, Posta A, Weber KL, et al. Limb salvage and reconstruction options in osteosarcoma. Adv Exp Med Biol, 2020, 1257: 13-29.
19.	Arkader A, Viola DC, Morris CD, et al. Coaxial extendible knee equalizes limb length in children with osteogenic sarcoma. Clin Orthop Relat Res, 2007, 459: 60-65.
20.	Morris CD, Wustrack RL, Levin AS. Limb-salvage options in growing children with malignant bone tumors of the lower extremity: A critical analysis review. JBJS Rev, 2017, 5(7): e7. doi: 10.2106/JBJS.RVW.16.00026.
21.	赵志庆, 郭卫, 燕太强. 儿童膝关节周围骨肉瘤治疗中肢体生长潜能保留的研究进展与展望. 肿瘤防治研究, 2024, 51(11): 898-907.
22.	Braun S, Thewes N, Holder J, et al. Accuracy of adult height predictions in patients with axial leg deviations using the modified and the abbreviated modified fels knee system. PLoS One, 2024, 19(11): e0311985. doi: 10.1371/journal.pone.0311985.
23.	Hubbard EW, Liu RW, Iobst CA. Understanding skeletal growth and predicting limb-length inequality in pediatric patients. J Am Acad Orthop Surg, 2019, 27(9): 312-319.
24.	Li Y, Liao F, Xu HR, et al. Is there a reliable method to predict the limb length discrepancy after chemotherapy and limb salvage surgery in children with osteosarcoma? Chin Med J (Engl), 2016, 129(16): 1912-1916.
25.	Wang L, Fan Y, Zhou Y, et al. Prognosis of limb-salvage treatment of osteosarcoma in adolescent patients: a meta-analysis. Oncol Lett, 2023, 26(5): 466. doi: 10.3892/ol.2023.14053.
26.	Xu M, Wang Z, Yu XC, et al. Guideline for limb-salvage treatment of osteosarcoma. Orthop Surg, 2020, 12(4): 1021-1029.
27.	Benedetti MG, Okita Y, Recubini E, et al. How much clinical and functional impairment do children treated with knee rotationplasty experience in adulthood? Clin Orthop Relat Res, 2016, 474(4): 995-1004.
28.	Zan P, Wang H, Cai Z, et al. Revision surgeries for tumor endoprostheses around the knee joint: a mid-long-term follow-up of 20 cases. World J Surg Oncol, 2022, 20(1): 76. doi: 10.1186/s12957-022-02542-0.
29.	Xu M, Tu J, Huang Y, et al. Comparison of oncological and functional outcomes in Lower-limb osteosarcoma pediatric patients: a large single-center retrospective cohort study. Int J Surg, 2024, 110(7): 4208-4220.
30.	Savvidou OD, Kaspiris A, Dimopoulos L, et al. Functional and surgical outcomes after endoprosthetic reconstruction with expandable prostheses in children: A systematic review. Orthopedics, 2019, 42(4): 184-190.
31.	Zou C, Zhao Z, Lin T, et al. Long-term outcomes of limb salvage treatment with custom-made extendible endoprosthesis for bone sarcoma around the knee in children. J Orthop Surg Res, 2020, 15(1): 14. doi: 10.1186/s13018-019-1534-x.
32.	Wong KC, Kumta SM. Joint-preserving tumor resection and reconstruction using image-guided computer navigation. Clin Orthop Relat Res, 2013, 471(3): 762-773.
33.	伍骥, 朱克顺, 潘庆联. 半关节置换术在小儿胫骨上段恶性骨肿瘤中的应用. 中国修复重建外科杂志, 2006, 20(10): 978-980.
34.	Zhao Z, Yang Y, Yan T, et al. Outcomes of fixed-hinged knee prosthesis for distal femoral osteosarcoma in skeletally immature patients: First results. J Knee Surg, 2023, 36(1): 68-78.
35.	Zan P, Shen J, Liu K, et al. Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children. Front Pediatr, 2023, 11: 1168637. doi: 10.3389/fped.2023.1168637.

1. Zhao X, Wu Q, Gong X, et al. Osteosarcoma: a review of current and future therapeutic approaches. Biomed Eng Online, 2021, 20(1): 24. doi: 10.1186/s12938-021-00860-0.
2. Grimer RJ. Surgical options for children with osteosarcoma. Lancet Oncol, 2005, 6(2): 85-92.
3. Aponte-Tinao L, Ayerza MA, Muscolo DL, et al. Survival, recurrence, and function after epiphyseal preservation and allograft reconstruction in osteosarcoma of the knee. Clin Orthop Relat Res, 2015, 473(5): 1789-1796.
4. Kim Y, Jeon DG, Cho WH, et al. Clinical outcomes of endoprosthetic reconstruction for proximal femoral resection. Jpn J Clin Oncol, 2021, 51(8): 1248-1252.
5. Becktell K, Chen Y, Yasui Y, et al. Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS). Pediatr Blood Cancer, 2024, 71(10): e31189. doi: 10.1002/pbc.31189.
6. No authors listed]. Osteosarcoma. Nat Rev Dis Primers, 2022, 8(1): 76. doi: 10.1038/s41572-022-00411-4.
7. Kang S, Lee JS, Park J, et al. Staged lengthening and reconstruction for children with a leg-length discrepancy after excision of an osteosarcoma around the knee. Bone Joint J, 2017, 99-B(3): 401-408.
8. Wang J, Tang J, Tan X, et al. Amputation predisposes to higher cancer-specific mortality than limb salvage surgery in pediatric patients with osteosarcoma of the limbs: A propensity matching analysis. Front Surg, 2022, 9: 817051. doi: 10.3389/fsurg.2022.817051.
9. Kaneuchi Y, Yoshida S, Fujiwara T, et al. Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity. J Pediatr Surg, 2022, 57(11): 702-709.
10. Kapukaya R, Karaali E, Çiloğlu O, et al. Epiphysis salvage reconstruction and associated complications following tumor resections in skeletally immature patients. Indian J Surg Oncol, 2021, 12(1): 164-171.
11. Sambri A, Staals E, Medellin MR, et al. Stanmore noninvasive extendible endoprosthesis in the treatment of bone sarcoma in the preadolescent. J Surg Oncol, 2019, 120(2): 176-182.
12. Lex JR, Adlan A, Tsoi K, et al. Frequency and reason for reoperation following non-invasive expandable endoprostheses: A systematic review. J Bone Oncol, 2021, 31: 100397. doi: 10.1016/j.jbo.2021.100397.
13. Dukan R, Mascard E, Langlais T, et al. Long-term outcomes of non-invasive expandable endoprostheses for primary malignant tumors around the knee in skeletally-immature patients. Arch Orthop Trauma Surg, 2022, 142(6): 927-936.
14. Gosheger G, Schulze M, Mathilda de Vaal M, et al. MUTARS^® Humero pro Femur replacement: A novel reconstructive procedure after malignant bone tumor resection of the femur in young children. J Bone Oncol, 2022, 35: 100444. doi: 10.1016/j.jbo.2022.100444.
15. Ji T, Yang Y, Li DS, et al. Limb salvage using non-hinged endoprosthesis and staged correction of leg-length discrepancy for children with distal femoral malignant tumors. Orthop Surg, 2019, 11(5): 819-825.
16. Li Y, Xu H, Yang Y, et al. Survival and functional outcomes after hemiarthroplasty in children with proximal tibial osteosarcoma. J Orthop Surg Res, 2024, 19(1): 619. doi: 10.1186/s13018-024-05103-1.
17. Xu H, Li Y, Yu F, et al. An innovative staged prosthetic lengthening reconstruction strategy for osteosarcoma-related leg discrepancy. Sci Rep, 2024, 14(1): 717. doi: 10.1038/s41598-023-50422-8.
18. Grinberg SZ, Posta A, Weber KL, et al. Limb salvage and reconstruction options in osteosarcoma. Adv Exp Med Biol, 2020, 1257: 13-29.
19. Arkader A, Viola DC, Morris CD, et al. Coaxial extendible knee equalizes limb length in children with osteogenic sarcoma. Clin Orthop Relat Res, 2007, 459: 60-65.
20. Morris CD, Wustrack RL, Levin AS. Limb-salvage options in growing children with malignant bone tumors of the lower extremity: A critical analysis review. JBJS Rev, 2017, 5(7): e7. doi: 10.2106/JBJS.RVW.16.00026.
21. 赵志庆, 郭卫, 燕太强. 儿童膝关节周围骨肉瘤治疗中肢体生长潜能保留的研究进展与展望. 肿瘤防治研究, 2024, 51(11): 898-907.
22. Braun S, Thewes N, Holder J, et al. Accuracy of adult height predictions in patients with axial leg deviations using the modified and the abbreviated modified fels knee system. PLoS One, 2024, 19(11): e0311985. doi: 10.1371/journal.pone.0311985.
23. Hubbard EW, Liu RW, Iobst CA. Understanding skeletal growth and predicting limb-length inequality in pediatric patients. J Am Acad Orthop Surg, 2019, 27(9): 312-319.
24. Li Y, Liao F, Xu HR, et al. Is there a reliable method to predict the limb length discrepancy after chemotherapy and limb salvage surgery in children with osteosarcoma? Chin Med J (Engl), 2016, 129(16): 1912-1916.
25. Wang L, Fan Y, Zhou Y, et al. Prognosis of limb-salvage treatment of osteosarcoma in adolescent patients: a meta-analysis. Oncol Lett, 2023, 26(5): 466. doi: 10.3892/ol.2023.14053.
26. Xu M, Wang Z, Yu XC, et al. Guideline for limb-salvage treatment of osteosarcoma. Orthop Surg, 2020, 12(4): 1021-1029.
27. Benedetti MG, Okita Y, Recubini E, et al. How much clinical and functional impairment do children treated with knee rotationplasty experience in adulthood? Clin Orthop Relat Res, 2016, 474(4): 995-1004.
28. Zan P, Wang H, Cai Z, et al. Revision surgeries for tumor endoprostheses around the knee joint: a mid-long-term follow-up of 20 cases. World J Surg Oncol, 2022, 20(1): 76. doi: 10.1186/s12957-022-02542-0.
29. Xu M, Tu J, Huang Y, et al. Comparison of oncological and functional outcomes in Lower-limb osteosarcoma pediatric patients: a large single-center retrospective cohort study. Int J Surg, 2024, 110(7): 4208-4220.
30. Savvidou OD, Kaspiris A, Dimopoulos L, et al. Functional and surgical outcomes after endoprosthetic reconstruction with expandable prostheses in children: A systematic review. Orthopedics, 2019, 42(4): 184-190.
31. Zou C, Zhao Z, Lin T, et al. Long-term outcomes of limb salvage treatment with custom-made extendible endoprosthesis for bone sarcoma around the knee in children. J Orthop Surg Res, 2020, 15(1): 14. doi: 10.1186/s13018-019-1534-x.
32. Wong KC, Kumta SM. Joint-preserving tumor resection and reconstruction using image-guided computer navigation. Clin Orthop Relat Res, 2013, 471(3): 762-773.
33. 伍骥, 朱克顺, 潘庆联. 半关节置换术在小儿胫骨上段恶性骨肿瘤中的应用. 中国修复重建外科杂志, 2006, 20(10): 978-980.
34. Zhao Z, Yang Y, Yan T, et al. Outcomes of fixed-hinged knee prosthesis for distal femoral osteosarcoma in skeletally immature patients: First results. J Knee Surg, 2023, 36(1): 68-78.
35. Zan P, Shen J, Liu K, et al. Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children. Front Pediatr, 2023, 11: 1168637. doi: 10.3389/fped.2023.1168637.

Chinese Journal of Reparative and Reconstructive Surgery

Reconstruction of bone defects after resection of osteosarcoma in children with artificial hemi-knee prosthesis

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