WATCH: Femur bone replacement surgery

Prior to 1970 primary bone sarcomas had a less than 25% five-year survival and the primary surgical treatment was amputation. With the advent of chemotherapy and more advanced imaging techniques, it became evident that limb-sparing surgery was possible without affecting the overall oncological outcome and survival. Today patients with non-metastatic primary bone sarcoma have an up to 65% cure rate.

The most common indication for major structural allografts and endoprostheses is in orthopaedic oncological conditions. Seventy per cent of all primary bone sarcomas occur around the knee joint and are metaphyso-diaphyseal with frequent epiphyseal involvement. The management of these lesions is currently wide resection and adjuvant/neoadjuvant chemotherapy. Radiation is occasionally used post surgery.In 85% of extremity bone sarcomas, limb-sparing surgery is possible.

Patients with Anderson Orthopaedic Research Institute (AORI) type 3 defects requiring revision total knee arthroplasty (TKA) in the non-oncological population will occasionally require a so called ‘tumour prosthesis’ or bulk structural allograft when more conventional methods of reconstruction are not possible.

The focus of this paper is on the management of bone deficiency in patients with primary bone tumours. Massive bone loss around the knee has been managed historically with a massive tumour implant, an allograft or an allograft/prosthetic composite.

Options for reconstruction here are diverse and it is of utmost importance that the most effective technique, with the lowest complication rate, is used because a delay in resumption of chemotherapy (after more than 21 days post surgery) is associated with a poorer prognosis.1

The technique of reconstruction used is dependent on the age of the patient, the size and location of the tumour, the histological grade, surgeon preference/familiarity and availabilityof graft material and implants, namely, bulk allograft and custom endoprosthetics.

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