Session 10: Tumor
Fredag den 23. oktober
09:00 – 10:00
Lokale: Reykjavik
Chairmen: Johnny Keller / Claus Lindkær Jensen
109. Use of pneumatic tourniquet does not reduce the total postoperative blood loss after transtibial amputation. A prospective case-control study of 76 non-traumatic transtibial amputations.
Christian Wied, Morten Tange Kristensen, Peter Toft Tengberg, Gitte Holm, Nicolai Bang Foss, Anders Troelsen
Dept. of Orthopaedic Surgery , Copenhagen University Hospital Hvidovre, Denmark; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Hvidovre, Denmark; Department of Anaesthesia, Copenhagen University Hospital Hvidovre, Denmark
Background: Tourniquet reduces the intraoperative blood loss
when applied during transtibial amputations (TTA).
However, side effects such as damage to vessels
and soft tissues as well as hyperperfusion remains
unilluminated. Further, the total postoperative blood
loss and risk of reoperation needs evaluation to
better balance the potential benefits and risks of
tourniquet.
Purpose / Aim of Study: The primary aim was to determine the total
calculated blood loss within the first four days after
TTA's, conducted with and without tourniquet.
Secondly, to investigate the association between the
use of tourniquets and re-amputations.
Materials and Methods: Primary TTA’s operated in 2013-14 at our institution
were eligible for inclusion (n=86). We excluded 8
because of bilateral amputations and 2 because of
traumas. The study group consisted of 76 TTA’s
performed due to diabetes related complications or
severe arteriosclerosis (38 with tourniquet / 38
without tourniquet). The decision to use tourniquet
relied on the surgeons. The total blood loss
(intraoperative until postoperative day 4) was
calculated based on the hemoglobin level using a
transfusion trigger of 6mmol/l and the estimated
blood volume.
Findings / Results: The demographic data showed no difference
between the two groups. The total calculated blood
loss on day four after surgery was 930 ml ± 763 in
the tourniquet group vs. 947 ml ± 717 in the non-
tourniquet group (p=0.98 in a multivariate analysis).
Correspondingly, no significant differences were
found in transfusion requirements after four days or
in the re-operation rates at one and three months
follow-up.
Conclusions: Performing a TTA with the use of tourniquet does not
reduce the total calculated blood loss or transfusion
requirements when evaluated on postoperative day
4. The use of tourniquet does not seem to influence
the re-amputation rates.
110. Is there a correlation between Skin Perfusion Pressure and healing after amputation below the knee?
Kate Smidt, Niels Krarup, Jan Abrahamsen, Thomas Jakobsen
Ortopædkirurgisk afdeling, Regionshospital Viborg; Klinisk Fysiologisk afdeling, Regionshospital Viborg
Background: When performing below knee
amputation, the vascular status of the
limb is of paramount significance for
wound healing. Skin Perfusion
Pressure (SPP) is one way to measure
healing potential. A SPP of 40 mm Hg
or above is believed to indicate a good
or a very good probability for healing
after amputation.
Purpose / Aim of Study: To examine the correlation between
SPP and wound healing after below
knee amputation.
Materials and Methods: One hundred and six consecutive
patients underwent 113 below knee
amputations from January 2009 to
December 2013 at the Regional
Hospital Viborg. The primary outcomes
were any need for further wound
management, amputation at a higher
level or even death within the first 90
days. These informations were
obtained from the medical records of
the patients.
SPP measured by photocell technique
was performed less than two days
prior to surgery.
Findings / Results: Seventy of 113 below knee
amputations (62%) had a SPP
performed prior to surgery. Of these
seventy amputations twenty had a
SPP of 40 mmHg or less. Five (25%)
of the amputations with a SPP values
of 40 mmHg or less had to be
reamputated at a higher level. Four
(20%) with a SPP values of 40 mmHg
or less needed further wound
management. Three of the patients
with a SPP values of 40 mmHg or less
died within 90 days.
Thus 50 amputations (71%) had a SPP
above 40 mm Hg. Of these 50
amputations three (6%) needed
reamputation at a higher level, one of
these patients died afterwards. Seven
(7/50=14%) needed further wound
management, off which two patients
died. In total twenty one of the patients
died within 90 days.
Conclusions: Several factors influence the outcome
after below knee amputation. The
group of patients is very fragile, and in
order for a better understanding of the
outcome, there is a need for a
prospective study.
111. Can inflammatory markers be included into models predicting survival after treatment for metastatic lesions in the extremities?
Michala S. Sørensen, Jonathan A. Forsberg, Klaus Hindsø, Michael M. Petersen
1Mukculoskeletal Section, Department of Orthopedics, Rigshospitalet, University hospital of Copenhagen; Regenerative Medicine, Naval Medical Research Center, Silver Spring, Maryland, USA; Children’s orthopaedics, Department of Orthopedics, Rigshospitalet, University hospital of Copenhagen,
Background: Prediction of survival is considered
valuable for surgeons treating
metastatic bone disease in the
extremities. Different models have
been developed however none
including inflammatory markers.
Purpose / Aim of Study: We aimed to 1) develop a model that
can estimate the likelihood of survival
at 3, 6 and 12 months after surgery,
based on variables that are easily
accessible from patient records
including inflammatory markers. 2)
Investigate its accuracy using the
receiver operator characteristic (ROC)
analysis and decision curve analysis
(DCA).
Materials and Methods: A consecutive cohort of 130 patients
having joint replacement surgery due
to metastatic lesions at Rigshospitalet
during the period 2003-2008 was
included. Demographics, clinical and
biochemical variables preoperatively
was included into the model (age,
gender, primary cancer group, ASA,
hemoglobin, C-reactive protein,
fracture vs. impending fracture,
visceral metastasis, multiple bone
metastasis). Primary cancer group was
grouped as proposed by Katagiri (1,2).
A Bayesian belief network (BBN) for
survival status at 3, 6 and 12 months
were developed and internally
validated and area under the ROC
curves calculated. Net benefit of the
model was evaluated with DCA.
Findings / Results: BBN for survival status at 3, 6 and 12
months was developed and internal
validation showed AUC of ROC curves
of 0.77 (CI: 0.66;0.87), 0.83 (CI:
0.74;0.91) and 0.87 (CI: 0.81;0.94)
respectively. DCA showed a clinical
net benefit using these models
compared to expecting all patients to
outlive the period.
Conclusions: We successfully developed a BBN for
predicting survival status at 3, 6 and 12
months based on various parameters
including C-reactive protein. Though
these results are encouraging, each of
these models should be externally
validated prior to being used clinically.
112. Implant and patient survival following limb-sparing surgery with reconstruction using the Global Modular Replacement System (GMRS) due to primary or secondary bone cancer. A retrospective study of 52 patients
Müjgan Yilmaz, Michala S. Sørensen, Michael M. Petersen
Musculoskeletal Tumor Section, Department of Orthopedics, University hospital of Copenhagen, Rigshospitalet, Denmark
Background: Today limb-sparing tumor resection is
possible in 90% of patients suffering
from bone sarcomas (BS) and the
preferred method of reconstruction is
the use of mega-prostheses. The
same surgical technique is
occasionally also used in the treatment
of patients suffering from metastatic
bone disease (MBD).
Purpose / Aim of Study: To investigate implant and patient
survival following limb-sparing surgery
using the GMRS mega-prosthesis in
BS or MBD patients.
Materials and Methods: A consecutive cohort of 52 patients
(mean age 47 (11-78) years,
F/M=21/31) treated with limb-sparing
surgery due to BS (n=37) or MBD
(n=15) of the lower extremities
(resection type: distal femur (n= 27),
proximal tibia (n=5), proximal femur
(n=17), total femur (n=3)) at our
orthopedic oncology tertiary referral
center from 2005 to 2013.
Patients were followed until death or
end of study (13.06.2015). Statistical
analysis used was Kaplan-Meier
analysis
Findings / Results: All-cause one-year and 5 year mortality
was 90.4 % and 63.0% for the
complete cohort (94.6% vs 72.5% for
sarcoma and 80.0% vs 40.0% for
metastatic bone disease). 18 patients
experienced reoperation of all causes
(mean time to first surgery 694 days
(range 4-3003 days). 4 patients had
removal of bone anchored prosthesis
components (median 925 days range
322-1855), resulting in a 5-year
estimated risk of revision of 93.5%. 3
patients had amputation due to local
recurrence (5 year limb survival rate
of 93.6%).
Conclusions: The use of the GMRS prosthesis for
reconstruction after limb-sparing bone
tumor resection of the lower
extremities has an acceptable risk of
revision of the bone anchored parts of
the implants and the risk of amputation
was low. The results should be
interpreted with caution due to
competing risk of short life survival of
especially the MBD patients in this
cohort.
113. In-vivo gentamicin concentrations in plasma and drain fluid after bone defect reconstruction using a gentamicin-eluting bone graft substitute
Peter Frederik Horstmann, Werner Hettwer, Zhijun Song, Michael Mørk Petersen
Muskuloskeletal Tumor Section, Rigshospitalet, Copenhagen University Hospital; Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital
Background: Reconstruction of bone defects after
bone tumor resection is associated
with an increased risk of infection. A
gentamicin-eluting bone graft
substitute consisting of sulphate and
apatite has been shown to be effective
for treatment of osteomyelitis and may
be a valuable addition to the
therapeutic and/or prophylactic
antibiotic regime for this indication.
Purpose / Aim of Study: To document early in-vivo
concentrations of gentamicin in plasma
and drain fluid after bone defect
reconstruction using a gentamicin-
eluting bone graft substitute.
Materials and Methods: We performed a prospective pilot study
from December 2014 to February 2015
in 7 patients (M/F: 4/3, mean age 51
(37-79) years) who underwent bone
defect reconstruction with a gentamicin-
eluting bone graft substitute
(CERAMENT™|G – BONESUPPORT
AB) containing 175 mg gentamicin per
10 mL. Indications for surgery were
metastatic bone disease (n=3), giant
cell tumor (n=2), aseptic prosthetic
loosening (n=1) and chondroid tumor
(n=1). Drain fluid and plasma was
collected immediately postoperatively
and each postoperative day until the
drain was removed and analyzed using
an antibody technique.
Findings / Results: A mean of 14 (10-20) mL gentamicin-
eluting bone graft substitute was used.
Mean drain fluid concentrations of
gentamicin were 1200 (723-2100)
mg/L immediately postoperative (0-2
hours), 1054 (300-1999) mg/L on day
1 (17-23 hours) and 509 (38-1000)
mg/L on day 2 (39-45 hours). Mean
plasma concentrations of gentamicin
were 1.26 (1.08-1.42) mg/L
immediately postoperative, 0.95 (0.25-
2.06) mg/L on day 1 and 0.56 (0.20-
0.88) mg/L on day 2.
Conclusions: Local implantation of a gentamicin-
eluting bone graft substitute for bone
defect reconstruction results in high
concentrations of gentamicin in the
drain fluid in the first postoperative
days and low plasma concentrations.
114. Risk Factors for Local Recurrence after Intralesional Curettage for Giant Cell Tumors of Bone
Peter Frederik Horstmann, Peter Holmberg Jørgensen, Mathias Rædkjær, Bjarne Hauge Hansen, Michala Skovlund Sørensen, Werner Hettwer, Tine Nymark, Michael Mørk Petersen
Muskuloskeletal Tumor Section, Copenhagen University Hospital; Department of Orthopedic Surgery, Sarcoma Center, University Hospital of Aarhus; Department of Orthopedic Surgery, Odense University Hospital
Background: Intralesional treatment of giant cell
tumors of bone (GCT) increases local
recurrence rates compared with wide
resection. Adjuvant treatment with
PMMA has been proposed to reduce
local recurrence rates. However, some
surgeons believe that other factors are
equally important.
Purpose / Aim of Study: To determine which patient
demographics, tumor characteristics,
or surgical/clinical parameters are risk
factors for local recurrence after
intralesional treatment of GCT.
Materials and Methods: Retrospective data from a national
cohort of all patients with GCT of the
appendicular skeleton (n=74, M/F:
37/37, median age 29 (12-68 years),
treated intralesionally between 1998
and 2013, was analyzed for
association of risk factors with local
recurrence using univariate,
multivariate Cox regression and
Kaplan-Meier survival analysis.
Findings / Results: The cumulative 4-year recurrence rate
was 37%. The only significant
independent risk factors associated
with local recurrence rate
were “preoperative diagnosis
confirmed by biopsy” (HR=0.30,
CI:0.10-0.90) and “treatment at an
oncology center” (HR=0.29 CI:0.08-
0.99). There was no independent
association between local recurrence
rate and other parameters such as
age, gender, tumor location and
Campanacci grade, pathological
fracture or the use of PMMA.
Conclusions: Our results suggest that confirmation
of histological diagnosis before
definitive surgery and referral to an
orthopedic oncology center are
important to avoid local recurrence of
GCT. We recommend that surgery for
GCT’s is performed at a dedicated
orthopedic oncology center, where
biopsy typically is a part of the
diagnostic routine. It seems that local
adjuvant therapy with PMMA in itself is
not a guarantee for a lower recurrence
rate.
115. Migration pattern of the osseointegrated implant system for transfemoral fixation evaluated with radiostereometry
Rehne Lessmann Hansen , Peter Holmberg Jørgensen, Klaus Kjær Petersen, Kjeld Søballe, Maiken Stilling
Ortopædkirurgisk forskningsenhed, Aarhus Universitetshospital; Tumorsektoren, Aarhus Universitetshospital; Ortopædkirurgisk afd, Aarhus Universitetshospital
Background: The osseointegrated(OI) implant system is a
treatment for transfemoral amputees with a short
residual femur and/or problems using socket
prostheses
Purpose / Aim of Study: To study fixation stability(migration) of the OI-
implant up to 24 months follow-up with model-
based radiostereometry (mbRSA)
Materials and Methods: 18 consecutive patients(12 males) mean
age 49.5(range 32-66) were operated
through a two stage procedure(S1,S2). At
S1, a titanium implant(fixture) was inserted
into the distal part of femur. At S2, 6 months
later, a rod(abutment) was inserted into the
fixture, exiting through the skin. Weight
bearing on the implant was not allowed
between S1 and S2(unloading phase) and
started after S2 (loading phase).
Stereoradiographs were obtained
postoperatively every 6 months. X, Y, and Z
translations and Total Translations (TT
=√(X2+Y2+Z2)) were evaluated using CAD-
models. Precision (double examinations)
was evaluated as standard deviation
(SD)x1.96
Findings / Results: During unloading the mean TT(SD) was
1.07(0.87) mm with Y-translation -0.16(0.34)
mm. During the loading phase TT at 6, 12, 18,
and 24 months was 0.55(0.40) mm, 0.64(0.57)
mm, 0.53(0.39) mm, and 0.87(0.94) mm There
was no continuous migration(TT) p>0.68 and no
continuous subsidence after S2 p>0.09.
Precision along the orthogonal axes were
X:0.62mm, Y:0.14mm and Z:0.63mm. At 2 years,
8 OI-implants migrated above the precision limit
on the Y-axis, 1 due to trauma, 4 had infections,
2 had no clinical explanation, and 1 with leg
pain during loading
Conclusions: MbRSA is feasible for measurements of fixation.
Precision is less than with hip stems due to
more difficult fitting of the model geometry.
Overall, the OI-implant system was found to be
stable after S2 on group level, but 8 patients
had measureable Y-axis migrations and most
had clinical conditions coherent with implant
migration
116. Reconstruction of metastatic bone defects with a bisphosphonate eluting bone graft substitute
Werner Hettwer, Peter Horstmann, Michael Mørk Petersen
Orthopaedic Department, Rigshospitalet
Background: Bisphosphonates inhibit the osteoclast
mediated bone destruction associated with
secondary malignant bone tumors. They
also induce apoptosis of tumor cells and
could therefore potentially contribute to
prevention of local recurrence as well as
restoration of bone.
Purpose / Aim of Study: To report an early clinical experience with
use of local delivery of zoledronic acid in the
reconstruction of metastatic bone defects.
Materials and Methods: Six patients (5f, 1m, mean age 64 (range
37-81) who had undergone reconstruction
of metastatic bone defects with implantation
of a gentamycin eluting sulphate-apatite
bone graft substitute (Cerament™|G,
BONESUPPORT, Lund, Sweden) which we
additionally loaded with zoledronic acid,
were prospectively followed for a mean of
12 months (range 6-17). In all 5 female
patients, the indication for treatment was a
partially contained bone defect associated
with incipient or actual pathologic fracture of
the acetabulum (n=3) or proximal humerus
(n=2) secondary to metastatic breast
cancer. The only male patient had wide
resection of a solitary lung cancer
metastasis from the proximal femur.
Findings / Results: Sequential imaging (X-ray/CT)
demonstrated progressive consolidation of
the inserted graft material without any
evidence of persistent osteolysis or local
recurrence. Rapid and homogeneous
remodeling typically started in well-
contained areas with cancellous bone
contact. Substantial bone formation was
also observed in uncontained areas where
graft material had been applied to the
surface of metallic implants or surrounding
cortical bone in some cases.
Conclusions: This small and inhomogenous case series
demonstrates that successful restoration of
metastatic bone defects with a
bisphosphonate eluting bone graft substitute
is possible in selected cases.