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Kerala Journal of Orthopaedics • kjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015

case report

6 Years Follow Up of Chondrosarcoma Left Proximal Femur Treated With Resection and Reconstruction With Custom Prosthesis, Autologous Bone Grafting and HAP Cylinders Melvin J George1 , Krishnakumar R2 and Renjit Kumar J3 1 DNB

Resident, Division of Spine and Musculoskeletal Oncology, Department of Orthopaedics, Amrita Institute of Medical Sciences and Research Centre, Kochi 2 Assistant

Professor, Division of Spine and Musculoskeletal Oncology, Department of Orthopaedics, Amrita Institute of Medical Sciences and Research Centre, Kochi Professor, Division of Spine and Musculoskeletal Oncology, Department of Orthopaedics, Amrita Institute of Medical Sciences and Research Centre, Kochi

Article Info Keywords chondrosarcoma resection and reconstruction hydroxyapatite (HAP) Correspondence [email protected] Source of funding Nil Conflict of interest Nil Available online at http://www.kjoonline.org/

Abstract High grade chondrosarcomas traditionally were treated with resection arthrodesis or amputation of the extremity, with unfavorable functional outcomes. Improved imaging and surgical techniques has stimulated the search for a more functional surgical approach. The current trend is for resection and reconstruction to save the limb whenever possible. Since most patients with primary bone sarcoma are young and active, treatment by amputation has poor psychological acceptance. Reconstruction of the defects is the major challenge in the management of bone sarcomas. The options now available are custom made prosthesis and bone grafts. Few studies were done with autologous grafts or custom made prosthesis alone. The combined use of all the modalities enabled us to fill the defect and augment the fixation effectively. We put forward a case report of chondrosarcoma reconstructed after an extensive resection using non vascularised fibula, corticocancellous grafts from ASIS and a custom made prosthesis. Cite this paper as: Melvin J George et al. 6 Years Follow Up of Chondrosarcoma Left Proximal Femur Treated With Resection and Reconstruction With Custom Prosthesis, Autologous Bone Grafting and HAP Cylinders. Kerala Journal of Orthopaedics 2016;28(1–2):72–77.

Introduction hondrosarcoma is the second most common type of bone cancer, next to osteosarcoma; with a prevalence of 11%–22% 1 . About 30% of skeletal system cancers are chondrosarcomas. Patients with chondrosarcoma are currently managed more often by resection and reconstruction. A limb-sparing resection with endoprosthetic reconstruction clearly is more cost-effective than amputation and

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works better functionally. Most patients with primary bone sarcoma are young and active. If treated by amputation, they probably will require a sophisticated artificial limb, which very often has poor psychological acceptance. Additional accessories may be required such as artificial sport limb, swimming limb, and spare limb. In addition, many patients will have stump problems which necessitate modifications of the socket. Reconstruction of the 72

Melvin J George et al

Figure 1. Pathology slide brought for second opinion — 10× view, H&E stained.

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Figure 2. Pathology slide brought for second opinion — 40× view, H&E stained.

defects using a novel technique using autogenous non vascularised fibula, cortico-cancellous ASIS grafts and HAP cylinders has provided better functional results and patient acceptance.

Case History A 42 year old man, presented with pain in the left proximal thigh for the past 4 years. He was treated with analgesics which gave temporary relief. Later, he developed rest pain and night cries. After appropriate radiological evaluation, he underwent an open biopsy of the left proximal femur, which was reported as grade 2 chondrosarcoma at another institution. The slides were reviewed by the pathologist in our institution and the diagnosis was revised as Chondrosarcoma grade 1. The pathology slides of the patient showed lobulated, hyaline cartilaginous lesion; and chondrocytes with pleomorphic, hyperchromatic, binucleated cells. On examination, the biopsy scar was healthy, hip movements were painful at terminal rotations. X-ray showed a lytic lesion over trochanteric area. (Figures 3 and 4). MSTS 2 score at the time of presentation was 50. MRI reported a solitary well defined intramedullary non-aggressive lesion with matrix mineralization involving proximal diaphysis with involvement of lesser trochanters and extension into neck of left femur without any extra-osseous soft tissue component or skip lesions; suggestive of low grade chondrosarcoma (Figures 5 and 6). Bone scan showed focal increased uptake in upper 3rd of left femur alone. CT scan of the chest did not reveal any lung metastasis. After detailed discussion of the treatment options with the patient, it was decided to carry out a limb salvage procedure.

Figure 3 He underwent resection and reconstruction with a hip as described below. The defect of resection was reconstructed with HAP cylinders and non vascularised ipsilateral fibula, augmented with autologus cortico-cancellous graft from contralateral ASIS. (Figures 7 and 8). Since the planned resection according to MRI was extensive and reconstruction might not be possible with routine grafting and HAP crystals, we had to resort to a custom made prosthesis. The resection was done with 1 cm normal margin all around and distally it went upto 10 cm below the lesser trochanter. No extra osseous spread was appreciated

Kerala Journal of Orthopaedicskjoonline.org • Volume 28 • Numbers 1–2 • January–June/July–December 2015


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Figure 6. Axial MRI section image showing the extent of the lesion. Figure 4

Figure 5. Coronal MRI section image showing the extent of the lesion. intra operatively. The abductors were sutured onto the remaining soft tissues. The custom made prosthesis was a long bipolar prosthesis with stem extending upto supracondylar area with distal interlocking option with 3 screws. (Dr. Dharia’s Mumbai hip — HIB surgicals, Opp. KEM Hospital, Mumbai – 12). HAP cylinders used are Chithra HAP cylinders manufactured by the biotechnology wing of Sri Chithira Institute of Medical Sciences and Technology, Thiruvananthapuram.

Figure 7. Immediate post operative X-ray Pelvis AP view with proximal femur — left, showing the implant in situ. The HPE study of the resected specimen confirmed our diagnosis of that of Chondrosarcoma — Grade 2; (Figures 9 and 10) showing invasion of the chondroblasts into the bone. Post-operative recovery was uneventful. He was mobilised with passive physiotherapy for hip, knee and active physiotherapy for ankle and toes. He was advised non-weight bearing for 6 weeks; then progressive partial and protected weight bearing as



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Figure 10

Figure 8. Immediate post operative X-ray Distal femur AP view — left, showing the distal interlocking system the custom made implant had.

Figure 11. 3 months post operative. Figure 9 tolerated. At 3 months (Figure 11), 6 months (Figure 12) and 1 year post operative follow up (Figure 13), X-ray evaluation showed progressive graft incorporation. At 2 years post-operative follow up (Figure 14), he had occasional pain, abductor lurch, fair range of movements and was walking with the aid of walking stick. On imaging, HAP cylinders appeared to be incorporating well; with mild resorption of HAP cylinders on the lateral aspect. (Figure 14). MSTS score was 83.33 then. At 4 years post operative follow up, he had

abductor lurch and showed better graft incorporation. (Figure 15). On follow up after 6 years, patient showed Trendelenberg gait, better graft incorporation and remained asymptomatic. (Figure 16). MSTS score was 93.33 then.

Discussion The treatment of chondrosarcoma is surgical and the goal is to relieve symptoms and prevent local recurrence or distal metastasis while preserving as much function as possible4. The surgical excision of bone tumors of the appendicular skeleton and pelvis requires a method of reconstruction of the



Figure 12. 6 months post operative.

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Figure 14. 2 year post operative X-ray.

Figure 15. 4 year post operative X-ray. Figure 13. 1 year post operative X-ray. bone defect if limb salvage is a priority. In the United Kingdom, reconstruction with endoprosthetic implants is the method of choice. It is believed that it affords the patient several advantages, including the ability to return rapidly to full weight-bearing functional activities 5 . It is preferable to do the biopsy at the same centre where the definitive surgery is planned. If the stage and size of chondrosarcoma mandates resection, the

reconstruction options must also be sought. In large lesions, reconstruction with autogenous bone graft alone is not possible. Moreover, this compromises the structural integrity of the reconstruction. The other option is to use allogenous structural bone grafting. But, the risks of transmitting infections and patient’s acceptance are the main drawbacks. A synthetic graft-prosthetic composite replacement gives us an excellent option for the same. Augmenting the same with autogenous structural and cancellous



77 outcome was not satisfactory or the follow up period was less than 5 years. But, we could return the patient to near functional normalcy after 2 years post-operative (MSTS score – 83.33) and a good functional outcome 6 years post-operative. (MSTS score – 93.33). The strict post operative physiotherapy protocol and the patient’s endurance have helped a lot for the better functional outcome. This report illustrates the reconstruction options for extensive lesions which call for resection.

Acknowledgement Dr. Amrita (PG Resident) and Dr. Annie Jojo (HOD, Dept. of Pathology, Amrita Institute of Medical Sciences and Research Centre) for their help and support on pathology slides and their description.

References

Figure 16. 6 year post operative X-ray. bone grafts helps in osseo-integration of the synthetic hydroxyapatite cylinders.

Conclusion In this particular case, the last option described above was used. There are only few similar cases reported till now. In those already published, the functional

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