Robert Lawrence Randall, MD, FACS, discussed the role of biological reconstructions as well as factors that determine whether a patient would benefit more from the reconstructions or traditional prosthetics known as endoprosthetics.
Biologic reconstructions with rotationplasty have demonstrated promising results for patients with extremity sarcomas and may provide benefits over conventional prosthetics in certain cases, according to R. Lor Randall, MD, FACS.
Rotationplasty, which is used after surgery and usually done in the lower leg, can be performed to rebuild limbs by rotating the lower leg 180 degrees and attaching it to the femur so that after removal of the bottom of the femur, the ankle can function as a knee.1 Additionally, the procedure is more cost effective than adopting an endoprosthetic. In a study performed in Myanmar from 2019 to 2020, patients with osteosarcomas of the distal femur or proximal tibia (n = 7) underwent modified rotationplasty and experienced good functional and aesthetic results.2
“The excitement is palpable [when discussing rotationplasty] because in surgical oncology and in sarcoma surgery we get so [focused on] artificial joints, metal prostheses, and bone transplants, and these biologic alternatives are available to us as well.”
In an interview with OncLive®, Randall, the David Linn Endowed Chair for Orthopaedic Surgery and a professor at UC Davis Comprehensive Cancer Center, discussed the role of biological reconstructions as well as factors that determine whether a patient would benefit more from the reconstructions or traditional prosthetics known as endoprosthetics.
Randall: When a person develops a bone sarcoma [in] the most common site [which] is the femur, there are a variety of options available to patients; for bone sarcomas, particularly osteosarcoma and Ewing’s, chemotherapy is a big part of it [and] for chondrosarcomas it’s mostly surgery. At the time of local control, we remove this large piece of bone with the associated tumor and then reconstruct it and in many adults we’ll do these endoprosthetics or these rebuilds with metal and plastic or allografts, but in younger patients, we’ll use body parts to rebuild the limbs. We do something called rotationplasty where after we remove the tumor, we rotate the ankle bone around and turn it into a biological knee. In the arm bone in the humerus area, sometimes we’ll remove a tumor and then use the collarbone, the clavicle, to attach and reconstruct the shoulder that way.
[There is] value added for these biologic reconstructions because you don’t have the cost of the prosthesis. You basically have the cost of doing the surgery, which is true for all [procedures], but then you use the patient’s anatomy to reconstruct and the cost is [for] the plate or device to hold the new body part together, which is dramatically less expensive than some of these fancy devices. Many of the emerging economies and emerging countries use these types of technologies with alacrity and they get amazing results with this technique; these patients often do more functionally than some of our patients in the United States who have these very expensive but delicate prostheses.
The older we get the more our biology wanes, whereas people that are younger [approximately] 25 to 30 can heal [from] some of these surgeries very well and do quite well with the biological alternatives. Older patients will usually have to opt for metal and plastic and other types of techniques. Other factors that influence this decision making are the comorbidities of the patients. Some of these patients are older; have a history of smoking, behavioral issues, or diabetes; [and] other risk factors make some of these biologic options riskier. We certainly shouldn’t offer these up to those patients and should consider the more conventional but more expensive technologies.
I read a very interesting article out of BMC Surgery which talked about this group of surgeons who were from Germany, went to Myanmar, and trained some of the surgeons in Myanmar on how to do these rotationplasties. [They] were able to improve the outcomes of these patients in an economy that could not afford some of the more expensive techniques [such as] endoprosthetics. If the same group of surgeons had come into Myanmar and talked about using some of these endoprosthetics, I don’t think it would have been sustainable within the economic framework of Myanmar to do those kinds of operations. Some of the most durable cancer reconstructions that we can do for bone sarcomas are able to be done in emerging economies and do as well if not better than some of those in developed economies.
Much less follow-up is required [but] there are risks up front; sometimes there’s microvascular reanastomosis and things whereby you have to do tricky interoperative maneuvers in order to get a good outcome. But if [the reconstruction] heals, then [patients] don’t need any of the maintenance and surveillance, they just need the cancer follow-up. Most will go on to heal and perform quite well vs when we put in these artificial metal and plastic joints [and] they invariably need their bushings and portions of their prosthesis fixed every 5 to 10 years.
The decision making is very nuanced; size of the tumor, age of the patient, comorbidities, the tumor type, and the overall prognosis, all of those will influence what the decision tree is for the team in advising the patient on the best surgical procedure. That speaks to what’s important for these bone and soft tissue sarcomas, that everyone is integrated, and everyone is communicating so that the medical oncologist can reach out to the surgeon and potentially have a preliminary conversation with the patient. Ultimately, it’s the orthopedic oncologist’s decision with the family, but that kind of communication can lead to the most confidence from the patient.
One of the things we should be doing is getting patients who have these biologic reconstructions, especially in the lower limb, long-term functional outcome data in the form of Gait Laboratory Analyses and things of that sort to be able to answer the age-old question of whether these patients have better function than their endoprosthetic counterparts. There are a lot of ways people will think about this, and some are not willing to consider the other options, but if we got good Gait Analysis on these patients, a large cohort, we could put this issue to rest.
For patients who are being treated by a multidisciplinary team of bone and soft tissue sarcoma specialists, [being] up front with these families and laying out all the options [is important]. When the medical oncologist or the pediatric oncologist talks to the family, they say job number 1 is to cure your family member of cancer, job number 2 is to give the best functional outcome of the reconstruction from where the cancer comes out, and job number 3 is to support you emotionally and physically through this process.
All of those are important, but job number 1 has to be getting the cancer out and that will require an up-front evaluation with the orthopedic surgeon or the surgical oncologist to talk about all the options. For the family not to worry about this at the day of their diagnosis but [rather] as they move through that neoadjuvant chemotherapy window to have ongoing discussions with the care team [is key] so that when they come to local control of the tumor, they have a good sense of what option they want to go down for their reconstruction.