The most common pediatric bone cancer is osteogenic. Repiphysis Prosthesis for Limb Preservation in Pediatric Patients With Bone Cancer

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1 Repiphysis Prosthesis for Limb Preservation in Pediatric Patients With Bone Cancer A Literature Review Kimberly Haynes Carrie Tyner Phoebe D. Williams Osteosarcoma is the most common bone sarcoma in children and adolescents. It occurs mainly around the knee joint; the distal femur is the most common location. When it occurs in children who are skeletally immature, a significant limb length discrepancy can occur. The Repiphysis prosthesis was developed in the 1980s to assist in reconstruction of the affected limb in these patients. Ten articles were reviewed to identify the challenges and complications that affect the functional outcome on this population. The reports included patients, aged 7 16 years, who were skeletally immature and had bone sarcomas of the lower extremities. Complications reported by the authors were similar and included aseptic loosening, mechanical failure, infection, flexion contracture of the knee, fracture, and neuropraxia. The most common pediatric bone cancer is osteogenic sarcoma (osteosarcoma); it occurs in about 3% of childhood cancers, or approximately 400 children per year (ACS, 2010). It mainly affects teenagers and young adults but it can also affect children aged 10 years and younger who are skeletally immature. The Repiphysis expandable prosthesis was developed specifically for the skeletally immature pediatric patient and has been used successfully for more than 10 years. However, complications with this prosthesis include mechanical failure, infection, neuropraxia, fracture, and flexion contracture of the knee joint ( Beebe et al., 2009, 2010a ; Saghieh et al., 2010 ). This review is focused on the use of the Repiphysis in the treatment of osteosarcoma of the lower extremity in the pediatric population. The distal femur is the most common site for osteosarcoma; therefore, the distal femoral growth plate must be removed to ensure complete resection of the tumor. If the child is skeletally immature, a significant limb length discrepancy will occur because the contralateral femur will continue to grow until skeletal maturity is achieved. To combat this problem, expandable prostheses were initially developed, which required numerous invasive lengthening procedures. Historically, in 1983, the Lewis Expandable Adjustable Prosthesis (LEAP) was the first of these prostheses used in the United States ( Neel & Letson, 2001 ). Over time, newer designs were developed; these required modular pieces to be surgically added to extend leg length. All of these types of prostheses required a formal surgical procedure. Complications with these techniques included loosening, neuropraxia, and notably infection. Subsequently, a noninvasive expandable prosthesis called Repiphysis (Wright Medical Technologies, Arlington, TN) was developed and is used at many institutions. It uses an electromagnetic field to heat up a spring embedded in polyethylene. The prosthesis is intended to be temporary and is eventually replaced with a permanent standard endoprosthesis once the child has reached skeletal maturity ( Table 1 ). Typical Management/Care of Osteosarcoma and Other Bone Cancers: Background According to Hogendoorn (2010), the management and care of osteosarcoma and other bone cancers is complex and multidisciplinary, including doctors and nurses in pediatric orthopaedic surgery and oncology, physical therapists, and others. Prompt diagnosis is needed and treatment may last for many years. These include protocols of chemotherapy (along with radiation in some cases) and removal of the tumor with possible placement of the Repiphysis prosthesis. Chemotherapy agents are administered prior to surgery (induction or neoadjuvant chemotherapy) and are then resumed almost immediately after the definitive surgery (adjuvant chemotherapy). These agents have known side effects Kimberly Haynes, DNP, RN, APRN, Sarcoma Institute of Menorah, Menorah Medical Center, Menorah Medical Center, Overland Park, KS. Carrie Tyner, RN, BSN, CPN, Graduate Student, University of Kansas School of Nursing, and Staff Nurse, Children s Mercy Hospital, Kansas City. Phoebe D. Williams, PhD, RN, FAAN, Professor, University of Kansas School of Nursing, Kansas City. The authors and planners have disclosed that they have no financial interests to any commercial company related to this educational activity. DOI: /NOR.0b013e bbb 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing March/April 2013 Volume 32 Number 2 81

2 TABLE 1. SUMMARY OF 4 RESEARCH REPORTS ON REPIPHYSIS PROSTHESIS a Saghieh et al. (2010) Beebe et al. (2009) Gupta et al. (2006) Beebe et al. (2010a) Sample size Age range at diagnosis 7 13 years 9 11 years 9 15 years 7 16 years 7 16 years Gender M-10 F-7 M-1 F-3 M-3 F-4 M-5 F-7 M-19 F-21 Diagnosis Osteosarcoma-16 Osteosarcoma-3 Osteosarcoma-7 Osteosarcoma-10 OGS-36 Ewing sarcoma-1 Ewing Sarcoma-1 Ewing sarcoma-2 ES-4 Tumor location Distal femur-10 Distal femur-3 Distal femur-7 Distal femur-7 DF-27 Proximal tibia-7 Proximal tibia-1 Proximal tibia-2 Proxtib-10 Proximal Humerus-3 Proxhum-3 Prosthesis Repiphysis Repiphysis Expandable DFRP-7 Repiphysis Repiphysis DFRP-10 DFRP-3 DFRP-7 33 PTRP-7 PTRP-1 PTRP-2 Other PHR-3 7 Average lengthening, cm Infection 3/17 0/7 1/12 Nerve palsy 0/4 0/7 0/12 Hardware failure 6/17 0/4 0/7 2/12 8/40 Fracture 2/17 0/4 0/7 2/12 4/40 Contracture 0/4 1/7 3/12 Converted to perm prosthesis 4/17 0/4 None prosthesis is 2/12 permanent Current status AWOD-12 AWOD-4 AWOD-5 AWOD-8 AWOD-29 AWD-3 AWD-1 AWD-2 AWD-6 DOD-2 DOD-1 DOD2 DOD-5 Revisions due to complications 7/17 0/4 0/7 3/12 10/40 Note. AWD alive with disease; AWOD alive without disease; DFRP distal femoral replacement prosthesis; DOD dead of disease; PHR proximal humeral replacement; PTRP proximal tibial replacement prosthesis. a Only the research reports in the literature review are included in this summary; the case reports and general treatment options are not included. Total ( Williams et al., 2012 ). Chemotherapy regimens are near constant and last approximately 1 year. At the same time, clinic visits continue (for the repeated procedures to lengthen the affected limb that has the implanted Repiphysis). The reviewed reports show that between one and eight individual lengthening procedures may be done on a patient with the Repiphysis prosthesis, over a period of several years ( Tyner, 2012 ). Figure 1 shows a radiograph of a Repiphysis prosthesis implanted in the distal femur of a patient ( Haynes, 2011 ). Methods A literature search was performed using PubMed, CINAHL, and Google Scholar. Key words such as Repiphysis prosthesis, expandable prosthesis, limbsalvage surgery, limb-sparing surgery, and osteosarcoma were used. Because the Repiphysis prosthesis has been available only since 1984, the literature is very limited. Ten articles on the Repiphysis prosthesis were found: four research reports, four articles discussing general treatment options, and two articles that discuss case reports. The American Cancer Society (2010a, 2010b) website cancer.org and a textbook on musculoskeletal cancer surgery ( Malawer & Sugarbaker, 2001 ) also provided more information. Review of Literature The American Cancer Society (2010b) estimated that in 2010, approximately 400 new cases of osteosarcoma would be diagnosed in children. The current treatment of osteosarcoma includes neoadjuvant chemotherapy followed by wide resection of the tumor and postoperative chemotherapy ( Beebe et al., 2010b ). Technological advances in surgical procedures, chemotherapy, and imaging modalities have allowed limb-sparing procedures to be the surgical treatment of choice, replacing amputation ( Gupta et al., 2006 ). The goal with limbsparing surgery in children and teenagers is to remove the tumor and reconstruct the joint with a prosthesis that will allow the patient to return to normal function 82 Orthopaedic Nursing March/April 2013 Volume 32 Number by National Association of Orthopaedic Nurses

3 F IGURE 1. Anteroposterior plain film of a Repiphysis prosthesis implanted in the distal femur (courtesy of Dr. H. Rosenthal). as they continue to grow and reach skeletal maturity. As with any surgical procedure, risks are involved. Most patients undergoing reconstructive limb-sparing surgery for cancer are immunocompromised because of the chemotherapy they are receiving before surgery (neoadjuvant chemotherapy). A lowered immune system due to chemotherapy puts the patient at a higher risk of infection. Other complications that can occur with a metal prosthesis include mechanical failure, flexion contracture, and neuropraxia ( Hogendoorn, 2010 ). Malawer and Sugarbaker (2001) state that there are several ways the extremity and joint can be reconstructed after tumor removal such as endoprosthesis, osteoarticular allograft, and allograft-prosthetic composite. The goal is to use the technique with the lowest complication rate so that a delay in resumption of adjuvant chemotherapy does not occur ( Yasko et al., 1997 ). Choosing the appropriate surgical reconstructive technique is important and should consider patients current lifestyle, habits, and expectations. In adults, the joint is commonly reconstructed with a metal endoprosthesis. When cemented in place, immediate fixation takes place, which allows for early mobilization and rehabilitation ( Malawer & Sugarbaker, 2001, p. 386). Expandable prostheses have been developed for children who were skeletally immature. The LEAP, first introduced in the 1980s, required repeated surgical procedures: a small incision was made and a chux key turned a mechanism that lengthened the prosthesis ( Beebe et al., 2009 ; Neel & Letson, 2001 ). In contrast, the Repiphysis prosthesis allows for noninvasive expansions by using electromagnetic fields to heat up a spring-loaded insert. These procedures can be done with or without anesthesia. The amount of lengthening is monitored by fluoroscopy and is completed in less than 20 seconds. The spring-loaded mechanism cools and the patient is able to bear weight immediately. Several institutions have been using the Repiphysis and have reported positive results ( Haynes, 2011 ). Research Reports Reviewed Saghieh et al. (2010) described their 7-year experience at a children s cancer center with the use of the Repiphysis expandable prosthesis in 17 patients. The institutional review board approval was received and data were collected from 2002 to The authors reported that (1) all 17 had chemotherapy and that surgery was performed at week 15 on average and (2) there were 10 males and 7 females, and the average age when the surgery was performed was 10.5 years (range, 7 13 years). Complications included three infections, six mechanical problems (failure of the expansion mechanism in four patients, femoral stem breakage in one patient, and loosening in two patients), and two tibial fractures distal to the stem ( Saghieh et al., 2010 ). In some patients, because of the need for open procedures to lengthen the limb, complications and morbidity were high (p. 461). Nevertheless, the authors state that with the Repiphysis noninvasive prosthesis, expansions occurred without the complications seen in the earlier prostheses. Moreover, the authors reported that successful lengthening occurred in all the 17 patients, and that even though complication rates were high, equal limb lengths were achieved at skeletal maturity. The authors concluded that the Repiphysis did offer skeletally immature patients a good alternative to amputation ( Saglieh et al., 2010, p. 463). Neel and Letson (2001) described 3 types of expandable prostheses: the LEAP prosthesis, a modular endoprosthetic mid-section replacing expandable prosthesis, and the Phenix Growing Prosthesis, which were all being used at their facility. They stated that the LEAP prosthesis needed a small incision so a chux key could be inserted for lengthening. Whereas a larger incision was needed when the modular mid-section replacing prosthesis was used to fully expose the prosthesis. A capsulotomy may also be needed when replacing the midsection. The authors reported that their 10-year review on 60 patients who were treated with the LEAP prosthesis found that most had positive outcomes (p. 346). The modular endoprosthetic mid-section replacing prosthesis, used at St. Jude Children s Research Hospital on 37 patients, also had satisfactory results. That is, 14 of the 37 patients had 17 expansions, whereas three patients had more than one. Two centimeters was the typical expansion. This resulted in the placement of a longer section (p. 346) a few complications occurred, including one patient who suffered neuropraxia, which partially resolved. Finally, the authors discussed the Phenix Growing Prosthesis (later renamed the Repiphysis Prosthesis). Four patients had their limbs reconstructed with the Phenix. The authors reported that 13 lengthenings occurred with no complications. These patients were able to undergo the lengthenings while awake and even activated the heating device themselves. Neel and Letson (2001) reported also that the patients experienced minimal discomfort and most walked out of the fluoroscopy suite (p. 345). Beebe et al. (2009) discussed a case series of four patients, aged 9 11 years, who underwent reconstruction with the Repiphysis expandable prosthesis for bone sarcomas (three osteosarcomas, one Ewing s sarcoma). All expansions took place in the operating room under general anesthesia and fluoroscopy. The follow-up occurred over an average of 31.5 months. Patients were evaluated by using the Musculoskeletal Tumor Society 2013 by National Association of Orthopaedic Nurses Orthopaedic Nursing March/April 2013 Volume 32 Number 2 83

4 scale, the 36-Item Short Form Health Survey questionnaire, and objective functional outcomes. The Musculoskeletal Tumor Society items included pain, function, emotional acceptance, support, walking ability, and gait the mean score reported was 78%. The 36-Item Short Form Health Survey measured a mental composite score and a physical composite score. The results revealed positive coping abilities even when the physical deficits persisted. The objective functional evaluations covered range of motion and strength, sit to stand, and gait. No complications occurred during the lengthening procedures. The authors concluded that the functional outcome can be satisfactory in pediatric patients who have undergone reconstruction and lengthenings with the Repiphysis prosthesis. One limitation in their study was the small sample size. Beebe et al. (2010b) reported the case study of a 14-year-old boy with osteosarcoma who had a Repiphysis, who presented with a spongy sensation while walking, had a knee effusion and crepitus, but had full range of motion to the affected knee. There was also varus/valgus instability distal to the knee. Radiographs showed debris near the prosthesis. In the operating room (for an exploratory surgery), the muscle around the prosthesis was covered in a dark gray film. Histological examination revealed connective tissue with giant-cell reaction, which generally indicates a foreign body, and macrophages, which indicate inflammation. Also, the cobalt chromium spring and the ceramic internal component were broken. Beebe et al. (2010b ) believed that ultimately this component fracture was the result of either a single catastrophic load or multiple cyclical loads that exceeded the limits of the locking mechanism. Once the locking mechanism is lost, the spring is then subjected to the full load, and this eventually caused the spring to break, and then the distorted coils of the spring broke the ceramic ring into pieces. These pieces then collected in the tissue and caused a reaction. Another article by a different author presented three similar case studies of complications from Repiphysis prostheses; two had osteosarcoma, and the third had Ewing s. The first case was an 8-year-old girl with osteosarcoma, whose Repiphysis prosthesis had reached maximal expansion after 4 years, and was sent to surgery for a new, longer one. Once in the operating room, the surgeon found gross mellatosis and wear debris and a dark greenish-gray pseudocapsule around the prosthesis. The debris was found to be from the internal (lengthening) mechanism ( Maheshwari, Bergin, & Henshaw, 2011 ). The second was an 11-year-old girl with osteosarcoma with a Repiphysis who presented 4 years after the original implant with leg discomfort, shortening of the leg, and telescoping and audible mechanical noises when she bore weight on it. The prosthesis was found to have a fracture of the spring and it was collapsed. There was extensive metal-wear debris and again, a dark greenish-gray pseudocapsule. The authors claim that the mechanism of failure for both of these cases was a failure of the locking mechanism, and then subsequent distortion of the spring, causing the ceramic ring to break. They believe that the trumpet flare also breaks off as well as pieces of the spring. Gupta et al. (2006) described their experiences with a noninvasive distal femoral expandable prosthesis that they developed. The prosthesis was implanted in seven skeletally immature patients who were being treated for osteosarcoma of the distal femur. The patients were 9 to 15 years old (mean age, 12.1 years). The prosthesis was lengthened by inserting the leg into a magnetic coil and positioning it over the output shaft of a gear box inside the prosthesis, which contains a threaded screw. As the magnetic coil engages the gearbox, lengthening occurs at 1 mm every 4 minutes as the threaded screw is rotated (p. 650). The desired expansion was 3 4 mm per session. Results on the seven patients showed no stem fractures, infection, local recurrence, implant failure, or aseptic loosening. Two complications were observed in one patient, a flexion deformity of 25 occurred at 4 months, and one participant died of disease. The authors concluded that their study results were positive, but cautioned that more data were needed on the longterm structural integrity of the prosthesis. Beebe et al. (2010a) also described retrospectively the use of the Repiphysis for the lower extremity and compassionate use in the upper extremity in 12 patients. Ten patients had osteosarcoma and two had Ewing s sarcoma. Of the 10 patients with osteosarcomas, six were in the femur, two in the proximal tibia, and two in the proximal humerus. The femur and humerus were the sites of the Ewing s sarcoma. At the time of implantation, the patients were 7 to 16 years old (average age was 10 years). The authors reported (a) an overall acceptable functional outcome with their patients for both the upper and lower extremity usage; (b) no complications of postlengthening pain were associated with the expansion procedure; (c) an advantage of the Repiphysis was that it achieved expansion noninvasively, therefore decreasing the risk of infection; and (d) complications that occurred included mechanical failure, aseptic loosening, contracture, and infection. Nystrom and Morcuende (2010) described several surgical treatment options for pediatric patients with primary bone tumors of the extremities. Surgical procedures such as limb ablation or amputation, rotationplasty, and reconstruction with endoprostheses were compared. The article also discussed some aspects of the preoperative surgical planning to be considered such as calculating the remaining growth, surgical technique, and exposure. The authors performed a literature review and described outcomes from the different expandable prostheses such as the LEAP, Pafford-Lewis, Kotz Modular Femur Tibia Reconstruction system, Stanmore Mark II and Mark III prosthesis, and the Phenix (now manufactured as the Repiphysis) that have been used. The authors reported similar complications such as aseptic loosening, mechanical failure, infection, and postoperative stiffness. Summary and Conclusions The literature review illustrates the need for a noninvasive expandable prosthesis for skeletally immature patients with bone tumors of the extremities. However, the number of reports is limited on the outcomes of the use of this device. The Repiphysis prosthesis may be a good 84 Orthopaedic Nursing March/April 2013 Volume 32 Number by National Association of Orthopaedic Nurses

5 option for young children and teenagers affected with bone cancer of the extremity. As discussed, the adult prostheses used in limb-sparing procedures cannot be used in children because of the limb length discrepancy that occurs as the contralateral limb continues to grow as the child matures. The Repiphysis prosthesis has been used as a temporary surgical reconstruction technique until the child reaches skeletal maturity at that time, the Repiphysis prosthesis is replaced with a permanent adult size implant. Complications reported in this literature review were similar across the studies; these included aseptic loosening, mechanical failure, infection, flexion contracture of the knee, fracture, and neuropraxia. Nevertheless, the authors have stated that despite these complications, as opposed to amputation, the Repiphysis prosthesis offers a limb-sparing option for skeletally immature children with bone cancer of the lower extremity. Pediatric patients with bone cancer of the lower extremity who are skeletally immature will continue to pose a problem for the Orthopaedic Oncology surgeons, nurses, and other allied healthcare professionals. The Repiphysis expandable prosthesis offers a good limbsparing surgical option. However, the surgeons who use it have reported many complications. There are many other variables that can affect the successful outcome for a patient with a Repiphysis such as family support and home situation, insurance coverage, living distance from the treating facility, patient age and maturity level, cancer status, sibling support, and patient motivation. The physical therapy needed after surgery is intense and the exercise regimen is difficult. The patient and family must be willing to follow the rehabilitation treatment plan. Having a dedicated multidisciplinary team of healthcare providers working with patients who have had the Repiphysis prosthesis implanted will decrease the complication rate. There are other expandable prostheses available and there are other surgical options available to this group of patients also. Amputation and rotationplasty are two other options for surgical management of bone cancer of the lower extremity. Both surgical procedures, such as the Repiphysis, offer complete resection of the tumor. A patient with an amputation will have years of prosthesis adjustments and revisions. A patient with a rotationplasty not only functions as an amputee but also has to deal with the issue of disfigurement. Treatment of bone cancer of the extremity in the pediatric and the adult population will continue to change as technological advances occur in prosthesis development and chemotherapy. Implications for Nursing Practice, Patients, and Families Caring for a patient with a Repiphysis prosthesis can be challenging and multifaceted; therefore, a multidisciplinary approach to care is needed. Advanced practice nurses specializing in orthopaedic surgery and pediatric oncology are an integral part of the patient s care. Patient and family education must start at the initial office visit and should continually be reinforced and changed to meet patient and family needs. According to Prouty et al. (2006 ), preoperative education supports patients by giving them a clear and consistent message from all members of the multidisciplinary team, preparing them for their surgical procedure and subsequent care (p. 257). Moreover, assessing patients health literacy is important, to make sure that the educational information is at the appropriate level for the patient and family to comprehend. The patient is usually preadolescent or adolescent and is currently undergoing chemotherapy treatment for primary bone cancer. The patient may be on an orthopaedic nursing unit after the reconstructive surgery with the Repiphysis. However, during chemotherapy, the patient will be on a medical oncology unit. Therefore, all nurses caring for these patients must have knowledge of the prosthesis, the cancer treatment, and the recovery process. An advanced practice registered nurse in oncology can teach the patient and family symptom monitoring and management during chemotherapy. Including the patient and family when discussing self-care to alleviate symptoms is essential to compliance with treatment regimens. Williams et al. (2012) reported, Such tracking enables clinicians in consultation with patients or parents to identify and prioritize symptom-related interventions (p. 9). An advanced practice registered nurse in orthopaedics must make sure that the patient and family understand the preoperative and postoperative instructions as well as the importance of following the physical therapy guidelines for rehabilitation. Physical therapy is paramount but can be difficult if the patient is in pain from the surgery or is suffering nausea, fatigue, or neutropenia from the chemotherapy. The nurse must also be aware of the other options available for patients with bone sarcoma of the extremity such as rotationplasty and amputation. These procedures can also provide successful functional outcomes. Ultimately, the goal of use of the Repiphysis is to offer pediatric patients with bone cancer the most effective, least-invasive surgical procedure, with the lowest complication rate, the highest functional outcome, and patient satisfaction. ACKNOWLEDGMENTS Special thanks to Jill Anderson, RN, MSN, PCNS, APON and Denise Hamer, RN, Children s Mercy Hospital Hematology/Oncology Clinic, Kansas City, MO, and Howard G. Rosenthal, MD, Sarcoma Institute of Menorah, Menorah Medical Center, Overland Park, KS. REFERENCES American Cancer Society ( 2010a ). Osteosarcoma. Retrieved December 1, 2010, from osteosarcoma/detailedguide/ osteosarcoma-detailedguide-toc American Cancer Society. ( 2010b ). Sarcoma adult soft tissue cancer. Retrieved December 1, 2010, from DetailedGuide/index Beebe, K., Benevenia, J., Kaushal, N., Uglialoro, A., Patel, N., & Patterson, F. ( 2010a, June ). Evaluation of a non invasive expandable prosthesis in musculoskeletal oncology patients for the upper and lower limbs. Orthopedics, 33 ( 6 ). Retrieved June 1, 2010, from by National Association of Orthopaedic Nurses Orthopaedic Nursing March/April 2013 Volume 32 Number 2 85

6 Beebe, K., Song, K., Ross, E., uty, B., Patterson, F., & Benevenia, J. ( 2009 ). Functional outcomes after limbsalvage surgery and endoprosthetic reconstruction with an expandable Prosthesis: A report of 4 cases. Arch Phys Med Rehabil, 90, Beebe, K., Uglialoro, A., Patel, N., Benevenia, J., & Patterson, F. ( 2010b ). Mechanical failure of the Repiphysis expandable prosthesis: A case report. Journal of Bone and Joint Surgery, 92, Gupta, A., Meswania, J., Pollock, R., Cannon, S. R., Briggs, T. W. R., Taylor, S., & Blunn, G. ( 2006, May ). Non invasive distal femoral expandable endoprosthesis for limb-salvage surgery in pediatric tumors. Journal of Bone and Joint Surgery, 88 ( 5 ), Haynes, K. K. ( 2011 ). The use of the Repiphysis prosthesis for limb preservation in pediatric patients with bone cancer. Unpublished DNP Capstone Project. Kansas City, KS: University of Kansas School of Nursing. Hogendoorn, P. ( 2010 ). Bone sarcomas: ESMO (European Society of Medical Oncology) clinical practice guidelines for diagnosis, treatment, and follow-up. Annals of Oncology, 21 ( 5 ), doi: / annonc/mdq233 Maheshwari, A., Bergin, P., & Henshaw, R. ( 2011 ). Modes of failure of custom expandable Repiphysis prostheses: A report of three cases. Journal of Bone and Joint Surgery. American Volume, 93 ( 13 ), e72. doi: / JBJS.J Malawer, M., & Sugarbaker, P. ( 2001 ). Musculoskeletal cancer surgery: Treatment of sarcomas and allied diseases. Dordrecht, the Netherlands : Kluwer Academic Publishers. Neel, M. D., & Letson, G. D. ( 2001 ). Modular endoprostheses for children with malignant bone tumors. Cancer Control, 8 ( 4 ), Nystrom, L., & Morcuende, J. ( 2010 ). Expanding endoprosthesis for pediatric musculoskeletal malignancy: Current concepts and results. The Iowa Orthopaedic Journal, 30, Prouty, A., Cooper, M., Thomas, P., Christensen, J., Strong, C., Bowie, L., & Oermann, M. ( 2006 ). Multidisciplinary patient education for total joint replacement surgery patients. Orthopaedic Nursing, 25 ( 4 ), Saghieh, S., About, M., Muwakkit, S., Saab, R., Rao, B., & Haider, R. ( 2010 ). Seven-year experience of using Repiphysis expandable prosthesis in children with bone tumors. Pediatric Blood Cancer, 55, Tyner, C. ( 2012 ). The Repiphysis prosthesis: A synthesis of research. Unpublished Graduate Research Project. Kansas City, Kansas: University of Kansas School of Nursing. Williams, P., Williams, A., Kelly, K., Dobos, C., Gieseking, A., Connor, R., Del Favero, D. ( 2012 ). A symptom checklist for children with cancer: The Therapy-Related Symptom Checklist-Children, TRSC-C. Cancer Nursing, 35, doi: /ncc.0b013e31821a51f6 Yasko, A., Reece, G., Gillis, T., & Pollock, R. ( 1997 ). Limbsalvage strategies to optimize quality of life: The M.D. Anderson Cancer Center Experience. Cancer Journal for Clinicians, 47, For more than 66 continuing nursing education articles on orthopaedic topics and 54 on pediatric topics, go to nursingcenter.com/ce. 86 Orthopaedic Nursing March/April 2013 Volume 32 Number by National Association of Orthopaedic Nurses