Guideline for Limb-Salvage Treatment of Osteosarcoma

Limited Revision with a Newly Designed Hinge Device for the Treatment of Mega-Prosthesis Hinge Failure: Two Case Reports

BACKGROUND

Surgical treatment for hinge failure in mega-prosthesis continues to be a challenge. This study introduces a new method for treating hinge failure by using a unilateral prosthesis and hinge revision.

CASE PRESENTATION

We here present two patients who underwent mega-prosthesis reconstruction after resection of osteosarcoma in the distal femur. To address the issue of knee hyperextension after mega-prosthesis reconstruction, one patient underwent three revision surgeries, two surgeries were performed using the original hinge, and one surgery involved a newly designed hinge. To resolve the problem of dislocation, one patient underwent three revisions, with the first two revisions not involving hinge replacement and the third revision involving a newly designed hinge. Two replacements of unilateral prosthesis and hinge renovations were successful.

CONCLUSIONS

Unilateral prosthesis and newly designed hinge device revision are effective in treating the failure of old-fashioned mega-prosthesis hinges.

Ferroptosis defense mechanisms: The future and hope for treating osteosarcoma

Currently, challenges such as chemotherapy resistance, resulting from preoperative and postoperative chemotherapy, postoperative recurrence, and poor bone regeneration quality, are becoming increasingly prominent in osteosarcoma (OS) treatment. There is an urgent need to find more effective ways to address these issues. Ferroptosis is a novel form of iron-dependent programmed cell death, distinct from other forms of cell death. In this paper, we summarize how, through the three major defense systems of ferroptosis, not only can substances from traditional Chinese medicine, antitumor drugs, and nano-drug carriers induce ferroptosis in OS cells, but they can also be combined with immunotherapy, differentiation therapy, and other treatment modalities to significantly enhance chemotherapy sensitivity and inhibit tumor growth. Thus, ferroptosis holds great potential in treating OS, offering more choices and possibilities for future clinical interventions.

Quality assessment of online osteosarcoma-related videos in Mainland China: A cross-sectional study

BACKGROUND

Information about orthopedics diseases on the Internet has not been extensively assessed. Our purpose was to evaluate the quality of online information of osteosarcoma on current video-sharing platforms in mainland China.

METHOD

TikTok and Bilibili were independently queried from June to July 2023 by four independent researchers using the Microsoft Edge web browser. Information about the videos and creators was recorded, and descriptive analyses were conducted.

RESULTS

After data extraction, a total of 95 videos were included, in which 43 videos were uploaded by certified doctors (45.3%), with 35 videos (36.8%) uploaded by certified orthopedic surgeons. Of the content of these videos, 78.9% were introduction (n = 75), 64.2% were on professional knowledge (n = 61), 28.4% were on treatment (n = 27), while 5.3% were on surgical techniques (n = 5). The mean DISCERN total score was 43.8 ± 13.4, and the mean JAMA score was 3.8 ± 0.3.

CONCLUSIONS

Videos about osteosarcoma on current video-sharing platforms were extensive, but were not comprehensive and professional. Although current online videos have the potential to improve public awareness on osteosarcoma, due to their quality and content, were not assessed to be good sources for medical education.

Using 3D Printing Technology to Manufacture Personalized Bone Cement Placeholder Mold for Bone Defect Repair and Reconstruction with Infection: A Case Report

BACKGROUND

Limb salvage surgery is the preferred treatment for most malignant bone tumors, but postoperative infection treatment is very challenging. Simultaneously controlling infection and solving bone defects are clinical treatment challenges.

CASE PRESENTATION

Here we describe a new technique for treating bone defect infection after bone tumor surgery. An 8-year-old patient suffered an incision infection after osteosarcoma resection and bone defect reconstruction. In response, we designed her a personalized, anatomically matched, antibiotic-loaded, bone cement spacer mold using 3D printing technology. The patient's infection was cured, and limb salvage was successful. In follow-up, the patient had returned to normal postoperative chemotherapy and was able to walk with the help of a cane. There was no obvious pain in the knee joint. At 3 months after operation, the range of motion of the knee joint was 0°-60°.

CONCLUSION

The 3D printing spacer mold is an effective solution for treating the infection with large bone defect.

Does joint-sparing tumor resection jeopardize oncologic and functional outcomes in non-metastatic high-grade osteosarcoma around the knee?

BACKGROUND

We previously reported joint-sparing tumor resection for osteosarcoma with epiphyseal involvement in which transepiphyseal osteotomy went through the in situ ablated epiphysis. However, we do not know whether this is a safe approach when compared with joint-sacrificed tumor resection. Our objective was to compare oncologic and functional outcomes between patients who underwent joint preservation (JP) and joint replacement (JR) tumor resection. Furthermore, we identified the risk factors of local recurrence, metastasis and survival.

METHODS

Eighty-nine patients with non-metastatic high-grade osteosarcoma around the knee were treated with limb-salvage surgery (JP in 47 and JR in 42). Age, gender, tumor location, pathologic fracture, plain radiographic pattern, limb diameter change, perivascular space alteration, surgical margin, local recurrence, metastasis, death, and the Musculoskeletal Tumor Society (MSTS)-93 scores were extracted from the records. Univariate analysis was performed to compare oncologic and functional outcomes. Binary logistic and cox regression models were used to identify predicted factors for local recurrence, metastasis, and survival.

RESULTS

Local recurrence, metastasis and overall survival were similar in the JP and JR group (p = 0.3; p = 0.211; p = 0.143). Major complications and limb survival were also similar in the JR and JP group (p = 0.14; p = 0.181). The MSTS score of 27.06 ± 1.77 in the JP group was higher than that of 25.88 ± 1.79 in the JR group (p = 0.005). The marginal margin of soft tissue compared with a wide margin was the only independent predictor of local recurrence (p = 0.006). Limb diameter increase and perivascular fat plane disappearance during neoadjuvant chemotherapy were independent predictors for metastasis (p = 0.002; p = 0.000) and worse survival (p = 0.000; p = 0.001).

CONCLUSIONS

Joint-sparing tumor resection with the ablative bone margin offers advantage of native joint preservation with favorable functional outcomes while not jeopardizing oncologic outcomes compared with joint-sacrificed tumor resection. Surgeon should strive to obtain adequate soft tissue surgical margin decreasing risk of local recurrence. Novel drug regimens might be reasonable options for patients with obvious limb diameter increase and perivascular fat disappearance during chemotherapy.

Custom-made semi-joint prosthesis replacement combined ligament advanced reinforcement system (LARS) ligament reconstruction for the limb salvage surgery of malignant tumors in the distal femur in skeletal immature children

Purpose

To explore the application of Custom-made Semi-joint prosthesis replacement combined with Ligament Advanced Reinforcement System (LARS) ligament reconstruction for the limb salvage surgery (LSS) of malignant tumors in the distal femur and provide selections for the LSS of malignant tumors in skeletal immature children.

Methods

A total of 8 children with malignant tumors in the distal femur who underwent Custom-made Semi-joint prosthesis replacement combined LARS ligament reconstruction for LSS from January, 2018 until December, 2019 in our bone and soft tissue tumor center were retrospectively recruited. The prosthesis related complications, oncological prognosis and knee function were observed, and the surgical efficacy was comprehensively evaluated.

Results

The average follow-up time was 36.6 months (30-50 months). The average osteotomy length was 13.2 cm (8-20 cm) according to the preoperative imaging results and the length of the customized prosthesis. Two years after operation, the average MSTS-93 score was 24.4 (16-29) which indicated good limb functions. The range of motion of the knee was 0°-120°, with an maximum average of 100°. At last follow-up, the average height of the children increased by 8.4 cm (6-13 cm), and the average limb shortening was 2.7 cm (1.8-4.6 cm). One patient had wound complications in the early postoperative period, wound scab fell off to form superficial ulcer, in whom debridement and suturing were performed. One patient developed hematogenous disseminated prosthesis infection 2 years after surgery, and the prosthesis is now in situ with anti-infection treatment. One patient developed pulmonary metastasis during follow-up, and received chemotherapy and targeted therapy with lesion well controlled. At the last follow-up, there was no local tumor recurrence or prosthesis loosening.

Conclusion

Under the premise of appropriate case selection, customized semi-joint prosthesis replacement combined with LARS ligament reconstruction provides a new option for LSS in children with distal femur malignant tumors. LARS ligament reconstruction ensures the stability and range of motion of the knee joint, which maximally preserves the epiphysis of the tibia side and the growth function of the tibia side, reduces the complications of limb length inequality in the long term and creates conditions for limb lengthening or total joint replacement in adults.

Composite microgranular scaffolds with surface modifications for improved initial osteoblastic cell proliferation

Polyester-based granular scaffolds are a potent material for tissue engineering due to their porosity, controllable pore size, and potential to be molded into various shapes. Additionally, they can be produced as composite materials, e.g., mixed with osteoconductive β-tricalcium phosphate or hydroxyapatite. Such polymer-based composite materials often happen to be hydrophobic, which disrupts cell attachment and decreases cell growth on the scaffold, undermining its primary function. In this work, we propose the experimental comparison of three modification techniques for granular scaffolds to increase their hydrophilicity and cell attachment. Those techniques include atmospheric plasma treatment, polydopamine coating, and polynorepinephrine coating. Composite polymer/β-tricalcium phosphate granules have been produced in a solution-induced phase separation (SIPS) process using commercially available biomedical polymers: poly(lactic acid), poly(lactic-co-glycolic acid), and polycaprolactone. We used thermal assembly to prepare cylindrical scaffolds from composite microgranules. Atmospheric plasma treatment, polydopamine coating, and polynorepinephrine coating showed similar effects on polymer composites' hydrophilic and bioactive properties. All modifications significantly increased human osteosarcoma MG-63 cell adhesion and proliferation in vitro compared to cells cultured on unmodified materials. In the case of polycaprolactone/β-tricalcium phosphate scaffolds, modifications were the most necessary, as unmodified polycaprolactone-based material disrupted the cell attachment. Modified polylactide/β-tricalcium phosphate scaffold supported excellent cell growth and showed ultimate compressive strength exceeding this of human trabecular bone. This suggests that all investigated modification techniques can be used interchangeably for increasing wettability and cell attachment properties of various scaffolds for medical applications, especially those with high surface and volumetric porosity, like granular scaffolds.

Osteosarcoma: Current Concepts and Evolutions in Management Principles

Osteosarcoma is a rare malignancy arising from mesenchymal tissue, and represents the most common bone sarcoma. The management of osteosarcoma is challenging, and requires a multidisciplinary approach. In daily clinical practice, surgery, radiotherapy, and conventional chemotherapy constitute the therapeutic armamentarium against the disease. However, a significant number of patients with initially localized osteosarcoma will experience local or distant recurrence, and the prognosis for metastatic disease remains dismal. There is a pressing need to identify novel therapeutic strategies to better manage osteosarcoma and improve survival outcomes. In this study, we present recent advances in the therapeutic management of osteosarcoma, including surgical and medical advances. The role of immunotherapy (immune checkpoint inhibitors, adoptive cellular therapy, cancer vaccines) and other targeted therapies including tyrosine kinase inhibitors is discussed; however, additional studies are required to delineate their roles in clinical practice.

Osteosarcoma of the Proximal Fibula: A Case Report and Review of the Literature

Osteosarcoma is the most common primary malignant bone tumor, especially in younger patients. Diagnosis is based on the combined evaluation of radiological, clinical, and pathological examinations. It is usually located in the distal femur, proximal tibia, and proximal humerus. The fibula is a rare localization for osteosarcoma. Surgery in this region is challenging due to the complex anatomic structures around the knee. Especially the peroneal nerve, lateral collateral ligament (LCL), and popliteal vessel branches are of critical importance. However, additional structures such as the arcuate ligament, biceps femoris, and iliotibial band play an essential role in the stabilization of the knee. Thus, these structures must be protected as much as possible. This case report aims to present the diagnosis and treatment process of conventional osteosarcoma in the proximal fibula, which was located close to the peroneal nerve and required LCL reconstruction after the resection.

The Use of Hydrogels for the Treatment of Bone Osteosarcoma via Localized Drug-Delivery and Tissue Regeneration: A Narrative Review

Osteosarcoma is a malignant tumor of bone that leads to poor mortality and morbidity. Management of this cancer through conventional methods involves invasive treatment options that place patients at an increased risk of adverse events. The use of hydrogels to target osteosarcoma has shown promising results both in vitro and in vivo to eradicate tumor cells while promoting bone regeneration. The loading of hydrogels with chemotherapeutic drugs provides a route for site-specific targeted therapy for osteosarcoma. Current studies demonstrate tumor regression in vivo and lysis of tumor cells in vitro when exposed to doped hydrogel scaffolds. Additionally, novel stimuli-responsive hydrogels are able to react with the tissue microenvironment to facilitate the controlled release of anti-tumor drugs and with biomechanical properties that can be modulated. This narrative review of the current literature discusses both in vitro and in vivo studies of different hydrogels, including stimuli-responsive, designed to treat bone osteosarcoma. Future applications to address patient treatment for this bone cancer are also discussed.

The combination of eddy thermal effect of biodegradable magnesium with immune checkpoint blockade shows enhanced efficacy against osteosarcoma

Osteosarcoma (OS) patients have a poor prognosis due to its high degree of heterogeneity and high rate of metastasis. Magnetic hyperthermia therapy (MHT) combined with immunotherapy is an effective strategy to treat solid and metastatic tumors. Here, we combined biodegradable magnesium (Mg) macroscale rods, which acted as an eddy thermo-magnetic agent under a low external alternating magnetic field, and immunotherapy to achieve a radical cure for OS. The eddy thermal effect (ETE) of the Mg rods (MgR) showed outstanding cytotoxic effects and enhanced the maturation of dendritic cells (DCs), and the mild MHT induced the immunogenic cell death (ICD) in the OS cells. Combined with immune checkpoint blockade (ICB) therapy, we obtained an excellent curative effect against OS, and a further evaluation demonstrated that the local MHT induced by the MgR increased T cells infiltration and the polarization of M1 macrophages. Interestingly, the biodegradable MgR also promoted bone osteogenesis. Our work highlighted the uneven ETE mediated by the biodegradable MgR induced a comprehensive immunologic activation in the OS tumor microenvironment (TME), which would inspire the application of MHT for the effective treatment of OS.

Neoadjuvant Chemotherapy and Expandable Prosthesis Reconstruction to Treat Osteosarcoma around the Knee in Children

OBJECTIVE

Survival and reconstruction in osteosarcoma is quite challenging. The study aimed to investigate the prognosis in patients treated with neoadjuvant chemotherapy and determine the clinical outcomes of expandable endoprosthesis reconstruction in children.

METHODS

From January 2009 to December 2014, we retrospectively analyzed 29 skeletally immature children (mean age, 10.5 years; range, 6-15 years) with osteosarcoma around the knee. Of the 29 patients who underwent neoadjuvant chemotherapy and limb salvage surgery, an expandable prosthesis was implanted for reconstruction. No patients were missed during follow-up. The evaluation index involved follow-up time, complication, functional results, and lengthening procedures. The survivorship and recurrence were assessed by GraphPad Software, and the function was evaluated by the Musculoskeletal Tumor Society (MSTS) scoring system.

RESULTS

A mean follow-up time was 8.9 years (range, 6-12 years), and the overall 5-year survival was 89.1% based on Kaplan-Meier analysis. Three patients suffered a relapse and one underwent amputation. Lung metastasis developed in one patient. At 6 months after the operation, patients had a mean MSTS score of 27 points (range, 24-29). Two patients underwent revision surgery, one for implant infection and one for aseptic loosening. Prognosis is correlated with alkaline phosphatase change after treatment.

CONCLUSIONS

Chemotherapy scheme and limb salvage can achieve high survival rates. This expandable prosthesis was associated with good function and low complication rates. The character of expandability could be a method to overcome discrepancies in the growth period.

Mediating effect assessment of ifosfamide on limb salvage rate in osteosarcoma: A study from a single center in China

Osteosarcoma is one of the most prevalent primary bone malignancies in children and adolescents. Surgery and chemotherapy are the standard treatment methods of osteosarcoma. Methotrexate, adriamycin, and cisplatin, and methotrexate, adriamycin, cisplatin, and ifosfamide regimens are both first-line neoadjuvant chemotherapy regimens for osteosarcoma. Moreover, the use of ifosfamide is highly controversial. Most studies of ifosfamide focused on the overall survival rate and event-free survival rate; few studies concentrated on surgical options. We conducted this retrospective study to compare the baseline characteristic of amputation and limb salvage osteosarcoma patients. Furthermore, we analyzed the direct and indirect roles in surgical decision-making and found that ifosfamide may play a partial mediating role in the surgery option choice by mediating tumor mass volume change, tumor response, and the shortest distance from the center of main blood vessels to the margin of the tumor lesion.

Patient-Specific Instruments for Forearm Sarcoma Resection and Allograft Reconstruction in Children: Results in 4 Cases

For pediatric malignant bone tumors located in the limbs, limb salvage surgery is the gold standard, but it requires adequate resection margins to avoid local recurrence. Primitive bone sarcomas of the forearm (radius or ulna) are very rare and the reconstruction remains challenging. We describe a method to ensure minimal but adequate resection bone margins with precision in four consecutive patients with primitive bone sarcomas of the forearm. During the preoperative planning, magnetic resonance imaging (MRI) was used to delineate the tumor and the tumor volume was transferred to computerized tomography (CT) by image fusion. A patient-specific instrument (PSI) was manufactured by 3D printing to allow the surgeon to perform the surgical cuts precisely according to the preoperative planning. The first PSI was used for the resection of the tumor, which adopted a unique position at the bony surface. A second PSI was intended for the cutting of the bone allograft so that it fitted perfectly with the bone defect. In all four cases, the safe margin obtained into the bone was free of tumor (R0: microscopically margin-negative resection). The functional result was very good in all four patients. This limb salvage surgical technique can be applied in forearm bone sarcoma and improves surgical precision while maintaining satisfactory local tumor control. It can also reduce the surgical time and allow a stable osteosynthesis.

Clinical value of ultrasound for the evaluation of local recurrence of primary bone tumors

Background

Early detection of local recurrence would improve the survival rate of patients with recurrent bone tumors. There is still no consensus on how to follow up after surgery of primary malignant bone tumors. Therefore, the purpose of this study is to evaluate the diagnostic value of ultrasound (US) for local recurrence after limb salvage by comparing it with other imaging modalities.

Methods

We retrospectively reviewed the medical records of patients who were regularly examined by US in our hospital after primary bone tumor surgery from January 2016 to December 2019, some of which underwent x-ray, computed tomography (CT), or ⁹⁹mTc-MDP bone scan. Recurrence was determined by pathologic confirmation. The cases were considered a true negative for no recurrence if no clinical or pathologic evidence for recurrence was found at least 6 months after the US examination. The Chi-square test or Fisher exact test was used to compare categorical data. p-values < 0.0083 were considered statistically significant.

Results

A total of 288 cases were finally enrolled in our research, including 66 cases with pathologic results. The sensitivity of US was 95.0%, higher than that of x-ray (29.6%) (p = 0.000). The accuracy of US was 96.9%, higher than that of x-ray (85.6%) (p = 0.000).

Conclusion

As a nonradiative and cost-effective examination, US may be used as a routine imaging method for postoperative surveillance of primary bone tumors, especially those with metal implants, if more multicenter prospective studies can be done in the future.

Efficacy of Neoadjuvant Chemotherapy plus Limb-Sparing Surgery for Osteosarcoma and Its Impact on Long-Term Quality of Life

Purpose

To assess the efficacy of neoadjuvant chemotherapy plus limb-sparing surgery for osteosarcoma and its impact on long-term quality of life.

Methods

Between August 2016 and December 2018, 90 patients with osteosarcoma treated in Nanchong Central Hospital were recruited and divided at a ratio of 1 : 1 to receive limb-sparing surgery (control group) or limb-sparing surgery plus neoadjuvant chemotherapy (study group) by random number table methods. The clinical endpoints were clinical efficacy and long-term quality of life.

Results

Limb-sparing surgery plus neoadjuvant chemotherapy was associated with a significantly higher efficacy versus limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy resulted in a significantly higher Enneking score and a higher good function rating of patients versus limb-sparing surgery. The two groups showed a high but similar 1-year survival rate. Patients given limb-sparing surgery plus neoadjuvant chemotherapy showed significantly higher 2-year and 3-year survival and a longer mean survival versus those receiving limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy resulted in significantly higher scores of role emotional, mental health, physical function, and social function and a lower bodily pain score than limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy was associated with significantly lower fatigue, nausea and vomiting, dyspnea, constipation, and diarrhea scores and a significantly higher health status score versus monotherapy of limb-sparing surgery.

Conclusion

Neoadjuvant chemotherapy plus limb-sparing surgery improves the postoperative limb function and long-term quality of life of patients with osteosarcoma, which shows great potential for clinical promotion.

Analysis of Clinical Manifestations and Prognostic Factors Affecting Osteosarcoma

Objective

This study is aimed at exploring the clinical manifestations and prognostic factors of osteosarcoma.

Methods

The clinical data of patients with osteosarcoma who were treated in our hospital from January 2018 to March 2020 were selected for retrospective analysis. The general information of the patients, including age, gender, tumor diameter, tumor location, tumor type, surgical method, and Enneking stage, distant disease metastasis, KPS score, and the number of postoperative adjuvant chemotherapy, were grouped by prognosis for statistical analysis. The clinical characteristics, morbidity and mortality, and prognostic factors of patients were statistically analyzed.

Results

Among the 83 patients in this group, there were 52 males and 31 females, 59 tumors > 10 cm in diameter and 24 tumors < 10 cm in diameter, 16 tumors in the upper limbs and 67 tumors in the lower limbs, 25 tumors in osteoblastoma, 16 tumors in chondroblastoma, 42 tumors in fibroblastoma, 62 tumors in stage II, and 21 tumors in stage III of Enneking stage, 10 tumors in distant metastasis, and 10 tumors in distant metastasis. The death rate of this group was 19.28% (16/83). Multifactor regression analysis confirmed that the Enneking stage III, distant metastasis, KPS score < 70, and the number of postoperative adjuvant chemotherapy < 6 were important factors influencing the death of osteosarcoma (P < 0.05).

Conclusion

Enneking stage III, distant metastasis, KPS score < 70, and the number of postoperative adjuvant chemotherapy < 6 are important influencing factors of osteosarcoma death. Clinical practice can take corresponding preventive and control measures according to the existence of these factors to ensure a good prognosis.

[Research on three-dimensional printing technology based on three-dimensional multimodality imaging to assist the operation of malignant bone tumors of limbs]

OBJECTIVE

To explore the role and effectiveness of three-dimensional (3D) printing technology based on 3D multimodality imaging in surgical treatment of malignant bone tumors of limbs.

METHODS

The clinical data of 15 patients with malignant bone tumors of the limbs who met the selection criteria between January 2016 and January 2019 were retrospectively analyzed. There were 6 males and 9 females, with a median age of 34 years (range, 17-73 years). There were 5 cases of osteosarcoma, 3 cases of chondrosarcoma, 2 cases of Ewing sarcoma, 1 case of hemangiosarcoma, 1 case of ameloblastoma, and 3 cases of metastatic carcinoma. The tumors were located in the humerus in 5 cases, ulna in 2 cases, femur in 3 cases, and tibia in 5 cases. The disease duration was 2-8 months (median, 4 months). Preoperative 3D multimodality imaging was administered first, based on which computer-assisted preoperative planning was performed, 3D printed personalized special instruments and prostheses were designed, and in vitro simulation of surgery was conducted, successively. Two cases underwent knee arthroplasty, 2 had semi-shoulder arthroplasty, 2 had proximal ulna arthroplasty, and 9 had joint-preserving surgery. Surgical margins, operation time, intraoperative blood loss, surgical complications, Musculoskeletal Tumor Society (MSTS) score, and oncological outcome were collected and analyzed.

RESULTS

All 15 patients completed the operation according to the preoperative plan, and the surgical margins were all obtained wide resection margins. The operation time was 80-240 minutes, with a median of 150 minutes. The intraoperative blood loss was 100-400 mL, with a median of 200 mL. There was no significant limitation of limb function due to important blood vessels or nerves injury during operation. One case of superficial infection of the incision was cured after dressing change, and the incisions of the other patients healed by first intention. All patients were followed up 6-48 months, with a median of 24 months. Two of the patients died of lung metastasis at 6 and 24 months after operation, respectively. No local recurrence, prosthesis dislocation, or prosthesis loosening occurred during follow-up. At last follow-up, the MSTS score ranged from 23 to 30, with an average of 25.

CONCLUSION

3D printing tecnology, based on 3D multimodality imaging, facilitates precise resection and reconstruction for malignant bone tumors of limbs, resulting in improved oncological and functional outcome.

Radiographic Assessment of Aseptic Loosening of Tumor-Type Knee Prosthesis in Distal Femur

OBJECTIVE

To measure the full-length anteroposterior and lateral radiographs of lower limbs after the resection of a tumor in the distal femur and tumor-type knee prosthesis replacement and to analyze the factors leading to aseptic loosening of the prosthesis.

METHODS

A total of 26 cases of tumor-type knee prosthesis replacement or revision due to the distal femoral tumor at our hospital from January 2007 to December 2019 were retrospectively analyzed. The patients were divided into the loosening and unloosening groups depending on whether aseptic loosening occurred after surgery. Full-length anteroposterior and lateral radiographs of lower limbs were used to measure bone resection length, length of prosthesis, distance of proximal apex of the medullary stem of the femoral prosthesis from the maximum arc of the anterior femoral arch, diameter of the medullary stem, etc. Data were analyzed, and the risk factors for aseptic loosening of the prosthesis were explored.

RESULTS

The ratio of the prosthetic length to the femoral length (63.72 ± 5.21) and the ratio of the femoral medullary stem diameter to the femoral diameter (26.03 ± 8.45) were smaller in the loosening group than in the unloosening group. The difference was statistically significant (p < 0.05). The distance between the apex of the medullary stem and the maximum arc of the anterior femoral arch was significantly shorter in the loosening group (3.47 ± 2.96) than in the unloosening group, and the difference was statistically significant (p < 0.05). The measurement of the lower limb alignment showed significant differences between the loosening and unloosening groups in terms of HKAA, mLDFA, and distance between the lower limb alignment and the center of the knee joint (p < 0.05). The logistic regression analysis showed that less than 30% ratio between the medullary stem diameter and the femoral diameter, less than 3 cm distance between the apex of the medullary stem and the maximum curvature of the anterior arch of the femur, distance between the lower limb alignment and the center of the knee joint, and presence of varus knee and valgus knee after the surgery were the risk factors for aseptic loosening of the prosthesis.

CONCLUSIONS

The diameter of the femoral medullary stem of the prosthesis, the apex position of the prosthetic stem, and the lower limb alignment are the risk factors for aseptic loosening of the prosthesis.

Evaluation of tumor-prostheses over time: Complications, functional outcome, and comparative statistical analysis after resection and reconstruction in orthopedic oncologic conditions in the lower extremities

Objectives:

Previous multicenter studies report variable outcomes and failure rates after tumor-prosthetic reconstructions. The purpose of this study was (1) to evaluate implant survival, limb survival, and functional outcome in a cohort of patients who underwent resection of primary malignancies or aggressive benign bone tumors and reconstruction with modern tumor-prostheses in the lower extremities and (2) to provide comparison to a historical cohort on previous generations of tumor-prostheses from the same center.

Methods:

A longitudinal retrospective single-center study of 72 consecutive patients (F/M = 30/42), mean age = 44 (range = 7–84) years with bone, soft tissue sarcoma adjacent to bone (n = 69), and aggressive benign bone tumors (n = 3) having surgery between 2006 and 2016 with bone resection and reconstruction with tumor-prostheses were compared to a historical cohort from1985 to 2005. Revisions were classified as major and minor revisions. Causes of failure were classified according to the Henderson classification. Fine and Gray competing risk analysis was used for assessing cumulative incidence for implant revision and limb amputation. Functional outcome was evaluated with Musculoskeletal Tumor Society Score system.

Results:

Forty-seven patients were alive at the end of the study. Mean follow-up was 6 years (range = 2–13 years). Ten-year cumulative risk of major revision was 18% (95% confidence interval = 9%–28%). Deep infection and recurrence of tumor caused most revisions in modern tumor-prostheses. Ten-year cumulative incidence of limb amputation was 11% (95% confidence interval = 3%–18%). According to the Henderson classification, the overall predominant failure mode was non-mechanical (n = 20, 51%). Mean Musculoskeletal Tumor Society Score was 20 (67%) (range = 0–30).

Conclusion:

A minimum of 2 years follow-up with modern modular tumor-prostheses demonstrated a relatively low risk of implant failure and amputation and also an acceptable functional outcome. No statistical difference of, implant survival, limb survival and functional outcome between tumor-prostheses over two time periods was observed, possibly explained by Type 2 error.

Meta-analysis of the prognosis after surgical treatment of osteosarcoma complicated by pathologic fracture

AIM

To evaluate the prognosis of surgical treatment of osteosarcoma complicated by pathologic fracture.

MATERIALS AND METHODS

We searched articles in PubMed, Web of Science, and Embase for studies published up to January 1, 2022, that reported the surgical prognosis of osteosarcoma patients complicated with/without pathologic fracture. The specific outcome indicators used in the meta-analysis included the local recurrence rate (LRR), distant metastasis rate (DMR), overall survival (OS) rate and disease-free survival (DFS) rate after surgical treatment such as amputation or limb salvage in the pathologic fracture group and non-pathologic fracture group. Crude and adjusted Odds Ratio (OR) with 95% confidence intervals were used to compare data between the case group and control group. Fifteen studies and 3839 patients were included in the final meta-analysis.

RESULTS

The difference between the pathologic fractures group and the non-pathologic fracture group was not statistically significance in LRR analysis (OR = 1.27, 95% CI: 0.88-1.84, P > 0.05); however, a statistically significant difference was found between two groups in DMR (OR = 1.42, 95% CI: 1.03-1.95, P < 0.05). For survival rates, the following ORs were found: 3-year OS (OR = 1.71, 95% CI: 1.25-2.35, P < 0.05); 5-year OS (OR = 1.41, 95% CI: 1.06-1.87, P < 0.05); 3-year DFS (OR = 1.88, 95% CI: 1.20-2.94, P < 0.05); and 5-year DFS (OR = 1.49, 95% CI: 1.10-2.03, P < 0.05). The pooled estimate of OR is 1.48 (95% CI: 0.72-3.04, P > 0.05) for local recurrence and 1.82 (95% CI: 0.92-3.60, P > 0.05) for distant metastasis in the amputation group and the limb salvage group for osteosarcoma patients with pathologic fractures, respectively. Our analysis indicated that patients with a pathologic fracture have a higher risk of DMR after surgery, but there is no significant difference in LRR between patients with a pathologic fracture and without. Additionally, in osteosarcoma patients with a pathologic fracture, there was no difference in LDR or DMR between limb-salvage surgery and amputation.

CONCLUSION

Complicated with pathologic fracture is a negative prognostic indicator of osteosarcoma, and its poor survival rates (both OS and DFS) may be associated with a higher DMR. For osteosarcoma patients with pathologic fractures treated with standard treatment, LRR and DMR exhibit no significant difference between amputation and limb-salvage surgery.

Clinical Application of Artificial Intelligence: Auto-Discerning the Effectiveness of Lidocaine Concentration Levels in Osteosarcoma Femoral Tumor Segment Resection

Adolescents and children worldwide are threatened by osteosarcoma, a tumor that predominantly affects the long bone epiphysis. Osteosarcoma is the most common and highly malignant bone tumor in youngsters. Early tumor detection is the key to effective treatment of this disease. The discovery of biomarkers and the growing understanding of molecules and their complex interactions have improved the outcome of clinical trials in osteosarcoma. This article describes biomarkers of osteosarcoma with the aim of positively influencing the progress of clinical treatment of osteosarcoma. Femoral bone tumor is a typical condition of osteosarcoma. Due to the wide range of femoral stem types, complexities in the distal femur, and tumors in the rotor part of femur, physicians following the traditional clinical approach face difficulties in removing the lesion and fixing the femur with resection of the tumor segment. In this paper, the effect of small doses of different concentrations of lidocaine anesthesia in patients undergoing lumpectomy for osteosarcoma femoral tumor segments is investigated. A computer-based artificial intelligence method for automated determination of different concentration levels of lidocaine anesthesia and amputation of osteosarcoma femoral tumor segment is proposed. Statistical analysis is carried on the empirical data including intraoperative bleeding, intraoperative and postoperative pain scores, surgical operation time, postoperative complications, patient satisfaction, and local anesthetic dose. The results showed that the patients in the study group had low intraoperative bleeding, short operation time, low postoperative hematoma formation rate, high patient satisfaction, higher dosage of anesthetic solution, and low dosage of lidocaine. Results revealed that mean arterial pressure and heart rate in extubating and intubating were significantly lower in the observation group than in the control group, and a significant difference (P < 0.05) was observed between the two groups. This proves that the proposed algorithm can adequately reduce bleeding, alleviate postoperative pain, shorten operation time, reduce complications, accelerate recovery, and ensure better treatment results.

Discovery and Characterization of Intercondylar Transphyseal Complexes and their Oncological Significance in Transphyseal Extension of Pediatric Osteosarcoma

Objective

To explore whether there exist undiscovered transphyseal vasculature‐canal compound structures in immature femurs and tibias, and reveal their potential oncological impact.

Methods

This investigation was divided into a morphological study and a clinical study. In the morphological part, a new‐identified anatomic structure was investigated by using radiographical, anatomical, and histological methodologies. Twenty‐eight 1‐mm‐slice thickness magnetic resonance images of pediatric knees were generated and 10 pediatric knees were dissected to verify the existence and universality, observe the radiographic and anatomic characteristics, and determined the located region of this structure. Hematoxylin–eosin staining, immunofluorescence, and angiography procedures were performed to illustrate its histological feature, molecular identification, and vascular origination, respectively. In the clinical part, 38 pediatric osteosarcoma patients were enrolled from January 2014 to December 2020. A descriptive clinical study including 13 typical participants was conducted to investigate the oncological significance of this new‐identified structure. Meanwhile, the discrepancy in transphyseal osteosarcoma extension between different physeal regions was evaluated in a cross‐sectional study.

Results

In the morphological study, we discovered a new‐found vasculature‐canal compound structure, intercondylar transphyseal complex (ITC), which originated from the middle genicular vessels, traversed the whole epiphysis, and breached the intact open physis in the immature proximal tibia or distal femur. The components of ITC included the juxta‐articular, epiphyseal, and transphyseal segments of vessels, the canals that traverse the entire epiphysis and physis and enclosed the vessels, vascular foramina on articular facet and foramina‐covered synovium. Depending on the location, ITCs can be divided into three types: femoral ITC, anterior tibial ITC, and posterior tibial ITC. Clinically, the ITC may facilitate intercondylar transphyseal sarcomatous dissemination without damaging the adjacent physeal cartilage. Compared to bilateral condylar physes, more osteosarcomas transgressed the open growth plates through intercondylar regions in which ITC was located (P = 0.022).

Conclusion

As the “gap” on intact open physis, ITC, which is a new‐identified compound structure in intercondylar regions of immature femur or tibia, may promote intercondylar transphyseal tumor extension. Moreover, the identification and characterization of ITC subvert some traditional comprehensions about physis and may provide novel perspectives for pediatric osteosarcomas.

Cutaneous diphtheria complicated oncologic reconstruction surgery in osteosarcoma

Diphtheria is an uncommon bacterial infection of the upper respiratory tract. We described a surgical site infection in a young adolescent female on maintenance chemotherapy. Corynebacterium diphtheriae was recovered from the wound, and she was treated with antibiotics and antitoxin. Cutaneous diphtheria should be considered in immunocompromised patients receiving chemotherapy.

Current Status and Prospects of Clinical Treatment of Osteosarcoma

Osteosarcoma, one of the common malignant tumors in the skeletal system, originates in mesenchymal tissue, and the most susceptible area of occurrence is the metaphysis with its abundant blood supply. Tumors are characterized by highly malignant spindle stromal cells that can produce bone-like tissue. Most of the osteosarcoma are primary, and a few are secondary. Osteosarcoma occurs primarily in children and adolescents undergoing vigorous bone growth and development. Most cases involve rapid tumor development and early blood metastasis. In recent years, research has grown in the areas of molecular biology, imaging medicine, biological materials, applied anatomy, surgical techniques, biomechanics, and comprehensive treatment of tumors. With developments in molecular biology and tissue bioengineering, treatment methods have also made great progress, especially in comprehensive limb salvage treatment, which significantly enhances the quality of life after surgery and improves the 5-year survival rate of patients with malignant tumors. This article provides a review of limb salvage, immunotherapy, gene therapy, and targeted therapy from traditional amputation to neoadjuvant chemotherapy, providing a reference for current clinical treatments for osteosarcoma.

Cryosurgery and vascularized fibular graft reconstruction in proximal tibia osteosarcoma in young children: A case report

Introduction

Osteosarcoma epidemiology in children younger than 5-year-old is very rare. Currently, limb salvage surgery becomes the preferred treatment in osteosarcoma. Wide excision using cryosurgery has been reported as an effective and safe procedure for malignant bone tumors.

Case report

A 5-year-old girl was presented with pain and a lump on her right knee. Physical examination showed a solid circumferential mass in the proximal tibia, with limited range of motion due to mass and pain. Osteoblastic lesion with a discrete margin and narrow transition zone on the proximal tibia from plain radiograph and magnetic resonance imaging (MRI) examination. Histopathological examination suggested osteosarcoma with a giant cell rich osteosarcoma subtype. Three cycles of neoadjuvant chemotherapy was conducted with cisplatin, ifosfamide, and adriamycin. We performed limb salvage surgery by wide excision with cryosurgery and vascularized fibular graft reconstruction. Wide excision was performed with the respect to preserve the epiphyseal plate. The proximal tibia segment was recycled using liquid nitrogen and re-implanted, fixed with a locking 2.7 mm T-plate and a straight reconstruction 2.7 mm reconstruction plate. Vascularized fibular graft was used to fill the bone defect on the medial side. Post-operative radiograph showed the plate and screws are well-fixated and the post-operative histopathological examination confirmed the diagnosis of conventional osteosarcoma HUVOS I. There was no post-operative complication observed, and the functional outcome was good.

Conclusions

Cryosurgery and vascularized fibular graft is a viable reconstructive option for proximal tibia osteosarcoma in very young children.

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Osteosarcoma in a very young child is rare.

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Few cases of osteosarcoma in very young child treated with cryosurgery

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Wide excision with cryosurgery and vascularized fibular graft reconstruction showed excellent functional outcome.

Osteosarcoma: a review of current and future therapeutic approaches

Osteosarcoma (OS) is the most common primary bone malignancy that affects children and young adults. OS is characterized by a high degree of malignancy, strong invasiveness, rapid disease progression, and extremely high mortality rate; it is considered as a serious threat to the human health globally. The incidence of OS is common in the metaphysis of long tubular bones, but rare in the spine, pelvis, and sacrum areas; moreover, majority of the OS patients present with only a single lesion. OS has a bimodal distribution pattern, that is, its incidence peaks in the second decade of life and in late adulthood. We examine historical and current literature to present a succinct review of OS. In this review, we have discussed the types, clinical diagnosis, and modern and future treatment methods of OS. The purpose of this article is to inspire new ideas to develop more effective therapeutic options.

Comprehensive Analysis of Aerobic Exercise-Related Genes Identifies CDCA4 That Promotes the Progression of Osteosarcoma

Background

Exercise has a positive impact on patients with osteosarcoma, improving function, reducing disability, maintaining independence and quality of life. Exercise may also directly affect the effectiveness of cancer treatment. Cell division cycle-associated protein 4 (CDCA4) is reported to function importantly during numerous human cancers development. Nevertheless, the details toward CDCA4 function are still to be investigated.

Methods

This study comprehensively analyzed the GSE74194 database and obtained aerobic exercise-related genes. Protein-protein interaction network (PPI) and Gene Ontology (GO) analysis were performed on the differentially expressed genes (DEGs). Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and tumor genome atlas (TCGA) data mining were applied to measure aerobic exercise-related gene CDCA4 level in osteosarcoma tissue. We conducted lots of functional experiments to uncover CDCA4 function and its corresponding mechanism in osteosarcoma.

Results

We screened a total of 547 DEGs related to aerobic exercise, of which 373 were up-regulated and 174 were down-regulated. PPI analysis revealed 90 genes that might play key roles. GO analysis showed that aerobic exercise-related DEGs were significantly enriched during the mitotic cell cycle, cell division, mitotic nuclear division and sister chromatid segregation, nuclear division, microtubule cytoskeleton organization involved protein, microtubule-based process, spindle organization, G2/M transition of mitotic cell cycle. Our results indicated that CDCA4 was increased in osteosarcoma tissues and cell lines, and its level had association with high mortality of osteosarcoma patients. Further studies revealed that absence of CDCA4 largely hindered osteosarcoma cancer cell proliferation, invasion, and migration.

Conclusion

Comprehensive bioinformatics analysis improves our understanding of the underlying molecular mechanisms of aerobic exercise on osteosarcoma. This provides evidence for the effect of aerobic exercise on CDCA4 expression. Our data suggested that CDCA4 could facilitate osteosarcoma development, and gave a hint that CDCA4 was a candidate target in the treatment of osteosarcoma, aerobic exercise might help the treatment and prognosis of patients with osteosarcoma.