Very long-term outcomes after endoprosthetic replacement for malignant tumours of bone

Bone transport nails for reconstruction of lower limb diaphyseal defects in patients with bone sarcomas : A case series

PURPOSE

Bone transport nails (BTN) are increasingly being used for defect reconstruction in orthopedic surgery, including orthopedic oncology. Herein, we report on preliminary outcomes in three adult sarcoma patients undergoing bone defect reconstruction of the lower limbs with a BTN.

METHODS

In this study three patients were retrospectively included; ID1 male, 18 years, Ewing's sarcoma of the right tibial diaphysis; ID2 female, 30 years, G2 periosteal osteosarcoma of the left femoral diaphysis; ID3 female, 28 years, epithelioid malignant peripheral nerve sheath tumor (MPNST) originating from the right proximal tibial metaphysis. All patients had been treated at a university hospital for primary sarcomas of the lower limbs and underwent defect reconstruction with a BTN (Precice® System, NuVasive GmbH, Globus Medical, Audubon, PA, USA).

RESULTS

Bone defect lengths were 8.5 cm, 14.1 cm and 14.4 cm, respectively. Bone transport time amounted to 5.3 months, 9.1 months and 10.3 months, and time to bony consolidation to 9.1 months, 12.3 months and 14.7 months, respectively (in ID1 and ID3 partially). Patient ID1 required revision surgery for a wire breakage (used for two-level transport) and one screw avulsion. Patient ID2 developed a peri-implant infection that was successfully treated with prolonged antibiotics. In ID3, an occult intraoperative distal femoral fracture was initially treated conservatively. A consecutive varus/flexion deformity and residual ipsilateral limb length discrepancy was addressed via distal femoral osteotomy and retrograde femoral growing nail implantation.

CONCLUSION

The Precice® BTN can be used for reconstruction of diaphyseal long bone defects in patients with primary malignant tumors; however, candidate patients have to be thoroughly counselled regarding the prolonged immobilization and partial weight-bearing period associated with the lengthening procedure as well as risk for complications and revision surgery.

Secondary Infection of Adverse Local Tissue Reaction Leading to Amputation in a Patient With a Modular Knee Endoprosthesis

Three years after endoprosthetic reconstruction of the proximal tibia, a patient presented with a skin ulceration near the surgical site. The knee was not clinically infected, but the patient had elevated serum cobalt levels. Dermatological evaluation diagnosed a friction ulcer. The ulcer failed to heal, and the patient underwent débridement and local flap advancement. Cultures grew Staphylococcus epidermidis, and they were treated with antibiotics. The ulceration recurred and repeated limb salvage was discussed, although eventually, the patient elected to undergo amputation. Pathology from the resected ulcer showed fibrinoid necrosis with aseptic lymphocytic vasculitis-associated lesion.

Two-stage revision for infection of oncological megaprostheses : a multicentre EMSOS study

Aims

The aim of this study was to assess the incidence of reinfection in patients after two-stage revision of an infected megaprosthesis (MPR) implanted after resection of a bone tumour.

Methods

A retrospective study was carried out of 186 patients from 16 bone sarcoma centres treated between January 2010 and December 2020. The median age at the time of tumour diagnosis was 26 years (IQR 17 to 33); 69 (37.1%) patients were female, and 117 (62.9%) were male.

Results

A total of 186 patients with chronic MPR infections were included. Median follow-up was 68 months (IQR 31 to 105). The most represented sites of MPR were distal femur in 93 cases (50.0%) and proximal tibia in 53 cases (28.5%). Polymicrobial infections were seen in 34 cases (18.3%). The most frequent isolated pathogens were staphylococci. Difficult-to-treat (DTT) pathogens were isolated in 50 cases (26.9%). The estimated infection recurrence (IR) rate was 39.1% at five years and 50.0% at ten years. A higher IR rate was found in DTT PJI compared to non-DTT infections (p = 0.019). Polymicrobial infections also showed a higher rate of infection recurrence (p = 0.046).

Conclusion

This study suggests that an infected MPR treated by two-stage revision and ultimately reimplantation with a MPR can be successful, but the surgeon must be aware of a high recurrence rate compared to those seen with infected conventional implants.

Japanese orthopaedic association (JOA) clinical practice guideline on the management of primary malignant bone tumors - Secondary publication

BACKGROUND

In Japan, there are currently no general guidelines for the treatment of primary malignant bone tumors. Therefore, the Japanese Orthopaedic Association established a committee to develop guidelines for the appropriate diagnosis and treatment of primary malignant bone tumors for medical professionals in clinical practice.

METHODS

The guidelines were developed in accordance with "Minds Clinical Practice Guideline Development Handbook 2014″ and "Minds Clinical Practice Guideline Development Manual 2017". The Japanese Orthopaedic Association's Bone and Soft Tissue Tumor Committee established guideline development and systematic review committees, drawing members from orthopedic specialists leading the diagnosis and treatment of bone and soft tissue tumors. Pediatricians, radiologists, and diagnostic pathologists were added to both committees because of the importance of multidisciplinary treatment. Based on the diagnosis and treatment algorithm for primary malignant bone tumors, important decision-making points were selected, and clinical questions (CQ) were determined. The strength of recommendation was rated on two levels and the strength of evidence was rated on four levels. The recommendations published were selected based on agreement by 70% or more of the voters.

RESULTS

The guideline development committee examined the important clinical issues in the clinical algorithm and selected 22 CQs. The systematic review committee reviewed the evidence concerning each CQ and a clinical value judgment was added by experts. Eventually, 25 questions were published and the text of each recommendation was determined.

CONCLUSION

Since primary malignant bone tumors are rare, there is a dearth of strong evidence based on randomized controlled trials, and recommendations cannot be applied to all the patients. In clinical practice, appropriate treatment of patients with primary malignant bone tumors should be based on the histopathological diagnosis and degree of progression of each case, using these guidelines as a reference.

Periprosthetic Joint Infection Surrounding Lower-Extremity Endoprostheses After Tumor Resection: Causative Microorganisms, Effectiveness of DAIR, and Risk Factors for Treatment Failure

Background

Periprosthetic joint infection (PJI) surrounding an endoprosthesis after reconstruction of a lower extremity following tumor resection is a common complication, and the treatment of these infections is challenging and often requires multiple surgical interventions or even implant removal. Because there has been limited evidence to support treatment strategies and understanding of the epidemiology of the causative microorganisms, we analyzed the effectiveness of debridement, antibiotics, and implant retention (DAIR), risk factors for the failure of DAIR, and causative microorganisms in patients with a PJI surrounding a lower-extremity endoprosthesis after tumor resection.

Methods

A retrospective cohort study was conducted in a tertiary referral center for orthopaedic oncology. All patients treated between 2000 and 2018 for PJI surrounding a lower-extremity endoprosthesis after tumor resection were included. Treatment outcomes and risk factors for failure were analyzed in patients primarily treated with DAIR. Causative microorganisms were recorded. The minimum follow-up period was 2 years.

Results

Of the 337 patients who underwent endoprosthetic reconstruction of a lower extremity after tumor resection, 67 patients (20%) developed a PJI surrounding the endoprosthesis. Of those patients, 55 were primarily treated with DAIR. The functional cure rate of DAIR was 65% (36 of 55). A median of 2 debridements per patient was needed. Chemotherapy (odds ratio [OR], 3.1 [95% confidence interval (CI), 1.0 to 9.3]) and an erythrocyte sedimentation rate of >50 mm/hr at diagnosis (OR, 4.5 [95% CI, 1.3 to 15.4]) were associated with treatment failure. Nineteen patients (28%) had a polymicrobial infection.

Conclusions

Although sequential procedures are often needed, DAIR has acceptable clinical outcomes and should be considered, dependent on expected survival and the risk factors for treatment failure noted in this study.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shared decision making in primary malignant bone tumour surgery around the knee in children and young adults: protocol for a prospective study

BACKGROUND

Children and young adults needing surgery for a primary malignant bone tumour around the knee face a difficult, life-changing decision. A previous study showed that this population wants to be involved more in the decision-making process and that more involvement leads to less decisional stress and regret. Therefore, a well-designed and standardized decision-making process based on the principles of shared decision-making needs to be designed, implemented, and evaluated.

METHODS

We developed a shared decision-making (SDM) model for this patient population, including an online decision aid (DA). This model has been implemented in the standard care of patients with a primary malignant bone tumour around the knee. Following implementation, we will analyse its effect on the decision-making process and the impact on patient experiences using questionnaires and interviews. Moreover, potential areas for improvement will be identified.

DISCUSSION

Given the importance of involving patients and parents in surgical decision-making, particularly in life-changing surgery such as malignant bone tumour surgery, and given the lack of SDM models applicable for this purpose, we want to share our model with the international community, including our study protocol for evaluating and optimising the model. This study will generate valuable knowledge to facilitate the optimisation of current patient care for local treatment. The sharing of our implementation and study protocol can serve as an example for other centres interested in implementing SDM methods in an era characterized by more empowered patients and parents who desire autonomy and reliable and realistic information.

Long-term functional outcome of limb-sparing surgery for paediatric bone sarcoma around the knee

Aims

Surgical limb sparing for knee-bearing paediatric bone sarcoma is considered to have a clinically significant influence on postoperative function due to complications and leg-length discrepancies. However, researchers have not fully evaluated the long-term postoperative functional outcomes. Therefore, in this study, we aimed to elucidate the risk factors and long-term functional prognosis associated with paediatric limb-sparing surgery.

Methods

We reviewed 40 patients aged under 14 years who underwent limb-sparing surgery for knee bone sarcoma (15 cases in the proximal tibia and 25 in the distal femur) between January 2000 and December 2013, and were followed up for a minimum of five years. A total of 35 patients underwent reconstruction using artificial materials, and five underwent biological reconstruction. We evaluated the patients' postoperative complications, survival rate of reconstruction material, and limb, limb function, and leg-length discrepancy at the final follow-up, as well as the risk factors for each.

Results

Complications were observed in 55% (22/40) of patients. The limb survival and reconstruction material rates at five and ten years were 95% and 91%, and 88% and 66%, respectively. Infection was the only risk factor in both survivals (p < 0.001, p = 0.019). In the 35 patients with limb preservation, the median International Society of Limb Salvage (ISOLS) score at the final follow-up was 80 (47% to 97%). Younger age (p = 0.027) and complications (p = 0.005) were poor prognostic factors. A negative correlation was found between age and leg-length discrepancy (R = -0.426; p = 0.011). The ISOLS scores were significantly lower in patients with a leg-length discrepancy of more than 5 cm (p = 0.005).

Conclusion

Young age and complications were linked to an unfavourable functional prognosis. Leg-length correction was insufficient, especially in very young children, resulting in decreased function of the affected limb. Limb-sparing surgery for these children remains a considerable challenge.

Coverage of lateral soft tissue defects with sartorius muscle flap after distal femoral replacement for malignant bone tumors

INTRODUCTION

To prevent infection after limb-sparing surgery for primary malignant bone tumors, it is important to cover the megaprosthesis with muscle tissue that has sufficient blood flow. Coverage with a lateral gastrocnemius flap has been reported in cases of distal femoral replacement in which the vastus lateralis and vastus intermedius muscles have been resected; however, the risk of peroneal nerve palsy is reportedly high because the muscle flap passes near the peroneal head. This study was performed to examine the postoperative outcomes of patients with primary malignant bone tumors of the distal femur who underwent wide resection (including the vastus lateralis and vastus intermedius muscles) followed by reconstruction with a megaprosthesis and coverage of the lateral side of the prosthesis with a sartorius muscle flap.

METHODS

We retrospectively analyzed three patients who underwent reconstruction with a megaprosthesis after wide resection of a primary malignant bone tumor of the distal femur involving the vastus lateralis and vastus intermedius muscles and reconstruction of the soft tissue defect on the lateral side of the prosthesis with a sartorius muscle flap.

RESULTS

The average defect size was 6 × 13 cm, the average time required for a sartorius muscle flap was 100 min, and the average implant coverage was 93%. The average postoperative follow-up period was 35 months, during which no postoperative complications such as infection, skin necrosis, or nerve palsy occurred.

DISCUSSION

The distally based sartorius muscle flap is easy to elevate in the supine position, has minimal functional loss after harvesting, and has minimal risk of nerve palsy. It can be advocated as the first option for coverage of soft tissue defects lateral to distal femoral replacement.

Incidence and risk of surgical site infection/periprosthetic joint infection in tumor endoprosthesis-data from the nationwide bone tumor registry in Japan

BACKGROUND

Surgical site infection (SSI)/periprosthetic joint infection (PJI) is a devastating complication in limb salvage surgery with endoprosthesis reconstruction for malignant bone tumors. The main bottleneck for data collection and analysis for the status of SSI/PJI in tumor endoprosthesis is the low absolute case numbers of this rare cancer. The accumulation of many cases is possible by administrating nationwide registry data.

METHODS

The data on malignant bone tumor resection with tumor endoprosthesis reconstruction were extracted from the Bone and Soft Tissue Tumor Registry in Japan. The primary endpoint was defined as the need for additional surgical intervention for infection control. The incidence of postoperative infection and its risk factors were analyzed.

RESULTS

A total of 1342 cases were included. The incidence of SSI/PJI was 8.2%. The incidence of SSI/PJI in the proximal femur, distal femur, proximal tibia, and pelvis were 4.9%, 7.4%, 12.6%, and 41.2%, respectively. Location in the pelvis or proximal tibia, tumor grade, indication of myocutaneous flaps, and delayed wound healing proved to be independent risks for SSI/PJI, whereas age, sex, previous surgery, tumor size, surgical margin, application of chemotherapy and radiotherapy were not significant.

CONCLUSIONS

The incidence was equal to those in previous studies. The result reconfirmed the high incidence of SSI/PJI in pelvis and proximal tibia cases and cases with delayed wound healing. Novel risk factors such as tumor grade and application of myocutaneous flaps were marked. The administration of nationwide registry data was informative for the analysis of SSI/PJI in tumor endoprosthesis.

Distal Femur Cemented Modular Prosthesis Failure Causing a Medical Device-Related Adverse Event: A Report of a Rare Case

A distal femoral cemented modular prosthesis is a viable option for post-bone tumor and limb salvage procedures. The major reasons for implant failures are the poor quality of implants, mechanical stress, biochemical reactions, and extended period of the implant in vivo use. Rare incidences have been reported of distal femur prosthesis implant malfunctioning in a subject having osteosarcoma. Common adverse events associated with implant failure include surgical site infections, swelling, pain, revision of the surgical procedure, cyst formation, and build-up of metal debris on soft tissues. Our case report summarizes gross malfunctioning of a distal femur cemented modular prosthesis experienced by a 24-year-old post-operated osteosarcoma patient who developed excruciating sudden pain and the inability to bear weight on the right leg, with the sudden onset of these symptoms developing while turning in bed.

Hip Preservation and Capanna Reconstruction for Pediatric Proximal Femur Ewing Sarcoma: A Report of 2 Cases

CASE

This is a first report describing preservation of the femoral head by transcervical resection of proximal femoral Ewing sarcoma in 2 pediatric patients. A unique Capanna reconstruction supported joint salvage. At 1 year, Pediatric Outcomes Data Collection Instrument and Pediatric Toronto Extremity Salvage Score outcomes were excellent. Surveillance magnetic resonance imaging was without evidence of recurrence or impaired perfusion to the femoral head.

CONCLUSION

We demonstrate the feasibility of hip joint preservation and maintenance of femoral head viability after transcervical resection of pediatric proximal femur bone sarcomas while preserving the medial circumflex femoral artery. This technique may be a preferred option over joint sacrifice and endoprosthetic replacement in young patients when tumor margins permit.

Surgical Management of Periprosthetic Joint Infections in Hip and Knee Megaprostheses

Periprosthetic joint infection is a feared complication after the megaprosthetic reconstruction of oncologic and non-oncologic bone defects of including the knee or hip joint. Due to the relative rarity of these procedures, however, optimal management is debatable. Considering the expanding use of megaprostheses in revision arthroplasty and the high revision burden in orthopedic oncology, the risk of PJI is likely to increase over the coming years. In this non-systematic review article, we present and discuss current management options and the associated results focusing on studies from the last 15 years and studies from dedicated centers or study groups. The indication, surgical details and results in controlling infection are presented for debridement, antibiotics, irrigation and retention (DAIR) procedure with an exchange of the modular components, single-stage implant exchange, two-stage exchanges and ablative procedures.

Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

BACKGROUND

Reconstruction with vascularized fibula grafts (VFG) after intercalary resection of sarcoma may offer longevity by providing early graft-host union and fracture healing. The ability of the fibula to hypertrophy under mechanical stress, as well as vascularized bone in the area, may also be advantageous, given that soft tissues may be compromised because of resection, chemotherapy, or radiation therapy. VFG with a massive allograft combines the primary mechanical stability of the graft with the biological potential of the vascularized fibula; however, complications and the durability of this combined reconstruction are not well described.

QUESTIONS/PURPOSES

(1) What was the proportion of complications after reconstruction with VFG, with or without allografts? (2) What was the functional result after surgical treatment as assessed by the Musculoskeletal Tumor Society (MSTS) score? (3) What was the survivorship of these grafts free from revision and graft removal?

METHODS

Between 1988 and 2021, 219 patients were treated at our institution for a primary malignant or aggressive benign bone tumor of the tibia with en bloc resection. Of those, 54% (119 of 219) had proximal tibial tumors with epiphyseal involvement and were treated with either intra-articular resection and reconstruction with an osteoarticular allograft, allograft-prosthesis composite (APC), or modular prosthesis according to age, diagnosis, and preoperative or postoperative radiotherapy. Nine percent (20) of patients had distal tibial tumors that were treated with intra-articular resection and reconstruction with ankle arthrodesis using allogenic or autologous grafts, and 0.5% (1 patient) underwent total tibial resection for extensive tumoral involvement of the tibia and reconstruction with an APC. Thirty-six percent (79) of patients had a metadiaphyseal bone tumor of the tibia and were treated with intercalary joint-sparing resection. We routinely use reconstruction with VFG after intercalary tibial resection for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands and in whom at least 1 cm of residual bone stock of the proximal or distal epiphysis can be preserved. By contrast, we routinely use intercalary massive allograft reconstruction in short resections or in patients with metastatic disease who do not have long life expectancy. We avoid VFG in patients with tibial bone metastasis, patients older than 70 years, or primary bone tumors in patients who may undergo postoperative radiotherapy; in these patients, we use alternative reconstructive methods such as intercalary prostheses, plate and cement, or intramedullary nailing with cement augmentation. According to the above-mentioned indications, 6% (5 of 79) of patients underwent massive allograft reconstruction because they were young and had intercalary resections shorter than 7 cm or had metastatic disease at diagnosis without long life expectancy, whereas 94% (74) of patients underwent VFG reconstruction. The median age at operation was 16 years (range 5 to 68 years). The diagnosis was high-grade osteosarcoma in 22 patients, Ewing sarcoma in 19, adamantinoma in 16, low-grade osteosarcoma in five, fibrosarcoma in three, malignant fibrous histiocytoma and Grade 2 chondrosarcoma in two, and malignant myoepitelioma, angiosarcoma of bone, malignant peripheral nerve sheath tumor of bone, squamous cell carcinoma secondary to chronic osteomyelitis, and desmoplastic fibroma in one patient each. Median follow-up was 12.3 years (range 2 to 35 years). The median tibial resection length was 15 cm (range 7 to 27 cm), and the median fibular resection length was 18 cm (range 10 to 29 cm). VFG was used with a massive allograft in 55 patients, alone in 12 patients, and combined with allogenic cortical bone struts in seven patients. We used VFG combined with a massive allograft in patients undergoing juxta-articular, joint-sparing resections that left less than 3 cm of residual epiphyseal bone, for intra-epiphyseal resections, or for long intercalary resections wherein the allograft can provide better mechanical stability. In these clinical situations, the combination of a VFG and massive allograft allows more stable fixation and better tendinous reattachment of the patellar tendon. VFG was used with cortical bone struts in distal tibia intercalary resections where the narrow diameter of the allograft did not allow concentric assembling with the fibula. Finally, VFG alone was often used after mid- or distal tibia intercalary resection in patients with critical soft tissue conditions because of previous surgery, in whom the combination with massive allograft would result in a bulkier reconstruction. We ascertained complications and MSTS scores by chart review, and survivorship free from revision and graft removal was calculated using the Kaplan-Meier estimator. In our study, however, the occurrence of death as a competing event was observed in a relatively low proportion of patients, and only occurred after the primary event of interest had already occurred. Considering the nature of our data, we did not consider death after the primary event of interest as a competing event.

RESULTS

In all, 49% (36 of 74) of patients experienced complications and underwent operative treatment. There were 45 complications in 36 patients. There was one instance of footdrop secondary to common peroneal nerve palsy, four wound problems, one acute vein thrombosis of the VFG pedicle and one necrosis of the skin island, two episodes of implant-related pain, 10 nonunions, six fractures, six deep infections, nine local recurrences, one Achilles tendon retraction, one varus deformity of the proximal tibia with postoperative tibial apophysis detachment, one knee osteoarthritis, and one hypometria. The median MSTS score was 30 (range 23 to 30); the MSTS score was assessed only in patients in whom the VFG was retained at the final clinical visit, although if we had considered those who had an amputation, the overall score would be lower. Revision-free survival of the reconstructions was 58% (95% confidence interval 47% to 70%) at 5 years, 52% (95% CI 41% to 65%) at 10 and 15 years, and 49% (95% CI 38% to 63%) at 20 and 30 years. Eight patients underwent VFG removal because of complications, with an overall reconstruction survival of 91% (95% CI 84% to 98%) at 5 years and 89% (95% CI 82% to 97%) at 10 to 30 years.

CONCLUSION

VFG, alone or combined with an allograft, could be considered in reconstructing a lower extremity after intercalary resections of the tibia for primary bone tumors, and it avoids the use of a large endoprosthesis. However, this procedure was associated with frequent, often severe complications during the first postoperative years and complication-free survival of 58% at 5 years. Nearly 10% of patients ultimately had an amputation. For patients whose reconstruction succeeded, the technique provides a durable reconstruction with good MSTS scores, and we believe it is useful for active patients with long life expectancy. Fractures, frequently observed in the first 5 years postoperatively, might be reduced using long-spanning plate fixation, and that appeared to be the case in our study. Nonbridging fixation can be an option in intraepiphyseal resection when a spanning plate cannot be used or in pediatric patients to enhance fibula hypertrophy and remodeling. We did not directly compare VFG with or without allografts to other reconstruction options, so the decision to use this approach should be made thoughtfully and only after considering the potential serious risks.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Outcome of Endoprosthesis used in Limb Salvage Surgery in a Malaysian Orthopaedic Oncology Centre

Introduction

To describe the duration of survival among bone tumour patients with endoprosthesis reconstruction and to determine frequency of implant failure, revision of surgery, and amputation after endoprosthesis reconstruction.

Materials and methods

A retrospective cross-sectional review of all patients with either primary bone tumour or secondary bone metastases treated with en bloc resection and endoprosthesis reconstruction from January 2008 to December 2020.

Results

A total of 35 failures were recorded among the 27 (48.2%) patients with endoprostheses. Some of the patients suffered from one to three types of modes of failure on different timelines during the course of the disease. Up to eight patients suffered from more than one type of failure throughout the course of the disease. Out of all modes of failure, local recurrence (type 5 failure) was the most common, accounting for 25.0% of all failure cases. Four patients (7.1%) eventually underwent amputation, which were either due to infection (2 patients) or disease progression causing local recurrence (2 patients).

Conclusion

The overall result of endoprosthesis reconstruction performed in our centre was compatible with other centres around the world. Moreover, limb salvage surgery should be performed carefully in a selected patient group to maximise the benefits of surgery.

Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives

PURPOSE OF REVIEW

This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques.

RECENT FINDINGS

The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.

What to improve: Results of fixed-hinge knee endoprosthesis reconstructions over 40 years in a single tumor center

INTRODUCTION

Over the past decades, numerous structural changes in implants, medical treatments, and surgical techniques have been made for Malignant Bone Tumors (MBT) around the knee. However, the overall care improvement is still unclear. The method is crucial when analyzing outcomes in surveys involving tumors, and a thorough assessment of the mortality is mandatory because death acts as competing event. The aims of this study were: 1) a comprehensive and longitudinal assessment of the revisions with an extensive follow-up and adequate methods; 2) a complete mortality review to consider competing risks.

HYPOTHESIS

The hypothesis was that some prosthesis's structural improvements were made while the surgical toll increased as well as an improvement of mortality was also expected.

MATERIAL AND METHODS

Analyses were performed on 248 patients with MBT (mean follow-up was 8.7 years, surgeries between 1972 and 2017). Three prosthesis models were successively used over time: 120 Guepar (older model), 42 Tornier, and 86 Stanmore (more recent model). The primary outcome was the assessment of revisions sorted out according to Henderson: type-1 soft-tissue failures or instability, type-2 aseptic loosening, type-3 structural failures, type-4 periprosthetic infections, type-5 tumoral progression. Death and amputations were considered as competing events. An extensive assessment of mortality was performed by merging the dataset with the French register of Deaths (INSEE). Cumulative probabilities were computed at 2, 5, 10, and 15 years and compared with Gray's tests.

RESULTS

The overall 5-year survival was, 80% (95% CI: 73-87) for Guepar, 69% (95% CI: 56-84) for Tornier, and 71% (95% CI: 62-82) for Stanmore (p=0.4). The 5-year cumulative risks for type-1 were 5% (95% CI: 1-9), 9% (95% CI: 0-18), and 17% (95% CI: 9-25) for Guepar, Tornier, and Stanmore, respectively (p=0.01). The 15-year cumulative risks for type-2 were 22% (95% CI: 15-39), 8% (95% CI: 0-17) and 8% (95% CI: 2-14) for Guepar, Tornier, and Stanmore, respectively (p=0.10). Ten patients had an implant failure, nine Guepar, and one Tornier. The 5-year cumulative risks for type-4 were 7% (95% CI: 2-12), 19% (95% CI: 7-31), and 12% (95% CI: 5-18) for Guepar, Tornier, and Stanmore, respectively (p=0.08). There were 29 tumoral progressions; the 15-year risks were 16% (95% CI: 2-22), 2% (95% CI: 0-7%), and 12% (95% CI: 4-19%) for Guepar, Tornier, and Stanmore, respectively (p=0.08). No difference whatsoever was found between the proximal tibial and distal femur.

CONCLUSION

There were some improvements in prosthesis design (forged steel instead of cast steel) and probably also in cemented stem fixation, but not in prosthetic joint infection and local recurrence over forty years. The overall mortality did not change significantly over the last 40 years amongst this specific cohort of patients who benefited from a hinge reconstruction prosthesis.

LEVEL OF EVIDENCE

III; comparative case series with sensibility analysis.

Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

Proximal femoral tumor resection followed by joint prosthesis replacement: a systematic review and meta-analysis

BACKGROUND

This study aimed to determine the prognostic outcome of hip joint replacement after resection of proximal femoral tumors by reviewing original studies.

METHODS

Two researchers independently searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to July 17, 2022. Then, the literature was screened by inclusion criteria. The basic information, primary outcomes, and secondary outcomes were extracted for weighted combined analysis. The quality of the included literature was evaluated using the Newcastle-Ottawa scale.

RESULTS

Twenty-four retrospective cohort studies comprising 2081 patients were included. The limb salvage rate was 98%. The survival rates at 1, 2, 3, 4, and 5 years were 80, 72, 65, 64, and 55% for patients with primary tumors and the rate at 1, 2, 3, 4, and 5 years were 44, 25, 17, 14, and 11% for patients with bone metastases, respectively.

CONCLUSION

As chemotherapy and radiotherapy treatment progressed, joint reconstruction after proximal femoral tumor resection improved patients' function and quality of life.

Beneath the Layers: Deciphering the Molecular Pathways, Therapeutic Avenues, and Neurological Connections of Soft Tissue Sarcomas

Soft tissue sarcomas (STSs) are a heterogeneous group of malignancies that have long posed challenges in terms of diagnosis, treatment, and management. This narrative review provides a comprehensive exploration into the multifaceted realm of STS, spanning from its historical origins to the latest advancements in research and clinical care. We delve into the molecular intricacies of STS, highlighting the genetic and epigenetic aberrations that drive these tumors. The review emphasizes the neurological implications of STS, a relatively underexplored area, shedding light on the interplay between tumor biology and neural processes. The evolving therapeutic landscape is discussed, with a focus on the promise of targeted therapies, immunotherapy, and precision medicine. A significant portion is dedicated to the patient-centric approach, underscoring the importance of holistic care that addresses both the physical and psychological needs of STS patients. Furthermore, we highlight the gaps in current research and clinical practices, offering insights into potential avenues for future exploration. This review serves as a valuable resource for clinicians, researchers, and the broader scientific community, encapsulating the current state of STS knowledge and pointing toward future directions in this dynamic field.

Cross-cultural adaptation and validation of a self-reporting tool to assess health-related quality of life for Egyptians with extremity bone sarcomas in childhood or adolescence

BACKGROUND

Validated self-reporting tools are required to evaluate the functional outcome and health-related quality of life (HRQOL) for those who had extremity bone sarcomas in their childhood or adolescence. Our study pursued cross-cultural adaptation and validation of the pediatric Toronto Extremity Salvage Score (pTESS) and Toronto Extremity Salvage Score (TESS) to assess the functional outcome for Egyptian children and adult survivors following surgeries of extremity bone sarcomas. In the modified versions of pTESS and TESS, mental domains were added to allow the evaluation of HRQOL using a specific instrument for childhood bone cancer.

METHODS

The internal consistency and test-retest reliability of the studied forms were assessed with Cronbach's alpha and Intra-class coefficients (ICC), respectively. For convergent validity, correlations between scores of the generic Pediatric Quality of Life Inventory (PedsQL 4.0) and pTESS /TESS scores were reported. Factor Analysis was feasible for pTESS-leg; due to the insufficient samples, only the average inter-item correlation coefficients were reported for the remaining versions.

RESULTS

Out of 233 participants, 134 responded to pTESS-leg, 53 to TESS-leg, 36 to pTESS-arm, and only 10 to TESS-arm. All versions showed excellent internal consistency (Cronbach's alpha >0.9), good test-retest reliability (ICC >0.8), moderate to strong correlations with PedsQL, and acceptable average inter-item correlation coefficients (≥0.3). Three factors were extracted for the pTESS-leg, in which all mental items were loaded on one separate factor with factor loadings exceeding 0.4. Active chemotherapy, less than one year from primary surgery, or tibial tumors were associated with significantly inferior pTESS/TESS scores in the lower extremity group.

CONCLUSION

The Egyptian pTESS and TESS are valid and reliable self-reporting tools for assessing the functional outcome following surgeries for extremity bone sarcomas. The modified pTESS and TESS versions, which include additional mental domains, enabled the assessment of the overall health status of our population. Future studies should include a larger sample size and evaluate the ability of pTESS/TESS to track progress over time.

Risk Factors for All-Cause Early Reoperation Following Tumor Resection and Endoprosthetic Reconstruction: A Secondary Analysis from the PARITY Trial

BACKGROUND

Oncologic resection and endoprosthetic reconstruction of lower-extremity musculoskeletal tumors are complex procedures fraught with multiple modes of failure. A robust assessment of factors contributing to early reoperation in this population has not been performed in a large prospective cohort. The aim of the present study was to assess risk factors for early reoperation in patients who underwent tumor excision and endoprosthetic reconstruction, with use of data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial.

METHODS

Baseline characteristics were assessed, including age, sex, tumor type, tumor location, presence of a soft-tissue mass, diabetes, smoking status, chemotherapy use, and neutropenia. Operative factors were recorded, including operative time, topical antibiotics, silver-coated prosthetics, endoprosthetic fixation, extra-articular resection, length of bone resected, margins, tranexamic acid, postoperative antibiotics, negative-pressure wound therapy, and length of stay. Univariate analysis was utilized to explore the differences between patients who did and did not undergo reoperation within 1 year postoperatively, and a multivariate Cox proportional hazards regression model was utilized to explore the predictors of reoperation within 1 year.

RESULTS

A total of 155 (25.7%) of 604 patients underwent ≥1 reoperation. In univariate analysis, tumor type (p < 0.001), presence of a soft-tissue mass (p = 0.045), operative time (p < 0.001), use of negative-pressure wound therapy (p = 0.010), and hospital length of stay (p < 0.001) were all significantly associated with reoperation. On multivariate assessment, tumor type (benign aggressive bone tumor versus primary bone malignancy; hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04 to 0.63; p = 0.01), operative time (HR per hour, 1.15; 95% CI, 1.10 to 1.23; p < 0.001), and use of negative-pressure wound therapy (HR, 1.93; 95% CI, 1.30 to 2.90; p = 0.002) remained significant predictors of reoperation within 1 year.

CONCLUSIONS

Independent variables associated with reoperation within 1 year in patients who underwent tumor resection and endoprosthetic reconstruction included tumor type (benign aggressive bone tumor versus primary bone malignancy), operative time, and use of negative-pressure wound therapy. These results will help to inform patients and surgeons regarding the risk of reoperation by diagnosis and reinforce operative time as a factor influencing reoperation. These results also support further investigation into the use of negative-pressure wound therapy at the time of surgery in this patient population.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Distal Humeral Replacement in Patients with Primary Bone Sarcoma: The Functional Outcome and Return to Sports

Distal humeral replacement (DHR) is a limb-salvage option for the endoprosthetic reconstruction of bone defects following the resection of a primary bone sarcoma. As primary bone sarcomas are only occasionally located around the distal humerus, there is a paucity of information regarding postoperative function, and patients' resumption of sporting activities. With advances in diagnostics and in surgical and oncological treatment leading to an increased patient life expectancy and higher quality of life, patients' functional outcome and return to sports activities are of increasing interest. Between 1997 and 2021, a total of 24 patients underwent DHR with a single-design modular implant at a tertiary sarcoma center. A total of 14 patients who died of their disease were excluded, leaving a study cohort of 10 patients, with a median age of 30 years on the day of surgery (IQR 20-37). At the last follow-up, after a median of 230 months (IQR 165-262), the median MSTS was 19 (IQR 13-24), the median TESS was 79 (IQR 66-87), the median SEV was 38% (IQR 24-53), the median TS was 6 (IQR 4-7), and the median WAS was 3 (IQR 1-8). Among the variables of gender, surgery on the dominant extremity, intraoperative nerve resection, extra-articular tumor resection, chemotherapy, radiotherapy, and revision surgeries, none were associated with a better/lower functional outcome score or return to sports activities. However, a higher level of sports performance prior to diagnosis (WAS > 10) was associated with a higher level of sports performance postoperatively (p = 0.044).

Does a novel bridging collar in endoprosthetic replacement optimise the mechanical environment for osseointegration? A finite element study

Introduction: Limb-salvage surgery using endoprosthetic replacements (EPRs) is frequently used to reconstruct segmental bone defects, but the reconstruction longevity is still a major concern. In EPRs, the stem-collar junction is the most critical region for bone resorption. We hypothesised that an in-lay collar would be more likely to promote bone ongrowth in Proximal Femur Reconstruction (PFR), and we tested this hypothesis through validated Finite Element (FE) analyses simulating the maximum load during walking. Methods: We simulated three different femur reconstruction lengths (proximal, mid-diaphyseal, and distal). For each reconstruction length one in-lay and one traditional on-lay collar model was built and compared. All reconstructions were virtually implanted in a population-average femur. Personalised Finite Element models were built from Computed Tomography for the intact case and for all reconstruction cases, including contact interfaces where appropriate. We compared the mechanical environment in the in-lay and on-lay collar configurations, through metrics of reconstruction safety, osseointegration potential, and risk of long-term bone resorption due to stress-shielding. Results: In all models, differences with respect to intact conditions were localized at the inner bone-implant interface, being more marked in the collar-bone interface. In proximal and mid-diaphyseal reconstructions, the in-lay configuration doubled the area in contact at the bone-collar interface with respect to the on-lay configuration, showed less critical values and trends of contact micromotions, and consistently showed higher (roughly double) volume percentages of predicted bone apposition and reduced (up to one-third) percentages of predicted bone resorption. In the most distal reconstruction, results for the in-lay and on-lay configurations were generally similar and showed overall less favourable maps of the bone remodelling tendency. Discussion: In summary, the models corroborate the hypothesis that an in-lay collar, by realising a more uniform load transfer into the bone with a more physiological pattern, creates an advantageous mechanical environment at the bone-collar interface, compared to an on-lay design. Therefore, it could significantly increase the survivorship of endo-prosthetic replacements.

Carbon-fiber-reinforced polyetheretherketone orthopedic implants in musculoskeletal and spinal tumors: imaging and clinical features

Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) orthopedic implants are gaining popularity in oncologic applications as they offer many potential advantages over traditional metallic implants. From an imaging perspective, this instrumentation allows for improved evaluation of adjacent anatomic structures during radiography, computed tomography (CT), and magnetic resonance imaging (MRI). This results in improved postoperative surveillance imaging quality as well as easier visualization of anatomy for potential image-guided percutaneous interventions (e.g., pain palliation injections, or ablative procedures for local disease control). CFR-PEEK devices are also advantageous in radiation oncology treatment due to their decreased imaging artifact during treatment planning imaging and decreased dose perturbation during radiotherapy delivery. As manufacturing processes for CFR-PEEK materials continue to evolve and improve, potential orthopedic applications in the spine and appendicular skeleton increase. An understanding of the unique properties of CFR-PEEK devices and their impact on imaging is valuable to radiologists delivering care to orthopedic oncology patients in both the diagnostic and interventional settings. This multidisciplinary review aims to provide a comprehensive insight into the radiologic, surgical, and radiation oncology impact of these innovative devices.

What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report

BACKGROUND

Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas.

QUESTIONS/PURPOSES

(1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis?

METHODS

The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys.

RESULTS

More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups.

CONCLUSION

There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Is High-dose Radiation Therapy Associated With Early Revision Due to Aseptic Loosening in Patients With a Sarcoma of the Lower Extremities Reconstructed With a Cemented Endoprosthesis?

BACKGROUND

The durability of endoprostheses after limb salvage surgery is influenced by surgical factors (resection length, implant location, and residual bone quality), implant design (modular versus custom design, rotating versus fixed hinge, coating, collars, and the use of cross pins), and host factors (patient's immune status, activity levels, and age). In general, radiation therapy increases the risk of fractures, infection, delayed wound healing, and impaired osseointegration. Several studies have shown exposure to radiation to be associated with higher endoprosthesis revision rates and higher periprosthetic infection rates, but results are inconsistent. Although radiation therapy is not routinely used in the treatment of many bone sarcomas in current practice, it is still used in high doses after resection and prosthetic reconstruction in patients who have Ewing sarcoma with close or positive margins and in patients with soft tissue sarcoma. It is also used in varying doses after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. These patients may be at an increased risk of complications due to their radiation exposure, but this is a difficult question to study given the rarity of these diagnoses and poor overall survival of these patients. We therefore leveraged a large, longitudinally collected, 40-year endoprosthesis database that included patients who received radiation to the extremity for many bone and soft tissue sarcomas to investigate the association between preoperative or postoperative radiation therapy and endoprosthesis survival.

QUESTIONS/PURPOSES

(1) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from amputation or revision due to any cause? (2) Is receiving preoperative or postoperative radiation therapy in low or high doses for the treatment of bone or soft tissue malignancy of the lower extremities associated with decreased implant survivorship free from revision specifically due to aseptic loosening? (3) Is receiving preoperative or postoperative radiation therapy for the treatment of Ewing sarcoma of the femur specifically associated with decreased implant survivorship free from revision specifically due to aseptic loosening?

METHODS

This was a retrospective, comparative study using our institution's database of 822 endoprostheses. Between 1980 and 2019, we treated 541 patients with primary cemented endoprostheses of the extremities. Of those patients, 8% (45 of 541) were excluded due to unknown radiation status, 3% (17 of 541) because of prior failed allograft, 15% (83 of 541) due to metastatic disease from a carcinoma, 1% (6 of 541) due to a nononcologic diagnosis, 4% (20 of 541) due to benign tumor diagnosis, 16% (87 of 541) due to upper extremity tumor location, 9% (49 of 541) due to not receiving chemotherapy, and 3% (14 of 541) due to expandable prostheses. Of the remaining 220 patients, 6% (13) were considered missing because they did not have 2 years of follow-up and did not reach a study endpoint. No patients had surgery within the last 2 years of the study end date. In all, 207 patients met inclusion criteria and were eligible for analysis. Patients who had received radiation to the lower extremities at any point in their treatment course were included in the radiation group and were compared with patients who did not receive radiation. For patients where radiation dose was available, the radiation group was subdivided into a low-dose (≤ 3000 cGy) and high-dose (> 3000 cGy) group. Revision surgery was defined as any surgery necessitating removal or replacement of the tibial or femoral stem. The complications necessitating revision or amputation were poor wound healing, aseptic loosening, implant breakage, deep infection, and tumor progression. The primary outcome of interest was implant survival free from revision or amputation due to any cause. The secondary outcome of interest was implant survival free from revision or amputation specifically due to aseptic loosening. The Kaplan-Meier survivorship curves were generated with implant survival free from revision or amputation as the endpoint and patient death as a competing risk. A log-rank test was used to identify differences in survivorship between the patients who received radiation and those who did not. Multivariate regression was used to identify factors associated with decreased implant survival. An odds ratio was used to determine relative effect size among the factors associated with decreased implant survival.

RESULTS

The mean implant survival time for patients who did not receive radiation was 18.3 years (95% confidence interval [CI] 15.4 to 21.3) whereas the mean implant survival time for patients who received low- and high-dose radiation were 19.1 years (95% CI 14.5 to 23.7; p = 0.59) and 13.8 years (95% CI 8.2 to 19.5; p = 0.65), respectively. The mean implant survival free from revision for aseptic loosening for patients who did not receive radiation was 27.1 years (95% CI 24.1 to 30.1) whereas the mean implant survival for patients who received low- and high-dose radiation were 24.1 years (95% CI 19.1 to 29.1; p = 0.34) and 16.4 years (95% CI 10.6 to 22.2; p = 0.01), respectively. Patients who received high-dose radiation had decreased 5-year implant survivorship free from amputation or revision due to aseptic loosening (73% [95% CI 44% to 89%]) compared with patients who did not receive radiation (95% [95% CI 90% to 99%]; p = 0.01). For patients treated for Ewing sarcoma of the femur, the 5-year implant survival free from amputation or revision due to aseptic loosening for patients who did not receive radiation (100% [95% CI 100% to 100%]) was no different compared with patients who received radiation (71% [95% CI 35% to 90%]; p = 0.56).

CONCLUSION

The results of this study may apply to scenarios where radiation is used, such as Ewing sarcoma with positive margins or local recurrence and after prosthetic reconstruction in patients with myeloma or bone metastasis after resection of periarticular destructive tumors. Surgeons may consider closer monitoring for early clinical and radiographic signs of aseptic loosening in patients who received high-dose radiation. These patients may also benefit from constructs that have increased resistance to aseptic loosening such as cross-pin or side plate fixation. The association between radiation and aseptic loosening should be further studied with larger studies with homogeneity in tumor diagnosis and prosthesis. The dose-dependent relationship between radiation and bone-related complications may also benefit from controlled, laboratory-based biomechanical studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.

Salvage of limb salvage in oncological reconstructions of the lower limb with megaprosthesis: how much to push the boundaries?

INTRODUCTION

Megaprosthesis represent the most commonly used limb salvage method after musculoskeletal tumor resections. Nevertheless, they are burdened by high complication rate, requiring several surgical revisions and eventually limb amputation. The aims of this study were to evaluate the effect of rescuing the limb with subsequent revisions on complication rates (a), incidence of amputations (b), and whether complications reduce functional outcome after the first surgical revision (c).

MATERIALS AND METHODS

We retrospectively reviewed 444 lower limb megaprosthesis implanted for primary musculoskeletal tumors or metastatic lesions, from February 2000 to November 2017. 59 patients received at least one revision megaprosthesis surgery. MSTS score was used to assess final functional results. Complication-revision-amputation free survival rates were calculated both at 5 and 10 years of follow-up.

RESULTS

Complication free survival, revision free survival and amputation free survival at 10 years were 47% and 53%, 61% and 67%, 90% and 86% among all 444 patients and the group of 59 revised patients, respectively. The incidence of further complications after the first complication was 26% in the group treated with no subsequent revision surgeries and 51% in the group with at least one revision surgery. We found a trend of inverse linear relationship between the number of complications needing subsequent revision surgeries and the final MSTS.

CONCLUSION

The number of further revision surgeries after limb salvage with megaprosthesis increases the incidence of complications. Repeated surgical revisions, in particular after infection, increase the amputation rate. The most frequent causes of failure were structural failures and infections. MSTS score was superior for patients undergoing limb salvage than amputees. However, MSTS progressively decreased with multiple revisions becoming inferior to the functional score of an amputated patient.

A Viability Analysis of Tumor-Bearing Frozen Autograft for the Reconstruction After Resection of Malignant Bone Tumors Using 99m Tc-MDP Scintigraphy

PURPOSE OF THE REPORT

Several methods are used to reconstruct bony defects after malignant tumor excision. Tumor-bearing frozen autograft reconstruction is a biological procedure in which tumor-bearing bone is reused after devitalization with liquid nitrogen to kill tumor cells. The viability of frozen autografts has not been fully evaluated over time. We therefore aimed to evaluate the viability of devitalized bone grafts, using 99m Tc-MDP scintigraphy.

PATIENTS AND METHODS

Seventy-four patients who underwent frozen autograft reconstruction after the excision of a malignant bone tumor were enrolled. Two hundred forty-two postoperative 99m Tc-MDP scans were reviewed. For a quantitative analysis, the region of interest on the frozen bone segment and a symmetric region of interest on the contralateral normal area were manually set. The radioactive tracer uptake ratio was calculated by dividing the count density of the frozen bone segment by that of the contralateral normal area in each image. An uptake ratio of 0.9 to 1.1 was defined as a normalization of tracer uptake.

RESULTS

Normalization of tracer uptake was achieved in 95% to 97% of the cases by 60 months postoperatively, and earlier in the middle zone and peripheral zone in the pedicle freezing group in comparison to the free freezing group (both P = 0.03). Fracture and nonunion was associated with a low uptake ratio, whereas infection was associated with a high uptake ratio before the occurrence of the event.

CONCLUSIONS

The calculation of the uptake ratio using 99m Tc-MDP scans was an objective and accurate evaluation method. The period to normalization of tracer uptake in the pedicle frozen bone was significantly earlier than that in the free frozen bone. The postoperative complications can be also predicted.

Apparent trends in the use of femoral megaprostheses: an analysis from the National Joint Registry

BACKGROUND

Megaprosthetic replacement (MPR) of the femur is typically reserved for salvage or oncological reconstruction. Presently little is known about the provision of femoral MPRs performed nationally, the trends in indications for their use, and their outcomes beyond published unit-level data. Although the National Joint Registry (NJR) collects data as part of a mandatory arthroplasty audit process, MPR data entry on this platform is thought to be inconsistent. The aim of this study is to determine current trends for femoral MPR procedures as submitted to the NJR.

METHODS

Data for all procedures submitted to the NJR using the following implants were extracted: METS (Stanmore/Stryker), MUTARS (Implantcast), Segmental (Zimmer), GMRS (Stryker) and MEGA C (LINK). Pseudoanonymized data were analyzed through the NJR's research Data Access Portal and are reported using descriptive statistics.

RESULTS

A total of 1781 procedures were identified. Submitted cases increased for primary and revision hip and knee categories over the study period, although they plateaued in recent years. MPR implants were most commonly used in revision hip arthroplasty procedures. MPR use for the management of peri-prosthetic fractures has increased and now represents the most commonly reported indication for MPR use in both hip and knee revision categories. Few centers submitted large MPR case volumes (which were noted to be lower than published unit case series, indicating NJR under-reporting), and the vast majority of centers submitting MPR cases did so in low volume.

CONCLUSIONS

Due to the limitations identified, reported case volumes must be interpreted with caution. An MPR-specific NJR data entry form has been developed to allow more accurate and tailored reporting of MPR procedures, to support specialist service provision, and to provide meaningful data for future research.

Biomechanical Analysis of Bone Graft Treated With Pasteurization or Cryotherapy Using Liquid Nitrogen: A Study Using Sheep Bone Model

Osteosarcoma is a common primary malignancy of the bone. Osteosarcoma prognosis improves tremendously when chemotherapy is given in adjunct to surgical intervention. Limb reconstruction with sterilized autologous bone graft stabilized by orthopaedics implants has become a choice of treatment, but the biomechanical property of the bone treated with such sterilization method is a point of concern as a graft with inferior biomechanical property might lead to graft failure. This study compares the biomechanical properties of the bones treated with cryotherapy using liquid nitrogen and pasteurization in the form of four-point bending compression tests. Six sheep tibia bones were used for each group of treatment with one control group where no treatment was given. In the four-point bending test, osteotomy was performed at the tibia; the proximal tibia was treated with liquid nitrogen and pasteurization respectively. The treated bone is then reconstructed with the corresponding distal bone with locking plate and screws (Jiangsu Trauhiu Medical Instrument Co. Ltd., Changzhou, China). The four-point bending test was performed with an Electropulse® E3000 universal testing machine (Instron®, High Wycombe, United Kingdom) and results in the form of maximum compressive load, stress, and strain were collected. Photographic analysis of the fracture location and pattern were documented and analysed. We found that both methods of sterilization did not alter the biomechanical properties of the treated bone to the extent of statistical significance in comparison with the control group. However, other factors such as histological changes post treatment, equipment availability, and long-term outcome must be considered.

Predictors of Functional Recovery among Musculoskeletal Oncology Patients Undergoing Lower Extremity Endoprosthetic Reconstruction

BACKGROUND AND OBJECTIVES

Functional outcomes are important for oncology patients undergoing lower extremity reconstruction. The objective of the current study was to describe patient reported function after surgery and identify predictors of postoperative function in musculoskeletal oncology patients undergoing lower extremity endoprosthetic reconstruction.

METHODS

We performed a cohort study with functional outcome data from the recently completed Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. We utilized the 100-point Toronto Extremity Salvage Score (TESS), which was administered pre-operatively and at 3, 6 and 12 months post-operatively. Higher scores indicate better physical functioning, and the minimally important difference is 11 points. We calculated mean functional scores at each timepoint after surgery and developed a logistic regression model to explore predictors of failure to achieve excellent post-operative function (TESS ≥ 80) at 1 year after surgery.

RESULTS

The 555 patients included in our cohort showed important functional improvement from pre-surgery to 1 year post-surgery (mean difference 14.9 points, 95%CI 12.2 to 17.6; p < 0.001) and 64% achieved excellent post-operative function. Our adjusted regression model found that poor (TESS 0-39) pre-operative function (odds ratio [OR] 3.3, 95%CI 1.6 to 6.6); absolute risk [AR] 24%, 95%CI 8% to 41.2%), older age (OR per 10-year increase from age 12, 1.32, 95%CI 1.17, 1.49; AR 4.5%, 95%CI 2.4% to 6.6%), and patients undergoing reconstruction for soft-tissue sarcomas (OR 2.3, 95%CI 1.03 to 5.01; AR 15.3%, 95%CI 0.4% to 34.4%), were associated with higher odds of failing to achieve an excellent functional outcome at 1-year follow-up. Patients undergoing reconstruction for giant cell tumors were more likely to achieve an excellent functional outcome post-operatively (OR 0.40, 95%CI 0.17 to 0.95; AR -9.9%, 95%CI -14.4% to -0.7%).

CONCLUSIONS

The majority of patients with tumors of the lower extremity undergoing endoprosthetic reconstruction achieved excellent function at 1 year after surgery. Older age, poor pre-operative function, and endoprosthetic reconstruction for soft tissue sarcomas were associated with worse outcomes; reconstruction for giant cell tumors was associated with better post-operative function.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Intermediate-term results and risk factors analysis of tumor endoprosthesis in paediatric patients after the resection of lower extremity bone sarcoma

BACKGROUND

Mechanical failure of the endoprostheses is a concern in paediatric patients with primary bone sarcoma. Their long-term results are variable in the Asian population, thus we aim to investigate the outcome by assessing the mechanical failure, its risk factors and the functional results.

METHODS

We retrospectively reviewed 38 paediatric patients (mean 13.29, range 6-18) with primary bone sarcoma of lower extremity undergone chemotherapy and limb salvage surgery with tumor endoprosthesis between 2003 and 2016. All hospital notes were reviewed for any type of failures. Risk factors for implant loosening like stem size, remaining bone length, stem length, extracortical bone bridge ingrowth (EBBI), the ratio of resected bone length to whole bone length, bone stem ratio and custom-made versus modular were analyzed. The limb function was recorded by Musculoskeletal Tumor Society (MSTS) score. Median follow-up time was 7.42 years (3.0-15.4 years) and minimum follow-up for surviving patients was 2 years.

RESULTS

Endoprosthesis survivorship, according to Kaplan Meier was 94.7%, 85.4% and 66.2% at 2, 5 and 10 years respectively. Type II failure occurred in three patients (7.9%). Type III failure occurred in four patients (10.5%). Type IV failure occured in two patients (5.2%). Only EBBI independently predicted implant loosening (p = .007). Risk factors like stem size, remaining bone length, stem length, the ratio of resected bone length to whole bone length and custom-made versus modular were not associated with increase in implant loosening (p > .05). The mean stem size was 9.41 mm in asymptomatic group, comparable with 9.22 mm in the failure group (p = .79). The MSTS score was 29.62.

CONCLUSIONS

Our data suggests that paediatric Chinese patients with small body built had good and excellent mid-term results in implant survival and limb function respectively. EBBI is important in preventing loosening in tumor endoprosthesis. In contrast to the reported higher failure risk with stem size <12 mm, we found no increased loosening rate with smaller stem size endoprosthesis.

LEVEL OF EVIDENCE

Class III.

Prosthetic reconstruction following resection of lower extremity bone neoplasms: A systematic review and meta-analysis

•

Prosthetics are the mainstay in surgery after resection of extremity bone tumors.

•

For these patients gait parameters deteriorated compared to healthy individuals.

•

Further refinement of surgical techniques is required.

•

New rehabilitation strategies and follow-up programming are needed.

Prosthetic reconstructive procedures have become the mainstay in contemporary surgical treatment following resection of extremity bone neoplasms. Given that these patients are of young age most of the time, achievement of robust functional outcomes is of paramount importance. The aim of this study is to assess the impact of this procedure on the gait parameters of cancer patients compared to healthy individuals. The Medline, Scopus and Cochrane databases were systematically searched until January 2022 for eligible studies. Gait parameters measured by gait analysis after prosthetic reconstruction were the outcomes of interest. Eight cohort studies were included in our analysis. From these, seven studied prosthetic reconstruction of the knee (distal femur or proximal tibia) and only one exclusively studied prostetic reconstructions of the proximal femur. Compared to healthy individuals a significant decrease was evident in gait velocity (-0.16 m/sec, 95 %CI: −0.23 to −0.09, p-value < 0.001), in stride length (-6.07 %height, 95 %CI: −9,36 to −2.78, p-value < 0.001), in cadence (-3.96 stride/min, 95 %CI: −5.41 to −2.51, p-value < 0.001) and significant increase in cycle time (0.10 s, 95 %CI: 0.03 to 0.17, p-value = 0.005). Prosthetic reconstruction following lower limb tumor resection significantly affects the gait of patients. This knowledge can be utilized for further refinement of surgical techniques, rehabilitation strategies and follow-up programming.

Rotationplasty after failed limb salvage: an alternative to amputation

PURPOSE

Limb salvage procedures for musculoskeletal tumors have inherent complications. Though most complications can be managed with retention of the reconstructions, occasionally salvaging these reconstructions is not possible. We evaluated the outcomes of patients undergoing rotationplasty after multiple failed revisions of limb salvage surgery and document the success rate of this "salvage" technique and the subsequent functional outcome of these patients.

METHOD

Between January 1, 1999, and December 31, 2018, 14 patients (12 male and 2 female) with a median age of 24 years (11-51 years) underwent rotationplasty after multiple failed revisions of limb salvage surgery. Indication for rotationplasty was infection (10 patients), failed megaprosthesis (2 patients), unstable biological reconstruction (1 patient) and local recurrence (1 patient). The mean number of surgeries done before the patient underwent rotationplasty was 5 (range 2-7).

RESULTS

One patient developed a vascular complication (venous congestion) immediately after rotationplasty and underwent an early amputation. The remaining 13 patients had no surgical complications. Mean Musculo Skeletal Tumor Society score in 13 evaluable patients was 26 (23-30).

CONCLUSION

Our study demonstrates the utility of rotationplasty as a "salvage" procedure after multiple failed lower limb salvage surgeries. It offers good success rates, low rates of complications and good functional outcomes in carefully selected cases.

What is the Cumulative Incidence of Revision Surgery and What Are the Complications Associated With Stemmed Cementless Nonextendable Endoprostheses in Patients 18 Years or Younger With Primary Bone Sarcomas About the Knee

BACKGROUND

Osteosarcoma and Ewing sarcoma are more common diagnoses in preadolescent and adolescent children compared with the adult population. A greater percentage of patients are treated with limb salvage and reconstruction using modular tumor endoprostheses. Implant-to-bone fixation can be cemented or cementless. Cementless tumor endoprostheses rely on biologic osteointegration for implant stability, and chemotherapy during childhood and adolescence can disturb the bone turnover rate and reduce bone mineral density, which in turn may predispose patients with uncemented endoprostheses to a high rate of revision surgeries.

QUESTIONS/PURPOSES

(1) What is the cumulative incidence of revision operations for any cause (wound dehiscence, periprosthetic fracture, hinge breakage, aseptic loosening, infection, local recurrence, implant removal, and amputation) of cementless tumor endoprostheses around the knee? (2) What is the cumulative incidence of aseptic loosening, periprosthetic fracture, hinge breakage, and infection, and what proportion of patients had other complications? (3) What was the mean limb length discrepancy (LLD) at the time of skeletal maturity? (4) What was the median Musculoskeletal Tumor Society (MSTS) score at most recent follow-up or just before implant removal/amputation if implant removal/amputation were performed?

METHODS

Between 2008 and 2019, we treated 328 patients younger than 18 years for a primary bone sarcoma around the knee at our institution. Of those, 138 were treated with resection and reconstruction using two different types of modular tumor endoprostheses. During this period, our general indications for an endoprosthesis were patients who were candidates for an intraarticular resection of the distal femur or proximal tibia and who were at least 10 years of age. Uncemented fixation was always preferred. Cemented fixation was only done when intraoperative press-fitting of a cementless stem was not possible. Among uncemented implants, 26 patients died before completing 2 years of follow-up with intact implants and without further surgery, three were lost to follow-up before 2 years, and four patients received implants as a secondary salvage surgery after a failed primary biologic reconstruction with a vascularized fibular bone graft, leaving 94 patients for evaluation in this retrospective study. The mean age was 15 ± 2 years and the median (interquartile range) follow-up duration was 51 months (39 to 74). We did a competing risks analysis to tally cumulative incidence of all-cause revision procedures and cumulative incidence of aseptic loosening, periprosthetic fracture, hinge breakage, and infection. Other complications, including wound dehiscence, local recurrence, and stem breakage, were characterized descriptively and ascertained by review of electronic records of a longitudinally maintained institutional database by the treating surgeons. LLD was measured by serial clinical assessments and CT scans, starting since primary salvage surgery and until the latest follow-up of every patient. For the analysis of remaining LLD, we included only patients who were skeletally immature at time of primary resection and who had reached skeletal maturity by their latest follow-up (73% [69 of 94]). Functional outcome was assessed using MSTS scores obtained from a review of electronic records of a longitudinally maintained institutional database.

RESULTS

The 8-year cumulative incidence of revision surgery for any cause was 32% (95% confidence interval 23% to 42%). The 8-year cumulative incidence of aseptic loosening was 5% (95% CI 2% to 11%), periprosthetic fracture was 9% (95% CI 4% to 15%), hinge breakage was 19% (95% CI 12% to 28%), and infection was 7% (95% CI 3% to 14%). Other complications included wound dehiscence in 2% (2 of 94), stem breakage in 2% (2 of 94), and local recurrence in 2% (2 of 94) of patients. Stress shielding of the cortical bone around implanted stems was observed in 26% (24 of 94). The mean LLD for those who were skeletally immature at the time of primary resection and who reached skeletal maturity was 3.5 ± 2.6 cm. At latest follow-up, the median (IQR) MSTS score for all patients, excluding those who had complete implant removal or amputation, was 26 (24 to 27) of a maximum score of 30.

CONCLUSION

We observed a high rate of early revision and relatively frequent complications associated with the use of cementless fixation, and although this was not a comparative study, the findings were not superior to those reported by others who have studied cemented fixation for this indication. Furthermore, there may be some disadvantages with cementless fixation, such as stress shielding. Comparative studies about fixation methods are needed. The prevalence of bushing breakage in the current study highlights the importance of future modifications in the hinge design of both types of prostheses used in this study. Patients who were skeletally immature at the time of primary surgery had a LLD no more than 5 cm at skeletal maturity; consequently, nonexpandable endoprostheses may be appropriate for some adolescent patients who have limited remaining growth, although which patients are best suited for this approach would require specific study.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Are Postoperative Infections in the First 12 Months after Wide Resection and Megaprosthetic Replacement Associated with the Survival of Osteosarcoma Patients? Results of a Multicenter Study

Simple Summary

Postoperative infection is one of the gravest complications in patients following megaprosthetic replacement due to primary malignant bone tumors. On the other hand, several studies have also suggested that patients with a variety of different cancers may have a better chance of survival following the development of an infection, possibly as a result of the immune and inflammatory host responses to infection. Our retrospective analysis of 437 extremity osteosarcoma patients found that patients with a poor response to neoadjuvant chemotherapy and an infection in the first 12 months after primary tumor surgery had a better chance of survival compared to patients without infections. If this finding can be validated in a different patient cohort, it would suggest that the efficacy of novel immunomodulatory treatments in osteosarcoma patients should be evaluated and reported separately for patients with a good and a poor response to preoperative chemotherapy, as the latter might benefit more from such treatments.

Abstract

Recent retrospective studies suggested that early postoperative infections might be associated with a survival benefit for extremity osteosarcoma patients, but the reported results have been conflicting. The files of 437 patients with a newly diagnosed, high-grade osteosarcoma of the extremities treated at 5 referral centers in Germany and Austria between 1989 and 2016 were retrospectively evaluated. All patients underwent multi-agent chemotherapy and limb-sparing tumor excision, followed by endoprothetic replacement. We used the Kaplan–Meier method to calculate survival curves, which we compared with the log-rank test. With a median follow-up of 100 months (interquartile range, 49–155 months), local recurrence (LR) probability, event-free survival (EFS), and disease-specific survival (DSS) after 5 years in this selected patient cohort amounted to 5%, 67%, and 79%, respectively, and 46 patients (10.5%) developed an early postoperative infection. We found no significant differences in LR, EFS, or DSS between patients with and without early infections, and there were no differences in known prognostic factors between the two groups. However, in subgroup analyses patients with a poor response to neoadjuvant chemotherapy and an early infection had a better DSS compared to patients without early infections (93% vs. 62% after 5 years, p = 0.044). Provided that our findings can be validated in separate patient cohorts, we believe that patient outcome after adjuvant immunomodulatory treatments in osteosarcoma patients should be evaluated and reported separately for good and poor responders to neoadjuvant chemotherapy in future studies.

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.

What Are the Long-term Surgical Outcomes of Compressive Endoprosthetic Osseointegration of the Femur with a Minimum 10-year Follow-up Period?

BACKGROUND

Endoprosthetic reconstruction after oncologic resection of bone tumors requires stable fixation between the prosthesis and residual host bone. Compressive osseointegration has been developed as an alternative to traditional stemmed implants to address the challenges and complications of achieving this fixation. Sufficient time has now passed from the advent of compressive implants to allow for an assessment of the intermediate-term and long-term results of this form of fixation.

QUESTIONS/PURPOSES

At a minimum follow-up of 10 years after implantation of a compressive osseointegration device for oncologic reconstruction: (1) What is the risk of periprosthetic fracture, aseptic loosening, or implant breakage resulting in revision surgery for endoprosthesis removal? (2) What is the long-term cortical response at the host-endoprosthesis interface as visualized on plain radiographs?

METHODS

A single-center, retrospective study was performed between 2002 and 2010, in which 110 patients with primary bone sarcoma of the proximal or distal femur were considered for oncologic resection and reconstruction. Patients were considered for a compressive osseointegration endoprosthesis if they were 50 years of age or younger, had not previously received femoral radiation, had no metabolic disease impairing bone healing, were not diagnosed with metastatic disease, and had life expectancy greater than six months. Of the 110 patients, 25 were treated with a compressive osseointegration implant of the proximal or distal femur, and 85 patients were treated with conventional stemmed implants or amputation because of older age, advanced disease, metabolic comorbidities, inability to tolerate a nonweightbearing postoperative period, or in the case of rotationplasty, patient preference. All patients who received this device during the period of study were considered eligible for inclusion in this review. The median (range) age was 18 years (7 to 50), and 13 of 25 patients were men. Five patients died of disease before the minimum follow-up duration of 10 years; two underwent amputation due to local recurrence and three died with the implant in situ, leaving 20 patients for complete analysis. Median follow-up was 144 months, and all 20 surviving patients had a minimum follow-up of 10 years (121 to 230 months). The primary endpoint was reoperation and implant removal for periprosthetic fracture, aseptic loosening, or mechanical breakage of any component of the compressive device in the endoprosthesis. In final analysis, death was considered a competing event to revision surgery, and cumulative incidence was reported after competing-event analysis. A secondary aim was radiographic evaluation of the host-implant interface to assess the long-term cortical response to compressive osseointegration.

RESULTS

Spindle fracture or loosening was noted in three patients, and the remaining 17 patients maintained the compression device until the final follow-up. The risk of reoperation for aseptic loosening, periprosthetic fracture, or mechanical breakage of the implant using a competing risks estimator was 12% at 10 years (95% CI 0% to 26%). These complications occurred within 29 months of the index surgery; no patients had implant loosening or mechanical breakdown after this initial period. On radiographic assessment, 14 patients demonstrated cortical hypertrophy of the bone-implant interface, six patients had maintenance of the native cortical contour, and no patients had cortical atrophy or narrowing at the implant interface.Conclusion Long-term follow-up in patients with compressive osseointegrative endoprosthetic devices demonstrated no late revisions because of periprosthetic fracture, aseptic loosening, or implant breakage in this cohort with a minimum 10-year follow-up. There was no evidence of late-onset cortical atrophy or stress shielding at the host-implant interface. This study supports the long-term stability of the interface between host bone and the endoprosthesis in compressive osseointegration devices.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

The functional outcome after tumor resection and endoprosthesis around the knee: a systematic review

The evidence for the functional outcome of endo- prosthetic replacement (EPR) after tumour resection has been from few cohort studies. A scoping search revealed no systematic review on patient reported outcome measures after EPR around the knee. The purpose of this study was to evaluate the functional outcome of distal femoral and proximal tibial EPR after tumour resection. A systematic review was conducted using the PRISMA guidelines. The search identified 2560 articles from MEDLINE, EMBASE, CINAHL, and Web of Science. 36 studies satisfying the selection criteria were included for data synthesis. Pooled analysis was performed for homogenous studies. Narrative synthesis was performed for all the studies due to heterogeneity in methodological and statistical analysis. Amongst the overall patient population of 2930, mean ages ranged from 18-66 years and the mean follow up periods in the studies ranged from 12 - 180 months. The weighted mean functional outcome was similar for patients who had DFEPR and PTEPR. The functional outcome scores of Rotating Hinge Knee implants (RHK) were significantly greater than that for Fixed Hinge Knee implants (FHK). The weighted mean functional outcome scores were higher after cemented fixation and after primary EPR procedures. The current evidence suggests that functional out- come after EPR in the knee is good, and RHK implants are better than FHK implants. Functional outcome after primary EPR was significantly better than following revision EPR, and this underscores the importance of minimising complications at the primary surgery.

Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection

Simple Summary

Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection.

Abstract

Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.

Reconstruction survival of segmental megaendoprostheses: a retrospective analysis of 28 patients treated for intercalary bone defects after musculoskeletal tumor resections

INTRODUCTION

Intercalary endoprosthetic reconstructions have been reserved for patients with a limited life expectancy due to reports of high rates of early mechanical and reconstruction failure.

MATERIALS AND METHODS

In this study, we retrospectively analyzed 28 patients who underwent intercalary endoprosthetic reconstruction of the femur (n = 17) or tibia (n = 11) regarding reconstruction survival and causes of complications and reconstruction failure.

RESULTS

A total of 56 stems were implanted in this collective, 67.9% of which were implanted using cementation. Eight different stem designs were implanted. The mean patient age at the time of operation was 42.3 years. The mean bone defect needing reconstruction measured 18.5 cm. Resection margins were clear in 96.4% of patients. Of twenty-six complications, five were not implant-associated. We observed infection in 10.7% (n = 3) and traumatic periprosthetic fracture in 3.6% (n = 1) of cases. The most frequent complication was aseptic stem loosening (ASL) (53.8%; n = 14) occurring in eight patients (28.6%). The metaphyseal and meta-diaphyseal regions of femur and tibia were most susceptible to ASL with a rate of 39.1% and 31.3% respectively. No ASLs occurred in epiphyseal or diaphyseal location. Overall reconstruction survival was 43.9% and 64.3% including patients who died of disease with their implant intact. Overall limb survival was 72.7%.

CONCLUSIONS

Proper planning of segmental reconstructions including stem design with regard to unique anatomical and biomechanical properties is mandatory to address the high rates of ASL in metaphyseal and metadiaphyseal stem sites. With continued efforts of improving stem design in these implantation sites and decreasing rates of mechanical failure, indications for segmental megaendoprostheses may also extend to younger patients with the localized disease for their advantages of early weight bearing and a lack of donor-site morbidity.

When Your Ankle Becomes a Knee - Long-Term Functional Outcome and Quality of Life with a Rotationplasty after Resection of Malignant Limb Tumors

BACKGROUND

Increasing numbers of patients surviving malignant bone tumors around the knee joint have led to an increasing importance to investigate long-term results. This study assessed the long-term results of rotationplasty after resection of malignant bone tumors regarding functional outcome and quality of life to allow better comparison with other treatment options in bone cancer treatment.

PROCEDURE

60 participants who underwent rotationplasty due to bone cancer took part in this multicentric questionnaire-based study. The long-term functional outcome was measured by the Musculoskeletal tumor society score (MSTS) and the Tegner activity level scale. The health-related quality of life (HRQL) was assessed by using the Short Form Health Survey (SF-36).

RESULTS

Patients treated with rotationplasty (median follow-up of 22 years, range 10-47 years) regained a high level of activity (median MSTS score of 24). Even a return to high level sports was possible (mean Tegner activity level scale of 4). Duration of follow-up did not influence the functional outcome. HRQL scores were comparable to the general German population. Concerns of psychological problems due to the unusual appearance of the rotated foot have not been confirmed.

CONCLUSION

Rotationplasty can be a good alternative to endoprosthetic replacement or amputation, either as primary surgery or as a salvage procedure. Especially for growing children and very active patients rotationplasty should be considered.

Distal Tibial Reconstruction in the Management of Primary Bone Tumors in Children and Adolescents

BACKGROUND

Distal tibial primary bone tumors are rare, and options for limb salvage surgery are limited and challenging. Importantly, local control has shown to be crucial and necessary for cure, and radical surgery is one of the most important components of therapy for some bone sarcomas. We investigated the feasibility and functional and oncological outcomes of distal tibial reconstruction using endoprosthesis in children with malignant bone tumors.

METHODS

Fourteen patients (median age 13.6 years) with primary bone tumors (4 Ewing sarcoma [ES], 10 osteosarcoma) of the distal tibiae were treated during 2013-2019. All patients had reconstruction using a modular (13 patients) or expandable custom-made titanium bone replacement system (1 patient). All patients received chemotherapy before and after surgery.

RESULTS

Twelve patients (85.7%) are alive with a median follow-up 20 months from diagnosis. Five-year estimates of event-free survival and overall survival were 60.6% and 76.4%, respectively. Three patients had postoperative complications requiring second surgery. Maximum dorsiflexion and plantar flexion of the foot were 20 degrees (range 0-20 degrees) and 20 degrees (range 5-20 degrees), respectively.

CONCLUSION

For select distal tibial sarcomas, after neoadjuvant chemotherapy pretreatment and radical resection, reconstruction using an endoprosthesis as a radical surgery provides an option was associated with a low rate of short-term local complications and relatively good early function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction for bone sarcomas: long-term outcomes

BACKGROUND

Computed tomography (CT) and magnetic resonance imaging (MRI) data can be fused to identify the tumor boundaries. This enables surgeons to set close but tumor-free surgical margins and excise the tumor more precisely. This study aimed to report our experience in performing computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction to treat bone sarcoma in the diaphysis and metaphysis of the femur and tibia.

METHODS

Between September 2008 and December 2015, 24 patients with bone sarcomas underwent surgical resection and joint-sparing reconstruction under image-guided computer navigation. The cohort comprised 16 males and eight females with a median age of 19.5 years (range: 12-48 years). The tumor location was the femoral diaphysis in three patients, distal femur in 19, and proximal tibia in two. The tumors were osteosarcoma (n = 15), chondrosarcoma (n = 3), Ewing sarcoma (n = 3), and other sarcomas (n = 3). We created a pre-operative plan for each patient using navigation system software and performed navigation-aided resection before reconstructing the defect with a custom-made prosthesis with extracortical plate fixation.

RESULTS

Pathological examination verified that all resected specimens had appropriate surgical margins. The median distance from the tumor resection margin to the joint was 30 mm (range: 13-80 mm). The median follow-up duration was 62.5 months (range: 24-134 months). Of the 24 patients, 21 remain disease free, one is alive with disease, and two died of the disease. One patient developed local recurrence. Complications requiring additional surgical procedures occurred in six patients, including one with wound hematoma, one with delayed wound healing, one with superficial infection, one with deep infection, and two with mechanical failure of the prosthesis. The mean Musculoskeletal Tumor Society score at the final follow-up was 91% (range: 80%-100%). The 5- and 10-year implant survival rates were 91.3% and 79.9%, respectively.

CONCLUSIONS

Computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction with extracortical plate fixation is a reliable surgical treatment option for bone sarcoma in the diaphysis and metaphysis of the femur and tibia.

Amputation for Extremity Sarcoma: Indications and Outcomes

Simple Summary

Sarcomas are malignant tumors of soft tissues or bone. While limb salvage surgery (LSS) is the standard treatment, amputation is an option especially in local recurrence (LR) or complications after LSS. Two groups with primary amputations (n = 120) or secondary amputations after failed LSS due to LR or complications (n = 29) were compared. Five-year LR-free survival was 84% and 17 (16%) patients developed LR, of which 16 were in group I and only one in group II. Overall survival (OS) at five years was 44%, and the rate was identical in both groups. In those group II patients who had a secondary amputation after LSS due to contaminated margins or LR (n = 12) five-year OS was 33% compared to 48% in patients with complications (n = 17). This study indicates the worse oncological outcomes with respect to OS of sarcoma patients needing an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same results.

Abstract

Background: Sarcomas are rare, malignant tumors of soft tissues or bone. Limb salvage surgery (LSS) is the standard treatment, but amputation is still an option, especially in local recurrence or complications after LSS. Methods: We retrospectively reviewed indications and oncological outcomes in patients who underwent an amputation. Two groups with either primary amputations (n = 120) or with secondary amputations after failed LSS with local recurrence or complications (n = 29) were compared with the main end points of LRFS and OS. Results: Five-year LRFS was 84% with 17 (16%) patients developing local recurrence, of which 16 (13%) occurred in group I. Forty-two (28%) patients developed metastatic disease and overall survival at five years was 44%. Overall survival (OS) was the same in both groups. In those group II patients who had a secondary amputation due to LR or insufficient margins after LSS (n = 12) the five-year OS was 33% compared to 48% in patients with amputation due to complications (n = 17) (n.s.). Conclusions: This study indicates the worse oncological outcomes with respect to OS of sarcoma patients requiring an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same oncological results.