Bone tumours around the elbow: a rare entity

Outcomes of management of primary benign aggressive or malignant bone tumors around the elbow by limb-salvage surgery

PURPOSE

Bone tumors around the elbow are rare, with frequently delayed diagnosis. The current study aimed to assess the functional and oncological outcomes of limb salvage surgery for primary benign aggressive or malignant bone tumors around the elbow.

METHODS

We conducted a retrospective review of patients with primary aggressive benign and malignant bone tumors around the elbow treated with limb salvage surgery between 1995 and 2020 at a single musculoskeletal oncology center. The minimum follow-up period was 24 months. Functional results were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the last follow-up visit. Local recurrence, chest metastasis, and complications were recorded.

RESULTS

This study included 30 patients, 19 males and 11 females, with a mean age of 25.4 ± 14.2 years. The tumor location was the distal humerus (n = 21), proximal radius (n = 5), and proximal ulna (n = 4). Reconstruction was done by elbow fusion using fibular graft (n = 10), mobile endoprosthesis (n = 9), excision arthroplasty (n = 7), and extracorporeal freezing and reimplantation (n = 4). The mean follow-up period was 36.2 ± 21.3 months. The median follow-up MSTS score was 27 [Interquartile range (IQR): 26-30]. Skeletally immature patients had a significantly higher MSTS score. The rate of postoperative complications was 26.7%.

CONCLUSION

Limb salvage surgery with different reconstructive options for benign aggressive and malignant bone tumors around the elbow can achieve good functional and oncological outcomes.

LEVEL OF EVIDENCE

Level IV.

Elbow hemiarthroplasty with a 3D-printed prosthesis for distal humeral bone defects after tumor excision: a case report

INTRODUCTION

The distal humerus is a rare site for primary and metastatic bone tumors. Due to the scarcity of cases and lack of standardized surgical strategies, it is often difficult for surgeons to choose the right choice. The application of a 3D-printed prosthesis with hemiarthroplasty for the treatment of the distal humerus after tumor resection can be a very effective option.

CASE PRESENTATION

We present a clinical case of a 3D-printed distal humeral prosthesis for the treatment of bone defects caused by metastatic bone tumors. The preoperative evaluation was aggressively performed, and the decision was made to distal humeral hemiarthroplasty (DHH) after wide resection of the tumor segment bone. Processing of the Digital Imaging and Communications in Medicine (DICOM) data from CT scans performed after mirror conversion using CT data of the contralateral humerus, we designed a 3D-printed distal humeral prosthesis with hemiarthroplasty. After reconstruction of bone and surrounding soft tissue by the 3D-printed prosthesis combined with the LARS ligament and regular follow-up for 12 months, the patient had an MSTS-93 score of 29 and an MEP of 100, which reached a good level, and the patient was fully competent in normal daily activities.

CONCLUSIONS

Our results show that the 3D-printed modular prosthesis with hemiarthroplasty is a very effective option for cases of large elbow bone defects due to primary bone tumors or metastatic disease. However, careful preoperative preparation is required for the best outcome. Careful preoperative preparation and long-term follow-up are essential for the best outcome.

EPIDEMIOLOGICAL PROFILE AND EVOLUTION IN MUSCULOSKELETAL TUMORS AT THE LEVEL OF THE ELBOW

Objective

To present the epidemiological profile of bone and soft tissue tumors that affect the elbow region treated at an oncology referral center in Brazil.

Methods

Retrospective observational case series study to evaluate the results of elbow cancer undergoing clinical and/or surgical treatment with the first visit from 1990 to 2020. The dependent variables were benign bone tumor, malignant bone tumor, benign soft tissue tumor, malignant soft tissue tumor. Independent variables were sex, age; presence of symptoms (pain/increase in local volume/fracture); diagnosis; treatment and recurrence.

Results

In total, 37 patients were included, 51.35% of whom were female, with a mean age at diagnosis of 33.5 years. Soft tissue neoplasms correspond to 51% of cases against 49% of bone tumors. Among the symptoms, the general prevalence of pain was 56.75%, the general increase in local volume occurred in 54.04% of the patients and the presence of fractures in 13.43%. Surgical treatment occurred in 75.67% of cases and recurrence in 16.21% of cases.

Conclusion

The tumors that affect the elbow in our series correspond mostly to benign tumors, involving bone or soft tissues, with a higher occurrence in young adult patients. Level of Evidence IV, Case Series.

Elbow hemiarthroplasty with a 3D-printed megaprosthesis for defects of the distal humerus or proximal ulna after tumour resection : a preliminary report

AIMS

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

METHODS

From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients.

RESULTS

Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively.

CONCLUSION

The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747-757.

Aggressive giant cell tumour (GCT) of the distal humerus in a young pregnant woman

A 25-year-old pregnant woman reported suffering from an aggressive giant cell tumour of the distal humerus extending into the elbow joint. The successful management required a careful evaluation of the various treatment options due to her pregnancy. Surgical excision of the mass was performed. The residual bone defect was reconstructed with an elbow mega-prosthesis. The patient made a pain-free recovery with a good range of motion and delivered the baby at term with no complications.

Monoarthritis of the Elbow Revealing Osteoid Osteoma: A Case Report and Literature Review

Osteoid osteoma is a rare benign osteoblastic tumor that mainly occurs in the extra-articular segments of lower limb long bones. The elbow is an exceptional location for osteoid osteoma. The diagnosis is usually delayed since the elbow is a rare site for this tumor and unspecific clinical signs, such monoarthritis, may mimic other more common conditions. We report the case of a 16-year-old girl who presented with chronic monoarthritis of the elbow which was treated falsely as tuberculous arthritis and monoarticular rheumatoid involvement. The laboratory tests were negative. Computed tomography scan and magnetic resonance imaging showed the focal nidus at the coronoid process of the ulna with mild synovitis. The diagnosis of osteoid osteoma was not made until the disease had been progressing for eighteen months and the elbow had already become stiff. Arthroscopic excision of the lesion was performed, and histopathology of the nidus was consistent with osteoid osteoma. Since then, the patient has been pain-free with an improved elbow range of motion.

Neoplastic Elbow Diseases and Mimickers

Tumors around the elbow are infrequent, and delayed diagnosis is a common theme because of the low incidence and lack of familiarity. However, just like any other site, the radiologic work-up of musculoskeletal tumors around the elbow remains the same, with plain films the first investigation in a patient with a suspected bone tumor and ultrasound the first modality to evaluate a soft tissue lump. The management of both bone and soft tissue tumors around the elbow is unique because of a large number of important structures in an anatomically confined space and little normal tissue to spare without severely compromising the joint's function. Many benign nonneoplastic entities can mimic bone and soft tissue tumors on imaging. It is important to keep the characteristic imaging appearance in mind while formulating a differential diagnosis to avoid an unnecessary additional work-up. This article reviews the most common benign and malignant bone and soft tissue tumors around the elbow, mimickers, imaging features, and current therapeutic concepts.

Pediatric Imaging of the Elbow: A Pictorial Review

The elbow is a complex joint, subject to a wide range of traumatic, inflammatory, metabolic and neoplastic insults. The pediatric elbow has several diagnostic pitfalls due to the normal developmental changes in children. Knowledge of these normal variants is essential for both diagnosis and management of their elbow injuries. Radiography remains the first imaging modality of choice. Magnetic resonance imaging is excellent in evaluating lesions within the bone and soft tissues. In this pictorial essay, we provide insights into pediatric elbow imaging, show a range of entities specific to the pediatric elbow, and discuss diagnostic pitfalls that result from normal elbow growth in children.

Joint replacement surgery for elbow tumours: a systematic review of outcomes

BACKGROUND

Tumour resection followed by joint reconstruction is a surgical option in the appropriate patient. The evidence for such reconstructive surgery of the elbow joint is limited. The aim of this study is to review the literature to evaluate the outcomes of joint replacement surgery in tumours of the elbow.

METHODS

A systematic review of PUBMED and EMBASE databases was conducted. Case series and comparative studies reporting results after total elbow arthroplasty, modular endo-prosthetic replacement and custom prosthesis were eligible for inclusion.

RESULTS

Eleven eligible studies were identified (n = 134). At mean follow-up of 44 months, the overall revision rate was 14% and complication rate was 28%. The mean Mayo Elbow Performance Score was 75, with 56% of patients reporting good or excellent outcomes. The mean post-operative range of motion was 97°.

DISCUSSION

Elbow prosthesis reconstruction after tumour resection can provide good functional outcomes at mid-term follow-up. The complication and revision rates are comparable to other indications for elbow replacement surgery. Further prospective studies are required to compare outcomes between different elbow arthroplasty options after tumour resection.

Synovial sarcoma of the elbow presenting with painful stiffness: a case report

Elbow stiffness is a challenging problem for the upper extremity surgeon to treat. It can significantly impact the patient's function in activities of daily living. While the most common etiologies are post-traumatic or secondary to arthritis, a large variety of etiologies should be considered with atypical presentations. It is important that the upper-extremity surgeon have a systematic approach to the diagnosis and management of elbow contracture in order to ensure malignant processes are considered. We present an unusual case of a young patient with atraumatic, non-arthritic elbow stiffness whose underlying diagnosis was a synovial sarcoma, as well as a review of the literature and differential for elbow stiffness. Level of evidence: IV.

Total elbow arthroplasty as a reconstruction option for distal humerus osteosarcoma: A case report

Introduction

Osteosarcoma is the second most common malignant bone tumor. The humerus is the third most common anatomical location for osteosarcoma, however, osteosarcoma around the elbow joint is uncommon. The intricacy of the elbow joint, limited soft tissue coverage, and proximity to nerves and arteries make the surgical resection and reconstruction complicated.

Case report

A 17-year-old boy came with a chief complaint of lump and pain on his left elbow. One month later, the patient felt there was a lump with a size of a marble on the left elbow, which getting bigger to a size of a tenis ball. Physical examination showed mass on the posterior aspect of the elbow with the size 14x12cm. Plain radiographs revealed osteolytic lesion and periosteal reaction of the distal humerus and the magnetic resonance imaging (MRI) showed a low intensity on T2-weighted imaging. Histopathological examination suggested osteosarcoma. The patient underwent neoadjuvant chemotherapy for 3 cycles. The patient was treated with limb salvage surgery by wide excision, cryosurgery followed by total elbow arthroplasty and ORIF with plate and screw. Postoperative plain radiographs showed the plate and screws are well-fixated. The patient can slowly regain his elbow motion without limitation one month postoperatively.

Conclusions

Distal humerus in an unusual site for osteosarcoma. Total elbow arthroplasty and ORIF with plate and screw is a favorable reconstruction option for distal humerus osteosarcoma with excellent postoperative functional outcomes.

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Osteosarcoma around elbow joint is very rare

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Limb salvage surgery is the standard procedure for the osteosarcoma, but the involvement of elbow joint made the decision for preservation difficult

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Total elbow arthroplasty and ORIF with plate and screw for distal humerus osteosarcoma provides good functional outcome

Chitosan applications in studying and managing osteosarcoma

Osteosarcoma has a high prevalence among children and adolescents. Common treatments of this disease are not promising enough. Molecular processes involved in the pathogenesis of osteosarcoma are not fully understood. Besides, the remnants of tumor cells after surgery can cause bone destruction and recurrence of the disease. Thus, there is a need to develop novel drugs or enhancing the currently-used drugs as well as identifying bone-repairing methods. Chitosan is a natural compound produced by the deacetylation of chitin. Research has shown that chitosan can be used in various fields due to its beneficial effects, such as biodegradability and biocompatibility. Regarding cancer, chitosan exerts several anti-tumor activities. Moreover, it can be used in diagnostic techniques, drug delivery systems, and cell culture methods. Herein, we aim to discuss the potential roles of chitosan in studying and treating osteosarcoma. We review the literature on chitosan's applications as a drug delivery system and how it can be combined with other substances to improve its ability of local drug delivery. We take a look into the studies concerning the possible benefits of chitosan in the field of bone tissue engineering and 3D culturing. Furthermore, anti-cancer activities of different compounds of chitosan are reviewed.