Controversies in orthopaedic oncology

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Glomangiomatosis of the lower leg

This paper demonstrates a case of multiple glomangiomas, or glomangiomatosis, including clinical presentation, imaging appearances, and subsequent management. Differentiating features from typical glomus tumors are described. To the best of our knowledge, this is the first reported case of a glomangioma involving the distal tibiofibular syndesmosis.

Partial Articular Resurfacing Secondary to Pediatric Hip Chondroblastoma Curettage with a 5-YearFollow-Up: A Case Report

CASE

This report describes a case of pediatric femoral head chondroblastoma, which was initially treated by minimally invasive curettage. At the 18-month follow-up, a subsequent osteochondral defect occurred, which was treated with a partial articular resurfacing system. At 5.5 years follow-up, he was symptom-free with minor degenerative x-ray changes.

CONCLUSION

We describe a technique of focal anatomic hip resurfacing using the HemiCAP system in a pediatric chondroblastoma patient who presented with an osteochondral defect after primary curettage. This approach yielded good short-term to midterm results and is a potential alternative to total hip arthroplasty in young patients.

Does resurfacing of asymptomatic full-thickness localized articular defects of the trochlea influence the outcome following unicompartmental knee arthroplasty of the medial compartment?: A retrospective cohort study with minimum seven-year follow-up

BACKGROUND

Patellofemoral joint (PFJ) degeneration has been found not to affect outcome following medial unicompartmental knee arthroplasty (UKA). However, PFJ disease occasionally presents as isolated trochlear cartilage lesions, with little available evidence regarding treatment options or necessity. We evaluated the effectiveness of concomitant trochlear resurfacing in patients undergoing medial UKA with asymptomatic trochlear lesions.

METHODS

We included 60 patients undergoing medial UKA with an associated full thickness lesion of the trochlea. A fixed bearing UKA implant (PKR™, Stryker, Warsaw, IND) was used in all cases. In 30 patients, trochlear lesions were resurfaced with a HemiCAP® PF Classic (HemiCAP® PFC) implant (Arthrosurface, Franklin, MA). Outcome measures included VAS-, KOOS-, WOMAC-, SF-36 scores and radiological assessment.

RESULTS

Average length of follow-up was 97.4 months (range: 88-106 months). Both groups showed significant improvement for all clinical scores post-operatively compared to pre-operatively (p < 0.001 for all). The UKA group showed a better VAS score at all follow-up moments (p < 0.01 for all), but no differences were found between both groups at all time points for other outcome measures. None of the HemiCAP® PFC implants needed to be revised within the timeframe of the study.

CONCLUSIONS

In this retrospective cohort study, we found a 100% survivorship of the HemiCAP® PFC implant at an average eight-year follow-up. However, no clinical benefits were found in performing trochlear resurfacing in conjunction with medial UKA for asymptomatic end-stage trochlear cartilage lesions. Therefore, these lesions can be safely ignored when performing a medial UKA.

Epidemiological study of soft-tissue sarcomas in Ireland

Soft‐tissue sarcomas (STS) account for 1% of adult and 7% of pediatric malignancies. Histopathology and classification of these rare tumors requires further refinements. The aim of this paper is to describe the current incidence and survival of STS from 1994 to 2012 in Ireland and compare these with comparably coded international published reports. This is a retrospective, population study based on the data from the National Cancer Registry of Ireland (NCRI). Incidence and relative survival rates for STS in Ireland were generated. Incidence of STS based on gender, age and anatomical location was examined. Annual mean incidence rate (European Age Standardized) in Ireland between 1994 and 2012 was 4.48 ± 0.15 per 100,000 person‐years. The overall relative 5‐year survival rate of STS for the period 1994–2011 in Ireland was 56%, which was similar to that reported in the U.K. but lower than in most of Europe and U.S.A. Survival rate fluctuated over the period examined, declining slightly in females but showing an increase in males. STS incidence trends in Ireland were comparable to international reports. Survival trends of STS were significantly different between Ireland and other European countries, requiring further study to understand causation.

Perioperative chemotherapy in the treatment of osteosarcoma: a 26-year single institution review

Background

Chemotherapy in the multimodality treatment of osteosarcoma has improved survival. Reported outcomes on adult patients are limited. Poor necrosis rates post neoadjuvant chemotherapy (NAC) is considered an adverse prognostic factor and attempts have been made to improve survival in this group.

Patients and methods

Adult and young adult patients diagnosed with osteosarcoma between January 1986 and August 2012 were retrospectively reviewed. Patients identified were stratified according to stage (localised or metastatic) and age (≤40 and >40 years). Event free survival (EFS) and overall survival (OS) outcomes were determined. In patients with localised disease ≤40 years, survival was assessed according to necrosis rates post NAC (<90 and ≥90%). NAC consisted of two cycles of methotrexate alternating with doxorubicin/cisplatin (MAP) followed by definitive surgery. Those with ≥90% tumour necrosis continued on MAP. Patients with <90% necrosis received ifosfamide and etoposide (IE) post operatively.

Results

A total of 108 patients were reviewed and 97 were included. Median age was 23 years (range 16–75) and 70% of patients were male. Five year EFS and OS across all groups was 57% and 63% respectively. Of the patients with localised disease (N = 81), 5-year overall survival (OS), with a median follow up of 7 years (2–26) was 70% (p < 0.0001). Patients aged 16–40 (N = 68) with localised osteosarcoma had a significantly improved 5-year OS (74%) compared to those >40 years (N = 13) (42%) (p = 0.004). Of the 68 patients with localised osteosarcoma ≤40 years, 62 were evaluated according to necrosis rates post MAP. In 33 patients who achieved ≥90% necrosis and continued MAP, 5-year OS was 82%. In 29 patients who had <90% tumour necrosis and received adjuvant IE, 5-year OS was 68% (p = 0.15). Multivariate analysis confirmed age and stage as prognostic factors but not poor necrosis rates in our treated population.

Conclusions

Long-term survival outcomes in a predominantly adult Irish population are similar to large reported trials. Age and stage at diagnosis are prognostic. Postoperative ifosfamide/etoposide alone in patients with poor necrosis rates is a feasible regimen, but its role in the adjuvant setting remains uncertain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13569-015-0032-0) contains supplementary material, which is available to authorized users.

Arsenic in private drinking water wells: an assessment of jurisdictional regulations and guidelines for risk remediation in North America

Arsenic is a known carcinogen found globally in groundwater supplies due to natural geological occurrence. Levels exceeding the internationally recognized safe drinking water standard of 10 μg/L have been found in private drinking water supplies in many parts of Canada and the United States. Emerging epidemiological evidence confirms groundwater arsenic to be a significant health concern, even at the low to moderate levels typically found in this region. These findings, coupled with survey data reporting limited public adherence to testing and treatment guidelines, have prompted calls for improved protective measures for private well users. The purpose of this review is to assess current jurisdictional provisions for private well water protection in areas where arsenic is known to naturally occur in groundwater at elevated levels. Significant limitations in risk management approaches are identified, including inconsistent and uncoordinated risk communication approaches, lack of support mechanisms for routine water testing and limited government resources to check that testing and treatment guidelines are followed. Key action areas are discussed that can help to build regulatory, community and individual capacity for improved protection of private well water supplies and enhancement of public health.

Switching chemotherapy in adult osteosarcoma patients with poor necrosis rates post neoadjuvant methotrexate, cisplatin, and doxorubicin (MAP)

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Background: Chemotherapy in the treatment of osteosarcoma has improved 5 year overall survival (OS) from 20% with surgery alone to 60-70%. However, poor tumor necrosis following neoadjuvant chemotherapy (NAC) is associated with decreased survival, therefore strategies to improve outcomes are required for these patients. Methods: Records from all adult patients diagnosed with osteosarcoma between 1986 and 2012 were retrospectively reviewed. Patients were stratified according to age at diagnosis (<40yrs and >40yrs), stage (localised or metastatic) and tumor necrosis post NAC (<90% and >90%). All patients received 2 cycles of methotrexate alternating with cisplatin/doxorubicin (MAP) preoperatively. Following surgery, patients with >90% tumor necrosis continued MAP whilst those with <90% necrosis switched to 4 cycles of ifosfamide and etoposide (IE). Results: 105 patients were identified and 98 who received systemic chemotherapy were included. Median age was 23yrs (Range 15-75yrs); 68% of patients were male. Limb sparing surgery was performed in 76% of applicable patients. Of the patients with localised disease (N=85), 5 year OS, with a median follow up of 8 years (1-26 yrs) was 68% (p=0.002). Patients <40 yrs with localised disease had a 5yr OS of 71% (N=73) compared to 40% in those >40 yrs (N=12) (p=0.05). 2/13 patients with metastatic disease at diagnosis are disease free >10 years post diagnosis. 65 of 73 patients with localised disease < 40 yrs had histology reviewed post neoadjuvant MAP. 34/65 (52%) had >90% tumor necrosis and continued on MAP, 5 yr OS 79%, 31 patients (48%) had <90% necrosis and received adjuvant IE, 5 yr OS 68% (P=0.10). Conclusions: Age and stage are important prognostic factors in patients with osteosarcoma treated with chemotherapy and surgery. Historically, patients with <90% tumor necrosis post NAC are considered to have a poorer prognosis. Switching from MAP to IE is an appropriate salvage regimen in such patients and appears to improve long term survival.

Ear reconstruction following severe complications of otoplasty

BACKGROUND

Correction of prominent ears is one of the most common operations performed in congenital deformity. Many appropriate corrective techniques have been described. While rare, severe complications destroying ear contours can occur and their correction should follow the established principles of ear reconstruction.

METHODS

A retrospective review of the notes of all patients who presented to Clinique George Bizet (1981-2007) in Paris, for correction of complications after undergoing prominent ear surgery at another facility, was performed. Each patient's age, gender, diagnosis, number of previous operations and final outcome were noted as available. Patients were included in this study if they had undergone one or more operations for prominent ears, leading to severe destructive complications, prior to consultation with the senior author and then underwent surgical repair with either an auricular (conchal) cartilage graft or with autogenous costal cartilage.

RESULTS

A total of 49 (25 female, 24 male) patients met the inclusion criteria. The mean age at presentation was 23 years (range of 10-59 years of age). The mean number of previous attempts to correct the ear deformity was 1.3 (1-12) times. Eight patients underwent reconstruction with a conchal cartilage graft and 41 with costal cartilage.

CONCLUSIONS

While more minor contour deformities are correctable with a contralateral conchal cartilage graft, when more than a quarter of the ear or more than two planes of its complex folds are deformed, costal cartilage is recommended for surgical repair. The principles of ear reconstruction should be well understood prior to attempting a repair of severe complications after otoplasty.

The role of hamstring tightness in plantar fasciitis

BACKGROUND

Plantar fasciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the calcaneus. Several etiological factors have been implicated in the development of plantar fasciitis; however, the role of hamstring tightness has not been evaluated.

METHODS

Fifteen volunteers (mean age 32.6 +/- 4.7 years) were prospectively analyzed for differences in forefoot loading using a Don-Joy brace (dj Orthopedics, Vista, CA) applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0 degrees, 20 degrees, and 40 degrees). Their mean popliteal angle was 6.5 degrees. Fifteen patients (mean age 40 +/- 16.5 years) with a diagnosis of chronic plantar fasciitis were similarly analyzed on the pedobarograph. These patients also had their hamstring tightness evaluated by measuring the popliteal angle. The mean popliteal angle was 23 degrees.

RESULTS

Increasing the angle of flexion from 0 to 20 degrees at the knee joint led to a statistically significant increase in pressure in the forefoot phase by an average of 0.08 K/cm(2)s (p < 0.05). An increase from 20 to 40 degrees led to increased forefoot phase pressure of 0.08 kg/cm(2)s (p < 0.05). The percentage of time spent in contact phase decreased from 35.37% to 30.87% to 26.37% with increasing flexion (p < 0.05). However there was an inverse increase in the time spent in the forefoot phase 46.6% to 55.6 to 61.25% with increasing degrees of flexion (p < 0.05).

CONCLUSION

The results indicate that an increase in hamstring tightness may induce prolonged forefoot loading and through the windlass mechanism be a factor that increases repetitive injury to the plantar fascia.

Gene therapy in plastic and reconstructive surgery

Gene therapy has been investigated in many aspects of plastic and reconstructive surgery. These areas ultimately involve various forms of tissue healing and the manipulation of bony and soft tissues to reconstruct defects secondary to neoplastic and congenital disorders and trauma. Most research has been limited to animal studies with the exception of clinical trials on the use of gene therapy in lower leg ulcer healing and as an adjunct to advanced recurrent squamous cell carcinoma of the head and neck. Overall, these preliminary studies have produced optimistic results. With the development of more efficient and safer delivery systems, the application of gene therapy in plastic surgery could become more widespread, especially in combination with tissue engineering technology.

Vascular endothelial growth factor gene therapy in ischaemic rat skin flaps

Gene therapy with the complementary DNA (cDNA) of the angiogenic cytokine vascular endothelial growth factor (VEGF) has emerged as a promising strategy in the treatment of myocardial and lower-limb ischaemia. The objective of this study was to determine whether these principles could be applied to a recognised model of skin-flap ischaemia. Plasmid vectors including the cDNA of green fluorescent protein (GFP) and one of three VEGF isoforms (A165, B167 or B186) were constructed, and their base sequences confirmed. GFP expression was used as a marker of successful in vitro transfection of human endothelial cells with each plasmid. The plasmids were then administered subcutaneously to rat abdominal skin flaps surgically rendered ischaemic, and the percentage of viable tissue was assessed at 1 week. Angiograms of the flaps and histological preparations of flap tissue were assessed for evidence of angiogenesis. The survival of flaps treated with VEGF A165 or B167 cDNA was significantly greater than that of controls (P < 0.05). The survival of flaps treated with VEGF B186 cDNA was greater than that of controls, but statistical significance was not reached. Angiograms and microvessel density counts failed to produce evidence of angiogenesis. With improved delivery strategies, VEGF may have a role in the management of surgical ischaemia.

Biofilm formation as microbial development

Biofilms can be defined as communities of microorganisms attached to a surface. It is clear that microorganisms undergo profound changes during their transition from planktonic (free-swimming) organisms to cells that are part of a complex, surface-attached community. These changes are reflected in the new phenotypic characteristics developed by biofilm bacteria and occur in response to a variety of environmental signals. Recent genetic and molecular approaches used to study bacterial and fungal biofilms have identified genes and regulatory circuits important for initial cell-surface interactions, biofilm maturation, and the return of biofilm microorganisms to a planktonic mode of growth. Studies to date suggest that the planktonic-biofilm transition is a complex and highly regulated process. The results reviewed in this article indicate that the formation of biofilms serves as a new model system for the study of microbial development.

A review of therapeutic angiogenesis and consideration of its potential applications to plastic and reconstructive surgery

The use of exogenous agents to stimulate the growth of new blood vessels into ischaemic tissue is a potentially revolutionary therapy in a wide variety of clinical specialties. Therapeutic angiogenesis research has been mostly confined to ischaemia of the heart and the lower limb. There has been relatively little research into the potential applications of the technique to plastic, reconstructive and burns surgery. In this paper, relevant published work is reviewed and potential applications of therapeutic angiogenesis to our specialty are considered.

Sentinel lymph node biopsy in malignant melanoma: a series of 100 consecutive patients

A consecutive cohort of 100 patients who had undergone sentinel lymph node biopsy (SLNB) was analysed retrospectively. Three areas were studied: success in finding the sentinel node(s); complications of the procedure; and extra costs incurred by SLNB. The sentinel node(s) were successfully identified in 98% of the lymph node basins biopsied. The overall complication rate was 33%. The additional cost of the procedure was estimated at 1420 pounds sterling per patient. SLNB can reliably identify the sentinel node. However there is a significant complication rate of the technique and considerable additional costs. SLNB requires further critical evaluation before it can be accepted as a standard treatment for patients with malignant melanoma.

The influence of experience and specialisation on the reliability of a common clinical sign

OBJECTIVES

To explore the influence of experience and specialisation on clinical judgement by comparing accuracy in diagnosing anaemia between a consultant general surgeon, a consultant ophthalmologist and their registrars.

PATIENTS AND METHODS

Conjunctival inspection of 101 patients, subsequent correlation with haemoglobin concentration.

MAIN OUTCOME MEASURES

Number of correct and incorrect diagnoses of anaemia.

RESULTS

54 patients were anaemic and 47 were not. Overall accuracy in diagnosing anaemia ranged from 0.61-0.69, sensitivity 0.52-0.65 and specificity 0.62-0.83. Agreements between pairs of examiners were 0.68-0.81, with kappa values of 0.36-0.60 when adjusted for chance agreement.

CONCLUSIONS

Neither experience nor specialisation significantly influenced our ability to diagnose anaemia, based on conjunctival inspection. Without critical analysis of clinical signs, we are unaware of their diagnostic limitations.

Malignant eccrine poroma of the hand

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Frostbite at the gym: a case report of an ice pack burn

The case is reported of a 59 year old woman who suffered a 1% total body surface area superficial partial thickness burn to her calf following the application of an ice pack. The cause, resulting injury, and subsequent management are discussed. It is possible that such injuries are common, but no similar reports were found in a literature search. Awareness of the risk of this type of injury is important for all those entrusted with advising patients on the treatment of minor soft tissue injuries.

Extracorporeal membrane oxygenation in the treatment of inhalation injuries

Smoke inhalation is a leading cause of death in burns patients. Conventional ventilation cannot always maintain adequate tissue oxygenation. Extracorporeal membrane oxygenation (ECMO) has rarely been used in the treatment of smoke inhalation injuries. ECMO is a proven therapy in severe neonatal respiratory failure and has also been used to good effect in the treatment of children and adults. We report the cases of two children who developed severe respiratory failure refractory to maximal ventilation, one case followed smoke inhalation alone, the other followed smoke inhalation and burns. Pre-ECMO PaO2/FIO2 ratios were 6.5 and 8 kPa, respectively. The patients were treated with veno venous ECMO for 72 and 144 h, respectively. The use of ECMO for respiratory failure due to smoke inhalation and thermal injury is discussed.

Mixed connective tissue disease presenting to the acute hand service

Mixed connective tissue disease is an autoimmune condition with a specific autoantibody. It commonly presents as Raynaud's disease and the patient is usually treated symptomatically. We present an unusual case of mixed connective tissue disease presenting as a acutely inflamed joint with considerable bony destruction.