Impact of topography and added TiN-coating on adult human dermal fibroblasts after seeding on titanium surface in-vitro

Complications of transcutaneous osseointegrated prosthetic systems (TOPS) focus on the metal-cutaneous interface at the stoma. Besides pain due to scare tissue as well as undefined neuropathic disorders, there is high evidence that the stoma presents the main risk causing hypergranulation and ascending infection. To restore the cutaneous barrier function in this functional area, soft-tissue on- or in-growth providing a vital and mechanically stable bio-artificial conjunction is considered a promising approach. In this study we assessed viability and proliferation of adult human dermal fibroblasts (HDFa) on modifications of a standard prosthetic titanium surface. Un-coated (TiAl6V4) as well as a titanium-nitrite (TiN) coated additive manufactured porous three-dimensional surface structures (EPORE®) were seeded with HDFa and compared to plain TiAl6V4 and polystyrene surfaces as control. Cell viability and proliferation were assessed at 24 h and 7 days after seeding with a fluorescence-based live-dead assay. Adhesion and cell morphology were analyzed by scanning electron microscopy at the respective measurements. Both EPORE® surface specifications revealed a homogenous cell distribution with flat and spread cell morphology forming filopodia at both measurements. Proliferation and trend to confluence was seen on un-coated EPORE® surfaces with ongoing incubation but appeared substantially lower on the TiN-coated EPORE® specification. While cell viability on both EPORE® specifications was comparable to plain TiAL6V4 and polystyrene controls, cell proliferation and confluence were less pronounced when compared to controls. The EPORE® topography allows for fibroblast adhesion and viability in both standard TiAl6V4 and - to a minor degree - TiN-coated specifications as a proof of principle.

Surgical Outcome and Oncological Survival of Osteofibrous Dysplasia-Like and Classic Adamantinomas: An International Multicenter Study of 318 Cases

BACKGROUND

Osteofibrous dysplasia-like adamantinoma (OFD-AD) and classic adamantinoma (AD) are rare, neoplastic diseases with only limited data supporting current treatment protocols. We believe that our retrospective multicenter cohort study is the largest analysis of patients with adamantinoma to date. The primary purpose of this study was to describe the disease characteristics and evaluate the oncological outcomes. The secondary purpose was to identify risk factors for local recurrence after surgical treatment and propose treatment guidelines.

METHODS

Three hundred and eighteen confirmed cases of OFD-AD and AD for which primary treatment was carried out between 1985 and 2015 were submitted by 22 tertiary bone tumor centers. Proposed clinical risk factors for local recurrence such as size, type, and margins were analyzed using univariable and multivariate Cox regression analysis.

RESULTS

Of the 318 cases, 128 were OFD-AD and 190 were AD. The mean age at diagnosis was 17 years (median, 14.5 years) for OFD-AD and 32 years (median, 28 years) for AD; 53% of the patients were female. The mean tumor size in the OFD-AD and AD groups combined was 7.8 cm, measured histologically. Sixteen percent of the patients sustained a pathological fracture prior to treatment. Local recurrence was recorded in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD. Metastatic disease was found in 18% of the AD cases and fatal disease, in 11% of the AD cases. No metastatic or fatal disease was reported in the OFD-AD group. Multivariate Cox regression analysis demonstrated that uncontaminated resection margins (hazard ratio [HR] = 0.164, 95% confidence interval [CI] = 0.092 to 0.290, p < 0.001), pathological fracture (HR = 1.968, 95% CI = 1.076 to 3.600, p = 0.028), and sex (female versus male: HR = 0.535, 95% CI = 0.300 to 0.952, p = 0.033) impacted the risk of local recurrence.

CONCLUSIONS

OFD-AD and AD are parts of a disease spectrum but should be regarded as different entities. Our results support reclassification of OFD-AD into the intermediate locally aggressive category, based on the local recurrence rate of 22% and absence of metastases. In our study, metastatic disease was restricted to the AD group (an 18% rate). We advocate wide resection with uncontaminated margins including bone and involved periosteum for both OFD-AD and AD.

LEVEL OF EVIDENCE

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

[Treatment concepts for complications after resection and defect reconstruction of pelvic tumours]

BACKGROUND

Partial pelvic resection, internal hemipelvectomy or sacrectomy as a result of bone sarcoma is still challenging. No matter what kind of reconstruction is used, there is still a much higher rate of complications in pelvic surgery compared to sarcoma surgery of the long bones.

OBJECTIVES

We describe the most common complications in pelvic sarcoma surgery and specific complications related to the reconstruction method. Handling strategies for these complications are specified.

METHODS

We performed a literature search and report our own experiences in the troubleshooting of pelvic surgery-related complications to gain an up-to-date overview of the state-of-the-art in management strategies.

RESULTS

Prospective randomized trials or meta-analyses on this topic are lacking. The literature search depicted that, besides local recurrence, deep infection after reconstruction is the most serious complication. An early revision with radical debridement has to be performed in order to save the reconstruction. In the case of a deep infection, the removal of all implants with a total loss of the reconstruction is often unavoidable. Therefore, an individualized risk-benefit analysis prior to surgery with respect to the type of reconstruction, or no reconstruction at all (hip transposition), together with the patient is advisable.

CONCLUSIONS

Complications-especially infections-after hemipelvectomy or sacrectomy are common. In the case of infection, in some cases, an early revision is the only chance to prevent a reconstruction from explantation.

[Complication management following resection and reconstruction of the upper limbs and shoulder girdle]

BACKGROUND

Sarcomas of the upper limbs commonly affect the proximal humerus or scapula. Complications after tumor resection and reconstruction are rare but cannot be neglected, particularly after tumor endoprosthetic reconstructions.

MATERIALS AND METHODS

The most common complications after resection of sarcomas of the upper limbs and shoulder girdle are described, and current knowledge regarding complication management is presented. Additionally, a selective literature search was performed, incorporating personal experiences.

RESULTS

Wound healing disorders and infections after tumor resection without specific reconstruction (clavicle resection, scapulectomy) usually respond well to conservative or surgical treatment. However, periprosthetic infections after reconstruction using a megaendoprosthesis constitute a severe and frequent complication, with an incidence of 5-10%. Two-stage implant replacement still represents the gold standard, although in selected cases, one-stage revision with retention of the prosthetic stem appears warranted. Secondary amputation as a result of periprosthetic infection is rare compared to the situation with infections of the lower limb. Mechanical complications necessitating surgical revision are mostly limited to joint dislocation after inverse total shoulder replacement (TSR). (Sub)luxation in anatomic TSR can be tolerated provided there is no tendency toward perforation of the skin in a asymptomatic patient. Biological reconstructions are most often indicated for reconstruction of intercalary defects of the humerus, and revision is necessitated most frequently by mechanical complications. Despite multiple surgical revisions, stable reconstructions and limb salvage can usually be achieved in the upper limb.

What is the Likelihood That Tumor Endoprostheses Will Experience a Second Complication After First Revision in Patients With Primary Malignant Bone Tumors And What Are Potential Risk Factors?

BACKGROUND

Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients.

QUESTIONS/PURPOSES

(1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision?

METHODS

Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models.

RESULTS

A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009).

CONCLUSIONS

Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Resection margins in soft tissue sarcomas]

BACKGROUND

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that arise from the mesenchymal tissue. STS can form anywhere in the human body, with the extremities being preferred sites of predilection.

TREATMENT

A fundamental pillar of treatment is the surgical resection of soft tissue sarcomas. The goal is always an R0 resection with a safety margin. There is no consensus in the literature about the desired tumor-free resection margin. The decisive factors for these resection margins are histopathology, presence of anatomical barriers (capsule, tendon, fascia, cartilage, periosteum) and possibilities of (neo-) adjuvant therapy.

DISCUSSION

References in the literature support the role of resection margins as a predictor of local recurrence. Regarding the role of resection margins in overall survival, available data is divergent. There are known prognostic factors that influence overall survival, such as histological subtype, tumor size, tumor grading, and presence of metastases. So far, several studies have attempted to quantify the margins of resection, but no consensus has been reached, and debates are ongoing. When analyzing all the results of the data in the literature, it seems appropriate to aim for a negative resection margin >1 mm including an anatomical border structure, if possible.

[Hemipelvectomy for pelvic sarcomas]

BACKGROUND

Hemipelvectomy is an important technique for the treatment of pelvic sarcomas.

OBJECTIVES

Presentation of the technical overview, as well as surgical and oncological outcomes of sarcoma patients treated with pelvic tumor resections and treatment recommendations.

METHODS

Retrospective analysis of 160 patients treated by pelvic tumor resection for chondrosarcoma between 1977 and 2014.

RESULTS

Chondrosarcoma was the most common diagnosis leading to pelvic tumor resection in this collective (38%). The mean patient age at operation was 49 years. 44 patients were treated for G1, 83 patients for G2 and 33 patients for G3 or dedifferentiated chondrosarcoma. The mean tumor diameter was ≥10 cm in 76.1% of cases. Limb salvaging operations were possible in 82.5% of patients. The most common reconstruction technique was hip transposition (38.7%). Clear resection margins were achieved in 86.9% (R0). Local recurrence was observed in 22.5%. Distant pulmonal metastasis was diagnosed in 25% of patients. Grading-specific survival was 81.8% for G1, 59% for G2 and 24.2% for G3 or dedifferentiated chondrosarcoma with a mean survival of 84.4, 89 and 69.4 months respectively.

CONCLUSIONS

Pelvic tumor resection with clear margins is the most important known positive predictive local factor affecting overall outcomes, in addition to uncontrollable factors such as grading and tumor size. Defect reconstruction depends on multiple factors such as patient age and adjuvant therapy. The stage of the disease has the greatest impact on overall survival rates and should be considered when contemplating pelvic tumor resections in sarcoma patients.

[Endoprostheses for stump formation after hip disarticulation]

BACKGROUND

Hip disarticulation is a psychologically and physically demanding procedure. However, it remains a therapeutical option whenever limb salvage proves impossible due to sarcoma, severe implant-associated infections or trauma. The stump lengthening procedure (SLP) is a surgical technique that allows partial salvage of the thigh through endoprosthetic proximal femur replacement after hip disarticulation, depending on the amount of viable soft tissue coverage. This leads to a more appealing visual appearance, facilitates prosthetic fitting and significantly improves limb function.

OBJECTIVES

Description of indications for SLP, surgical technique, presentation of clinical and functional outcomes.

METHODS

Review of applying literature and presentation of outcomes of our own SLP collective.

RESULTS

The risk of local recurrence does not increase after SLP compared to hip disarticulation. While the majority of patients can be fitted with an exoprosthesis, a walking aid is usually necessary for ambulation. Exoprostheses are usually worn throughout the entire day, and patients manage distances of a mean of 2000 metres, even if reconstruction lengths are less than 10 cm. Patients aged 50 years or older tend to wear their exoprosthesis for shorter periods of daywear and achieve significantly poorer functional scores. Postoperative complications are common at a rate of 52%. Periprosthetic infection (21%) and soft tissue perforation of the implant with subsequent implant-associated infection (14%) were the most severe complications observed.

CONCLUSIONS

The stump lengthening procedure poses a feasible alternative to classic hip disarticulation in patients with multiple prior operations and/or advanced stages of disease. It leads to satisfactory cosmetic and functional results without jeopardizing local tumor control. Stump perforation presents as the most common complication. Apart from improving the ability to sit down comfortably, both patients treated with a curative and palliative intent manage to ambulate using exoprostheses. With increasing age at the time of operation, walking aids are necessary for ambulation.

Ultra-short stem anchorage in the proximal tibial epiphysis after intercalary tumor resections: analysis of reconstruction survival in four patients at a mean follow-up of 56 months

INTRODUCTION

Tumors localized in the proximal tibial meta-diaphysis often lead to osteoarticular resections.

MATERIALS AND METHODS

In this study, we retrospectively reviewed four patients who underwent intercalary tumor resection and reconstruction using an ultra-short stem in the proximal tibial epiphysis, a procedure that to our knowledge has not been reported in literature so far.

RESULTS

At the time of operation, the mean patient age was 26.2 years. Three patients were male and one was female. Patients were diagnosed with osteosarcoma in two cases, Ewing's sarcoma and malignant fibrous histiocytoma of bone in one case each. In all cases, wide tumor resections were achieved (osteotomy 3-3.5 cm below the tibia plateau joint surface, mean resection length of tibial bone 18 cm) at a mean time of operation of 198.8 min. Two superficial wound-healing disorders occurred, leading to one surgical revision in each case. One local tumor recurrence occurred 12 months after operation in a patient who discontinued his adjuvant chemotherapy. This patient died of disease, 31 months after operation. Three patients are alive with no evidence of disease at a mean follow-up of 56 months. Walking is not impaired and light sports activities have been reported in all cases. The mean MSTS score is 28/30.

CONCLUSIONS

Therefore, we report this reconstruction technique to be considered for special indications where the functional outcome can be improved by preservation of the knee joint in tumors of the proximal meta-diaphyseal tibial region.

Selective arterial Embolisation of Aneurysmal Bone Cysts of the Sacrum: a promising Alternative to Surgery

PURPOSE

The sacrum is a rare but unfavourable location for Aneurysmal Bone Cysts (ABCs), surgical procedures aiming to achieve local tumour control can be mutilating. Aim of this study was to evaluate whether selective arterial embolisation (AE) of ABC of the sacrum is an effective treatment and might be an alternative to surgical treatment options.

MATERIALS AND METHODS

Between 2007 and 2011 six patients (mean age 13.7 years, range 8 - 18 years) with an ABC of the sacrum were treated by AE. Follow-up was performed by MRI-scans as well as clinical examination (mean 36.5 months, range 14 - 56 months).

RESULTS

No treatment related complications have been observed. AE resulted in devascularisation of ABC and led to local tumour control in all patients. A partial consolidation was noticed in three patients. Pain relief was achieved in five of six patients, neurological deficits dissolved. In two patients more than one embolization was necessary. In one of these patients due to exacerbation of pain a surgical decompression was performed.

CONCLUSION

AE of sacral ABCs can serve as an effective and safe treatment option. Thus it might be an alternative to potentially harmful surgical procedures. In case of ongoing tumour growth or pain recurrence AE can be repeated. In case of treatment failure surgical interventions are still possible.

KEY POINTS

• transarterial embolisation enables local tumour control in sacral ABCs. • transarterial embolisation of sacral ABCs is a safe procedure. • in case of tumour progression repetitive embolisations are possible and effective.

[Quality in Revision Arthroplasty: A Comparison between Claims Data Analysis and External Quality Assurance]

BACKGROUND

External quality assurance for revisions of total knee arthroplasty (TKA) and total hip arthroplasty (THA) are carried out through the AQUA institute in Germany. Data are collected by the providers and are analyzed based on predefined quality indicators from the hospital stay in which the revision was performed. The present study explores the possibility to add routine data analysis to the existing external quality assurance (EQS). Differences between methods are displayed. The study aims to quantify the benefit of an additional analysis that allows patients to be followed up beyond the hospitalization itself.

MATERIAL AND METHODS

All persons insured in an AOK sickness fund formed the population for analysis. Revisions were identified using the same algorithm as the existing external quality assurance. Adverse events were defined according to the AQUA indicators for the years 2008 to 2011.The hospital stay in which the revision took place and a follow-up of 30 days were included. For re-operation and dislocation we also defined a 365 days interval for additional follow-up. The results were compared to the external quality control reports.

RESULTS

Almost all indicators showed higher events in claims data analysis than in external quality control. Major differences are seen for dislocation (EQS SD: 1.87 vs. claims data [cd] SD: 2.06 %, cd+30 d: 2.91 %, cd+365 d: 7.27 %) and reoperation (hip revision: EQS SD: 5.88 % vs. claims data SD: 8.79 % cd+30 d: 9.82 %, cd+365 d: 15.0 %/knee revision: EQS SD: 3.21 % vs. claims data SD: 4.07 %, cd+30 d: 4.6 %, cd+365 d: 15.43 %). Claims data could show additional adverse events for all indicators after the initial hospital stay, rising to 77 % of all events.

CONCLUSIONS

The number of adverse events differs between the existing external quality control and our claims data analysis. Claims data give the opportunity to complement existing methods of quality control though a longer follow-up, when many complications become evident.

[Benign cartilage tumors. What should I do with incidental findings?]

BACKGROUND

The majority of benign bone tumors are cartilage tumors. Most common are enchondroma and osteochondroma. Often they represent incidental findings in radiological diagnostics. Thus, the incidence of cartilage tumors is unknown, as most of them are never diagnosed due to the absence of any symptoms.

OBJECTIVES

This article describes the diagnostic and therapeutic approach of benign cartilage tumors, focusing on incidental findings.

METHODS

The current knowledge and our own experience in the diagnostics and treatment of benign condroid tumors are presented.

RESULTS

As enchondroma represent most often the classic incidental finding without any symptoms or clinical findings, osteochondroma are often diagnosed in young patients by clinical examination showing a painless swelling that can increase in size according to skeletal growth. Most of these asymptomatic enchondroma and osteochondroma are so called "leave me alone lesions" and do not need any treatment, while other benign tumors (e.g., atypical cartilage tumors, chondroblastoma, chondromyxoidfibroma or osteochondroma with a cartilage cap of over 2 cm) need surgical treatment. These active or local aggressive tumors must be differentiated from the "leave me alone lesions". Additionally, patients with syndromes like Ollier disease (enchondromatosis), Maffucci syndrome or hereditary multiple exostosis must be examined and checked carefully as malignant degradation is possible.

CONCLUSION

As most cartilage tumors are benign and remain benign, inappropriate diagnostics or operative treatment just to provide security is obsolete. Plain X-ray is often enough for follow-up and other modalities only become necessary when symptoms occur.

Development of curative therapies for Ewing sarcomas by interdisciplinary cooperative groups in Europe

Curative therapies for Ewing sarcoma have been developed within cooperative groups. Consecutive clinical trials have systematically assessed the impact and timing of local therapy and the activity of cytotoxic drugs and their combinations. They have led to an increase of long-term disease-free survival to around 70% in patients with localized disease. Translational research in ES remains an area in which interdisciplinary and international cooperation is essential for future progress. This article reviews current state-of-the art therapy, with a focus on trials performed in Europe, and summarizes novel strategies to further advance both the cure rates and quality of survival.

[Interdisciplinary diagnostic and treatment of bone sarcomas of the extremities and trunk]

Contrary to the relatively common benign bone tumours and tumour-like lesions, bone sarcomas are rare malignancies with an incidence of 0.8 new cases per 100 000 persons per year. The most common primary malignant bone tumour is osteosarcoma, followed by chondrosarcoma and Ewing sarcoma. Osteosarcomas and Ewing sarcomas occur predominantly in children, adolescents and young adults, while chondrosarcomas primarily affect older patients. Most of the tumours are located in the extremities and the pelvis and in about 90% of the cases the surgical treatment can be performed by means of a limb-sparing wide resection. An endoprosthetic or biological reconstruction of the resulting defect, depending on several patient- und tumour-related factors, is usually necessary. Apart from the surgical treatment, patients with osteosarcoma and Ewing sarcoma require a pre- and postoperative chemotherapy, while Ewing sarcoma patients often undergo radiation therapy as well. Regular follow-up examinations are required after the completion of treatment for the early detection and management of local and/or systemic recurrences as well as treatment-related complications. An extensive experience in the clinical and imaging features as well as the interdisciplinary treatment of these tumours is necessary for optimal patient care. Without it mistakes are often made, which can have grave consequences on the patients' prognosis and functional outcome. The centralised treatment of these patients in specialised sarcoma centres is therefore recommended.

Interleukin-6 in two-stage revision arthroplasty

The purpose of this study was to evaluate whether the serum level of interleukin 6 (IL-6) could be used to identify the persistence of infection after the first stage of a two-stage revision for periprosthetic joint infection.

Between 2010 and 2011, we prospectively studied 55 patients (23 men, 32 women; mean age 69.5 years; 36 to 86) with a periprosthetic joint infection. Bacteria were identified in two intra-operative tissue samples during re-implantation in 16 patients. These cases were classified as representing persistent infection.

To calculate a precise cut-off value which could be used in everyday clinical practice, a 3 x 2 contingency table was constructed and manually defined.

We found that a serum IL-6 ≥ 13 pg/mL can be regarded as indicating infection: its positive-predictive value is 90.9%. A serum IL-6 ≤ 8 pg/mL can be regarded as indicating an absence of infection: its negative predictive value is 92.1%.

The serum IL-6 level seems to be a reasonable marker for identifying persistent infection after the first stage of a revision joint arthroplasty and before attempting re-implantation.

Cite this article: Bone Joint J 2015;97-B:71–5.

[New surgical treatment options for bone tumors]

Primary bone neoplasms can be classified into benign, locally/aggressive and rarely metastasizing and malignant tumors. Patients with benign tumors usually undergo surgical treatment in cases of local symptoms, mainly consisting of pain or functional deficits due to compression of important anatomical structures, such as nerves or blood vessels. Locally/aggressive and rarely metastasizing tumors exhibit an infiltrative growth pattern, so that surgical treatment is necessary to prevent further destruction of bone leading to local instability. Finally, the surgical treatment of malignant tumors is, with few exceptions, considered to be a prerequisite for long-term survival, either alone or in combination with systemic chemotherapy. Whereas the main objective of surgery in the treatment of benign tumors is relief of local symptoms with a minimum amount of damage to healthy tissue and minimizing the risk of local recurrence while ensuring bone stability in locally aggressive and rarely metastasizing tumors, the primary goal in the operative treatment of bone sarcomas is the resection of the tumor with clear surgical margins followed by defect reconstruction and the preservation of function. This review examines the current developments in the surgical treatment of primary bone neoplasms with respect to the management of the tumors and novel reconstructive options.

Effects of an exercise intervention on bone mass in pediatric bone tumor patients

The aim was to evaluate the effects of additional exercises during inpatient stays on bone mass in pediatric bone tumor patients. 21 patients were non-randomly allocated either to the exercise group (n = 10) or the control group (n = 11). DXA of the lumbar spine, the non-affected femur and both calcanei was performed after completion of neoadjuvant chemotherapy (baseline), as well as 6 and 12 months after baseline. Bone mineral content (BMC), bone mineral density (BMD) and height-corrected lumbar spine Z-scores were determined. Group changes after 6 and 12 months were compared by covariance analyses. Additionally, daily physical activities (PA) were assessed by means of accelerometry. After adjusting for initial age, height and weight, mean reductions in lumbar spine and femoral BMC were lower in the exercise group (not significant). Effect sizes during the observational period for lumbar spine and femur BMC were generally small (partial η² = 0.03). The exercise group demonstrated substantially higher PA levels in terms of gait cycles per day, per hour and moderate PA (activities above 40 gait cycles per minute). Additional exercises for bone tumor patients are feasible during hospitalization. Though the intervention did not influence BMC, it appeared beneficial regarding PA promotion with respect to volume and intensity.

Endoprosthetic replacement after extra-articular resection of bone and soft-tissue tumours around the knee

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan-Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%). These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

Pelvic reconstruction with compound osteosynthesis following hemipelvectomy: A clinical study

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing's sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing's sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.

Management of bone tumours in paediatric oncology

The management of bone tumours in paediatric oncology requires careful multidisciplinary planning due to the need for multimodal therapy approaches. The non-specific symptoms often lead to a delayed definitive diagnosis of a bone tumour. Imaging procedures are of major importance for an individualised and optimised treatment planning. They have to be carried out before any surgery, including biopsies. The introduction of multi-agent chemotherapy has led to a significant improvement in survival rates in patients suffering from Ewing's sarcomas and osteosarcomas. However, local therapy still remains indispensable in order to achieve long-term survival. For osteosarcoma, surgery remains the only adequate local therapy modality. Radiotherapy may be considered if surgery is not feasible. In these cases, high radiation doses need to be applied. The choice for local therapy modality is not as clear in patients with Ewing's sarcoma. Today, surgery is often preferred if a wide or at least marginal resection can be carried out. Additional radiotherapy is advised in patients with marginal/intralesional resection or poor histological response to induction chemotherapy. Definitive radiotherapy is recommended for inoperable lesions. In the future, new radiotherapy approaches, such as intensity-modulated radiotherapy or proton therapy, may yield better results with minor risks of late effects.

The treatment of locally recurrent chondrosarcoma

The aim of this study was to define the treatment criteria for patients with recurrent chondrosarcoma. We reviewed the data of 77 patients to examine the influence of factors such as the intention of treatment (curative/palliative), extent of surgery, resection margins, status of disease at the time of local recurrence and the grade of the tumour. A total of 70 patients underwent surgery for recurrent chondrosarcoma. In seven patients surgery was not a viable option. Metastatic disease occurred in 41 patients, appearing synchronously with the local recurrence in 56% of cases. For patients without metastasis at the time of local recurrence, the overall survival at a mean follow-up after recurrence of 67 months (0 to 289) was 74% (5 of 27) compared with 19% (13 of 50) for patients with metastasis at or before the development of the recurrence. Neither the type/extent of surgery, site of tumour, nor the resection margins for the recurrent tumour significantly influenced the overall survival.

With limited survival for patients with metastatic disease at the time of local recurrence (0% for patients with grade III and de-differentiated chondrosarcoma), palliative treatment, including local radiation therapy and debulking procedures, should be discussed with the patients to avoid long hospitalisation and functional deficits. For patients without metastasis at the time of local recurrence, the overall survival of 74% justifies an aggressive approach including wide resection margins and extensive reconstruction.

Intramedullary and total femur replacement in revision arthroplasty as a last limb-saving option

There has been a substantial increase in the number of hip and knee prostheses implanted in recent years, with a consequent increase in the number of revisions required. Total femur replacement (TFR) following destruction of the entire femur, usually after several previous revision operations, is a rare procedure but is the only way of avoiding amputation. Intramedullary femur replacement (IFR) with preservation of the femoral diaphysis is a modification of TFR. Between 1999 and 2010, 27 patients with non-oncological conditions underwent surgery in our department with either IFR (n = 15) or TFR (n = 12) and were included in this study retrospectively. The aim of the study was to assess the indications, complications and outcomes of IFR and TFR in revision cases. The mean follow-up period was 31.3 months (6 to 90). Complications developed in 37% of cases, 33% in the IFR group and 4% in the TFR group. Despite a trend towards a slightly better functional outcome compared with TFR, the indication for intramedullary femur replacement should be established on a very strict basis in view of the procedure’s much higher complication rate.

The influence of tumor- and treatment-related factors on the development of local recurrence in osteosarcoma after adequate surgery. An analysis of 1355 patients treated on neoadjuvant Cooperative Osteosarcoma Study Group protocols

BACKGROUND

Local recurrence (LR) in osteosarcoma is associated with very poor prognosis. We sought to evaluate which factors correlate with LR in patients who achieved complete surgical remission with adequate margins.

PATIENTS AND METHODS

We analyzed 1355 patients with previously untreated high-grade central osteosarcoma of the extremities, the shoulder and the pelvis registered in neoadjuvant Cooperative Osteosarcoma Study Group trials between 1986 and 2005. Seventy-six patients developed LR.

RESULTS

Median follow-up was 5.56 years. No participation in a study, pelvic tumor site, limb-sparing surgery, soft tissue infiltration beyond the periosteum, poor response to neoadjuvant chemotherapy, failure to complete the planned chemotherapy protocol and biopsy at a center other than the one performing the tumor resection were significantly associated with a higher LR rate. No differences were found for varying surgical margin widths. Surgical treatment at centers with small patient volume and additional surgery in the primary tumor area, other than biopsy and tumor resection, were significantly associated with a higher rate of ablative surgery.

CONCLUSIONS

Patient enrollment in clinical trials and performing the biopsy at experienced institutions capable of undertaking the tumor resection without compromising the oncological and functional outcome should be pursued in the future.

Expression of beta-catenin and p53 are prognostic factors in deep aggressive fibromatosis

AIMS

To determine the prognostic significance of beta-catenin in aggressive fibromatosis and to identify potential molecular markers for new targeted therapies.

METHODS AND RESULTS

A tissue microarray of 37 cases of deep aggressive fibromatosis was constructed and subjected to immunohistochemical analysis for beta-catenin, p53, smooth muscle actin (SMA), desmin, Ki67, c-erbB2, epidermal growth factor receptor (EGFR), c-kit, CD34 and S100. Complete clinical follow-up was available for 23 patients. Nuclear beta-catenin expression was associated with an increased rate of local tumour recurrence (60.0% 1-year and 0% 5-year event-free survival; P < 0.05). Furthermore, p53 expression was associated with an increased risk of tumour recurrence (50% 1-year event-free survival rate and 0% 5-years event-free survival rate, P < 0.05). The coexpression of p53 and beta-catenin was significantly correlated (P < 0.05). No statistically significant association was seen between MIB1 and p53 or beta-catenin expression, respectively. No expression of EGFR, c-erbB2 or c-kit was seen.

CONCLUSIONS

The overexpression of beta-catenin and p53 is associated with a decreased event-free survival in deep aggressive fibromatosis. Further studies are required to establish whether these findings can lead to an improvement in the treatment of this rare neoplasm.

The effect of rotationplasty on the ankle joint: long-term results

In patients with rotationplasty the biomechanical conditions in the ankle joint are altered dramatically. By displacement and reduction of the weight-bearing area of the joint, the stress affecting its cartilage is increased. The use of an exoprothesis results in skin and soft tissue irritation. Due to these biomechanical changes, a prearthrotic deformity or skin problems could be expected. The current study examines changes in 21 patients treated with rotationplasty (mean follow-up 13.5 years) because of a malignant bone tumour or a femoral segmental defect. Local tenderness, skin and soft tissue changes, problems with exoprostheses, and pain was assessed by clinical examination and documented. Osseous changes were evaluated by plain X-ray. A MRI-scan was also obtained in five patients. Hardened skin and blisters were located at the main loading areas of the rotated foot. These changes could be reduced by optimizing the exoprosthetic fit. Radiographically, a slight asymptomatic attenuation of the articular space was observed in four patients and a slight coexistent subchondral sclerosis with small osteophytes in one patient. No degenerative changes were observed on X-ray and no cartilaginous changes were observed on MRI. The results suggest that the foot is able to adapt to the load changes after this procedure and that rotationplasty does not cause an inevitable arthrosis in the ankle joint.

[Cartilage tumours of the bone. Diagnosis and therapy]

Primary malignant bone tumours are rare. The annual incidence of these tumours is 10 per 1 million. Nearly 30% of the primary malignant bone tumours are malignant cartilage tumours. The frequency of benign cartilage tumours cannot be definitely estimated because these tumours are normally clinically inapparent and therefore often diagnosed as an incidental finding. The cartilage tumours appear as benign lesions (e.g. chondroma), as borderline tumours (proliferative chondroma vs grade I chondrosarcoma) or as highly malignant chondrosarcoma (e.g. dedifferentiated chondrosarcoma). Commensurate with the different clinical and oncological manifestations of the cartilage tumours, there are wide differences in the treatment and clinical course of the individual tumour. This article discusses the problems in the diagnosis and treatment of cartilage tumours from an orthopaedic point of view.

Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity

BACKGROUND

Limb salvage is viable in the majority of patients with malignant bone tumors, but especially in case of extensive tumors and bad soft tissue conditions, it is challenging in upper extremity.

OBJECTIVES/METHOD

The clinical and radiological results of 21 patients, who had free vascularized fibular grafts (VFG), for diaphyseal (14), and epipyseal (7) defect reconstruction of the upper extremity, are presented. The indications for VFG were resection after osteosarcoma (9 cases), Ewings sarcoma (9 cases), chondrosarcoma (1 case), rhabdomyosarcoma (1 case), and 1 case of fibrous dysplasia. The 20 malignant tumors were staged as follows: 2a (1), 2b (18), 3 (1). The mean follow-up was 43.6 months (min 6.0-max 131.9). Functional results were described and graded quantitatively according to the MSTS-score.

RESULTS

Results were satisfactory with regard to pain, emotional acceptance, manual dexterity, and function. Lifting ability was decreased in two patients. Hypertrophy index was 31% (min 13%-max 71%). Main complications were fracture (5), pseudoarthrosis (4), prolonged wound healing (4), temporary nerve irritation (2), and deep infection (1). Re-operation was required in eight patients (12 operations).

CONCLUSION

VFG offers a good possibility for biological reconstruction of large skeletal defects, with an acceptable complication and re-operation rate. When conservative treatment of complications was not successful, further surgery led to recovery in the majority of cases.

Characteristics and outcome of infections associated with tumor endoprostheses

INTRODUCTION

Infection associated with prosthesis used after tumor resection is a common and serious complication. The purpose of the current retrospective study was to describe the course of infection in patients with a tumor endoprosthesis and the determination of risk factors associated with failed limb salvage.

MATERIAL AND METHODS

30 patients with an infection associated with a tumor endoprosthesis were investigated with regard to treatment strategies, number and type of revision operations, duration of hospital stay, determination of risk factors associated with failed limb salvage and final outcome.

RESULTS

Limb salvage related to the complication infection was achieved in 19 patients (63.3%). Two-stage reimplantation of an endoprosthesis was successful in 14 patients but subsequently failed in one patient. Out of 11 patients where limb salvage failed, an amputation was performed in 6 patients, a rotationplasty in 4, and stump lengthening procedure in 1 patient. A poor soft tissue condition was a significant (P<0.05) risk factor for failed limb salvage. No patient receiving chemotherapy with a poor soft tissue condition had limb salvage surgery. The mean number of revision operations per patients was 2.6. The mean duration of hospital stay was 68 days.

CONCLUSION

Infection associated with prosthesis is a serious complication and is involved with long hospitalization. Limb salvage failed mostly in the case of a poor soft tissue condition. In these cases repeated revision surgery should be avoided and ablative surgery recommended at an early stage. Rotationplasty is an alternative to amputation in the case of an infection of the proximal or distal part of the femur.

Treatment of primary malignant bone tumours of the distal tibia

We treated 15 patients with primary malignant bone tumours of the distal tibia of which 14 were treated by limb salvage surgery. Reconstructions were done by allografts with or without microvascular fibula transfer, by bone transport, by fibula transfer alone or by endoprosthetic replacement. The most successful methods were bone transport and endoprosthetic replacement. However, serious complications with deep infections leading to secondary amputation occurred in four patients and in all reconstruction groups. After a mean follow up of 7 years, no local recurrence occurred, and all patients were alive and free of disease. After radical resection, bone transport in defects less than 15 cm is a viable option. In larger defects in children, allograft with vascularised fibula is an acceptable alternative, but amputation still has a role in this group. In adults, endoprosthetic replacement with proper soft tissue coverage is a viable option in cases with large bony defects.

Rotationplasty type BI versus type BIIIa in children under the age of ten years

Type BI rotationplasty is currently indicated for children with tumours of the proximal femur whereas type BIIIa rotationplasty is reserved for those in which the entire femur has to be removed. Our aim was to compare these two types of rotationplasty and determine whether the knee should be preserved in children with tumours of the proximal femur. We compared the post-operative complications, oncological outcome, range of movement, Enneking score and radiographs of six children, who had undergone type BI rotationplasty with those of 12 who had undergone type BIIIa rotationplasty.

Patients with type BI rotationplasty had a mean Enneking score of 21.6 compared with 24.4 in those with type BIIIa rotationplasty, and worse mean results in all of the parameters investigated. We conclude that type BI rotationplasty has a worse functional outcome and more complications than type BIIIa rotationplasty in children under the age of ten years.

Endoprosthetic replacement of the humerus combined with trapezius and latissimus dorsi transfer: a report of three patients

INTRODUCTION

To improve the functional outcome after proximal and/or total humerus replacement, we combined the surgical procedures described by Bateman and Gerber.

MATERIALS AND METHODS

In three patients after wide tumor resection, endoprosthetic replacement with a modular tumor endoprosthesis (MUTARS System) was performed. In addition to a capsular and muscular reconstruction using the Trevira tube, a trapezius transfer onto the Trevira tube in combination with a latissimus dorsi transfer onto the Trevira tube was performed. The patients were immobilized for 6 weeks after surgery with an abductor cast.

RESULTS

After a follow-up of 1 year, there was no significant improvement of the shoulder function in comparison with patients who did not undergo the combined muscle transfer (control group n=16: mean abduction 37.5 degrees ; mean anteversion 35.0 degrees ; mean internal rotation 15.2 degrees ; mean external rotation 25.2 degrees ).

CONCLUSION

In our patients, the combination of the Gerber and the Bateman procedures did not improve the shoulder function in patients with proximal and/or total humerus replacements. Therefore, the functional results do not justify two separate approaches and a prolonged operation time.

Primary multifocal osseous Hodgkin disease: a case report and review of the literature

PURPOSE

Hodgkin disease (HD) typically involves the lymphatic system at one or more sites. Rarely, Hodgkin disease presents as an osseous lesion without involvement of lymph nodes. Therefore, the histologic diagnosis of osseous HD can be problematic. We present a rare case of multifocal osseous HD and a review the literature with special emphasis on treatment and prognosis.

METHODS

Osteomyelitis and lymphoma are the main differential diagnoses and can only be excluded histologically by the presence of Sternberg Reed cells or by immunohistochemical examinations. This case reports a 21-year old man with a Hodgkin lymphoma located at the proximal femur and the proximal tibia.

RESULTS

Staging studies revealed no other tumor manifestations. Regarding the Ann Arbor classification, the presented case should be a stage IV disease. The patient is without evidence of disease 4 years after curettage, local radiation therapy, and systemic chemotherapy despite the poor prognosis considering the Ann Arbor classification.

CONCLUSION

Reviewing the few reported cases, osseous HD must be distinguished from systemic HD with diffuse bone marrow involvement and from osseous metastases in advanced stage of disease because it seems to have a better prognosis.

Umkehrplastik im operativen Behandlungsplan der prim�r malignen Knochentumoren

Long-term survival of patients with a malignant bone tumor increased with a combined therapeutic approach using chemotherapy and possibly radiation therapy. Today up to 80% of patients with an osteosarcoma or Ewing's sarcoma survive. Therefore, it is important that the functional outcome and the quality of life are good after resection of the tumor. Before the era of endoprosthetic devices, rotationplasty, which was introduced in 1974 by Salzer for surgery of malignant bone tumors and modified by Winkelmann, protected many patients from an amputation. Although many authors favor limb-saving procedures today, rotationplasty obtained excellent functional and psychosocial results. Rotationplasty can be recommended in tumors with a large soft tissue component, in tumors located in the proximal femur and proximal tibia, and in children under 10 years of age. Furthermore, rotationplasty can be used in patients in whom a limb-salvage procedure failed because of infection or repeated changes of the endoprosthesis.

[Multiple enchondromatosis: Ollier's disease]

In contrast to solitary enchondroma,patients with multiple enchondromatosis of bone (Ollier's disease) get affected in childhood by bone swelling and growth retardation. In adults, the main problem is the risk of malign transformation up to 40%.Pain, increasing local tumor and thinning of the corticalis are the typical clinical and radiological signs of transformation to a low grade chondrosarcoma. There is no need for a regular radiological screening. If a malign transformation occurs,marginal or wide resection of the lesion should be performed.

[Options for surgical treatment of malignant bone tumors]

Beside the susceptibility to a (neo-) adjuvant therapy, the surgical margin is the most important prognostic factor in the treatment of primary malignant bone tumors. If adjuvant therapy is not possible, the outcome of the disease depends on the selected surgical treatment. Limb salvage has proven to be a safe procedure for local tumor control and provides good functional results. The surgeon has to consider the best surgical option depending on the site and size of the tumor but also depending on the patient's age and the overall prognosis. Surgical techniques and possible complications of the most common procedures in tumor surgery are described.

The multicentric epitheloid hemangioendothelioma of bone: a case example and review of the literature

Epitheloid hemangioendothelioma of bone is a rare primary bone malignancy. Diagnosis can be difficult for physicians who are not experienced with bone neoplasms. We also had difficulties in diagnosis and treatment in one of our patients with a multicentric epitheloid hemangioendothelioma involving the pelvis, left femur, and left tibia. We recommend a complete skeletal survey with magnetic resonance imaging because it can reveal previously undetected lesions on conventional radiographs. We performed an extraarticular resection of the hip joint including the spina iliaca anterior inferior, resection of the femur, and amputation of the lower leg. The femur was replaced by a modular endoprosthesis. The patient is provided with an above-knee prosthesis and is able to walk even longer distances with a cane 2 years after surgery. In our opinion it is necessary to perform a wide resection of this tumour in order to treat a patient with curative intention. Palliative radiotherapy should only be used for a non-resectable tumour or in metastatic disease. Chemotherapy is not a treatment option.