Can low-grade chondrosarcoma in flat bones be treated with intralesional curettage and cryotherapy?

BACKGROUND AND OBJECTIVES

Chondrosarcomas in flat bones are thought to be more aggressive in their behavior, and little is known about intralesional treatment outcomes of low-grade chondrosarcoma in these locations. We tried to find the differences between patients who had low-grade chondrosarcoma in their flat bones versus those with long bone involvement with regard to (1) disease outcome, (2) functional outcome, and (3) treatment complications.

METHODS

We retrospectively reviewed 44 patients with primary low-grade chondrosarcoma who were treated with intralesional curettage and cryotherapy. The patients were divided by location of tumor, group I (flat bones, seven patients) and group II (long bones, 37 patients).

RESULTS

The local recurrence rate was higher in group I with 5 years disease-free survival of 80.0% in group I and 97.0% in group II (p = 0.001). All recurrent cases were noted to have initially presented with soft tissue extension (Enneking stage IB). The mean Musculoskeletal Tumor Society score at the last follow-up was 21.7 in group I and 27.9 in group II (p = 0.045).

CONCLUSIONS

Intralesional curettage and cryotherapy for low-grade chondrosarcoma appear to be a safe and reasonable surgical option for patients with lesions confined to bone (Enneking stage IA).

LEVEL OF EVIDENCE

Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Quantifying muscle strength, size, and neuromuscular activation in adolescent and young adult survivors of musculoskeletal sarcoma: Identifying correlates and responses to functional strengthening

BACKGROUND

Medical and surgical treatment for musculoskeletal sarcoma (MSS) place survivors at risk for impairments in muscle properties including muscle strength, muscle size, and neuromuscular activation. The purpose of this study was to explore muscle properties, gross motor performance, and quality of life (QoL) and the changes in response to a 6-week functional strengthening intervention (PT-STRONG) in MSS survivors of childhood cancer (CCS).

METHODS

Eight lower extremity MSS CCS (13-23 years old) performed baseline testing and three completed PT-STRONG. Participants completed measurements of knee extension strength using handheld dynamometry, vastus lateralis (VL) and rectus femoris (RF) muscle thickness using ultrasonography at rest, and neuromuscular activation using electromyography during strength testing and a step-up task. Participants also completed gross motor and QoL assessments.

RESULTS

Compared with the non-surgical limb, MSS CCS had lower surgical limb knee extension strength, VL muscle thickness, and RF step-up muscle rate of activation (RoA). Compared with normative values, MSS CCS had decreased bilateral knee extension strength, gross motor performance, and physical QoL. Positive correlations among muscle strength, muscle thickness, and gross motor performance were identified. After PT-STRONG, MSS CCS had improvements in VL muscle thickness, VL and RF RoA duing step-up, gross motor performance, and physical QoL.

CONCLUSIONS

Positive association between larger muscle thickness with greater knee extension strength, and higher knee extension strength with better gross motor performance indicate that comprehensive physical therapy assessment and interventions that identify and target impairments in muscle properties to guide clinical decision making should be considered for MSS CCS into survivorship.

Radiolucent Implants for Fixation of Impending and Pathologic Fractures

Radiolucent implants offer theoretical advantages of increased ability to evaluate the fracture site for healing and recurrence and potentially less effect on radiation treatment, avoiding scatter. Their clinical utility and outcomes have yet to be proven in a well-designed randomized trial or large cohort study, although studies based on other indications have shown relative safety and they are approved by the US Food and Drug Administration for treatment of pathologic fractures. Further research is necessary to better understand when and how these implants should be implemented in practice. [Orthopedics. 2022;45(3):e115-e121.].

Metastatic prostate carcinoma: A rare presentation initially misdiagnosed as a rib fracture

Metastatic prostate carcinoma mainly occurs in bone as an osteoblastic lesion or lesions in the pelvis, spine, or chest wall. We present a unique case of a singular metastatic osteolytic lesion in the rib initially misdiagnosed as a fracture in a 61-year-old male. A single rib fracture in a patient with no history of trauma should raise suspicion for metastatic disease. We would encourage prostate cancer to be included in the differential diagnosis for an osteolytic lesion in a male over the age of 40. We review the current literature on this rare presentation of bone metastasis as well as the pathogenesis of metastatic prostate carcinoma as it relates to a solitary metastatic osteolytic lesion.

Imaging of spindle cell lipoma

AIM

To review the evaluation, diagnosis, and treatment of spindle cell lipoma (SCL) with emphasis on the location of these tumours and the spectrum of magnetic resonance imaging (MRI) and computed tomography (CT) appearances.

MATERIALS AND METHODS

The MRI and CT findings of 27 histopathologically proven SCLs were evaluated retrospectively. Imaging features evaluated included margins, percentage visible fat, MRI signal characteristics, oedema, and contrast enhancement patterns.

RESULTS

Patient ages ranged from 18 to 80 years with an average age of 56.5 years. Men were affected twice as frequently as women (M=18, F=9). SCLs ranged in size from 2 to 10 cm, with an average greatest dimension of 5.5 cm. Five lesions (19%) contained no visible fat on CT or MRI, and the leading differential diagnosis of high-grade soft-tissue sarcoma diagnosis was suggested by referring surgeons. Five lesions (19%) had <50% fatty areas, nine lesions (52%) demonstrated >50% but <90% fat at MRI or CT. Only three of 25 lesions (12%) had an appearance of a typical lipoma on unenhanced MRI sequences. All SCLs that were imaged with contrast medium (n = 18) demonstrated some degree of enhancement, with eight (44%) showing marked enhancement, four (22%) showing moderate, and six (33%) minimal enhancement.

CONCLUSION

SCLs have considerably variable imaging appearances and may have minimal or no visible fat at MRI or CT. Imaging features may make it difficult to distinguish this benign tumour from a potentially higher-grade malignant tumour.

Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma

Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.

Cytogenetic Single-Institution Analysis: 101 Consecutive Cases of Soft-Tissue Tumors of the Extremities

We summarize the results and clinical usefulness of cytogenetic analysis that is routinely performed for musculoskeletal tumors. We performed cytogenetic analysis and traditional histologic evaluation on 101 (51 malignant/ 50 benign) consecutive tumors that were surgically excised. The successful culture rate for cytogenetic analysis was 86% (87/101). Fifty-four percent (25/46) of clearly malignant tumors that were successfully cultured demonstrated significant clonal abnormalities. Fifty-one percent (21/41) of benign tumors that were cultured had significant cytogenetic clonal aberrations. Increased cellular ploidy (> 50 chromosomes/cell) was demonstrated in 14/46 malignant and 1/41 benign tumors that were successfully cultured. Hyperploidy was highly correlated with malignancy (p < 0.001); the only "benign" tumor was a multiply recurrent and giant cell, demonstrating histologic changes consistent with early sarcomatous transformation. As expected, cytogenetic abnormalities frequently occurred in malignant tumors. Surprisingly, almost half of the benign tumors had significant clonal cytogenetic aberrations. Consistent findings of extra chromosomes 5 and 7 in samples of pigmented villonodular synovitis strongly favored a neoplastic origin for this condition. Although the presence or absence of cytogenetic aberrations cannot be used to determine malignant potential, increased cellular ploidy is highly indicative of malignancy. Modern molecular genetics have become more popular, but cytogenetic analysis can be useful for classifying the malignant potential of recurrent and difficult to diagnose tumors of the musculoskeletal system.

Plantar Fibromatosis: Pathophysiology, Surgical and Nonsurgical Therapies: An Evidence-Based Review

Plantar fibromatosis (morbus Ledderhose), an extra-abdominal desmoid tumor of the plantar foot, is a rare benign hyperproliferative disorder of the plantar fascia with an unknown etiology. The main clinical characteristics include slow growing nodules on the medial and central bands of the plantar fascia, which may become painful and negatively affect ambulation. Most established conservative therapies today target symptomatic relief. As symptoms progress, therapies such as injections, shockwave ablation, radiation, and/or surgery may be required. This review aims to provide insight into the pathophysiology of this condition in addition to detailing current and investigational therapies for this disorder. Many therapies have been proven in similar conditions, which could lead to promising treatment options for plantar fibromatosis.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Glomus Tumor of the Sciatic Nerve: An Extraspinal Cause of Sciatica

Glomus tumors are small, benign tumors that arise from glomus bodies, structures found normally within the dermis that assist in temperature regulation via their vasoconstrictive response to sympathetic stimuli. Glomus tumors are found typically in the hand and are classically a cause of focal pain and temperature sensitivity. They often present as a small blue lesion seen under the nail bed of a finger or a toe and cause point tenderness. Glomus tumors of peripheral nerves are exceedingly rare and can lead to disability akin to compressive neuropathy when present. This case report explores the unusual presentation of a rare and large glomus tumor of the sciatic nerve. The patient presented with symptoms such as those mentioned above and was assumed to have sciatica emanating from spinal and neuroforaminal stenosis. Although she repeatedly and appropriately sought medical attention for her condition, she was improperly diagnosed and ultimately experienced a significant deterioration of her function, eventually undergoing an unnecessary surgical procedure. On referral to the authors' institution, the patient was evaluated and found to have a glomus tumor involving the sciatic nerve. This is the largest glomus tumor of a peripheral nerve that has been reported to date. Although the patient's presentation was insidious and her diagnosis was uncommon, this underscores the importance of developing a differential diagnosis based primarily on a thorough physical examination and, only then, correlating imaging to clinical findings. Additionally, given the atypical presentation and intractable course of this patient's condition, the examiner must consider neoplastic entities and space-occupying lesions as part of the differential diagnosis. [Orthopedics. 2018; 41(1):e151-e153.].

Long-term Results of Intercalary Endoprosthetic Short Segment Fixation Following Extended Diaphysectomy

Intercalary endoprosthetic reconstruction following diaphyseal resection of osseous tumors offers functional advantages through preservation of native joints adjacent to the resected defect. Use of such implants is restricted by the amount of bone available for stem fixation adjacent to the defect. This study aimed to determine whether short osseous segment fixation with acceptable outcomes and complication rate can be reliably achieved with a customized intercalary endoprosthesis following extended diaphysectomy. A retrospective review of prospectively collected data was performed on 6 patients receiving customized anchor plugs for short segment fixation with a double compressive osseointegration intercalary implant to reconstruct segmental defects. Five of the implants were augmented with cement to support fixation in metaphyseal bone. Patient age at surgery ranged from 12 to 86 years. At mean follow-up of 39 months, mean Musculoskeletal Tumor Society functional score was 26.3, with 5 of 6 patients achieving scores of 27 or greater. Stable fixation was achieved in all patients, with the shortest segment of bone 3.7 cm in length. Three mechanical implant failures requiring revision surgery occurred. No patient required revision of the entire implant, secondary adjacent joint replacement, or secondary amputation. No patient exhibited aseptic loosening, and no case was complicated by infection. Excellent functional outcomes were seen with follow-up out to 9 years. This suggests that cement-augmented double compressive osseointegration intercalary endoprosthetic reconstruction can extend the benefits of intercalary replacement to many patients who otherwise might require adjacent joint or physeal sacrifice. However, patients should be counseled on the high risk of implant failure with subsequent need for revision surgery. [Orthopedics. 2017; 40(6):e964-e970.].

Implant Fracture after Long-Stemmed Cemented Hemiarthroplasty for Oncologic Indications

Although a long-stemmed cemented hemiarthroplasty is frequently recommended for oncologic lesions of proximal femur, we have observed an alarming number of spontaneous stem fractures. The purpose of this retrospective study was to identify the associated risk factors for stem fractures in a study cohort of 60 (61 prostheses) during 1983-2007. At a mean follow-up of 41 months, 4/61 (6.6%) stems had fractured after a mean of 36 (12-92) months after surgery. All failed implants were Osteonics Omnifit (4/27; 14.8%) and multivariate analysis did not show any correlation with other studied variables. While the failures were successfully salvaged by conversion to a modular proximal femoral replacement, any implant failure in this population is devastating. Spontaneous onset of thigh pain in patients with long stems, particularly if associated with other risk factors, should raise suspicion of a fatigue fracture of the stem.

Surgical advances in bone and soft tissue sarcoma: 50 years of progress

As the American Society of Clinical Oncology celebrates its 50th anniversary, physicians can appreciate the significant advances made in the treatment of patients with sarcoma. Historically, these rare tumors have garnered great interest in the medical profession, due to their ability to reach extraordinary size, resulting in substantial deformities and disabilities. Fortunately, advances in surgical management, which have occurred concurrently with advances in imaging, diagnostic techniques, and both local and systemic adjuvant treatments, offer patients diagnosed with sarcoma significant hope for successful treatment and the expectation of a meaningful quality of life.

Long-term results of intralesional curettage and cryosurgery for treatment of low-grade chondrosarcoma

BACKGROUND

Data regarding outcomes following intralesional curettage and cryosurgical treatment of low-grade chondrosarcoma of bone are limited. The aim of this study was to assess the long-term oncologic and functional outcomes of two different cryosurgery techniques.

METHODS

Forty-three low-grade chondrosarcoma lesions (in forty-two patients) were treated with intralesional curettage and cryosurgery from June 1983 to October 2006. Eleven lesions were treated with cryoprobes and thirty-two were treated with the modified direct-pour Marcove technique. The mean patient age was 44.9 ± 11.3 years (range, 21.8 to 66.4 years), and the mean duration of follow-up was 10.2 ± 4.6 years (range, five to 22.5 years). Indications for treatment included a radiographic appearance consistent with a cartilage tumor with evidence of aggressive behavior. Pearson correlation and multivariate analyses were used to evaluate the relationships between predictive factors (including lesion size, soft-tissue extension, and location, patient age, cortical erosion, and presence of preoperative pain) and outcomes.

RESULTS

The mean overall Musculoskeletal Tumor Society (MSTS) score was 26.5 ± 3.1 (range, 17 to 30). There were four local recurrences, all in patients who had had tumor extension out of the bone with soft-tissue involvement at initial presentation. The mean time to recurrence was 2.4 ± 2.3 years (range, 0.6 to 5.6 years). No patients developed metastatic disease during the follow-up period. There were no differences between the cryoprobe and Marcove techniques with respect to the MSTS score, fracture, or local recurrence. A significant correlation between tumor recurrence and soft-tissue extension was found (r = 0.79). Kaplan-Meier survivorship, with freedom from recurrence as the end point, was 90.7%.

CONCLUSIONS

Intralesional curettage and cryosurgery for low-grade chondrosarcoma is safe and effective in selected patients. The presence of preoperative cortical breakthrough and soft-tissue extension was the strongest predictor of local recurrence following use of this technique.

LEVEL OF EVIDENCE

Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Bilateral synchronous tibial periosteal osteosarcoma with familial incidence

Multifocal or multicentric osteosarcoma (OS) has been described as tumor occurrence at two or more sites in a patient without visceral metastasis. These may be synchronous (more than one lesion at presentation) or metachronous (new tumor developing after the initial treatment). The incidence of multifocal OS has ranged from 1.5 to 5.4% in large series, with the synchronous type being rarer. Similarly, periosteal OS is another rare subtype of surface OS and constitutes less than 2% of all OS. An 11-year-old female was diagnosed with bilateral synchronous tibial periosteal OS, which were confirmed by CT-guided biopsies. After neoadjuvant chemotherapy, the patient underwent a staged wide local resection of the tumors. The defect was reconstructed with a proximal tibial replacement on the left side and autologous bone grafting on the right side. The patient did well after surgery and is free of disease at 5.5 years of follow-up. However, her brother also developed a right tibial periosteal osteosarcoma 4 years after her index surgery. Genetic analysis of blood sample from both patients showed a similar missense mutation in at least one allele of TP53 gene (exon 8). To the best of our knowledge, a case of bilateral 'synchronous' periosteal OS with a familial incidence has not been reported before.

Extensile posterior approach to the ankle with detachment of the achilles tendon for oncologic indications

BACKGROUND

We describe an extensile posterior approach to the ankle with detachment of the Achilles tendon for resection of extensive tumors involving the posterior ankle. To the best of our knowledge, this approach and its results have not been reported for oncologic indications.

METHODS

The surgical technique involved detachment of the Achilles tendon, tumor resection and reconstruction of the Achilles tendon with anchor sutures, and was used in six patients. The diagnosis was pigmented villonodular synovitis (5) and chondroblastoma (1).

RESULTS

At a mean of 6 (range, 2 to 10) years followup, all patients were free from tumor. All patients could walk an unlimited amount without any support. There were no problems with Achilles incompetence. The mean Musculoskeletal Tumor Society score was 97 ± 4.2% (range, 90 to 100) and the mean Achilles Tendon Total Rupture Score was 95 ± 5.7 (range, 87 to 100). One patient with screwed suture anchors had backing out of two anchors along with deep infection, requiring surgical debridement and anchor removal. One other patient had a post-traumatic small wound dehiscence which responded to local wound care.

CONCLUSION

Excellent exposure, tumor control and patient function were achieved by this approach in a select group of patients. The surgical technique described in this report offers another alternative for an extensile posterior approach to the ankle and/or subtalar joints.

Aseptic loosening rates in distal femoral endoprostheses: does stem size matter?

BACKGROUND

Long-term survival of distal femoral endoprosthetic replacements is largely affected by aseptic loosening. It is unclear whether and to what degree surgical technique and component selection influence the risk of loosening.

QUESTIONS/PURPOSES

We (1) established the overall failure and aseptic loosening rates in a tumor population and asked (2) whether stem diameter and specifically the diaphysis-to-stem ratio predicts loosening, and (3) whether resection percentage correlates with failure.

METHODS

We retrospectively reviewed the charts of all 93 patients in whom 104 distal femoral replacements had been performed from 1985 to 2008. We extracted the following data: age, need for revision surgeries, tumor diagnosis, adjunct treatment, and implant characteristics. We reviewed radiographs and determined stem size, bone diaphyseal width, and resection percentage of the femur. Kaplan-Meier survivorship was calculated for all implant failures and failures resulting from aseptic loosening. We evaluated radiolucent lines in patients with radiographic followup over 5 years. We identified independent risk factors for loosening. The minimum followup for radiographic evaluation was 5 years (mean, 12.7 years; range, 5.4-23.5 years).

RESULTS

Overall implant survival for 104 stems in 93 patients was 73.3% at 10 years, 62.8% at 15 years, and 46.1% at 20 years. Survival from aseptic loosening was 94.6% at 10 and 15 years and 86.5% at 20 years. Of the variables analyzed, only bone:stem ratio independently predicted aseptic failure. Patients with stable implants had larger stem sizes and lower bone:stem ratios than those with loose implants (14.5 mm versus 10.7 mm and 2.02 versus 2.81, respectively).

CONCLUSIONS

Our data suggest durability relates to selecting stems that fill the canal.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Metaphyseal and diaphyseal chondroblastomas

OBJECTIVE

Epiphyseal/apophyseal locations are important diagnostic radiological features of chondroblastomas (CB). Although the tumor may secondarily involve the metaphysis, reports of primary metaphyseal or diaphyseal CB without any epiphyseal or apophyseal involvement are exceptionally rare and frequently present as a diagnostic dilemma. The purpose of this study was to present seven cases of pure metaphyseal and/or diaphyseal CB along with a review of pertinent literature.

METHODS

A retrospective review of databases at two major referral centers revealed 390 cases of CB between 1960 and 2009. Out of these, seven histologically proven CB cases (1.8%) were found to be radiologically located in metaphysis and/or diaphysis, without involving the epiphysis and/or apophysis, and formed the study cohort.

RESULTS

There were four males and three females (age range 2-25 years). Locations included proximal femur (n = 1), distal femur (2), proximal humerus (2), clavicle (1), and proximal radius (1). All lesions showed marginal sclerosis. A periosteal reaction was seen in five cases (71%), cortical expansion in four cases (57%), and chondroid matrix in four cases (57%). A CT (two cases) demonstrated a matrix in both cases. An MR (one case) showed extensive perilesional edema. Bone scan (one case) showed intense uptake.

CONCLUSION

Pure metaphyseal and/or diaphyseal CB are exceedingly rare. A presumptive diagnosis may be considered in the appropriate age group in the presence of chondroid matrix, perilesional edema, periosteal reaction, and marginal sclerosis. Regardless of all the diagnostic possibilities, biopsy may still be required. However, knowledge of this entity will help make the final diagnosis and guide the correct treatment.

Implant design and resection length affect cemented endoprosthesis survival in proximal tibial reconstruction

Endoprosthetic reconstruction of the proximal tibia continues to pose many challenges. A retrospective analysis of 44 consecutive patients who underwent cemented proximal tibial replacement were included to investigate if patient age, surgical stage, type of implant, stem diameter, or resection length could be associated with implant failure. Fifteen patients (34%) suffered prosthetic failure, 7 due to infection. Prosthetic-related complications occurred in 13 patients (30%). Custom design prosthesis and longer length of resection were significantly associated with prosthesis survival in a Cox regression analysis (P = .001, hazard ratio = 8.747 and P = .044, hazard ratio = 1.217, respectively). Cemented proximal tibial replacement offers a functional knee, but reducing risk of complications still remains challenging. Prosthetic design and length of resection affect overall cemented endoprosthesis survival.

Telangiectatic osteosarcoma of the patella

Although osteosarcoma is the most common primary malignancy of bone, it has only been reported to arise from the patella in a handful of cases. Telangiectatic osteosarcoma accounts for <5% of all osteosarcomas, and it is distinguished histologically by spaces, often blood filled, separated by septa containing highly malignant cells and radiographically by a predominately lytic and/or expansile component. Telangiectatic osteosarcoma can be radiologically confused with aneurysmal bone cyst or giant cell tumor. A 22-year-old otherwise healthy man presented with increasing pain, swelling, and limited flexion of the right knee after failing physical therapy for anterior knee pain. Standard anteroposterior and lateral radiographs demonstrated a diffuse destructive process involving the majority of the patella (including loss of the inferior patellar cortex) and a lytic lesion of the proximal tibia. Apparent osteoid matrix was visible in the soft tissue extension along the inferior pole of the patella. A computed tomography scan of the chest showed 2 pulmonary nodules consistent with metastatic disease. Evaluation of core needle biopsy showed osteosarcoma with telangiectatic features. Given that the majority of the tumor involved the patella/extensor mechanism, it was clear that the tumor originated in the patella. This case presents the first published report of a telangiectatic osteosarcoma arising from the patella.

Aggressive Digital Papillary Adenocarcinoma in a 15-year-old Female

Aggressive digital papillary adenocarcinoma is a rare neoplasm of eccrine sweat gland origin that typically presents as a mass on a finger, toe, or the adjacent skin. Less than 100 cases have been reported. The majority of these cases are described in males in their fifth to seventh decade. We report a case of an aggressive digital papillary adenocarcinoma of the right second toe in a 15-year-old white female. A metastatic work-up, computed tomography of the chest, abdomen, pelvis, and a bone scan, was negative. The patient underwent amputation of the right second toe through the metatarsophalangeal joint. Two sentinel lymph nodes were biopsied and found to be negative for metastatic disease. One year after surgery the patient has no evidence of disease recurrence. To our knowledge, this is the youngest reported case of an aggressive digital papillary adenocarcinoma.

Distal femur resection with endoprosthetic reconstruction: a long-term followup study

The distal femur is a common site for primary and metastatic bone tumors and therefore, it is a frequent site in which limb-sparing surgery is done. Between 1980 and 1998, the authors treated 110 consecutive patients who had distal femur resection and endoprosthetic reconstruction. There were 61 males and 49 females who ranged in age from 10 to 80 years. Diagnoses included 99 malignant tumors of bone, nine benign-aggressive lesions, and two nonneoplastic conditions that had caused massive bone loss and articular surface destruction. Reconstruction was done with 73 modular prostheses, 27 custom-made prostheses, and 10 expandable prostheses. Twenty-six gastrocnemius flaps were used for soft tissue reconstruction. All patients were followed up for a minimum of 2 years. Function was estimated to be good or excellent in 94 patients (85.4%), moderate in nine patients (8.2%), and poor in seven patients (6.4%). Complications included six deep wound infections (5.4%), six aseptic loosenings (5.4%), six prosthetic polyethylene component failures (5.4%), and local recurrence in five of 93 patients (5.4%) who had a primary bone sarcoma. The limb salvage rate was 96%. Distal femur endoprosthetic reconstruction is a safe and reliable technique of functional limb sparing that provides good function and local tumor control in most patients.

Diagnosis of primary bone tumors with image-guided percutaneous biopsy: experience with 110 tumors

PURPOSE

To determine the diagnostic accuracy of image-guided percutaneous biopsy in 110 primary bone tumors of varying internal compositions.

MATERIALS AND METHODS

One hundred ten consecutive patients with primary bone tumors underwent biopsy with computed tomography (CT) or fluoroscopy. Ninety-one patients underwent surgical follow-up and 19 received medical treatment and underwent subsequent imaging studies. Final analysis of bone biopsy results included tumor type, malignancy, final tumor grade, biopsy complications, and effect on eventual treatment outcome.

RESULTS

Seventy-seven tumors were malignant and 33 were benign. Most common tumors at biopsy were osteosarcoma (n = 20), lymphoma (n = 18), chondrosarcoma (n = 16), and giant cell tumor (n = 16). Correct final diagnosis was attained in 97 (88%) patients. Sixty-three lesions were solid nonsclerotic; 26, sclerotic; and 21, lytic with cystic centers containing internal areas of fluid, hemorrhage, or necrosis. In six of 21 lesions with a predominant cystic internal composition, problems occurred in determining a final diagnosis. In 13 patients, definite correct diagnosis was not obtained with initial percutaneous bone biopsy. Of these patients, benign bone tumors were better defined with surgical specimens in seven, a diagnosis of malignancy was changed to that of another malignancy in four, and the diagnosis was changed from benign to malignant in two. Nine patients underwent open surgical biopsy. Seven of the difficult cases were of cystic tumors with hemorrhagic fluid levels visible at CT or magnetic resonance imaging. The only complication was a small hematoma.

CONCLUSION

Percutaneous biopsy of primary bone tumors is safe and accurate for diagnosis and grade of specific tumor. In cases with nondiagnostic biopsy, open-procedure biopsy is likely to be associated with similar diagnostic difficulties.

Survival after induction chemotherapy and surgical resection for high-grade soft tissue sarcoma. Is radiation necessary?

BACKGROUND

Induction chemotherapy can produce dramatic necrosis in sarcomas-raising the question of whether or not radiation is necessary. This study reviews the clinical outcome of a subset of patients with high-grade extremity soft tissue sarcomas (STS) who were treated with induction chemotherapy and surgical resection but without radiation.

METHODS

Nonmetastatic, large, high-grade STS of the pelvis and extremities were treated with intra-arterial cisplatin, adriamycin, and, after 1995, ifosfamide. After induction, oncologic resection and histologic evaluation were performed. Good responders with good surgical margins were not treated with radiation.

RESULTS

Thirty-three patients, with a median follow-up of 5 years, were included. Limb salvage rate was 94%. Median tumor necrosis was 95%. Four patients developed metastatic disease with three subsequent deaths. Two local recurrences occurred; both patients were salvaged with reresection and adjuvant external beam radiotherapy, although one died of metastatic disease 10 years later. Relapse-free and overall survival is 80% and 88% at 5 and 10 years by Kaplan-Meier analysis.

CONCLUSIONS

Intensive induction chemotherapy can be extremely effective for high-grade STS, permitting limb-sparing surgery in lieu of amputation. Radiation may not be necessary if a good response to induction chemotherapy and negative wide margins are achieved. All patients with large, deep, high-grade STS of the extremities should be considered candidates for induction chemotherapy.

The percutaneous needle biopsy is safe and recommended in the diagnosis of musculoskeletal masses

BACKGROUND

The purpose of this study was to analyze the role of percutaneous core needle biopsy in the diagnosis of musculoskeletal sarcomas.

METHODS

One hundred eighty-five biopsy procedures were performed on 161 musculoskeletal tissue masses suspected of being a sarcoma in 155 patients who underwent subsequent tumor resection. A percutaneous core needle biopsy was performed on all masses either in the clinic or under radiologic guidance. If an adequate diagnosis could not be made on the basis of this biopsy specimen, an open incisional biopsy was performed.

RESULTS

One hundred seventy-three core needle biopsy procedures were performed: 90 without radiologic guidance, 55 computed tomography guided, and 28 fluoroscopically guided. Twelve open incisional biopsies were performed. Eighty-three sarcomas, 67 benign mesenchymal tumors, and 11 metastatic epithelial tumors were identified. Analysis of the data reveals that only 7.4% of the masses required open biopsy. In 88.2% of the masses, a single percutaneous biopsy procedure was adequate, and no additional biopsy was necessary. There was a 1.1% rate of complications; none caused a change in the patient's treatment plan. There was a 1.1% rate of major diagnostic errors, none of which ultimately impacted on the patient's outcome. There were no unnecessary amputations. Percutaneous needle biopsy showed a positive predictive value of 100%, a negative predictive value of 82%, a sensitivity of 81.8%, and a specificity of 100%. The accuracy of a single-needle biopsy procedure to identify benign versus malignant lesions, exact grade, and exact pathology was 92.4%, 88.6%, and 72.7%, respectively.

CONCLUSIONS

The percutaneous needle biopsy was found to be extremely effective and safe for the diagnosis of musculoskeletal masses. This method allowed 88% of patients with suspected sarcomas to undergo a single-needle biopsy procedure before the initiation of definitive treatment. Patients undergoing percutaneous needle biopsy had lower rates of major diagnostic errors and complications than previously described for open biopsy. Open biopsy offered limited additional information when preceded by a needle biopsy, given that these tumors were difficult to identify even after final resection.

Reconstruction of hip stability after proximal and total femur resections

Dislocation is the most common complication after proximal and total femur endoprosthetic reconstruction. The current study describes a surgical technique of acetabular preservation and reconstruction of the joint capsule and abductor mechanism that recreates joint stability and avoids dislocation. Between 1980 and 1996, 57 patients underwent proximal or total femur resection with endoprosthetic reconstruction. Forty-six patients had primary sarcoma of bone, nine had other bone tumors, and two had metabolic bone disease. The acetabulum was spared and not resurfaced in all patients. Bipolar hemiarthroplasty was performed in 49 patients, and fixed unipolar hemiarthroplasty was performed in eight. Soft tissue reconstruction included Dacron tape capsulorrhaphy over the prosthetic neck, reattachment of the abductor mechanism to the prosthesis, and extracortical bone fixation. The average followup period was 6.5 years (range, 2-18.2 years). Dislocation occurred in only one (1.7%) patient, and aseptic prosthetic loosening occurred in three (5.3%) patients. Four patients with primary bone sarcoma had local recurrence, of whom one required amputation of the limb. The limb salvage rate was 98%. Eighty-one percent of the patients had a good to excellent functional outcome. Acetabular preservation, capsulorrhaphy, and reconstruction of the abductor mechanism recreate hip stability and avoid dislocation after proximal and total femur endoprosthetic reconstruction.

Extraspinal bone and soft-tissue tumors as a cause of sciatica. Clinical diagnosis and recommendations: analysis of 32 cases

STUDY DESIGN

Between 1982 and 1997, the authors treated 32 patients with sciatica who subsequently were found to have a tumor along the extraspinal course of the sciatic nerve.

SUMMARY OF BACKGROUND DATA

Extraspinal compression of the sciatic nerve by a tumor is a rare cause of sciatica. Signs and symptoms overlap those of the more common causes of sciatica (i.e., herniated disc and spinal stenosis).

OBJECTIVE

To characterize the unique clinical presentation of these patients and to formulate guidelines that may lead to early diagnosis.

METHODS

All pertinent clinical data and studies were reviewed retrospectively, and standard demographic data were collected for analysis.

RESULTS

These patients typically sought treatment for an insidious onset of sciatic pain that was constant, progressive, and unresponsive to change in position or bed rest. The mean time to final diagnosis was 11.9 months (median, 6 months). Seventeen patients were able to locate their pain to a specific point along the extraspinal course of the sciatic pain, and a mass was noted in 13 patients. Eighteen of these tumors were in the pelvis, 10 in the thigh, and 4 in the popliteal fossa and calf.

CONCLUSIONS

A high index of clinical suspicion is the key to early diagnosis of bone or soft-tissue tumors as a cause of sciatica; special attention should be given to pain pattern, physical examination of the entire course of the sciatic nerve, and selection of proper imaging studies. Routine anteroposterior plain radiography of the pelvis as part of the initial imaging screening process is recommended.

Cryosurgery in the treatment of giant cell tumor. A long-term followup study

Between 1983 and 1993, 102 patients with giant cell tumor of bone were treated at three institutions. Sixteen patients (15.9%) presented with already having had local recurrence. All patients were treated with thorough curettage of the tumor, burr drilling of the tumor inner walls, and cryotherapy by direct pour technique using liquid nitrogen. The average followup was 6.5 years (range, 4-15 years). The rate of local recurrence in the 86 patients treated primarily with cryosurgery was 2.3% (two patients), and the overall recurrence rate was 7.9% (eight patients). Six of these patients were cured by cryosurgery and two underwent resection. Overall, 100 of 102 patients were cured with cryosurgery. Complications associated with cryosurgery included six (5.9%) pathologic fractures, three (2.9%) cases of partial skin necrosis, and two (1.9%) significant degenerative changes. Overall function was good to excellent in 94 patients (92.2%), moderate in seven patients (6.9%), and poor in one patient (0.9%). Cryosurgery has the advantages of joint preservation, excellent functional outcome, and low recurrence rate when compared with other joint preservation procedures. For these reasons, it is recommended as an adjuvant to curettage for most giant cell tumors of bone.

Delayed reduction of traumatic knee dislocation. A case report and literature review

Knee dislocation after high energy trauma poses a major challenge to patients and treating physicians. The case presented documents the history and treatment of an unreduced posterior knee dislocation discovered 24 weeks after injury. Delayed surgical reduction was achieved, and satisfactory results were obtained with 22 months of followup of the patient. A detailed review of the literature found no comparable examples of longstanding traumatic dislocations of the knee but shed light on the probable cause for this unusual case. Close clinical followup, even after appropriate initial treatment of knee dislocations, is needed to eliminate similar occurrences.

Fit of the uncemented femoral component and the use of cement influence the strain transfer the femoral cortex

To determine whether the strain patterns produced in the femoral cortex after uncemented femoral arthroplasty are influenced by the fit of the component and whether these patterns are different from those of cemented components, cortical surface strains of cadaveric femurs subjected to loads simulating single-limb stance were measured before and after the insertion of uncemented, collared, straight-stemmed femoral components. The effects of press fit, loose fit, and precise fit of the components were evaluated and were contrasted to the strain patterns occurring after insertion of cemented femoral components. Strains varied markedly, depending on the fit of the stem of the uncemented femoral component within the isthmus. Nearly normal patterns of femoral strain were produced when the femoral stem was fit precisely at the isthmus, and the proximal femoral strains were similar to those of the intact state. In contrast, press fit and loose fit at the isthmus altered the strain patterns. The proximal medial axial strains were significantly reduced with press fit, to a mean of 39% of normal (p < 0.05), and increased with loose fit, to a mean of 141% of normal (p < 0.05). The prostheses fixed with cement showed a mean reduction in proximal medial axial strains to 33% of normal, which was comparable with press fit uncemented components even though the collar was well seated. Thus, our findings indicated that, in the immediate postoperative period, femoral strain patterns can be influenced by the fit of an uncemented component within the isthmus and by the use of cement.

High assembly strains and femoral fractures produced during insertion of uncemented femoral components. A cadaver study

The assembly strains produced in cadaver femurs during uncemented femoral arthroplasty were measured using strain gages and photoelastic coatings. Resecting the femoral neck, reaming the canal with power drills, and rasping with an optimal size rasp, as determined by preoperative radiographic templating, produced small assembly strains, up to 300 microstrain. Insertion of an optimal-size prosthesis after preparing the femoral canal with instruments the same size as the prosthesis produced moderate assembly strains, up to 1,000 microstrain. Half a millimeter press-fit of optimal prostheses produced larger assembly strains, up to 2,000 microstrain. Half a millimeter press-fit of a prosthesis that was also one size (1.0 mm) larger than that determined to be optimum produced even larger assembly strains (2,000-6,000 microstrain) and longitudinal linear fractures in the femoral cortex. Insertion of prostheses that were smaller than the rasps produced minimal strains in the femoral cortex. The magnitude of peak strains produced by press-fitting the femoral components and the small amounts of disparity between the size of the recess and the prosthesis necessary to produce these strains show the narrow range of tolerances available to the surgeon. Cementless femoral arthroplasty requires great care in preparing the femoral canal to the appropriate size as determined from preoperative templating, using accurate and precisely toleranced instrumentation and prosthetic components in order to avoid femoral fractures, yet obtain a stable fit.