Navigation-assisted pelvic resections and reconstructions for periacetabular chondrosarcomas

OBJECTIVES

Survival in patients with chondrosarcomas has not improved over 40 years. Although emerging evidence has documented the efficacy of navigation-assisted surgery, the prognostic significance in chondrosarcomas remains unknown. We aimed to assess the clinical benefit of navigation-assisted surgery for pelvic chondrosarcomas involving the peri-acetabulum.

METHODS

We studied 50 patients who underwent limb-sparing surgery for periacetabular chondrosarcomas performed with navigation (n = 13) without it (n = 37) at a referral musculoskeletal oncology centre between 2000 and 2015.

RESULTS

The intralesional resection rates in the navigated and non-navigated groups were 8% (n = 1) and 19% (n = 7), respectively; all bone resection margins were clear in the navigated group. The 5-year cumulative incidence of local recurrence was 23% and 56% in the navigated and non-navigated groups, respectively (p = 0.035). There were no intra-operative complications related to use of navigation. There was a trend toward better functional outcomes in the navigated group (mean MSTS score, 67%) than the non-navigated group (mean MSTS score, 60%; p = 0.412). At a mean follow-up of 63 months, the 5-year disease-specific survival was 76% and 53% in the navigated and non-navigated group, respectively (p = 0.085), whilst the 5-year progression-free survival was 62% and 28% in the navigated and non-navigated group, respectively (p = 0.032).

CONCLUSION

This study confirmed improved local control and progression-free survival with the use of computer navigation in patients with limb-salvage surgery for periacetabular chondrosarcomas, although the advancement in other treatment modalities is required for improvement of disease-specific survival.

Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity

BACKGROUND/PURPOSE

Limb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation.

PATIENTS AND METHODS

Retrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018.

RESULTS

We analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3-9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010).

CONCLUSION

The prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation.

LEVEL OF EVIDENCE

Level III.

Delay in diagnosis of primary osteosarcoma of bone in children: Have we improved in the last 15 years and what is the impact of delay on diagnosis?

Aims

Examine: (1) If length of symptoms (LS) of children with osteosarcoma has improved in the last 15 years (2) Is delay in diagnosis related to the presence of metastases at presentation? (3) The impact of delay in diagnosis on prognosis.

Methods

250 consecutive patients with a diagnosis of osteosarcoma of bone treated at a national bone tumor treatment center between 2004 and 2018 were studied retrospectively. Three groups comprising those diagnosed over a five-year period (Group 1: 2004-2008, Group 2: 2009-2013; Group 3: 2014-2018) were studied.

Results

There were 126 males and 124 females with a mean age 12.2 years. The median LS for all patients was eight weeks. The median LS for Group 3 was significantly shorter than that for other groups. Development of metastasis during follow-up period was significantly less in Group 3 compared to the other groups. Overall survival gradually improved over the whole study period. There was no difference in the proportion presenting with metastases at diagnosis between the three groups. The survival rates in patients with LS shorter than 4 weeks was better than those with LS longer than 4 weeks, irrespective of the study time period.

Conclusions

There has been an improvement in the LS in patients diagnosed with osteosarcoma over the last 15 years. The development of metastasis during follow-up has reduced and the overall survival in the last 15 years has improved. LS longer than 4 weeks is associated with a poorer prognosis.

Bony Maturity of the Tibial Tuberosity With Regard to Age and Sex and Its Relationship to Pathogenesis of Osgood-Schlatter Disease: An Ultrasonographic Study

BACKGROUND

Although tensile force on an immature tibial tuberosity is considered the main cause of Osgood-Schlatter disease (OSD), the relationship between bony maturity and the pathogenesis of OSD remains obscure.

PURPOSE

To survey the bone maturation process of the tibial tuberosity by age and sex and clarify its relationship to OSD.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 731 Japanese basketball players aged 6 to 14 years were enrolled in this study. Ultrasonographic examination was performed in all participants (1462 knees) to evaluate the bony maturity of the tibial tuberosity by use of the Ehrenborg classification. The age- and sex-specific prevalence of each stage was investigated, and the prevalence of symptomatic OSD and its relationship with bony maturity were also assessed.

RESULTS

The process of bone maturation occurred 1 to 2 years earlier in female participants compared with male participants. Among female participants, 59.2% were already at the epiphyseal stage (stage E) by 10 years of age, and 47.4% were skeletally mature by 14 years. Among male participants, conversely, only 8.0% were at stage E by 10 years of age, and only 13.8% were skeletally mature by 14 years. The overall prevalence of symptomatic OSD was 6.8% (males, 6.4%; females, 7.2%), and the onset was 1 year earlier in the female participants. The prevalence of symptomatic OSD tended to increase with age and bony maturity, significantly increasing from the cartilaginous stage (stage C) to the apophyseal stage (stage A) (odds ratio, 9.48) and from stage A to stage E (odds ratio, 2.22).

CONCLUSION

The tibial tuberosity matures earlier in female participants. The risk of OSD is greater in stage A than stage C and in stage E than stage A. The risk of OSD increases with age in males but not in females.

Extra-articular resection of shoulder joint for bone sarcomas: Oncologic and limb-salvage outcomes of 32 cases compared with shoulder disarticulation and forequarter amputation

BACKGROUND AND OBJECTIVES

We aimed to identify the overall survival (OS), surgical complications, survival of reconstruction, and functional outcome of patients who underwent extra-articular resection of the shoulder joint for primary bone sarcomas. The OS and local recurrence rates in patients who underwent an amputation were also evaluated for comparison.

METHODS

Thirty-two patients treated between 1988 and 2017 were studied. The tumours were located in the humerus in 22 (69%) and scapula in 10 patients (31%). The resection types were Malawer type IV in 6 (19%), type V in 21 (66%), and type VI in 5 patients (15%). Reconstruction was performed with endoprosthesis in 23 patients (72%) while excision arthroplasty with the suspension of the humerus to the clavicle was performed in 9 patients (28%). Surgical margins were wide in 16, marginal in 8, intralesional in 3, and not available in 5 patients. During the study period, 40 patients underwent a forequarter amputation and 11 patients underwent a shoulder disarticulation.

RESULTS

The 5-year OS for patients who underwent extra-articular resection of the shoulder joint was 42% which was not statistically different compared with that of patients who underwent amputation (5-year OS = 30%; P = .091). The 5-year survival of the reconstruction was 94%, similar for endoprosthesis and excision arthroplasty. Local recurrence and complications developed in 6 (19%) and 10 patients (31%), respectively. Failures of the reconstruction requiring revision surgery occurred in two patients (6%). Limb salvage was achieved in 30 patients (94%). The median Musculoskeletal Tumour Society functional score was 61% (interquartile range, 57%-70%) and was similar in the endoprosthesis and excision arthroplasty group.

CONCLUSIONS

Extra-articular resection of the shoulder joint for bone sarcomas is an effective limb-salvage method. However, local recurrence remains a principal concern.

The adequacy of resection margin for non-infiltrative soft-tissue sarcomas

OBJECTIVES

There remains no consensus on what constitutes an adequate margin of resection for non-infiltrative soft-tissue sarcomas (STSs). We aimed to investigate the role of resection margins in millimetres for non-infiltrative STSs.

METHODS

502 patients who underwent surgical resection for a localized, non-infiltrative, high-grade STSs were studied. The prognostic significance of margin width was analysed and compared with the conventional R- and R+1-classification of surgical margins.

RESULTS

The overall local recurrence (LR) rate was 13%; 9% and 27% with negative and positive margins, respectively (p < 0.001). In patients with negative margins, the LR rates were greater than 10% in patients with margins ≤5.0 mm but reduced to less than 4% with margins >5.0 mm. When classified by the R- (or R+1)-classification, the 5-year cumulative LR incidence was 8%, 23% (16%), and 31% for R0, R1, and R2, respectively, which did not stratify the LR risk with negative margins. On the other hand, an accurate risk stratification was possible by metric distance; the 5-year cumulative incidence of LR was 29%, 10%, and 1% with 0 mm, 0.1-5.0 mm, and >5.0 mm, respectively (p < 0.001). This classification also stratified the LR risk in patients with or without adjuvant radiotherapy.

CONCLUSION

While a negative margin is essential to optimize local control in patients with non-infiltrative STSs, surgical margin width greater than 5 mm minimises the risk of local failure regardless of the use of adjuvant radiotherapy.

Is 2 mm a wide margin in high-grade conventional chondrosarcomas of the pelvis?

AIMS

Controversy exists as to what should be considered a safe resection margin to minimize local recurrence in high-grade pelvic chondrosarcomas (CS). The aim of this study is to quantify what is a safe margin of resection for high-grade CS of the pelvis.

METHODS

We retrospectively identified 105 non-metastatic patients with high-grade pelvic CS of bone who underwent surgery (limb salvage/amputations) between 2000 and 2018. There were 82 (78%) male and 23 (22%) female patients with a mean age of 55 years (26 to 84). The majority of the patients underwent limb salvage surgery (n = 82; 78%) compared to 23 (22%) who had amputation. In total, 66 (64%) patients were grade 2 CS compared to 38 (36%) grade 3 CS. All patients were assessed for stage, pelvic anatomical classification, type of resection and reconstruction, margin status, local recurrence, distant recurrence, and overall survival. Surgical margins were stratified into millimetres: < 1 mm; > 1 mm but < 2 mm; and > 2 mm.

RESULTS

The disease--specific survival (DSS) at five years was 69% (95% confidence interval (CI) 56% to 81%) and 51% (95% CI 31% to 70%) for grade 2 and 3 CS, respectively (p = 0.092). The local recurrence-free survival (LRFS) at five years was 59% (95% CI 45% to 72%) for grade 2 CS and 42% (95% CI 21% to 63%) for grade 3 CS (p = 0.318). A margin of more than 2 mm was a significant predictor of increased LRFS (p = 0.001). There was a tendency, but without statistical significance, for a > 2 mm margin to be a predictor of improved DSS. Local recurrence (LR) was a highly significant predictor of DSS, analyzed in a competing risk model (p = 0.001).

CONCLUSION

Obtaining wide margins in the pelvis remains challenging for high-grade pelvic CS. On the basis of our study, we conclude that it is necessary to achieve at least a 2 mm margin for optimal oncological outcomes in patients with high-grade CS of the pelvis. Cite this article: Bone Joint J 2021;103-B(6):1150-1154.

Missed causative tumors in diagnosing tumor-induced osteomalacia with (18)F-FDG PET/CT: a potential pitfall of standard-field imaging

OBJECTIVE

We describe herein two tumor-induced osteomalacia (TIO) cases for whom the causative lesions, located in their popliteal fossa, that were not identified in the standard field of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT), which usually images only the head, trunk, and proximal parts of the extremities.

CLINICAL PRESENTATION AND INTERVENTION

A 47 years old Japanese man with multiple pathological fractures due to osteomalacia, accompanied by muscle weakness, hypophosphatemia, and an elevation of alkaline phosphatase (ALP) was referred to our hospital. A (18)F-FDG PET/CT scan was performed, but no (18)F-FDG uptake was detected in the standard field of imaging. Magnetic resonance imaging revealed a small subcutaneous tumor (1.9×1.2×0.6cm) of the left posteriomedial knee, displaying uniform enhancement on gadolinium-enhanced T1-weighted fat-suppression imaging. The tumor was resected widely and diagnosed as phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). The other patient was a 31 years old Japanese woman with multiple pathological fractures, hypophosphatemia and elevated of ALP and was referred to our hospital on suspicion of TIO. Although the causative lesion was not identified in the standard field of (18)F-FDG PET/CT, (18)F-FDG uptake (SUVmax 2.9) was detected on the right knee in the additional whole-body (18)F-FDG PET/CT. Magnetic resonance imaging revealed a soft-tissue tumor (6.4×4.1×2.9cm) in the right posterior knee. Following biopsy, the tumor was marginally resected, and was pathologically diagnosed as PMTMCT.

CONCLUSION

Once patients are suspected to have TIO, a whole-body nuclear imaging study such as (18)F-FDG PET/CT should be performed, in order not to miss the hidden causative tumor, especially occurring in the distal extremities.

Establishment and Characterization of a Novel Human Clear-cell Sarcoma of Soft-tissue Cell Line, RSAR001, Derived from Pleural Effusion of a Patient with Pleural Dissemination

BACKGROUND/AIM

Clear cell sarcoma (CCS) of soft tissue is exceedingly rare and frequently exhibits aggressive behavior. Toward the goals of improving the aggressive course and poor prognosis of CCS, and establish new therapeutic methods, molecular genetic and biological characterizations of CCS are required.

MATERIALS AND METHODS

A new human CCS cell line (designated RSAR001) was established from the pleural effusion of a 44-year-old man with multiple lung metastases and pleural dissemination. The cell line and its xenograft were characterized including their morphology, immunohistochemistry, cytogenetic analysis, reverse transcription-polymerase chain reaction, direct sequencing analysis, and fluorescence in situ hybridization analysis.

RESULTS

The cell line has been maintained for over 12 months with more than 50 passages. RSAR001 cells exhibited a fascicular or diffuse growth pattern of short spindle- or oval-shaped cells with clear cytoplasm in heterotransplanted tumor, that was similar to the primary tumor. Immunophenotypically, RSAR001 cells in vitro and in vivo exhibited almost the same characteristics as the primary tumor. Cytogenetic analyses revealed a translocation, t(12;22)(q13;q12). Reverse transcription-polymerase chain reaction and direct sequencing analysis detected transcripts of the Ewing sarcoma breakpoint region 1-activating transcription factor 1 (EWSR1-ATF1) type 1 fusion gene. Fluorescence in situ hybridization using a break-apart probe for the EWSR1 gene on 22q12 showed a rearrangement.

CONCLUSION

These findings indicate that the RSAR001 cell line harbors EWSR1-ATF1 type 1 chimeric fusion gene, which is specific to CCS. RSAR001 cells might be useful for investigating biological behaviors and developing new treatments such as molecular-targeting antitumor drugs or immunological drugs for CCS.

Surgical outcomes and prognostic factors of non-metastatic radiation-induced sarcoma of bone

BACKGROUND

The survival and prognostic factors in non-metastatic, radiation-induced bone sarcomas of bone have not been described. Moreover, the quantitative data about surgical outcomes and complications after limb-salvage surgery versus amputation are quite limited.

METHODS

Twenty-five patients with non-metastatic, radiation-induced sarcoma of bone who underwent definitive surgery were analysed. Histological diagnosis was osteosarcoma in 19 and undifferentiated pleomorphic sarcoma in six. The definitive surgery was limb-salvage surgery in 15 patients and an amputation in 10.

RESULTS

The 5-year overall survival rate (OS) and the 5-year event-free survival rate (EFS) were 53% (95% CI 31%-70%) and 40% (21%-59%), respectively. Patients with wide or radical surgical margins (n = 13) showed significantly better OS compared with those with marginal (n = 8) or intralesional (n = 2) margins (5-year OS, radical or wide = 74%, marginal = 17%, intralesional = 0%, p = 0.044). The risk of local recurrence was significantly higher in the limb-salvage group compared to the amputation group (49% vs 0%, p = 0.011). OS and EFS were not significantly different between limb-salvage group and an amputation group (p = 0.188 and 0.912, respectively).

CONCLUSIONS

We believe non-metastatic, radiation-induced sarcoma of bone should be resected with the aim of achieving wide or radical margins. Although limb-salvage surgery was related to higher rates of local recurrence compared with those of the amputation group, OS and EFS were not different among two groups. Surgeons need to discuss the higher risk of local recurrence in limb-salvage surgery.

Primary dumbbell-shaped epidural myxoid liposarcoma of the thoracic spine: A case report and review of the literature

Myxoid liposarcoma frequently occurs in the deep soft tissue of the extremities, particularly in the thigh. The present study describes an extremely rare case of primary dumbbell-shaped epidural myxoid liposarcoma of the thoracic spine occurring in a 22-year-old woman. Although preoperative magnetic resonance imaging findings were thought to be compatible with schwannoma, the pathological diagnosis of the resected tumor was myxoid liposarcoma. The patient underwent three courses of adjuvant chemotherapy with doxorubicin and ifosfamide, and exhibited no symptoms or signs of local recurrence or metastasis for 18 months post surgery. The present case suggests that, when radiologically diagnosing spinal epidural tumors, clinicians should consider the possibility of myxoid liposarcoma.

Very late relapse of high-grade osteosarcoma: A case report and review of the literature

RATIONALE

Osteosarcoma is the most common primary malignant bone tumor in children. The prognosis of osteosarcoma has improved with the use of aggressive systemic chemotherapy in addition to surgery. The relapse of osteosarcomas is usually as lung metastasis observed within 2 to 3 years after the initial treatment. A relapse is rarely observed at >10 years.

PATIENT CONCERNS

We report the case of a 51-year-old Japanese man who was treated for high-grade osteosarcoma of the femur at 13 years old. He was referred to our hospital with a suspicion of primary lung cancer based on back pain, respiratory distress, and an abnormal mass on chest radiograph.

DIAGNOSES

Computed tomography-guided biopsy confirmed the lung lesion as a metastatic recurrence of high-grade osteosarcoma without local recurrence.

INTERVENTIONS

Chemotherapy was planned, but the patient's general condition rapidly deteriorated and thus palliative therapy was provided.

OUTCOMES

The patient died 2 months after the initial consultation.

LESSONS

The survival durations of osteosarcoma patients have been prolonged by recent progress in multimodality therapy, and thus clinicians as well as osteosarcoma patients should always keep in mind the possibility of very late relapse.

Chondrosarcoma of bone in children and adolescents

PURPOSE

Chondrosarcomas typically present in adults during the fifth to seventh decades and are rare in young patients. The biological behaviour and oncological outcomes may be different in children and adolescents.

METHODS

We retrospectively evaluated the outcomes of all patients with chondrosarcoma of bone who were younger than 18 years of age at the time of diagnosis and were treated at our centre between 1995 and 2018.

RESULTS

The 15 consecutive patients studied included nine male and six female cases, with a mean age at diagnosis of 13 years (7 to 17). The median follow-up was 117 months (30 to 277). The tumours were primary and secondary in ten and five patients, respectively. The tumours were central in 13 and surface in two patients. The tumour locations were the humerus in five, digits in five, femur in three, radius in one and pelvis in one patient. The histological grades were grade I in seven, grade II in seven and grade III in one patient. The surgical treatments were limb salvage in ten patients and ray amputation in five patients. The surgical margins were wide in eight, marginal in two and intralesional in five patients. All the patients were alive and continuously free of disease at the time of the last follow-up. No patient developed metastases or local recurrence.

CONCLUSION

Chondrosarcoma of bone in children and adolescent patients has a very good prognosis and is less aggressive compared with published outcomes in older patients.

LEVEL OF EVIDENCE

IV.

Biological reconstruction of the proximal femur after treatment of benign lesions: comparison of functional and oncological outcomes for children and adults

PURPOSE

Describe and compare the functional and oncological outcomes and complications between paediatric and adult patients after intra-lesional treatment of benign tumours of the proximal femur, stabilised with an autologous non-vascularised fibular strut graft (NVFSG).

METHODS

Retrospective review including 54 patients with a benign histopathological diagnosis treated between 1987 and 2018. The mean age at operation was 17 years (range, 3 to 37 years) with a median follow-up of 39.5 months (IQR 46.7 months). Patients were grouped according to their age at diagnosis (< 16 years versus ≥ 16 years). Data collection included weight-bearing status, Musculoskeletal Tumour Society (MSTS) score, local recurrence, revision surgery and complications. Local recurrence-free survival (LRFS) and revision-free survival (RFS) were calculated and compared between groups.

RESULTS

The median MSTS score for all patients was 98.3% (IQR 6.7%) without a statistically significant difference (p = 0.146) between both groups. The median time to full weight-bearing was 12 weeks (IQR 0 weeks). Local recurrence occurred in five (9%) patients. LRFS for all patients was 96% at 2 years and 88% at 5 years. Although local recurrence was more frequent in the paediatric group, LRFS did not significantly differ (p = 0.155, 95% CI 223.9 to 312.3) between both groups. Reoperation rate was 13% and was indicated for local recurrence, post-operative fracture, graft resorption and avascular necrosis. RFS for all patients was 90% at 2 years and 85% at 5 years. There was no statistically significant difference (p = 0.760, 95% CI 214.1 to 304.6) regarding RFS between both groups.

CONCLUSION

The use of an autogenous NVFSG after intra-lesional curettage of benign proximal femoral lesions allows for a biological, structural stabilisation without additional osteosynthesis, hastening weight-bearing and avoiding metalwork-related complications with minimal post-operative morbidity and complications and excellent functional and oncological outcome for both children and adults.

Talipes Equinus Deformity Caused by Fibrous Gastrocnemius Muscle Contracture After Direct Contusion in Football Players: Report of Two Cases

Two main causes of gastrocnemius contracture have been considered: 1) congenital deformities in pediatric patients, such as limb-length discrepancy, cerebral palsy, flatfoot, and clubfoot; and 2) secondary conditions such as immobilization for trauma or a nonfunctional limb. Talipes equinus deformity caused by fibrous gastrocnemius contracture after a direct muscle contusion is extremely rare. We describe 2 cases of talipes equinus deformity caused by fibrous gastrocnemius muscle contracture after a direct contusion in football players. Both of the players had a talipes equinus deformity with a severe restriction of ankle dorsiflexion, and a cord-like structure was observed at the proximal part of the lateral gastrocnemius head. Both patients' histological examinations revealed fibrous tendon-like tissue within the structure. After discission of the cord-like structures, the restriction of ankle dorsiflexion was completely resolved, and the patients were able to fully return to playing football without any discomfort in their calves.

Primary malignant lymphoma of the talus: A case report and review of the literature

Malignant lymphoma commonly occurs in adults, with a peak incidence between the seventh and ninth decades of life. Although malignant lymphoma usually occurs in the lymph nodes, it rarely occurs primarily in the bone. We herein describe an extremely rare case of primary malignant lymphoma of the talus in a 74-year-old man. Although plain radiographs showed no abnormality, gadolinium-enhanced magnetic resonance imaging (MRI) revealed a well-circumscribed intra- and extraosseous tumor of the talus. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/MRI revealed a marked increase of FDG uptake in the right ankle and the right inguinal lymph nodes. As the tumor was diagnosed as diffuse large B-cell lymphoma by core needle biopsy, combination therapy with chemo- and radiotherapy was initiated. The patient achieved complete remission, with no sign of recurrence at 8 months after initial chemoradiotherapy. Since primary malignant lymphoma of the bone is chemo- and radiosensitive and has a good prognosis, accurate staging by radiological investigation as well as correct pathological diagnosis by biopsy are required for optimal treatment.

Pelvic Ewing sarcoma: Should all patients receive pre-operative radiotherapy, or should it be delivered selectively?

BACKGROUND

Locally recurrent disease following surgical resection of Ewing sarcoma (ES) confers a poor prognosis. Limited evidence is available evaluating non-selective use of pre-operative radiotherapy (RT) for patients with pelvic ES and its effect on local control and survival.

PATIENTS AND METHODS

49 consecutive patients with pelvic ES were identified retrospectively from a prospectively collated database. Patients either received non-selective pre-operative RT and surgery (n = 27), or selective post-operative RT (n = 22) (surgery alone (n = 11) or surgery and post-operative RT (n = 11)).

RESULTS

Patients who had non-selective pre-operative radiotherapy appeared to have a higher LRFS, 88.0% compared to 66.5% in the selective RT group (p = 0.096, Kaplan Meier; p = 0.028, Chi-squared). Administration of non-selective, pre-operative RT to all patients with pelvic ES elevates the LFRS to that of the good responder group (≥90% tumour necrosis and margins, p = 0.880). There was no difference in metastasis-free survival, 60.0% and 54.5% (p = 0.728) and overall survival (OS), 57.7% and 63.6% (p = 0.893). The majority of pre-operative RT patients had both good necrosis (≥90%) (p = 0.003) and widely excised tumours, 81.5% vs 59.1% (p = 0.080). Tumour volume ≥250 ml was associated with worse LRFS (p = 0.045) and post-operative complications (p = 0.017). There may be improved LRFS (p = 0.057) with pre-operative proton-beam RT compared to surgery and selective post-operative RT.

CONCLUSION

Pre-operative photon or proton-beam RT to all pelvic ES may improve LRFS compared to the selective delivery of post-operative RT. Radiotherapy delivered to all patients results in a greater percentage of highly necrotic tumours at surgical excision, enabling a greater proportion of patients with wide resection margins.

Walking ability after resection of soft tissue sarcoma of the thigh and the sciatic nerve

Walking ability may be fairly well maintained after sciatic nerve resection combined with wide resection of soft tissue sarcoma, therefore, surgeons should not hesitate to perform sciatic nerve resection to achieve an adequate surgical margin.

Salvage Reconstruction With the Masquelet Technique Following Wide Resection for Chondrosarcoma of the Proximal Femoral Metaphysis: A Case Report

BACKGROUND

Bone reconstruction following a wide resection for a malignant musculoskeletal tumor remains challenging, especially for an intercalary defect following the resection of a metaphyseal lesion.

CASE REPORT

Here, we describe a surgical procedure using the Masquelet technique for the biological reconstruction of a huge subtrochanteric bone defect following failed pasteurized autologous bone grafting for a conventional chondrosarcoma of the proximal femoral metaphysis with a subtrochanteric pathological fracture. The patient, a 43-year-old Japanese male, was able to walk without a cane or a brace at 15 months after the final operation (International Society of Limb Salvage score, 86.7%).

CONCLUSION

This procedure should be considered as one of the reconstruction options following the wide resection of malignant bone tumors located in the metaphysis.

Effect of locomotive syndrome on knee pain in severe knee osteoarthritis

BACKGROUND

Locomotive syndrome (LS) presents symptoms related to decreased mobility due to musculoskeletal disorders. Knee osteoarthritis (KOA) is a significant public health concern linked to age-related musculoskeletal issues and is among the conditions contributing to LS. Age-related lower extremity muscle weakness exacerbates knee pain in KOA, but the impact of LS on knee pain is not clear, prompting the present investigation.

METHODS

We conducted a cross-sectional study of 76 participants (152 knee joints) with bilateral severe KOA scheduled for total knee arthroplasty. The study investigated the association between the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain subscale and LS using a multiple linear regression model, which included covariates and scaled estimated regression coefficients.

RESULTS

LS had a negative impact on KOOS pain (β: 0.35, 95 % confidence interval [CI]: 24.08; -6.05) (p < 0.05) and high self-efficacy had a positive impact (β: 0.25, 95%CI: 1.27; 16.34) (p < 0.05). Age, gender, BMI, Kellgren-Lawrence grade, and Central Sensitization did not influence KOOS pain.

CONCLUSIONS

Our findings demonstrate that LS negatively affected knee pain while self-efficacy positively affected it. LS has been attracting attention in relation to mobility, but the fact that it also affected the knee pain in severe KOA is an important clinical finding. Further research is required to focus on the relationship between the prevention and improvement of LS, and knee pain in severe KOA.

Atypical Fracture of the Scapular Spine: A Case Report

Atypical fractures are gaining attention as a severe potential side effect of long-term treatment with bone-modifying agents (e.g., bisphosphonate and denosumab) for osteoporosis. Most atypical fractures occur in weight-bearing bones; the femur is the most frequent site. Atypical fractures occurring in non-weight-bearing bones are extremely rare. We describe an atypical fracture of the scapular spine in a 92-year-old Japanese woman with osteoporosis who had been treated with minodronate for ~7 years. Although the dislocation of the fracture site remained after conservative treatment, there was no obstacle to her daily life.

A new era in the management of spinal metastasis

Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.