Risk factors for local recurrence of upper extremity desmoid tumors

INTRODUCTION

Upper extremity (UE) desmoid tumors are locally aggressive neoplasms with high recurrence rates. Our study sought to analyze the demographics and treatment strategies of UE desmoid tumors and identify risk factors for recurrence.

MATERIALS AND METHODS

A retrospective review of 52 patients with histologically confirmed UE desmoid tumors treated at our institution between 1990 and 2015 was conducted. Survival was assessed using the Kaplan-Meier method and the Cox proportional hazards model was used for risk factor analysis.

RESULTS

For the entire cohort, median age was 40 (29-47) years, 75% were female, and 48% had local recurrence. The median tumor size was 45 (15-111) cm3 on imaging. Twenty-two patients had a previous resection. The most common treatments were surgery alone (50%) and surgery with adjuvant radiotherapy (21%). Tumor size ≥5 cm and tumor volume ≥40 cm3 on imaging were associated with increased recurrence (p = 0.006 and p = 0.005, respectively). Age and sex were not associated with local recurrence. Patients with a tumor size ≥5 cm were 2.6 times more likely to present with recurrence. At the 10-year mark, a lower local recurrence-free survival was seen in patients with tumors ≥5 cm (72.2% vs. 36.3%, p = 0.042) or ≥40 cm3 (67.2% vs. 32.7%, p = 0.034).

CONCLUSION

In our study, only tumor dimensions appeared to modify recurrence risk.

Debridement, Antibiotics, and Implant Retention (DAIR) Plus Offers Similar Periprosthetic Joint Infection Treatment Success Rates to Two-Stage Revision in Oncologic Megaprosthesis

BACKGROUND

Prosthetic joint infections (PJIs) after megaprosthesis implantation are associated with high rates of treatment failure and amputation. Our study analyzed PJI treatment success rates by surgical strategy and assessed risks of reinfection and amputation.

METHODS

We retrospectively analyzed the outcomes of patients diagnosed with PJI after undergoing megaprosthesis implantation for oncologic indications. The 2011 Musculoskeletal Infection Society criteria were used to define PJI. Reinfection, reoperation, and amputation for PJI recurrence were assessed. A total of 67 patients with megaprosthesis PJIs were included. There were fourteen patients who were treated with debridement, antibiotics, and implant retention (DAIR), 31 with DAIR plus (DAIR with modular component exchange and stem retention), and 21 with two-stage revisions. Kaplan-Meier estimates were used for survival analyses and Cox proportional hazards for risk factor analyses.

RESULTS

The two-year reinfection-free survival was 25% for DAIR and 60% for DAIR plus or two-stage revision (P = .049). The five-year amputation-free survival was 84% for DAIR plus or two-stage revision, and 48% for DAIR (P = .13). Reinfection-free, reoperation-free, and amputation-free survival were similar between DAIR plus and two-stage revision at the 2- and 5-year marks. Body mass index ≥30 (hazard ratio [HR] = 2.65) and chronic kidney disease (HR = 11.53) were risk factors for reinfection. Treatment with DAIR plus or two-stage revision (HR = 0.44) was a protective factor against reinfection.

CONCLUSIONS

A DAIR was associated with high rates of treatment failure and higher amputation rates than DAIR plus or 2-stage surgery. A DAIR plus was not inferior to 2-stage revision clearing a PJI and might be performed in patients who cannot withstand two-stage revision surgery.

What Are the Functional and Surgical Outcomes of Tibial Turnup-plasty for Salvage in Patients With Chronic Lower Extremity Infection?

BACKGROUND

Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown.

QUESTIONS/PURPOSES

(1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty?

METHODS

A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive.

RESULTS

The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50.

CONCLUSION

The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Primary Clear Cell Sarcoma of Bone: Clinicopathologic Study of a Rare Presentation

Clear cell sarcoma (CCS) is an uncommon malignant mesenchymal neoplasm of young adults with a predilection for tendons and aponeuroses of distal extremities, a distinctive nested growth pattern, melanocytic differentiation, and usually an EWSR1::ATF1 fusion. Distinction from melanoma can be challenging but is critical for clinical management. Rare cases of primary bone CCS have been reported. The purpose of this study was to evaluate the clinicopathologic features of a series of primary bone CCS. Three cases of primary bone CCS were identified out of 140 CCS diagnosed between 2010 and 2021. Two patients were female, and 1 patient was male; ages were 19, 47, and 61 years. All tumors arose in the long bones of the extremities (femur, humerus, fibula). Two tumors also involved regional lymph nodes at presentation. Two showed characteristic histologic features, in the form of nests and fascicles of uniform epithelioid to spindle cells with prominent nucleoli and pale eosinophilic to clear cytoplasm; 1 tumor showed sheet-like growth, unusual focal pleomorphism, and more notable nuclear atypia. By immunohistochemistry, S100 protein was positive in 2/3 cases, SOX10 in 3/3, HMB-45 in 2/3, MiTF in 2/2, and melan A in 1/3. All cases were confirmed to harbor EWSR1 rearrangement and EWSR1::ATF1 fusion or t(12;22). On follow-up, all 3 patients developed metastases and died of disease, 5, 18, and 21 months after diagnosis. In summary, CCS rarely presents in the skeleton. At such locations, distinction from metastatic melanoma is particularly challenging. Clinical and pathologic features are similar to conventional CCS of soft tissue. Primary bone CCS may pursue an aggressive clinical course.

Prognostic Significance of Percentage and Size of Dedifferentiation in Dedifferentiated Chondrosarcoma

Dedifferentiated chondrosarcoma is rare, aggressive, and microscopically bimorphic. How pathologic features such as the amounts of dedifferentiation affect prognosis remains unclear. We evaluated the percentages and sizes of dedifferentiation in a consecutive institutional series of dedifferentiated chondrosarcomas from 1999 to 2021. The statistical analysis included cox proportional hazard models and log-rank tests. Of the 67 patients (26 women, 41 men; age, 39 to >89 [median 61] years; 2 with Ollier disease), 58 presented de novo; 9 were identified with conventional chondrosarcomas 0.6-13.2 years (median, 5.5 years) prior. Pathologic fracture and distant metastases were noted in 27 and 7 patients at presentation. The tumors involved the femur (n = 27), pelvis (n = 22), humerus (n = 7), tibia (n = 4), scapula/ribs (n = 4), spine (n = 2), and clivus (n = 1). In the 56 resections, the tumors ranged in size from 3.5 to 46.0 cm (median, 11.5 cm) and contained 1%-99.5% (median, 70%) dedifferentiated components that ranged in size from 0.6 to 24.0 cm (median, 7.3 cm). No correlation was noted between total size and percentage of dedifferentiation. The dedifferentiated components were typically fibrosarcomatous or osteosarcomatous, whereas the associated cartilaginous components were predominantly grade 1-2, rarely enchondromas or grade 3. The entire cohort's median overall survival and progression-free survival were 11.8 and 5.4 months, respectively. In the resected cohort, although the total size was not prognostic, the percentage of dedifferentiation ≥20% and size of dedifferentiation >3.0 cm each predicted worse overall survival (9.9 vs 72.5 months; HR, 3.76; 95% CI, 1.27-11.14; P = .02; 8.7 vs 58.9 months; HR, 3.03; 95% CI, 1.21-7.57; P = .02, respectively) and progression-free survival (5.3 vs 62.1 months; HR, 3.05; 95% CI, 1.13-8.28; P = .03; 5.3 vs 56.6 months; HR, 2.50; 95% CI, 1.06-5.88; P = .04, respectively). In conclusion, both the percentages and sizes of dedifferentiation were better prognostic predictors than total tumor sizes in dedifferentiated chondrosarcomas, highlighting the utility of their pathologic evaluations.

Venous Thromboembolic Event Following Soft Tissue Sarcoma Diagnosis is Associated with the Development of Pulmonary Metastasis

BACKGROUND

This study aimed to investigate whether venous thromboembolic events (VTEs) are clinically relevant predictors of pulmonary metastatic disease in patients with soft tissue sarcomas (STSs).

PATIENTS AND METHODS

In this retrospective cohort analysis, we included patients with STS surgically treated for sarcoma between January 2002 and January 2020. The primary outcome of interest was development of pulmonary metastasis after non-metastatic STS diagnosis. Tumor depth, stage, type of surgical intervention, chemotherapy, radiation therapy, body mass index, and smoking status were collected. Episodes of VTEs following STS diagnosis, including deep vein thrombosis, pulmonary embolism, and other thromboembolic events, were also obtained. Univariate analyses and multivariable logistic regression were used to identify potential predictors for pulmonary metastasis.

RESULTS

We included 319 patients with mean age of 54.9 ± 16 years. Thirty-seven patients (11.6%) had VTE after STS diagnosis, and 54 (16.9%) developed pulmonary metastasis. Univariate screening revealed pulmonary metastasis, pre- and postoperative chemotherapy, smoking history, and VTE after surgery as potential predictors of pulmonary metastasis. Multivariable logistic regression revealed smoking history [odds ratio (OR) 2.0, confidence interval (CI) 1.1-3.9, P = 0.04] and VTE (OR 6.3, CI 2.9-13.6, P < 0.001) as independent risk factors for predicting pulmonary metastasis in patients with STS, after adjusting for the factors in the univariate screening as well as age, sex, stage of the tumor, and neurovascular invasion.

CONCLUSIONS

Patients with VTE after STS diagnosis have an odds ratio of 6.3 for developing metastatic pulmonary disease compared with patients without venous thromboembolic events. Smoking history was also associated with future pulmonary metastases.

The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up

BACKGROUND CONTEXT

Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up.

PURPOSE

The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up.

STUDY DESIGN/SETTING

Retrospective, single-center, cohort study.

PATIENT SAMPLE

Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral.

OUTCOME MEASURES

The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS).

METHODS

Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method.

FUNDING STATEMENT

No funding was obtained for this work.

RESULTS

Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810).

CONCLUSION

Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.

Clinical Implications and Treatment Strategies for ESR1 Fusions in Hormone Receptor-Positive Metastatic Breast Cancer: A Case Series

In hormone receptor-positive metastatic breast cancer (HR+ MBC), endocrine resistance is commonly due to genetic alterations of ESR1, the gene encoding estrogen receptor alpha (ERα). While ESR1 point mutations (ESR1-MUT) cause acquired resistance to aromatase inhibition (AI) through constitutive activation, far less is known about the molecular functions and clinical consequences of ESR1 fusions (ESR1-FUS). This case series discusses 4 patients with HR+ MBC with ESR1-FUS in the context of the existing ESR1-FUS literature. We consider therapeutic strategies and raise the hypothesis that CDK4/6 inhibition (CDK4/6i) may be effective against ESR1-FUS with functional ligand-binding domain swaps. These cases highlight the importance of screening for ESR1-FUS in patients with HR+ MBC while continuing investigation of precision treatments for these genomic rearrangements.

Comparison of carbon fibre and titanium intramedullary nails in orthopaedic oncology

Aims

Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture.

Methods

This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively.

Results

Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival.

Conclusion

This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation.

Level of evidence: III, Retrospective study

Cite this article: Bone Jt Open 2022;3(8):648–655.

Sclerostin immunohistochemical staining in surgically treated giant cell tumor of bone

BACKGROUND

Giant cell tumor of bone (GCTB) is a destructive lesion with a high potential for recurrence. RANK-ligand targeted therapy has provided promising, yet mixed results. Sclerostin (SOST) inhibition results in a net anabolic response and is currently used in the treatment of osteoporosis. The application to GCTB is unknown.

OBJECTIVES

We sought to determine if GCTB stained for SOST on immunohistochemistry and correlate its expression with predictor variables.

METHODS

All patients at a single institution undergoing surgery for GCTB between 1993 and 2008 with a minimum of 6 months follow-up were included. Primary outcomes included the presence of SOST staining, secondary outcomes included the correlation of patient and tumor-specific predictor variables.

RESULTS

SOST antibody staining of any cell type was present in 47 of 48 cases (97.9%). Positivity of the stromal cells was present in 39 of 48 cases (81.3%) and was associated with radiographic aggressiveness (p = 0.023), symptomatic presentation (p = 0.032), prior surgery (p = 0.005), and patient age (p = 0.034). Positivity of giant cells was present in 41 of 48 cases (85.4%) and was not significant with predictive factors.

CONCLUSIONS

Sclerostin staining in GCTB is a novel finding and warrants further research to define the role of sclerostin as a prognostic factor and therapeutic target.

Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures

BACKGROUND

The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations.

METHODS

We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test.

RESULTS

The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization.

CONCLUSIONS

Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk.

LEVEL OF EVIDENCE

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

Primary and Metastatic Bone Tumors of the Patella: Literature Review and Institutional Experience

BACKGROUND

Patellar tumors are rare but certainly must be considered in the differential diagnosis in patients with knee pain. Diagnosis can be challenging as often patellar neoplasms are confused with benign conditions and their clinical presentation is usually not specific. We performed an institutional and a literature review to determine what are the most common tumors affecting the patella and what is the best management.

METHODS

This is a case series from our institution including all patients with benign, malignant, and metastatic patellar neoplasms. Charts were reviewed for patient demographics, clinical presentation, pathology characteristics, radiographic classification, and oncologic and functional outcomes.

RESULTS

Twenty-four patients were identified; twelve patients had benign lesions, 10 metastatic and 2 primary malignant tumors. Chondroblastoma and Giant Cell Tumor were the most common tumors. Management of benign lesions with intralesional curettage and packing with bone graft or cement demonstrated excellent results with no local recurrence. In terms of malignant tumors, the spectrum of treatment is variable; it could range from medical management alone or in combination with surgical procedures to total patellectomy with reconstruction of the extensor mechanism.

CONCLUSION

Patellar tumors should be part of the differential in patients with chronic knee pain that does not respond to initial conservative interventions. Recurrence rate with intralesional curettage and bone grafting or cement packing is very low and therefore should be the treatment of choice for benign intraosseous neoplasms. Resection with negative margins in malignant neoplasms or bone metastasis decreases local recurrence but only in the former group there is a potential impact in survival.

Tubercle-Sparing Proximal Tibial Reconstruction in Patients with Primary and Metastatic Bone Disease: A Case Report

CASE

Two patients with cancer involving their proximal tibia required proximal tibial replacement (PTR). One had a soft-tissue sarcoma that involved her posterior cortex, and the other had extensive metaphyseal destruction from metastatic breast cancer. Their anterolateral cortex and tibial tubercle were uninvolved, permitting tubercle-sparing PTR. A plate was applied to the bone bridge in the latter patient in anticipation of radiotherapy. Both healed uneventfully and had minimal extensor lag 2 weeks postoperatively.

CONCLUSION

Tubercle-sparing PTR preserves extensor mechanism function with minimal lag. It should be considered in patients with cancer when sparing the anterolateral cortex is oncologically safe.

Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved

BACKGROUND

Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins.

METHODS

This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths.

RESULTS

For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm³, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery.

CONCLUSIONS

The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.

Temporizing Wound VAC Dressing Until Final Negative Margins are Achieved Reduces Myxofibrosarcoma Local Recurrence

BACKGROUND

The microinvasive nature of suprafascial myxofibrosarcoma reduces the accuracy of intraoperative margin assessment, and tumor bed resections after soft-tissue reconstruction are unreliable. In 2017, we began temporizing the excised tumor bed with a wound VAC, delaying soft-tissue coverage until final negative margins were achieved. We compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS).

METHODS

We retrospectively studied suprafascial myxofibrosarcomas managed from January 1, 2000 to January 1, 2019 for patients who received neoadjuvant or adjuvant radiation and had at least 2 years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed by using Fisher's exact test or Student's t test. A p value < 0.05 was considered significant.

RESULTS

Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed reexcision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Postoperative infectious and wound complications were equivalent.

CONCLUSIONS

Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.

VAC temporization pending final margins after suprafascial myxofibrosarcoma excision to reduce the rate of local recurrence

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Background: The microinvasive nature of suprafascial myxofibrosarcoma complicates the accuracy of intraoperative margin assessment, and tumor bed resections after soft tissue reconstruction are unreliable. For the past 3 years we have temporized the excised tumor bed with a wound VAC, delaying soft tissue coverage until final negative margins were achieved. Here, we compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS). Methods: We retrospectively studied suprafascial myxofibrosarcomas managed from 1/1/2000 to 1/1/2019 who received neoadjuvant or adjuvant radiation and had at least 2-years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed using Fisher’s Exact Test or Students t-test. A p-value < 0.05 was considered significant. Results: Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed re-excision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Post-operative infectious and wound complications were equivalent (Table). Conclusions: Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.[Table: see text]

Outcomes of VAC temporization following the excision of microinvasive sarcomas pending negative formal pathologic margins

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Background: Microinvasive sarcomas can yield a high number of false negative intraoperative pathology margin analyses. Additional oncologic resection after soft tissue coverage is technically challenging and oncologically inaccurate. As a result the rate of local recurrence for these histologies can be 25% or higher. In select patients we have temporized the sarcoma tumor bed with a wound VAC pending final pathologic margins. If positive, the patient can return to the OR for a tumor bed excision. If negative, soft tissue coverage can proceed. Here we evaluate our outcomes using this approach. Methods: We retrospectively studied patients with primary sarcomas managed with a VAC temporizing approach from from 1/1/2003 to 12/1/2019 with a minimum of 2 years of oncologic follow-up. Patients with unplanned ("oopsie") excisions were also included. Our primary outcome was local recurrence. Data is presented as percentages or mean ± standard deviation where appropriate. Results: Sixty-three patients were included (Table). Mean age was 62.3 ± 22.3 (median 67.3) years, 23 (36.5%) were female, and mean age-adjusted charlson comorbidity index was 5.3 ± 1.9. Twenty-four (38.1%) had undergone “oopsie” excisions. R0 margins were achieved in 59 (93.7%) patients, while the other 4 were known R1 resections due to patient tolerance or anatomy. Five local recurrences (7.9%) were diagnosed 3.2 ± 1.5 years after surgery, of which 3 had known positive margins. Free flaps were needed in 17 (27.0%) patients. Metastatic disease was diagnosed in 8 (12.7%) patients, who all died of disease. Mean follow-up was 4.4 ± 2.9 years. Conclusions: VAC temporization results few local recurrences in patients with formally confirmed negative margins. This technique is particularly useful in the treatment of microinvasive disease or in the management of vulnerable hosts who may not be able to tolerate additional surgery in the future.[Table: see text]

Do Cohabitants Reliably Complete Questionnaires for Patients in a Terminal Cancer Stage when Assessing Quality of Life, Pain, Depression, and Anxiety?

BACKGROUND

Patients with bone metastases often are unable to complete quality of life (QoL) questionnaires, and cohabitants (such as spouses, domestic partners, offspring older than 18 years, or other people who live with the patient) could be a reliable alternative. However, the extent of reliability in this complicated patient population remains undefined, and the influence of the cohabitant's condition on their assessment of the patient's QoL is unknown.

QUESTIONS/PURPOSES

(1) Do QoL scores, measured by the 5-level EuroQol-5D (EQ-5D-5L) version and the Patient-reported Outcomes Measurement Information System (PROMIS) version 1.0 in three domains (anxiety, pain interference, and depression), reported by patients differ markedly from scores as assessed by their cohabitants? (2) Do cohabitants' PROMIS-Depression scores correlate with differences in measured QoL results?

METHODS

This cross-sectional study included patients and cohabitants older than 18 years of age. Patients included those with presence of histologically confirmed bone metastases (including lymphoma and multiple myeloma), and cohabitants must have been present at the clinic visit. Patients were eligible for inclusion in the study regardless of comorbidities, prognosis, prior surgery, or current treatment. Between June 1, 2016 and March 1, 2017 and between October 1, 2017 and February 26, 2018, all 96 eligible patients were approached, of whom 49% (47) met the selection criteria and were willing to participate. The included 47 patient-cohabitant pairs independently completed the EQ-5D-5L and the eight-item PROMIS for three domains (anxiety, pain, and depression) with respect to the patients' symptoms. The cohabitants also completed the four-item PROMIS-Depression survey with respect to their own symptoms.

RESULTS

There were no clinically important differences between the scores of patients and their cohabitants for all questionnaires, and the agreement between patient and cohabitant scores was moderate to strong (Spearman correlation coefficients ranging from 0.52 to 0.72 on the four questionnaires; all p values < 0.05). However, despite the good agreement in QoL scores, an increased cohabitant's depression score was correlated with an overestimation of the patient's symptom burden for the anxiety and depression domains (weak Spearman correlation coefficient of 0.33 [95% confidence interval 0.08 to 0.58]; p = 0.01 and moderate Spearman correlation coefficient of 0.52 [95% CI 0.29 to 0.74]; p < 0.01, respectively).

CONCLUSION

The present findings support that cohabitants might be reliable raters of the QoL of patients with bone metastases. However, if a patient's cohabitant has depression, the cohabitant may overestimate a patient's symptoms in emotional domains such as anxiety and depression, warranting further research that includes cohabitants with and without depression to elucidate the effect of depression on the level of agreement. For now, clinicians may want to reconsider using the cohabitant's judgement if depression is suspected.

CLINICAL RELEVANCE

These findings suggest that a cohabitant's impressions of a patient's quality of life are, in most instances, accurate; this is potentially helpful in situations where the patient cannot weigh in. Future studies should employ longitudinal designs to see how or whether our findings change over time and with disease progression, and how specific interventions-like different chemotherapeutic regimens or surgery-may factor in.

Diagnoses, treatment, and oncologic outcomes in patients with calcaneal malignances: Case series, systematic literature review, and pooled cohort analysis

BACKGROUND AND OBJECTIVES

Malignant tumors of the calcaneus are rare but pose a treatment challenge.

AIMS

(1) describe the demographics of calcaneal malignancies in a large cohort; (2) describe survival after amputation versus limb-salvage surgery for high-grade tumors.

METHODS

Study group: a "pooled" cohort of patients with primary calcaneal malignancies treated at two cancer centers (1984-2015) and systematic literature review. Kaplan-Meier analyses described survival across treatment and diagnostic groups; proportional hazards modeling assessed mortality after amputation versus limb salvage.

RESULTS

A total of 131 patients (11 treated at our centers and 120 patients from 53 published studies) with a median 36-month follow-up were included. Diagnoses included Ewing sarcoma (41%), osteosarcoma (30%), and chondrosarcoma (17%); 5-year survival rates were 43%, 73% (70%, high grade only), and 84% (60%, high grade only), respectively. Treatment involved amputation in 52%, limb salvage in 27%, and no surgery in 21%. There was no difference in mortality following limb salvage surgery (vs. amputation) for high-grade tumors (HR 0.38; 95% CI 0.14-1.05), after adjusting for Ewing sarcoma diagnosis (HR 5.15; 95% CI 1.55-17.14), metastatic disease at diagnosis (HR 3.88; 95% CI 1.29-11.64), and age (per-year HR 1.04; 95% CI 1.02-1.07).

CONCLUSIONS

Limb salvage is oncologically-feasible for calcaneal malignancies.

A Limited Fixation, Olecranon Sparing Approach, for Management of Geriatric Intra-Articular Distal Humerus Fractures

Purpose

We propose that geriatric comminuted intra-articular distal humerus fractures can be effectively treated with a limited fixation approach aimed at achieving varus/valgus stability with columnar fixation, but allowing intra-articular comminution to heal by secondary congruency against an intact olecranon, thus avoiding an olecranon osteotomy.

Methods

Fifty-six elderly patients with AO 13-C type fractures, who underwent surgical fixation with ≥12-months of follow-up were retrospectively reviewed. Thirty patients were treated with intra-articular open reduction internal fixation (ORIF) with an olecranon osteotomy and 26 patients were treated with our limited fixation (L-ORIF) approach. Outcomes were range of motion (ROM), complications, additional surgery, and patient-reported outcome measures (PROMIS).

Results

At final follow-up, the average elbow ROM was 97° (40°-155°) in the ORIF group and 86.5° (20°-145°) in the L-ORIF group. There was a trend toward more complications and additional surgery in the ORIF group. PROMIS scores for pain were 53.1 and 52.14, and PROMIS functional scores were 41.7 and 41.4 in the ORIF and L-ORIF group respectively. No differences in outcomes were statistically significant.

Conclusion

A limited fixation technique based on achieving varus/valgus stability with columnar fixation, demonstrated equivalent outcomes in elderly patients with intra-articular distal humerus fractures when compared to intra-articular ORIF with an olecranon osteotomy.

Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty

BACKGROUND

Knee stiffness requiring manipulation under anesthesia (MUA) is an undesirable outcome following total knee arthroplasty (TKA), but risk factors for, and optimal timing of, MUA remain unclear.

METHODS

Primary TKAs performed at a single center were retrospectively reviewed. Clinical variables were compared between patients who underwent MUA and those who did not; variables that differed were utilized to identify an appropriately matched control group of non-MUA patients. The MUA group was divided into early (MUA ≤6 weeks from index) and late (>6 weeks) subgroups. Flexion values at multiple time points were compared.

RESULTS

In total, 1729 TKA patients were reviewed; MUA was performed in 62 patients. Patients undergoing MUA were younger (55.2 vs 65.3 years, P < .001) and had higher rates of current smoking (21.0% vs 7.3%, P < .001) and prior procedure (59.7% vs 40.4%, P = .002), most commonly arthroscopy; a control group of patients not requiring MUA, matched on the basis of these variables, was identified. While no difference in pre-TKA flexion existed across groups, final flexion in the early MUA group (106.7°) was equivalent to that of controls (115.6°), while final flexion in the late MUA group was not (101.3°, P = .001).

CONCLUSION

TKA patients undergoing MUAs were younger, more likely to be current smokers, and more likely to have undergone prior knee surgery. Even in patients with severe initial postoperative limitations in range of motion, MUA within 6 weeks may allow for final outcomes that are equivalent to those experienced by similar patients not requiring manipulation.

Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty

BACKGROUND

Patients undergoing total hip or knee arthroplasty frequently receive blood transfusions. The relationship between transfusion and the risk of infection following total joint arthroplasty is unclear. In this study, we sought to examine the impact of allogeneic and autologous transfusion on the risk of acute infection following total hip and total knee arthroplasty.

METHODS

We performed a retrospective study of consecutive primary total knee arthroplasties and total hip arthroplasties. Patients who had a reoperation for suspected infection within three months after the arthroplasty were identified. Differences in risk factors were assessed across transfusion groups: no transfusion, autologous only, and allogeneic exposure (allogeneic with or without additional autologous transfusion). Backward-stepwise logistic regression analysis was used to compare reoperations (as outcomes) between cases with and those without allogeneic exposure. Prespecified covariates were body mass index, diabetes, an American Society of Anesthesiologists (ASA) score of >2, preoperative hematocrit, and total number of units transfused perioperatively.

RESULTS

We identified 3352 patients treated with a total hip or knee arthroplasty (1730 total knee arthroplasties and 1622 total hip arthroplasties) for inclusion in the study. Transfusion was given in 1746 cases: 836 of them had allogeneic exposure, and 910 had autologous-only transfusion. There were thirty-two reoperations (0.95%) for suspected infection. Between-group risk-factor differences were observed. The mean age and the rates of diabetes, immunosuppression, ASA scores of >2, and bilateral surgery were highest in the allogeneic group, as were estimated blood loss, surgery duration, and total number of units transfused (p < 0.001). In the unadjusted analyses, the rate of reoperations for suspected infection was higher in the cases with allogeneic exposure (1.67%) than in those without allogeneic exposure (0.72%) (p = 0.013). Autologous-only transfusion was not associated with a higher reoperation rate. However, multivariable logistic regression demonstrated that the total number of units transfused (p = 0.011) and an ASA score of >2 (p = 0.008)-but not allogeneic exposure-were significantly predictive of a reoperation.

CONCLUSIONS

Perioperative allogeneic transfusion was associated with a higher rate of reoperations for suspected acute infection. However, patients with allogeneic exposure had increased infection risk factors. After adjustment for the total number of units transfused and an ASA score of >2, allogeneic exposure was not significantly predictive of a reoperation for infection.

Stair ascending and descending in hip resurfacing and large head total hip arthroplasty patients

Large head total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) are alternatives to standard THA that generally have head sizes larger than 36mm. This study examined 20 patients (10 large head THA and 10 HRA), at an average of 18months postoperatively, and 15 healthy control subjects during stair negotiation. Hip kinetic and kinematic variables and ground reaction forces were measured. The THA and HRA groups ascended the stairs with increased peak hip flexion angles and decreased hip extension angles as compared with controls. The operative groups also descended the stairs with decreased hip flexion moments. No differences between the operative groups were observed. Eighteen months postoperatively, patients with large head THA or HRA display abnormal flexion and extension during a physically-demanding task.