Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

Midterm outcomes of total hip arthroplasty after internal hemipelvectomy and iliofemoral arthrodesis

BACKGROUND AND OBJECTIVES

Recent studies have reported acceptable outcomes after arthrodesis takedown and conversion to total hip arthroplasty (THA); however, there are no reports on outcomes after oncologic resection, which are inherently complex and may portend poorer outcomes. The purpose of this study was to examine the surgical and functional outcomes of patients who underwent prior hemipelvectomy for tumor resection and were later converted to THA.

METHODS

All patients who had prior iliofemoral arthrodesis after oncologic resection that were later converted to THA at a single institution were examined. Charts were reviewed for demographic information, operative information, functional outcomes, and complications/reoperations.

RESULTS

All three patients in this study were males who underwent internal hemipelvectomies for chondrosarcoma. Patients were converted to THA at a mean of 26 years after arthrodesis. Mean follow-up after conversion to THA was 7.4 years. During this follow-up period, two of the three patients required revision surgery. At last follow-up, the mean Harris Hip Score was 81 and the mean Mayo Hip Score was 67, and all patients were ambulatory without significant pain.

CONCLUSIONS

Overall, patients who undergo iliofemoral arthrodesis after oncologic hemipelvectomy and are later converted to THA can expect to have a reasonable outcome, despite a high rate of complications and revision surgery.

Reverse Shoulder Arthroplasty Megaprosthesis for Surgical Management of Severe Proximal Humeral Bone Loss

INTRODUCTION

Shoulder arthroplasty in the setting of severe proximal humerus bone loss can be challenging. The purpose of this study was to evaluate the outcomes of a modular segmental megaprosthesis when implanted in a reverse configuration for complex primary arthroplasty, reconstruction at the time of oncologic resection, and revision shoulder arthroplasty.

MATERIALS AND METHODS

A Joint Registry Database was queried to identify all shoulder arthroplasties performed at a single institution using the Comprehensive Segmental Revision System® reverse shoulder arthroplasty (SRS-RSA, Zimmer Biomet, Warsaw, IN, USA). A retrospective review of electronic medical records and radiographs was performed to record demographic data, indication, outcomes, complications, and revision surgery.

RESULTS

Between February 2012 and October 2022, 76 consecutive SRS-RSA were implanted. An analysis of patients with minimum 12-month follow-up yielded 53 patients with a mean follow-up of 4.1 ± 2.43 years. Surgical complication rate in this cohort was observed in 41.5% (22/53) of cases. Overall, revision rate at final follow-up was 26.4% (14/53), with a significant difference between the primary and revision cohorts. The number of prior surgeries was a significant risk factor for revision surgery, with a hazard ratio of 1.789 (p<.001 95%CI [1.314-2.436]). When analyzing aseptic humeral loosening rates across study cohorts, a significant difference was found between the primary arthroplasty (0%, n = 0) and the revision arthroplasty cohorts (22.2%, n = 6) (p = 0.04).

DISCUSSION

Reverse shoulder arthroplasty using a modular segmental megaprosthesis remains a reasonable salvage option for shoulder reconstruction in the setting of proximal humeral bone loss. Due to the substantial bone loss and soft tissue deficiencies typically present in these cases, surgeons should educate patients on the relatively high complication rate, particularly when used in the setting of a previous failed arthroplasty.

Active surveillance of diffuse-type tenosynovial giant cell tumors: A retrospective, multicenter cohort study

BACKGROUND

Diffuse-type tenosynovial giant cell tumor (D-TGCT) is a mono-articular, soft-tissue tumor. Although it can behave locally aggressively, D-TGCT is a non-malignant disease. This is the first study describing the natural course of D-TGCT and evaluating active surveillance as possible treatment strategy.

METHODS

This retrospective, multicenter study included therapy naïve patients with D-TGCT from eight sarcoma centers worldwide between 2000 and 2019. Patients initially managed by active surveillance following their first consultation were eligible. Data regarding the radiological and clinical course and subsequent treatments were collected.

RESULTS

Sixty-one patients with primary D-TGCT were initially managed by active surveillance. Fifty-nine patients had an MRI performed around first consultation: D-TGCT was located intra-articular in most patients (n = 56; 95 %) and extra-articular in 14 cases (24 %). At baseline, osteoarthritis was observed in 13 patients (22 %) on MRI. Most of the patients' reported symptoms: pain (n = 43; 70 %), swelling (n = 33; 54 %). Eight patients (13 %) were asymptomatic. Follow-up data were available for 58 patients; the median follow-up was 28 months. Twenty-one patients (36 %) had radiological progression after 21 months (median). Eight of 45 patients (18 %) without osteoarthritis at baseline developed osteoarthritis during follow-up. Thirty-seven patients (64 %) did not clinically deteriorate during follow-up. Finally, eighteen patients (31 %) required a subsequent treatment.

CONCLUSION

Active surveillance can be considered adequate for selected therapy naïve D-TGCT patients. Although follow-up data was limited, almost two-thirds of the patients remained progression-free, and 69 % did not need treatment during the follow-up period. However, one-fifth of patients developed secondary osteoarthritis. Prospective studies on active surveillance are warranted.

Long-term outcome of total hip arthroplasty in patients with multiple hereditary exostosis

BACKGROUND

Multiple hereditary exostosis (MHE) is a rare autosomal dominant disorder characterized by multiple osteochondromas. There is a paucity of literature concerning total hip arthroplasty (THA) in patients with MHE. The aim of this study is to report long-term outcomes of THA in patients with MHE.

METHODS

Fourteen patients undergoing 15 THA's for the treatment of osteoarthritis in the presence of osteochondromas and proximal femoral deformity secondary to MHE were reviewed. Mean age at the time of surgery and follow-up was 56 and 12 years. Seven (47%) had uncemented femoral components. Eleven hips had coxa valga on preoperative imaging. Clinical outcomes were assessed with both Harris hip scores (HHS) and Musculoskeletal Tumor Society Scores (MSTS).

RESULTS

Following surgery, there was an improvement in the HHS (48-82, p < 0.01) and MSTS scores (41-70%, p < 0.01). Complications occurred in 5 patients leading to reoperation in 3 patients, of which 2 patients underwent a revision procedure at 19 and 20-years postoperative. The 10-year revision free survival was 100%.

CONCLUSIONS

THA in the setting of MHE reliably improves patient function. One in three patients will have a postoperative complication; however, the long-term incidence of revision is low.

Durability of intercalary endoprosthesis for humeral reconstruction

INTRODUCTION

The humerus is a common site of metastases and primary tumors. For some patients with a segmental defect and/or diaphyseal cortical destruction a cemented intercalary device may provide a more reliable construct, however data on their use is limited.

METHODS

We reviewed 43 (28 male and 15 female) patients treated with an intercalary humeral spacer at a single tertiary referral center between 1989 and 2022. Humeral lesions were most commonly secondary to metastatic disease (n = 29, 68%), with 25 (58%) patients presenting with a pathologic fracture. Mean age and body mass index were 66 years and 27.9 kg/m2 . First generation taper joint device were used in 22 patients and second-generation lap device in 21 patients.

RESULTS

Following reconstruction the 2-year overall survival was 30%. Mechanical complications occurred in 11 patients, most commonly aseptic loosening (n = 6, 14%). With death as a competing risk, the cumulative incidence of mechanical failure was 28% at 2-years postoperative. Following the procedure, mean Musculoskeletal Tumor Society scores was 70% and mean shoulder elevation was 87°.

CONCLUSION

Reconstruction of the humeral diaphysis with an intercalary endoprosthesis provides restoration of function of the upper extremity, however, is associated with one in four patients having mechanical failure.

Whole Blood Metal Levels in the Setting of an Oncologic Endoprosthesis: Is There Cause for Concern?

BACKGROUND

Massive modular endoprostheses have become a primary means of reconstruction after oncologic resection of a lower extremity tumor. These implants are commonly made with cobalt-chromium alloys that can undergo wear and corrosion, releasing cobalt and chromium ions into the surrounding tissue and blood. However, there are few studies about the blood metal levels in these patients.

QUESTION/PURPOSE

What is the whole blood cobalt and chromium ion level in patients with massive modular endoprostheses?

METHODS

We performed a cross-sectional study of our total joints registry to identify patients with a history of an endoprosthetic reconstruction performed at our institution. Patients who were alive at the time of our review in addition to those undergoing an endoprosthetic reconstruction after an oncologic resection were included. Whole blood samples were obtained from 27 (14 male and 13 female) patients with a history of a lower extremity oncologic endoprosthesis. The median time from surgery to blood collection was 8 years (range 6 months to 32 years). Blood samples were collected and stored in metal-free ethylenediaminetetraacetic acid tubes. Samples were analyzed on an inductively coupled plasma mass spectrometer in an International Organization for Standardization seven-class clean room using polytetrafluoroethylene-coated instruments to reduce the risk of metal contamination. The analytical measuring range was 1 to 200 ng/mL for chromium and cobalt. Cobalt and chromium levels were considered elevated when the blood level was ≥ 1 ppb.

RESULTS

Cobalt levels were elevated in 59% (16 of 27) of patients, and chromium levels were elevated in 26% (seven of 27). In patients with elevated metal ion values, 15 of 17 patients had a reconstruction using a Stryker/Howmedica Global Modular Replacement System implant.

CONCLUSION

Blood metal levels were elevated in patients who received reconstructions using modular oncology endoprostheses Future work is needed to establish appropriate follow-up routines and determine whether and when systemic complications occur because of elevated metal levels and how to potentially address these elevated levels when complications occur. Prospective and retrospective collaboration between multiple centers and specialty societies will be necessary to address these unknown questions in this potentially vulnerable patient group.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis

BACKGROUND

Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis.

METHODS

A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment.

RESULTS

Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18).

CONCLUSION

Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.

Advances in Oncologic Shoulder Girdle Resection and Reconstruction

The bony shoulder girdle consists of the clavicle, humerus, and scapula, which work synergistically to form a complex articulation that is essential for use of the upper extremity. The shoulder girdle is the most common location for primary and secondary bone tumors in the upper extremity, and following resection of these tumors, reconstruction of the upper extremity is challenging. Compared with those in the lower extremity, reconstructive techniques in the upper extremity have historically been unreliable and fraught with complications and poor functional outcomes. Newer reconstructive techniques using reverse total shoulder arthroplasty and functional muscle flaps have shown promise to improve outcomes while reducing complications for proximal humerus reconstructions. Despite these advancements, reconstruction following scapulectomy remains challenging and is still associated with more frequent complications and compromised function.

Controversies in Oncologic Pediatric Limb Salvage

With advances in chemotherapy and radiation therapy, surgical treatment of patients with bone sarcomas has advanced from most patients undergoing an amputation to now most patients undergoing a limb salvage procedure. With the advances of limb salvage surgical techniques, reconstructive procedures have expanded to include autografts, allografts, endoprosthetic replacements, and rotationplasty. In a growing child, the decision to perform each of these reconstructive options is individualized and each needs to be considered to provide the patient with the optimal oncologic and functional outcome, while being durable to minimize the risk of complications and subsequent surgeries.

Reconstruction following oncological iliosacral resection

Aims

The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed.

Methods

A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19).

Results

Overall, 27 patients (45%) were reconstructed, while 33 (55%) had no formal reconstruction. There was no difference in the use of chemotherapy (p = 1.000) or radiotherapy (p = 0.292) between the groups. Patients with no reconstruction had a mean larger tumour (11 cm (SD 5) vs 8 cm (SD 4); p = 0.014), mean shorter operating times (664 mins (SD 195) vs 1,324 mins (SD 381); p = 0.012), and required fewer blood units (8 (SD 7) vs 14 (SD 11); p = 0.012). Patients undergoing a reconstruction were more likely to have a deep infection (48% vs 12%; p = 0.003). Nine reconstructed patients had a hardware failure, with five requiring revision. Postoperatively 55 (92%) patients were ambulatory, with no difference in the proportion of ambulatory patients (89% vs 94%; p = 0.649) or mean Musculoskeletal Tumor Society Score (59% vs 65%; p = 0.349) score between patients who did or did not have a reconstruction. The ten-year disease-specific survival was 69%, with no difference between patients who were reconstructed and those who were not (78% vs 45%; p = 0.316). There was no difference in the rate of metastasis between the two groups (hazard ratio (HR) 2.78; p = 0.102).

Conclusion

Our results demonstrate that SIJ reconstruction is associated with longer operating times, greater need for blood transfusion, and more postoperative infections, without any improvement in functional outcomes when compared to patients who did not have formal SIJ reconstruction.

Oncological and functional outcomes after resection of malignant tumours of the scapula

Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

Methods

We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification.

Results

The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05).

Conclusion

Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence.

Is Bone Marrow Aspiration and Biopsy of Clinical Importance in the Initial Staging of Extraskeletal Ewing Sarcoma?

BACKGROUND

Extraskeletal Ewing sarcoma are rare tumors within the Ewing sarcoma family. Initial staging studies for extraskeletal Ewing sarcoma historically have included imaging and bone marrow aspiration and biopsy (BMAB). However, recent studies on Ewing sarcoma of bone have questioned the utility of BMAB in the initial staging of patients, but no studies of which we are aware have evaluated the role of BMAB in extraskeletal Ewing sarcoma. We suspected that BMAB was of low diagnostic yield in patients with extraskeletal Ewing sarcoma and exposed patients to potential morbidity without an impact on their clinical course.

QUESTION/PURPOSE

Is BMAB a useful test in the staging of extraskeletal Ewing sarcoma?

METHODS

Between January 1996 and December 2021, our institution evaluated 109 patients with a listed diagnosis of extraskeletal Ewing sarcoma. Those patients were retrospectively reviewed for this study. Of those, we considered patients with biopsy-confirmed diagnosis of extraskeletal Ewing sarcoma. Biopsy was performed based on institutional protocols, with all diagnoses assigned by a board-certified pathologist. Based on that criteria, 96% (105 of 109) were eligible. An additional 18% (20 of 109) were excluded because records of their initial diagnostic and staging workup were not available. This left 78% (85 of 109) for analysis. Of those, 52% (44 of 85) were male. The average age was 32 ± 16 years. Primary tumor locations included extremities in 26% (22 of 85), paraspinal in 20% (17 of 85), chest in 19% (16 of 85), retroperitoneum in 13% (11 of 85), intraabdominal in 12% (10 of 85), intrapelvic in 7% (6 of 85), and head or neck in 4% (3 of 85). Initial diagnostic and staging information, including the use of PET-CT, bone scan, CT chest, and BMAB, was collected. Metastatic disease at the time of presentation or during follow-up was noted. The utility of BMAB was determined by the rate of positive tests in those undergoing BMAB during the initial staging process. Descriptive statistical analysis was sufficient to address the study question, and therefore no comparative statistics were performed.

RESULTS

BMAB was obtained during the initial staging process in 64% (54 of 85) of patients. This BMAB was negative in all 54 patients, including those with known metastatic disease.

CONCLUSION

Diagnosing metastatic disease in extraskeletal Ewing sarcoma is important as the presence of metastases at diagnosis adversely affects prognosis. The routine use of BMAB in the staging process of extraskeletal Ewing sarcoma is of low diagnostic yield. BMAB is unlikely to diagnose metastatic involvement even in patients with known metastases to bone. We do not have enough data to suggest whether other modalities, such as PET-CT, might be more useful. Similar studies should be pursued to determine the utility of the remainder of staging modalities in patients with extraskeletal Ewing sarcoma to elucidate the most efficient and effective staging protocol.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Tibial intraneural ganglion cysts at the superior tibiofibular joint treated with joint resection alone: a proof of concept

BACKGROUND

Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst.

METHODS

Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded.

RESULTS

We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst.

CONCLUSIONS

This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint.

A Ready-to-Use Purified Exosome Product for Volumetric Muscle Loss and Functional Recovery

Large skeletal muscle defects owing to trauma or following tumor extirpation can result in substantial functional impairment. Purified exosomes are now available clinically and have been used for wound healing. The objective of this study was to evaluate the regenerative capacity of commercially available exosomes on an animal model of volumetric muscle loss (VML) and its potential translation to human muscle injury. An established VML rat model was used. In the in vitro experiment, rat myoblasts were isolated and cocultured with 5% purified exosome product (PEP) to validate uptake. Myoblast proliferation and migration was evaluated with increasing concentrations of PEP (2.5%, 5%, and 10%) in comparison with control media (F10) and myoblast growth medium (MGM). In the in vivo experiment, a lateral gastrocnemius-VML defect was made in the rat hindlimb. Animals were randomized into four experimental groups; defects were treated with surgery alone, fibrin sealant, fibrin sealant and PEP, or platelet-rich plasma (PRP). The groups were further randomized into four recovery time points (14, 28, 45, or 90 days). The isometric tetanic force (ITF), which was measured as a percentage of force compared with normal limb, was used for functional evaluation. Florescence microscopy confirmed that 5% PEP demonstrated cellular uptake ∼8-12 h. Compared with the control, myoblasts showed faster proliferation with PEP irrespective of concentration. PEP concentrations of 2.5% and 5% promoted myoblast migration faster compared with the control (<0.05). At 90 days postop, both the PEP and fibrin sealant and PRP groups showed greater ITF compared with control and fibrin sealant alone (<0.05). At 45 days postop, PEP with fibrin sealant had greater cellularity compared with control (<0.05). At 90 days postop, both PEP with fibrin sealant and the PRP-treated groups had greater cellularity compared with fibrin sealant and control (<0.05). PEP promoted myoblast proliferation and migration. When delivered to a wound with a fibrin sealant, PEP allowed for muscle regeneration producing greater functional recovery and more cellularity in vivo compared with untreated animals. PEP may promote muscle regeneration in cases of VML; further research is warranted to evaluate PEP for the treatment of clinical muscle defects.

The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors

Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.

Targeted Muscle Reinnervation to Reduce Postoperative Pain in Patients Undergoing Hindquarter Resections

BACKGROUND/AIM

Pre-emptive targeted muscle reinnervation (TMR) at the time of amputation results in less phantom limb pain (PLP) compared with untreated amputee controls. There is limited literature describing the technique in patients undergoing hindquarter amputation despite up to 90% of these patients reporting PLP and 50% presenting with painful neuroma. The purpose of the current study was to describe the motor nerves accessible through a primary hind-quarter amputation to be used for TMR and review pain outcomes in clinical case correlates of patients with TMR.

PATIENTS AND METHODS

Six limbs were obtained from three fresh adult cadavers and proximal sensory and motor nerves were dissected. A review of patients undergoing hindquarter amputation with TMR was conducted.

RESULTS

Transfers for the sciatic, femoral, and obturator nerves were identified in cadavers. In reviews of patients, they were taking narcotic and neuro-leptic pain medication for a mean of 23 days and 168 days. At most recent follow-up, no patient reported debilitating phantom pain nor pain associated with neuromas.

CONCLUSION

Given the positive preliminary results in our study group as well as the accessible neuroanatomy, pre-emptive TMR should be considered at the time of surgery to limit PLP and dependence on pain medications.

Management of giant cell tumors of the distal radius

Background

The distal radius is the most common location for giant cell tumors (GCT) in the upper extremity. Treatment should balance the goals of maximizing function and minimizing recurrence and other complications. Given the complexity in surgical treatment, various techniques have been described without clear standards of treatment.

Objectives

The purpose of this review is to provide an overview of evaluation of patients presenting with GCT of the distal radius, discuss management, and provide an updated summary on outcomes of treatment options.

Conclusion

Surgical treatment should consider tumor Grade, involvement of the articular surface, and patient-specific factors. Options include intralesional curettage and en bloc resection with reconstruction. Within reconstruction techniques, radiocarpal joint preserving and sparing procedures can be considered. Campanacci Grade 1 tumors can be successfully treated with joint preserving procedures, whereas for Campanacci Grade 3 tumors consideration should be given to joint resection to prevent recurrence. Treatment of Campanacci Grade 2 tumors is debated in the literature. Intralesional curettage and adjuvants can successfully treat cases where the articular surface can be preserved, while en-bloc resection should be used in cases where the articular surface cannot undergo aggressive curettage. A variety of reconstructive techniques are used for cases needing resection, with no clear gold standard. Joint sparing procedures preserve motion at the wrist joint, whereas joint sacrificing procedures preserve grip strength. Choice of reconstructive procedure should be made based on patient-specific factors, considering relative functional outcomes, complications, and recurrence rates.

Multidisciplinary Treatment of Merkel Cell Carcinoma of the Extremities: Outcomes and Factors Associated with Poor Survival in Nodal Disease

Merkel cell carcinoma (MCC) has a tendency for lymphatic spread and locoregional recurrence, although there is little data examining the risk factors for patients with lymph node-positive extremity lesions. The purpose of the current study was to examine the outcomes and risk factors associated with nodal metastasis in extremity MCC. We retrospectively reviewed the medical record of 120 patients with extremity MCC evaluated at our institution between 1994 and 2021. The mean age of this cohort was 71 years; 33% of patients were female; and 98% were Caucasian. Seventy-eight (65%) patients presented with localized disease. Thirty-seven (31%) patients had stage III disease, and five (4%) patients had stage IV disease. Treatment of primary lesions consisted primarily of margin-negative excision and adjuvant radiotherapy. Nodal metastases were most treated with adjuvant radiation or completion lymph node dissection. Five-year disease-specific survival in our series was 88% for patients with localized disease, 89% for stage IIIa disease, 40% for stage IIIb disease and 42% for stage IV. Factors associated with worse survival included immunosuppression and macroscopic nodal disease. In conclusion, extremity MCC has a low rate of local recurrence when treated with margin-negative excision and adjuvant radiation. However, treatment of nodal metastases remains a challenge with high rates of recurrence and mortality, particularly for patients who are immunosuppressed or who have macroscopic nodal disease.

Comparison of Fixation Techniques for Lower Extremity Rotationplasty

BACKGROUND

Rotationplasty is a reconstructive, limb-sparing surgery indicated for patients with lower extremity musculoskeletal tumors. The procedure involves rotation of the distal lower extremity to allow the ankle to function as the new knee joint and provide an optimum weight-bearing surface for prosthetic use. Historically there is limited data comparing fixation techniques. The purpose of this study is to compare clinical outcomes between intramedullary nailing (IMN) and compression plating (CP) in young patients undergoing rotationplasty.

METHODS

A retrospective review of 28 patients with a mean age of 10±4 years undergoing a rotationplasty for either a femoral (n=19), tibial (n=7), or popliteal fossa (n=2) tumor was performed. The most common diagnosis was osteosarcoma (n=24). Fixation was obtained with either an IMN (n=6) or CP (n=22). Clinical outcomes of patients undergoing rotationplasty were compared between the IMN and CP groups.

RESULTS

Surgical margins were negative in all patients. The mean time to union was 24 months (range 6 to 93). There was no difference in the meantime to the union between patients treated with an IMN versus those with a CP (14±16 vs. 27±26 mo, P=0.26). Patients undergoing fixation with an IMN were less likely to have a nonunion (odds ratio: 0.35, 95% confidence interval: 0.03-3.54, P=0.62). Postoperative fracture of the residual limb only occurred in patients undergoing CP fixation (n=7, 33% vs. n=0, 0%, P=0.28). Postoperative fixation complications occurred in 13 (48%) patients, most commonly a nonunion (n=9, 33%). Patients undergoing fixation with a CP were more likely to have a postoperative fixation complication (odds ratio: 20, 95% CI: 2.14-186.88, P<0.01).

CONCLUSIONS

Rotationplasty is an option for limb salvage for young patients with lower extremity tumors. The results of this study reveal fewer fixation complications when an IMN can be used. As such, IMN fixation should be considered for patients undergoing a rotationplasty, though equipoise should be shown by surgeons when determining technique.

Lack of radiosensitivity predicts poor disease specific survival in myxoid liposarcoma

BACKGROUND

Compared to other sarcomas, myxoid liposarcoma (ML) is known to be radiosensitive, with improved oncologic outcomes. Although these tumors "shrink" following radiotherapy, there is a paucity of data examining the degree of radiosensitivity and oncologic outcome. The purpose of the study was to evaluate pre- and postradiotherapy tumor volume to determine if size reduction impacts outcome.

METHODS

We reviewed 62 patients with ML undergoing surgical resection combined with preoperative radiotherapy, with pre- and postradiotherapy MRI. This included 34 (55%) males, with a mean age of 47 ± 14 years. All tumors were deep to the fascia, and 12 (19%) patients had tumors with a >5% round-cell component.

RESULTS

The mean volume reduction was 54% ± 29%. Compared to patients with >25% volume reduction, patients with reduction ≤25% had worse 10-year disease specific survival (86% vs. 37%, p < 0.01), in addition to an increased risk of metastatic disease (HR 4.63, p < 0.01) and death due to disease (HR 4.52, p < 0.01).

CONCLUSION

Lack of volume reduction is a risk factor for metastatic disease and subsequent death due to disease in patients with extremity ML treated with combined preoperative radiotherapy and surgery. This data could be used to stratify patients for adjuvant therapies and follow-up intervals.

Outcome of Multidisciplinary Treatment of Merkel Cell Carcinoma of the Hand and Wrist

BACKGROUND/AIM

Skin cancers are the most common malignancy of the hand and wrist. Merkel cell carcinoma (MCC) is a rare, aggressive non-melanoma skin cancer arising from cutaneous neuroendocrine cells and is known for local and distant recurrence. The purpose of the current study was to examine the treatment outcome of patients with MCC of the hand and wrist.

PATIENTS AND METHODS

We reviewed 25 patients (18 males:7 females) with MCC that occurred in the hand and wrist. The mean age at the time of biopsy of 71±11 years.

RESULTS

Tumors were located on the hand (n=13), finger/thumb (n=9), and wrist (n=3). Local control included wide local excision (n=22). This included 21 non-amputation resections and one 5^th digit ray amputation. Sentinel lymph node biopsy was performed in 21 patients with positive nodal disease in seven cases. Adjuvant radiotherapy was delivered to the primary site in 17 patients and additionally to the regional lymph node basin in six patients. Recurrence within five years was noted in 40% of patients (mean time to recurrence 18.4±20.6 months). Recurrence-free and disease-specific survival rates at 5-years were 54.8% and 67.6%.

CONCLUSION

MCC is a rare cutaneous neuroendocrine carcinoma with a high propensity for regional nodal spread. Despite aggressive local treatment, adjuvant radiotherapy to the primary site and regional nodes, MCC of the hand and wrist has a high rate of recurrence and mortality within five years of diagnosis.

Treatment outcomes of extraskeletal Ewing sarcoma

PURPOSE

Extraskeletal Ewing sarcoma (EES), is a rare soft tissue sarcoma. Treatment for EES commonly involves chemotherapy and surgical resection (ST) or less commonly combined chemotherapy, surgery, and radiotherapy (ST + RT). The purpose of the current study was to evaluate our institutional experience treating EES.

METHODS

We reviewed 36 (18 males:18 females) patients (mean age 30 years) with a nonretroperitoneal/visceral EES treated with either ST (n = 24, 67%) or ST + RT (n = 12, 33%). All patients were treated with chemotherapy, most commonly vincristine, doxorubicin, cyclophosphamide/ifosfamide and etoposide (VDC/IE, n = 23, 66%) Radiotherapy was mostly delivered preoperatively (n = 9). The mean follow-up was 8 years.

RESULTS

The 10-year disease specific survival for patients was 78%, with no difference in the survival between patients in the ST versus the ST + RT groups (83% vs. 71%, p = 0.86). There was no difference in the 10-year local recurrence (91% vs. 100%, p = 0.29) or metastatic free survival (87% vs. 75%, p = 0.45) between the ST and ST + RT groups.

CONCLUSION

The results of the current study highlight the ability to achieve excellent local control with chemotherapy and surgery for EES. We recommend for multidisciplinary management of patients with EES, including chemotherapy and surgery, with use of radiotherapy if there is concern for a potentially close margin of resection.

Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Prophylactic lymphaticovenous anastomosis (LVA) for preventing lymphedema after sarcoma resection in the lower limb: A report of three cases and literature review

Patients with soft tissue tumors of the lower extremities are at greater risk to develop postoperative disruption of lymphatic vessels. Currently, there is no widely effective cure for lymphatic dysfunction. Therefore, the best strategy is to prevent it and reconstruct efficient drainage as soon as the original pathway is damaged. We present a report of three prophylactic LVA cases after sarcoma resection in the lower limb, and a literature review to show the feasibility of prophylactic LVAs. The patients were 35, 73, and 77 years old, respectively, at the time of the procedure. All three patients had sarcoma in the medial thigh and underwent radiation therapy before the surgery. The locations of the LVAs include the medial thigh and medial and lateral calf. During the surgery, methylene blue and/or indocyanine green were injected to identify lymphatic vessels. Postoperative recovery was uneventful immediately after the surgery. At follow-up visits, all three patients reported improved functions with no significant swelling in the lower limb. One patient experienced a surgical wound infection that resolved after antibiotic admission. Two patients had a history of cardiac diseases, a major risk factor for developing postoperative lymphedema, but these two patients did not develop lymphedema with the treatment of prophylactic LVAs. These results suggest that prophylactic LVA may be an effective strategy to prevent secondary lymphedema after sarcoma resection. Further investigation is warranted.

One-Stage Synovectomies Result in Improved Short-Term Outcomes Compared to Two-Stage Synovectomies of Diffuse-Type Tenosynovial Giant Cell Tumor (D-TGCT) of the Knee: A Multicenter, Retrospective, Cohort Study

Diffuse-type tenosynovial giant cell tumors' (D-TGCTs) intra- and extra-articular expansion about the knee often necessitates an anterior and posterior surgical approach to facilitate an extensive synovectomy. There is no consensus on whether two-sided synovectomies should be performed in one or two stages. This retrospective study included 191 D-TGCT patients from nine sarcoma centers worldwide to compare the postoperative short-term outcomes between both treatments. Secondary outcomes were rates of radiological progression and subsequent treatments. Between 2000 and 2020, 117 patients underwent one-stage and 74 patients underwent two-stage synovectomies. The maximum range of motion achieved within one year postoperatively was similar (flexion 123-120°, p = 0.109; extension 0°, p = 0.093). Patients undergoing two-stage synovectomies stayed longer in the hospital (6 vs. 4 days, p < 0.0001). Complications occurred more often after two-stage synovectomies, although this was not statistically different (36% vs. 24%, p = 0.095). Patients treated with two-stage synovectomies exhibited more radiological progression and required subsequent treatments more often than patients treated with one-stage synovectomies (52% vs. 37%, p = 0.036) (54% vs. 34%, p = 0.007). In conclusion, D-TGCT of the knee requiring two-side synovectomies should be treated by one-stage synovectomies if feasible, since patients achieve a similar range of motion, do not have more complications, but stay for a shorter time in the hospital.

Sentinel Lymph Node Biopsy for Extremity and Truncal Soft Tissue Sarcomas: A Systematic Review of the Literature

BACKGROUND

Regional lymph node metastasis (RLNM) occurs infrequently in patients with soft tissue sarcoma (STS), although certain STS subtypes have a higher propensity for RLNM. The identification of RLNM has significant implications for staging and prognosis; however, the precise impact of node-positive disease on patient survival remains a topic of controversy. Although the benefits of sentinel lymph node biopsy (SLNB) are well documented in patients with melanoma and breast cancer, whether this procedure offers a benefit in STS is controversial.

METHODS

A systematic literature search was performed and articles reviewed to determine if SLNB in patients with extremity/truncal STS impacts disease-free or overall survival.

RESULTS

Six studies were included. Rates of sentinel lymph node positivity were heterogeneous (range 4.3-50%). The impact of SLNB on patient outcomes remains unclear. The overall quality of available evidence was low, as assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system.

CONCLUSIONS

The literature addressing the impact of nodal basin evaluation on the staging and management of patients with extremity/truncal STS is confounded by heterogeneous patient cohorts and clinical practices. Multicenter prospective studies are warranted to determine the true incidence of RLNM and whether SLNB could benefit patients with clinically occult RLNM at diagnosis.

Twenty-Year Experience With Primary Distal Radioulnar Joint Arthroplasty From a Single Institution

PURPOSE

The use of implant arthroplasty in the distal radioulnar joint is increasing. Two main types of implants are commonly used, ulnar head prosthesis (UHP) and hemi or semi-constrained total distal radioulnar joint arthroplasty. The literature consists mainly of small patient series. The purpose of this study was to examine our long-term outcomes of distal radioulnar joint arthroplasty.

METHODS

Patient data were collected in a patient registry from 2000 to 2019. The follow-up included radiographic examination, physical examination, Mayo Wrist Scores, pain level, range of motion, and grip strength. Reoperations were recorded. The implants were a semi-constrained prosthesis and a metallic UHP. The mean age at surgery was 50 years. Patient demographics were similar, but the semi-constrained group had a higher preoperative percentage of instability (85 vs 52 percent). The median follow-up time was 30 months for the semi-constrained implants group and 102 months for the UHP group.

RESULTS

A total of 53 primary semi-constrained total joint arthroplasties and 102 UHPs were included. The grip strength and Mayo Wrist Score improved for both the implant groups. Pain reduced in 76% of the patients. Supination improved for the semi-constrained total joint arthroplasty group. Lifting capacity was better in the semi-constrained total joint arthroplasty patients. The unadjusted reoperation rate was 23% for the semi-constrained implants group and 34% for the UHP group. Twenty-two implants were bilateral; these had comparable results to unilateral implants. Kaplan-Meier survival curves demonstrated 94% survival rate for the semi-constrained implants group and 87% survival for the UHP group after 5 years. The risk factors associated with reoperation for the combined implant group included younger age at surgery, previous wrist surgery, ulnar shortening, and wrist fusion.

CONCLUSIONS

Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. The semi-constrained implants group had better lifting capacity. The bilateral implants had comparable outcomes to the unilateral implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of Proximal Humeral Oncologic Lesions

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.

Management of Scapular Tumors

Scapular resections are large oncologic undertakings. Due to the soft tissue coverage of the scapula, tumors are often able to be resected with a negative margin. Involvement of the brachial plexus and axillary vessels is rare, allowing for a limb-salvage surgery in most cases. Functional outcomes are based on the magnitude of resection; patients undergoing a partial scapulectomy and those with glenoid preservation demonstrate improved outcomes compared to patients undergoing a total scapulectomy or glenoid resection. Although scapular endoprosthetics are available, there is limited data to support their routine use.

Restoration of hamstring function following sciatic nerve resection at the greater sciatic foramen with reconstruction involving acellular nerve allograft and vascularized sural nerve autograft: A case report

Segmental loss of the sciatic nerve secondary to oncologic resection or trauma is detrimental to hamstring and leg function. The diameter of this nerve and the length of its axons spanning the lower extremity create significant challenges in reconstruction and optimizing return of sensory or motor function. The purpose of this report is to describe outcomes of a free vascularized sural nerve graft to preserve hamstring function in a large proximal sciatic nerve defect beginning at the greater sciatic foramen. A 44-year-old female underwent neoadjuvant chemotherapy and radiation for treatment of a left sciatic nerve synovial cell sarcoma. The patient underwent R0 resection of the proximal left sciatic nerve resulting in a 15 cm defect. An ipsilateral vascularized sural nerve graft was used to reconstruct the medial aspect of the sciatic nerve, prioritizing the tibial division, in an effort to restore hamstring function and plantar sensation. A 5 cm allograft nerve was added to the cutaneous branches of the sural nerve graft to better span the large defect and reconstruct the lateral aspect of the nerve. The patient's postoperative course was uneventful. At 1-year follow-up, the patient showed MRC grade 4/5 strength with knee flexion and steady gait pattern with a left ankle-foot orthosis. Outcomes support the use of a single vascularized nerve graft alongside acellular nerve allograft to restore motor function in large diameter and large defect mixed nerve injuries.

Surgical Outcomes of Primary Dermatofibrosarcoma Protuberans: A Retrospective, Multicenter Study

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive tumor with a low rate of metastatic disease. Previous series have shown a superiority of Mohs micrographic surgery (MMS) compared with wide local excision (WLE). Likewise, there is paucity of data examining the long-term follow-up of patients.

OBJECTIVE

The purpose of the current study was to examine the outcome of surgical treatment of primary DFSP of the trunk and extremities.

METHODS

We reviewed 236 patients (115 females, 121 males, mean age 41 ± 15 years) undergoing MMS (n = 81, 34%) or WLE (n = 155, 66%) to treat a primary DFSP. Mean tumor size and follow-up was 4 ± 2 cm and 7 years, respectively. Final margins were negative in 230 (97%) patients.

RESULTS

There was no difference (p > 0.05) in patient age, sex, tumor size, negative margin excision, or history of a previous inadvertent excision between patients who underwent WLE and those undergoing MMS. There were two cases of local recurrence and two cases of metastasis, with no difference in the 5-year local recurrence-free survival (98% vs. 99%, p = 0.69) or metastatic-free survival (98% vs. 100%, p= 0.27) between WLE and MMS.

CONCLUSION

There was no difference in oncologic outcome comparing MMS with WLE for DFSP outside the head and neck. The goal of treatment for DFSP is to achieve a negative margin, regardless of surgical treatment modalities. A 'less is more' approach to follow-up can likely be taken for patients with completely resected DFSP in easy-to-examine anatomical areas. In these patients, no formal follow-up should be required.

Outcome of Scapular Ewing Sarcoma

BACKGROUND/AIM

Ewing sarcoma is a common primary bone tumor, often located in the distal femur or pelvis. Although the scapula is a flat bone similar to the pelvis, scapular Ewing sarcoma is rare. The aim of this study was to review our institution's experience with the management of scapular Ewing sarcomas.

PATIENTS AND METHODS

We reviewed 9 patients with an Ewing sarcoma of the scapula, which included 5 males and 4 females with a mean age of 19±6 years. All patients were treated with chemotherapy and local control. Local control included surgical resection (n=7) and definitive radiotherapy (n=2). Mean follow-up was 6 years.

RESULTS

Prior to induction chemotherapy, the mean tumor size and volume were 10±2 cm and 181±112 cm3, respectively. Following induction chemotherapy, there was a reduction in the mean tumor size (6±3, p=0.02) and volume (20±12 cm3, p<0.01). The mean tumor necrosis in patients undergoing resection was 72±23%. The median survival was 30-months, and the 5-year disease specific survival was 38%. At most recent follow-up, the mean Musculoskeletal Tumor Society Score was 79±14%.

CONCLUSION

Scapular Ewing sarcoma is a rare, aggressive tumor. Even with chemotherapy and local control with surgery or definitive radiotherapy, patient survival is poor.

Merkel cell carcinoma of unknown primary: Clinical presentation and outcomes

BACKGROUND

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous malignancy that usually occurs in the head/neck or extremities. However, there are reports of MCC developing in the lymph nodes or parotid gland without evidence of a primary cutaneous lesion.

METHODS

We reviewed 415 patients with biopsy-proven MCC. Patients with MCC of unknown primary (n = 37, 9%, MCCUP) made up the study cohort. The primary endpoints of the study were rate of recurrence, disease-free survival, and overall survival.

RESULTS

Patients with MCCUP presented with tumors in lymph nodes (n = 34) or parotid gland (n = 3). Nodal disease was most commonly detected in the inguinal/external iliac (n = 15) or axillary (n = 14) regions. The mean age at diagnosis was 70 years and 24% were female. Patients presented with distant metastases in 24.3% of cases. Patients with stage IIIA disease treated with regional lymph node dissection (RLND) had a lower risk of disease recurrence (hazard ratio 0.26, p = 0.046). Recurrence-free survival was 59.3% at 5 years. Disease-specific survival was 63.3% at 5 years.

CONCLUSION

Patients with MCCUP have a high risk of recurrence and mortality. The optimal treatment for MCCUP has yet to be elucidated, although therapeutic RLND appears beneficial for these patients.

New school technology meets old school technique: Intensity modulated proton therapy and laparoscopic pelvic sling facilitate safe and efficacious treatment of pelvic sarcoma

Purpose

Small bowel tolerance may be dose-limiting in the management of some pelvic and abdominal malignancies with curative-intent radiation therapy. Multiple techniques previously have been attempted to exclude the small bowel from the radiation field, including the surgical insertion of an absorbable mesh to serve as a temporary pelvic sling. This case highlights a clinically meaningful application of this technique with modern radiation therapy.

Methods and Materials

A patient with locally invasive, unresectable high-grade sarcoma of the right pelvic vasculature was evaluated for definitive radiation therapy. The tumor immediately abutted the small bowel. The patient underwent laparoscopic placement of a mesh sling to retract the abutting small bowel and subsequently completed intensity modulated proton therapy.

Results

The patient tolerated the mesh insertion procedure and radiation therapy well with no significant toxic effects. The combination approach achieved excellent dose metrics, and the patient has no evidence of progression 14 months out from treatment.

Conclusions

The combination of mesh as a pelvic sling and proton radiation therapy enabled the application of a curative dose of radiation therapy and should be considered for patients in need of curative-intent radiation when the bowel is in close proximity to the target.

Treatment of giant cell tumors of the distal radius: A long-term patient-reported outcomes study

INTRODUCTION

The distal radius is a common location for giant cell tumors (GCTs) of bone. Management includes intralesional curettage or wide excision, however, long-term comparisons of treatment options are limited. The purpose of the current study was to evaluate our institutions' outcomes of treatment of these tumors.

METHODS

We reviewed 24 GCT of the distal radius in 23 patients (12 males: 11 females) with a mean age of 42 years at the time of surgery. Functional outcomes were collected including the Musculoskeletal Tumor Society Score (MSTS), QuickDash, the Visual Analog Scale (VAS), and the Patient Rated Wrist Evaluation (PRWE). The mean follow-up was 13 years.

RESULTS

Tumor grade included Campanacci Grade II (n = 14) and Grade III (n = 10). Treatment included extended intralesional curettage (n = 16) and wide excision (n = 8). Reconstruction mainly included bone grafting/cement (n = 16) or free vascularized fibula radiocarpal arthrodesis (n = 5). At most recent follow-up, there was no difference in MSTS, VAS, and PRWE (p > 0.05) between patients undergoing a joint sparing or arthrodesis. Patients undergoing arthrodesis had a lower QuickDASH score (13.7 vs. 20.8, p = 0.04) CONCLUSIONS: Treatment for GCT of the distal radius is individualized however in the setting of articular surface involvement, arthrodesis can lead to superior functional results at long-term follow-up.

Impact of racial disparities and insurance status in patients with bone sarcomas in the USA : a population-based cohort study

Aims

Socioeconomic and racial disparities have been recognized as impacting the care of patients with cancer, however there are a lack of data examining the impact of these disparities on patients with bone sarcoma. The purpose of this study was to examine socioeconomic and racial disparities that impact the oncological outcomes of patients with bone sarcoma.

Methods

We reviewed 4,739 patients diagnosed with primary bone sarcomas from the Surveillance, Epidemiology and End Results (SEER) registry between 2007 and 2015. We examined the impact of race and insurance status associated with the presence of metastatic disease at diagnosis, treatment outcome, and overall survival (OS).

Results

Patients with Medicaid (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.15 to 1.72) and uninsured patients (OR 1.90; 95% CI 1.26 to 2.86) had higher risks of metastatic disease at diagnosis compared to patients with health insurance. Compared to White patients, Black (OR 0.63, 95% CI 0.47 to 0.85) and Asian/Pacific Islander (OR 0.65, 95% CI 0.46 to 0.91) were less likely to undergo surgery. In addition, Black patients were less likely to receive chemotherapy (OR 0.67, 95% CI 0.49 to 0.91) compared to White patients. In patients with chondrosarcoma, those with Medicaid had worse OS compared to patients with insurance (hazard ratio (HR) 1.65, 95% CI 1.06 to 2.56).

Conclusion

In patients with a bone sarcoma, the cancer stage at diagnosis varied based on insurance status, and racial disparities were identified in treatment. Further studies are needed to identify modifiable factors which can mitigate socioeconomic and racial disparities found in patients with bone sarcomas.

Cite this article: Bone Joint Res 2022;11(5):278–291.

How Do the Outcomes of Radiation-Associated Pelvic and Sacral Bone Sarcomas Compare to Primary Osteosarcomas following Surgical Resection?

Radiation-associated sarcoma of the pelvis and/or sacrum (RASB) is a rare but challenging disease process associated with a poor prognosis. We hypothesized that patients with RASB would have worse surgical and oncologic outcomes than patients diagnosed with primary pelvic or sacral bone sarcomas. This was a retrospective, multi-institution, comparative analysis. We reviewed surgically treated patients from multiple tertiary care centers who were diagnosed with a localized RASB. We also identified a comparison group including all patients diagnosed with a primary localized pelvic or sacral osteosarcoma/spindle cell sarcoma of bone (POPS). There were 35 patients with localized RASB and 73 patients with POPS treated with surgical resection. Patients with RASB were older than those with POPS (57 years vs. 38 years, p < 0.001). Patients with RASB were less likely to receive chemotherapy (71% for RASB vs. 90% for POPS, p = 0.01). Seventeen percent of patients with RASB died in the perioperative period (within 90 days of surgery) as compared to 4% with POPS (p = 0.03). Five-year disease-specific survival (DSS) (31% vs. 54% p = 0.02) was worse for patients with RASB vs. POPS. There was no difference in 5-year local recurrence free survival (LRFS) or metastasis free survival (MFS). RASB and POPS present challenging disease processes with poor oncologic outcomes. Rates of perioperative mortality and 5-year DSS are worse for RASB when compared to POPS.

Outcomes of Intramedullary Nail Fixation for Metastatic Disease: Impending and Pathologic Fractures

BACKGROUND/AIM

Intramedullary nail (IMN) fixation has become a treatment mean for impending and pathologic femur fractures. Currently there continues to be a lack of data examining functional outcomes, complications, and survivorship of patients treated with IMNs for metastatic disease of the femur.

PATIENTS AND METHODS

We retrospectively identified 183 IMNs placed for impending (n=145) or pathologic (n=38) metastatic fractures from 2010 to 2018. Functional outcomes and complications including blood transfusions, venous thromboembolisms (VTEs) and reoperations were studied.

RESULTS

Patients with impending lesions were more likely to be ambulatory at final follow-up (pathologic: 82%, impending: 99%, p<0.0001) and reported greater musculoskeletal tumor society scores (p<0.0001). Likewise, pathologic fractures were associated with greater discharge to non-home locations (p<0.0001) and were more likely to require a postoperative transfusion (pathologic: 66%, impending: 22%, p=0.0001). However, there was no difference in the incidence of VTEs (p=1.00) or reoperations (p=0.69) between cohorts. Patients treated for impending fractures had improved overall survival at 1 year (54% vs. 26%, p<0.0001).

CONCLUSION

IMN fixation was durable in impending and pathologic femoral fractures. Early identification of metastases remains critical as patients treated for impending lesions had greater functional outcomes, fewer complications and improved survivorship compared to patients treated for pathologic fractures.

Intrinsic Tendon Regeneration After Application of Purified Exosome Product: An In Vivo Study

Background:

Tendons are primarily acellular, limiting their intrinsic regenerative capabilities. This limited regenerative potential contributes to delayed healing, rupture, and adhesion formation after tendon injury.

Purpose:

To determine if a tendon’s intrinsic regenerative potential could be improved after the application of a purified exosome product (PEP) when loaded onto a collagen scaffold.

Study Design:

Controlled laboratory study.

Methods:

An in vivo rabbit Achilles tendon model was used and consisted of 3 groups: (1) Achilles tenotomy with suture repair, (2) Achilles tenotomy with suture repair and collagen scaffold, and (3) Achilles tenotomy with suture repair and collagen scaffold loaded with PEP at 1 × 10¹² exosomes/mL. Each group consisted of 15 rabbits for a total of 45 specimens. Mechanical and histologic analyses were performed at both 3 and 6 weeks.

Results:

The load to failure and ultimate tensile stress were found to be similar across all groups (P ≥ .15). The tendon cross-sectional area was significantly smaller for tendons treated with PEP compared with the control groups at 6 weeks, which was primarily related to an absence of external adhesions (P = .04). Histologic analysis confirmed these findings, demonstrating significantly lower adhesion grade both macroscopically (P = .0006) and microscopically (P = .0062) when tendons were treated with PEP. Immunohistochemical staining showed a greater intensity for type 1 collagen for PEP-treated tendons compared with collagen-only or control tendons.

Conclusion:

Mechanical and histologic results suggested that healing in the PEP-treated group favored intrinsic healing (absence of adhesions) while control animals and animals treated with collagen only healed primarily via extrinsic scar formation. Despite a smaller cross-sectional area, treated tendons had the same ultimate tensile stress. This pilot investigation shows promise for PEP as a means of effectively treating tendon injuries and enhancing intrinsic healing.

Clinical Relevance:

The production of a cell-free, off-the-shelf product that can promote tendon regeneration would provide a viable solution for physicians and patients to enhance tendon healing and decrease adhesions as well as shorten the time required to return to work or sports.

Lymphedema Is a Significant Risk Factor for Failure After Primary Total Hip Arthroplasty

BACKGROUND

Lymphedema is a chronic disease characterized by fluid buildup and swelling that can lead to skin and soft-tissue fibrosis and recurring soft-tissue infections. Literature with regard to the increased risk of complications following a surgical procedure in patients with lymphedema is emerging, but the impact of lymphedema in the setting of primary total hip arthroplasty (THA) remains unknown. The purpose of this study was to review outcomes following primary THA performed in patients with lymphedema compared with a matched cohort without lymphedema.

METHODS

Using our institutional total joint registry and medical records, we identified 83 patients (57 were female and 26 were male) who underwent THA with ipsilateral lymphedema. For comparison, these patients were matched 1:6 (based on sex, age, date of the surgical procedure, and body mass index [BMI]) to a group of 498 patients without lymphedema who underwent primary THA for osteoarthritis. Subsequently, postoperative complications and implant survivorship were evaluated for each group. The mean follow-up for each group was 6 years. Survivorship was compared between cohorts using Kaplan-Meier methodology and included both survivorship free of infection and survivorship free of reoperation or revision. Univariate Cox regression analysis was utilized to assess the association between patient factors for the time to event outcomes noted above.

RESULTS

In patients with a history of lymphedema, there was an increased risk of complications (hazard ratio [HR], 1.97; p < 0.01), including reoperation for any cause (HR, 3.16; p < 0.01) and postoperative infection (HR, 4.48; p < 0.01). The 5-year infection-free survival rate was 90.3% for patients with lymphedema compared with 97.7% for patients without lymphedema (p < 0.01).

CONCLUSIONS

Patients with lymphedema are at increased risk for complications, including reoperation and infection, following primary THA. These data emphasize the importance of appropriate preoperative counseling in this population and should encourage efforts to identify methods to improve outcomes, including further investigation of the effects of preoperative optimization of lymphedema prior to THA and methods for improved perioperative management.

LEVEL OF EVIDENCE

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

Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma

IMPORTANCE

Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred.

OBJECTIVE

To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma.

DESIGN, SETTING, AND PARTICIPANTS

Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021.

EXPOSURES

En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT.

MAIN OUTCOMES AND MEASURES

Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03.

RESULTS

A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.

Preoperative Risk Factors for Fibrosarcomatous Transformation in Dermatofibrosarcoma Protuberans

BACKGROUND/AIM

Dermat of ibrosarcoma protuberans (DFSP) is a soft-tissue sarcoma with a high risk of local recurrence, though typically never metastasizes. DFSP can transform into high-grade fibrosarcoma (DFSP-FS), which has a risk of metastasis. Currently, treatment for DFSP includes Moh's micrographic surgery (MMS); however, this is not recommended for DFSP-FS. Often, the transformation to DFSP-FS is not recognized until the final histological diagnosis. At that point, wide local excision (WLE) of a previous MMS site can be morbid. As such, we analyzed patient risk factors to allow identification of DFSP-FS transformation at presentation.

PATIENTS AND METHODS

We reviewed 368 (174 female, 194 male) patients with a mean age of 42 years from two sarcoma centers. A total of 319 (87%) patients had a history of DFSP and 49 (13%) had DFSP-FS.

RESULTS

When comparing patients with a DFSP to those with a DFSP-FS, patients with a DFSP-FS were more likely (p<0.05) to be older, female and with larger tumors. A painful mass and rapidly enlarging mass were associated with DFSP-FS.

CONCLUSION

Patients who presented with DFSP-FS were found to typically have a larger, painful, and growing mass. Patients with these features should be referred for WLE over MMS at presentation.

Impact of preoperative sarcopenia in patients undergoing sacral tumor resection

INTRODUCTION

Sacral tumor resection is known for a high rate of complications. Sarcopenia has been found to be associated with wound complications; however, there is a paucity of data examining the impact of sarcopenia on the outcome of sacral tumor resection.

METHODS

Forty-eight patients (31 primary sarcomas, 17 locally recurrent carcinomas) undergoing sacrectomy were reviewed. Central sarcopenia was assessed by measuring the psoas:lumbar vertebra index (PLVI), with the 50th percentile (0.97) used to determine which patients were high (>0.97) versus low (<0.97).

RESULTS

Twenty-four (50%) patients had a high PLVI and 24 (50%) had a low PLVI (sarcopenic). There was no difference (p > 0.05) in the demographics of patients with or without sarcopenia. There was no difference in the incidence of postoperative wound complications (odds ratio [OR] = 1.0, p = 1.0) or deep infection (OR = 0.83, p = 1.0). Sarcopenia was not associated with death due to disease (hazard ratio [HR] = 2.04, p = 0.20) or metastatic disease (HR = 2.47, p = 0.17), but was associated with local recurrence (HR = 6.60, p = 0.01).

CONCLUSIONS

Central sarcopenia was not predictive of wound complications or infection following sacral tumor resection. Sarcopenia was, however, an independent risk factor for local tumor recurrence following sacrectomy and should be considered when counseling patients on the outcome of sacrectomy.

Allograft prosthetic composite reconstruction using a reverse total shoulder arthroplasty for failed oncologic proximal humerus reconstruction

INTRODUCTION

Endoprosthetic or allograft reconstruction are the preferred reconstruction techniques for proximal humeral bone tumors. Failure of these reconstructions may occur, but historically revision is performed rarely due to the lack of reliable options. Reverse shoulder arthroplasty with an allograft prosthetic composite (rAPC) may provide a revision option. The purpose of the current study was to evaluate our institutional outcome of these procedures.

METHODS

Eleven (6 male, 5 female) patients (mean age 51 ± 17 years) underwent revision of a failed oncologic reconstruction of the proximal humerus utilizing a rAPC. The most common indication for revision was subluxation (n = 6) and the most common previous implant was an endoprosthesis (n = 5).

RESULTS

Revision resulted in improvements in shoulder elevation (39° vs. 62°, p = 0.02), external rotation (13° vs. 25°, p = 0.04), American Shoulder and Elbow Surgeons score (39 vs. 58, p = 0.004) and Musculoskeletal Tumor Society Scores (51% vs 69%, p = 0.002). There were 2 re-revision procedures performed. One for an allograft fracture and one for allograft resorption and loosening.

CONCLUSIONS

Revision with a rAPC can effectively restore patient function. Due to the complexity of the cases, we advocate for these procedures to be performed by subspecialty upper extremity surgeons trained in complex revision shoulder arthroplasty.