Controversies in orthopaedic oncology

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures

BACKGROUND

Dislocation rates after hemiarthroplasty reportedly vary from 1% to 17%. This serious complication is associated with increased morbidity and mortality rates. Approaches to this surgery are still debated, with no consensus regarding the superiority of any single approach.

AIM

To compare early postoperative complications after implementing the direct anterior and posterior approaches (PL) for hip hemiarthroplasty after femoral neck fractures.

METHODS

This is a comparative, retrospective, single-center cohort study conducted at a university hospital. Between March 2008 and December 2018, 273 patients (a total of 280 hips) underwent bipolar hemiarthroplasties (n = 280) for displaced femoral neck fractures using either the PL (n = 171) or the minimally invasive direct anterior approach (DAA) (n = 109). The choice of approach was related to the surgeons' practices; the implant types were similar and unrelated to the approach. Dislocation rates and other complications were reviewed after a minimum follow-up of 6 mo.

RESULTS

Both treatment groups had similarly aged patients (mean age: 82 years), sex ratios, patient body mass indexes, and patient comorbidities. Surgical data (surgery delay time, operative time, and blood loss volume) did not differ significantly between the groups. The 30 d mortality rate was higher in the PL group (9.9%) than in the DAA group (3.7%), but the difference was not statistically significant (P = 0.052). Among the one-month survivors, a significantly higher rate of dislocation was observed in the PL group (14/154; 9.1%) than in the DAA group (0/105; 0%) (P = 0.002). Of the 14 patients with dislocation, 8 underwent revision surgery for recurrent instability (posterior group), and one of them had 2 additional procedures due to a deep infection. The rate of other complications (e.g., perioperative and early postoperative periprosthetic fractures and infection-related complications) did not differ significantly between the groups.

CONCLUSION

These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate (< 1%) than the PL.

Acute total hip replacement by direct anterior approach combined with intrapelvic fixation for geriatric acetabular fracture of the anterior column

Management of anterior column acetabular fracture in the elderly is challenging. Open reduction and internal fixation do not allow early weight bearing and are associated with a high risk of failure compared to younger patients. Therefore, acute fixation and total hip arthroplasty may be an option. This technical note describes a combined procedure: anterior intrapelvic approach for fracture fixation and a direct anterior approach to the hip for THR. Fracture reduction and arthroplasty were achievable in all five patients. The mean operative time was 289min, and the mean blood loss was 2120mL. At short term, no complication was noticed. Combining these two "muscle-sparing" approaches could help manage anterior column fractures in elderly patients. Level of evidence: IV.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Outcome of Surgically Treated Leiomyosarcoma of the Extremities: A Retrospective Overview

AIM

This study was interested in extremity leiomyosarcoma with focus on clinical outcome after surgery with or without adjuvant therapy.

PATIENTS AND METHODS

A retrospective case series of all patients with leiomyosarcoma, surgically treated between 2000 and 2015 and a minimum follow-up of 2 years, was drawn from institutional databases in Belgium and the Netherlands. Postoperative complications were reported with the Radiation Therapy Oncology Group (RTOG) and the Henderson classification.

RESULTS

Seventy-five patients were operated on, of whom 47 underwent (neo)adjuvant therapy. Infection was observed in 11 patients, seven associated with (neo)adjuvant radiotherapy. Dermatological complaints were observed in 26 patients, 10 associated with (neo)adjuvant radiotherapy. Overall survival was 60%. Local recurrence occurred in 11 (15%) patients.

CONCLUSION

This study describes favourable clinical outcome following (neo)adjuvant radiotherapy. In the future, larger databases on leiomyosarcoma should enhance the power of these findings and define the benefits of adjuvant therapy in leiomyosarcoma.

Aseptic Loosening after Total Hip Arthroplasty in an Acromegalic Patient: A Case Report

Introduction:

Acromegaly is a rare disorder characterized by excess secretion of growth hormone and its principle mediator, insulin-like growth factor-1. Although acromegaly is frequently associated with osteoarthritis, the outcome of arthroplasty in this population is not documented.

Case Report:

We report here a case of aseptic loosening of an uncemented total hip arthroplasty acetabulum in an acromegalic patient that was revised with a cemented cup. It has been suggested that the incidence of this complication is increased in other pathology with a similarly high bone-turnover (e.g., Paget’s disease), but this complication has however not yet been reported in the setting of acromegaly.

Conclusion:

Although coincidence cannot be ruled out, multiple metabolic hypotheses could account for an altered osseointegration process in the presence of acromegaly, which could lead to a higher risk of loosening.