Reconstruction of the extensor mechanism after proximal tibia endoprosthetic replacement

The proximal tibia is a difficult area in which to perform a wide resection of a bone tumor. This difficulty is due to the intimate relationship of tumor in this location to the nerves and blood vessels of the leg, inadequate soft tissue coverage after endoprosthetic reconstruction, and the need to reconstruct the extensor mechanism. Competence of the extensor mechanism is the major determinant of functional outcome of these patients. Between 1980 and 1997, 55 patients underwent proximal tibia resection with endoprosthetic reconstruction for a variety of malignant and benign-aggressive tumors. Reconstruction of the extensor mechanism included reattachment of the patellar tendon to the prosthesis with a Dacron tape, reinforcement with autologous bone-graft, and attachment of an overlying gastrocnemius flap. All patients were followed for a minimum of 2 years; 6 patients (11%) had a transient peroneal nerve palsy, 4 patients (7.2%) had a fasciocutaneous flap necrosis, and 2 patients (3.6%) had a deep wound infection. Full extension to extension lag of 20 degrees was achieved in 44 patients, and 8 patients required secondary reinforcement of the patellar tendon. Function was estimated to be good to excellent in 48 patients (87%). Reattachment of the patellar tendon to the prosthesis and reinforcement with an autologous bone-graft and a gastrocnemius flap are reliable means to restore extension after proximal tibia endoprosthetic reconstruction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results

BACKGROUND AND OBJECTIVES

Uncontrolled metastatic carcinoma of the shoulder girdle is a difficult oncologic problem. This study reviews our experience with palliative forequarter amputation with emphasis on patient selection criteria, preoperative radiologic assessment, surgical technique, epineural postoperative analgesia, and clinical outcome.

METHODS

Eight patients who underwent palliative forequarter amputation for metastatic carcinoma between 1980 and 1999 were analyzed retrospectively. Diagnoses included breast carcinoma (n = 3), squamous cell carcinoma (n = 2), hypernephroma (n = 2), and carcinoma of unknown origin (n = 1). All patients presented with severe, intractable pain and a useless extremity. Venography demonstrated obliteration of the axillary vein in each of the patients in whom this procedure was performed. Exploration of the brachial plexus confirmed tumor encasement and unresectability in all patients. Epineural catheters for bupivacaine infusion were placed for postoperative pain control.

RESULTS

All patients experienced dramatic pain relief and improved mobility and overall function. Life-threatening hemorrhage and sepsis were alleviated. There were no instances of phantom limb pain or adverse psychological reactions, and no complications related to epineural analgesia.

CONCLUSIONS

Palliative forequarter amputation is relatively safe and reliable and provides effective pain relief for selected patients with unresectable metastatic carcinoma to the axilla and bony shoulder girdle in whom radiotherapy and/or chemotherapy has not been effective. The triad of pain, motor loss, and an obliterated axillary vein is indicative of brachial plexus infiltration and unresectability.

Giant cell tumor of the hand: superior results with curettage, cryosurgery, and cementation

At our institution giant cell tumors arising in all locations are treated with curettage, cryosurgery, and cementation to avoid resection or amputation, increase local tumor control over curettage alone, and avoid the morbidity associated with immobilization. We report the oncologic and functional results of 3 patients with giant cell tumors arising from the tubular bones of the hand who were treated in this manner. At a mean follow-up period of 54 months there were no local recurrences. No patient complained of pain. Digital range of motion and grip strength were within normal limits for all 3 patients. All patients returned to their previous occupational and recreational activities. One instance of minor wound necrosis was successfully treated conservatively. There were no other complications (fractures, infections, neuropraxias, or vascular damage). Curettage, cryosurgery, and cementation performed by experienced surgeons appears to be a safe, effective, and reliable method for treating selected giant cell tumors of the hand.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Metastatic renal cell carcinoma of bone: indications and technique of surgical intervention

PURPOSE

We describe the efficacy of surgical excision of metastatic renal cell carcinoma of bone for achieving local tumor control, pain control and functional outcome with emphasis on the indications and techniques of surgical intervention as well as oncological outcome.

MATERIALS AND METHODS

Between 1980 and 1997 we performed surgery on 45 patients (56 lesions) with metastatic renal cell carcinoma of bone. Indications for surgery were solitary bone metastasis, intractable pain, or impending or present pathological fracture. Surgery involved wide excision in 29 cases, marginal excision with adjunctive liquid nitrogen in 25 and amputation in 2.

RESULTS

None of the patients had significant bleeding intraoperatively. Mean hospital stay was 9.8 days, during which there was no flap necrosis, deep wound infection, nerve palsy or thromboembolic complication. Postoperatively pain was significantly relieved in 91% of patients, while 89% achieved a good to excellent functional outcome, and 94% with metastatic lesions of the pelvic girdle and lower extremities were ambulatory. Local recurrence developed in only 4 of the 56 lesions (7.1%), including 3 after marginal resection. Survival was more than 2 years in 22 patients (49%) and more than 3 in 17 (38%).

CONCLUSIONS

Surgical excision is safe and reliable for restoring mechanical bone stability, relieving pain and providing good function in most patients with metastatic renal cell carcinoma who meet the criteria for surgical intervention. Relatively prolonged survival in these cases justifies considering surgical intervention when feasible.

Reconstruction of hip stability after proximal and total femur resections

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

Biopsy of musculoskeletal tumors. Current concepts

Biopsy is a key step in the diagnosis of bone and soft tissue tumors. An inadequately performed biopsy may fail to allow proper diagnosis, have a negative impact on survival, and ultimately necessitate an amputation to accomplish adequate margins of resection. Poorly performed biopsy remains a common finding in patients with musculoskeletal tumors who are referred to orthopaedic oncology centers. The principles by which an adequate and safe biopsy of musculoskeletal tumors should be planned and performed are reviewed, and the surgical approach to different anatomic locations is emphasized.

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

STUDY DESIGN

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

SUMMARY OF BACKGROUND DATA

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role and biology of cryosurgery in the treatment of bone tumors. A review

The application of liquid nitrogen as a local adjuvant to curettage in the treatment of bone tumors was introduced three decades ago. This technique, termed cryosurgery, was shown to achieve excellent local control in a variety of benign-aggressive and malignant bone tumors. However, early reports showed that cryosurgery was associated with a significant injury to the adjacent rim of bone and soft-tissue, resulting in high rates of fractures and infections. These results reflected an initial failure to appreciate the potentially destructive effects of liquid nitrogen and establish appropriate guidelines for its use. We review the biological effect of cryosurgery on bone, surgical technique, and current indications for its use.

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

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

Translocation (12;14) in lipoma: a case report and review of the literature

We report a case of an intramuscular lipoma with the following karyotype: 46,XY,t(12;14) (q14-15;q24). To our knowledge, this is the third report of a t(12;14) as a sole abnormality in a lipoma.

Parosteal osteosarcoma: value of MR imaging and CT in the prediction of histologic grade

PURPOSE

To evaluate the use of magnetic resonance (MR) imaging and computed tomography (CT) for predicting the histologic grade of parosteal osteosarcomas.

MATERIALS AND METHODS

Sixty parosteal osteosarcomas were analyzed for tumor size and location, presence of a cleavage plane, intramedullary extension, soft-tissue mass (distinct from ossified mass), and the presence and pattern of ossification. Axial and longitudinal views were evaluated for specific osseous sites within the bone. Tumors were classified as low grade (grade 1) or high grade (grades 2-3).

RESULTS

There were 32 low-grade lesions and 28 high-grade lesions. Average maximal lengths of low- and high-grade tumors were 7.7 and 15.0 cm, respectively. A cleavage plane was present in 20 (62%) low-grade and 19 (68%) high-grade lesions. On cross-sectional images, intramedullary extension was present in 13 (41%) low-grade and 14 (50%) high-grade lesions. A focal soft-tissue mass distinct from the ossific matrix was identified in 25 (89%) high-grade lesions and in only two (6%) low-grade lesions. All 17 high-grade lesions evaluated with MR imaging were of predominantly high signal intensity on T2-weighted images.

CONCLUSION

A poorly defined soft-tissue component distinct from the ossific matrix is the most distinctive feature of high-grade parosteal osteosarcoma and may be an optimal site for biopsy.

Percutaneous transpedicular biopsy of vertebral body lesions

STUDY DESIGN

This prospective study evaluates the use of transpedicular biopsy in obtaining diagnostic tissue from vertebral body lesions.

OBJECTIVE

To report the authors' experience of all (N = 32) percutaneous transpedicular biopsies performed between 1990-1994.

SUMMARY OF BACKGROUND DATA

Previous articles have discussed the value of open biopsy of the vertebral body using a Craig needle. A large series of closed percutaneous transpedicular biopsies have not been reported.

METHODS

The authors evaluated 32 patients (26 outpatients, six inpatients) who underwent transpedicular biopsy for T1-L4 lesions of the vertebral bodies. None of the tumors had an extraosseous component. Biopsy specimens were obtained from 25 lesions using C-arm fluoroscopy; seven were guided by computed tomography. All biopsies were performed with a 14- to 17-gauge bone biopsy needle.

RESULTS

The needle passed through the pedicle into the site of disease in all patients, as confirmed by C-arm fluoroscopy or computed tomography. There were 22 malignancies; four isolated compression fractures, two at T6, one at T7, one at T8; four cases of infection or inflammation; and one case each of Paget's disease and myelofibrosis. Two patients required a second biopsy because the tissue sample was suspicious for lymphoma but not diagnostic. All 26 outpatients were discharged after a 2-hour observation period. There were no complications.

CONCLUSION

Transpedicular biopsy of deep vertebral body lesions using a bone biopsy needle under computed tomography or fluoroscopy guidance can be performed safely and efficaciously as an outpatient procedure.

Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas

We evaluated the long-term clinical results and the survival of the prostheses in eighty-two patients who had had a limb-sparing procedure by means of the implantation of a large-segment prosthesis. All patients had had a high-grade bone sarcoma of the distal, middle, or proximal part of the femur; the proximal part of the humerus; the proximal part of the tibia; or the pelvis. The duration of follow-up ranged from two to twelve years (median, three and one-half years). Function was evaluated with the revised 30-point classification system of the Musculoskeletal Tumor Society. The survival of the prostheses was analyzed with regard to several variables with use of Kaplan-Meier survival estimates. Sixty-eight patients were alive at the latest follow-up evaluation. The survival rate of the prostheses was 83 per cent at five years and 67 per cent at ten years. Twelve prostheses were revised, and eleven revisions were successful. The rate of revision was highest (six of thirteen) in the patients who had had a tumor of the proximal part of the tibia. In contrast, only three (10 per cent) of the thirty-one patients who had had a tumor of the distal part of the femur and three (10 per cent) of the twenty-nine who had had a tumor of the proximal part of the humerus had a revision. Eleven patients (13 per cent) had an infection, which necessitated an amputation in six. Five patients (6 per cent) had a local recurrence, and nine patients (11 per cent), including the six already mentioned, ultimately needed an amputation. Patients who had had a tumor of the proximal part of the humerus had the highest functional scores, while those who had had a tumor of the proximal part of the tibia had the lowest scores. Large-segment prostheses were a good reconstructive option for the treatment of high-grade bone sarcomas in our patients. The rates of long-term survival of the prostheses were acceptable and the functional results were good or excellent after this form of treatment at most of the anatomical sites at which they were used.

Reconstruction using the saddle prosthesis following excision of primary and metastatic periacetabular tumors

From 1988 to 1991, 17 patients with malignant periacetabular tumors underwent limb-sparing surgery and reconstruction using the saddle prosthesis. There were 8 patients with primary malignant lesions (Group 1), and 9 patients with metastatic or systemic tumor involving the periacetabular pelvis (Group 2). All resections included excision of the acetabulum. Patients ranged in age from 24 to 76 years (average, 59.8 years). Local control was achieved in all patients. Wide margins were obtained in all patients with primary pelvic tumors. Functional outcomes were rated as follows excellent (10), good (2), fair (1), and poor (4). Three patients, all of whom had pulmonary metastasis before surgery, died within 8 months of surgery. Of the remaining 14 patients, 5 patients died between 6 and 28 months after the index procedure. At the end of the followup period, 9 patients were still alive (6 in Group 1 and 3 in Group 2), with a followup period ranging from 15 to 62 months (average, 33.4 months). The overall results for surviving patients were 7 excellent and 2 good results, with no fair or poor results.

Treatment of large subchondral tumors of the knee with cryosurgery and composite reconstruction

The radiographic and clinical outcomes of 9 patients with large benign aggressive or low-grade malignant periarticular tumors of the knee who were treated with cryosurgery and composite reconstruction (cementation, bone graft, and internal fixation) in lieu of primary resection were analyzed. The minimum followup was 2 years (range, 24-103 months). There were 6 giant cell tumors and a single case each of chondroblastoma, chondrosarcoma, and fibrosarcoma in the study group. Six lesions involved the distal femur and 3 the proximal tibia. Functional outcomes were graded according to the Enneking Modified System for the Functional Evaluation of Tumor and The Knee Rating Scale of The Hospital for Special Surgery. All lesions extended to within 2 mm of the articular surface. Local tumor control was achieved in 8 patients (89%). The single local recurrence was successfully managed with repeat curettage, cryosurgery, cementation, and internal fixation. All 9 patients had excellent functional outcomes according to both evaluation scales.

Malignant fibrous histiocytoma at the site of hip replacement in association with chronic infection

A case of malignant fibrous histiocytoma that developed at the site of an infected metallic implant is presented. The total hip endoprosthesis was composed of a cobalt-chromium alloy. There was a relatively short latency period (less than 2 years) between the initial surgery and the development of malignancy in this patient. The authors urge development of a tumor registry to discover if the association between hip replacement and malignancy is coincidental.

Giant cell tumor of the tendon sheath: MR findings in nine cases

OBJECTIVE

The purpose of this study was to determine the MR findings in patients with giant cell tumors of the tendon sheath.

MATERIALS AND METHODS

MR imaging findings in nine surgically proved cases of giant cell tumors of the tendon sheath were evaluated on both T1- and T2-weighted images. Of nine lesions, three involved the foot, two involved the thumb, two involved the knee, one involved the proximal part of the tibia, and one involved the proximal part of the femur.

RESULTS

All nine lesions were hypointense on T1-weighted images; the signal intensity of most of the tumors was approximately equal to that of skeletal muscle. On the T2-weighted images, three lesions were hypointense relative to skeletal muscle, two lesions were approximately isointense relative to skeletal muscle, and two lesions were slightly hyperintense relative to skeletal muscle but hypointense relative to fat. The remaining two lesions had a more heterogeneous appearance on T2-weighted images.

CONCLUSION

On both T1- and T2-weighted images, giant cell tumor of the tendon sheath has a signal intensity similar to that of its pathologic counterpart, pigmented villonodular synovitis. The decreased signal intensity on both T1- and T2-weighted images is an uncommon appearance of extraarticular soft-tissue masses, in particular when they occur in the hands or feet, and this may suggest the diagnosis of giant cell tumor of the tendon sheath.

Analysis of surgical treatment of 33 foot and ankle tumors

Thirty-three patients treated for tumors of the foot and ankle at one cancer institution over a 14-year period were reviewed. There were 15 females and 18 males, with an age range of 1 to 64 years (average 22.6 years). Twenty-one tumors were benign, 11 were malignant, and 1 tumor had metastasized. The most common diagnoses were: fibromatosis (10), aneurysmal bone cyst (4), synovial sarcoma (4), chondrosarcoma (3), and other (12). Surgical procedures included: wide resection (14), local resection (8), curettage and cryosurgery (7), and below-knee amputation (4). Follow-up from surgery was 1 to 13 years (average 7.2 years). There were no local recurrences. Functional results were good-to-excellent in 82% (27/33) of patients. Fifty-five percent (18/33) of the patients were full weightbearing and enjoyed unlimited activity.

Surgical management of pelvic and extremity osteosarcoma

Between 60-80% of all patients with osteosarcomas of the pelvis and the extremities can now be safely treated with limb-sparing surgery. Results (as defined by rates of local recurrence, overall survival, and function) are equal to or better than those associated with amputation. Successful use of limb-sparing procedures, however, depends on a well-developed surgical plan. An understanding of the biologic behavior and growth patterns of these lesions is fundamental. Staging of the primary tumor must involve a full complement of imaging modalities, including plain radiography, bone scintigraphy, computerized axial tomography (CAT), magnetic resonance imaging (MRI), and angiography. The biopsy must be well placed to reduce the possibility of tissue contamination, which is a common reason for amputation. Restaging is necessary before surgery for patients who have undergone neoadjuvant therapy; there is recent evidence that preoperative therapy may make limb-sparing surgery possible in more than 50% of patients who otherwise would have required amputation. Relative contraindications to limb-sparing surgery include major involvement of the neurovascular bundle, pathologic fracture, inappropriate biopsy site, infection, immature skeletal age, and extensive muscle involvement. Each of these factors is relative, and patient selection decisions must be made on an individual basis. Limb-sparing surgery consists of the following three phases: tumor resection, skeletal reconstruction, and soft tissue and muscle transfers. The range of reconstruction techniques has been broadened by developments in bioengineering. Among the more commonly used techniques are custom endoprostheses and allograft replacements. Future progress in induction regimens and reconstructive techniques will undoubtedly enable limb-sparing surgery to be a satisfactory alternative to amputation in even more patients.

Liposarcoma of the extremities: MR and CT findings in the histologic subtypes

The findings on images of liposarcomas of the extremities in 48 patients (26 men and 22 women aged 20-85 years) were reviewed to correlate the histologic subtypes with radiologic appearance. Computed tomographic scans were obtained in 36 patients; magnetic resonance (MR) images, in 27 patients. The study group had 19 myxoid, 12 well-differentiated, nine round cell, and eight pleomorphic liposarcomas. Well-differentiated liposarcomas were predominantly composed of fat, typically with thick septa, which were hyperintense on T2-weighted spin-echo MR images. The heterogeneity of tumor helped differentiate tumor subtypes. Eleven of 19 myxoid tumors were mildly heterogeneous. Round cell and pleomorphic subtypes, which tend to be aggressive, were generally heterogeneous. Well-differentiated liposarcomas may be confidently differentiated from other subtypes of liposarcoma. Except for the well-differentiated subtypes, liposarcomas often contain no fat. Moderate to marked heterogeneity is common in high-grade liposarcomas; myxoid liposarcomas tend to be homogeneous and may mimic cysts.

Staging and treatment of primary and persistent (recurrent) osteoid osteoma. Evaluation of intraoperative nuclear scanning, tetracycline fluorescence, and tomography

The purposes of this study were (1) to evaluate the various methods of preoperative staging of osteoid osteomas, (2) to compare the different methods of intraoperative localization and excision of the tumor, and (3) to develop a clinical strategy for the treatment of persistent (recurrent) lesions. From 1978 until 1986, 14 consecutive patients had excision of osteoid osteomas. All patients' operative reports, roentgenograms, bone scans, computed tomographic scans and histologic studies were reviewed. With an average follow-up period of 94.5 months, 13 of 14 patients were cured with one operative procedure. One patient required two procedures. No patient developed a recurrence. Eleven of 14 niduses were confirmed on hematoxylin and eosin sections. Computed tomographic scan was the most useful preoperative study in localizing the nidus. It helped determine the surgical approach and the portion of bone to be resected. Intraoperative nuclear scanning (IONS) is a reliable technique in confirming complete removal of the nidus, with no increase in operative time. Intraoperative scanning did not appreciably affect the amount of bone resected. Recurrent tumors can be reliably resected, with a high cure rate, by careful preoperative staging and with use of IONS.

Well-differentiated extraskeletal osteosarcoma. A soft-tissue homologue of parosteal osteosarcoma

We describe a unique case of a low-grade extraskeletal osteosarcoma revealing both histologic and radiologic features reminiscent of parosteal osteosarcoma. The tumor, which had been present for 10 years, occurred in the left axilla of a 74-year-old black woman. To date, all the published cases of extraskeletal osteosarcoma have been high-grade neoplasms; to our knowledge, this is the first reported case of a low-grade extraskeletal osteosarcoma.

A new surgical classification system for shoulder-girdle resections. Analysis of 38 patients

A new, six-stage surgical classification system is described for shoulder-girdle resections for patients being treated by limb-sparing procedures for bone and soft-tissue tumors. The classification is based upon current concepts of oncological surgery, the structures removed, the type of resection performed, and the relationship of the resection to the glenohumeral joint, and it indicates the increasing surgical magnitude of the procedure. Data from 38 patients with an average follow-up period of 4.6 years (range, two to 8.4 years) were analyzed. Thirty-two tumors were in bone and six in soft tissue. Eighty-seven percent (33 of the 38 tumors) were malignant. Twenty-four lesions were located in the proximal humerus and 14 in the scapula. The system permitted classification of all shoulder girdle resections done in this study's institutions. The classification is proposed as a means of establishing a uniform terminology in the comparison of such data.

Major amputations done with palliative intent in the treatment of local bony complications associated with advanced cancer

Palliative amputations were performed on 11 patients (7 men, 4 women) with disseminated disease to control local bony complications. The average patient age was 54 years (range 14-78 years). The primary diseases were melanoma/sarcoma (seven patients) and carcinoma (four patients). All had pain; eight had intractable pain that could not be controlled by analgesics. All 11 patients had additional severe local complications, which included recurrent pathological fracture (4), sepsis (2), hemorrhage (2), radiation necrosis (2), and iliofemoral thrombosis secondary to tumor (1). Previous attempts of palliation had been made in all 11 patients, and 8 had undergone previous operative procedures (5 had undergone two or more) prior to amputation. Three anterior hemipelvectomies, five posterior hemipelvectomies, two hip disarticulations, and one forequarter amputation were performed. All patients survived the surgery, and there were no intraoperative complications. All patients received dramatic relief of pain. Postoperative complications included two cases of flap necrosis and two infections; all resolved satisfactorily. The six patients who were nonambulatory before surgery ambulated postoperatively, and two eventually ambulated with a prosthesis. Six of 11 patients survived 1 year or longer, with a median postoperative survival period of 13 months (average 16 months). Although major amputations are viewed at times as offering little to already-compromised patients, they can improve dramatically the quality of life in selected patients.

Postoperative infusional continuous regional analgesia. A technique for relief of postoperative pain following major extremity surgery

A new technique using postoperative infusional continuous regional analgesia (PICRA) for postoperative pain relief was investigated in 23 surgical patients treated by amputation (12 patients) or by limb-salvage resection operations (11 patients). Bupivacaine was delivered into peripheral nerve sheaths via catheters placed therein at the time of surgery. Only patients in whom the nerves were easily accessible were treated. Catheters were placed in the axillary sheath, the lumbosacral trunk, and the femoral nerve sheaths of patients treated with shoulder girdle and pelvic procedures (resections and amputations), and within the sciatic nerve sheath of those treated with lower extremity procedures. The anesthetic agent was delivered at controllable rates. Regional analgesia was obtained in the operative site with minimal motor or sensory decrease. To assess the efficacy of this technique, the results of this study group were compared with those of a matched group of 11 patients treated with similar surgical procedures but who received epidural morphine. Eleven of the 23 patients on PICRA required no supplemental narcotic agents. The mean level of the narcotic agents required by the remaining 13 PICRA patients was approximately one third of that required by the matched group of 11 patients receiving epidural morphine. Overall, the patients on PICRA had an 80% reduction of narcotic requirements when compared to the historical controls. The technique is reliable and can be performed by the surgeon, requiring about a ten-minute increase in operating time. It has potentially wide application in orthopedics in procedures in which the major nerves are easily accessible (e.g., pelvic fractures and revision hip surgery) and for patients with intractable pain of the extremities.

Osteosarcoma. Clinical features and evolving surgical and chemotherapeutic strategies

Osteosarcoma is the most common neoplasm of bone in children and adolescents. The first effective therapy became available in the early 1970s, and although controversy existed for several years regarding the relative value of aggressive multiagent chemotherapy, presently about 60% of patients with resectable primary tumors and no metastases at diagnosis will be cured. New imaging methods, including computerized tomography, magnetic resonance imaging, and radionuclide techniques, that are sensitive to changes in local tumor perfusion have improved the ability to define the extent of tumor and the response to chemotherapy, and to plan surgery. Although amputation historically has been the primary method for local tumor control, newer surgical techniques and endoprosthetic devices, coupled with effective preoperative chemotherapy, have offered less radical surgery for 50% to 80% of patients with osteosarcoma. New therapeutic agents, including ifosfamide and the immunosuppressive drug, muramyl tripeptide phosphatidylethanolamine, hold promise for improvement in the cure rate of osteosarcoma.

Cryosurgery and acrylic cementation as surgical adjuncts in the treatment of aggressive (benign) bone tumors. Analysis of 25 patients below the age of 21

This article reviews the clinical experience with cryosurgery (use of liquid nitrogen) and acrylic cementation (polymethylmethacrylate; PMMA) in the treatment of aggressive, benign bone sarcomas and the biologic basis of this technique. The results of 25 patients below the age of 21 treated by cryosurgery, with an average follow-up period of 60.8 months, are reported. Three approaches to surgical reconstruction were used: Group 1 (four patients) had cryosurgery with no reconstruction, Group 2 (13 patients) had bone graft reconstruction alone, and Group 3 (eight patients) had composite osteosynthesis with internal fixation, bone graft, and/or PMMA. The overall control rate was 96% (one recurrence). The tumor types were giant-cell tumor, chondroblastoma, aneurysmal bone cyst, and malignant giant-cell tumor. Nineteen lesions involved the lower extremity, and six lesions were located in the upper extremity. There were two secondary fractures (8%), one local flap necrosis, and one synovial fistula. There were no infections. Two epiphyseodeses were performed. The functional results were excellent (83%), good (13%), and fair (4%). The technique of composite osteosynthesis is recommended for all large tumors of the lower extremity. Cryosurgical results compare favorably with those obtained by en bloc resection and demonstrate the ability of cryosurgery to eradicate tumors while avoiding the need for extensive resections and reconstructive procedures.

Tumors of the shoulder girdle. Technique of resection and description of a surgical classification

Limb-sparing surgery is safe and reliable for most bone and soft-tissue tumors of the shoulder girdle. Eighty to ninety percent of patients with high-grade sarcomas of the shoulder can be safely treated by the various surgical techniques described. Attention must be paid to appropriate patient selection, preoperative staging, and planning. In addition, careful skeletal and muscular reconstruction of the surgical defect is necessary for a successful outcome. A new, universal, classification schemata (types I-VI) of shoulder girdle resections has been developed. This classification system is based on the bones resected, the status of the abductor mechanism, and the relationship to the glenohumeral joint. This system permits easy description and comparison of the various limb-sparing procedures performed.

Limb-sparing surgery for high-grade malignant tumors of the proximal tibia. Surgical technique and a method of extensor mechanism reconstruction

A surgical technique designed for safe and easy access to the popliteal vessels, resection of a large segment of the tibia and knee joint, and a method of patellar/extensor mechanism reconstruction and soft-tissue coverage that utilizes a transferred medial gastrocnemius muscle is reported. Eleven patients have been treated with this technique, including seven patients with a minimum follow-up evaluation of two years (average, 49.5 months; range, 24.6-84.4 months). There were five males and two females, with an average age of 28.7 years. The histologic diagnoses were osteosarcoma, four patients; malignant fibrous histiocytoma, one patient; chondrosarcoma, one patient; and poorly differentiated sarcoma, one patient. The surgical stages were Stage IIA, one patient, and IIB, six patients. Six intraarticular resections and one extraarticular resection were performed; all were classified as wide excisions. Four prosthetic replacements and three arthrodeses were performed. Pathological specimens showed meniscal and patellar tendon involvement in two patients and pericapsular tibiofibular joint involvement in six patients. Local complications were transient peroneal nerve palsy in four patients and superficial skin slough in one patient. All resections obtained negative margins, and there was no local recurrence or metastatic disease. Functional results (Musculoskeletal Tumor Society System classification) were excellent in one patient, good in four, fair in one, and poor in one. Limb-sparing surgery for high-grade tumors of the proximal tibia is recommended for carefully selected patients.

The effect of cryosurgery and polymethylmethacrylate in dogs with experimental bone defects comparable to tumor defects

The effects of liquid nitrogen (LN) and polymethylmethacrylate (PMMA) on normal bone, bone graft incorporation, and reossification were evaluated by simulating a tumor in dogs with experimental bone cavity. Ten skeletally mature mongrel dogs (20 femora) were divided into three groups: Group I, controls; Group II, LN (with and without bone graft); and Group III, PMMA (with and without LN). Roentgenograms, whole-mount histology, and tetracycline fluorescence studies were performed on the distal femur. Correlation of these studies showed that (1) marked trabecular and bone necrosis, extending 7-12 mm around the circumference of the cavity, developed by three and seven weeks after LN but no bony necrosis occurred after PMMA; (2) the pattern of reossification following cryosurgery was delayed and abnormal, demonstrating increased calcification and metaplastic bone formation; (3) cryosurgery decreased the rate of bone graft incorporation; (4) the cryonecrotic rim following cryosurgery correlated with an abortive attempt at peripheral reossification; and (5) cryosurgery had no effect on the articular cartilage. Cryosurgery is effective in causing bone necrosis, whereas PMMA is not, and the pattern of reossification is delayed and altered by freezing. This study suggests that microvascular thrombosis with subsequent ischemic infarction of bone is a major cause of bone necrosis following cryosurgery.

Estrogen receptor protein in bone and soft tissue tumors

Thirty-three histologically diverse bone and soft tissue tumors were analyzed biochemically for the presence of estrogen receptor protein (ERP) and progesterone receptor by means of a conventional, commercially available, steroid-binding assay (dextran-coated charcoal method) on fresh frozen tissue. These results were compared with analysis of ERP by using a specific monoclonal antibody both in an enzyme immunoassay and on frozen tissue sections by using immunohistochemical procedures. Frozen tissue sections were also examined for the presence of estrogen and progesterone receptors using fluorescein-labeled steroids. Six of the 33 tumors (18%) contained low levels of ERP ranging from 19 to 73 fmol/mg as determined by the dextran-coated charcoal method. The remaining 27 cases contained no (less than 10 fmol/mg) ERP. The ERP-positive group included a fibromatosis, leiomyosarcoma, liposarcoma (2 cases), neural sarcoma, and a synovial sarcoma. Four were high grades sarcomas, and two were low grade sarcomas. There was excellent agreement between the ERP levels determined by the dextran coated charcoal method and those determined by enzyme immunoassay. ERP could not be demonstrated immunohistochemically on frozen tissue sections of the tumors even though it could be demonstrated in breast carcinomas serving as positive controls. The failure of the immunohistochemical technique may be related to the low levels of ERP in these tumors and the difficulty of detecting antigen at threshold levels. Cytochemical localization of receptor protein employing fluoresceinated steroids did not correlate with cytosolic ERP as determined by enzyme immunoassay or the dextran coated charcoal method. Moreover, the high level of background fluorescence gave rise to a significant amount of intraobserver and interobserver variation. Although the clinical significance of ERP protein in mesenchymal tumors is still uncertain, the present findings, coupled with various clinical observations suggesting hormonal dependency of some mesenchymal tumors, indicate that investigation of a larger group of patients amenable to statistical analysis is warranted.

The Tikhoff-Linberg procedure: report of ten patients and presentation of a modified technique for tumors of the proximal humerus

The Tikhoff-Linberg resection is a limb-sparing surgical option to be considered for bony and soft-tissue tumors in and around the proximal humerus and shoulder girdle. Careful selection of patients whose tumor does not involve the neurovascular bundle in the axilla is required. The distal clavicle, upper humerus, and part or all of the scapula are resected. The tumor remains covered by the deltoid muscle plus portions of the muscles that arise from or insert into the resected specimen. In patients with tumors of the proximal humerus a custom prosthesis is used to maintain length and stabilize the distal humerus. Elbow flexion plus stability of the shoulder without the need of an orthosis may be achieved with muscle transfers. Function of the hand and forearm after Tikhoff-Linberg resection should be near normal. Review of results in 10 patients shows no local recurrences and excellent function. The major postoperative problem was nerve palsy. The Tikhoff-Linberg procedure should continue to be used for limb salvage in selected patients with tumors in or around the shoulder girdle.

Surgical management of aggressive and malignant tumors of the proximal fibula

En bloc resection of tumors of the proximal fibula by a specified route allows safe exposure of the popliteal vessels and resection of the fibula, tibiofibular joint, and adjacent musculature. Type I (marginal excision) and Type II (wide intracompartmental resection) procedures performed in ten consecutive patients were evaluated. There were five male and five female patients; the average age was 18.9 years. The histologic diagnoses were osteosarcoma (2 patients), Ewing's sarcoma (3 patients), aggressive osteoblastoma (1 patient), giant cell tumor (3 patients), and "active" osteochondroma (1 patient). All resections achieved negative margins, with no local recurrences from 14 to 37 months after operation. Pathologic specimens showed a high incidence of direct muscle infiltration. Local complications included peroneal palsy (2 patients), flap necrosis (2 patients), and synovial fistula (1 patient). No secondary surgical procedures were required. At follow-up evaluation no knees showed ligamentous instability, and ankle function was good. Selected patients with aggressive (benign) and malignant tumors of the proximal fibula can be treated successfully by resection. A good functional outcome can be anticipated.

Gastrocnemius transposition flap in conjunction with limb-sparing surgery for primary bone sarcomas around the knee

A primary gastrocnemius transposition flap is a useful technique for prosthetic coverage following extensive soft-tissue and bone resection for sarcomas of the knee joint. The gastrocnemius transposition flap is also a useful secondary procedure to treat local complications following attempted limb-sparing surgery. The gastrocnemius transposition flap is a simple procedure with minimal morbidity. Both medial and lateral flaps may be utilized if necessary. In addition, such flaps do not jeopardize local tumor control. We now recommend primary gastrocnemius transposition flaps for most limb-sparing procedures around the knee joint, especially when a prosthesis is utilized with or without adjuvant chemotherapy.

Emergency hemipelvectomy in the control of life-threatening complications

Emergency hemipelvectomy (HP) is a rare procedure. Only three incidents have been previously reported. This paper describes six additional cases, analyzes our results, and sets forth criteria for patient selection. There were five men and one woman. The median age was 38.5 years. Primary underlying diseases were sarcoma (three cases), peripheral vascular disease (one), deep vein thrombosis (one), and drug abuse (one). Life-threatening peripelvic sepsis and hemorrhage were indications for emergency HP. All six patients had multiple procedures prior to definitive HP. Four classical and two modified HPs were performed. The mean operative time was 3.5 hours, the mean blood loss 2292 ml. There were no intraoperative complications. The median duration of hospitalization was 56 days. Five of six patients were saved. Life-threatening peripelvic sepsis or hemorrhage associated with tumor recurrence, radiation, or failed vascular reconstruction is an indication for emergency HP. Neither age nor physical condition should be a deterrent. The patient should not be allowed to advance to a premorbid state before HP is considered, although concomitant intra-abdominal disease is a contraindication. HP is recommended in lieu of hip disarticulation. We anticipate that the need for emergency HP will increase as limb salvage procedures for extremity sarcomas and dysvascular disease become more frequent.

Skip metastases in osteosarcoma: recent experience

Osteosarcoma associated with a skip metastasis (SM) is a rare occurrence. The impact of modern chemotherapy on this entity has not been previously reported. This paper presents three cases treated by primary amputation and postoperative chemotherapy. All patients developed typical pulmonary and subsequent bony metastases. The average disease-free interval was 6.7 months. None appeared to benefit either from intensive chemotherapy or thoracotomy. The disease disseminated extensively in all three patients without radiologic or clinical response to the varied chemotherapeutic or additional surgical procedures. We conclude that a SM is a grave prognostic sign despite modern adjuvant modalities and suggest that a different therapeutic strategy is required.

Unicameral bone cyst with epiphyseal involvement: clinicoanatomic analysis

Epiphyseal involvement of a unicameral bone cyst (UBC) is rare. This anatomic setting represents a distinct clinical and radiographic entity. This study reports a new case and analyzes the clinical and biological behavior of seven additional UBCs with epiphyseal involvement from the literature. We report the first successful treatment of this variant with methylprednisolone acetate. The average age was 20.1 years with a male to female ratio of 1.3:1. Anatomic location: proximal femur (4), proximal humerus (2), and proximal tibia (2). Both age and location were atypical when compared to the classic metaphyseal location. Radiographically, all lesions presented a characteristic involvement of the epiphysis and metaphysis in various proportions. The epiphyseal plates were judged closed versus open in 50%, respectively. Follow-up ranged from 9 months to 3 years. Six cases healed following a single curettage (three with and three without bone graft). There were no late complications of fracture, deformity, shortening, or avascular necrosis. Recurrence was 0%. No secondary procedures were required. We conclude the age, location, and radiographic appearance is atypical and diagnosis is difficult, but the biological behavior is less aggressive and the prognosis more favorable than the typical, metaphyseal UBC. Curettage with or without bone graft has a high success rate. We recommend aspiration and intralesional methylprednisolone as the initial management. We hypothesize that epiphyseal UBCs have a better prognosis than metaphyseal location alone due to the older age, atypical location, and the potential of the epiphysis to reossify.

The effect of the Anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh

The results of surgical treatment in 40 patients with a soft tissue sarcoma of the thigh were analyzed to determine the influence of the anatomic setting on the effectiveness of the procedure. The anatomic setting, based on functional anatomic compartments, was defined as either intra- or extracompartmental. The lesions were graded for aggressiveness as either high or low. The lesions were staged by biologic aggressiveness, anatomic setting, and metastases. The procedures, whether amputations or local resections, were classified by the relationship of the surgical margin to the pseudocapsule and reactive zone about the lesion as marginal, wide, or radical. Marginal procedures were done four times with two recurrences. Wide margins were achieved 12 times. When done for low grade lesions, there were no recurrences (0/2), but when done for high grade lesions, the recurrence rate was 30% (3/10). Radical margins were obtained 24 times. There was one recurrence after a radical procedure. Recurrence rates did not depend upon whether the procedure was a resection or amputation but upon the margin achieved. The anatomic setting of the lesion was intracompartmental in 13 cases and extracompartmental in 27. Not only were surgically adequate margins achieved more often for intracompartmental lesions (10/13) than for extracompartmental lesions (17/27), but there was a significant difference in the manner required to achieve an adequate margin. Although 9 of the 13 intracompartmental lesions were amenable to nonablative resection, only 3 of 27 extracompartmental lesions were resectable. The margin required for local control (wide vs. radical) was dictated by the biologic aggressiveness (grade) of the lesion. How the necessary margin was most satisfactorily achieved (resection vs. amputation) was determined by the anatomic setting (intra- vs. extracompartmental).

Giant cell tumor and aneurysmal bone cyst of the talus: clinicopathological review and two case reports

Two cases of giant cell tumor and aneurysmal bone cyst of the talus were analyzed with a review of eight cases from the literature. This anatomic setting represents a distinct clinical and roentgenographic entity with a less aggressive natural history than the more common sites. All lesions presented a characteristic radiographic involvement of the head and neck of the talus. Eight of ten lesions were treated by curettage, with or without bone grafting, and healed. Two underwent partial en bloc resection. None developed late fracture, recurrence, avascular necrosis, or metastases. We concluded that a giant cell tumor or aneurysmal bone cyst when located in the talus may be difficult to differentiate but tends to exhibit a less aggressive biological behavior and a more favorable prognosis than the more classical proximal lesion. Talectomy is not indicated in the primary treatment. Curettage with or without bone graft has a high success rate. Cryosurgery should be reserved for a recurrent lesion.