Is higher body mass index associated with secondary osteoarthritis in patients treated with bone cement for benign aggressive bone tumors? Long-term evaluation of 43 patients

BACKGROUND

This study was designed to investigate the secondary osteoarthritis rate in patients with benign aggressive bone tumors treated with curettage and cementing at long-term follow up.

METHODS

Patients diagnosed with benign aggressive bone tumor (giant cell or aneurysmal bone cyst), treated with extended curettage and cementation with polymethylmethacrylate, who had a minimum of 60 months of follow up after surgery were included in this study. After definitive diagnoses were confirmed by a histopathologist, we decided to perform standard surgical management. Osteoarthritis was staged radiologically using the Kellgren-Lawrence scoring system, and the contralateral knees of the patients were used as the control group. Based on the Kellgren-Lawrence classification system, stages 3 and 4 were accepted as the existence of osteoarthritis. Body mass index, the distance to the subchondral joint line, tumor mass volume, the location of the tumor (i.e., femur, tibia, medial condyle, or lateral condyle), age, and sex were also investigated, all of which are factors that can affect the occurrence of osteoarthritis.

RESULTS

Forty-three patients, 24 male (56%) and 19 female (44%), were included in the study. The mean age of the patients was 29.5 ± 10 years, and mean follow up duration was 128.7 months. Tumor localization was the distal femur in 20 patients (46.5%) and the proximal tibia in 23 patients (53.5%). The mean tumor mass volume was 77.84 cm3 and the distance to the knee joint subchondral line was 3.2 ± 2 mm. According to this scoring system, 14 patients were at stage 0, 10 patients were at stage 1, 10 patients were at stage 2, four patients were at stage 3, and five patients were at stage 4. When we compared osteoarthritis development, the affected knee had a significantly higher rate of osteoarthritis development than the contralateral knee. A univariate analysis demonstrated that age (P = 0.002) and body mass index (P = 0.045) were associated with secondary osteoarthritis. Moreover, multivariate analysis demonstrated that none of the variables were independently associated with secondary osteoarthritis.

CONCLUSION

Patients with contralateral osteoarthritis had bilateral knee osteoarthritis, indicating that primary osteoarthritis progressed in both knees. Seven of the 43 patients (16.2%) showed secondary osteoarthritis. Although age and body mass index were associated with secondary osteoarthritis in univariate analysis, none of the variables were independently associated with secondary osteoarthritis in the multivariate analysis.

Is liquid nitrogen recycled bone and vascular fibula combination the biological reconstruction of choice in lower extremity long bone tumor-related defects?

INTRODUCTION

Combination techniques, which encompass the combined use of vascularized bone grafts with massive allografts or autografts (recycled bone grafts), are especially important in the biological reconstruction of tumor-related lower extremity long bone defects. Liquid nitrogen recycled bone (frozen autograft) and free vascular fibula graft (FVFG) combination, which was coined as the "frozen hotdog (FH)" method by the authors, has not been as widely used nor its outcomes reported for significantly sized patient groups. This study aims to provide an answer to whether FH is a safe and effective reconstructive tool for limb salvage in malignant tumors of the lower extremity regarding radiological, functional, and oncological outcomes.

PATIENTS AND METHODS

Sixty-six (male/female: 33/33) patients, who underwent FH reconstruction for tumor-related massive defects of lower extremity long bones between 2006 and 2020, were retrospectively analyzed. The mean age was 15.8 (3.8-46.7) years. The most common tumor localizations were distal femur (42.4%) and proximal tibia (21.2%) while classic osteosarcoma and Ewing's sarcoma were the most common pathologies (60.6% and 22.7%, respectively). Mean resection and FVFG lengths were 160 (90-320) mm and 192 (125-350) mm, respectively. The mean follow-up was 73.9 (24-192) months.

RESULTS

The mean MSTS score was 25.4 (15-30) and the mean ISOLS radiographic score was 22.6 (13-24). Mean time to full weight bearing without any assistive devices was 15.4 (6-40) months and the median time was 12 months. MSTS score negatively correlated with resected segment length and vascular fibula length (p < 0.001; p = 0.006). Although full contact apposition of the FH segment correlated with earlier full weight bearing compared to partial apposition (mean 13.7 vs. 17.9 months) (p = 0.042), the quality of reduction did not affect the ISOLS radiographic score at LFU. Overall limb survival rate was 96.3% at 5 and 10 years while FH survival rate was 91.0% and 88.1% at 5 and 10 years. Local recurrence-free survival rates were 88.8% and 85.9%, and overall survival was 89.9% and 86.1% at 5 and 10 years, respectively. Limb length discrepancy was the most common complication with 34 (51.5%) patients while shell nonunion was seen in 21 (31.8%) patients and graft fracture in 6 (9.1%).

CONCLUSION

The "FH" method is a safe, effective, and extremely cost-efficient reconstructive tool for tumor-related lower extremity long bone defects. Patient compliance to protracted weight-bearing, ensuring the vitality of the FVFG, and achieving an oncologically safe resection are key factors for a successful outcome.

Femoral Discrepancy After Childhood Bone Sarcoma Surgery Can Be Treated With Magnetic Intramedullary Nails

This study aims to determine whether femoral lengthening with a magnetic motorized intramedullary nail (PRECICE; NuVasive) is safe and effective in patients with discrepancy due to limb salvage performed for bone sarcomas before skeletal maturity. Six patients (male, 4; female, 2) with a mean age of 9.3 years (range, 4.8-12.8 years) at the time of index limb salvage surgery were retrospectively analyzed. Four patients had undergone biological reconstruction with liquid-nitrogen recycled frozen autograft shell and inlaid vascular fibula combination and 2 had undergone nonbiological reconstruction with distal femur modular tumor endoprosthesis. The mean age at PRECICE operation was 16.1 years (range, 13.4-20.1 years). The mean prelengthening femoral discrepancy was measured as 60 mm (range, 39-80 mm). Lengthening was achieved in 5 of these 6 patients. Although the PRECICE nail was successfully implanted in the sixth patient, lengthening could never be performed owing to failure to overcome the chronic diaphyseal nonunion first, as intended with compressive use of the nail. For the other 5 patients, in whom lengthening was performed, the mean lengthening was 45 mm (range, 35-52 mm), the mean ratio of achieved to planned lengthening was 93% (range, 74%-100%), and the mean bone-healing index was 41 days per cm (range, 24-69 days per cm). Mean Musculoskeletal Tumor Society score improved from 25.6 to 27.2 after lengthening. No major complications occurred. The outcomes of this study demonstrate that the PRECICE implant can safely and effectively correct femoral length discrepancy caused by limb salvage performed for osteosarcoma before skeletal maturity. [Orthopedics. 2023;46(1):27-34.].

Long-term results of different surgical options in the management of solitary enchondroma

BACKGROUNDS

We aimed to compare the average 10-year results of patients treated with three different surgical methods, that is, extended curettage, extended curettage with grafting and extended curettage with cementation for the management of solitary enchondromas.

METHODS

Two hundreds and three patients with a solitary enchondroma who underwent surgery at our department between 1990 and 2015 were evaluated retrospectively. Only extended curettage was performed in Group A (n: 75), extended curettage with grafting with autologous bone graft from the iliac crest in Group B (n: 58), and extended curettage with bone cement in Group C (n: 70). Surgical complications and recurrence were analysed and compared between these groups.

RESULTS

No significant differences were noted among the groups in terms of gender (P = 0.654), age (P = 0.264) and follow-up duration (P = 0.919). The mean follow-up period in all groups was 122.9 ± 39 (range: 60-271) months. In addition to curettage and cementation, three patients received mechanical support with plate screws because of fracture risk. One patient in the extended curettage with grafting group had surgical site infection that was treated with simple debridement and antibiotherapy. One patient in the extended curettage group had lost motions of the proximal interphalangeal joint, which was treated with aggressive physiotherapy.

CONCLUSION

We compared the average 10-year results of patients treated with three surgical options, namely, extended curettage, extended curettage with grafting, and extended curettage with cementation and no difference was found among the groups in local control of solitary enchondromas.

Relationship of Postoperative Achilles Tendon Elongation With Plantarflexion Strength Following Surgical Repair

BACKGROUND

Little data exist regarding the adverse effects of Achilles tendon (AT) elongation after rupture repair on plantarflexion strength. This study aimed to investigate the effect of AT elongation measured using AT resting angle (ATRA) on the plantarflexion strength in patients with surgically treated acute AT rupture.

METHODS

A retrospective chart review was performed on 40 patients (15 female and 25 female) who underwent open operative repair due to an acute AT rupture. At the final follow-up, AT elongation was assessed using ATRA. Plantarflexion strength (peak torques and angle-specific torques) was measured using an isokinetic dynamometer. All variables were obtained from the operated and unoperated contralateral ankles of the patients.

RESULTS

The mean ATRA was greater in the operated ankles (mean, 57 degrees; range, 39-71 degrees) compared with the unoperated ones (mean, 52 degrees; range, 36-66 degrees; P = .009). Except the plantarflexion torque at 20 degrees of plantarflexion (P = .246), all the other angle-specific torques were lower in the operated ankles (P < .05). Peak flexion torque at 30 degrees/s was lower in the operated ankle (P = .002). A negative correlation was found between operated/unoperated (O/N) ATRA and O/N plantarflexion torque ratios at 0 degrees (r = -0.404; P = .01), 10 degrees (r = -0.399; P= .011), and 20 degrees (r = -0.387; P = .014).

CONCLUSION

Postoperative AT elongation measured using ATRA may have a deleterious effect on the plantarflexion strength in patients with surgically treated acute AT rupture.

LEVEL OF EVIDENCE

Level IV, case series.

Neoadjuvant radiotherapy for myxoid liposarcomas: Oncologic outcomes and histopathologic correlations

OBJECTIVE

The aim of this study was to evaluate the histopathological features of primary extremity myxoid liposarcoma before and after neoadjuvant radiation therapy, and to evaluate the oncological outcomes of the patients.

METHODS

The study included 23 patients (16 men and 7 women with a mean age of 43 (24-69) years) with primary myxoid liposarcoma of the extremities, who were treated between January 1998 and December 2015. Inclusion criteria were histopathological confirmation of the diagnosis with both the initial biopsy and the resection specimen, and having undergone neoadjuvant radiotherapy. Demographic, clinical and histopathological data were evaluated.

RESULTS

Over a mean follow-up time of 55.2 (8-139) months, 5 patients (21.7%) died secondary to disease progression, leaving 18 patients (78.3%) still alive at the time of last follow-up. Only one patient (4%) experienced local recurrence and six (26%) patients developed distant metastases. Disease-free survival at 5 and 10 years were 66%; whereas, overall patient survival at 5 and 10 years were 78.1% and 71.0%, respectively. Tumor size (>15 cm) and presence of metastasis were significantly associated with increased overall mortality. On histopathology, necrosis was present in 12/23 resection specimens. Hyalinization/fibrosis and residual viable tumor was present in all specimens. Adipocytic maturation/cytodifferentiation was seen in 8/23 patients.

CONCLUSION

Neoadjuvant radiotherapy was effective for myxoid liposarcomas histopathologically, although these histopathological features did not affect the patients' oncological outcomes. Favorable oncological outcomes were obtained with neoadjuvant radiotherapy, surgical resection and chemotherapy.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Two-year experience with cell salvage in total hip arthroplasty

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.