Improved nationwide survival of sarcoma patients with a network of reference centers

BACKGROUND

We investigated the impact of the implementation of a network of reference centers for sarcomas (NETSARC) on the care and survival of sarcoma patients in France since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTBs), funded by the French National Cancer Institute (INCa) since 2010. Its aims are to improve the quality of diagnosis and care of sarcoma patients. Patients' characteristics, treatments, and outcomes are collected in a nationwide database. The objective of this analysis was to compare the survival of patients in three periods: 2010-2012 (non-exhaustive), 2013-2015, and 2016-2020.

RESULTS

A total of 43 975 patients with sarcomas, gastrointestinal stromal tumors (GISTs), or connective tissue tumors of intermediate malignancy were included in the NETSARC+ database since 2010 (n = 9266 before 2013, n = 12 274 between 2013 and 2015, n = 22 435 in 2016-2020). Median age was 56 years, 50.5% were women, and 13.2% had metastasis at diagnosis. Overall survival was significantly superior in the period 2016-2020 versus 2013-2015 versus 2010-2012 for the entire population, for patients >18 years of age, and for both metastatic and non-metastatic patients in univariate and multivariate analyses (P < 0.0001). Over the three periods, we observed a significantly improved compliance to clinical practice guidelines (CPGs) nationwide: the proportion of patients biopsied before surgery increased from 62.9% to 72.6%; the percentage of patients presented to NETSARC MDTBs before first surgery increased from 31.7% to 44.4% (P < 0.0001). The proportion of patients with R0 resection on first surgery increased (from 36.1% to 46.6%), while R2 resection rate decreased (from 10.9% to 7.9%), with a better compliance and improvement in NETSARC centers.

CONCLUSIONS

The implementation of the national reference network for sarcoma was associated with an improvement of overall survival and compliance to guidelines nationwide in sarcoma patients. Referral to expert networks for sarcoma patients should be encouraged, though a better compliance to CPGs can still be achieved.

Improved Metastatic-Free Survival after Systematic Re-Excision Following Complete Macroscopic Unplanned Excision of Limb or Trunk Soft Tissue Sarcoma

BACKGROUND

Whether re-excision (RE) of a soft tissue sarcoma (STS) of limb or trunk should be systematized as adjuvant care and if it would improve metastatic free survival (MFS) are still debated. The impact of resection margins after unplanned macroscopically complete excision (UE) performed out of a NETSARC reference center or after second resection was further investigated.

METHODS

This large nationwide series used data from patients having experienced UE outside of a reference center from 2010 to 2019, collected in a French nationwide exhaustive prospective cohort NETSARC. Patient characteristics and survival distributions in patients reexcised (RE) or not (No-RE) are reported. Multivariate Cox proportional hazard model was conducted to adjust for classical prognosis factors. Subgroup analysis were performed to identify which patients may benefit from RE.

RESULTS

Out of 2371 patients with UE for STS performed outside NETSARC reference centers, 1692 patients were not reviewed by multidisciplinary board before treatment decision and had a second operation documented. Among them, 913 patients experienced re-excision, and 779 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, size, depth, grade and histotype in patients re-excised (RE) or not (No-RE). In univariate analysis, final R0 margins are associated with a better MFS, patients with R1 margins documented at first surgery had a better MFS as compared to patients with first R0 resection. The study identified RE as an independent favorable factor for MFS (HR 0.7, 95% CI 0.53-0.93; p = 0.013). All subgroups except older patients (>70 years) and patients with large tumors (>10 cm) had superior MFS with RE.

CONCLUSIONS

RE might be considered in patients with STS of limb or trunk, with UE with macroscopic complete resection performed out of a reference center, and also in originally defined R0 margin resections, to improve LRFS and MFS. Systematic RE should not be advocated for patients older than 70 years, or with tumors greater than 10 cm.

Low rate of periprosthetic femoral fracture with the Hueter anterior approach using stems cemented according to the 'French paradox'

Aims

The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the 'French paradox' principles through the Hueter anterior approach (HAA) in patients older than 70 years.

Methods

From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.

Results

Among the 416 THAs, two PFFs (0.48% (95% confidence interval 0.13 to 1.74)) were observed, including one Vancouver type B2 fracture 24 days postoperatively and one intraoperative Vancouver type B1 fracture. Valgus malalignment and higher canal bone ratio were found to be associated with PFF.

Conclusion

This study demonstrated that short CK femoral components cemented according to the French paradox were associated with a low rate of early PFF (0.48%) in patients aged over 70 years. Longer follow-up is warranted to further evaluate the rate of fracture that may occur during the bone remodelling process and with time.

The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) is a valid and reliable measure to assess psychological readiness before returning to sport following peroneal tendon pathology surgery

PURPOSE

The objective of this study was to validate a scale that could help surgeons evaluate patients' psychological readiness to return to sport (RTS) after peroneal tendon pathology surgery.

METHODS

The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale, which had previously been validated in ankle ligament reconstruction patients, was adapted to evaluate the psychological preparedness for RTS in athletic patients who underwent peroneal tendinopathy surgery. The Foot and Ankle Outcome Score (FAOS) and Foot Ankle Ability Measurement (FAAM) scores were employed as patient-related outcome measurement (PROM) instruments.

RESULTS

This study included 57 patients. There was a strong correlation between ALR-RSI and both FAOS and FAAM (r = -0.68 and 0.74, respectively). ALR-RSI was considerably higher in patients who returned to sports than in those who did not. The mean score was 72.9 ± 19.0 in patients who returned to the same preinjury level, 48.5 ± 24.0 in those who returned to a lower level and 53.6 ± 31.1 in patients who changed their athletic activity (p < 0.0001). Furthermore, ALR-RSI showed at least a similar discrimination ability when compared to FAOS and FAAM. The test-retest intraclass correlation coefficient was 0.95. The Cronbach's α statistic used to measure the internal consistency was high (0.95). A Youden index of 0.65 was observed for a cut-off score of 68 points.

CONCLUSION

ALR-RSI is a valid instrument for assessing psychological readiness to RTS in an athletic population following peroneal tendon surgery. When compared to the most commonly used PROMs, it was strongly correlated and demonstrated at least similar discrimination capacity. This could assist surgeons in identifying athletes who will have poor postoperative results and advising them on their capability to RTS.

LEVEL OF EVIDENCE

Level III.

Validation of the Ankle Ligament Reconstruction-Return to Sports after Injury (ALR-RSI) Score as a Tool to Assess Psychological Readiness to Return to Sport in an Active Population After Ankle Fracture Surgery: A Cross-sectional Study

Ankle injuries account for 15% to 25% of all sports injuries resulting in significant pain and loss of function. The purpose of this cross-sectional study was to validate a scale to help surgeons quantify the psychological readiness to Return To Sport (RTS) in patients undergoing ankle fracture surgery. ALR-RSI was used to assess the psychological readiness for RTS in athletic patients who underwent ankle fracture fixation between January 2020 and January 2021. Participants filled out ALR-RSI and 2 Patient-Related Outcome Measurement (PROM) tools: Olerud-Molander Ankle Score (OMAS) and Self-Reported Foot and Ankle Score (SEFAS). A total of 93 patients were included. There was a strong correlation between ALR-RSI and both OMAS and SEFAS, with Pearson coefficients of r = 0.58 and 0.53, respectively. ALR-RSI was significantly higher in the RTS group than in those who no longer practiced their main preinjury sport. Moreover, the discriminant validity of ALR-RSI (AUC = 0.81) was better than that of the SEFAS and OMAS (AUC = 0.64 and 0.65, respectively, p = .001). The intra-class correlation coefficient ρ of 0.94 showed excellent reproducibility. At an optimal cutoff value of 76.7, ALR-RSI had a sensitivity of 81% and a specificity of 75% with a Youden index of 0.56. In conclusion, ALR-RSI was a valid and reproducible tool to evaluate the psychological readiness for RTS in an active population after an ankle fracture. This score could help surgeons identify athletes who may have unfavorable postoperative outcomes and provide support on the ability to RTS.

Severe Postoperative Pain in Total Knee Arthroplasty Patients: Risk Factors, Insights and Implications for Pain Management via a Digital Health Approach

Up to 25% of patients undergoing knee arthroplasty report chronic pain postoperatively. Early identification of high-risk individuals can enhance pain management strategies. This retrospective analysis investigates the incidence of severe postoperative pain and its associated risk factors among 740 patients who underwent total knee arthroplasty. Utilizing a digital application, patients provided comprehensive data encompassing pre- and postoperative pain levels, analgesic usage, and completed a chronic pain risk assessment. Participants were categorized into two distinct groups based on their pain status at three months post-op: Group D+ (14%), characterized by pain scores exceeding 40/100 and/or the utilization of level 2 or 3 analgesics, and Group D- (86%), who did not meet these criteria. An analysis of pain trajectories within these groups revealed a non-linear progression, with specific patterns emerging amongst those predisposed to chronic pain. Notably, patients with a trajectory towards chronic pain exhibited a plateau in pain intensity approximately three weeks post-surgery. Significant preoperative risk factors were identified, including elevated initial pain levels, the presence of comorbidities, pain in other body areas, heightened joint sensitivity and stiffness. This study highlights the utility of digital platforms in enhancing patient care, particularly through the continuous monitoring of pain. Such an approach facilitates the early identification of potential complications and enables timely interventions.

Initial Active Surveillance Strategy for Patients with Peripheral Sporadic Primary Desmoid-Type Fibromatosis: A Multicentric Phase II Observational Trial

BACKGROUND

Stabilization or spontaneous regressions are demonstrated in more than half of patients affected by primary desmoid-type fibromatosis (DF) in retrospective studies. The objective of this phase II study was to prospectively assess the behavior of primary sporadic DT managed by active surveillance (AS).

METHODS

This prospective, multicenter, observational study (NCT01801176) included patients ≥18 years of age with primary sporadic DF located in an extremity or the abdominal/thoracic wall. At inclusion, all patients were initially placed on AS. Follow-up was based on clinical and radiological evaluation by magnetic resonance imaging (MRI) performed at 1, 3, 6, 9, and 12 months, and then every 6 months for 3 years. The primary endpoint was progression-free survival (PFS) at 3 years according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, as evaluated by a Central Review Board.

RESULTS

Between 2012 and 2015, 100 patients were enrolled. The female/male ratio was 8 and the median age was 34 years (interquartile range [IQR] 30.8-43.9). Median follow-up was 46.6 months (IQR 36.8-61.1) and the 3-year PFS was 53.4% (95% confidence interval 43.5-63.1%). At progression (48 patients), 23 patients received active treatment. Fifty-eight patients (58%) presented with spontaneous tumor regression (decrease > 0% compared with the initial size) during the first 3 months (n = 35, 35%) or after an initial progression (n = 23, 23%), of whom 26 (26%) had partial responses (PRs). The median time to PR was 31.7 months (25.3-not available).

CONCLUSIONS

These data support the use of AS as the primary approach to select patients with peripheral DF who require aggressive treatment.

What to improve: Results of fixed-hinge knee endoprosthesis reconstructions over 40 years in a single tumor center

INTRODUCTION

Over the past decades, numerous structural changes in implants, medical treatments, and surgical techniques have been made for Malignant Bone Tumors (MBT) around the knee. However, the overall care improvement is still unclear. The method is crucial when analyzing outcomes in surveys involving tumors, and a thorough assessment of the mortality is mandatory because death acts as competing event. The aims of this study were: 1) a comprehensive and longitudinal assessment of the revisions with an extensive follow-up and adequate methods; 2) a complete mortality review to consider competing risks.

HYPOTHESIS

The hypothesis was that some prosthesis's structural improvements were made while the surgical toll increased as well as an improvement of mortality was also expected.

MATERIAL AND METHODS

Analyses were performed on 248 patients with MBT (mean follow-up was 8.7 years, surgeries between 1972 and 2017). Three prosthesis models were successively used over time: 120 Guepar (older model), 42 Tornier, and 86 Stanmore (more recent model). The primary outcome was the assessment of revisions sorted out according to Henderson: type-1 soft-tissue failures or instability, type-2 aseptic loosening, type-3 structural failures, type-4 periprosthetic infections, type-5 tumoral progression. Death and amputations were considered as competing events. An extensive assessment of mortality was performed by merging the dataset with the French register of Deaths (INSEE). Cumulative probabilities were computed at 2, 5, 10, and 15 years and compared with Gray's tests.

RESULTS

The overall 5-year survival was, 80% (95% CI: 73-87) for Guepar, 69% (95% CI: 56-84) for Tornier, and 71% (95% CI: 62-82) for Stanmore (p=0.4). The 5-year cumulative risks for type-1 were 5% (95% CI: 1-9), 9% (95% CI: 0-18), and 17% (95% CI: 9-25) for Guepar, Tornier, and Stanmore, respectively (p=0.01). The 15-year cumulative risks for type-2 were 22% (95% CI: 15-39), 8% (95% CI: 0-17) and 8% (95% CI: 2-14) for Guepar, Tornier, and Stanmore, respectively (p=0.10). Ten patients had an implant failure, nine Guepar, and one Tornier. The 5-year cumulative risks for type-4 were 7% (95% CI: 2-12), 19% (95% CI: 7-31), and 12% (95% CI: 5-18) for Guepar, Tornier, and Stanmore, respectively (p=0.08). There were 29 tumoral progressions; the 15-year risks were 16% (95% CI: 2-22), 2% (95% CI: 0-7%), and 12% (95% CI: 4-19%) for Guepar, Tornier, and Stanmore, respectively (p=0.08). No difference whatsoever was found between the proximal tibial and distal femur.

CONCLUSION

There were some improvements in prosthesis design (forged steel instead of cast steel) and probably also in cemented stem fixation, but not in prosthetic joint infection and local recurrence over forty years. The overall mortality did not change significantly over the last 40 years amongst this specific cohort of patients who benefited from a hinge reconstruction prosthesis.

LEVEL OF EVIDENCE

III; comparative case series with sensibility analysis.

Unusual entrapment symptomatology treated in 115 cases by neurolysis of the common fibular nerve at the fibular head combined with neurolysis of the posterior tibial nerve at the tarsal tunnel

INTRODUCTION

Entrapment of the common fibular nerve (CFN) at the head of the fibula and entrapment of the posterior tibial nerve (PTN) at the tarsal tunnel are the most common nerve entrapment syndromes in the lower limb. Our aim was to study the results of combined neurolysis of the CFN and PTN for chronic lower limb pain. We hypothesized that combined neurolysis allowed a reduction of this chronic pain.

MATERIAL AND METHOD

This bi-centric retrospective study took place from January 2015 to November 2018, with a single senior surgeon. The inclusion criteria were all patients operated on for an idiopathic entrapment syndrome with neurolysis of the PTN at the tarsal tunnel, combined with neurolysis of the CFN at the head of the fibula. The primary endpoint was the pain evolution assessed on a numerical analogue scale (NAS) preoperatively and postoperatively on D+21, and at the last follow-up. The secondary endpoint was to determine the prognostic factors on the clinical outcome of neurolysis.

RESULTS

One hundred and fifteen neurolysis were included, comprising 64 women and 38 men with a mean age of 57±17.6 years. The preoperative pain (NAS0) was evaluated at 6±2.4 points. At D+21 postoperatively, there was a significant reduction in pain (NASD+21: 3±2.6 points, p<0.01). Similarly, at the last follow-up (with a mean follow-up of 37±8.4 months), there was a significant reduction in pain (NASLFU: 2±2.5, p<0.01). A history of systemic inflammatory disease was the only factor associated with a less significant decrease in pain at D+21, according to a multivariate analysis (p<0.01). There were 14 complications (12%) not requiring revision surgery.

CONCLUSION

This study is the first to demonstrate the efficacy of combined neurolysis of the CFN at the head of the fibula and the PTN at the tarsal tunnel, in the treatment of idiopathic nerve entrapment syndrome of the lower limb.

LEVEL OF EVIDENCE

IV; Retrospective comparative study.

Digital Rehabilitation after Knee Arthroplasty: A Multi-Center Prospective Longitudinal Cohort Study

Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient's pain, participation, and speed of recovery. Furthermore, most digital systems lack human support in case of need. The aim of this study was to investigate the engagement, safety, and clinical effectiveness of a personalized and adaptative app-based human-supported digital monitoring and rehabilitation program. In this prospective multi-center longitudinal cohort study, 127 patients were included. Undesired events were managed through a smart alert system. Doctors were triggered when there was a suspicion of problems. The drop-out rate, complications and readmissions, PROMS, and satisfaction were collected through the app. There was only 2% readmission. Doctor actions through the platform potentially avoided 57 consultations (85% of alerts). The adherence to the program was 77%, and 89% of the patients would recommend the use of the program. Personalized human-backed-up digital solutions can help to improve the rehabilitation journey of patients after TKA, lower healthcare-related costs by lowering the complication and readmission rate, and improve patient reported outcomes.

Surgical site infection after pelvic bone and soft tissue sarcoma resection: Risk factors, microbiology, and impact of extended postoperative antibiotic prophylaxis

BACKGROUND

Pelvic bone and/or soft tissue sarcoma removal surgeries are associated with a high rate of surgical site infection (SSI). The recommended antibiotic prophylaxis (ABP) duration is 24-48 h. We aimed to assess the impact of extended ABP (5 days) on the SSI rate and describe the microbiology of SSI in bone and/or soft tissue pelvic sarcomas.

METHODS

We retrospectively included all consecutive patients who underwent pelvic bone and/or soft tissue sarcoma removal surgery between January 2010 and June 2020.

RESULTS

We analyzed 146 patients with pelvic bone (45, 31%) or soft tissue (101, 69%). Sixty patients (41%) developed SSI. SSI occurred in 13/28 (46.4%) in the extended ABP group versus 47/118 (39.8%) in the standard group (p = 0.53). In multivariable analysis, risk factors for SSI were surgery duration (OR: 1.94 [1.41-2.92] per h), stay in postoperative ICU for more than 2 days (12.0 [2.8-61.3]), and shred or autologous skin flap (39.3 [5.8-409.5]). Extended ABP was not associated with SSI. SSI were mainly polymicrobial with Enterobacterales (57.4%) and Enterococcus (45%).

CONCLUSIONS AND DISCUSSION

Pelvic bone and/or soft tissue sarcoma removal surgery is highly prone to postoperative infection. Extending the ABP to 5 days does not reduce the level of SSI.

Management and outcomes of adolescent and young adult sarcoma patients: results from the French nationwide database NETSARC

BACKGROUND

The initial management of patients with sarcoma is a critical issue. We used the nationwide French National Cancer Institute-funded prospective sarcoma database NETSARC to report the management and oncologic outcomes in adolescents and young adults (AYAs) patients with sarcoma at the national level.

PATIENTS AND METHODS

NETSARC database gathers regularly monitored and updated data from patients with sarcoma. NETSARC was queried for patients (15-30 years) with sarcoma diagnosed from 2010 to 2017 for whom tumor resection had been performed. We reported management, locoregional recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) in AYA treated in French reference sarcoma centers (RSC) and outside RSC (non-RSC) and conducted multivariable survival analyses adjusted for classical prognostic factors.

RESULTS

Among 3,227 patients aged 15-30 years with sarcoma diagnosed between 2010 and 2017, the study included 2,227 patients with surgery data available, among whom 1,290 AYAs had been operated in RSC, and 937 AYAs in non-RSC. Significant differences in compliance to guidelines were observed including pre-treatment biopsy (RSC: 85.9%; non-RSC 48.1%), pre-treatment imaging (RSC: 86.8%; non-RSC: 56.5%) and R0 margins (RSC 57.6%; non-RSC: 20.2%) (p < 0.001). 3y-OS rates were 81.1% (95%CI 78.3-83.6) in AYA in RSC and 82.7% (95%CI 79.4-85.5) in AYA in non-RSC, respectively. Whereas no significant differences in OS was observed in AYAs treated in RSC and in non-RSC, LRFS and PFS were improved in AYAs treated in RSC compared to AYAs treated in non-RSC (Hazard Ratios (HR): 0.58 and 0.83, respectively).

CONCLUSIONS

This study highlights the importance for AYA patients with sarcoma to be managed in national sarcoma reference centers involving multidisciplinary medical teams with paediatric and adult oncologists.

Biology and Management of High-Grade Chondrosarcoma: An Update on Targets and Treatment Options

This review provides an overview of histopathology, clinical presentation, molecular pathways, and potential new systemic treatments of high-grade chondrosarcomas (CS), including grade 2−3 conventional, dedifferentiated, and mesenchymal CS. The diagnosis of CS combines radiological and histological data in conjunction with patient clinical presentations. Conventional CS is the most frequent subtype of CS (85%) and represents about 25% of primary bone tumors in adults; they can be categorized according to their bone location into central, peripheral, and periosteal chondrosarcomas. Central and peripheral CS differ at the molecular level with either IDH1/2 mutations or EXT1/2 mutations, respectively. CDKN2A/B deletions are also frequent in conventional CS, as well as COL2A1 mutations. Dedifferentiated CS develops when low-grade conventional CS transforms into a high-grade sarcoma and most frequently exhibits features of osteosarcoma, fibrosarcoma, or undifferentiated pleomorphic sarcoma. Their molecular characteristics are similar to conventional CS. Mesenchymal CS is a totally different pathological entity exhibiting recurrent translocations. Their clinical presentation and management are different too. The standard treatment of CSs is wide en-bloc resection. CS are relatively radiotherapy resistant; therefore, doses >60 Gy are needed in an attempt to achieve local control in unresectable tumors. Chemotherapy is possibly effective in mesenchymal chondrosarcoma and is of uncertain value in dedifferentiated chondrosarcoma. Due to resistance to standard anticancer agents, the prognosis is poor in patients with metastatic or unresectable chondrosarcomas. Recently, the refined characterization of the molecular profile, as well as the development of new treatments, allow new therapeutic options for these rare tumors. The efficiency of IDH1 inhibitors in other malignancies suggests that these inhibitors will be part of IDH1/2 mutated conventional CS management soon. Other treatment approaches, such as PIK3-AKT-mTOR inhibitors, cell cycle inhibitors, and epigenetic or immune modulators based on improving our understanding of CS molecular biology, are emerging.

Netrin-1 Secreted by Human Osteoarthritic Articular Chondrocytes Promotes Angiogenesis in Vitro

OBJECTIVE

Netrin-1 expression in articular cartilage is correlated with osteoarthritic changes. We aimed to investigate the contribution of Netrin-1 secreted by human osteoarthritic articular chondrocytes to angiogenesis process in vitro.

DESIGN

Human articular chondrocytes were extracted from non-osteoarthritic (n = 10) and osteoarthritic (n = 22) joints obtained from surgical specimens and incubated for 24 hours. Medium conditioned by non-osteoarthritic and osteoarthritic articular chondrocytes were collected. Human umbilical vein endothelial cells (HUVEC) were treated with control and conditioned medium and assessed using assays for cell adherence, migration, and tube formation. Netrin-1 expression and secretion was compared between non-osteoarthritic and osteoarthritic chondrocytes by qPCR, Western blot, and ELISA. The role of chondrocyte-secreted Netrin-1 on HUVEC functions was assessed by immunological neutralization using an anti-Netrin-1 monoclonal antibody.

RESULTS

As compared with medium conditioned by non-osteoarthritic chondrocytes, medium conditioned by osteoarthritic chondrocytes permitted tube formation by HUVEC. Both non-osteoarthritic and osteoarthritic chondrocytes expressed Netrin-1 at the RNA and protein levels. At the RNA level, Netrin-1 expression did not differ between non-osteoarthritic and osteoarthritic chondrocytes. At the protein level, Netrin-1 appeared as a full protein of 64 kDa in non-osteoarthritic chondrocytes and as two cleaved proteins of 55 kDa and 64 kDa in osteoarthritic chondrocytes. Immunological neutralization of endogenous Netrin-1 reduced the pro-angiogenic and pro-inflammatory transcriptional profile of HUVEC treated with the medium conditioned by osteoarthritic chondrocytes, as well as their capacities to form tubes.

CONCLUSIONS

Medium conditioned by osteoarthritic chondrocytes permits tube formation by HUVEC in vitro. This permissive effect is mediated by Netrin-1.

Is the osteosynthesis of lateral malleolar fractures by pin/cerclage effective? A retrospective study

INTRODUCTION

Lateral malleolar fractures are present in about 90% of ankle fractures. The standard treatment is plate osteosynthesis. Although the plates are thin, the risk of cicatricial complications is not insignificant and can lead to cutaneous or even infectious complications and the latter can cause functional repercussions. We therefore aimed to evaluate a technique consisting of osteosynthesis of the lateral malleolus using two cerclages and two intramedullary pins.

HYPOTHESIS

Our hypothesis is that the use of osteosynthesis by pin/cerclage of the lateral malleolus makes it possible to have objective reduction criteria, similar to the reference treatment.

METHODS

This is a retrospective study of patients who had an interligamentous spiral fracture of the lateral malleolus. One group of patients had internal fixation of the lateral malleolus fracture by pins, and the other by plate. Our primary outcome was to compare the reduction of the fracture of the lateral malleolus between the two techniques using the "Dime sign", the measurement of the talocrural angle and respect for Shenton's line.

RESULTS

A total of 118 lateral malleolar fractures were included: 56 patients (47.5%) in the "pin" group and 62 patients (52.5%) in the "plate" group. The mean age of the patients was 46.6 years (17.4) with an average body mass index of 25.2kg/m² (4.8) and 55.1% of the patients were women. We found a difference in the reduction criteria between the two groups by looking at Shenton's line: 73.2% (41/56) of postoperative X-rays in the "pin" group respected Shenton's line, compared to 90.3% (56/62) in the "plate" group (p=0.02). We did not find any difference regarding the "Dime sign" and the talocrural angle.

CONCLUSION

Our study shows the superiority of plate osteosynthesis for lateral malleolar fractures compared to pin/cerclage osteosynthesis, regarding one of the three radiological criteria for reduction. No significant difference was found in the one-year rates of complications and of hardware removal, between the two groups.

LEVEL OF EVIDENCE

IV, retrospective study.

Does delayed weight bearing in the surgical management of fractures of the upper end of the femur in the elderly lead to more complications? A prospective study

INTRODUCTION

Fractures of the upper end of the femur (FUEF) lead to increased mortality and dependence in the elderly. However, mechanical complications after surgery persist in up to 20% of cases, which may justify a delayed resumption of full weight bearing to protect the osteosynthesis during consolidation.

HYPOTHESIS

Our hypothesis was that the late resumption of weight bearing in an elderly population after a FUEF would be limited by a higher frequency of medical complications.

METHODS

This was a prospective monocentric study including patients aged 80 or over with an isolated FUEF requiring osteosynthesis. The operator decided on the discharge. The primary endpoint was to show a difference in a medical complication score created for this study (APRETAR), between a group with, and a group without, weight bearing delayed by 45 days.

RESULTS

Between 2016 and 2019, 254 patients (88±5.6 years, 77.6% women) were included, and of these, 70 (27.6%) had delayed weight bearing. The mean APRETAR at 45 days was greater in the delayed weight bearing group (5.9±8.6 vs. 5.7±11.0; p<0.001). One-year mortality was 12.6% (32 patients), with no difference between the two groups (p=0.51). The level of dependence was significant (IADL at 2.2±1.7), with some comorbidities (Charlson at 2.9±2.2 and CIRS-G at 6.5±4.3) and all comparable across the two groups but with low cognitive levels, especially in the group with delayed weight bearing (MMSE 15.9±10.7 vs. 21±6.9; p<0.001).

CONCLUSION

This prospective study shows that delaying weight bearing in the elderly population, even for mechanical problems with FUEF, statistically increases medical complications but in a clinically acceptable manner.

LEVEL OF EVIDENCE

II, Prospective cohort study.

Time is Money! Influence on Operating Theater and Sterilization Times of Patient-specific Cutting Guides and Single-use Instrumentation for Total Knee Arthroplasty: A Full Factorial Design of 136 Patients

Background

Patient-specific cutting guides (PSGs) and single-use disposable instrumentation (SUI) have emerged as potential beneficial innovations for total knee arthroplasty. The aim of this study was to evaluate the impact of PSG and SUI for total knee arthroplasty on operating room (OR) and sterilization times.

Methods

A monocentric, prospective, interventional, full factorial design study, including 136 patients, compared patient-specific (PSG, n = 68) to conventional cutting guides (n = 68) and SUI (n = 68) to conventional instrumentation (CVI, n = 68). In the OR, we recorded the number of instrument trays, operating time, and room occupancy time. In the central sterile services department, the total sterilization duration was assessed. The primary outcome was operating time and sterilization duration. Secondary outcomes were difference in the number of trays, Oxford Knee Score, and postoperative mechanical axis.

Results

The median operating time was 80 minutes (Q1-Q3: 73-90) and was significantly increased for SUI compared to that for CVI (+5 minutes, P = .0072). The median sterilization duration was 1261 minutes (Q1-Q3: 934-1603). It was significantly in favor of SUI (936 minutes) over CVI (1565 minutes) (+629 minutes, P < .0001). The total number of instrument trays was 404 for 136 patients: 252 for CVI and 152 for SUI (P < .0001) and 189 for PSG and 215 for conventional cutting guides (P = .0006). There was no significant difference in OKS (P = .86) nor in the postoperative alignment which was between 177° and 183° (75% patients, P = .24).

Conclusions

SUI lowers the number of instrument trays and sterilization duration. PSG is not associated with significant OR or sterilization time reduction. The use of SUI could reduce the risk of noncompliance of instrument trays.

Overall survival in patients with re-excision of positive microscopic margins of limb and trunk wall soft tissue sarcoma operated outside of a reference center: a nationwide cohort analysis

Background

This French nationwide NETSARC exhaustive prospective cohort aims to explore the impact of systematic re-excision (RE) as adjuvant care on overall survival (OS), local recurrence free survival (LRFS), and local and distant control (RFS) in patients with soft tissue sarcoma (STS) with positive microscopic margins (R1) after initial resection performed outside of a reference center.

Methods

Eligible patients had experienced STS surgery outside a reference center from 2010 to 2017, and had R1 margins after initial surgery. Characteristics and treatment comparisons used chi-square for categorical variables and Kruskall-Wallis test for continuous data. Survival distributions were compared in patients reexcised (RE) or not (No-RE) using a log-rank test. A Cox proportional hazard model was used for subgroup analysis.

Results

A total of 1,284 patients had experienced initial STS surgery outside NETSARC with R1 margins, including 1,029 patients with second operation documented. Among the latter, 698 patients experienced re-excision, and 331 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, tumor size, tumor depth, and histotype in the population of patients re-excised (RE) or not (No-RE). The study identified RE as an independent favorable factor for OS (HR 0.36, 95%CI 0.23–0.56, p<0.0001), for LRFS (HR 0.45, 95%CI 0.36–0.56, p<0.0001), and for RFS (HR 0.35, 95%CI 0.26–0.46, p<0.0001).

Conclusion

This large nationwide series shows that RE improved overall survival in patients with STS of extremities and trunk wall, with prior R1 resection performed outside of a reference center. RE as part of adjuvant care should be systematically considered.

Level of evidence II

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10121-5.

Soft tissue sarcoma incidences and clinical characteristics are significantly different in France and Taiwan

BACKGROUND

The incidence of different soft tissue sarcoma (STS) histotypes among ethnic and geographic populations has not been comprehensively investigated.

METHODS

Data from 2013 to 2016 were obtained from national cancer registry databases in France and Taiwan. Liposarcoma (LPS), leiomyosarcoma (LMS), angiosarcoma (AS), synovial sarcoma (SS), and malignant peripheral nerve sheath tumor (MPNST) were selected as index STSs to estimate the age-standardized incidence rates (ASRs) and other clinical features between patients.

RESULTS

In total, 9398 patients (7148 from France and 2250 from Taiwan) were included. The ASRs of AS (5.4 vs. 2.8) and MPNST (2.0 vs. 1.0) were significantly higher in Taiwan; France had significantly higher ASRs for LPS (12.0 vs. 10.0), LMS (9.7 vs. 7.6), and SS (1.7 vs. 1.2). Patients in Taiwan with LMS or LPS were younger than their French counterparts. With regard to the distribution according to primary anatomic site, French patients had higher odds for extremity and truncal LMS (odds ratio [OR], 2.84; p < .001), AS (OR, 2.67; p < .001), MPNST (OR, 1.55; p = .027), and LPS (OR, 1.38; p < .001) and for breast AS (OR, 10.58; p < .001). Taiwanese patients had higher odds for liver AS (OR, 10.72; p < .001) and uterine LMS (OR, 3.21; p < .001). SS age and distribution according to primary anatomic site did not differ significantly between the French and Taiwanese populations.

CONCLUSIONS

Significant differences in the incidence and clinical characteristics of index STS suggested that geographic (environmental) and ethnicity factors likely play a vital role in the pathogenesis of STS.

Intercalary allograft reconstruction following femoral tumour resection: mid- and long-term results and benefits of adding a vascularised fibula autograft

Purpose

Bone healing in femoral reconstructions using intercalary allografts can be compromised in a tumour context. There is also a high revision rate for non-union, infection, and fractures in this context. The advantages and disadvantages of an associated vascularised fibula graft (VFG) are still a matter of debate.

Methods

In a multicentre study, we retrospectively analysed 46 allograft reconstructions, operated on between 1984 and 2017, of which 18 were associated with a VFG (VFG+) and 28 without (VFG−), with a minimum follow-up of 2 years. We determined the cumulative probability of bone union as well as the mid- and long-term revision risks for both categories by Kaplan-Meier survival analysis and a multivariate Cox model. We also compared the MSTS scores.

Results

Significant differences in favour of VFG+ reconstruction were observed in the survival analyses for the probability of bone union (log-rank, p = 0.017) and in mid- and long-term revisions (log-rank, p = 0.032). No significant difference was observed for the MSTS, with a mean MSTS of 27.6 in our overall cohort (p = 0.060). The multivariate Cox model confirmed that VFG+ was the main positive factor for bone union, and it identified irradiated allografts as a major risk factor for the occurrence of mid- and long-term revisions.

Conclusion

Bone union was achieved earlier in both survival and Cox model analyses for the VFG+ group. It also reduced the mid- and long-term revision risk, except when an irradiated allograft was used. In case of a tumour, we thus recommend using VFG+ from a fresh-frozen allograft, as it appears to be a more reliable long-term option.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02650-x.

Resection and extemporaneous coverage of a soft tissue sarcoma with a pedicled groin flap in the trochanteric region: Technical note

The main issues pertaining to oncological surgery of the musculoskeletal system are tumour resection with sufficient margins, and the coverage of inherent defects. We report the use of a pedicled cutaneous groin flap as coverage for a trochanteric defect following an oncological resection of a grade III pleomorphic soft tissue sarcoma in a 75-year-old patient. This flap is not routinely used in the coverage of a defect in this region. The interest of this original process lies in its technical ease, and in the possibility of lifting the flap directly after resection, without changing the set-up.

Sarcomas of the hand: A retrospective series of 26 cases

BACKGROUND

Hand sarcomas frequently suffer from a delayed diagnosis, and the current guidelines for their management are often not followed.

METHODS

The objectives of our study were to determine: (1) the rate of inadequate initial treatments; (2) the rates of mortality, recurrence, and complementary excision in a cohort of patients with a sarcoma of the hand who were treated at our reference center between 2000 and 2015.

RESULTS

The series comprised 26 patients (mean age 40 years). Of the 20 patients not initially treated at a reference center, 17 had inadequate initial treatment. Of the six patients treated at our center, one had inadequate initial care. Significantly more patients had inadequate initial care outside a reference center (p=0.0045). The cumulative probabilities of recurrence or metastases at 5 years were 15% and 30%, respectively. Survival by cumulative incidence was 71% at 5 years and 56% at 10 years.

CONCLUSIONS

Sarcomas of the hand are a deadly pathology. All diagnostic uncertainty warrants referral of the patient to a reference center.

LEVEL OF PROOF

IV.

Acetabular reconstruction after advanced acetabular metastasis resection: Modified Harrington technique with a Kerboull reinforcement device

The surgical treatment of acetabular bone metastases rests on total hip arthroplasty (THA). In the event of major bone defects, the reconstruction may prove challenging. Two complicating factors are the need to obtain a mechanically stable acetabulum and the unfeasibility of using an autograft to increase the bone stock. The technique described in 1981 by Harrington involves implanting steel rods to reinforce the pelvis before sealing the prosthetic cup. We have now been using this technique for several years, and based on our accumulated experience we introduced several substantial modifications. The most important among them is the use of a Kerboull acetabular reinforcement device (KARD) in addition to the iliac pins. This reinforcement of the acetabulum, which is widely used for THA, serves as the basis for guiding the reconstruction, while also facilitating the sealing of the prosthetic cup. Furthermore, we use centrally threaded rods to avoid secondary displacement. Finally, we routinely use a dual-mobility cemented cup to decrease the risk of dislocation. Here, we describe our acetabular reconstruction technique based on a modified Harrington technique, which is used for acetabular reconstruction in patients with advanced acetabular metastases managed at our French referral centre.

Proximal femur versus acetabular extra-articular resection of the hip joint for primary malignant bone tumors: a retrospective comparative review of 33 cases

Introduction

Extra-articular resection (EAR) of the hip joint is prone to significant complications and morbidity. Thus, this study evaluates the cumulative incidences and main reasons of reoperation following EAR of primary malignant bone tumors (PMBT) of the hip to determine whether the outcomes are different between EAR of the pelvis and that of the proximal femur.

Patients and methods

Thirty-three patients presented with a PMBT of the proximal femur or pelvis were included in this study. Among all PMBTs, 58% originated from the pelvis and 42% were from the proximal femur. Twenty patients had chondrosarcomas (61%), 10 had osteosarcomas (30%), and 3 had sarcomas of another histological subtype (9%).

Results

The mean follow-up was of 76 months (range: 24–220 months). The cumulative probabilities of revision for any reason were 52% (95% confidence interval [CI] 30–70%) 5 years after surgery. The 5-year cumulative probabilities of revision were 13% (95% CI 4–27%), 24% (95% CI 10–42%), and 34% (95% CI 14–56%) for mechanical, infectious, and tumoral reasons, respectively. The 5-year cumulative probabilities of revision for any reason were 78% (95% CI 37–94%) and 14% (95% CI 2–38%) for the pelvis and proximal femur, respectively (p = 0.004). Posterior column preservation was significantly associated with more mechanical complications even after adjusting for the resection site (p = 0.043).

Conclusion

Half of patients undergoing EAR of the hip joint for PMBT of the proximal femur or acetabulum will require another operation. EAR of the pelvis is associated with significantly worse outcome than EAR of the proximal femur.

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial

IMPORTANCE

Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period.

OBJECTIVE

To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019.

INTERVENTIONS

Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR.

MAIN OUTCOMES AND MEASURES

The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale.

RESULTS

A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01671917.

Rare bone sarcomas: A retrospective analysis of 145 adult patients from the French Sarcoma Group

The benefit of chemotherapy (CT) in rare bone sarcomas is not documented in prospective studies. Our retrospective study from the French sarcoma network for bone tumors ResOs was performed in adult patients (pts) from 1976 to 2014, with histologically verified diagnosis of leiomyosarcomas (LMS), undifferentiated pleomorphic sarcoma (UPS) or radiation-associated sarcomas of bone. The median follow-up was 4.7 years (95% CI: 3.7-6.5). Clinical features, treatment modalities and outcomes were recorded and analyzed from 145 pts (median age 53 years [range 20-87]). Site of disease was extremities (66%) or axial skeleton (34%), 111 (77%) presented with localized and potentially resectable disease. The most common histological subtypes were UPS (58%) and LMS (33%); 58% were high-grade tumors. Surgery was performed in 127 pts. In the 111 localized pts, 28 pts (25%) underwent upfront surgery or exclusive radiotherapy (RT; >50 Gy) without CT, whereas 83 pts (75%) received either neoadjuvant (n = 26) or adjuvant CT (n = 13) or both (n = 44). Neoadjuvant and adjuvant CT was mostly doxorubicin-based (95%/86%) and cisplatin-based (67%/63%). R0 resection was achieved in 59 pts, and a good histological response in 15 patients (25%). Adjuvant RT was performed in 24 (22%) pts. For the whole cohort (n = 145), the 5-year overall survival (OS) rate was 53% [42; 62]. In univariate analysis, age ≤ 60 was associated with a longer disease-free survival (DFS) (P = .0436). Neoadjuvant and adjuvant CT tended to be associated with better DFS (P = .056) with no significant impact on OS in this retrospective series.

Ankle CT scan allows better management of posterior malleolus fractures than X-rays

PURPOSE

Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture.

METHODS

A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m²) (11.4 kg/m²) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver's agreement were compared between conventional X-rays and CT scan.

RESULTS

Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [- 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]).

CONCLUSION

A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

TRIAL REGISTRATION NUMBER

2218999v0, date of registration: 11/08/2020 (retrospectively registered).

Does using the direct anterior approach with a standard table for total hip arthroplasty reduce leg length discrepancies? Comparative study of traction table versus standard table

INTRODUCTION

Primary total hip replacement (THR) comes with a risk of leg length discrepancy (LLD), which occurs in 25 % of cases, especially when the surgery is done using an anterior approach on a traction table, since it is not easy to verify the lengths of the legs. By doing the anterior approach on a standard table an intraoperative visual evaluation of leg lengths can be done after the trial implants are in place. As far as we know, the ability to set the leg length has not been compared between procedures done on a standard table or a traction table. This led us to carry out a retrospective comparative study to determine whether using a standard table for anterior THR will 1) allow better control over leg length, 2) increase the risk of incorrect implant positioning, 3) increase the surgical complication rate.

HYPOTHESIS

Anterior THR on a standard table will allow better control over leg length than anterior THR on a traction table.

MATERIAL AND METHODS

This single center retrospective study included 266 THRs done between January 1, 2018 and November 2, 2019 for primary (n=219) or secondary (n=47) hip osteoarthritis. The 137 cases done with a traction table were compared to the 129 cases with a standard table. The two groups were comparable in terms of age, sex, body mass index, indication and bilateral implants. They were not comparable in the surgeon experience (more junior surgeons in the standard table group [p<0.001]) and types of implants used (more cementless cups and stems in the standard table group [p=0.001]). Radiographs were used to measure the LLD, cup inclination, and femoral stem placement in the frontal plane. Any early complications were documented. The target was for the operated leg to be the same length as the contralateral leg, which was defined as within 10mm of each other.

RESULTS

The mean postoperative LLD was comparable between the traction table group 1.56±7.32 mm (min -15.6 max 17.2) and the standard table group 0.53±6.93 mm (min -16.4 max 13.7) (p=0.24). In the traction table group, 81 % (111/137) of patients had legs of the same length, versus 84 % (109/129) in the standard table group (p=0.7). Cup inclination was comparable with a mean of 40.4±7.1 degrees (min 23.4; max 58.5) in the traction table group versus 39.3±7.5 degrees (min 19.9; max 60.9) in the standard table group (p=0.21). The frontal position of the femoral stem was comparable between groups with a mean of 0.09±0.45 degrees (min -1; max 3.98) in the traction table group versus 0.08±0.59 degrees (min -4.97; max 1.93) in the standard table group (p=0.86). There were 5 complications (3.7 %) in the traction table group versus 11 (8.5 %) in the standard table group (p=0.16).

CONCLUSION

Use of a standard table to carry out THR by the direct anterior approach does not provide better control over leg length than using a traction table, subject to preoperative planning. When doing the procedure on a standard table, the implant placement is at least comparable, with a similar risk of complications.

LEVEL OF EVIDENCE

III; case matched study.

Parosteal osteosarcoma associated with a low-grade component mimicking well-differentiated liposarcoma: a case report

Parosteal osteosarcomas and well-differentiated liposarcomas are both well-differentiated locally aggressive tumors. They both have simple karyotypes with amplification of the 12q13-15 regions including MDM2 and CDK4 genes. In this report, we describe the case of a parosteal osteosarcoma intertwined with a low-grade component similar to a well-differentiated liposarcoma. The association of a bone component with an adipose component was initially overlooked. We describe the histological, imaging, and molecular characteristics of this tumor stressing the importance of radio-pathological correlation. To our knowledge, this is the second report of a parosteal osteoliposarcoma. Awareness of this rare presentation may allow radiologists and surgeons to recognize the peripheral fatty component as an integral part of the tumor.

The ankle ligament reconstruction-return to sport after injury (ALR-RSI) is a valid and reproducible scale to quantify psychological readiness before returning to sport after ankle ligament reconstruction

PURPOSE

Chronic ankle instability is the main complication of ankle sprains and requires surgery if non-operative treatment fails. The goal of this study was to validate a tool to quantify psychological readiness to return to sport after ankle ligament reconstruction.

METHODS

The form was designed like the anterior cruciate ligament-return to sport after injury scale and "Knee" was replaced by the term "ankle". The ankle ligament reconstruction-return to sport after injury (ALR-RSI) scale was filled by patients who underwent ankle ligament reconstruction and were active in sports. The scale was then validated according to the international COSMIN methodology. The AOFAS and Karlsson scores were used as reference questionnaires.

RESULTS

Fifty-seven patients (59 ankles) were included, 27 women. The ALR-RSI scale was strongly correlated with the Karlsson score (r = 0.79 [0.66-0.87]) and the AOFAS score (r = 0.8 [0.66-0.87]). A highly significant difference was found in the ALR-RSI between the subgroup of 50 patients who returned to playing sport and the seven who did not: 68.8 (56.5-86.5) vs 45.0 (31.3-55.8), respectively, p = 0.02. The internal consistency of the scale was high (α = 0.96). Reproducibility of the test-retest was excellent (ρ = 0.92; 95% CI [0.86-0.96]).

CONCLUSION

The ALR-RSI is a valid, reproducible scale that identifies patients who are ready to return to the same sport after ankle ligament reconstruction. This scale may help to identify athletes who will find sport resumption difficult.

LEVEL OF EVIDENCE

III.

Abstract 3721: Relationship between insulin resistance and chemosensitivity of high grade bone sarcoma

Background: Neoadjuvant chemotherapy with intercalated surgery is the standard of care for resectable high-grade bone sarcoma (BS) but identification of biomarkers for chemosensitivity prediction is still needed. Insulin-like Growth Factor (IGF) pathway was first linked with sarcoma biology approximately 30 years ago (El-Brady OM, 1990).

Methods: We recruited 138 pts with newly diagnosed primary localized or metastatic BS. We measured fasting blood glucose and insulin, body mass index (BMI). The HOMA-IR (Homeostasis Model Assessment) score ((Glucose (mmol/l) x Insulin) / 22.5), which has been proven to reliably detect insulin resistance IR was calculated, and patients with HOMA-IR &gt; 2.6 were considered as IR. We collected characteristics usually associated with insulin resistance: age, obesity, diabetes, dyslipidemia and hypertension.

Results: Out of 138 pts, 50 (36%) were insulin resistant: HOMA-IR &gt;2.6. Thirty-two IR patients (64%) had no cardiovascular risk factor. In univariate analysis, IR was associated with obesity (BMI &gt; 30 kg/m2)(22% vs 3%, p=0.0015), but not with age (median 36,8 vs 41 years, p=0.19). IR was more prevalent in Ewing sarcoma (14/29; 48%) and chondrosarcoma (7/16; 44%) followed by osteosarcoma (25/67; 37%) and other rare bone sarcomas (4/26; 15.3%), but not significantly (p=0.097). After neoadjuvant chemotherapy and surgery of Ewing tumor and osteosarcoma, pathologic tumor necrosis was higher in IR pts (88.9 vs 75%, p= 0.028).

Conclusion: Our results suggest that metabolic profile may help to discriminate best candidates for neoadjuvant chemotherapy in high-grade bone sarcomas. Further studies are needed to confirm and explain these results.

Citation Format: Pascaline Boudou-Rouquette, Ithar Gataa, Sixtine De Percin, Camille Tlemsani, David Biau, Valerie Dumaine, Virginie Audard, Frédérique Larousserie, Philippe Anract, Anne Jouinot, François Goldwasser. Relationship between insulin resistance and chemosensitivity of high grade bone sarcoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3721.

Traumatic Patellar Tendon Rupture Repair Using Synthetic Ligament Augmentation

Rupture of the patellar tendon is an infrequent pathology, and surgical repair with nonabsorbable sutures is the gold standard for management. Many surgeons augment the repair using one of many proposed methods: cerclage wires, Dall-Miles cables, autologous hamstring grafts, and tendon allografts. In this study, we propose the augmentation of patellar tendon repair using an artificial ligament. The questions to be assessed in this study are as follows: (1) measurement of functional results 1 year after surgery using the Lysholm score and (2) the incidence of both rerupture, and surgical complications within the first year postsurgery, the median knee range of motion at 3 months and 1-year postsurgery, patient satisfaction, and postsurgery patellar height, measured using the Caton-Deschamps Index. In our center, we performed 30 suture repairs of traumatic patellar tendon ruptures between 2015 and 2016. Tendon repair was always augmented using an artificial ligament (LT60, Orthomed). The results were evaluated 1 year after surgery. The 1-year postsurgery median Lysholm score was 96 (first quartile-third quartile [Q1-Q3]: 95-100). None of the following complications were reported: second surgery for any reason, new rupture, and superficial or deep infection. Radiological analysis showed a median Caton Index of 1 (Q1-Q3: 0.9-1) postsurgery. Excellent Lysholm scores were observed 1 year after synthetic ligament augmentation of patellar tendon sutures, with a low rate of complications compared with published studies.

Anterior approach without traction table: A means of saving time and money in hemiarthroplasty for femoral neck fracture? A case-matched study with and without traction table

BACKGROUND

The costs incurred by management of displaced femoral neck fracture are a public health issue. The anterior approach can be used for partial hip replacement, but costs in terms of equipment and time incurred by using a traction table have not to our knowledge been estimated in this indication. We therefore performed a case-control study, comparing (1) installation and deinstallation times (IT, DT) in partial hip replacement using a standard versus a traction table (ST, TT), and (2) operating times, limb-length radiography and intraoperative complications.

HYPOTHESIS

Performing the anterior approach on a standard table saves installation and deinstallation time and operating time, without leading to more intraoperative complications.

MATERIALS AND METHODS

A comparative retrospective study included 102 patients (mean age, 84.8±8 years; 46 ST, 56 TT). Installation time (IT) was calculated between entry in the operating room and performance of the incision; operating time (OT) between incision and closure; and deinstallation time (DT) between closure and leaving the operating room.

RESULTS

Mean IT in ST (25.5±6.2min) was significantly shorter than in TT (33.9±6.2min) (p=1.1*10^-9), as were DT (13±4.7 versus 17±3.4min) (p=4.1*10^-6) and OT (73.5±15.9 versus 82.6±21.3minutes) (p=0.01). There were 4 intraoperative complications: 1 greater trochanter fracture in ST and 2 greater trochanter fractures and 1 proximal femoral fracture in TT. Limb-length discrepancy was comparable between ST (3.7±3.2mm (range, 0-15mm)) and TT (5.3±4.6mm (range, 0-20mm)) (p=0.06).

DISCUSSION

Patient installation on a standard table reduced installation, deinstallation and operating time compared to use of a traction table, without increasing the complications rate.

LEVEL OF EVIDENCE

III, case-control study.

Dual mobility constructs in revision total hip arthroplasty: survivorship analysis in recurrent dislocation versus other indications at three to twelve-year follow-up

BACKGROUND

The aim of this retrospective study was to evaluate the clinical, radiologic, and survival results of dual mobility (DM) sockets in revision total hip arthroplasty (THA) performed for instability versus revision THAs performed for other reasons.

METHODS

From a computerized database, we identified 84 revision THAs using a modern DM socket performed in 81 patients with a mean age of 71 years. Indication for revision was recurrent dislocation in 47 hips, and other reasons in the remaining 37 hips. A survivorship analysis according to the actuarial method was carried out on the entire series using revision for any cause, revision for dislocation, and radiological cup loosening revised or not, as the end points.

RESULTS

Of the 81 patients, twelve died, six were lost to follow-up, eight had been revised, and 55 patients (58 hips) were unrevised and alive at a mean follow-up of 6.4 years. Dislocation occurred in four of the 47 (8.5%) hips for which indication for revision was dislocation versus one of the remaining 37 (2.7%) hips [odds ratio = 3.4 (0.4-31.3), p = 0.07]. According to our criteria, three acetabular components of which one was revised were considered as loosened. When using revision for dislocation as the end-point, the survival rate at seven years was 90.4 ± 5.3% (IC_95%, 79.9-100) in the 47 hips for which the indication for revision was dislocation versus 100% in the remaining 37 hips (log-rank, p = 0.5).

CONCLUSIONS

The current study indicated that DM sockets represent an interesting solution to prevent dislocation in revision THAs at mid-term follow-up.

Integrated molecular characterization of chondrosarcoma reveals critical determinants of disease progression

Chondrosarcomas are primary cancers of cartilaginous tissue with highly contrasting prognoses. These tumors are defined by recurrent mutations in the IDH genes and other genetic alterations including inactivation of CDKN2A and COL2A1; however, these have no clinical value. Here we use multi-omics molecular profiles from a series of cartilage tumors and find an mRNA classification that identifies two subtypes of chondrosarcomas defined by a balance in tumor differentiation and cell cycle activation. The microRNA classification reveals the importance of the loss of expression of the 14q32 locus in defining the level of malignancy. Finally, DNA methylation is associated with IDH mutations. We can use the multi-omics classifications to predict outcome. We propose an mRNA-only classifier to reproduce the integrated multi-omics classification, and its application to relapsed tumor samples shows the progressive nature of the classification. Thus, it may be possible to use mRNA-based signatures to detect patients with high-risk chondrosarcomas.

Results of API-AI based regimen in osteosarcoma adult patients included in the French OS2006/Sarcome-09 study

In the OS2006 study, patients younger than 18 years were treated with a methotrexate-based regimen (MTX), patients older than 25 years with a doxorubicin-cisplatin-ifosfamide-based regimen (API-AI), whereas patients aged 18-25 years received either API-AI or MTX. We herein report the prespecified subgroup analysis of the outcome of 106 patients treated with API-AI. Preoperative chemotherapy combined three doxorubicin-ifosfamide-cisplatin (API) and two doxorubicin-ifosfamide (AI) courses. Postoperative chemotherapy was assigned by risk group: localised patients with a good histological response (<10% viable cells) received two AI and two cisplatin-ifosfamide (PI) courses; patients with synchronous metastases, poor histological response or unresectable primary received five cycles of etoposide-ifosfamide (EI). Of the 106 patients, 61 were randomised to receive or not zoledronate. Median age was 30 years (range 18-67), 66 (62%) patients were >25 years. The primary tumours were axial in 28 patients (26%), and 28 (26%) presented with metastases. Ninety-six patients (91%) had surgery, conservative in 82 (85%); 36 patients (38%, 95% CI 28-48%) were good responders. Toxicity was manageable, with no significant difference in severe acute toxicity between patients aged >25 years and those younger. With a median follow-up of 4.8 years, the 5-year event-free survival and overall survival rates were 46% (95% CI 36-56) and 57% (95% CI 47-67), respectively. The primary tumour size and initial metastases correlated with a higher risk of event. In these 106 osteosarcoma adult patients, API-AI proved feasible with no excess of toxicity, and favourable activity despite poor-prognosis factors.

Surgery in reference centers improves survival of sarcoma patients: a nationwide study

BACKGROUND

NETSARC (netsarc.org) is a network of 26 sarcoma reference centers with specialized multidisciplinary tumor boards (MDTB) aiming to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and expert pathological review are mandatory for sarcoma patients nationwide. In the present work, the impact of surgery in a reference center on the survival of sarcoma patients investigated using this national NETSARC registry.

PATIENTS AND METHODS

Patients' characteristics and follow-up are prospectively collected and data monitored. Descriptive, uni- and multivariate analysis of prognostic factors were conducted in the entire series (N = 35 784) and in the subgroup of incident patient population (N = 29 497).

RESULTS

Among the 35 784 patients, 155 different histological subtypes were reported. 4310 (11.6%) patients were metastatic at diagnosis. Previous cancer, previous radiotherapy, neurofibromatosis type 1 (NF1), and Li-Fraumeni syndrome were reported in 12.5%, 3.6%, 0.7%, and 0.1% of patients respectively. Among the 29 497 incident patients, 25 851 (87.6%) patients had surgical removal of the sarcoma, including 9949 (33.7%) operated in a NETSARC center. Location, grade, age, size, depth, histotypes, gender, NF1, and surgery outside a NETSARC center all correlated to overall survival (OS), local relapse free survival (LRFS), and event-free survival (EFS) in the incident patient population. NF1 history was one of the strongest adverse prognostic factors for LRFS, EFS, and OS. Presentation to an MDTB was associated with an improved LRFS and EFS, but was an adverse prognostic factor for OS if surgery was not carried out in a reference center. In multivariate analysis, surgery in a NETSARC center was positively correlated with LRFS, EFS, and OS [P < 0.001 for all, with a hazard ratio of 0.681 (95% CI 0.618-0.749) for OS].

CONCLUSION

This nationwide registry of sarcoma patients shows that surgical treatment in a reference center reduces the risk of relapse and death.

Assessment of resection margins in bone sarcoma treated by neoadjuvant chemotherapy: Literature review and guidelines of the bone group (GROUPOS) of the French sarcoma group and bone tumor study group (GSF-GETO/RESOS)

BACKGROUND

Standardized reports are essential to meeting the bone sarcoma reference center certification requirements of the French National Cancer Institute (INCa). The usual classifications of the Musculoskeletal Tumor Society (MSTS), the American Joint Committee on Cancer (AJCC/IUCC) TNM R classification and the American College of Pathologists, are inexact inasmuch as they fail to include chemotherapy impact on tumor cells in assessing surgical margins. This leads to inconsistent interpretation by teams managing bone sarcoma. The present literature analysis sought to assess the limitations of existing classifications for purposes of standardized reporting of the management of surgical specimens from patients with osteosarcoma or Ewing sarcoma receiving neoadjuvant chemotherapy, by addressing the following questions: 1) What is the prognostic value of margins and chemotherapy response in the classifications? 2) What are the histologic changes induced by chemotherapy, with what impact on interpretation of margins?

METHOD

A PubMed literature analysis was performed, targeting the prognostic value of resection margin assessment, in September 2018. French bone pathology group (Groupe français des pathologistes osseux) and international guidelines on bone specimen management were referred to so as select items for a standardized report. Eight of the 523 articles retrieved met the study eligibility criteria.

RESULTS

Minimal distance between tumor and surgical margin, with a>2mm threshold, seemed to be the optimal parameter for predicting local recurrence. Good chemotherapy response and appendicular skeletal location were associated with lower risk of local recurrence. None of the available classifications take into account the microscopic changes induced by chemotherapy in interpreting resection margins.

DISCUSSION

To standardize practice, GROUPOS developed a standardized report for bone sarcoma specimens, considering the histopathologic changes in the tumor after neoadjuvant chemotherapy. The TNM R system was adapted and a threshold of>2mm was chosen as an acceptable limit to qualify surgical resection as safe (R0). R1 status (≤2mm) was subdivided into subgroups a, b and c, to include margin measurement in relation to the post-chemotherapy scar: R1a, resection within the scar; R1b, resection in healthy tissue,≤2mm from the scar and/or residual viable cells; and R1c, resection within the lesion in contact with viable cells or within coagulation necrosis areas. The GROUPOS members drew up this standardized report so as to ensure a common language, improving bone sarcoma management in specialized centers. Reliable data can thus be established for national and international multicenter studies.

LEVEL OF EVIDENCE

IV.

Metabolic profile and neoadjuvant chemotherapy sensitivity in high-grade bone sarcoma

e22506

Background: Neoadjuvant chemotherapy with intercalated surgery is the standard of care for resectable high-grade bone sarcoma (BS) but identification of biomarkers for chemosensitivity prediction is still needed. Methods: We recruited 121 pts with new primary localized or metastatic BS, measured fasting blood glucose and insulin, body mass index (BMI). The HOMA-IR (Homeostasis Model Assessment) score ((Glucose (mmol/l) x Insulin) / 22.5), which has been proven to reliably detect insulin resistance was calculated, and patients with HOMA-IR > 2.6 were considered as insulin resistant (IR). We collected characteristics usually associated with insulin resistance (IR): age, obesity, diabetes, dyslipidemia and hypertension. Results: Out of 121 pts, 48 (40%) were IR: HOMA-IR > 2.6. Thirty IR patients (62%) had no cardiovascular risk factor. In univariate analysis, IR was associated with obesity (BMI > 30 kg/m2)(23% vs 3%, p = 0.0013), but not with age (median 38.4 vs 43.3 years, p = 0.15). IR was more prevalent in Ewing sarcoma (12/21; 57%) and chondrosarcoma (7/13; 54%) followed by osteosarcoma (25/61; 41%) and other rare bone sarcomas (4/26; 15.3%)(p = 0.037). After preoperative chemotherapy and surgery of Ewing tumor and osteosarcoma, pathologic tumor necrosis was higher in IR pts (85.8 vs 69.3%, p = 0.012). Using multivariate linear regression models, IR was independently associated with pathologic tumor necrosis (p = 0.042) but not with obesity (p = 0.55). Conclusions: Our results suggest that tumor-induced metabolic profile may help to discriminate best candidates for preoperative chemotherapy in high-grade bone sarcomas. Further studies are needed to confirm and explain these results.

Improved local relapse-free and overall survival with secondary surgery after a first R1 or R2 resection in soft tissue sarcoma (STS) of the limbs or trunk wall: An analysis 10,931 patients (pts) in NETSARC

11056

Background: We previously reported that secondary resection (2Surg) improved local relapse free (LRFS) but not overall survival (OS) in a retrospective series of pts with localized STS after unplanned 1st excision. Here we investigated the impact of 2Surg specifically after a first R1 or R2 resection in the 10931 pts with STS of the limb or trunk wall included in the nationwide NETSARC database from 2010 to 2017. Methods: NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDT), funded by the French NCI (INCa). Since 2010, presentation to an MDTB and second pathological review are mandatory for sarcoma pts. Statistics were performed with SPSS23.0. LRFS, metastasis-free survival (MFS), OS compared with the logrank test. Results: The series included 5598 (51.2%) males. Median age was 56.7. Tumor sites: 5295 (49.4%) lower limb, 3670 (33.6%) trunk wall. 1966 (18.0%) upper limb. As previously reported in the entire series, local RFS (LRFS) and RFS (p<0.001), but not OS, were superior for pts presented to a NETSARC MDT (NMDT), or operated in a NETSARC center (N=4417, 41%). LRFS & OS were best for pts presented to a NMDT AND operated in NETSARC centers; while the worst LRFS & OS were observed in pts presented in a NMDT but not operated there (p<0.001). Among the 2081 pts with a first R1 resection in whom 2Surg was documented, 1047 (50.3%) were reoperated. R1 reoperated pts had a superior LRFS, metastatic free survival (MFS) and OS (p<0.001). LRFS (p<0.001), MFS (p=0.05) and OS (p<0.001) were superior after 2Surg only in pts operated 1st outside a Netsarc center. There were 823 pts with a first surgery with R2 resection in whom 2Surg was documented: 619 (75.2%) were reoperated. R2 reoperated patients had a superior LRFS and OS (p=0.01). MFS was not different. LRFS (p<0.001) & OS (p<0.001) were superior after 2Surg only in pts operated 1st outside a Netsarc center. 2028 (%) pts had 2Surg. Pts for whom 2Surg was in a NetSARC center had a superior LRFS (p<0.001) and OS (p=0.01) when operated first outside a NETSARC center. Conclusions: In this nationwide series of limb or trunk wall STS, 2Surg after a R1 or R2 primary excision improves LRFS & OS when the pts were operated 1st outside a reference center. 2Surg in a NETSARC center was associated with a better LRFS and OS.

Sarcomas in patients over 90: Natural history and treatment-A nationwide study over 6 years

Soft tissue sarcomas (STS) are rare tumors accounting for less than 1% of human cancers. While the highest incidence of sarcomas is observed in elderly, this population is often excluded or poorly represented in clinical trials. The present study reports on clinicopathological presentation, and outcome of sarcoma patients over 90 recorded in the Netsarc.org French national database. NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor board (MDTB), funded by the French National Cancer Institute to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB, second pathological review, and collection of sarcoma patient characteristics and follow‐up are collected in a database Information of patients registered from January 1, 2010, to December 31, 2016, in NETSARC were collected, analyzed and compared to the younger population. Patients with sarcomas aged >90 have almost exclusively sarcomas with complex genomics (92.0% vs. 66.3%), are less frequently metastatic (5.3% vs. 14·7%) at diagnosis, have more often superficial tumors (39.8% vs. 14.7%), as well as limbs and head and neck sites (75.2% vs. 38.7%) (all p < 0.001). Optimal diagnostic procedures and surgery were less frequently performed in patients over 90 (p < 0.001). These patients were less frequently operated in NETSARC centers, as compared to those of younger age groups including aged 80–90. However, local relapse‐free survival, metastatic relapse‐free survival and relapse‐free survival were not significantly different from those of younger patients, in the whole cohort, as well as in the subgroup of operated patients. As expected overall survival was worse in patients over 90 (p < 0.001). Patients over 90 who were not operated had worse overall survival than younger patients (9.9 vs. 27.3 months, p < 0.001). Patients with STS diagnosed after 90 have distinct clinicopathological features, but comparable relapse‐free survival, unless clinical practice guidelines recommendations are not applied. Standard management should be proposed to these patients if oncogeriatric status allows.

What's new?

While the highest incidence of soft‐tissue sarcoma (STS) is observed in the elderly, this population is often excluded or poorly represented in clinical trials. Therefore, little is known about the characteristics, treatment, and outcomes of STS in these patients. In this study, the authors analyzed numerous clinical characteristics of patients with sarcoma diagnosed at age 91 or older. They conclude that standard STS management and clinical practice guidelines should be followed for these patients if possible.