H. Wafa

The effect of an unplanned excision of a soft-tissue sarcoma on prognosis

We investigated whether our policy of routine re-excision of the tumour bed after an unplanned excision of a soft-tissue sarcoma was justified. Between April 1982 and December 2005, 2201 patients were referred to our hospital with the diagnosis of soft-tissue sarcoma, of whom 402 (18%) had undergone an unplanned excision elsewhere. A total of 363 (16.5%) were included in this study. Each patient was routinely restaged and the original histology was reviewed. Re-excision was undertaken in 316 (87%). We analysed the patient, tumour and treatment factors in relation to local control, metastasis and overall survival. Residual tumour was found in 188 patients (59%). There was thus no residual disease in 128 patients of whom 10% (13) went on to develop a local recurrence. In 149 patients (47%), the re-excision specimen contained residual tumour, but it had been widely excised. Local recurrence occurred in 30 of these patients (20%). In 39 patients (12%), residual tumour was present in a marginal resection specimen. Of these, 46% (18) developed a local recurrence. A final positive margin in a high-grade tumour had a 60% risk of local recurrence even with post-operative radiotherapy. Metastases developed in 24% (86). The overall survival was 77% at five years. Survival was related to the grade of the tumour and the finding of residual tumour at the time of re-excision. We concluded that our policy of routine re-excision after unplanned excision of soft-tissue sarcoma was justified in view of the high risk of finding residual tumour.

Retrospective evaluation of the incidence of early periprosthetic infection with silver-treated endoprostheses in high-risk patients

We conducted a case-control study to examine the merit of silver-coated tumour prostheses. We reviewed 85 patients with Agluna-treated (silver-coated) tumour implants treated between 2006 and 2011 and matched them with 85 control patients treated between 2001 and 2011 with identical, but uncoated, tumour prostheses. In all, 106 men and 64 women with a mean age of 42.2 years (18.4 to 90.4) were included in the study. There were 50 primary reconstructions (29.4%); 79 one-stage revisions (46.5%) and 41 two-stage revisions for infection (24.1%). The overall post-operative infection rate of the silver-coated group was 11.8% compared with 22.4% for the control group (p = 0.033, chi-square test). A total of seven of the ten infected prostheses in the silver-coated group were treated successfully with debridement, antibiotics, and implant retention compared with only six of the 19 patients (31.6%) in the control group (p = 0.048, chi-square test). Three patients in the silver-coated group (3.5%) and 13 controls (15.3%) had chronic periprosthetic infection (p = 0.009, chi-square test). The overall success rates in controlling infection by two-stage revision in the silver-coated group was 85% (17/20) compared with 57.1% (12/21) in the control group (p = 0.05, chi-square test). The Agluna-treated endoprostheses were associated with a lower rate of early periprosthetic infection. These silver-treated implants were particularly useful in two-stage revisions for infection and in those patients with incidental positive cultures at the time of implantation of the prosthesis. Debridement with antibiotic treatment and retention of the implant appeared to be more successful with silver-coated implants.

Surgical options and outcomes in bone sarcoma.

Bone sarcomas are challenging to treat. The primary goal of treatment is local control of the disease while, if possible, achieving salvage of the limb and its function. There is no ideal method of reconstruction in limb-salvage surgery but the choice of the method of reconstruction should be individualized based upon many factors including the patient’s age, the extent and location of the tumor, the wishes of the patient, and the availability of surgical facilities and expertise, as well as the cost of the procedure. In this review, the authors explore the advantages and disadvantages of the different methods of limb reconstruction. The surgical management of bone sarcomas is a real challenge to the orthopedic surgeon, owing to the diversity of sites in which tumors arise, combined with the extension of the tumor into adjacent soft tissues and their proximity, in many cases, to major neurovascular structures. There have been dramatic improvements in survival for patients with osteosarcoma and Ewing’s sarcoma in the past 30 years owing to increasing effectiveness of chemotherapy. This, along with developments in imaging techniques (magnetic resonance imaging in particular) has led to earlier diagnosis and more accurate preoperative staging. Whilst traditional treatment for bone tumors used to be amputation, advances in surgical techniques have made limb-salvage procedures a valid alternative method of treatment to amputation in 80–85% of patients with primary bone sarcomas.

Does amputation offer any survival benefit over limb salvage in osteosarcoma patients with poor chemonecrosis and close margins

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence. Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.

Very long-term outcomes after endoprosthetic replacement for malignant tumours of bone.

AIMS The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone. PATIENTS AND METHODS We conducted a retrospective analysis of a prospectively maintained database to identify all patients who had undergone an endoprosthetic replacement more than 25 years ago and who were still alive. Their outcomes were investigated with reference to their complications and need for further surgery. A total of 230 patients were identified. Their mean age at diagnosis was 20.7 years (five to 62). The most common diagnosis was osteosarcoma (132). The most common site was the distal femur (102). RESULTS The mean follow-up was 29.4 years (25 to 43). A total of 610 further operations were undertaken, an average of 2.7 further operations per patient. A total of 42 patients (18%) still had the original prosthesis in place. The risk of amputation was 16% at 30 years (31 patients). Those without infection had a mean of 2.1 further operations (one to nine) while those with infection had a mean of 4.6 further operations (two to 11). The risk of infection persisted throughout the life of the prosthesis with a mean of 1% per year becoming infected. Of the 60 patients who developed an infection, 21 (35%) developed this following the primary procedure at a mean of 50 months, but another 19 developed this within a year of another surgical procedure. The risk of infection after any further surgery was 2.7%. The site with the highest risk of infection was the proximal tibia (43.3%). TAKE HOME MESSAGE This study highlights the inevitable need for further surgery following first-generation endoprosthetic reconstruction, although in most cases, limb salvage is maintained. Late complications, especially infection, continue for the lifetime of the implant. Cite this article: Bone Joint J 2016;98-B:857-64.

Does Total Humeral Endoprosthetic Replacement Provide Reliable Reconstruction With Preservation of a Useful Extremity

AbstractBackgroundControversy exists regarding the ideal method of reconstruction after proximal humeral resection and several reconstructive techniques have been reported. The reconstructive options are very limited when resection of the entire humerus is required. One option is endoprosthetic reconstruction, but there have been few published studies on the outcome of total humeral endoprosthetic reconstruction.Questions/purposesThe purposes of this study were (1) to assess the longevity of total humerus prostheses in those patients who survived their disease; (2) to review the complications associated with this prosthesis; and (3) to assess the Musculoskeletal Tumor Society functional score in survivors.MethodsThirty-four patients (10 males, 24 females) with a mean age of 26 years (range, 7–86 years) were included in this study. Histological diagnosis was osteosarcoma in 15 patients, chondrosarcoma in seven, Ewing’s sarcoma in seven, metastatic carcinoma in three, liposarcoma in one, and giant cell tumor of bone in one remaining patient. Twenty-nine patients had their total humeral endoprosthetic replacement for primary reconstruction, whereas the remaining five patients received their implants for failures with other reconstructive techniques. At a minimum followup of 3 months (mean, 8.2 years; range, 3 months to 29 years), 16 patients were alive with no evidence of disease, whereas 13 of the remaining 18 died with metastatic disease. Local recurrence was seen in five patients and all eventually died of disease progression. ResultsAccording to the Kaplan-Meier survival analysis, the cumulative 10-year implant survival rate was 90%. Periprosthetic infection was seen in four patients, postoperative radial nerve palsy in one, and proximal migration of the prosthesis in three, whereas three patients needed a change of the articular elbow bushings at a mean of 16 years after the implant insertion. The mean Musculoskeletal Tumor Society functional score of the 28 patients who survived their disease for more than 12 months after the index procedure and could therefore be functionally assessed was 83% (range, 60%–93%).ConclusionsFrom this small, preliminary report, we suggest that total humeral endoprosthetic replacement may be a reasonable option of reconstruction after tumor resection. We have shown that this prosthesis preserves the function of the hand. The local recurrence rate observed suggests that careful selection of patients is crucial. Infection was our most common surgical complication, but we showed that in those who survived their tumor, this prosthesis offers a method to preserve a functional upper extremity in some patients. Further study with more patients is necessary to confirm the value of this reconstruction method.Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The use of extracorporeally irradiated autografts in pelvic reconstruction following tumour resection

The aim of this study was to evaluate the functional and oncological outcome of extracorporeally irradiated autografts used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone tumour of the pelvis. There were 13 males and five females with a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic sarcoma, six a Ewings sarcoma, and five a chondrosarcoma. At a mean follow-up of 51.6 months (4 to 185), nine patients had died with metastatic disease while nine were free from disease. Local recurrence occurred in three patients all of whom eventually died of their disease. Deep infection occurred in three patients and required removal of their graft in two while the third underwent a hindquarter amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the 16 patients who could be followed-up for at least 12 months was 77% (50 to 90). Those 15 patients who completed the Toronto Extremity Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after an internal hemipelvectomy. It has an acceptable morbidity and a functional outcome that compares favourably with other available reconstructive techniques.

Intraosseous hibernoma: a case report and review of the literature

A hibernoma is a rare lipomatous tumour sharing morphological features with brown fat [1–3]. Brown fat is involved in thermoregulation and can be focally found in the head and neck region in neonates, children and young adults [4]. Hibernoma is a well-demarcated, slow-growing benign tumour, which rarely recurs after surgical excision. Sixty-one percent of hibernomas occur in the third and fourth decades with a predilection for the upper trunk and thigh. These normally arise in the subcutis or within skeletal muscle [5]. An intraosseous location appears to be very rare in hibernomas. An intraosseous hibernoma of the sacrum has been described by Kumar and colleagues [1]. Thorns and colleagues describe hibernoma-like histological changes in a bone marrow trephine without an apparent mass lesion [2]. Reyes and colleagues describe a case of bilateral femoral hibernomas; however, histological and radiological documentation on this case is not available [3]. We report a case of intraosseous hibernoma within the ilium in a 40-year-old woman and describe its imaging and pathological features.

The surgical treatment of acromioclavicular joint injuries

Acromioclavicular joint (ACJ) injuries are common, but their incidence is probably underestimated. As the treatment of some sub-types is still debated, we reviewed the available literature to obtain an overview of current management. We analysed the literature using the PubMed search engine. There is consensus on the treatment of Rockwood type I and type II lesions and for high-grade injuries of types IV, V and VI. The treatment of type III injuries remains controversial, as none of the studies has proven a significant benefit of one procedure when compared with another. Several approaches can be considered in reaching a valid solution for treating ACJ lesions. The final outcome is affected by both vertical and horizontal post-operative ACJ stability. Synthetic devices, positioned using early open or arthroscopic procedures, are the main choice for young people. Type III injuries should be managed surgically only in cases with high-demand sporting or working activities. Cite this article: EFORT Open Rev 2017;2:432–437. DOI: 10.1302/2058-5241.2.160085.

Tumours of the Hand

The hand is the site of many different types of benign and malignant neoplasms. These lesions may originate in either soft tissues or bone. The most common benign tumours of the hand include enchondromas, ganglions, giant cell tumours of the tendon sheath, and epidermoid cysts while squamous cell carcinoma represents the most common hand malignancy. This chapter describes the clinical, radiological and histological findings, in addition to the treatment strategies of the most common tumours of the hand and wrist.