Jaymin Shah

Surgical management of pelvic bone sarcoma with internal hemipelvectomy: Oncologic and Functional outcomes

INTRODUCTION The management of pelvic sarcoma is challenging and goals of surgery are adequate oncologic local control, maintenance of optimum function with good quality of life. METHODS We have evaluated the results of internal hemipelvecotmy including age, type of resection, reconstruction, radiotherapy or chemotherapy. From 2010 to 2016, 23 patients with pelvic bone tumors (13 with Ewings sarcoma, 9 with Osteosarcoma, 1 with chondrosarcoma) were treated by surgical resection. RESULTS The mean follow-up was 18 months (0.5-5) years. In 12 patients reconstruction was performed and 11 were without reconstruction. A total of 3 patients (13%) had an infection develop at a mean follow up of 1 month. Surgical debridements and antibiotics in three patients led to complete recovery. One patient had sciatic nerve injury.One patient had injury to femoral vein; was treated with femoral vein reconstruction. Two patients (9%) developed a local recurrence and were treated with best supportive treatment. Distal pulmonary metastases were seen in four patients and treated with supportive treatment. Five-year disease-specific survival rates of all patients were 83%. The mean functional MSTS score was 18(14-24). CONCLUSIONS Proper selection of patients, preopertive planning and wide surgical margins with reconstruction provides good functional outcomes following internal hemipelvectomy. The surgical site infection and flap necrosis tend to be minor complication and can be managed leading to optimal outcomes and justifies the need for this complex surgery. The oncological and functional outcome after internal hemipelvectomy suggests that its an effective method for treatment of patients with pelvic sarcomas.

Giant cell tumor of distal radius treated with ulnar translocation and wrist arthrodesis: What are the functional outcomes?

Introduction: The aim is to analyze the functional outcomes of patients of giant cell tumor (GCT) of distal radius treated with ulnar translocation and wrist arthrodesis. Methods: Study included 25 patients of aggressive GCT of distal radius, resected and reconstructed using ulnar translocation and wrist arthrodesis. The ulna-carpal radius fixation was performed with plate and screws. The patients were followed to bony union and minimum follow-up was 1 year. Result: Twenty-two patients were of Campanacci grade 3 and three patients were of Campanacci grade2. The mean follow-up was of 23 months (12–36). All patients had an excellent range of pronation and supination. The mean Musculoskeletal Tumor Society score was 24 (range 22–28). Grip strength of affected hand compared to the contra lateral hand was found good in 17 cases and average in 7 cases. The mean bone union time at ulna to radius junction was at 6.5 (5–8) months and ulna to carpal junction at 4.5 (4–6) months. The complications were surgical site infection (one case), recurrence (one case) and failure of union (one case), and ulna graft fracture with implant failure in (two cases). Conclusion: Reconstruction of distal end of radius using ulnar translocation and wrist arthrodesis provides excellent functional outcomes with preservation of rotational movement of forearm and hand function. Reconstruction of the distal radius by ulnar translocation without complete detachment from surrounding soft tissues functions like vascularized graft without use of microvascular techniques.

Anterior tibial artery perforator plus flaps: Role in coverage of posttumor excision defects around the knee joint and upper leg

Objective: Posttumor excision defects can be very large, and many do require postoperative radiotherapy. It is therefore important to provide stable and durable wound coverage to provide ability to withstand radiotherapy as well as providing cover to vital structures. Methods: Between July 2014 and June 2016, eight females and six male patients with defects around the knee were operated upon using a perforator plus flap from the anterior tibial artery perforator. In all except two patients, the defects were the result of posttumor extirpation, while in the latter, it was due to impending implant exposure following bone tumor excision and tibial prosthesis. A constant perforator at the neck of the fibula was found using hand-held Doppler. The base of the flap was always kept intact. The flap was then transposed toward the defect and inset in a tensionless manner. Results: The average flap dimension was 14 cm × 5.5 cm. The mean follow-up was 11 months (6–20 months). All the flaps survived well except in one patient who developed partial tip necrosis, providing stable coverage of the wound. Two patients developed local recurrence and had to undergo above-knee amputation. Conclusions: The planning for the reconstruction of defects following tumor resection is to be done in accordance with a multidisciplinary team approach involving oncosurgeon, reconstructive plastic surgeons, and radiation specialist. The perforator plus flap is an excellent choice in defects around the knee to cover neurovascular structures, bone, or implant.

Segmental excision versus intralesional curettage with adjuvant therapy for giant cell tumour of bone

To the Editor: We read with interest the article by Yacob et al. 1 The authors concluded that local recurrence of giant cell tumour (GCT) of bone was not associated with surgical option. Can the authors advise whether any patient had pathological fracture; what the characteristics of the pathological fracture were, for example timing, displacement pattern, and intraarticular extension. Did patients with pathological fracture have a similar outcome to those without? What was the outcome following curettage? In one study, patients with and without a pathological fracture at the time of presentation have a comparable local recurrence rate. 2 The presence of a pathological fracture should not preclude the option of curettage. 2 Was the outcome different in patients with GCT of the ulna or radius? Most such tumours are resected rather than curetted. 3 Was there any adjuvant used following curettage and was burr used to provide extended curettage?

Letter to the Editor: Wrist fusion through centralisation of the ulna for recurrent giant cell tumour of the distal radius.

To the Editor: We read with interest the article by Meena et al.1 It would have been great if the authors had provided data on functional outcome based on the modified Musculoskeletal Tumor Society (MSTS) score, as well as grip strength and range of motion of the metacarpophalangeal joint. In one study, the mean MSTS score was 26 (87%; range, 20–28).2 In another, the grip strength at final follow-up in 25 patients without recurrence or failure was reported to be good in 12, fair in 10, and poor in 3.3

Wide Resection versus Curettage with Adjuvant Therapy for Giant Cell Tumour of Bone

To the Editor: We read with interest the article by Kamal et al.1 The authors commented that there was no association between type of surgery and tumour recurrence, metastasis, or outcome. How many patients had pathological fracture? What were the fracture characteristics? What was the outcome in patients with pathological fracture treated with curettage and what was the recurrence rate? What kind of adjuvant therapy was used? What type of reconstruction was used following wide resection around the knee joint? Patients with and without a pathological fracture at the time of presentation have been reported to have a comparable local recurrence rate.2 Different adjuvant methods and their combination lead to variable outcomes.3

Salvage of the proximal femur following pathological fractures involving benign bone tumors

Dear Editor, We read with interest the article by Carvallo et al. [1], who have demonstrated that majority of pathologic fractures following a benign bone tumor of the proximal femur can be successfully treated with curettage, burring, bone grafting, and internal fixationwithout increasing the risk of local recurrence or negatively impacting functional outcome. Wewish to put forth several queries.First, in the current study, which approach for the proximal femur was used forcurettage and bone grafting?Was a combination of an anterior approach to the hip joint and a lateral approach to the proximal femurused for surgical exposure? The results of Hu et al. [2] show that for bone tumors of the femoral neck, the combination of anterior, and lateral approaches may produce good clinical and functional results with minimal complications. We believe that the surgical technique would be of interest to the readers. Second, allograft autograft was used for filling the void after curettage the current study. It would be informative for the authors to elaborate on the details of timing of bone unionfollowing the curettage, burring, bone grafting, and internal fixation. Roudbari et al. [3] studied 119 patients, of whom 63 were treated with an allograft and 56 were treated with an autograft. A 96.6% of the patients had complete incorporation of the graft into host bone by 6 months after operation. Third, what physiotherapy and weight-bearing protocol was used in the current study? In a study by Nakamura et al. [4], full weightbearing was allowed 16 weeks after operation using a synthetic bone graft in benign tumors of the proximal femur. Finally, it would be of interest to know the effects of the timing of repair of the pathological fracture and displacement patterns on the functional outcomes.