Sean P. Scully

Survival Analysis of Hips Treated with Core Decompression or Vascularized Fibular Grafting Because of Avascular Necrosis

Avascular necrosis of the femoral head is a multifaceted process that leads to articular incongruity and subsequent osteoarthrosis of the joint. Clinicians concur that primary treatment should focus on preservation of the natural surface of the joint; however, there has not been a consensus on how best to accomplish this. While a number of therapeutic interventions have been reported, the efficacy has varied markedly and there have been few statistical comparisons. The purpose of the current study was to use statistical analysis to compare the results of two widely used procedures, vascularized fibular grafting (614 hips; 480 patients) and core decompression (ninety-eight hips; seventy-two patients), for the treatment of avascular necrosis. The patients were stratified according to age and the stage of disease, and a survival analysis was performed with total hip arthroplasty as the end point for failure. None of the eleven hips that had Ficat stage-I disease needed a total joint replacement after being treated with either regimen. Analysis of the hips that had stage-II disease revealed rates of survival, at fifty months, of 65 per cent (twenty-eight of forty-three hips) after core decompression and 89 per cent (ninety-nine of 111 hips) after vascularized fibular grafting. For the hips that had Ficat stage-III disease, the rates of survival at fifty months were 21 per cent (ten of forty-seven hips) after core decompression and 81 per cent (405 of 500 hips) after vascularized fibular grafting. Among the hips that had Ficat stage-II or III disease, the rate of eventual total joint arthroplasty after vascularized fibular grafting was significantly lower than that after core decompression (p < 0.0001). The results indicate that the increased morbidity associated with vascularized fibular grafting is justified by the associated delay in or prevention of articular collapse in hips that have stage-II or III disease.

Current etiologies and modes of failure in total knee arthroplasty revision.

Although total knee arthroplasty is a very effective intervention and increasing in prevalence, failures do occur. We studied patients presenting for total knee arthroplasty revision to determine any modifiable causes of failure, both short and long term, and where future efforts should be directed to reduce the incidence of failure. A multicenter prospective observational cohort study of 318 consecutive patients, with minimum 1 year follow-up, undergoing total knee arthroplasty revision was performed. Associations between modes of failure were also assessed. The mean time from primary procedure to total knee arthroplasty revision was 7.9 years. Many patients (64.4%) had more than one cause of failure. Thirty-one percent of patients were early (< 2 years) failures at a mean of 11 months. These had a higher prevalence of infection, perioperative factors and comorbidities. Late failures occurred at a mean of 119.2 months. Other major causes of failure included instability (28.9%), wear (24.5%) and component loosening suggesting the importance of modifications in technique, implants and other areas. Application of these findings will ultimately reduce revision numbers through continued refinement of total knee arthroplasty practice and through further specific investigation of these modes of failure.Level of Evidence: Therapeutic study, level II-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Chondrosarcoma in the United States (1973 to 2003): An Analysis of 2890 Cases from the Seer Database

BACKGROUND Current demographic, prognostic, and outcomes data on the diagnosis and treatment of chondrosarcoma have been based on case series reported by individual treatment centers. The SEER (Surveillance, Epidemiology and End Results) database is a validated national epidemiological surveillance system and cancer registry that has been used extensively to evaluate treatment outcomes in cases of malignancy. The purpose of the present study was to use this database to identify demographic and prognostic characteristics of chondrosarcoma and to describe the natural history following the treatment of this rare disease in the United States over the last thirty years. METHODS Two thousand eight hundred and ninety patients with chondrosarcoma were identified in the SEER database, and information regarding the demographic and clinical characteristics of the patients, the histological features and grade of the tumors, the location and size of the tumors, the surgical stage at the time of diagnosis, the use of surgery and radiation treatment, and survival were extracted. RESULTS Comparison of the overall and disease-specific survival rates revealed that patients who survived for ten years were more likely to die of events that were unrelated to chondrosarcoma. The disease-specific survival rate leveled off at ten years of follow-up. Univariate analysis revealed that female sex, a low histological grade, and local surgical stage were associated with a significant disease-specific survival benefit. An age of fifty years or less and an appendicular location of the tumor were associated with a significant overall survival benefit. On multivariate analysis, only grade and stage had significant association with disease-specific survival. On the basis of a comparison of survival rates according to the decade of diagnosis, it appears that there has been no significant improvement in survival over the last thirty years. CONCLUSIONS Only grade and stage are independent prognostic factors for survival in cases of chondrosarcoma. Current treatment algorithms have not improved the survival rates of patients with chondrosarcoma over the past thirty years. Routine patient surveillance following treatment should be extended to ten years of follow-up.

Metastatic Carcinoma to Skeletal Muscle: A Report of 15 Patients

The records of 15 patients with metastatic carcinoma to skeletal muscle treated between 1979 and the present were reviewed. Fourteen patients were referred with a diagnosis of soft tissue sarcoma and one with suspected infection. There was a previous diagnosis of carcinoma in eight patients but seven patients had no prior diagnosis of a known malignancy. Primary tumors were lung (eight), melanoma (two), gastrointestinal (one), kidney (one), and bladder (one). No primary tumor could be identified in two patients. Local control of metastatic lesions was achieved by radiotherapy in 11 patients as an initial measure. Two patients underwent wide excision and one declined treatment for local tumor control. Eight patients died within 12 months of presentation and survival analysis indicated a 25% overall survival at 60 months. Two patients remained free of disease at 132 months and 72 months. From this study and a review of 52 cases reported in the literature, the authors are unable to find any clinical or radiographic characteristics that distinguish metastatic carcinoma to muscle from soft tissue sarcomas. Surgical resection can be reserved for cases in which radiation does not provide local control.

Pathologic fracture in osteosarcoma : prognostic importance and treatment implications.

Background: The presence of a pathologic fracture in an osteosarcoma has been considered a poor prognostic factor and an indication for immediate amputation. The purpose of the present study was to determine, in the current era of neoadjuvant chemotherapy, whether a pathologic fracture in an osteosarcoma has prognostic importance and whether limb salvage can be safely performed in such patients without compromising clinical outcome. Methods: In a cooperative effort of the Musculoskeletal Tumor Society, members from eight institutions provided retrospective data on fifty-two patients with osteosarcoma who had a pathologic fracture and on fifty-five patients with osteosarcoma who had not had a pathologic fracture and had been followed for at least two years or until disease recurrence, metastasis, or death. The two groups were matched for patient age and tumor location. Outcomes examined were survival and local recurrence. A subgroup analysis was performed to assess differences in outcome within the group with the pathologic fracture. Results: The five-year estimated survival rates were 55% for the group with a pathologic fracture and 77% for the group without a fracture (p = 0.02). The rate of survival without a local recurrence at five years was 75% for the group with a fracture and 96% for the group without a fracture (p = 0.007). In the group with a fracture, seven (23%) of the thirty patients managed with limb salvage and four (18%) of the twenty-two managed with an amputation had a local recurrence (p = 0.75). Eleven (37%) of the thirty patients with a fracture who were managed with limb salvage and ten (45%) of the twenty-two patients with a fracture who were managed with an amputation died of the disease (p = 0.50). Five patients underwent open reduction and internal fixation followed by limb-salvage surgery. Two of them had a local recurrence and died at an average of eight months postoperatively. The remaining three patients were alive at an average of 6.1 years postoperatively. Local disease control and the survival of these patients were not significantly different from those for the thirty-three patients who were treated with nonoperative immobilization of the fracture followed by limb-salvage surgery. Conclusions: Patients with osteosarcoma who present with a pathologic fracture or sustain one during preoperative chemotherapy have an increased risk of local recurrence and a decreased rate of survival compared with patients who have not sustained a pathologic fracture. The performance of a limb-salvage procedure in carefully selected patients with a pathologic fracture does not significantly increase the risk of local recurrence or death. Factors predictive of improved outcome, such as the response to chemotherapy and union of the fracture, should be taken into account when limb salvage is being considered.

Dedifferentiated Chondrosarcoma: The Role of Chemotherapy with Updated Outcomes

BACKGROUND There are very few published data on the survival of patients with dedifferentiated chondrosarcoma, or, more specifically, on the efficacy and role of chemotherapy, especially in the era of modern diagnostic and treatment modalities. The current study examines the influence of advancements in imaging and chemotherapy on outcome and serves as an extension to a previous study published in 1986. METHODS Forty-two patients with dedifferentiated chondrosarcoma who had presented to our institution between 1986 and 2000 were identified, and a retrospective chart review was performed. The study group included twenty-four men and eighteen women with an average age of sixty-six years. The diagnosis of dedifferentiated chondrosarcoma was verified histologically, and data on treatment, adjuvant therapy, and survival were obtained from the medical records of all patients. All patients had been followed for a minimum of twenty-four months. RESULTS The tumors were classified, according to the system of the Musculoskeletal Tumor Society, as grade IIA (five), grade IIB (twenty-six), and grade III (eleven). Three patients underwent biopsy only, eighteen had a limb-sacrificing procedure, and twenty-one had a limb-sparing procedure. In the group of patients who underwent resection, the surgical margins were classified as intralesional in three, marginal in two, wide in nineteen, and radical in fifteen. Twenty-seven patients received neoadjuvant therapy; of these, twenty-three received chemotherapy only, two received radiotherapy only, and two received combined therapy. The median survival time was 7.5 months, and the five-year rate of disease-free survival was 7.1%. With the numbers available, there was no significant difference in the rate of disease-free survival with respect to the use of chemotherapy (p = 0.54), the location of surgical margins (p = 0.14), the histological subtype (p = 0.87), the tumor stage at the time of diagnosis (p = 0.43), the tumor size (p = 0.79), or the performance of limb-sparing as opposed to limb-sacrificing procedures (p = 0.42). CONCLUSIONS Despite advances in diagnostic modalities and adjuvant therapies, dedifferentiated chondrosarcoma continues to carry a poor prognosis. While local control is achieved in the majority of cases, distant disease remains the greatest clinical challenge, developing in 90% of patients. Efforts are needed to continue to encourage earlier diagnosis and to develop effective adjuvant therapies for the control of distant disease. The routine use of current adjuvant chemotherapy and its inherent risks in this population should be reconsidered.

Chondrosarcoma of bone: analysis of 108 cases and evaluation for predictors of outcome.

Chondrosarcoma is the second most common malignant bone tumor and is relatively unresponsive to chemotherapy and radiation regimens. In addition, the clinical course of chondrosarcoma is difficult to predict. The purpose of this study was to review the authors’ experience with chondrosarcoma and ascertain any factors related to prognosis and clinical outcome. The medical records of 108 patients followed up for a minimum of 2 years were retrospectively reviewed. There were 31 low-grade and 77 high-grade chondrosarcomas. One hundred one patients underwent surgical resection. There was a statistically significant association between positive margins and local recurrence, metastasis, and death. Tumor grade was not predictive of outcome. Proliferation indices (MIB-1 expression determination through immunohistochemistry) were quantitated in 39 patients. A significant association was seen between MIB-1 expression and recurrence and death. Thus, objective quantitation of tumor proliferation was more predictive than was histologic grade of outcome in chondrosarcoma. Although histologic grade continues to be the standard grading system for chondrosarcoma, the current study contributes to ongoing research and validation of alternative techniques that may be more reliable in guiding prognosis and treatment of chondrosarcoma.

Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection.

During the years 1985 to 1989, 82 patients were included in the soft tissue sarcoma protocol. Preoperative irradiation (50-54 Gy) was performed in all patients before tumor extirpation. Microwave hyperthermia was performed in conjunction with radiation in patients who had gross tumor remaining after initial biopsy. Primary closure with vascularized tissue (flaps) in lieu of conventional wound closure by skin approximation led to less complications (19% versus 51%), fewer secondary procedures for wound closure (10% versus 35%), shorter average hospitalization (15 versus 48 days) and greater limb salvage rate (97% versus 91%). The authors conclude that vascularized tissue (flaps) for primary wound closure in irradiated tissue leads to improved wound healing, and should be considered the procedure of choice for heavily irradiated soft tissue sarcoma defects.

Surgical management of conventional grade I chondrosarcoma of long bones.

We retrospectively reviewed 70 patients with low-grade (Grade I) chondrosarcoma of the appendicular skeleton treated at the Mayo Clinic from 1980 to 2001. Fifty-four patients underwent wide resections and three patients underwent marginal excision for radiographically aggressive lesions. Thirteen patients were treated with intralesional curettage for more indolent lesions. The mean age of the patients was 43 years (range, 5-85 years) and the minimum followup was 0.2 year (mean, 8.5 years; range, 0.2-22.8 years). Of the patients who had wide resection, one experienced local recurrence and one had metastasis develop. One patient in the group treated with intralesional curettage had local recurrence and metastasis. We observed no difference in overall survival rate between the intralesional curettage group and the wide resection group. Although there was no difference in the treatment outcome between the two groups, patients with more radiographically aggressive lesions underwent more extensive surgery. The data suggest in selected patients less radiographically aggressive Grade I chondrosarcoma can be safely treated with intralesional curettage without compromising patient outcome.Level of Evidence: Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Synovial sarcoma of the foot and ankle

Synovial sarcoma of the foot and ankle frequently is misdiagnosed, which leads to delays in treatment. The clinical records of 14 patients with synovial sarcoma of the foot and ankle were reviewed. Common findings at presentation were an enlarging mass with a variable incidence of pain, tenderness, and edema. The patients tended to be younger than patients with other soft tissue sarcomas (30 years) and had a median duration of symptoms of 14 months. Of the 14 patients, 12 underwent an attempted curative surgical procedure. Ten patients had partial foot amputations or below knee amputations, whereas two had an attempted limb salvage by wide resection. Of the 14 patients, one experienced regionally recurrent disease and eight had pulmonary metastasis developed. All patients who had metastasis develop died of their disease. Tumor size was not observed to be a prognostic variable in this group of patients. Patients with biphasic histologic features had a better outcome than did those with a monophasic subtype. Patients with a prolonged duration of symptoms before diagnosis had a better outcome, presumably because these tumors biologically were less aggressive. Wide resection can be considered in a select group of patients.