William F. Enneking

A system for the surgical staging of musculoskeletal sarcoma

A surgical staging system for musculoskeletal sarcomas stratifies bone and soft-tissue lesions of any histogenesis by the grade of biologic aggressiveness, by the anatomic setting, and by the presence of metastasis. The three stages: I--low grade; II--high grade; and III--presence of metastases, are subdivided by (a) whether the lesion is anatomically confined within well-delineated surgical compartments, or (b) beyond such compartments in ill-defined fascial planes and spaces. Operative margins are defined as intralesional, marginal, wide, and radical, and relate the surgical margin to the lesions, its reactive zone, and anatomic compartment. The system defines prognostically significant progressive stages of risk which also have surgical implications. When the system is linked to clearly defined surgical procedures, it permits appropriate evaluation and comparison of the new treatment protocols designed to replace standard surgical treatment.

A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system.

The need for a standardized system of end result reporting of various surgical alternatives after limb salvaging and ablative procedures for musculoskeletal tumors was clearly recognized during the first International Symposium on Limb Salvage (ISOLS) in 1981. During the ensuing four biannual symposia, there has been an ongoing developmental experience with a system extensively field tested in 1989 by the Musculoskeletal Tumor Society (MSTS). This system of functional evaluation has been adopted by the MSTS and ISOLS for their joint studies and program presentation. In brief, the system assigns numerical values (0-5) for each of six categories: pain, and function and emotional acceptance in upper and lower extremities; supports, and walking and gait in the lower extremity; and hand positioning, and dexterity and lifting ability in the upper extremity. Demographic information and a patient satisfaction component is included. A numerical score and percent rating is calculated to allow for comparison of results. The system has been field tested in 220 patients with low (+/-) interobserver variability. It was well accepted by the participants, and its usage is recommended by the MSTS to facilitate valid comparative end result studies of musculoskeletal tumor reconstructions.

A SYSTEM OF STAGING MUSCULOSKELETAL NEOPLASMS

A system for staging benign and malignant musculoskeletal lesions is presented. This system, first devised at the University of Florida in 1977, was based on data assembled from 1968 through 1976. It was field tested by the Musculoskeletal Tumor Society and published in Clinical Orthopaedics and Related Research in 1980. In the ensuing five years, the system has undergone refinement. It has recently been adapted by the American Joint Committee Task Force on Bone Tumors and proposed by them to the International Union Against Cancer (IUCC) for international usage. Based upon histologic grade (G), anatomic site (T), and presence or absence of metastases (M), it describes the progressive stages, irrespective of histogenesis, that assess the progressive degrees of risk to which the patient is subject. This system articulates well with current radiologic techniques of staging and serves as a useful guide in the selection of an appropriate definitive surgical procedure. Its usage permits comparative end result studies on the effect of surgical and nonsurgical methods of management.

Retrieved Human Allografts: A Clinicopathological Study

Background: We studied seventy-three massive preserved human allografts, retrieved from two to 156 months after implantation, to provide insight into the mechanisms of their repair. Methods: The specimens were studied with radiographic and histological techniques that permitted time-related quantitative analysis of the reparative mechanisms of union, cortical repair, soft-tissue attachment, fracture, and characteristics of the allograft-cement interface and the articular cartilage. Results: Union at cortical-cortical junctions occurred slowly (approximately twelve months) by host-derived external callus that bridged the junction and filled the gap between abutting cortices. The bone in the gap did not undergo stress-oriented remodeling even after many years, and, when the union was intentionally disrupted, failure occurred at the cement line that marked the allograft-host junction. Repair of the necrotic graft matrix was both external and internal. External repair consisted of the apposition of a thin seam of host bone on the outer surface of the graft, coating about 40% of the surface at one year and 80% at two years. Internal repair was confined to the ends and the periphery of the cortices and penetrated so slowly that only 15% to 20% of the graft was repaired by five years, after which deeper repair seldom occurred. Graft fractures in specimens retrieved soon after fracture showed only necrotic bone adjacent to the fracture site, whereas those retrieved after fracture-healing showed a marked increase in internal repair of the bone about the fracture site. When bone cement had been used to fix a prosthesis, there was no evidence of bone resorption or loosening of the device. The osteoarticular specimens showed no survival of chondrocytes in the articular cartilage. However, the architecture of the acellular cartilage was well preserved after two to three years and occasionally after as many as five years. Late degenerative changes in the articular cartilage coincided with subchondral revascularization and fragmentation, and the articulating surfaces became covered by a pannus of fibrovascular reparative tissue. Degenerative changes in articular cartilage occurred earlier and were more advanced in specimens retrieved from patients with an unstable joint than in those retrieved from patients with a stable joint. Conclusions: Repair of massive human allografts is an indolent process that follows a fairly predictable course during the first few years and is influenced by other biological activities, such as fracture repair, supplementary autografting, and tumor recurrence. Clinical Relevance: These observations provide a clear, detailed picture of the extent, timing, and deficiencies in the incorporation and repair of large human allografts preserved by conventional banking techniques. As such, they provide a basis for comparative studies of the efficacy of the recently developed osteoinductive substances currently under investigation.

Fibrous Dysplasia. Pathophysiology, Evaluation, and Treatment

Fibrous dysplasia is a common benign skeletal lesion that may involve one bone (monostotic) or multiple bones (polyostotic) and occurs throughout the skeleton with a predilection for the long bones, ribs, and craniofacial bones. The etiology of fibrous dysplasia has been linked to an activating mutation in the gene that encodes the alpha subunit of stimulatory G protein (G(s)alpha) located at 20q13.2-13.3. Most lesions are monostotic, asymptomatic, and identified incidentally and can be treated with clinical observation and patient education. Bisphosphonate therapy may help to improve function, decrease pain, and lower fracture risk in appropriately selected patients with fibrous dysplasia. Surgery is indicated for confirmatory biopsy, correction of deformity, prevention of pathologic fracture, and/or eradication of symptomatic lesions. The use of cortical grafts is preferred over cancellous grafts or bone-graft substitutes because of the superior physical qualities of remodeled cortical bone.

The effect of the anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh

The results of surgical treatment in 40 patients with a soft tissue sarcoma of the thigh were analyzed to determine the influence of the anatomic setting on the effectiveness of the procedure. The anatomic setting, based on functional anatomic compartments, was defined as either intra‐ or extracompartmental. The lesions were graded for aggressiveness as either high or low. The lesions were staged by biologic aggressiveness, anatomic setting, and metastases. The procedures, whether amputations or local resections, were classified by the relationship of the surgical margin to the pseudocapsule and reactive zone about the lesion as marginal, wide, or radical.

The Intra-articular Effects of Immobilization on the Human Knee

The Intra-Articular Effects of Immobilization on the Human Knee W. ENNEKING;MARSHALL HOROWITZ; The Journal of Bone & Joint Surgery

The Silent Hip in Idiopathic Aseptic Necrosis: Treatment By Bone-grafting

After identifying six stages in the development of idiopathic aseptic necrosis of the femoral head in a refrospective study of fifty-three patients with bilateral disease, the results in the treatment of eleven asymptomatic hips (Stages 1 and 2) by Phemister-type fibular and tibial bone grafts were analyzed. Using a defined rating system based on the amount of change after operation in the stage of the disease and in the Iowa hip rating, seven hips were classified satisfactory; three, fair; and one, poor, in which the grafts were not placed properly. From these cases it was concluded that this procedure is warranted in the treatment of the silent (asymptomatic) hip in selected patients with bilateral idiopathic aseptic necrosis.

Allograft-prosthesis Composite Versus Megaprosthesis in Proximal Femoral Reconstruction

A review of 33 patients who underwent proximal femoral resection for primary bone tumor and reconstruction with an allograft-prosthesis composite or a megaprosthesis is presented to consider the relative merits of the 2 procedures. Clinical function, reconstruction survival, and associated complications were analyzed. Eighteen composites in 16 patients and 18 megaprostheses in 17 patients were analyzed. Infection in the composite group and instability in the megaprosthesis group were the common causes of failure and removal of reconstructions. The average functional evaluation in 14 surviving patients with composites was 87% of normal. In 10 surviving patients with megaprostheses, the average function was 80% when complications were avoided. Survival analysis of the patients with reconstructions showed a 10 year survival of 76% for the patients with composites and 58% for those with megaprostheses. Both composite and megaprosthetic reconstruction of the proximal femur seem to function equally well from the perspective of function and survival because no statistically significant difference could be shown by this review.

Giant-cell tumor of bone with pulmonary metastases.

We reviewed the cases of seven patients with histologically benign primary giant-cell tumor of bone and histologically proved metastases to the lung. All seven had a Stage-3, aggressive, benign lesion with interruption of the cortex and soft-tissue extension. The main histological features of the primary lesion were identical to those of the pulmonary metastases. In only one of the seven patients were the metastases detected simultaneously with the primary lesion. All seven patients were treated by surgical resection of the lung nodules and chemotherapy. Of the seven patients, four were alive and free of disease after an average follow-up of nine years; two were receiving chemotherapy; and one, who had had immunosuppression for an allograft transplant, died less than one year after the discovery of the pulmonary lesions. Based on this small series, we concluded that patients with a Stage-3 giant-cell tumor of bone may be at risk for pulmonary spread of the disease. This lesion, with its benign histological picture even in lung lesions, has a favorable prognosis when treated with pulmonary resection of the nodules. However, the role for chemotherapy after pulmonary surgery is still unclear.