Prognostic value of necrosis after neoadjuvant therapy for soft tissue sarcoma.

BACKGROUND AND OBJECTIVES: While treatment-induced tissue necrosis is a well-documented predictor of patient survival in malignant bone tumors, its prognostic value in soft tissue sarcomas is controversial. A prior study from our institution did not find a prognostic value to tumor necrosis. We analyze a more extensive database of high-grade soft tissue sarcomas treated with neoadjuvant chemotherapy, radiation therapy, or both to re-evaluate if the degree of tumor necrosis alone can be used as a predictive factor for local recurrence, metastasis, and disease-specific survival. METHODS: Two hundred and seven patients with high-grade extremity soft tissue sarcoma received neoadjuvant chemotherapy and/or radiation therapy and wide excision. Tumor treatment response was determined by histopathologic analysis, and patients were followed for local recurrence, metastasis, or death. RESULTS: Tumor necrosis ≥ 90% correlates with improved disease-free survival with univariate analysis, but this does not reach statistical significance on multivariate analysis. Age and tumor volume were found to be the only independent predictors of disease-free survival on multivariate analysis. CONCLUSIONS: There is insufficient evidence to support the use of necrosis to prognosticate survival and alter chemoradiation regimens in high grade soft tissue sarcomas of the extremity. Larger studies are needed to definitively address the prognostic value of necrosis. LEVEL OF EVIDENCE: Level II, Prognostic

Early clinical and radiographic results of minimally invasive anterior approach hip arthroplasty.

We present a retrospective review of the early results and complications in a series of 35 consecutive patients with 43 total hip arthroplasties performed through an anterior muscle sparing minimally invasive approach. We found the early complication rates and radiographic outcomes comparable to those reported from arthroplasties performed via traditional approaches. Complications included dislocation (2%), femur fracture (2%), greater trochanteric fracture (12%), postoperative periprosthetic intertrochanteric fracture (2%), femoral nerve palsy (5%), hematoma (2%), and postoperative iliopsoas avulsion (2%). Radiographic analysis revealed average cup anteversion of 19.6° ± 6.6, average cup abduction angle of 48.4° ± 7, stem varus of 0.9° ± 2, and a mean leg length discrepancy of 0.7 mm. The anterior approach to the hip is an attractive alternative to the more traditional approaches. Acceptable component placement with comparable complication rates is possible using a muscle sparing technique which may lead to faster overall recovery.

Moving beyond response criteria: new measures of success in the treatment of sarcomas.

There is an urgent need to develop new therapies for soft tissue sarcomas. Traditional cytotoxic therapies, such as doxorubicin and ifosfamide, have been the standard approach to this disease. However, newer paradigms are emerging that are less toxic while targeting dysregulated pathways, tumor hypoxia, and genetic translocations. These newer therapies require different measures of activity as standard response criteria may inaccurately measure their effectiveness. Serious consideration of select endpoints and measures of tumor response are crucial to make significant strides in the treatment of sarcomas. Current studies on soft tissue sarcomas are slowly abandoning response rates while employing progression-free survival and time to progression as improved endpoints. With time and data, our understanding of the relative activity of these agents will grow and lead to improved benefits for our patients.

A meta-analysis of osteosarcoma outcomes in the modern medical era.

Four decades ago, specialized chemotherapy regimens turned osteosarcoma, once considered a uniformly fatal disease, into a disease in which a majority of patients survive. Though significant survival gains were made from the 1960s to the 1980s, further outcome improvements appear to have plateaued. This study aims to comprehensively review all significant, published data regarding osteosarcoma and outcome in the modern medical era in order to gauge treatment progress. Our results indicate that published survival improved dramatically from 1960s to 1980s and then leveled, or in some measures decreased. Recurrence rates decreased in the 1970s and then leveled. In contrast, published limb salvage rates have increased significantly every recent decade until the present. Though significant gains have been made in the past, no improvement in published osteosarcoma survival has been seen since 1980, highlighting the importance of a new strategy in the systemic management of this still very lethal condition.

Endoprostheses last longer than intramedullary devices in proximal femur metastases.

BACKGROUND: The proximal femur is the most common site of surgery for bone metastases, and stabilization may be achieved through intramedullary fixation (IMN) or endoprosthetic reconstruction (EPR). Intramedullary devices are less expensive, less invasive, and may yield improved function over endoprostheses. However, it is unclear which, if either, has any advantages. QUESTIONS/PURPOSES: We determined whether function, complications, and survivorship differed between the two approaches. METHODS: We retrospectively reviewed 158 patients with 159 proximal femur metastatic lesions treated with surgical stabilization. Forty-six were stabilized with IMN and 113 were treated with EPR. The minimum followup was 0.25 months (mean, 16 months; median, 17 months; range, 0.25-86 months). RESULTS: The mean Musculoskeletal Tumor Society score was 24 of 30 (80%) after IMN and 21 of 30 (70%) after EPR. There were 12 complications (26%) in the IMN group, including 10 nonunions, six of which went on to mechanical failure. There were complications in 20 of 113 (18%) of the EPR group, which consisted of 10 dislocations (9%) and 10 infections (9%). There were no mechanical failures with EPR. Both implants remained functional for the limited lifespan of these patients in each group at all time intervals. EPRs were associated with increased implant longevity compared with IMNs (100% versus 85% 5-year survival, respectively) and a decreased rate of mechanical failure (0% versus 11%, respectively) when compared with the intramedullary devices. CONCLUSIONS: Patients with metastatic disease to the proximal femur may live for long periods of time, and these patients may undergo stabilization with either IMN or EPR with comparable functional scores and the implant survivorship exceeding patient survivorship at all time intervals. Endoprostheses demonstrate a lower mechanical failure rate and a higher rate of implant survivorship without mechanical failure than IMN devices. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A Rare Case Report of Extensive Polyostotic Gorham's Disappearing Bone Disease Involving the Upper Extremity.

Gorham's disease is a rare disorder involving the proliferation of endothelial channels resulting in resorption and disappearance of bone. An unusual case of polyostotic Gorham's disease affecting the scapula, humerus, radius, and ulna in a 39-year-old woman is described. The patient had extensive disease spreading across both the glenohumeral and humeroulnar joints. This is the first report of Gorham's disease spreading across multiple joints in the upper extremity.

A comparison of fine-needle aspiration, core biopsy, and surgical biopsy in the diagnosis of extremity soft tissue masses.

BACKGROUND: Biopsy tissue can be obtained through a fine needle, a wider coring needle, or through an open surgical incision. Though much literature exists regarding the diagnostic yield of these techniques individually, none compare accuracy of diagnosis in the same mass. QUESTIONS/PURPOSES: We asked how the diagnostic accuracy of fine-needle aspiration, core biopsy, and open surgical biopsy compare in regard to identifying malignancy, establishing the exact diagnosis, and guiding the appropriate treatment of soft tissue masses. PATIENTS AND METHODS: We prospectively studied 57 patients with palpable extremity soft tissue masses, performing fine-needle aspiration, followed by core biopsy, followed by surgical biopsy of the same mass. RESULTS: Open surgical biopsy was 100% accurate on all accounts. With regard to determining malignancy, fine-needle aspiration and core biopsy had 79.17% and 79.2% sensitivity, 72.7% and 81.8% specificity, 67.9% and 76% positive predictive value, 82.8% and 84.4% negative predictive value, and an overall accuracy of 75.4% and 80.7%, respectively. In regard to determining exact diagnosis, fine-needle aspiration had a 33.3% accuracy and core biopsy had a 45.6% accuracy. With regard to eventual treatment, fine-needle aspiration was 38.6% accurate and core biopsy was 49.1% accurate. CONCLUSIONS: In soft tissue mass diagnosis, core biopsy is more accurate than fine-needle aspiration on all accounts, and open biopsy is more accurate than both in determining malignancy, establishing the exact diagnosis, and the guiding appropriate treatment.

Gallery of uncommon orthopedic implants: a guide for emergency radiologist.

The purpose of this gallery of orthopedic implants was to provide a reference for emergency radiologists to quickly identify uncommon devices in the shoulders, hips, and extremities. The cases presented in this exhibit will include unusual arthroplasties and prostheses as well as bone graft implants (including allograft and autograft). Bone grafts are frequently used for the treatment of bone defects, which may be caused by trauma, infection, or avascularity. Autogenous cancellous, corticocancellous, or cortical bone grafts are often used, either free or vascularized. Alternative bone graft substitutes are also used. An obvious complication of bone grafts is the failure of incorporation. Joint arthroplasty is the most frequently performed orthopedic procedure after fracture fixation. Major indications include degenerative joint disease, inflammatory arthropathy, avascular necrosis, and complicated fractures. Custom orthopedic implants are frequently used for less common indications or for patients with bone tumors. The common hardware complications are infections, loosening, small particle disease/osteolysis, periprosthetic fracture, hardware fracture or dislocation, and recurrent disease, especially in patients with tumors. Many of the devices used by orthopedic surgeons are infrequently seen in everyday radiology practice. With such variations, correct recognition of the prosthetic devices and their complications is very important. The goal of this exhibit was to familiarize the radiologist with both the normal and abnormal appearance of many atypical orthopedic implants. It is important to understand the purpose and proper function of a device, but not necessarily important to describe every device by its proper brand name. Although this exhibit is not meant to be inclusive of every unusual orthopedic implant, we will present multiple examples of orthopedic hardware involving the shoulder, humerus, elbow, forearm, wrist, hand, pelvis, hip, femur, knee, tibia, ankle, and foot that are not likely seen in everyday practice.

Modified Harrington reconstruction for advanced periacetabular metastatic disease.

BACKGROUND/OBJECTIVES: Destructive metastatic lesions about the acetabulum result in pain and functional limitations. We assessed whether periacetabular reconstruction (PAR) improves quality of life by examining outcome measures of pain, function, and mobility. METHODS: Thirty-seven patients with a mean follow-up of 23.6 months (range, 0.5-112 months) were retrospectively reviewed. All patients underwent modified Harrington reconstruction with periacetabular screws, cement, and total hip arthroplasty. RESULTS: The mean preoperative MSTS score of 14 (47%, 14/30) improved to 20 (67%, 20/30) after the procedure. Thirty-five patients who were alive 1 month after the procedure were reviewed for outcome. Postoperatively, patients reported a significant improvement in pain (P < 0.0001), mobility (P < 0.0385), and function (P < 0.0186). Kaplan-Meier survivorship curves showed 59% implant- and 55% patient survival at 2 years; and 49% implant- and 39% patient survival at 5 years. Complications included infection (16%, 6/37) and instability (16%, 6/37). CONCLUSIONS: Our experience with PAR has shown good results with improved postoperative functional scores. Implants will generally exceed life expectancy and are an option to restore quality of life.

Periacetabular reconstruction with a new endoprosthesis.

UNLABELLED: Reconstruction of the Type II pelvic resection is challenging. Currently available reconstructive options have inherent problems including graft and implant failure, pain, poor function, and high major complication rates. The periacetabular reconstruction (PAR) endoprosthesis was designed to be secured with internal fixation and bone cement to the remaining ilium and support a reconstructed acetabulum. This construct potentially avoids the complications of graft or hardware failure, while maintaining early mobilization, comfort, limb lengths, and function. We retrospectively reviewed 25 patients who underwent Type II pelvic resection and reconstruction with the PAR endoprosthesis, analyzing function, complications, and survivorship. The minimum followup was 13 months (mean, 29.4 months; range, 13 to 108 months). We compared the PAR data with the literature for the Mark II saddle endoprosthesis. The PAR's average MSTS score was 20.8 (67%), major complications occurred in 14 (56%), and implant survivorship was 84% at 2 years and 60% at 5 years. The rate of failure at the ilium-saddle interface was lower and implant survivorship higher than those in the published literature for the Mark II saddle. We recommend use of the PAR endoprosthesis for reconstruction of large defects following Type II pelvic resection. The modified saddle design provides greater inherent stability, allowing for faster rehabilitation and improved longevity without increased complications and is an improvement over the currently available saddle prostheses. LEVEL OF EVIDENCE: Level III, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

The linear cutting stapler may reduce surgical time and blood loss with muscle transection: a pilot study.

UNLABELLED: Because of skeletal muscle's density and vascularity, its transection with standard electrocautery can be tedious. In a pilot study we asked whether a linear cutting stapling device decreased surgical time, blood loss, transfusion rates, and complications in patients undergoing above-knee amputation when compared to traditional electrocautery. We retrospectively reviewed 11 patients with above-knee amputation cases using a linear cutting stapling device over a 10-year period and compared those to 13 patients in whom we used electrocautery. The patients treated with the linear cutting stapling device had an average of 97 minutes of surgical time, 302 cc blood loss, and 1.55 units transfusion, compared to an average 119 minutes, 510 cc, and 2.15 units, respectively, with the electrocautery cases. Despite the trends, these parameters, as well as major complications, were similar in these two small groups. In skeletal muscle transection, we believe the linear cutting stapler is a reasonable and potentially cost-effective technical alternative to electrocautery, possibly resulting in less blood loss and shorter surgical time with similar rates of complications. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hip disarticulation for severe lower extremity infections.

UNLABELLED: Hip disarticulation is rarely performed for infections and variable mortality rates have been reported. We determined the number of deaths following hip disarticulation for severe lower extremity infections in 15 patients. Indications for hip disarticulation were necrotizing soft tissue infections in seven patients and persistent infections of the proximal thigh in eight patients. The most common microorganism was Staphylococcus aureus, present in eight patients. Hip disarticulation was performed emergently in seven patients and electively in eight patients. All patients survived the operation and at 1 month postoperatively 14 of 15 patients were alive. Hip disarticulation for these severe infections had high survival, even when performed emergently for life-threatening infections. We believe hip disarticulation is a reasonable option treating severe infections of the lower extremity and should be part of the armamentarium of the orthopaedic surgeon. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Unusual locations for metastatic malignancy of the hand: a report of three cases.

Metastatic tumors of the hand bones are very rare. This report presents three cases of metastatic lesions involving the bones of the hand. These metastases, with adenocarcinoma of the lung as the primary malignancy, were the first clinical presentation of adenocarcinoma in two of these patients. The hamate bone was involved in one patient and the proximal phalanx of the ring finger was involved in the other patient. The third patient developed metastatic disease to the distal phalanx 8 months after initial diagnosis. The authors emphasize that a lytic lesion in the hand may be the first clinical sign of a malignancy or progression to metastatic disease.

Cryoablation and resection influences patient survival for soft tissue sarcomas: impact on survivorship and local recurrence.

Cryosurgical ablation has been used successfully for treating various carcinomas and bone tumors; however, few studies report the use of cryosurgery followed by tumor resection for the treatment of soft tissue sarcomas. We evaluated local recurrence, progression of disease, histologic necrosis from the cryoablation, complications, patient survival, and functional outcomes using this approach. We retrospectively reviewed 38 patients with no prior treatment for their neoplasm who underwent cryosurgery followed by wide excision of soft tissue sarcomas. Three patients developed local recurrence. Sixteen patients had evidence of more than 95% tumor necrosis, and 11 of these had 100% histologic necrosis. We observed a difference in overall survival and disease-free survival based on the adequacy of freezing process. Patients with more than 95% necrosis had a survival rate of 94% at 2 years and 86% at 5 years, while those with less than 95% necrosis survived 53% at 2 years and 34% at 5 years. Complications included transient neuropraxia (13%), superficial wound infections (8%), and seroma (21%). Cryosurgical ablation appears a safe and effective method of devitalizing tumor cells of soft tissue sarcomas.

Tumor necrosis has no prognostic value in neoadjuvant chemotherapy for soft tissue sarcoma.

Neoadjuvant chemotherapy for treatment of soft tissue sarcomas is controversial, and the correlation between local recurrence and survival is unclear. Histologic necrosis is a well-documented predictor of survival in patients with malignant bone tumors; however, the association is unknown in patients with soft tissue sarcomas. We assessed the prognostic significance of tumor necrosis for treatment of soft tissue sarcomas. We retrospectively collected data from 82 patients who received neoadjuvant chemotherapy for treatment of soft tissue sarcomas of the extremities. Patients had wide resections if tumors were high-grade, deep to the investing fascia, and had clear margins. We quantified the amount of necrosis and analyzed the relationship with local recurrence and overall survival. At an average followup of 65 months (range, 24-154 months), the 5-year local recurrence rates for patients with less than 95% and 95% or greater necrosis were 20% and 33%, respectively. The overall 5-year survivorship rates for patients with less than 95% necrosis and 95% or greater necrosis were 82% and 78%, respectively. There was no difference in recurrence-free survival or overall patient survival based on the amount of histologic necrosis. Tissue necrosis from neoadjuvant chemotherapy does not seem to predict outcome in soft tissue sarcomas.

The early diagnosis of sacroiliac joint infections in children.

UNLABELLED: We retrospectively reviewed the medical records and imaging studies of 15 children with infections of the sacroiliac joint to determine the usefulness of specific examinations and studies to aid in the early diagnosis of this condition. The clinical presentation, physical examination findings, pertinent laboratory data, and imaging studies were reviewed. Thirteen patients (87%) were febrile at the time of presentation. One patient presented in septic shock requiring intubation and critical care management. Tenderness to palpation over the sacroiliac joint was present in all 9 patients who had this examination performed, and the flexion abduction external rotation test was positive in 10 of 12 patients (83%) who had this test done. Laboratory indicators of infection were elevated in most patients, and 6 patients (46%) had positive blood cultures, most commonly growing Staphylococcus aureus. Initial conventional radiographs were negative in all but 1 patient. Radionuclide 99-m-technetium bone scans were positive in 7 of 10 patients (70%), and magnetic resonance imaging studies were ultimately positive in 13 of 14 patients (93%). However, within the first 6 days after the onset of symptoms, only 5 of 8 bone scans (63%) and 5 of 9 magnetic resonance imaging studies (57%) were consistent with infection. We conclude that while diagnostic imaging studies are ultimately helpful in confirming the diagnosis of sacroiliac joint infections in children, studies made within 6 days of the onset of symptoms may not always confirm the diagnosis. The early diagnosis of this condition is best made on the basis of clinical and laboratory findings. LEVEL OF EVIDENCE: Therapeutic Study, level IV (Case series [no, or historical control group]).

Endoprosthetic reconstruction for neoplasms of the proximal femur.

UNLABELLED: Limb salvage has become an important alternative to amputation in the treatment of bone neoplasms. We sought to determine whether the survivorship of modular proximal femur endoprostheses compares to that of custom implants and if specified factors predict failure. We additionally assessed the intermediate clinical and functional results with regard to complications and outcome. We retrospectively reviewed 96 consecutive patients who underwent endoprosthetic reconstruction for neoplastic disease and assessed patient, implant, and limb survivorship. The mean patient age was 59 years (range, 14-86 years). The average duration of followup was 18.1 months (range, 1-129 months). Nine (9.3%) prostheses failed and the rate of revision was 7.3% (7/96). Overall implant survival was 82% at 5 years and 10 years. Survivorship of the limb was 99% at 5 years. Patients in whom the articulating head segment was a total hip had a higher rate of revision compared with those who had undergone bipolar replacement. The mean MSTS score was 22 points (range, 15-25 points). Modular endoprosthetic replacement of the proximal femur is a durable reconstructive option and implants will generally outlive the patient with neoplastic disease. Bipolar head segments should be used whenever possible because of increased survival and decreased rates of dislocation. LEVEL OF EVIDENCE: Therapeutic study, level IV (case series).

Influence of cryosurgery on treatment outcome of low-grade chondrosarcoma.

Successfully managing low-grade chondrosarcomas with margins considered less than wide would minimize the need for extensive reconstruction. We report our experience using cryotherapy as an adjuvant to treat patients with low-grade intracompartmental chondrosarcomas. Ten consecutive patients had intralesional resections including curettage, cryo-surgery, and polymethylmethacrylate application. Eight of these patients required prophylactic skeletal stabilization. We retrospectively reviewed the outcomes for tumor recurrence, disease progression, and complications. The Musculo-skeletal Tumor Society rating scale was used to evaluate functional outcome, and the mean score was 27 points (range, 25-30 points). The mean age of the patients was 54.4 years (range, 29-83 years), and the average followup was 38.5 months (range, 24-60 months). Patients were treated for lesions of the femur (n = 3), humerus (n = 3), scapula (n = 2), tibia (n = 1), and acetabulum (n = 1). There was no evidence of recurrence or metastases. At the latest followup, all patients were well, however, one patient had hardware loosening. In this small group of patients, intralesional resection with adjuvant cryoablation provided an alternative to more radical procedures for low-grade intracompartmental chondrosarcoma.

Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes.

BACKGROUND: Previous studies have demonstrated high complication rates after harvest of iliac crest bone grafts. This study was undertaken to compare the morbidity related to the harvest of anterior iliac crest bone graft with that related to the harvest of posterior iliac crest bone graft and to determine differences in functional outcome. METHODS: The medical records of eighty-eight consecutive patients who had undergone a total of 108 iliac crest bone-grafting procedures for the treatment of chronic osteomyelitis from 1991 to 1998 were retrospectively reviewed. Demographic characteristics, the location of the harvest, the volume of bone graft that was harvested, the estimated blood loss, and postoperative complications were recorded. Fifty-eight patients completed a questionnaire pertaining to postoperative and residual pain, sensory disturbances, functional limitations, cosmetic appearance, and overall satisfaction with the bone-graft harvesting procedure. RESULTS: Sixty-six anterior and forty-two posterior bone-graft harvest sites were evaluated at a minimum of two years after the operation. A major complication was associated with 8% (five) of the sixty-six anterior sites and 2% (one) of the forty-two posterior sites. The rates of minor complications were 15% (ten) and 0%, respectively. In the series as a whole, there were ten minor complications (9%) and six major complications (6%). The rates of both minor complications (p = 0.006) and all complications (p = 0.004) were significantly higher after the anterior harvest procedures than they were after the posterior procedures. The postoperative pain at the donor site was significantly more severe (p = 0.0016) and of significantly greater duration (p = 0.0017) after the anterior harvests. No patient reported functional limitations at the latest follow-up evaluation. CONCLUSIONS: In this series, the complication rate was lower than those previously reported by other investigators. Harvest of a posterior iliac crest bone graft was associated with a significantly lower risk of postoperative complications. On the basis of the results of this study, we recommend that iliac crest bone graft be harvested posteriorly whenever possible.