Controversies in orthopaedic oncology.

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

As simple as it sounds? The treatment of simple bone cysts in the proximal femur in children and adolescents: Retrospective multicenter EPOS study of 74 patients.

Purpose: Simple bone cysts are among the most prevalent benign cystic tumor-like lesions in children. Proximal femoral simple bone cysts may require specific treatment because of increased fracture risk. With limited literature available on this specific localization, consensus regarding optimal treatment is lacking. We present a large international multicenter retrospective cohort study on proximal femoral simple bone cysts. Methods: All consecutive pediatric patients with proximal femoral simple bone cyst from 10 tertiary referral centers for musculoskeletal oncology were included (2000-2021). Demographics, primary treatment, complications, and re-operations were evaluated. Primary outcomes were time until full weight-bearing and failure-free survival. Results: Overall, 74 simple bone cyst patients were included (median age 9 years (range = 2-16), 56 (76%) male). Median follow-up was 2.9 years (range = 0.5-21). Index procedure was watchful waiting (n = 6), percutaneous procedure (n = 12), open procedure (n = 50), or osteosynthesis alone (n = 6). Median time until full weight-bearing was 8 weeks (95% confidence interval = 0.1-15.9) for watchful waiting, 9.5 (95% confidence interval = 3.7-15.3) for percutaneous procedure, 11 (95% confidence interval = -0.7 to 13.7) for open procedure, and 6.5 (95% confidence interval = 5.9-16.1) for osteosynthesis alone (p = 0.58). Failure rates were 33%, 58%, 29%, and 0%, respectively (p = 0.069). Overall failure-free survival at 1, 2, and 5 years was 77.8% (95% confidence interval = 68.2-87.4), 69.5% (95% confidence interval = 58.5-80.5), and 62.0% (95% confidence interval = 47.9-76.1), respectively. Conclusion: A preferred treatment for proximal femoral simple bone cysts remains unclear, with comparable failure rates and times until full weight-bearing. Watchful waiting may be successful in certain cases. If not feasible, osteosynthesis alone can be considered. Treatment goals should be cyst control, minimizing complications and swift return to normal activities. Therefore, an individualized balance should be made between undertreatment, with potentially higher complication risks versus overtreatment, resulting in possible larger interventions and accompanying complications. Level of evidence: Level IV, retrospective multicentre study.

Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial.

BACKGROUND: Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS: The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS: This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Chondrosarcoma of the Femur: Is Local Recurrence Influenced by the Presence of an Extraosseous Component?

BACKGROUND: Chondrosarcoma (CS) is the second most common surgically treated primary malignancy of the bone. The current study explored the effect of the margin and extraosseous tumor component in CS in the femur on local recurrence (LR), LR-free survival (LRFS), and disease-specific survival (DSS). METHODS: Among 202 patients, 115 were in the proximal extremity of the femur, 4 in the corpus of the femur, and 83 in the distal extremity of femur; 105 patients had an extraosseous tumor component. RESULTS: In the Kaplan-Meier analysis, factors significant for decreased LRFS were the extraosseous tumor component (p < 0.001), extraosseous tumor component arising from the superior aspect (p < 0.001), histological grade (p = 0.031), and narrow surgical margin < 3 mm (p < 0.001). Factors significantly affecting DSS were the histological grade (p < 0.001), extraosseous component (p < 0.001), LR (p < 0.001), metastases (p < 0.001), and surgical margin (p < 0.001). CONCLUSIONS: In CS of the femur, the presence of an extraosseous tumor component has a predictive role in LRFS, and extraosseous tumor component arising from the superior aspect was significant for decreased LRFS. Wide margins were more commonly achieved when the tumor had only an intraosseous component, and the rate of LR was significantly higher in cases with an extraosseous tumor component. When the extraosseous component arose from the superior aspect of the femur, LR occurred more frequently despite achieving adequate margins.

Intraosseous conventional central chondrosarcoma does not metastasise irrespective of grade in pelvis, scapula and in long bone locations.

Background: Histological grade has been regarded as the most important prognostic factor in conventional central chondrosarcoma. To evaluate whether the presence of an extraosseous tumour component is associated with a decreased metastasis-free survival or disease-specific survival and alternatively to develop a simple prognostic and clinical decision-making tool. Material and methods: We searched two prospectively maintained international sarcoma centre databases for primary non metastatic central conventional chondrosarcomas of all grades in pelvis, scapula or long bone location, undergoing curative treatment, diagnosed between 2000 and 2020. Pre-treatment MRI scans were reviewed for the presence of an extraosseous mass. The metastasis-free survival (MFS) and disease-specific survival (DSS) were estimated by the Kaplan-Meier method from surgery to event, death or last follow-up. Results: 336 patients were identified between 2000 and 2020, undergoing surgical treatment for conventional central chondrosarcoma. 111 patients (33 %) had grade 1 tumours, 149 patients (44 %) had grade 2, and 76 patient (23 %) had grade 3 chondrosarcomas determined as the highest grade in the final resected specimen. An extraosseous soft tissue component was more frequent in higher grade tumours (p < 0.001) and present in 200 cases (60 %). None of the patients with an intraosseous tumour developed metastases or died of the disease. For patients with extraosseous tumour component, MFS was 92 % (95 % CI, 96-100) at 2-years and 74 % (95 % CI, 67-81) at 10-years and DSS was 91 % (95 % CI, 87-95) at 2-years and 75 % (95 % CI, 68-82) at 10-years. The MFS and DSS was significantly different (p < 0.001) for those patients with or without an extraosseous tumour component, irrespective of grade or anatomical location. Discussion: The results of this study has shown that the metastatic potential of intraosseous conventional central chondrosarcoma is negligible. The presence of an extraosseous soft tissue component may be used for prognostication and to guide treatment pathways for patients with central cartilage tumours.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial.

BACKGROUND: Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking. METHODS AND FINDINGS: The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely. CONCLUSIONS: In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

Pelvic bone sarcomas, prognostic factors, and treatment: A narrative review of the literature.

Primary sarcomas of bone are rare malignant mesenchymal tumors. The most common bone sarcomas are osteosarcoma, Ewing's sarcoma, and chondrosarcoma. The prognosis has improved over the years, but bone sarcomas are still life-threatening tumors that need a multidisciplinary approach for diagnosis and treatment. Bone sarcomas arising in the pelvis present a unique challenge to orthopedic oncologists due to the absence of natural anatomical barriers, the close proximity of vital neurovascular structures, and the high mechanical demands placed on any pelvic reconstruction following the excision of the tumor. While radiotherapy has an important role especially in Ewing's sarcoma and chemotherapy for both Ewing's sarcoma and osteosarcoma, surgery remains the main choice of treatment for all three entities. While external hemipelvectomy has remained one option, the main aim of surgery is limb salvage. After complete tumor resection, the bone defect needs to be reconstructed. Possibilities to reconstruct the defect include prosthetic or biological reconstruction. The method of reconstruction is dependent on the location of tumor and the surgery required for its removal. The aim of this article is to give an insight into pelvic bone sarcomas, their oncological and surgical outcomes, and the options for treatment based on the authors' experiences.

Chondrosarcoma of the Proximal Humerus: Does the Margin Affect Survival?

Chondrosarcoma (CS) is the second most common primary malignant bone tumour and, in the absence of reliable chemotherapy and radiotherapy, is effectively a surgical disease. Overall disease specific survival (DSS) is affected by tumour grade, whilst resection margin contributes to local recurrence free survival (LRFS). The aim of this study was to investigate factors that affect the local and systemic prognoses for conventional central CSs arising from the proximal humerus. A multi-centre, retrospective study from three international collaborative sarcoma centres identified 110 patients between 1995 and 2020 undergoing treatment for a conventional central CS of the proximal humerus; 58 patients (53%) had a grade 1 tumour, 36 (33%) had a grade 2 tumour, and 16 patients (13%) had a grade 3 CS. The mean age of patients was 50 years (range 10-85). The incidence of local recurrence (LR) was 9/110 (8.2%), and the disease specific mortality was 6/110 (5.5%). The grade was a statistically significant factor for LRFS (p < 0.001). None of the grade 1 tumours developed LR. The DSS was affected by the grade (p < 0.001) but not by the LR (p = 0.4). Only one patient with a grade 2 tumour died from the disease. The proximal humeral grade 1 CS behaved as a benign tumour, having no cases of LR nor death due to disease. Grade 2 CSs of the proximal humerus behaved in a more indolent way when compared with comparable grade tumours elsewhere in the appendicular skeleton, being locally aggressive with a higher LR rate than grade 1 CSs but still having very low mortality and a high rate of DSS. The LR in grade 2 CSs did not affect the DSS; therefore, surgical management in proximal humeral grade 2 CSs should have a greater emphasis on preserving function whilst maintaining an adequate margin for resection. The proximal humeral grade 3 CS was, as elsewhere in the skeleton, an aggressive, high-grade tumour. Therefore, surgical management should include en bloc resection with clear margins to avoid LR.

A comparison of the functional results and costs of functional cast and volar-flexion ulnar deviation cast at 2-year follow-up in 105 patients aged 65 and older with dorsally displaced distal radius fracture: A randomized controlled trial.

BACKGROUND AND PURPOSE: Non-operative treatment is the most common treatment option for older patients with distal radius fracture (DRF). Traditionally, wrists have been placed in volar-flexion and ulnar deviation position (VFUDC). In recent years, there has been a trend towards using a functional position cast (FC). However, long-term results for these different casting positions are lacking. PATIENTS AND METHODS: This randomized, controlled, prospective study evaluates the functional results and costs of the 2 casting positions in patients 65 and older with DRF. Primary end point in this study was Patient-Reported Wrist Evaluation (PRWE) at 24 months, and secondary end points were cost-effectiveness of treatment, health-related quality of life measurement (15D), short version of Disabilities of arm, shoulder and hand score (QuickDASH), and VAS at 24 months. The trial was registered in ClinicalTrials.gov (NCT02894983, https://clinicaltrials.gov/ct2/show/NCT02894983). RESULTS: We enrolled 105 patients, of which 81 (77%) continued until 24-month follow-up. 8 patients (18%) were operated in the VFUDC group and 4 (11%) in the FC group. Patients in the VFUDC group also received more frequent physical therapy. The difference in PRWE score between the VFUDC and FC groups at 24 months was -4.31. The difference in the cost of treatment per patient was €590. Both findings favored FC. INTERPRETATION: We found a slight, but consistent difference in the functional results between groups. These results suggest that VFUDC is not superior to FC when treating Colles' type DRF. Cost analysis revealed overall costs in the VFUDC group are nearly double those in the FC group, mostly due to more physical therapy, additional visits to hospital, and additional examinations. Therefore, we recommend FC in older patients with Colles' type DRF.

Chondrosarcoma of the Chest Wall: A Single Institution Review of 50 Cases.

INTRODUCTION: Chondrosarcoma (CS) is most common primary osseous tumor of the chest wall. The aim of this study was to report results from surgical procedures and evaluate clinical factors predicting survival of patients with chest wall CSs treated in a single tertiary sarcoma center. MATERIALS AND METHODS: Fifty patients with primary CS located in the ribs and sternum were included. Details of the clinical data and oncological outcomes, including local recurrence (LR) and disease-specific survival (DSS), were collected. RESULTS: The tumor was primarily originated in the sternum in 6 patients (12.5%) and in ribs 2 to 11 in the remaining patients. Specimens were histologically graded 1 in 13 patients (26%), 2 in 28 (56%), 3 in 8 (16%), and 1 (2%) as mesenchymal grade 3 CS. R0 margins were obtained in all cases. Reconstruction was warranted in 47 (94%) cases. Local recurrence developed in 3 (6%) patients, and the median time to LR was 17 (range, 16-68) months. Eight (16%) patients developed metastasis. Increasing tumor volume was a statistically significant factor for reduction of DSS. CONCLUSIONS: Chondrosarcoma of the chest wall can be treated effectively with clear margins, resulting in lower LR rate and higher DSS than CS of the extremities and pelvis. Metastasis of the chest wall mostly occurs in high-grade tumors, and the locations of the metastases differ greatly from those observed in CS of the extremities and pelvis. Metastases are commonly extrapulmonary, indicating the need for postoperative follow-up with multiple imaging modalities to monitor recurrence and metastases.

Mortality following proximal humerus fracture-a nationwide register study of 147,692 fracture patients in Sweden.

Little is known about survival after proximal humerus fracture. In this manuscript, we found the mortality to be high (almost four times higher than in age- and sex-matched controls). While frailty hip fracture has gained attention, we hope our manuscript will shed light on frailty proximal humerus fracture patients. INTRODUCTION: Proximal humerus fractures (PHF) are common and occur mostly after the 6th decade of life. While mortality following PHF has been reported previously, mortality data after longer follow-up on a national level is lacking. METHODS: We obtained data from the Swedish Hospital Discharge Register (SHDR), on all adult patients (≥ 18 years) with a diagnosis of PHF (S42.2, S42.20, or S42.21) for the period between 2001 and 2016. We used the Swedish Cause of Death Register (SCDR) to investigate mortality in the fracture cohort. We compared the mortality of fracture patients with age- and sex-matched population-based mortality data obtained from Statistics Sweden. RESULTS: A total of 147 692 PHF patients were identified, with a male to female ratio of 1:3. The mean age was 69 years (range, 18 to 111). Most patients were treated non-surgically (n = 126,487, 86%). The crude mortality rate was 2.2% at 1 month, 4.1% at 3 months, 8.5% at 12 months, and 24% at 48 months after sustaining a PHF. Mortality increased with age; however, the standardized mortality rate (SMR) was highest among young patients. SMR was 5.4 in the 18- to 39-year age group, 3.9 in the 40- to 64-year age group, 1.8 in the 65-79-year age group, and 1.2 in the ≥ 80-year-old population. The age-adjusted SMR was 3.9 in the whole adult PHF population. CONCLUSION: The mortality rate and SMR suggest that PHF patients are heterogeneous. Some older PHF patients may benefit from specialized care (e.g., orthogeriatric), and this should be evaluated in future studies.

Do's and Don'ts in Primary Aneurysmal Bone Cysts of the Proximal Femur in Children and Adolescents: Retrospective Multicenter EPOS Study of 79 Patients.

BACKGROUND: Aneurysmal bone cysts (ABC) are rare benign cystic bone tumors, generally diagnosed in children and adolescents. Proximal femoral ABCs may require specific treatment strategies because of an increased pathologic fracture risk. As few reports are published on ABCs, specifically for this localization, consensus regarding optimal treatment is lacking. We present a large retrospective study on the treatment of pediatric proximal femoral ABCs. METHODS: All eligible pediatric patients with proximal femoral ABC were included, from 11 tertiary referral centers for musculo-skeletal oncology (2000-2021). Patient demographics, diagnostics, treatments, and complications were evaluated. Index procedures were categorized as percutaneous/open procedures and osteosynthesis alone. Primary outcomes were: time until full weight-bearing and failure-free survival. Failure was defined as open procedure after primary surgery, >3 percutaneous procedures, recurrence, and/or fracture. Risk factors for failure were evaluated. RESULTS: Seventy-nine patients with ABC were included [mean age, 10.2 (±SD4.0) y, n=56 male]. The median follow-up was 5.1 years (interquartile ranges=2.5 to 8.8).Index procedure was percutaneous procedure (n=22), open procedure (n=35), or osteosynthesis alone (n=22). The median time until full weight-bearing was 13 weeks [95% confidence interval (CI)=7.9-18.1] for open procedures, 9 weeks (95% CI=1.4-16.6) for percutaneous, and 6 weeks (95% CI=4.3-7.7) for osteosynthesis alone ( P =0.1). Failure rates were 41%, 43%, and 36%, respectively. Overall, 2 and 5-year failure-free survival was 69.6% (95% CI=59.2-80.0) and 54.5% (95% CI=41.6-67.4), respectively. Risk factors associated with failure were age younger than 10 years [hazard ratios (HR)=2.9, 95% CI=1.4-5.8], cyst volume >55 cm 3 (HR=1.7, 95% CI=0.8-2.5), and fracture at diagnosis (HR=1.4, 95% CI=0.7-3.3). CONCLUSIONS: As both open and percutaneous procedures along with osteosynthesis alone seem viable treatment options in this weight-bearing location, optimal treatment for proximal femoral ABCs remains unclear. The aim of the treatment was to achieve local cyst control while minimizing complications and ensuring that children can continue their normal activities as soon as possible. A personalized balance should be maintained between undertreatment, with potentially higher risks of pathologic fractures, prolonged periods of partial weight-bearing, or recurrences, versus overtreatment with large surgical procedures, and associated risks. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The impact of full-thickness rotator cuff tear on shoulder function and quality of life in patients who sustain a proximal humerus fracture-a prospective cohort study.

BACKGROUND: Only few studies have investigated the impact of rotator cuff integrity on patients with proximal humerus fracture (PHF). We aimed to determine if the presence of a rotator cuff tear impairs shoulder function and health-related quality of life (HRQoL) after nonsurgically treated PHF. METHODS: Sixty-seven patients with PHF were recruited prospectively in a cohort. Presence of a full-thickness rotator cuff tear was determined by ultrasound examination. After 6 and 12 months, Constant-Murley Score; Disability of the Arm, Shoulder and Hand; the Visual Analog Scale; EuroQol-5 Domain; and the 15D scores were compared between the patients with a rotator cuff tear and patients with an intact rotator cuff. RESULTS: The prevalence of a full-thickness rotator cuff tear was 34%. After 12 months, the mean Constant-Murley Score was 65.7 (standard deviation 16.3) in the intact rotator cuff group vs. 53.9 (16.0) in the rotator cuff tear group (mean diff. 11.8, 95% confidence interval 2.5; 21.2) and was found to be a clinically relevant difference. A significantly lower HRQoL was found on the EuroQol-5 Domain score after 12 months in the rotator cuff tear group with a median score of 1 (interquartile range 0.23) in the intact rotator cuff group vs. 0.75 (interquartile range 0.34) in the rotator cuff tear group (P = .03). In the remaining outcome measures, no statistically significant between-group differences were detected. CONCLUSION: Rotator cuff tear in older adults with nonsurgically treated PHF may be considered a prognostic factor for poorer shoulder function and HRQoL. This knowledge can support the planning of treatment.

Measuring functional outcome in upper extremity soft-tissue sarcoma: Validation of the Toronto extremity salvage score and the QuickDASH patient-reported outcome instruments.

Interest in functional outcome (FO) and health-related quality of life (HRQL) in extremity soft-tissue sarcoma (STS) patients has increased. The aim of this study was to validate two FO questionnaires for upper extremity STS patients: the Toronto Extremity Salvage Score (TESS) and short version of the Disability of Arm, Shoulder and Hand (QuickDASH), based on Finnish population data. A multi-center study was conducted at two academic sarcoma centers. Surgically treated upper extremity STS patients were invited to participate. Patients completed the TESS and the QuickDASH with HRQL questionnaires the 15D and the QLQ-C30. The scores were analyzed and compared. Fifty-five patients with a mean follow-up period of 4.7 years were included. Mean age was 63 years (standard deviation [SD] 14.6). The mean score for TESS was 88.5 (SD 15.1) and for QuickDASH 17.8 (SD 19.6). The QuickDASH had a statistically significantly better score coverage. A ceiling effect was noted, 27% and 20% for TESS and QuickDASH, respectively. The TESS and QuickDASH scores were strongly correlated (r= -0.89). The TESS score strongly correlated with the QLQ-C30 (r = 0.79) and the 15D score (r = 0.70). The QuickDASH score correlated strongly with the QLQ-C30 score (r=-0.71) and moderately with the 15D score (r= -0.56). The TESS score had a statistically significantly stronger correlation with the 15D score than QuickDASH (p<0.005). Both the TESS and the QuickDASH provide reliable scores for assessing FO in upper extremity STS patients. The QuickDASH has a better coverage, whereas TESS showed a stronger correlation to HRQL scores.

Is 2 mm a wide margin in high-grade conventional chondrosarcomas of the pelvis?

AIMS: Controversy exists as to what should be considered a safe resection margin to minimize local recurrence in high-grade pelvic chondrosarcomas (CS). The aim of this study is to quantify what is a safe margin of resection for high-grade CS of the pelvis. METHODS: We retrospectively identified 105 non-metastatic patients with high-grade pelvic CS of bone who underwent surgery (limb salvage/amputations) between 2000 and 2018. There were 82 (78%) male and 23 (22%) female patients with a mean age of 55 years (26 to 84). The majority of the patients underwent limb salvage surgery (n = 82; 78%) compared to 23 (22%) who had amputation. In total, 66 (64%) patients were grade 2 CS compared to 38 (36%) grade 3 CS. All patients were assessed for stage, pelvic anatomical classification, type of resection and reconstruction, margin status, local recurrence, distant recurrence, and overall survival. Surgical margins were stratified into millimetres: < 1 mm; > 1 mm but < 2 mm; and > 2 mm. RESULTS: The disease--specific survival (DSS) at five years was 69% (95% confidence interval (CI) 56% to 81%) and 51% (95% CI 31% to 70%) for grade 2 and 3 CS, respectively (p = 0.092). The local recurrence-free survival (LRFS) at five years was 59% (95% CI 45% to 72%) for grade 2 CS and 42% (95% CI 21% to 63%) for grade 3 CS (p = 0.318). A margin of more than 2 mm was a significant predictor of increased LRFS (p = 0.001). There was a tendency, but without statistical significance, for a > 2 mm margin to be a predictor of improved DSS. Local recurrence (LR) was a highly significant predictor of DSS, analyzed in a competing risk model (p = 0.001). CONCLUSION: Obtaining wide margins in the pelvis remains challenging for high-grade pelvic CS. On the basis of our study, we conclude that it is necessary to achieve at least a 2 mm margin for optimal oncological outcomes in patients with high-grade CS of the pelvis. Cite this article: Bone Joint J 2021;103-B(6):1150-1154.

Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? A retrospective case-control study.

BACKGROUND AND OBJECTIVE: Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique. METHODS: We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds. RESULTS: From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace- group (p = 0.002). CONCLUSIONS: The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.

Clinical differences between central and peripheral chondrosarcomas.

AIMS: Chondrosarcoma is the second most common primary sarcoma of bone: conventional chondrosarcoma accounts for 85% of all cases. Conventional chondrosarcoma may be central or peripheral. Most studies group central and peripheral chondrosarcomas together, although there is growing evidence that their clinical behaviour and prognosis differ. The aims of this study were to analyze any differences in characteristics between central and peripheral chondrosarcomas and to investigate the incidence and role of different syndromes. METHODS: Data from two international tertiary referral sarcoma centres between January 1995 and December 2018 were retrospectively reviewed. The study population consisted of 714 patients with surgically treated conventional chondrosarcoma of the pelvis and limbs. RESULTS: In patients with Ollier's disease and Mafucci's syndrome, 12/20 (60%) and 2/5 (60%) of malignancies, respectively, were in the limbs, most frequently in the proximal humerus, proximal tibia, and in the hands and feet. In patients with hereditary multiple exostosis (HME), 20/29 (69.0%) of chondrosarcomas were in the pelvis and scapula, specifically in the ilium in 13/29 (44.8%) and the scapula in 3/29 (10.3%). In central chondrosarcoma, survival of patients with Ollier's disease and non-syndromic patients was the same (p = 0.805). In peripheral chondrosarcoma, survival among HME patients was similar (p = 0.676) in patients with tumours of the pelvis and limbs. CONCLUSION: Both central and peripheral chondrosarcoma have specific characteristics. HME is frequently seen in patients with a peripheral chondrosarcoma, in whom tumours are commonly located in the ilium and scapula. The incidence of Ollier's disease is uncommon in patients with a central chondrosarcoma. Disease-specific survival is equal in different subtypes after adjustment for histological grade. The local recurrence-free survival is the same for different locations and subtypes after adjustment for surgical margin. Cite this article: Bone Joint J 2021;103-B(5):984-990.

Chondrosarcoma of the hands and feet.

METHODS: A multicentre retrospective study was carried out at two tertiary sarcoma centres. A database search identified all patients with a CS treated between January 1995 and January 2018. There were 810 CSs of which 76 (9.4%) were located in the fingers, toes, metacarpals, and metatarsal bones. RESULTS: The median age of the study population was 55 years (36 to 68) with a median follow-up of 52 months (22 to 87) months. Overall, 70% of the tumours were in the hand (n = 54) and 30% in the foot (n = 22). Predictors for LR were margin (p = 0.011), anatomical location (p = 0.017), and method of surgical management (p = 0.003). Anatomical location (p = 0.026), histological grade between 1 and 3 (p = 0.004) or 2 and 3 (p = 0.016), and surgical management (p = 0.001) were significant factors for LR-free survival. Disease-specific survival was affected by histological grade (p < 0.001), but not by LR (p = 0.397). CONCLUSION: Intralesional curettage of a low-grade CS is associated with an increased risk of LR, but LR does not affect disease-specific survival. Therefore, for low-grade CSs of the hands and feet, surgical management should aim to preserve function. In grade 2 CS, our study did not show any decreased disease-specific survival after recurrence; however, we suggest a more aggressive surgical approach to these tumours to prevent local recurrence, especially in the metacarpal and metatarsal bones. In high-grade tumours, the incidence of progressive disease is high and, therefore, the treatment of the primary tumour should be aggressive where possible, and patients observed closely for the development of metastatic disease. Cite this article: Bone Joint J 2021;103-B(3):562-568.

Soft tissue reconstruction after pelvic amputation: The efficacy and reliability of free fillet flap reconstruction.

BACKGROUND: The majority of hindquarter amputation defects can be reconstructed with local anterior or posterior thigh flaps. Less than 5% of soft tissue defects require free flap reconstruction after tumour resection. Lower extremity fillet flap is described for reconstructing such defects, but the majority of publications are case reports or short single institutional series. There is a lack of data regarding the oncological outcomes of this highly selected patient group. METHODS: Three tertiary sarcoma units treated twelve patients with hindquarter amputation or hip disarticulation for oncological indications with a free flap reconstruction of the soft tissue defect. RESULTS: The median age of patients was 60 (range 12-76) years. Bone resection was carried out through the SI-joint in six patients and through the sacrum in five patients, with one patient undergoing hip disarticulation. Nine patients had R0 resection margin and three had R1 resection. The median surgical time and flap ischaemia time was 420 (249-650) and 89 (64-210) min, respectively. Median hospital and ICU stay was 18 (10-42) and 3 (1-8) days, respectively. Median blood loss was 2400 (950-10000) ml. There were three returns to theatre due to vascular compromise, with one total flap loss due to arterial thrombosis. Overall survival was 58% (95%CI 28-91%) both at 1-year and at 3-years. DISCUSSION: Carefully selected patients requiring hindquarter amputation with extensive soft tissue defect necessitating free flap reconstruction can be reconstructed with a lower extremity free fillet flap with low rate of local wound complications. Survival of these patients is similar to that in patients requiring less extensive resection.