Surgical Treatment and Proposed Modified Classification for Harrington Class III Periacetabular Metastases.

OBJECTIVES: This study aims to: (i) evaluate the outcome of patients with Harrington class III lesions who were treated according to Harrington classification; (ii) propose a modified surgical classification for Harrington class III lesions; and (iii) assess the efficiency of the proposed modified classification. METHODS: This study composes two phases. During phase 1 (2006 to 2011), the clinical data of 16 patients with Harrington class III lesions who were treated by intralesional excision followed by reconstruction of antegrade/retrograde Steinmann pins/screws with cemented total hip arthroplasty (Harrington/modified Harrington procedure) were retrospectively reviewed and further analyzed synthetically to design a modified surgical classification system. In phase 2 (2013 to 2019), 62 patients with Harrington class III lesions were classified and surgically treated according to our modified classification. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) 93 scoring system. The outcome of local control was described using 2-year recurrence-free survival (RFS). Owing to the limited sample size, we considered P < 0.1 as significant. RESULTS: In phase 1, the mean surgical time was 273.1 (180 to 390) min and the mean intraoperative hemorrhage was 2425.0 (400.0 to 8000.0) mL, respectively. The mean follow-up time was 18.5 (2 to 54) months. Recurrence was found in 4 patients and the 2-year RFS rate was 62.4% (95% confidence interval [CI] 31.6% to 93.2%). The mean postoperative MSTS93 score was 56.5% (20% to 90%). Based on the periacetabular bone destruction, we categorized the lesions into two subgroups: with the bone destruction distal to or around the inferior border of the sacroiliac joint (IIIa) and the bone destruction extended proximal to inferior border of the sacroiliac joint (IIIb). Six patients with IIIb lesions had significant prolonged surgical time (313.3 vs 249.0 min, P = 0.022), massive intraoperative hemorrhage (3533.3 vs 1760.0 mL, P = 0.093), poor functional outcome (46.7% vs 62.3%, P = 0.093), and unfavorable local control (31.3% vs 80.0%, P = 0.037) compared to the 10 patients with IIIa lesions. We then modified the surgical strategy for two subgroup of class III lesions: Harrington/modified Harrington procedure for IIIa lesions and en bloc resection followed by modular hemipelvic endoprosthesis replacement for IIIb lesions. Using the proposed modified surgical classification, 62 patients in the phase 2 study demonstrated improved surgical time (245.3 min, P = 0.086), intraoperative hemorrhage (1466.0 mL, P = 0.092), postoperative MSTS 93 scores (65.3%, P = 0.067), and 2-year RFS rate (91.3%, P = 0.002) during a mean follow-up time of 19.9 (1 to 60) months compared to those in the phase 1 study. CONCLUSION: The Harrington surgical classification is insufficient for class III lesions. We proposed modification of the classification for Harrington class III lesions by adding two subgroups and corresponding surgical strategies according to the involvement of bone destruction. Our proposed modified classification showed significant improvement in functional outcome and local control, along with acceptable surgical complexity in surgical management for Harrington class III lesions.

Retrospective cohort study of 68 sacral giant cell tumours treated with nerve-sparing surgery and evaluation on therapeutic benefits of denosumab therapy.

AIMS: To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs). METHODS: This is a retrospective cohort study of patients with GCT who presented between January 2011 and July 2017. Intralesional curettage was performed and patients treated from 2015 to 2017 also received denosumab therapy. The patients were divided into three groups: Cohort 1: control group (n = 36); cohort 2: adjuvant denosumab group (n = 9); and cohort 3: neo- and adjuvant-denosumab group (n = 17). RESULTS: There were 68 patients within the study period. Six patients were lost to follow-up. The mean follow-up was 47.7 months (SD 23.2). Preoperative denosumab was found to reduce intraoperative haemorrhage and was associated with shorter operating time for tumour volume > 200 cm3. A total of 17 patients (27.4%) developed local recurrence. The locoregional control rate was 77.8% (7/9) and 87.5% (14/16) respectively for cohorts 2 and 3, in comparison to 66.7% (24/36) of the control group. The recurrence-free survival (RFS) rate was significantly higher for adjuvant denosumab group versus those without adjuvant denosumab during the first two years: 100% vs 83.8% at one year and 95.0% vs 70.3% at two years. No significant difference was found for the three-year RFS rate. CONCLUSION: Preoperative denosumab therapy was found to reduce intraoperative haemorrhage and was associated with shorter operating times. Adjuvant denosumab was useful to prevent early recurrence during the first two years after surgery. Cite this article: Bone Joint J 2020;102-B(2):177-185.

A Rare Case of Supinator Intramuscular Myxoma with Encasement of the Posterior Interosseous Nerve.

Intramuscular myxomas are rare, benign mesenchymal tumors. Tumor location in the forearm is very rare among all the intramuscular myxomas. To the best of our knowledge, there were two cases of supinator intramuscular myxoma reported in the literature, and we intend to report the third case of supinator myxoma with encasement of the posterior interosseous nerve (PIN). A 67-year-old lady presented with history of left proximal forearm swelling for the past 5 years. Magnetic resonance imaging showed a lobulated multiseptated lesion seen within left supinator muscle, which was hyperintense on T2-weighted images (T2WI) and hypointense on T1-weighted images (T1WI), with peripheral enhancement post contrast. The tissue diagnosis of myxoma was confirmed via an open biopsy. She underwent en bloc resection of the tumor. The PIN was encased by the tumor; it was preserved and carefully released from the tumor. The nerve sheath served as an excision margin. In conclusion, we present a rare case of an intramuscular myxoma in the supinator muscle. In view of the location, extra attention should be paid during excision surgery to locate the PIN and to avoid damaging the surrounding structures.

Primary Melanoma of the Third Metatarsal.

Melanoma is a well-known malignant neoplasm of the skin, although it can also arise from other structures. Bone metastasis is not an uncommon event associated with melanoma, although primary osseous melanoma is very rare. In the present report, we describe a case of primary melanoma arising from the left third metatarsal in an adult male. The lesion was treated with surgical excision without adjunct chemotherapy, and recurrence developed approximately 12 months after the foot surgery. The patient died of the cancer 34 months after it had been identified. Primary melanoma arising in a metatarsal is rare, and we wished to highlight this unusual presentation.

The use of pre-operative halo traction to minimize risk for correction of severe scoliosis in a patient with Fontan circulation: a case report and review of literature.

PURPOSE: Patients with Fontan circulation have increased cardio-respiratory risk during major spinal surgery. We report a case of severe scoliosis with a Cobb angle of 123.3° in a 16-year-old boy with Fontan circulation treated with single stage posterior segmental pedicle screw instrumentation and fusion. METHODS: Case report. RESULTS: The use pre-operative halo-ring traction for a duration of 6 weeks in this case lead to improvement in cobb angle from 123.3°, kyphotic angle 87.1° to cobb angle of 78.0°, kyphotic angle 57.2° (on bending and stress films). The operation was completed in 150 min, blood loss 1050 ml (25 ml/kg), and cell salvage of 490 ml. He was immediately extubated post correction, but monitored in ICU for a day. Total length of stay was 8 days without any perioperative morbidity or allogeneic blood transfusion. Final post-operative radiograph showed a cobb angle of 44.2°, kyphotic angle 22.8°. Follow up at 27 months showed solid union with no significant loss of correction. CONCLUSION: From this case experience, pre-operative halo traction is a useful surgical strategy in patients with Fontan circulation with severe kyposcoliosis to achieve adequate correction without additional osteotomies to minimize the risk of surgical correction.