Haemorrhagic soft-tissue sarcoma: Oncological outcomes and prognostic factors for survival.

INTRODUCTION: Haemorrhagic soft-tissue sarcomas (HSTS) are characterised by aggressive local growth and highly metastatic behaviour. We aimed to describe oncological outcomes and prognostic factors. MATERIALS AND METHODS: Retrospective review including 64 patients treated with palliation (n = 7), with limb salvage surgery (LSS) (n = 9), with neoadjuvant radiotherapy (RT) + LSS (n = 12), with LSS + adjuvant RT (n = 30) or amputation (n = 6). Kaplan-Meier survival analysis estimated overall survival (OS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS). After uni- and multivariate analysis, prognostic factors affecting OS, MFS and LRFS were identified. RESULTS: Median age was 67 years (IQR 23 years) with median follow-up of 11 months (IQR 28 months). All cases were high grade. Eight (13%) had pulmonary metastases at presentation and another 40 (63%) developed metastases after median 9 months (IQR 19 months). Median OS was 12 months (IQR 38 months), and estimated OS after two-years was 15.9% and 52.9% for patients with and without metastatic disease at presentation, respectively. Improved OS was associated with negative resection margins (p = 0.031), RT (p = 0.045), neoadjuvant RT (versus adjuvant RT, p = 0.044) and amputation (versus LSS, p < 0.001). MFS was 35.1% after two-years. LR occurred in 18 of 51 (35.3%) patients with surgically treated localised disease. LRFS was 63.4% after two-years and significantly affected by a negative margin (p = 0.042) and RT (p = 0.001). CONCLUSION: Haemorrhagic soft-tissue sarcomas should be excised, either with amputation or LSS with a clear resection margin. If LSS is attempted, neoadjuvant RT reduces the risk of tumour spillage and early LR, enhances the feasibility of achieving clear resection margins, and offers superior overall survival compared to adjuvant RT.

Geographic Access to High-Volume Care Providers and Survival in Patients with Bone Sarcomas: Nationwide Patterns in the United States.

BACKGROUND: Clinical practice guidelines recommend centralized care for patients with bone sarcoma. However, the relationship between the distance that patients travel to obtain care, institutional treatment volume, and survival is unknown. METHODS: We used the National Cancer Database to examine associations between travel distance and survival among 8,432 patients with bone sarcoma diagnosed from 2004 to 2015. Associations were identified using multivariable Cox regression analyses that controlled for sociodemographic, clinical, and hospital-level factors; subgroup analyses stratified patients by histological diagnosis, tumor stage, and pediatric or adult status. RESULTS: Mortality risk was lower among patients who traveled ≥50 miles (≥80.5 km) than among patients who traveled ≤10 miles (≤16.1 km) (hazard ratio [HR], 0.69 [95% confidence interval (CI), 0.63 to 0.76]). Among hospital-level factors, facility volume independently affected survival: mortality risk was lower among patients at high-volume facilities (≥20 cases per year) than at low-volume facilities (≤5 cases per year), with an HR of 0.72 (95% CI, 0.66 to 0.80). The proportion of patients who received care at high-volume facilities varied by distance traveled (p < 0.001); it was highest among patients who traveled ≥50 miles (53%) and lower among those who traveled 11 to 49 miles (17.7 to 78.9 km) (32%) or ≤10 miles (18%). Patients who traveled ≥50 miles to a high-volume facility had a lower risk of mortality (HR, 0.65 [95% CI, 0.56 to 0.77]) than those who traveled ≤10 miles to a low-volume facility. In subgroup analyses, this association was evident among patients with all 3 major histological subtypes; those with stage-I, II, and IV tumors; and adults. CONCLUSIONS: This national study showed that greater travel burden was associated with higher survival rates in adults, a finding attributable to patients traveling to receive care at high-volume facilities. Despite the burdens associated with travel, modification of referral pathways to specialized centers may improve survival for patients with bone sarcoma. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Outcomes of soft-tissue sarcoma in nonagenarians.

AIMS: Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. METHODS: Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation. RESULTS: A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group. Amputation was also associated with longer survival times (p < 0.050). Overall median survival time was limited to 20 months (0 to 80). CONCLUSION: Early and aggressive treatment with appropriate oncological surgery confers the lowest LRR and a survival advantage versus conservative treatment in this cohort of patients. With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means, such as GP, local oncology, and/or patient-led follow-up. Cite this article: Bone Joint J 2022;104-B(1):177-182.

A Quantifiable Risk Factor for ACL Injury: Applied Mathematics to Model the Posterolateral Tibial Plateau Surface Geometry.

BACKGROUND: The mechanism for traumatic ruptures of the native anterior cruciate ligament (ACL) is frequently a noncontact injury involving a valgus moment with internal rotation of the tibia. The abnormal rotation and translation of the lateral femoral condyle posteroinferiorly relative to the lateral tibial plateau is thought to be related to the geometry of the tibial plateau. PURPOSE/HYPOTHESIS: The purpose of the study was to mathematically model the posterior tibial plateau geometry in patients with ACL injuries and compare it with that of matched controls. The hypothesis was that increased convexity and steepness of the posterior aspect of the lateral plateau would subject knees to higher forces, leading to a potentially higher risk of ACL injury. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We mathematically modeled the posterior curvature of the lateral tibial plateau in 64 patients with ACL injuries and 68 matched controls. Using sagittal magnetic resonance imaging scans of the knee, points on the articular cartilage of the posterolateral tibial plateau were selected and curve-fitted to a power function (y = a × xn ). For coefficient a and coefficient n, both variables modulated the shape of the curve, where a larger magnitude represented an increase in slope steepness. Groups were compared using a Mann-Whitney test and α < .05. RESULTS: There was a significant difference in surface geometry between the patients with ACL injuries and matched controls. The equation coefficients were significantly larger in the patients with ACL injuries: coefficient a (ACL injury, 0.9 vs control, 0.68; P < .0001) and coefficient n (ACL injury, 0.34 vs control, 0.30; P = .07). For coefficient a, there was a 78.9% sensitivity, 77.5% specificity, and odds ratio of 12.6 (95% CI, 5.5-29.0) for ACL injury using a cutoff coefficient a = .78. CONCLUSION: Patients with ACL injuries had a significantly greater posterolateral plateau slope. The steeper drop off may play a role in higher anterior translation forces, coupled with internal rotation torques on the knee in noncontact injury, which could increase ACL strain and predispose to ACL injury.

An Extraosseous Aneurysmal Bone Cyst in a 59-Year-Old Man: A Case Report.

CASE: A 59-year-old man presented with a history of a painful, rapidly growing mass on the anteromedial aspect of his thigh. On examination, he had a mobile, hard, and nontender mass. Magnetic resonance imaging revealed a well-encapsulated, heterogeneous mass with high-intensity internal septations. Blood-filled spaces were observed within the mass with no involvement of the underlying normal bony structures. The mass was excised, and the diagnosis of an extraosseous aneurysmal bone cyst was confirmed histologically. CONCLUSIONS: Extraosseous aneurysmal bone cysts are rare benign lesions that can mimic malignant tumors. Careful clinical and pathological assessment should be performed in such cases.

Improving ergonomics in the operating room for orthopaedic surgeons in order to reduce work-related musculoskeletal injuries.

INTRODUCTION: Orthopaedic surgery is characterized by surgical tasks that are physical, repetitive and require some degree of stamina from the surgeon. Occupational injuries are alarmingly common in orthopaedic surgery with two-thirds of all surgeons reporting a work-related musculoskeletal (MSK) injury during their career. One of the leading causes of the high level of MSK injuries among orthopaedic surgeon is lack of ergonomics of the operating room. Implementing an ergonomic process has been shown to be effective in reducing the risk of developing MSK disorders in other high-risk industries. We reviewed well-established and effective ergonomic guidelines from the industrial workplace and determined the pertinent principles that could be transferred to the operating room to help reduce the number and severity of common orthopaedic work-related MSK injuries. METHODS: We reviewed the ergonomic guidelines, primarily from the Occupational Safety and Health Administration (OSHA), that specifically address minimizing the risk of these work-related injuries and that are transferable to the operating room. In addition, the ergonomic guidelines from the Canadian Center for Occupational Health and Safety (CCOHS), the National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) were reviewed. RESULTS: Many of the guidelines to avoid work-related injuries in industry are transferable to the operating room. The pertinent guidelines clearly indicated how to adjust the height of the operating table, the proper design of hand and power tools and the modifications to the operating room environment that can help prevent injury. These guidelines from industry include maintaining a neutral posture and joint alignment, working with the appropriate hand tools and minimizing the lower extremity fatigue by using the proper footwear and floor mats. DISCUSSION: Optimizing the occupational environment and utilizing well-established ergonomic principle from industry is both feasible and practical in the operating room to decrease the incidence of musculoskeletal injuries among this high-risk profession. These guidelines are simple, effective and are easy to implement by orthopaedic surgeons in order to minimize their risk of sustaining a work-related injury.

Development of a Large Animal Long-Term Intervertebral Disc Organ Culture Model That Includes the Bony Vertebrae for Ex Vivo Studies.

Intervertebral disc (IVD) degeneration is a common cause of low back pain. Testing potential therapeutics in the regeneration of the disc requires the use of model systems. Although several animal models have been developed to investigate IVD degeneration, they are technically challenging to prepare, expensive, present with limitations when performing biomechanical studies on the disc, and are impractical in large-scale screening of novel anabolic and scaffolding agents. An IVD organ culture system offers an inexpensive alternative. In the current paradigm, the bony endplates are removed to allow for nutrient diffusion and maintenance of disc cell viability. Although this is an excellent system for testing biologics, it results in concave cartilage endplates and, as such, requires special platens for loading purposes in a bioreactor as flat ones can overload the annular disc region leading to improper loading. Furthermore, the absence of bone makes it unsuitable for applying complex cyclic loading, a topic of interest in the study of chronic progressive degeneration, as multiaxial loading is more representative of daily forces encountered by the IVD. We have developed and validated a novel long-term IVD organ culture model that retains vertebral bone and is easy to prepare. Our model is ideal for testing potential drugs and alternate-based therapies, in addition to investigating the long-term effects of loading paradigms on disc degeneration and repair.

The Effects of Naproxen on Chondrogenesis of Human Mesenchymal Stem Cells.

Currently, there are no established treatments to prevent, stop, or even retard the degeneration of articular cartilage in osteoarthritis (OA). Biological repair of the degenerating articular cartilage would be preferable to surgery. There is no benign site where autologous chondrocytes can be harvested and used as a cell source for cartilage repair, leaving mesenchymal stem cells (MSCs) as an attractive option. However, MSCs from OA patients have been shown to constitutively express collagen type X (COL-X), a marker of late-stage chondrocyte hypertrophy. We recently found that naproxen (Npx), but not other nonsteroidal anti-inflammatory drugs, can induce collagen type X alpha 1 (COL10A1) gene expression in bone marrow-derived MSCs from healthy and OA donors. In this study, we determined the effect of Npx on COL10A1 expression and investigated the intracellular signaling pathways that mediate such effect in normal human MSCs during chondrogenesis. MSCs were cultured in standard chondrogenic differentiation media supplemented with or without Npx. Our results show that Npx can regulate chondrogenic differentiation by affecting the gene expression of both Indian hedgehog and parathyroid hormone/parathyroid hormone-related protein signaling pathways in a time-dependent manner, suggesting a complex interaction of different signaling pathways during the process.

Synovial osteochondroma originating from the synovium of the anterior cruciate ligament.

Primary synovial osteochondromatosis is a rarely seen disorder of the synovium in any joints. Among reported cases of knee osteochondromatosis, those originating from the anterior cruciate ligament (ACL) are very rare. We report an unusual case of primary synovial osteochondromatosis. A 27-year-old woman complained of a restricted range of right-knee motion and pain when walking. With locking symptoms similar to those associated with a meniscus bucket handle tear. Although plain radiograph and MRI showed normal appearance, diagnostic arthroscopy revealed the curious appearance of a huge mass seated on ACL. In addition, the sign of proliferation of synovium and cartilaginous tissues were apparent. The ACL mass has been removed while preserving the ACL fibres. Histological examination confirmed a diagnosis of osteochondromatosis. To the best of our knowledge, this is the first report to describe synovial osteochondromatosis originating from ACL fibres and has been resected while preserving the ACL.