Allograft-prosthetic composite reconstruction of the proximal part of the tibia. An analysis of the early results.

BACKGROUND: Allograft-prosthetic composite reconstruction of the proximal part of the tibia is one option following resection of a skeletal tumor. Previous studies with use of this technique have found a high prevalence of complications, including fracture, infection, extensor mechanism insufficiency, and loosening. To address some of these problems, we adopted certain measures, including muscle flap coverage, meticulous tendon reconstruction, rigid implant fixation, and careful rehabilitation. The goal of the present study was to evaluate the functional outcome and complications in patients undergoing allograft-prosthetic composite reconstruction of the proximal part of the tibia. METHODS: Twelve patients who underwent allograft-prosthetic composite reconstruction of the proximal part of the tibia after tumor resection were retrospectively evaluated at a median follow-up of forty-nine months. Clinical records and radiographs were reviewed to evaluate patient outcome, healing at the allograft-host junction, function, construct survival, and complications. RESULTS: Nine patients had no extensor lag, and three patients had 5 degrees to 15 degrees of extensor lag. The mean amount of knee flexion was 103 degrees (range, 60 degrees to 120 degrees ). The mean Musculoskeletal Tumor Society score was 24.3 (81%) of a maximum of 30. Complete bone union occurred in nine patients, and partial union occurred in three patients. At the time of writing, no secondary bone-grafting procedures had been required to achieve union, and no revision or removal of the reconstruction had been performed. Rotational or free flaps provided satisfactory wound coverage in all patients. A deep infection occurred in one patient whose allograft and prosthesis were successfully retained after treatment with surgical débridement and intravenous antibiotics. CONCLUSIONS: After osteoarticular resection of destructive tumors of the proximal part of the tibia, an allograft-prosthetic composite reconstruction can provide consistently good functional results with an acceptably low complication rate. Technical aspects of the procedure that may favorably affect outcome include soft-tissue coverage with muscle flaps and rigid fixation with a long-stemmed implant.

Risk of local recurrence after deltoid-sparing resection for osteosarcoma of the proximal humerus.

BACKGROUND: The anatomy of the shoulder poses special challenges with regard to limb-sparing surgery. Resection of the deltoid muscle is considered by some surgeons to be necessary to achieve adequate margins for osteosarcoma of the proximal humerus. However, this can compromise the functional results after reconstruction of the shoulder. The goal of the current study was to determine whether deltoid-sparing resection can be safely performed for osteosarcoma of the proximal humerus. METHODS: Between 1978 and 2005, 23 consecutive patients with high-grade nonmetastatic osteosarcoma of the proximal humerus underwent limb-sparing surgery with preservation of the deltoid muscle. All patients received neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy. The mean follow-up was 90 months (range, 7 months-279 months). RESULTS: The overall survival at 5 years was 77%. At the time of last follow-up, 14 (61%) of 23 of patients were alive without evidence of disease. Three (13%) patients developed local recurrence. Two of these patients had poor responses to chemotherapy, with tumor necrosis of 50% and 70%. The third patient had a pathologic fracture of the humerus. Positive surgical margins were associated with local recurrence, and 2 of 4 patients with a positive surgical margin developed local recurrence (P = .01). CONCLUSIONS: Preservation of the deltoid muscle can be performed for carefully selected patients with osteosarcoma of the proximal humerus. Routine use of the procedure is not justified, because it may be associated with an elevated risk of recurrence. The risk of local recurrence appears to be related to positive surgical margins and possibly the percentage of tumor necrosis.

Therapeutic guidelines for the treatment of bone metastasis: a report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology.

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Functional outcome following endoprosthetic reconstruction of the proximal humerus.

BACKGROUND: The proximal humerus is a common site for tumors, either metastatic or primary. Thus it is a frequent site of intervention in musculoskeletal oncology surgery. We looked at the use of endoprosthetic reconstructions in surgical intervention for tumors of the proximal humerus. METHODS: A review of our database from 1990 to 2005 revealed 83 proximal humeral endoprosthetic reconstructions following an intra-articular, deltoid muscle, and axillary nerve sparing resection. Medical records and radiographs were reviewed to determine shoulder range of motion, MSTS scores, and any complications. The median patient age was 55 years (range, 13-80). The mean follow-up was 30 months (range, 1-199). RESULTS: Mean active abduction was 41 degrees (range, 10-90 degrees) and mean active forward flexion was 42 degrees (range, 5-115 degrees). The mean MSTS score was 63% (range, 40-83%). Implant-related complications included 2 deep infections and 22 patients with proximal migration of the prosthesis. No prostheses loosened. Only 2 required removal (1 for infection and 1 for progression of metastatic disease). CONCLUSIONS: A proximal humeral endoprosthesis provides a durable reconstruction with a relatively low complication rate. Although it provides a stable platform for elbow and hand function, actual shoulder function is limited.

Surgical management of primary osteosarcoma.

Surgical strategies for the primary tumor for patients with extremity and pelvis osteosarcoma have evolved from the ablative to limb-sparing approaches over the past three decades. Favorable oncologic and functional outcomes with contemporary tissue-conserving techniques consistently observed in skeletally mature patients have prompted the application of similar approaches to a growing number of eligible skeletally immature patients. In response to emerging long-term outcome data, current strategies have focused principally on refining the nature and scope of surgical resection to preserve uninvolved tissues, and on the adoption of novel biological and nonbiological skeletal and soft-tissue reconstruction methods to optimize function. We focus on these clinical issues and discuss current efforts to advance the surgical management of the primary tumor and address the limitations of the definitive treatment of the primary tumor, including locally recurrent disease and complications of skeletal reconstructions.

Analysis of the osteoinductive capacity and angiogenicity of an in vitro generated extracellular matrix.

In this study, the osteoinductive potential of an in vitro generated extracellular matrix (ECM) deposited by marrow stromal cells seeded onto titanium fiber mesh scaffolds and cultured in a flow perfusion bioreactor was investigated. Culture periods of 8, 12, and 16 days were selected to allow for different amounts of ECM deposition by the cells as well as ECM with varying degrees of maturity (Ti/ECM/d8, Ti/ECM/d12, and Ti/ECM/d16, respectively). These ECM-containing constructs were implanted intramuscularly in a rat animal model. After 56 days, histologic analysis of retrieved constructs revealed no bone formation in any of the implants. Surrounding many of the implants was a fibrous capsule, which was often interspersed with fat cells. Within the pore spaces, the predominant tissue response was the presence of blood vessels and young fibroblasts or fat cells. The number of blood vessels on a per area basis calculated from a histomorphometric analysis increased as a function of the amount of ECM within the implanted constructs, with a significant difference between Ti/ECM/d16 and plain Ti constructs. These results indicate that although an in vitro generated ECM alone may not induce bone formation at an ectopic site, its use may enhance the vascularization of implanted constructs.

Management of radiation-associated fractures.

High-dose radiation is injurious to bone and is a known risk factor for the development of late fracture. Management of radiation-induced fractures is generally thought to be difficult, with prolonged healing times and a high nonunion rate. There is a relative paucity of literature to guide treatment. Fractures of the long bones typically should be managed with intramedullary nailing. A low threshold should exist for supplemental bone grafting, and a vascularized fibula graft should be considered for persistent nonunion. To prevent refracture, fixation should be left in situ indefinitely. Resection of the fracture site and reconstruction with an oncologic endoprosthesis is an effective salvage procedure. Periarticular fractures should be treated with joint arthroplasty, which allows early mobilization and avoids prolonged healing times. Fractures of expendable bones, primarily the clavicle, typically should be managed with débridement or resection.

Aneurysmal bone cysts recur at juxtaphyseal locations in skeletally immature patients.

Aneurysmal bone cysts are associated with a high rate of recurrence. Many aneurysmal bone cysts arise near open physes or articular cartilage in skeletally immature patients. Fear of damaging these structures could cause surgeons to curette the tumors less aggressively. We hypothesized location of an aneurysmal bone cyst in a periarticular or juxtaphyseal location would increase the risk of recurrence. We retrospectively studied 53 patients with aneurysmal bone cysts treated between 1989 and 2004. All patients had primary disease, and all patients underwent curettage of the lesion. Ten patients (18.9%) had local recurrence. Gender, race, and size did not predict recurrence; however 12 years of age or younger was associated with recurrence. Of the 19 juxtaphyseal cysts directly adjacent to an open physis, eight developed recurrence. Of the five periarticular cysts, two developed recurrence. The data suggest the risk of recurrence is highest in pediatric patients with juxtaphyseal or periarticular aneurysmal bone cysts. Meticulous treatment of these cysts is necessary, but we believe an overly aggressive approach that destroys the physis or articular cartilage is not warranted. Preservation of these structures remains a high priority of treatment.

Proximal femoral endoprosthesis for the treatment of metastatic.

Traditional reconstructive options may not always be adequate to treat the extensive bone loss that can occur with metastatic disease of the proximal femur. Another method of treatment is resection of the proximal femur and reconstruction with an endoprosthesis. However, the more extensive surgery raises concern for a higher perioperative complication rate in this potentially medically unstable population. This study reviewed 57 patients with metastatic disease treated with 58 proximal femoral endoprostheses. The only perioperative complications were 2 symptomatic deep venous thromboses. Late complications included 3 dislocations, 2 deep venous thromboses, 1 pulmonary embolism, and 4 infections. Three deaths occurred during the perioperative period, all from underlying cancer. Proximal femoral endoprostheses offer a safe treatment option for patients with extensive metastatic disease.

Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas.

OBJECTIVE: We conducted a prospective trial to define the local recurrence rates for selected patients with T1 soft tissue sarcomas (STS) treated by surgery alone. SUMMARY BACKGROUND DATA: Retrospective data suggest that some patients with small STS can be safely treated by surgery alone. There are no defined criteria to select patients for such treatment. METHODS: Patients with T1 primary STS were treated with function-preserving surgery and microscopic assessment of surgical margins. Postoperative external-beam radiation was employed selectively for patients with microscopically positive (R1) final surgical margins. Patients who underwent resection with microscopically negative (R0) final margins did not receive radiotherapy. RESULTS: Eighty-eight eligible and evaluable patients were entered on this protocol between March 1996 and April 2002. Tumor sites included the extremities (n=60), and trunk (n=26). Fifty-one patients (58%) had high-grade STS; 60 (68%) had superficial (T1a) disease. Fourteen patients (16%) underwent R1 resection and were treated with postoperative radiation; 74 (84%) underwent R0 resection and were treated by surgery alone. The median follow-up was 75 months. Isolated local recurrences were observed in 11 patients (13%; 6 in R1 arm, 5 in R0 arm). In the R0 surgery-alone arm, the cumulative incidence rates of local recurrence at 5 and 10 years were 7.9% and 10.6%, respectively; and the 5- and 10-year sarcoma-specific death rates were 3.2% and 3.2%. CONCLUSION: Selected patients with primary T1 STS of the extremity and trunk can be treated by R0 surgery alone with acceptable local control and excellent long-term survival.

The effects of medications on bone.

Medications taken for the treatment of arthritis and psychotropic and epileptic disorders, as well as anticoagulants, antacids, bisphosphonates, corticosteroids, and antineoplastic drugs, can profoundly affect bone metabolism. In some scenarios (eg, osteoporosis), these effects are intended; in others (eg, rickets, osteomalacia secondary to antiepileptic drugs), potentially adverse side effects of medications on bone may occur. Nonsteroidal anti-inflammatory drugs appear to delay fracture healing and bone ingrowth, although these effects are reversible. Disease-modifying antirheumatic drugs do not appear to affect bone metabolism adversely when taken in the low dosages currently prescribed. Bisphosphonates are useful in restoring bone mass in cases of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease, and neoplastic conditions with bone loss and hypercalcemia. Corticosteroids and cancer chemotherapeutic agents generally affect bone adversely and increase fracture risk.

Patient survival after surgery for osseous metastases from renal cell carcinoma.

BACKGROUND: Skeletal metastases from renal cell carcinoma are highly destructive vascular lesions. They pose unique surgical challenges due to the risk of life-threatening hemorrhage and resistance to other treatments. The goal of this retrospective study was to evaluate factors that may affect survival after surgical treatment of metastases of renal cell carcinoma. METHODS: We performed a retrospective review of a series of 295 consecutive patients who had been treated for metastatic renal cell carcinoma at one institution between 1974 and 2004. There were 226 men and sixty-nine women. A total of 368 metastases of renal cell tumors to the extremities and pelvis were treated. The surgical procedures included curettage with cementing and/or internal fixation (214 tumors), en bloc resection (117), closed nailing (twenty-seven), amputation (four), and other measures (six). Overall survival was calculated with Kaplan-Meier analysis. The log-rank test was used to evaluate the effect of different variables on overall survival. RESULTS: The overall patient survival rates at one and five years were 47% and 11%, respectively. The metastatic pattern had a significant effect on the survival rate (p < 0.0001): patients with a solitary bone metastasis had the most favorable overall survival rate. Patients with multiple bone-only metastases had a better survival rate than patients with pulmonary metastases (p = 0.009). A clear-cell histological subtype was also associated with better survival (p < 0.0001). The tumor grade did not predict survival (p = 0.17). Fifteen patients (5%) died within four weeks after surgery. The causes included acute pulmonary failure (seven patients), multiorgan failure (six), cerebrovascular accident (one), and hypercalcemia (one). There were no deaths attributable to intraoperative hemorrhage. DISCUSSION: Survival beyond twelve months is possible for a substantial proportion of patients with metastatic renal cell carcinoma. Patients with a clear-cell histological subtype, bone-only metastases, and a solitary metastasis have superior survival rates. The presence of pulmonary metastases does not predict early death in a reliable manner, and some patients may survive for years with pulmonary and systemic disease. The data are important for surgeons to consider when choosing treatment for these patients. For example, local control of disease and implant stability are important issues for patients with a potential for a long duration of survival.

Curettage of biopsy-diagnosed grade 1 periacetabular chondrosarcoma.

Intralesional excision of intraosseous grade 1 periacetabular chondrosarcoma may seem an attractive alternative to the current recommendation of joint-sacrificing, en bloc resection. We report eight patients who initially underwent this treatment to identify if local tumor control can be achieved consistently. All patients had a percutaneous biopsy that was interpreted as grade 1 chondrosarcoma. The final histology after curettage indicated Grade 1 chondrosarcoma in five patients, Grade 2 in two, and dedifferentiated chondrosarcoma in one. Three of the five patients with true grade 1 chondrosarcoma have been free of disease at a median followup of 108 months. The other two patients with grade 1 chondrosarcoma on the curettage specimen recurred as higher-grade tumors. Three patients died of high-grade chondrosarcoma at a median of 23 months (range 17-72 months). Overall, the majority of patients in this cohort had either a misdiagnosis or recurrence of higher-grade disease. Based on these observations, in the absence of a predictable method to identify the true intraosseous grade 1 chondrosarcomas of the pelvis, curettage must be undertaken with the understanding that a percutaneous biopsy may misrepresent the histologic grade and that curettage may result in a higher risk of recurrence.

Disease- and recurrence-free survival after surgical resection of solitary bone metastases of the pelvis.

For patients with advanced cancer who present with or develop a bone lesion as the only focus of cancer beyond the primary site, en bloc resection of the metastasis may optimize local tumor control, provide durable pain relief, and possibly prolong patient survival. For patients with pelvic metastasis, however, this surgery can be associated with a high risk of complications. We analyzed fourteen consecutive patients with a solitary metastasis to the bony pelvis who underwent en bloc resection to determine if the benefits of surgery outweigh the surgical morbidity. The epicenter of the tumor was isolated to the ilium (four patients), the pubis (one patient), and the ischium (three patients), or to the periacetabular region (six patients). Surgical margins were negative for tumor in 13 of 14 patients. No local recurrence developed at last follow-up for six survivors (median 74.5 months) and eight non-survivors (median 53 months). Local pain relief was achieved in all patients. For patients with a solitary pelvic metastasis, the favorable median patient survival justifies consideration of a radical surgical approach to achieve pain palliation and tumor control.

Orthopaedic metal devices coated with a novel antiseptic dye for the prevention of bacterial infections.

Gendine is a novel antiseptic dye with broad-spectrum antimicrobial activity that may be used to coat plastics and metal devices. Our objective was to determine the efficacy of gendine-coated orthopaedic metal devices in preventing methicillin-resistant Staphylococcus aureus (MRSA) colonisation. Stainless steel and titanium Schanz rods were coated with gendine. The zone of inhibition (ZoI) around the rods with and without gamma-irradiation was determined by a modified Kirby-Bauer method. A previously published bioprosthetic biofilm colonisation model, modified Kuhn's method, was used to determine the adherence of MRSA to coated and uncoated rods, with and without irradiation, after insertion into bovine bone and after 3 months shelf life followed by 2 weeks of immersion in serum. The gendine-coated Schanz metal rods showed a net ZoI of 16 mm against MRSA before and after irradiation. Gendine-coated rods showed no biofilm formation (0 colony-forming units (CFU)), which was a significant reduction (P<0.001) compared with uncoated controls (>5000 CFU). Coated rods exposed to high-dose gamma-irradiation and coated rods drilled into bone also showed significant efficacy (P<0.001) in preventing biofilm adherence. After 2 weeks, gendine-coated rods maintained significant durability (P<0.01), resulting in 90% reduction in MRSA biofilm adherence compared with uncoated control rods. Results indicate that gendine-coated metal rods are highly efficacious in the prevention of MRSA biofilm.

Imaging characteristics of locally recurrent tumors of bone.

OBJECTIVE: The purpose of this article is the identification of recurrent tumor of bone utilizing radiography, CT, and MRI. CONCLUSION: Radiography is frequently used to identify recurrence of treated bone tumors through findings such as osteolysis, cortical reactions, and characteristic matrix mineralization. CT can help evaluate the character of osseous and calcific abnormalities. Comparison with prior radiographs can be crucial for differentiation between postoperative alterations of bone and subtle signs of recurrence. MRI can identify soft-tissue masses and is useful for imaging patients with metallic hardware when it is optimized to decrease artifacts.

Chemotherapy response is an important predictor of local recurrence in Ewing sarcoma.

BACKGROUND: Local recurrence in Ewing sarcoma is associated with a poor prognosis. The purpose of the study was to determine the factors that predict local recurrence after surgical treatment of the primary tumor. METHODS: Between 1990 and 2001, 64 patients underwent surgical resection of Ewing sarcoma. Surgical margins were assessed histologically and radiologically. Response to preoperative chemotherapy was determined by detailed specimen mapping. Local recurrence-free survival (LRFS) was calculated by Kaplan-Meier analysis. Multivariate analysis was performed with the Cox proportional hazards model. RESULTS: A number of factors were found to be associated with local recurrence on univariate analysis. Patients with a good response to chemotherapy (> or = 90% tumor necrosis), had superior LRFS at 5 years (86% vs 51%, P = .015). Central site of disease was associated with an increased rate of recurrence. The LRFS at 5 years was 50% for the chest wall, 74% for pelvic/scapular, and 86% for extremity tumors (P = .083). Positive surgical margin was not a strong predictor of recurrence (P = .72). A critical analysis of minimal surgical margin based on preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scans also failed to reveal an association between margin and local recurrence. In multivariate analysis, the 2 independent predictors of local recurrence were histological response to chemotherapy and central site of disease. CONCLUSION: Local recurrence after surgical resection is a complex phenomenon. An important predictive factor is the response to chemotherapy. In the current study, this seems to have the largest impact. Central site of disease may be a second independent predictive factor.