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.

Prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults: a nationwide cross-sectional study.

Thailand has transitioned from an aging society to an aged society, which implies that the prevalence of age-related disorders will increase; however, epidemiological data specific to the prevalence of age-related degenerative musculoskeletal disorders among Thai older adults remain limited. Accordingly, the aim of this study was to investigate the prevalence of age-related musculoskeletal diseases, including osteoporosis, sarcopenia, and high falls risk among healthy community-dwelling Thai older adults. This cross-sectional nationwide study enrolled Thai adults aged ≥60 yr from 2 randomly selected provinces from each of the 6 regions of Thailand via stratified multistage sampling during March 2021 to August 2022. All enrolled participants were evaluated for BMD, skeletal muscle mass, grip strength, and gait speed. Osteoporosis was diagnosed according to the World Health Organization definition, and sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Falls risk was determined using the self-rated Fall Risk Questionnaire. A total of 2991 eligible participants were recruited. The mean age of participants was 69.2 ± 6.5 yr (range: 60-107), and 63.1% were female. The prevalence of osteoporosis, sarcopenia, and high falls risk was 29.7%, 18.1%, and 38.5%, respectively. Approximately one-fifth of subjects (19.1%) had at least 2 of 3 risk factors (ie, osteoporosis, sarcopenia, and high falls risk) for sustaining a fragility fracture, and 3.4% had all 3 risk factors. In conclusion, the results of this study revealed a high and increasing prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults. Since these conditions are all major risk factors for fragility fracture, modification of Thailand's national health care policy is urgently needed to address the increasing prevalence of these conditions among healthy community-dwelling older adults living in Thailand.

Establishing Normative Values for Performance-Based Tests in Older Thai Adults: A Nationwide Cross-Sectional Study.

OBJECTIVE: To determine normative values and identify contributing factors for physical performance tests in older, Thai, community-dwelling adults. DESIGN: Nationwide cross-sectional study. SETTING: Thai older community-dwelling adults. PARTICIPANTS: Thai older community-dwelling adults aged ≥60 years who had no major health problems (N=1430) between March 2021 and August 2022. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Normative values for the timed Up and Go (TUG) test, gait speed test, and 5-times sit-to-stand (5TSTS) test were determined for sex and age groups. Multivariable quantile regression analysis was employed to evaluate the participants, considering factors that may influence physical performance, such as height, and Charlson comorbidity index (CCI). RESULTS: The study included 1430 eligible participants. Their mean age was 68.4±5.8 years, and 58.5% were women. Men demonstrated superior physical performance in the medians (p50) of the TUG (10.0 s vs 11.0 s), gait speed (0.98 m/s vs 0.91 m/s), and 5TSTS (14.0 s vs 16.1 s) tests compared with women. These differences were consistently observed across age groups. Moreover, age, sex, and height were significantly associated with poor physical performance. CONCLUSION: This study observed variations in the normative values of TUG, gait speed, and 5TSTS tests among different age groups of older, Thai, community-dwelling adults. Additionally, our findings identified age, sex, and height as significant contributing factors to physical performance in this population.

Sarcopenia in Thai community-dwelling older adults: a national, cross-sectional, epidemiological study of prevalence and risk factors.

BACKGROUND: Sarcopenia is an age-related condition characterized by a progressive loss of skeletal muscle mass. It leads to declining physical performance, potentially culminating in a diminished quality of life or death. This study investigated the prevalence of sarcopenia and its associated risk factors among Thai community-dwelling individuals of advanced age. METHODS: Between March 2021 and August 2022, we conducted a nationwide community-based epidemiological survey across all six major regions of Thailand. Participants with sarcopenia were identified according to the 2019 criteria of the Asian Working Group for Sarcopenia (AWGS). The risk factors were examined using multivariable logistic regression. RESULTS: Of the 2456 participants, the overall prevalence of sarcopenia was 18.1%, with nearly two-thirds (66.9%) classified as having severe sarcopenia. Multivariate analysis identified six associated risk factors for sarcopenia. They are a lower body mass index (odds ratio [OR] = 11.7, 95% confidence interval [CI] = 7.8-17.4), suboptimal leg calf circumference (OR = 6.3, 95% CI = 4.3-9.5), male sex (OR = 2.8, 95% CI = 2.2-3.7), a history of chronic obstructive pulmonary disease (OR = 2.3, 95% CI = 2.3-5.0), advanced age (OR = 2.1, 95% CI = 1.3-3.3), and an increasing time in the timed up-and-go test (OR = 1.1, 95% CI = 1.0-1.1). CONCLUSIONS: This is the first large-scale national study to represent the prevalence and risk factors for sarcopenia in Thai community-dwelling individuals of advanced age using the AWGS 2019 criteria. Interventions such as lifestyle modifications and appropriate nutrition should be promoted throughout adulthood to maintain muscle strength and delay the onset of sarcopenia, particularly in males. TRIAL REGISTRATION: The Central Research Ethics Committee of the National Research Council of Thailand authorized the study protocol (approval number COA-CREC023/2021).

What Are the MSTS Scores and Complications Associated With the Use of Three-dimensional Printed, Custom-made Prostheses in Patients Who Had Resection of Tumors of the Hand and Foot?

BACKGROUND: There are a few good options for restoring bone defects in the hand and foot. 3D-printed implants have been used in the pelvis and elsewhere, but to our knowledge, they have not been evaluated in the hand and foot. The functional outcome, complications, and longevity of 3D-printed prostheses in small bones are not well known. QUESTIONS/PURPOSES: (1) What are the functional outcomes of patients with hand or foot tumors who were treated with tumor resection and reconstruction with a 3D-printed custom prosthesis? (2) What complications are associated with using these prostheses? (3) What is the 5-year Kaplan-Meier cumulative incidence of implant breakage and reoperation? METHODS: Between January 2017 and October 2020, we treated 276 patients who had tumors of the hands or feet. Of those, we considered as potentially eligible patients who might have extensive loss in their joint that could not be fixed with a bone graft, cement, or any prostheses available on the market. Based on this, 93 patients were eligible; a further 77 were excluded because they received nonoperative treatment such as chemoradiation, resection without reconstruction, reconstruction using other materials, or ray amputation; another three were lost before the minimum study follow-up of 2 years and two had incomplete datasets, leaving 11 for analysis in this retrospective study. There were seven women and four men. The median age was 29 years (range 11 to 71 years). There were five hand tumors and six tumors of the feet. Tumor types were giant cell tumor of bone (five), chondroblastoma (two), osteosarcoma (two), neuroendocrine tumor (one), and squamous cell carcinoma (one). Margin status after resection was ≥ 1 mm. All patients were followed for a minimum of 24 months. The median follow-up time was 47 months (range 25 to 67 months). Clinical data; function according to the Musculoskeletal Tumor Society, DASH, and American Orthopedic Foot and Ankle Society scores; complications; and survivorship of implants were recorded during follow-up in the clinic, or patients with complete charts and recorded data were interviewed on the telephone by our research associates, orthopaedic oncology fellows, or the surgeons who performed the surgery. The cumulative incidence of implant breakage and reoperation was assessed using a Kaplan-Meier analysis. RESULTS: The median Musculoskeletal Tumor Society score was 28 of 30 (range 21 to 30). Seven of 11 patients experienced postoperative complications, primarily including hyperextension deformity and joint stiffness (three patients), joint subluxation (two), aseptic loosening (one), broken stem (one), and broken plate (one), but no infection or local recurrence occurred. Subluxations of the metacarpophalangeal and proximal interphalangeal joints in two patients' hands were caused by the design of the prosthesis without a joint or stem. These prostheses were revised to a second-generation prosthesis with joint and stem, leading to improved dexterity. The cumulative incidence of implant breakage and reoperation in the Kaplan-Meier analysis was 35% (95% CI 6% to 69%) and 29% (95% CI 3% to 66%) at 5 years, respectively. CONCLUSION: These preliminary findings suggest that 3D implants may be an option for reconstruction after resections that leave large bone and joint defects in the hand and foot. Although the functional results generally appeared to be good to excellent, complications and reoperations were frequent; thus, we believe this approach could be considered when patients have few or no alternatives other than amputation. Future studies will need to compare this approach to bone grafting or bone cementation. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Tumor-to-bone distance and radiomic features on MRI distinguish intramuscular lipomas from well-differentiated liposarcomas.

BACKGROUND: To develop a machine learning model based on tumor-to-bone distance and radiomic features derived from preoperative MRI images to distinguish intramuscular (IM) lipomas and atypical lipomatous tumors/well-differentiated liposarcomas (ALTs/WDLSs) and compared with radiologists. METHODS: The study included patients with IM lipomas and ALTs/WDLSs diagnosed between 2010 and 2022, and with MRI scans (sequence/field strength: T1-weighted (T1W) imaging at 1.5 or 3.0 Tesla MRI). Manual segmentation of tumors based on the three-dimensional T1W images was performed by two observers to appraise the intra- and interobserver variability. After radiomic features and tumor-to-bone distance were extracted, it was used to train a machine learning model to distinguish IM lipomas and ALTs/WDLSs. Both feature selection and classification steps were performed using Least Absolute Shrinkage and Selection Operator logistic regression. The performance of the classification model was assessed using a tenfold cross-validation strategy and subsequently evaluated using the receiver operating characteristic curve (ROC) analysis. The classification agreement of two experienced musculoskeletal (MSK) radiologists was assessed using the kappa statistics. The diagnosis accuracy of each radiologist was evaluated using the final pathological results as the gold standard. Additionally, we compared the performance of the model and two radiologists in terms of the area under the receiver operator characteristic curves (AUCs) using the Delong's test. RESULTS: There were 68 tumors (38 IM lipomas and 30 ALTs/WDLSs). The AUC of the machine learning model was 0.88 [95% CI 0.72-1] (sensitivity, 91.6%; specificity, 85.7%; and accuracy, 89.0%). For Radiologist 1, the AUC was 0.94 [95% CI 0.87-1] (sensitivity, 97.4%; specificity, 90.9%; and accuracy, 95.0%), and as to Radiologist 2, the AUC was 0.91 [95% CI 0.83-0.99] (sensitivity, 100%; specificity, 81.8%; and accuracy, 93.3%). The classification agreement of the radiologists was 0.89 of kappa value (95% CI 0.76-1). Although the AUC of the model was lower than of two experienced MSK radiologists, there was no statistically significant difference between the model and two radiologists (all P > 0.05). CONCLUSIONS: The novel machine learning model based on tumor-to-bone distance and radiomic features is a noninvasive procedure that has the potential for distinguishing IM lipomas from ALTs/WDLSs. The predictive features that suggested malignancy were size, shape, depth, texture, histogram, and tumor-to-bone distance.

Robustness of Radiomic Features: Two-Dimensional versus Three-Dimensional MRI-Based Feature Reproducibility in Lipomatous Soft-Tissue Tumors.

This retrospective study aimed to compare the intra- and inter-observer manual-segmentation variability in the feature reproducibility between two-dimensional (2D) and three-dimensional (3D) magnetic-resonance imaging (MRI)-based radiomic features. The study included patients with lipomatous soft-tissue tumors that were diagnosed with histopathology and underwent MRI scans. Tumor segmentation based on the 2D and 3D MRI images was performed by two observers to assess the intra- and inter-observer variability. In both the 2D and the 3D segmentations, the radiomic features were extracted from the normalized images. Regarding the stability of the features, the intraclass correlation coefficient (ICC) was used to evaluate the intra- and inter-observer segmentation variability. Features with ICC > 0.75 were considered reproducible. The degree of feature robustness was classified as low, moderate, or high. Additionally, we compared the efficacy of 2D and 3D contour-focused segmentation in terms of the effects of the stable feature rate, sensitivity, specificity, and diagnostic accuracy of machine learning on the reproducible features. In total, 93 and 107 features were extracted from the 2D and 3D images, respectively. Only 35 features from the 2D images and 63 features from the 3D images were reproducible. The stable feature rate for the 3D segmentation was more significant than for the 2D segmentation (58.9% vs. 37.6%, p = 0.002). The majority of the features for the 3D segmentation had moderate-to-high robustness, while 40.9% of the features for the 2D segmentation had low robustness. The diagnostic accuracy of the machine-learning model for the 2D segmentation was close to that for the 3D segmentation (88% vs. 90%). In both the 2D and the 3D segmentation, the specificity values were equal to 100%. However, the sensitivity for the 2D segmentation was lower than for the 3D segmentation (75% vs. 83%). For the 2D + 3D radiomic features, the model achieved a diagnostic accuracy of 87% (sensitivity, 100%, and specificity, 80%). Both 2D and 3D MRI-based radiomic features of lipomatous soft-tissue tumors are reproducible. With a higher stable feature rate, 3D contour-focused segmentation should be selected for the feature-extraction process.

Novel CSF1R-positive tenosynovial giant cell tumor cell lines and their pexidartinib (PLX3397) and sotuletinib (BLZ945)-induced apoptosis.

Tenosynovial giant cell tumor (TGCT) is a mesenchymal tumor derived from the synovium of the tendon sheath and joints, most frequently in the large joints. The standard of care for TGCTs is surgical resection. A new targeting approach for treating TGCTs has emerged from studies on the role of the CSF1/CSF1 receptor (CSF1R) in controlling cell survival and proliferation during the pathogenesis of TGCTs. We established four novel cell lines isolated from the primary tumor tissues of patients with TGCTs. The cell lines were designated Si-TGCT-1, Si-TGCT-2, Si-TGCT-3, and Si-TGCT-4, and the TGCT cells were characterized by CSF1R and CD68. These TGCT cells were then checked for cell proliferation using an MTT assay and three-dimensional spheroid. The responses to pexidartinib (PLX3397) and sotuletinib (BLZ945) were evaluated by two-dimensional MTT assays. All cells were positive for α­smooth muscle actin (α­SMA), fibroblast activation protein (FAP), CSF1R, and CD68. Except for Si-TGCT-4, all TGCT cells had high CSF1R expressions. The cells exhibited continuous growth as three-dimensional spheroids formed. Treatment with pexidartinib and sotuletinib inhibited TGCT cell growth and induced cell apoptosis correlated with the CSF1R level. Only Si-TGCT-4 cells demonstrated resistance to the drugs. In addition, the BAX/BCL-2 ratio increased in cells treated with pexidartinib and sotuletinib. With the four novel TGCT cell lines, we have an excellent model for further in vitro and in vivo studies.

Late Distal Ureteral Stricture in Internal Hemipelvectomy Without Bone Reconstruction: A Case Report.

We report the case of a patient with Ewing sarcoma involving the right pelvis in a 14-year-old girl who had multicycles of neo-adjuvant chemotherapy and preoperative radiation therapy. She underwent an internal hemipelvectomy type I resection, according to Enneking and Dunham's classification without bony reconstruction. There was no intra- and perioperative complication. The patient has good function and needs no gait aids. She can walk with equinus foot compensated for leg shortening 5 centimeters and without a shoe-lift. There is no sign of disease relapse. However, she developed late ureteral stricture at 8-year postoperatively and was successfully treated with a ureteral stent.

Experience of total scapular excision for musculoskeletal tumor and reconstruction in eastern Asian countries.

Total scapulectomy and reconstruction has been performed for scapular tumor, however, most of the reconstruction methods have resulted in poor functional outcomes and there is still room for improvement. Most of the reports of reconstruction after scapulectomy are from a single institution. In the present study, we investigated functional outcomes after total scapulectomy in a multicenter study in The Eastern Asian Musculoskeletal Oncology Group (EAMOG). Thirty-three patients who underwent total scapulectomy were registered at EAMOG affiliated hospitals. The patients were separated into no reconstruction group (n=8), humeral suspension group (n=15) and prosthesis group (n=10). Functional outcome was assessed by the Enneking score. One-way ANOVA was used to compare parameters between the patient groups. Complications included five local recurrences, one superficial infection, one dislocation and one clavicle protrusion. The average follow-up period was 43.5  months. The average active flexion range was 45.8° (0-120°), and 37.1° in abduction (0-120°). The mean total functional score was 22.9 out of 30 (15-29), which is a satisfactory score following resection of the shoulder girdle. There were significant differences in reconstruction methods for active range of motion. Bony reconstruction provided better range of motion in this study. There was a variety of reconstruction methods after scapulectomy in the eastern Asian countries. Although better functional score was obtained using scapular prosthesis or recycled bone and prosthesis composite grafting, postoperative function is still lower than preoperative function. Modified designed prosthesis with or without combination of recycle bone or allograft would restore the lost shoulder function in the future.

Use of warm Ringer's lactate solution in the management of locally advanced giant cell tumor of bone.

BACKGROUND: This study was conducted to discover the effectiveness and safety of using warm Ringer's lactate solution (RLS) as a local treatment in the management of locally advanced giant cell tumor of bone with marked soft tissue invasion, including nearby neurovascular bundles. PATIENTS AND METHODS: This was a longitudinal cohort study with an average follow-up period of 4.6 ± 0.3 years, ranging from 4.2 to 5.9 years. There were 21 patients (9 male and 12 female), with the ages of subjects ranging from 12 to 64 years. Eight patients (38 %) were tumor recurrence cases. Pathological fracture was found in 15 patients (71 %). After extended curettage, warm RLS (50 °C) was locally applied for 20 min. Bone stabilization and reconstruction were then performed. RESULTS: All patients survived the operation. No additional neurovascular injury resulting from the use of warm RLS was found. Patients who had neurological deficit before the operation experienced significant improvement in motor and sensory function during the follow-up period. Complication was found in one patient (5 %). Two patients (9.5 %), had tumor recurrence and 19 patients (90.5 %) were tumor-free with good to acceptable function. CONCLUSION: Use of warm Ringer's lactate solution as an adjunctive local treatment during intra-lesional curettage of giant cell tumor with locally soft tissue extension was found to be safe with relatively low recurrence rate. However, additional studies to identify the optimum thermoablation dose at each part of the body should be undertaken before this technique can be used as a standard treatment.

Plate Fixation Technique for Reducing Osteoarticular Allograft Fracture: A Preliminary Report.

Background: Osteoarticular allograft is now commonly used as a reconstructive biomaterial to replace bone defect following removal of aggressive bone tumors and for revision of failed arthroplasty. Good long-term clinical result of allograft replacement has been demonstrated. However, the rate of complications is high, including deep infection, allograft fracture, delayed union or non-union, and joint instability. Prevalence of allograft fracture ranges from 12-54 percent. Many studies recommend avoiding plate and screw fixation, or they advise the use of a modified screw fixation technique that minimizes the number of screws and changes screw alignment. Objective: The objective of this study was to compare the efficacy of the conventional technique with a new method of plate and screw fixation in osteochondral allograft following removal of aggressive bone tumors. Material and Method: From September 1988 to February 2015, 52 patients with primary aggressive benign or malignant bone tumor underwent massive bone allograft reconstruction. There were 25 males and 27 females with a mean age of 27-years. Giant cell tumor and osteosarcoma comprised most of the diagnoses. Thirty-five of the tumors were located around the knee. Average length of allograft was 12.9 cm. Twenty-nine patients were reconstructed using standard technique and 23 patients were fixed using only one dynamic compression plate with limited and 15-degree divergent-angle screw fixation at the allograft. Results: Mean follow-up time in the group treated by conventional fixation was 84.5 months. There were 13 fractures (44.8%) in the conventional fixation group, with a median time to graft fracture of 4.9 months. The 23 patients with new technique fixation were followed-up for a mean duration of 60.5 months. Six fractures (26.1%) occurred in this group, with a median time to graft fracture of 10.40 months. Differences between groups for incidence of allograft fracture and median time to fracture were not statistically significant (p = 0.163 and p = 0.244, respectively). Most patients with allograft fracture were treated surgically using autogenous bone grafting and revision of internal fixation. Conclusion: The new method of osteochondral allograft fixation using single plate, fewer screws, and divergent screw fixation yielded a lower fracture rate and a longer median time to fracture than the conventional method; however the differences between groups did not achieve statistical significance. The results of this preliminary study should be confirmed in a larger group of allografts over a longer follow-up period.

Osteosarcoma in Asian Populations Over the Age of 40 Years: A Multicenter Study.

BACKGROUND: Elderly patients with osteosarcoma (OSA) are no longer uncommon; however, many questions remain regarding this population. We investigated the clinicopathological characteristics and prognostic factors of OSA in an Asian population over the age of 40 years. METHODS: This was a multi-national, multi-institutional study by the Eastern Asian Musculoskeletal Oncology Group (EAMOG). RESULTS: A total of 232 patients were enrolled (116 males and 116 females), with a median age of 50 years at diagnosis; 25 (10.8 %) patients exhibited initial metastasis. Median follow-up was 52 months for survivors. We observed 102 osteolytic and mixed radiographic findings for 173 lesions. Histological subtypes other than osteoblastic type were frequent. Radiation-associated OSA was seen in seven patients, with a 5-year overall survival (OS) of 16.7 %. No Paget's OSA was observed. High-grade spinopelvic OSA was seen in 29 (12.5 %) patients. The 5-year OS was 59.4 % in patients without initial metastasis and 45.2 % in patients with spinopelvic OSA. While surgery and initial metastasis were common prognostic factors for OS, chemotherapy was not. Histologic response to neoadjuvant chemotherapy was poor in 61 of 83 patients. CONCLUSION: This study revealed distinct clinicopathological features of OSA patients over 40 years of age compared with younger patients, such as the high incidence of axial tumors, common osteolytic and mixed radiographic findings, the high frequency of unusual histologic subtypes, and poor prognosis. Contrary to Western elderly patients with OSA, there was no Paget's OSA in this study, which may result in a lower incidence of secondary OSA. Prognostic factor analyses demonstrated chemotherapy did not influence OS.

Using polypropylene mesh graft for soft-tissue reconstruction in internal hemipelvectomy: a case report.

We report the case of a patient with chondrosarcoma involving the right pelvis and contralateral pubic area in a 45-year-old male who underwent an extensive internal hemipelvectomy without bony reconstruction. We demonstrate the technique of using polypropylene mesh graft for soft-tissue reconstruction. Follow-up at 7.5 years showed a good oncological and functional outcome.

The second fracture of the same clavicle: prevalence and fracture configurations.

OBJECTIVE: To study second fracture at the same clavicle including prevalence, fracture configurations related to malunion types of the first fracture, and healing. MATERIAL AND METHOD: Between 2008 and 2011, the authors reviewed medical records and radiographs of the clavicles of patients who sustained acute clavicular fractures from motorcycle accident. Second fracture at the same clavicle and prevalence were studied. Malunion of the first fracture of the same clavicle were typed and configurations of the second fracture at the same clavicles were described related to type of the malunion. RESULTS: There were 552 clavicular fractures. Four cases of which sustained a second fracture at the same clavicles. Malunion of the first clavicular fracture of the four cases were typed: type I, extension, type II, flexion, and type III, bayonet. There were one, two, and one case of second clavicular fractures of the type I, II, and III clavicular malunion. The configuration of second clavicular fracture of the type I malunion clavicle is located at lateral fragment, inferior displacement, and dorsal angulation with dorsal cortex conminution. The type II malunion clavicle is located at lateral fragment with minimal displacement. For the type III malunion clavicle, the second fracture is located at medial fragment with mild inferior displacement and inferior angulation. The four cases of the second fractures of the same clavicles healed within two months without complication. CONCLUSION: The prevalence of second fracture at the same clacicles was 7.2:1000. The three types of the first fracture malunion were extension, flexion, and bayonet. The configuration of the second fracture at the same clavicles depends on malunion types of the first clavicular fracture. They healed without complication.

The outcomes of treatment of giant cell tumor of bone around the knee.

BACKGROUND: Giant cell tumor of bone has been characterized as an aggressive benign bone tumor and commonly occurs at the distal femur and the proximal tibia. The recommended treatment has ranged from intralesional curettage to wide excision and the decision depends on severity of the tumor extent, rate of local recurrence,functional and morbidity outcomes. OBJECTIVE: To compare extended curettage and wide excision in Grade II-III giant cell tumor of bone around the knee with regard to their effectiveness in tumor control and complication. MATERIAL AND METHOD: There were 54 patients with a giant cell tumor which involved the distal femur or proximal tibia who had been managed consecutively at Siriraj Hospital between 1994-2009. The lesion of all patients were staged according to the system of Campanacci et al. There were 21 males and 33 females with mean age of 34 years. Thirty-five tumors located at distal femur and 19 located at proximal tibia. Fourteen patients had a Grade II lesion and 40 had a Grade III lesion. Thirty patients received extended curettage whereas other 24 patients had a wide excision. Fisher's exact analysis was used for statistical analysis for the outcome of tumor recurrence in each surgery. RESULTS: The mean follow-up time was 59 months. There were 7 (23.3 percent) local recurrences in the extended curettage group and 2 (8.3 percent) in the wide excision group. Most recurrences occurred within one year postoperatively. There was no statistical difference for the outcome of tumor recurrence in each group (p = 0.270). All patients with tumor recurrence were successfully treated with re-curettage, except for 3 patients who was treated by above-knee amputation. The functional analysis was excellence in the extended curettage group (94 percent) and good in the wide excision group (77.6 percent) according to the Musculoskeletal Tumor Society functional classification. CONCLUSION: The authors believe that using extended curettage was not significantly different in percentage of local recurrence when compared with wide excision for Campanacci's Grade II-III of giant cell tumor of bone. Even better function was found in extended curettage group, the choice of surgical treatment should be considered in individual patient which depends on the extent of bone destruction and risk of tumor recurrence.

Wide resection of sacral chordoma via a posterior approach.

PURPOSE: The study was carried out to report the results of wide resection in sacral chordoma using a posterior approach and gauze packing technique. MATERIALS AND METHODS: The study was carried out between 1990 and 2002; there were 21 patients who underwent the operation. Fourteen patients were male and seven were female. Their ages ranged between 29 and 75 years. Most of the patients presented with sacral mass, pain and neurological deficit. Total sacrectomy and bone reconstruction were carried out in 12 patients. Subtotal sacrectomy was carried out in the remaining nine patients. All patients were followed up for at least seven years. RESULTS: All survived after the operation. Operative time ranged between five and ten hours. All patients needed blood transfusion which ranged between four and 11 units. After the operation, all patients had a certain degree of bowel and bladder dysfunction. Five patients had local complications including infection in three patients with wound disruption and two patients with a seroma. During the follow-up, three patients (14%) had tumour recurrence and one of the patients expired. The remaining 18 patients were still tumour-free at the seven-year follow-up. CONCLUSION: Wide resection via the posterior approach and gauze packing technique could be used for management of sacral chordoma with acceptable results.

Factors of local recurrence of giant cell tumor of long bone after treatment: plain radiographs, pathology and surgical procedures.

BACKGROUND: To evaluate the relationship between local recurrence of giant cell tumor (GCT) after surgical treatments and plain radiography, pathology grade and surgical procedures. MATERIAL AND METHOD: Patients with pathologically proven primary giant cell tumor of long bones, who underwent surgical treatment in Siriraj Hospital between 1995 and 2007, were retrospectively reviewed. Plain radiographic findings were reviewed by an experienced musculoskeletal radiologist without knowledge of the clinical history or pathologic results. Specific attention on plain radiographic evaluations included site of tumor in long bone, total tumor volume, expansion of cortex, breaking of cortex, and presence of pathological fracture. Patients with grade III tumor were excluded due to malignant histology. Patients received treatments with amputation were also excluded due to no possibility of tumor recurrence. Only patients who received surgical treatments with wide excision or curettage with cement were included in the present study. Univariate analysis and Cox proportional hazard ratio was used to evaluate the influence of plain radiographic findings and histology grade on risk of tumor recurrence. RESULTS: Seventy-four patients participated in this study and included 32 males (43%) and 42 (57%) females with a mean age of 35 years (range 17 to 84). The median follow-up time was 3.2 years. Forty-eight patients (65%) underwent curettage with cement or bone graft and 26 patients (35%) underwent wide excision. Sixty-three patients (85%) did not develop tumor recurrence while 11 patients (15%) developed local recurrent tumor. Those occurred only in patients who underwent curettage with cement or bone graft. None of the patients who underwent wide excision developed local recurrence. Median of time after operation to recurrence was 3.5 years (range, 0.5 to 10.3 years). Local recurrence occurred in the distal femur in five patients (45%), in the proximal tibia in five patients (45%), and in distal radius in one patient (9%). Risk of local recurrence of GCT was not statistically different in patients with any abnormal features of plain radiography as well as histology grade. CONCLUSION: No radiographic findings and histological grade of GCT can predict tumor recurrence after curettage procedure. Compared with wide excision, risk of local recurrence in patients that received treatment with curettage was significantly higher. However the choice of treatment should be balanced between preserving maximal joint function and risks of tumor recurrence.

The prognostic factors of recurrent GCT: a cooperative study by the Eastern Asian Musculoskeletal Oncology Group.

BACKGROUND: Giant-cell tumor (GCT) of bone is a common primary benign tumor with high local recurrence and potential distant metastasis or malignant transformation. We have investigated the clinical behavior of recurrent GCT of bone in the extremities. METHODS: We retrospectively reviewed 110 patients with recurrent GCTs of bone in the extremities treated by the Eastern Asian Musculoskeletal Oncology Group. The factors that affected the number of recurrences and distant metastasis were analyzed. RESULTS: The median interval between initial surgery and the first recurrence of GCT was 16 months (2-180 months). All patients received additional surgery for first recurrence. Twenty-five patients had a second recurrence and 6 patients had a third recurrence. The mean interval between the initial surgery and the first recurrence correlated with the eventual number of recurrences-14.1 months for the repeated recurrence groups (two and three recurrences) and 28.3 months for the single recurrence group (p = 0.016). Campanacci grade did not correlate with repeated recurrence (p = 0. 446). The venue of the initial surgery did not correlate with recurrence but did affect preservation of the adjacent joint (chi-squared test; p = 0.046). Campanacci grade II and III also correlated with sacrifice of the adjacent joint (p = 0.020). The incidence of lung metastasis and malignant transformation were 7.5% (8 out of 107 patients) and 2.7% (3 out of 110 patients), respectively. Repeat recurrence was associated with lung metastasis (p = 0.018). CONCLUSIONS: Early local recurrence of GCT is a risk factor for repeat recurrence. Repeat recurrence also correlates with lung metastasis. Recurettage with meticulous adjuvant treatment to completely preclude recurrent lesions is a reasonable method for preserving the adjacent joint. However, a continuous careful follow-up is mandatory.

Functional outcome following excision of a tumour and reconstruction of the distal radius.

We retrospectively studied the functional and oncological results of 15 patients after reconstruction of the distal radius with osteoarticular allograft or non-vascularised fibular graft following wide excision of an aggressive benign or malignant tumour. Eight patients underwent osteoarticular allograft and seven patients had a non-vascularised autogenous fibular graft reconstruction. The average time for incorporation of the graft was 6 and 5 months in each reconstruction respectively. There was no tumour recurrence after follow up over 41.5-95.5 (average 60.5) months. All patients had good and excellent functional results. Three patients in the group reconstructed with osteoarticular allograft had plate loosening and graft fractures which were successfully treated subsequently.