Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China.

PURPOSE: There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery. METHODS: This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group. RESULTS: Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group. CONCLUSIONS: Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Efficacy and safety of a 3D-printed arthrodesis prosthesis for reconstruction after resection of the proximal humerus: preliminary outcomes with a minimum 2-year follow-up.

BACKGROUND: The purpose of this study was to investigate the feasibility of using a three-dimensional (3D)-printed arthrodesis prosthesis for reconstruction of the proximal humeral defect after tumor resection. METHODS: A novel proximal humeral prosthesis was designed to restore bone continuity and shoulder arthrodesis and was fabricated via 3D printing technology. Ten patients with primary malignancies in the proximal humerus underwent intra-articular resection and replacement with this prosthesis from 2017 to 2019. Baseline and operative data, oncological and prosthetic survival, and functional status were summarized. RESULTS: This cohort consisted of 9 males and 1 female with a mean age of 32.1 ± 16.1 years. Diagnoses included 5 cases of osteosarcoma, 3 cases of chondrosarcoma and 1 each case of undifferentiated pleomorphic sarcoma and malignant myoepithelioma. The mean operative duration, intraoperative hemorrhage and postoperative length of hospitalization were 151.5 ± 61.0 min, 410.0 ± 353.4 ml and 5.3 ± 1.9 d, respectively. The mean follow-up duration was 29.3 ± 6.4 months, with a minimum of 24 months for the surviving patients. Two patients experienced local recurrence, and four patients developed distant metastases. Detachment of the taper occurred in two patients. One was managed conservatively, and the other received amputation due to concurrent tumor recurrence. The mean MSTS-93 and ASES scores and ranges of forwards flexion and abduction were 24.9 ± 3.1, 79.4 ± 8.3, 71.3 ± 19.4°, and 61.3 ± 16.4°, respectively. The functional outcomes were independent of the preservation of the axillary nerve. Histological study of the glenoid component showed evidence of bone ingrowth at the bone-prosthesis porous interface. CONCLUSION: Application of the 3D-printed arthrodesis prosthesis might be a safe and efficacious method for functional reconstruction in patients who underwent resection of the proximal humerus, especially for those without preservation of the axillary nerve.

Epidemiological characteristics of 1385 primary sacral tumors in one institution in China.

BACKGROUND: Sacral tumors and tumor-like lesions are a rare group of lesions that can affect children and adults of all ages. Little is known about clinical characteristics of age, gender, histologic type, and anatomic site in China. METHODS: A total of 1385 patients with sacral tumors and tumor-like lesions, which had the clinical record at our bone tumor center from January 2000 to November 2018 were analyzed. The metastatic cancers were not included in the present study. RESULTS: A total of 51.7% (716 cases) were malignant and 48.3% (669 cases) were benign tumors or tumor-like lesions. Of malignant tumors, chordoma was the most common malignant tumor (316 cases, 22.8% of all tumors), followed by chondrosarcoma, myeloma, and other histologic types. The most common histological type of benign tumors was a giant cell tumor accounting for 14.8% (205 cases) of all tumors, followed by neurofibroma, schwannoma, and other types. The most common age group affected by malignant bone tumors was the 51- to 60-year-old group, followed by the 41- to 50-year-old group. The most commonly affected age group for benign tumors and tumor-like lesions was the 31- to 50-year-old group, followed by the 21- to 30-year old group. Furthermore, the following histologic types had gender predilection. Chordoma, chondrosarcoma, myeloma, and osteosarcoma affected more frequently males than females. Malignant peripheral nerve sheath tumor, lymphoma, giant cell tumor, neurofibroma, tuberculosis, teratoma, and epidermoid cyst more frequently affected females than males. CONCLUSIONS: The large cohort of sacral tumors and tumor-like lesions in our database may reveal their clinical characteristics of age, gender, histologic type, and anatomic site in China and features of sacral tumors and tumor-like lesions are fairly distinct from the mobile spine and extremities.

Outcome of surgical treatment of children and adolescents with primary malignant sacral tumours.

BACKGROUND: Little is known about the clinical outcome of children and adolescent patients with primary malignant sacral tumours. METHOD: We retrospectively reviewed 40 patients with malignant sacral tumours aged ≤ 18 years, receiving surgery based on the previous proposed surgical resection classification at our centre from 2003 to 2018. The following data were collected in the present study: age, gender, radiological images, detailed information of the surgical procedure, pulmonary and other metastasis at presentation, complications, local recurrence, metastasis, and death during the follow-up were recorded from the clinical and follow-up files. RESULTS: The mean follow-up was 30.7 months (range, 5.2-146.7 months). The incidence of local recurrence was 27.5% (11/40). Seven cases had surgical site infection and there were 12 cases of wound dehiscence. One had a deep venous thrombosis and one had femoral artery thrombosis. Three had fixation breakage and then received a revision. Tenty-two patients (22/40, 55%) were free of disease. A total of 13 deaths (13/40, 32.5%) were observed and the mean overall survival period was 17.1 months (range, 6.3-34.2 months), and a pulmonary metastasis occurred in 18 patients (45%, 18/45) at the 12.0 ± 10.3 months (range, 2.2-35.3 months) after initial surgery. The overall survival rates at one, two and five years were respectively 88.3%, 62.5%, and 51.9%. In the stratification analysis of young patients with primary malignant tumours at the sacrum after surgery, it revealed the influence of pathological grade, location, and age on the oncological outcomes. Kaplan-Meier estimated a survivorship curve of patients with high and low-grade malignant tumours and showed statistical differences in the overall survival and distant relapse-free survival rates between two groups. Afterwards, the result demonstrated that paediatric patients aged ≤ 14 years had worse prognosis than those aged > 14 years. CONCLUSIONS: It is satisfactory for the outcome of surgical treatment of children and adolescent patients with primary malignant sacral tumours based on proposed surgical classification. Furthermore, paediatric patients aged ≤ 14 years have the tendency of poor prognosis compared to adolescent aged > 14 years.

Extra-articular resection is a limb-salvage option for sarcoma involving the hip joint.

INTRODUCTION: With the development of surgical techniques and improvements in hemi-pelvic prosthesis systems, extra-articular resection can be performed as a limb-salvage procedure in selected patients whose hip joint is invaded by a sarcoma. The aim of this study was to describe the indications for and the technical details, post-operative complications, and oncologic and functional outcomes of this procedure. METHODS: Eighteen patients with Enneking IIB or IB sarcoma who underwent extra-articular resection of the hip joint were enrolled. A modular pelvic endoprosthesis combined with a femoral endoprosthesis was used to reconstruct the bone and joint defect. Pathological diagnoses included osteosarcoma (7 patients), chondrosarcoma (7), undifferentiated high-grade pleomorphic sarcoma (3), and malignant peripheral nerve-sheath tumour (1). RESULTS: Wide, marginal and intralesional surgical margin was achieved in 13, four and one patients, respectively. There was one peri-operative death and the other 17 patients were followed up for 35.0 months (range, 10-75 months). Three patients had early-stage dislocations. One had a traumatic dislocation three years later. Two patients had wound complications. The average MSTS 93 score was 63.5% ± 10.8%. Four patients had local recurrence. The estimated three-year disease-free survival and overall survival for the 18 patients were both 50.0%. CONCLUSION: Although technically demanding, extra-articular resection of hip is a limb-salvage procedure that is worth considering for carefully selected patients.

Acetabular Reconstruction With Femoral Head Autograft After Intraarticular Resection of Periacetabular Tumors is Durable at Short-term Followup.

BACKGROUND: Pelvic reconstruction after periacetabular tumor resection is technically difficult and characterized by a high complication rate. Although endoprosthetic replacement can result in immediate postoperative functional recovery, biologic reconstructions with autograft may provide an enhanced prognosis in patients with long-term survival; however, little has been published regarding this approach. We therefore wished to evaluate whether whole-bulk femoral head autograft that is not contaminated by tumor can be used to reconstruct segmental bone defects after intraarticular resection of periacetabular tumors. QUESTIONS/PURPOSES: In a pilot study, we evaluated (1) local tumor control, (2) complications, and (3) postoperative function as measured by the Musculoskeletal Tumor Society score. METHODS: Between 2009 and 2015, we treated 13 patients with periacetabular malignant or aggressive benign tumors with en bloc resection, bulk femoral head autograft, and cemented THA (with or without a titanium acetabular reconstruction cup), and all were included for analysis here. During that time, the general indications for this approach were (1) patients anticipated to have a good oncologic prognosis and adequate surgical margins to allow this approach, (2) patients whose pelvic bone defects did not exceed two types (Types I + II or Types II + III as defined by Enneking and Dunham), and (3) patients whose medical insurance would not cover what otherwise might have been a pelvic tumor prosthesis. During this period, another 91 patients were treated with pelvic prosthetic replacement, which was our preferred approach. Median followup in this study was 36 months (range, 24-99 months among surviving patients; one patient died 8 months after surgery); no patients were lost to followup. Bone defects were Types II + III in five patients, and Types I + II in eight. After intraarticular resection, ipsilateral femoral head autograft combined with THA was used to reconstruct the segmental bone defect of the acetabulum. In patients with Types I + II resections, the connection between the sacrum and the acetabulum was reestablished with a fibular autograft or a titanium cage filled with dried bone-allograft particles which was enhanced by using a pedicle screw and rod system. Functional evaluation was done in 11 patients who remained alive and maintained the femoral head autograft at final followup; one other patient received secondary resection involving removal of the femoral head autograft and internal fixation, and was excluded from functional evaluation. Endpoints were assessed by chart review. RESULTS: Two patients experienced local tumor recurrence. Finally, eight patients did not show signs of the disease, one patient died of disease for local and distant tumor relapse, and four patients survived, but still had the disease. Three of these four patients had distant metastases without local recurrence and one had local control after secondary resection but still experienced system relapse. We observed the following complications: hematoma (one patient; treated surgically with hematoma clearance), delayed wound healing (one patient; treated by débridement), deep vein thrombosis (one patient), and hip dislocation (one patient; treated with open reduction). The median 1993 Musculoskeletal Tumor Society score was 83% (25 of 30 points; range, 19-29 points), and all patients were community ambulators; one used a cane, three used a walker, and nine did not use any assistive devices. CONCLUSIONS: In this small series at short-term followup, we found that reconstruction of segmental bone defects after intraarticular resection of periacetabular tumors with femoral head autograft does not appear to impede local tumor control; complications were in the range of what might be expected in a series of large pelvic reconstructions, and postoperative function was generally good. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Lateral lumbar vertebral body screw predisposes to neuralgia after limb-salvage surgery for pelvic tumors: a single-center, retrospective study of 349 cases.

PURPOSE: To investigate the incidence and risk factors of neuralgia after limb-salvage surgery for pelvic tumors with focus on the reconstruction methods. METHODS: We included 349 cases of pelvic tumors treated with internal hemipelvectomy and reconstruction in our center from January 2009 to May 2015. None of these cases had major lumbosacral nerves invaded by the tumors. Demographic and medical data were reviewed and documented for statistical analyses. The locations of lateral lumbar vertebral body screws (LLVBSs) were evaluated in 26 cases. RESULTS: The overall incidence of post-operative neuralgia was 8.3 %. Pre-admission requirement of analgesics (OR 4.089; 95 % CI 1.711-9.774) and application of LLVBS (OR 11.848; 95 % CI 4.369-32.129) were independent risk factors of neuralgia. The horizontal location of LLVBS did not affect the incidence of neuralgia when it was placed near the midline of the vertebra. CONCLUSIONS: The incidence of post-operative neuralgia was 8.3 % in this study cohort. The LLVBS technique could increase the risk of post-operative neuralgia.

Reconstruction of segmental bone defect of long bones after tumor resection by devitalized tumor-bearing bone.

BACKGROUND: The reconstruction of an intercalary bone defect after a tumor resection of a long bone remains a challenge to orthopedic surgeons. Though several methods have been adopted to enhance the union of long segmental allografts or retrieved segmental autografts to the host bones, still more progresses are required to achieve a better union rate. Several methods have been adopted to devitalize tumor bone for recycling usage, and the results varied. We describe our experiences of using devitalized tumor-bearing bones for the repairing of segmental defects after tumor resection. METHODS: Twenty-seven eligible patients treated from February 2004 to May 2012 were included. The segmental tumor bone (mean length, 14 cm) was resected, and then devitalized in 20% sterile saline at 65 °C for 30 min after the tumor tissue was removed. The devitalized bone was implanted back into the defect by using nails or plates. RESULTS: Complete healing of 50 osteotomy ends was achieved at a median time of 11 months (interquartile range (IQR) 9-13 months). Major complications included bone nonunion in four bone junctions (7.4%), devitalized bone fracture in one patient (3.7%), deep infection in three patients (11.1%), and fixation failure in two patients (7.4%). The bone union rates at 1 and 2 years were 74.1 and 92.6%, respectively. The average functional score according to the Musculoskeletal Tumor Society (MSTS) 93 scoring system was 93 % (IQR 80-96.7%). CONCLUSIONS: Incubation in 20% sterile saline at 65 °C for 30 min is an effective method of devitalization of tumor-bearing bone. The retrieved bone graft may provide as a less expensive alternative for limb salvage. The structural bone and the preserved osteoinductivity of protein may improve bone union.

[Surgical treatment and prognostic analysis of osteosarcoma in adults older than 40 years].

OBJECTIVE: To determine the prognostic factors of primary osteosarcoma in adults. METHODS: This is a review of 54 patients older than 40 years (24 men and 30 women) who were treated between 1998 and 2011 at the authors' institution. Demographic information and follow-up data were obtained and statistically analyzed. RESULTS: Tumors involved the limbs in 30 patients (55.5%) and axial skeleton in 17 patients (31.5%), and arose from soft tissue in 7 patients (13%). And 6 patients (11.1%) had synchronous metastasis. According to our review, tumors were treated surgically in 52 patients (96.3%). Local recurrence was documented in 14 patients (26.9%). Metastasis after diagnosis appeared in 21 patients (38.9%). In the 52 patients who received the surgical treatment, the 5 year disease-free survival and overall survival rates were 43.7% and 50.4%, respectively. CONCLUSION: Adult patients with primary osteosarcoma had a poor clinical outcome. Inadequate surgical margins, more tumors in the axial location due to high recurrence rates, metastatic disease at presentation, and large tumor volumes were associated with significantly lower survival rates. Aggressive multi-agent treatment regimens might improve survival.

Preservation of the contralateral sacral nerves during hemisacrectomy for sacral malignancies.

PURPOSE: This study aimed to evaluate the oncologic and functional outcome of the cases treated with hemisacrectomy through a sagittal plane in the sacrum and simultaneous en bloc resection together with the ipsilateral sacroiliac joint without sacrificing the contralateral sacral nerves and summarize tumor resection techniques and reconstruction strategy. METHODS: En bloc resection of a sacral malignancy with ipsilateral sacroiliac joint and preservation of the contralateral sacral nerves by sagittal hemisacrectomy had been performed in 15 patients. An intra-abdominal aortic balloon was used in all these cases and a combined posterior-anterior approach was adopted. A modified Galveston technique was used to reestablish spinopelvic stability and a nonvascularized fibula autograft was used in selected cases. RESULTS: Contralateral sacral nerves were preserved in all 15 patients. Adequate margins (wide and marginal margin) were accomplished in 10 patients. Local recurrence occurred in seven (47%) patients, and four of these had an inadequate margin. There was no perioperative death. Four (27%) patients had wound problems. No mechanical breakdown occurred until the last follow-up. All the patients were able to walk without the use of a walking aid. Sphincter function was partially preserved in all these patients. At the last follow-up, seven (47%) patients survived without evidence of disease, two (13%) patients lived with disease, and six (40%) patients had died of disease. CONCLUSIONS: This procedure has an oncologic outcome that is similar to that of other high sacrectomy and a much better function outcome. Although demanding, it is indicated in selected patients.

Experience with wound complications after surgery for sacral tumors.

PURPOSE: The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence. METHODS: The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥ 12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors. RESULTS: Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥ 10 cm, and instrumentation used were risk factors for wound complications. CONCLUSIONS: The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

Indocyanine green fluorescence imaging may detect tumour residuals during surgery for bone and soft-tissue tumours.

The aim of this study was to determine the rate of indocyanine green (ICG) staining of bone and soft-tissue tumours, as well as the stability and accuracy of ICG fluorescence imaging in detecting tumour residuals during surgery for bone and soft-tissue tumours. ICG fluorescence imaging was performed during surgery in 34 patients with bone and soft-tissue tumours. ICG was administered intravenously at a dose of 2 mg/kg over a period of 60 minutes on the day prior to surgery. The tumour stain rate and signal-to-background ratio of each tumour were post hoc analyzed. After tumour resection, the tumour bed was scanned to locate sites with fluorescence residuals, which were subsequently inspected and biopsied. The overall tumour stain rate was 88% (30/34 patients), and specific stain rates included 90% for osteosarcomas and 92% for giant cell tumours. For malignant tumours, the overall stain rate was 94%, while it was 82% for benign tumours. The ICG tumour stain was not influenced by different pathologies, such as malignant versus benign pathology, the reception (or lack thereof) of neoadjuvant chemotherapies, the length of time between drug administration and surgery, the number of doses of denosumab for patients with giant cell tumours, or the tumour response to neoadjuvant chemotherapy. The overall accuracy rate of successfully predicting tumour residuals using fluorescence was 49% (23/47 pieces of tissue). The accuracy rate after en bloc resection was significantly lower than that after piecemeal resection (16% vs 71%; p < 0.001). A high percentage of bone and soft-tissue tumours can be stained by ICG and the tumour staining with ICG was stable. This approach can be used in both benign and malignant tumours, regardless of whether neoadjuvant chemotherapy is adopted. The technique is also useful to detect tumour residuals in the wound, especially in patients undergoing piecemeal resection.

Outcomes of Semiknee Replacement in Skeletally Immature Bone Sarcoma Patients.

INTRODUCTION: A semiknee mega endoprosthesis (SKMEP) was used to replace the resected distal femur or proximal tibia in skeletally immature bone sarcoma patients. This study investigated the surgical technique, endoprosthesis survival rate, functional outcome, complications, and approaches to resolve limb-length discrepancy (LLD) following this procedure. PATIENTS AND METHODS: In total, 15 girls and 16 boys with a mean age of 9.1 years (range, 4-12) and 8.9 years (range, 5-13), respectively, were included in this study. The mean length of the resected distal femur (15 cases) and proximal tibia (16) was 145.0 and 122.8 mm, respectively. Altogether, 19 custom-made SKMEPs and 12 modular units were used to reconstruct the bone and joint defects. RESULTS: The average follow-up was 82.8 months (range, 4-225 months). Five patients died of disease. Seven SKMEPs were revised to total knee endoprosthesis after a mean of 40.3 months. Nineteen patients retained the original SKMEP, and the mean LLD was 4.3 cm (range, 0-10 cm). One case each of Henderson type 1B, type 2A, type 2B, and type 5B failures was observed. Knee subluxation occurred in two cases. Although a slight laxity of the knee was identified on physical examination, the average Musculoskeletal Tumor Society 93(MSTS93) functional score was 84.5% (range, 57-97%). The estimated implant survival was 70.5% at 5 years. CONCLUSION: This was the largest retrospective study reporting the application of SKMEP in bone sarcoma patients. For selected skeletally immature bone sarcoma patients, SKMEP is an option with satisfactory functional outcomes and survival rates. However, heightening pads or shoes to compensate the LLD were indispensable before subsequent LLD was adjusted by further operation(s).

Integrated analysis of single-cell and bulk RNA sequencing data reveals an immunostimulatory microenvironment in tumor thrombus of osteosarcoma.

Tumor thrombus of bone sarcomas represents a unique reservoir for various types of cancer and immune cells, however, the investigation of tumor thrombus at a single-cell level is very limited. And it is still an open question to identify the thrombus-specific tumor microenvironment that is associated with the tumor-adaptive immune response. Here, by analyzing bulk tissue and single-cell level transcriptome from the paired thrombus and primary tumor samples of osteosarcoma (OS) patients, we define the immunostimulatory microenvironment in tumor thrombus of OS with a higher proportion of tumor-associated macrophages with M1-like states (TAM-M1) and TAM-M1 with high expression of CCL4. OS tumor thrombus is found to have upregulated IFN-γ and TGF-ß signalings that are related to immune surveillance of circulating tumor cells in blood circulation. Further multiplexed immunofluorescence staining of the CD3/CD4/CD8A/CD68/CCL4 markers validates the immune-activated state in the tumor thrombus samples. Our study first reports the transcriptome differences at a single-cell level between tumor thrombus and primary tumor in sarcoma.

Elbow hemiarthroplasty with a 3D-printed megaprosthesis for defects of the distal humerus or proximal ulna after tumour resection : a preliminary report.

AIMS: The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection. METHODS: From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. RESULTS: Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. CONCLUSION: The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747-757.

Ultra-Short Course of Neo-Adjuvant Denosumab for Nerve-Sparing Surgery for Giant Cell Tumor of Bone in Sacrum.

STUDY DEIGN: This was a retrospective study about sacral giant cell tumor of bone (GCTB). OBJECTIVE: This study aimed to investigate whether ultra-short course of neo-adjuvant denosumab treatment for sacral GCTB could (1) induce radiological and histological response? (2) Facilitate nerve-sparing surgery? (3) Achieve satisfactory oncological and functional outcomes? SUMMARY OF BACKGROUND DATA: Previous reports on long course of neo-adjuvant denosumab treatment for GCTB showed significant tumor response and a relatively high recurrent rate after curettage. METHODS: Sixty-six patients with sacral GCTB treated with neoadjuvant denosumab and nerve-sparing surgery were categorized into ultra-short course group (≤3 doses and operation within D21 since 1st dose, 41 patients) or conventional group (>3 doses or operation after D21 since 1st dose, 25 patients). The radiological and histological response, operative data, oncological and functional outcomes were compared. RESULTS: The ultra-short course group demonstrated fewer doses of neo-adjuvant denosumab (mean: 2.1 vs. 4.8, P  < 0.001) and shorter time to surgery (12.2 days vs. 72.3 days, P < 0.001). Similar patterns of radiological and histological response were observed in the two groups with less fibrosis and ossification in the ultra-short course group. The operative duration (199.9 min vs. 187.8 min, P = 0.364) and estimated blood loss (1552.4 mL vs. 1474.0 mL, P = 0.740) were comparable. Most (94.8%) of the patients received adjuvant denosumab. After a mean follow-up of 29.4 months, three cases (8.8%) and five cases (20.8%) showed local recurrence in each group (P = 0.255). The estimated recurrence-free survival (56.2 vs. 51.2 months, P = 0.210) and the functional status [Motor-Urination-Defecation scores: 25.9 vs. 25.7, P = 0.762] did not differ between the two groups. CONCLUSION: Ultra-short course of neo-adjuvant denosumab for sacral GCTB could elicit radiological and histological responses as conventional course did. The less degree of fibrosis and ossification might facilitate nerve-sparing surgery and help to achieve satisfactory local control and functional status.Level of Evidence: 4.

Surgical classification of different types of en bloc resection for primary malignant sacral tumors.

PURPOSE: The purpose of the study was to develop a surgical classification system for primary malignant sacral tumors. METHODS: The sacrum is divided into three regions 1, 2 and 3 by the S1-S2 and S2-S3 junctions. En bloc resections were classified into five types: type I involves regions 1, or 1 and 2, or regions 1, 2 and 3, type II involves regions 2 and 3, and type III involves only region 3. Type IV includes sagittal hemisacrectomy and resection of a portion of the adjacent ilium. Type V includes the sacrum and the fifth lumbar vertebra. 117 patient cases (68 females and 49 males) were reviewed. RESULTS: There were two perioperative deaths. Of the 35 patients who should have undergone type I resection, local recurrence (LR) occurred in four of the 14 patients who underwent type I resection with free margins without tumor rupture. The other 21 patients underwent piecemeal resection, and LR occurred in 15 (P = 0.013). 35 patients underwent type II resection. Free margin without tumor rupture was accomplished in 26 and LR occurred in 6. Tumor rupture (TR) occurred in the other 9 and LR occurred in seven (Yates' P = 0.012). All 33 patients underwent type III resection with free margins without tumor rupture. LR occurred in five. 11 patients had type IV resection. Free margin without tumor rupture was accomplished in seven and LR occurred in three. TR occurred in the other four, and LR occurred in two (Yates' P = 0.689). One patient underwent type V resection with free margin without tumor rupture and LR occurred. Postoperatively, less than 1/3 needed long-term urethral catheterization. No patients received colostomy for postoperative fecal incontinence. All the patients were able to ambulate. CONCLUSION: Our classification system and the corresponding surgical approaches are helpful in dealing with primary malignant sacral tumors. Better oncologic results could be expected if free margin without tumor rupture was accomplished.

[Evaluation of prognostic factors for synovial sarcoma].

OBJECTIVE: To determine the independent prognostic factors of primary synovial sarcoma. METHODS: The clinical data of 52 patients followed up from 66 patients with synovial sarcoma treated between September 1997 and September 2008 was analyzed retrospectively. There were 28 male and 24 female patients aged from 11 to 71 years old. Three and five-year overall survival (OS), recurrence rate and 9 prognostic factors were analyzed in this study. Univariate and multivariate analysis were performed to determine the prognostic factors of OS. RESULTS: Fifty-two patients were followed up with the follow-up time ranged from 6 to 88 months (median 32 months). The 3-, 5-year overall survival rate and local recurrence rate were 52.8%, 30.3% and 32.7% respectively. Univariate showed tumor size < 5 cm, tumor located at extremities, adequate surgical margin and radical resection combined with radiotherapy had better survival rate (P < 0.05). Multivariate analysis demonstrated that tumor size, primary site and adequate surgical margin were independent prognostic factors for OS. Patients received radical resection combined with radiotherapy have longer median relapse time (25 months) compared with marginal resection combined with radiotherapy (18 months) and single radical resection (12 months). Thirty-five (67%) patients were treated with chemotherapy and seventeen (33%) patients received no chemotherapy for the primary tumor. Treatment with chemotherapy was not associated with an improved OS (P = 0.52). CONCLUSIONS: The independent prognostic factors of synovial sarcoma are tumor size, primary site and adequate surgical margin. Doxorubicin and ifosfamide based chemotherapy was not associated with an improved OS in patients with synovial sarcoma. Radical resection combined with radiotherapy can best control local condition.

Surgical treatment of pelvic chondrosarcoma involving periacetabulum.

BACKGROUND AND OBJECTIVES: Surgical treatment of pelvic chondrosarcoma involving acetabulum is challenging. Primary goals of surgical treatment include local control and prevention of distant metastases. A secondary goal is maintenance of quality of life by avoiding major amputative surgery. The purpose of the study was to review the oncological outcome, functional outcome, and the surgical complications of patients with periacetabular chondrosarcomas in the context of resection and reconstruction treated at one tumor center in the past decade. METHODS: Forty-five cases between June 1998 and June 2007 were retrospectively reviewed. There were 26 men and 19 women with an average age of 41.2 (18-63) years. Patients were followed up for a median time of 37 months (18-119 months). There were 32 patients with conventional chondrosarcomas, 9 with dedifferentiated chondrosarcomas, and 4 with mesenchymal chondrosarcomas. According to Enneking's classification there were: Type II-1, Type I + II-8, Type II + III-23, Type I + II + IV-8, and Type I + II + III-5. Six patients had an external hemipelvectomy, whereas 39 patients underwent a limb-salvage procedure. In 27 patients the defect was reconstructed by a modular hemipelvic endoprosthesis and in 4 patients reconstruction by saddle endoprosthesis. Five patients received reconstruction with devitalized tumor bone and three underwent iliofemoral arthrodesis. RESULTS: The 5-year estimated survival was 62.6%. Local recurrence occurred in 10 (22.2%) patients at an average of 18 months after operations. Ten (22.2%) patients had distant metastasis. The average MSTS 93 score was 68.3% (33.3-100). Eighteen complications occurred in 13 patients (28.9%). Wound complication occurred in six (13.3%) patients. Deep infection rate was 11.1%. CONCLUSIONS: Favorable oncological and functional outcome can be achieved in selected patients with periacetabular chondrosarcomas. The complication rates were still high; however, facing the goal of limb salvage, a certain number of complications is acceptable.

Increasing serum alkaline phosphatase is associated with bone deformity progression for patients with polyostotic fibrous dysplasia.

BACKGROUND: Fibrous dysplasia (FD) is a rare bone disorder in which normal intramedullary bone is replaced by fibro-osseous tissue, which is complicated by the progression of Shepherd's crook deformity. How to predict the progression of Shepherd's crook deformity is still a challenging for the orthopedic surgeon. METHODS: A total of 159 cases were reviewed in the retrospective study between January 2000 and September 2016. Clinical and monitoring data were collected. We analyzed the correlationship between the bone turnover markers and other parameters (age, gender, FD type, deformity, BMI, and lesion location). RESULTS: Age, gender, lesion location, lesion type, and shepherd's crook deformity had a close relationship with preoperative ALP level in the univariate analysis, and the multivariate analysis showed age, gender, lesion type, and shepherd's crook deformity had the significant relationship with the preoperative serum ALP level. The surgery could remove the bone lesion and suppressed the abnormal bone metabolism. Furthermore, the preoperative ALP level of FD patients with the shepherd's crook deformity was obviously higher than that without deformity, and the preoperative calcium and phosphorus levels of FD patients with deformity were significantly lower than that without deformity. Notably, for some patients with progression of the shepherd's crook deformity during the follow-up, ALP increased to the high level and at that time X-ray showed the shepherd's crook deformity severely progressing. CONCLUSIONS: PFD with higher serum ALP level has obvious tendency to progress severely, and risk factors of progression to the deformity are the condition of bony metabolism and FD type. The deformity of PFD may be related to high speed of bone turnover, which is exactly reflected by the levels of serum ALP and calcium. Evaluation of patients with FD should include a thorough evaluation of calcium/phosphate metabolism and bone turnover.