Surgical outcome of malignant primary bone tumours in elderly and very elderly patients.

PURPOSE: Elderly patients with bone cancer are thought to have poorer access to specialist treatment and therefore suboptimal outcome. The aim of this study was to review the clinical course, outcome and survivorship in geriatric patients with primary bone tumours. METHODS: We analysed 66 consecutive patients aged 60 years or older who were surgically treated for primary bone tumours between 1997 and 2012. The cohort was divided into two groups: elderly (60-70 years, n = 31) and very elderly (>70 years, n = 35). Clinicopathologic characteristics, treatment, outcome and survival were analysed. The mean follow up was 58.5 months (range two to 188). RESULTS: There were 51 chondrosarcomas (grade I, n = 29; grade II, n = 15; grade III, n = 7), ten osteosarcomas and four of other primary malignant bone tumours. Twenty-three prostheses for joint reconstruction were implanted; procedures involving the transposition of free vascularised flaps were performed in six patients. Seven patients had amputation as a primary procedure, four in the elderly and three in the very elderly group. Local recurrence was recorded in eight cases (12.1%). Secondary surgery was performed in nine (13.6%) patients (six recurrences, two haematomas, one deep infection). At final follow up, 77.3% of patients were alive (elderly 83.9%, very elderly 71.4%) and there was no significant difference in the five-year survival rates between both groups. CONCLUSIONS: Elderly and very elderly patients with bone tumours receive satisfactory treatment and achieve good surgical outcome. Treatment decisions in the geriatric population should not be influenced by age alone.

Venous thromboembolism in orthopaedic oncology.

AIMS: Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. METHODS: MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. RESULTS: In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. CONCLUSION: Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:-1751.

Vacuum-assisted closure to aid wound healing in foot and ankle surgery.

BACKGROUND: Although vacuum-assisted closure (VAC) is a well-established technique in other surgical specialties, its use has not been established in the foot and ankle. The aims of this study were to determine if vacuum-assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, if it helps debride wounds, and if it prevents the need for further surgery. METHODS: We retrospectively reviewed 15 patients (18 wounds or ulcers) with primary diagnoses of diabetes (10 patients), chronic osteomyelitis (two patients), peripheral vascular disease (two patients), and spina bifida (one patient). Eleven of the 15 patients had serious comorbidities, such as peripheral neuropathy, renal failure, and wound dehiscence. All wounds were surgically debrided before VAC therapy was applied according to the manufacturer's instructions. The main outcome measures were time to satisfactory wound closure, changes in the wound surface area, and the need for further surgery. RESULTS: Satisfactory healing was achieved in 13 of the 18 wounds or ulcers at an average of 2.5 months. VAC therapy failed in five patients (five class III ulcers), three of whom required below-knee amputations. Wound or ulcer size decreased from an average of 7.41 cm(2) before treatment to an average of 1.58 cm(2) after treatment. CONCLUSION: VAC therapy is a useful adjunct to the standard treatment of chronic wound or ulcers in patients with diabetes or peripheral vascular disease. Its use in foot and ankle surgery leads to a quicker wound closure and, in most patients, avoids the need for further surgery.

Surgical treatment of recurrent proximal tibio-fibular joint ganglion cysts.

BACKGROUND: Complex symptomatic ganglion cysts arising from the proximal tibio-fibular joint (PTJ) are not an uncommon presentation in specialist knee clinics and can be managed by aspiration or excision. There is, however, a high rate of recurrence and often there is progressive involvement of the common peroneal nerve (CPN) and its branches, and permanent nerve damage may result. METHODS: This study is a review of the outcome of recalcitrant and recurrent cyst disease with CPN involvement treated by proximal fibulectomy. Nine patients with clinical and radiological diagnosis of a ganglion cyst involving the proximal tibio-fibular joint were treated by proximal fibulectomy. Average age was 47.2years (19 to 75). Patients were followed up clinically and radiologically. Medical notes were reviewed to assess clinical/pathological characteristics, surgical outcome, recurrence rate and the symptoms of instability and nerve function. RESULTS: None of the patients were lost to follow-up. After an average follow-up of 83months (15 to 150), none of the patients had clinical or radiological evidence of recurrence. All patients were pain-free and had a complete resolution of nerve symptoms and no evidence of CPN injury. None of the patients complained of localised pain or knee instability and there were no wound healing problems. CONCLUSIONS: MRI now confirms TFJ-ganglion cysts to be more common than previously recognised. Where there is refractory disease with progressive nerve symptoms and evidence of nerve sheath involvement, joint excision by proximal fibulectomy gives a satisfactory functional result in controlling disease and preventing further nerve damage. LEVEL OF EVIDENCE: IV.

Use of the composite pedicled pectoralis minor flap after resection of soft tissue sarcoma in reconstruction of the glenohumeral joint.

The surgical repair of an extensive anterior glenohumeral soft tissue defect is complicated by glenohumeral instability and subsequent significant functional deficit. This surgical note offers a relatively simple reconstruction of the anterior capsule and subscapularis muscle using a pectoralis minor pedicle flap. This reconstruction is supplemented with functional reconstruction of the anterior glenohumeral joint. A conventional deltopectoral approach is utilized and pectoralis minor is freed from its coracoid insertion, released, and mobilized without compromising the pedicle entering from the dorsum and inferior one-third of the muscle. The mobilized pectoralis minor vascular pedicle has sufficient length for the pectoralis minor to be transferred to provide coverage of the anterior shoulder joint even in full external rotation, providing anterior stability. To further improve glenohumeral stability and shoulder function, the pectoralis major muscle can be split with the clavicular part reinserted lateral to the bicipital groove onto the lesser tuberosity replacing subscapularis function while stabilising the glenohumeral joint.