Staged Management of Infection with Adjustable Spacers After Megaprosthesis Implantation in Primary Sarcoma Patients.

Background: While periprosthetic joint infection has always been a significant concern for orthopaedic surgeons, the rate of infection is five to ten times higher after tumor prosthesis implantation. With the growing use of mega-implants, the number of these infections has also increased. We aimed to investigate the results of our patients with a primary malignant musculoskeletal tumor, who underwent two-stage revision surgery for an infected mega-prosthesis. We also presented the emerging complicatons and required soft tissue reconstruction procedures. Methods: The study included 32 primary bone and soft tissue sarcoma patients who underwent a two-stage revision procedure for infection. After a rigorous bone and soft tissue debridement procedure at the first stage, antibiotic-loaded bone cement was wrapped around a cloverleaf type intramedullary nail and inserted into the forming gap. After a minimum of 6 weeks of antibiotic therapy, depending on patients' clinical signs and serum infection markers, the reimplantation stage was undertaken. Results: The mean oncologic follow-up period was 28 months (range 5-96 months). During this period, 11 patients died because of non-infection related causes, 12 patients were alive with their disease, whereas 9 patients were totally free of their oncologic condition. The infection was eradicated in all survivors except one patient, where a high-level transfemoral amputation became necessary. Conclusion: Periprosthetic infection after tumor proshesis implantation in cancer patients can be managed with same principles as conventional arthroplaty procedures, taking care that they are immunocompromised and vulnerable patients and their bone stock loss is significant which makes surgical options more challenging.

External validation of the PATHFx decision-support tool on Turkish patients with skeletal metastasis.

Objective: Accurate determination of life expectancy becomes very important when determining the treatment of patients with pathologic fractures. We aimed to investigate the predictive role of the PATHFx model in Turkish patients by estimating the area under curve (AUC) of the receiver operator characteristic (ROC) and externally validating the results of PATHFx on the Turkish population. Methods: The data of 122 patients who presented to one of four orthopaedic oncology referral centres in Istanbul (2010-2017) and underwent surgical management of pathologic fractures were retrospectively collected. Patients were evaluated according to age, sex, type of pathologic fracture, presence of organ metastasis, presence of lymph node metastasis, haemoglobin concentration at presentation, primary oncologic diagnosis, number of bone metastases, and Eastern Cooperative Oncology Group (ECOG) status. Estimations of the PATHFx program by months were statistically evaluated using ROC analysis. Results: In our study population (122 patients), all survived the first month, 102 survived the third month, 89 were alive at 6 months, and 58 patients survived at 12 months. At 18 and 24 months, 39 and 27 patients were alive, respectively. The AUC value was 0.677 at 3 months, 0.695 at 6 months, 0.69 at 12 months, 0.674 at 18 months, and 0.693 at 24 months. The 3-, 6-, 12-, 18-, and 24-month survival rates were statistically significant (P < 0.01 and P < 0.05). ECOG performance status was 0-2 points in 33 patients (Memorial Sloan-Kettering Cancer Center (MSKCC) data set: 93 cases, our data set: 33 cases). ECOG performance status was 3-4 points in 89 patients (MSKCC data set: 96 cases, our data set: 89 cases). Conclusions: The objective data used by PATHFx for prediction provided statistically accurate estimates on Turkish patients, who are presumed to have mixed genomes through history from both Europe and Asia, and demonstrates its applicability to the Turkish population.

Age-adjusted Charlson Comorbidity Index is a valuable prognostic tool in operable soft tissue sarcoma of trunk and extremities.

BACKGROUND: Advanced age and presence of comorbidities affect prognosis and treatment decisions in patients with soft tissue sarcoma (STS). However, coeffect of age and comorbidities is still unknown. We aimed to investigate prognostic value of age-adjusted Charlson Comorbidity Index (ACCI) in trunk and extremity STS operated with curative intent. HYPOTHESIS: Preoperative ACCI might predict survival outcomes independently in patients with STS of trunk and extremities. PATIENTS AND METHODS: The study included 151 patients and ACCI was calculated for each patient. We categorized the patients into two groups according to median ACCI. We retrospectively collected data about clinicopathologic and treatment-related factors, and evaluated potential prognostic factors for disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. RESULTS: Median age was 50 (18-86) years. There were 89 male and 62 female patients. Lower extremities were the most common tumor sites (73.5%). Most of the patients had high grade tumors (84.1%) and stage 3 disease (66.9%). Radiotherapy and chemotherapy were carried out in 106 and 58 patients, respectively. Overall prevalence of comorbidity was 29.1%. Median ACCI was 3 (2-9). Older age (p<0.001), worse performance status (p<0.001), larger tumor size (p=0.03), higher grade tumors (p=0.03) and advanced stage (p=0.04) were associated with higher ACCI (≥3). Median follow-up time was 32 months, 50.3% of patients had disease recurrence, and 35.8% died. Median DFS (p=0.001) and OS (p=0.001) of patients with low ACCI (<3) were significantly longer than patients with high ACCI. Multivariate analysis determined ACCI as an independent prognostic indicator for both DFS (HR 1.72, p=0.02) and OS (HR 2.02, p=0.04). DISCUSSION: ACCI is a valuable prognostic tool to be used in the preoperative setting of patients with STS. Higher ACCI was found to be independently associated with worse survival outcomes. For each patient with STS, evaluating comorbidities and combining them with age appears to be a critical step in modifying therapy options. LEVEL OF EVIDENCE: IV, retrospective observational study.

Floating phalanx; simultaneous double dislocation of the interphalangeal joint in a finger: A case report and literature review.

Isolated proximal and distal interphalangeal joint (DIPJ) dislocations are widely seen as a result of sporting injuries and major trauma. The combination of dorsal dislocation of the DIPJ in the same finger concomitant to traumatic dorsal dislocation of the proximal interphalangeal joint (PIPJ) is a rarely seen injury. The case is, here, presented of a 65-year-old female patient with proximal and DIPJ dislocation of the right-hand ring finger accompanied by volar and dorsal plate injuries in the proximal and distal joints. With this case, it was aimed to introduce a new term of 'floating phalanx' into medical literature. The treatment was applied to the patient of closed reduction under peripheral block and the application of an aluminium finger splint in semiflexion. In a 24-month follow-up period, the 4th finger of the patient was observed to be stable and has pain-free range of movement. This case is an uncommon case of volar and dorsal plate avulsion fractures with PIPJ and DIPJ dorsal dislocation treated successfully with closed reduction and conservative treat-ment with excellent functional results.

Treatment of locally aggressive benign bone tumors by means of extended intralesional curettage without chemical adjuvants.

Objectives: The aim of this study is to present the clinical, oncological, and functional results of locally aggressive benign bone tumors treated with extended intralesional curettage without the use of adjuvant in a tertiary orthopedic oncology center. Method: A total of 172 patients treated with surgical curettage and high-speed burrs for the diagnosis of aneurysmal bone cyst, giant cell tumor, osteoblastoma, chondroblastoma, and chondromyxoid fibroma were included in the study. Demographic, radiological, and clinical data of the patients were analyzed. Results: One-hundred seventy two patients (101 (59%) female and 71 (41%) male) with a mean age of 23 years (6-84). The mean follow-up period was 48 months (18-108). In the study, a total of 8 (4.6%) patients had postoperative complications, 17 (9.9%) patients had recurrence in the postoperative period. Diameter greater than 5 cm was found to be a risk factor for recurrence (p < 0.004). The probability of developing complications was found to be significantly higher in patients with recurrence (p < 0.001). There was no significant relationship between recurrence and age, tumor type, and tumor stage. Conclusion: Successful treatment results can be obtained with extended surgical curettage, high-speed burr, and cauterization without the use of chemical adjuvants in locally aggressive bone tumors.

Implant survival and functional results of endoprosthetic reconstruction for proximal femoral metastases with pathological fractures.

BACKGROUND: This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures. METHODS: A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated. RESULTS: The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95-0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30-56.6%) and the median KPS score was 40 (30-50). Postoperative third month, the median MSTS score was 56.6 (53.3-86.6%) and the median KPS score was 60 (40-70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure. CONCLUSION: Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.

Is bipolar hemiarthroplasty an appropriate type of hip articulation following proximal femoral or total femoral resections for musculoskeletal malignancies?

BACKGROUND: Different approaches are applied for reconstruction in patients with a musculoskeletal malignancy which require a proximal femoral or total femoral resection. We aimed to evaluate the treatment outcomes of patients who underwent a proximal femoral or total femoral resection due to bone and soft tissue tumors and had an endoprosthetic reconstruction by a bipolar hemiarthroplasty type of hip articulation. METHODS: We retrospectively identified 133 patients who underwent a proximal femoral or total femoral endoprosthetic replacement after resection of a bone or soft tissue malignancy. There were 74 male and 59 female patients, with a mean age of 55.02 ± 16.92 years (range 11-84 years) and a median follow-up of 24.47 ± 24.45 months (range 6-164 months). Patient demographics, surgical, and oncological data were recorded. Acetabular wear was measured using the classification proposed by Baker. Functional assessment was performed using the Musculoskeletal Tumor Society (MSTS) functional score. RESULTS: There was no statistically significant difference among primary diagnostic groups in terms of gender, prosthesis type, trochanter major resection, local recurrence, complication/revision rate, and MSTS Score (p > 0.05, for each parameter). On the other hand, a statistically significant difference was detected in terms of degree of acetabular erosion among diagnostic groups (p < 0.001); the acetabular erosion rate (AER) was found to be lower in patients with metastatic carcinoma than in patients with a diagnosis of primary bone or soft tissue sarcoma. The univariable analysis revealed that the effect of age, primary diagnosis, localization, follow-up time, and presence and number of distant organ metastasis variables on AER were found to be statistically significant (p = 0.018, p = 0.035, p = 0.002, p = 0.007, p = 0.031, p = 0.040, respectively). CONCLUSION: In patients who undergo a proximal femoral or a total femoral resection due to a musculoskeletal tumor, bipolar hemiarthroplasty is an adequate type of hip articulation method, since it does not affect the revision requirements and functional outcomes of patients with acetabular erosion.

Tricks and pitfalls in the surgical treatment of malignant bone tumours of the forearm in children and adolescents.

Malignant bone tumours around the forearm are rare. Nowadays, oncological and surgical management of bone sarcomas of this region has improved significantly. Although the anatomical features are complex, limb-sparing surgery is possible with wide surgical resection. Biological reconstruction methods are promising in this anatomically unique region. In addition, meticulous soft-tissue reconstruction yields good functional results in the hand and wrist. This study reviews malignant bone tumours of the forearm and their oncological and surgical management. Malignant bone tumours should be treated with a multidisciplinary approach based on chemotherapy, radiotherapy and limb salvage procedures.

Efficacy and Safety of Tranexamic Acid in Resection and Endoprosthetic Reconstruction of Distal Femoral Osteosarcomas in Children: A Retrospective Cohort Study.

BACKGROUND: This study aimed to investigate the effect of intravenous tranexamic acid (TXA) on blood loss and transfusion rates in children who underwent resection and endoprosthetic reconstruction of distal femoral osteosarcomas. METHODS: The medical records of 56 patients who underwent resection and endoprosthetic reconstruction for distal femoral osteosarcomas between 2017 and 2019 were retrospectively reviewed. Patients were divided into 2 groups: group 1 consisted of 25 patients (11 male and 14 female, mean age 15.2±3 y) who received preoperative 15 mg/kg intravenous TXA, and group 2 consisted of 31 control patients (18 male and 13 female, mean age 14.3±2.6 y) who did not receive TXA. The groups were compared based on their total blood loss, intraoperative blood loss, hidden blood loss, postoperative drain output, transfusion requirements, preoperative and postoperative hemoglobin (Hb) and hematocrit (Htc) difference, length of hospital stays, operative time, and complications. RESULTS: The mean total blood loss was lower in intravenous TXA group (1247.5±300.9 mL) when compared with control group (1715.7±857.0 mL) (P=0.018). The mean intraoperative blood loss in intravenous TXA group (386±109 mL) was lower than that in control group (977.4±610.7 mL) (P<0.001). Postoperative drain output at 24 and 48 hours was 198.0±61.8 and 72.4±27.4 mL in intravenous TXA group, respectively, and was low compared with 268.4±118.2 and 117.1±67.8 mL in control group (P=0.028 and 0.006). The rate of patients requiring transfusion was significantly lower in intravenous TXA group (56%) than in control group (83.9%). Preoperative and postoperative 6, 24, and 72 hours Hb and Htc differences were significantly lower in intravenous TXA group [(-1.7±1.8 g/dL P<0.001; -2.0±1.5 g/dL P<0.001; -2.3±1.7 g/dL P<0.001, for Hb) (-5.7±4.6, P<0.001; -6.9±4.0, P<0.001; -9.6±9.1, P<0.001, for Htc)]. Intravenous TXA group had shorter hospital stay time in comparison to control group (P<0.001). The operative time was significantly longer in the control group (P<0.05). No increase in pulmonary embolism or venous thromboembolism rate was observed with intravenous TXA use. CONCLUSION: We conclude that administration of intravenous TXA reduces intraoperative and postoperative blood loss, transfusion rates, and hospital stay in resection and endoprosthetic reconstruction of the distal femoral osteosarcomas in children. TYPE OF STUDY: This was a retrospective comparative study. LEVEL OF EVIDENCE: Level III.

The impact of pathological fractures on surgery, morbidity, functional and oncological outcomes in patients with primary bone sarcomas.

Background Although rare, pathological fractures may occur in primary bone sarcomas. There have been studies reporting that such patients have a poorer prognosis than those without a pathological fracture. This study investigates the impact of pathological fractures on surgery, morbidity, functional and oncological outcomes in patients with primary bone sarcomas. Patients and methods A retrospective analysis of 568 patients with primary bone sarcomas, treated between 2005 and 2019, was performed. The study included 41 patients with a pathological fracture and 51 control patients who did not have a pathological fracture. A multivariate Cox regression analysis was used to investigate the impact of pathological fractures and further independent variables on amount of intraoperative bleeding, duration of surgery, number of muscles and major neurovascular structures included in resection, tumor volume, surgical volume, Musculoskeletal Tumor Society (MSTS) functional score, postoperative complication rate, and local recurrence, distant metastasis, and survival rates. Results There were 36 (39%) female and 56 (61%) male patients. No statistically significant difference was noted in tumor volume, tumor/surgical volume percentage, number of major neurovascular structures included in resection, postoperative complication rate, and local recurrence, distant metastasis, and survival rates between the two groups (p > 0.05). A significantly higher amount of intraoperative bleeding and number of transfused blood components, a longer duration of surgery, and a higher amount surgical volume and number of resected muscles were detected in Group 1 compared to Group 2 (p=0.001, p=0.002, p=0.007, p=0.007, p < 0.001, respectively). The MSTS functional scores were lower in patients with a pathological fracture than in those without a pathological fracture (p=0.001). Conclusion We conclude that a pathological fracture through a primary bone sarcoma has no adverse effect on prognostic factors such as local recurrence, distant metastasis, and survival. However, pathological fractures increase the amount of intraoperative bleeding and surgical volume and result in a longer surgery, in addition to decreased functional outcomes.

Limb salvage surgery of primary and metastatic bone tumors of the lower extremity: Functional outcomes and survivorship of modular endoprosthetic reconstruction.

OBJECTIVE: The study was aimed to determine the survivorship and functional outcomes of modular endoprosthetic reconstruction in the management of primary and metastatic bone tumors of the lower limbs and to investigate the rate and causes of implant failure. METHODS: A total of 84 limbs of 82 patients (49 male, 33 female; mean age=48 years, age range=13-78 years) with a minimum follow-up of 12 months in whom resection and modular endoprosthetic reconstructions were performed for primary or metastatic bone tumors of the lower extremity were retrospectively reviewed and included in the study. The mean follow-up was 43 (range=13-119) months. Functional status was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the final follow-up. Implant survival was defined as the time from implantation until partial or complete exchange of the prosthesis secondary to mechanical or nonmechanical causes or amputation. The effects of the anatomical site on functional scores and implant survival were statistically analyzed. Additionally, the effects of diagnosis and adjuvant treatments on functional scores, implant survival, and failure rates were investigated. RESULTS: At the time of the study, 55 patients were still alive with a mean follow-up of 48 (range=15-119) months. The mean MSTS scores resulting from the final follow-up of all patients and of those surviving were 87.9% (range=16%-100%) and 86.8% (range=16%-100%), respectively. Overall implant survival was 95.2%, 89.2%, 87%, and 87% at 1, 2, 3, and 4 years, respectively. Statistically, both functional scores and implant survival analysis in different anatomical sites were found similar. In 15 of the patients (17.8%), endoprosthetic reconstructions had failed. The causes of failure were soft tissue failure (dislocation) in 5 patients, infection in 5, structural/mechanical failure in 2, local recurrence in two, and aseptic loosening in one. The diagnosis and receiving preoperative and/or postoperative adjuvant treatment did not affect functional scores, implant survival or failure rates. CONCLUSION: The results of this study have shown that modular endoprosthetic replacement can provide satisfactory functional results and a durable mid-term limb salvage option in the management of patients with primary and metastatic bone tumors of the lower limbs. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study.

OBJECTIVE: This study aimed to investigate amputation-related factors after limb-salvage surgery (LSS) in patients with extremity-located bone and soft-tissue sarcomas and determine the relationship between these factors and patient survival. METHODS: In this retrospective study at our institution, patients in whom LSS was first performed because of an extremity-located musculoskeletal sarcoma, and subsequently amputation was carried out for various indications were included. Patient and tumor characteristics, details of surgical procedures, indications of amputation, number of operations, presence of metastasis before amputation, and post-amputation patient survival rates were analyzed. RESULTS: A total of 25 patients (10 men, 15 women; mean age=41.96±21.88 years), in whom amputation was performed after LSS as initial resection of an extremity sarcoma or re-resection(s) of a local recurrence, were included in the study. The leading oncological indication for amputation was local recurrence that occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis in 1 (4%) patient. The patients underwent a median of 2 (range, 1-4) limb-salvage procedures before amputation. Distant organ metastasis was detected in 22 (88%) patients during follow-up; in 13 (52%) of these patients, metastasis was present before amputation. A total of 11 (44%) patients were alive at the time of study with no evidence of the disease (n=3) or with disease (n=8), and 14 (56%) patients died of disease. The mean overall and post-amputation survival were 47±20.519 (range, 11-204) months and 22±4.303 (range, 2-78) months, respectively. The median follow-up was 27 (range, 6-125) months. CONCLUSION: The most common causes of amputation after LSS were local recurrence and prosthetic infection. Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation.

BACKGROUND: In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children. METHODS: We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation. RESULTS: Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases. CONCLUSIONS: This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction after periacetabular tumor resection with Lumic® endoprosthesis: What are the midterm results?

INTRODUCTION: This study aimed to analyze the midterm outcomes of LUMiC® endoprosthetic reconstruction following periacetabular resection of primary bone sarcomas and carcinoma metastases. PATIENTS AND METHODS: We retrospectively reviewed the charts of 21 patients (11 male [52.3%], 10 female [47.6%]; mean age 47 ± 16 years) for whom a LUMiC® endoprosthesis (Implantcast) was used to reconstruct a periacetabular defect after internal hemipelvectomy. The tumor was pathologically diagnosed as Ewing's sarcoma in six (28.5%), chondrosarcoma in 10 (47.6%), and bone metastasis from carcinoma in five (23.8%) patients. RESULTS: The median follow-up of patients was 57.8 months (95% confidence interval: 51.9-63.7). The implant survival rate at 1, 2, and 5 years were 95.2%, 85.7%, and 80.9%, respectively. The overall complication rate was 33.3% (n = 7). Four (19%) complications resulted in reconstruction failure. Total reoperation rate was 28.5% (n = 6). The complications were soft tissue failure/dislocation in two patients, aseptic loosening in one, infection in two, and local recurrence in two. At the time of study, seven patients were alive with no evidence of disease, seven were alive with disease, and seven died of disease. The 5-year overall survival rate and local recurrence-free survival rates were 67% and 76%, respectively. The median Musculoskeletal Tumor Society score at final follow-up was 70% (range: 50%-86.6%). CONCLUSION: We conclude that LUMiC® endoprosthesis provides good functional outcomes and a durable reconstruct. Even though this reconstruction method presents some complications, it provides a stable pelvis in the management of periacetabular malignant tumors.

Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series.

OBJECTIVE: The aim of this study was to present the mid-term functional outcomes and recurrence rate in patients with giant cell tumor of bone (GCTB) treated by intralesional extended curettage, electrocauterization, and polymethylmethacrylate (PMMA) cementation. METHODS: In this retrospective observational study, 79 consecutive patients (41 females, 38 males; mean age=39 years; age range=19-62 years) who were diagnosed and treated for GCTB between 2005 and 2017 were identified from hospital medical records. All patients were treated by intralesional extended curettage using high-speed burr, electrocauterization of the cavity, and filling the defect with PMMA. No additional local adjuvants were used. The mean follow-up period was 47 months (range=24-96). The tumors were graded according to the radiological classification system described by Campanacci. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS) preoperatively, one year postoperatively, and at the final follow-up. Postoperative complications and recurrence rates were recorded. RESULTS: Twenty-nine tumors were located in the distal femur, 23 in the proximal tibia, nine in the distal radius, five in the proximal humerus, five in the pelvis, three in the proximal fibula, two in the distal ulna, two in the distal tibia, and one in the second metatarsal. According to Campanacci classification, 37 tumors were grade III, 32 grade II, and 10 grade I. The mean MSTS score was 46.1% (range 40.2 to 71.4%) preoperatively, 91.7% (range 73.3% to 100%) one year postoperatively, and 86.3 % (range 66.2% to 96,1%) at the final follow-up. The overall complication rate was 7.6%; which included local tumor recurrence in four patients, superficial wound infection in one, and deep wound infection in another. The recurrence rate was 5.1% (4 patients). Recurrent tumors were located at the distal femur in three patients and proximal tibia in one. CONCLUSION: With satisfactory functional results and low recurrence rates at the mid-term follow-up, GCTB can be treated effectively with intralesional extended curettage, electrocauterization, and PMMA cementation. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Evaluation of factors affecting survival rate in primary bone sarcomas with extremity and pelvis involvement.

OBJECTIVE: This study is an evaluation of the overall survival rate and factors affecting survival in patients with osteosarcoma, chondrosarcoma, or Ewing's sarcoma. This study aimed to determine the effect of factors related to the preoperative period, patient, tumor, treatment, and postoperative period on survival. METHODS: A total of 114 patients (64 male and 50 female) with osteosarcoma, chondrosarcoma, or Ewing's sarcoma treated between 2005 and 2013 were included in this study. All the patients received standard treatment and were followed up regularly. In all, 44 cases of (conventional and telangiectatic) osteosarcoma, 30 cases of Ewing's sarcoma, and 40 cases of high-grade chondrosarcoma were identified using the Bone and Soft Tissue Tumor Registry. Gender, age, tumor size and localization, pathological fractures, histopathological type, grade, surgical treatment, adjuvant treatments, relapse of the disease, and postoperative complication data were obtained from follow-up forms. The learning curve of institutional expertise was also evaluated. The patient survival rate was calculated using the Kaplan-Meier method, and log-rank statistical methods were used to compare survival rates. RESULTS: The mean length of survival of the patients was 72 months. There was a 56% 5-year survival rate, and the event-free survival rate was 53%. The survival of patients with Ewing's sarcoma whose prodromal period was less than 12 weeks was significantly higher than that of the other groups (p=0.031). The survival of patients with tumor size greater than 150 cc, with local recurrence and distant metastases was low for all groups. Survival rates were significantly lower in osteosarcoma and Ewing's sarcoma patients with stage III tumor or metastasis at diagnosis. The survival of patients with osteosarcoma diagnosed between 2010 and 2013 was significantly higher than that of the earlier group (p=0.02). CONCLUSION: Decreasing the prodromal period (early diagnosis) can improve survival by preventing the local and systemic spread of the tumor. Increase in the surgical experience is likely to have a positive effect on survival rates, especially for patients with osteosarcoma. The relapse of the disease is a poor prognostic factor for survival despite aggressive surgery and adjuvant therapies. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Long-term Follow-up of Eosinophilic Granulomas of the Axial and Appendicular Skeleton Managed With Biopsy Alone.

BACKGROUND: This study aimed to evaluate the long-term clinical and radiologic follow-up results of eosinophilic granulomas (EGs) of the axial and appendicular skeleton managed with biopsy alone. METHODS: Fifty-five patients with unifocal osseous EGs of the axial and appendicular skeleton were followed after biopsy. Patients were divided into 2 groups on the basis of localization of the lesions. In group 1, there were 32 (58.2%) children with extremity long bone involvement: femur, tibia, humerus, ulna, and radius. Group 2 included 23 (41.8%) patients with lesions located in other appendicular and axial skeleton bones: pelvis, scapula, clavicle, lumbar, and thoracic vertebrae. After confirming the diagnosis by a closed biopsy, no further surgical intervention was performed. Clinical recovery included regression of the localized symptoms, mainly pain resolution. Functional improvement was assessed by Musculoskeletal Tumor Society (MSTS) scoring. Radiologic healing was defined as ossification of the entire lesion with cortical thickening in long and flat bones, and restoration of vertebral body height in the spine. Complications, including local recurrence, were determined. RESULTS: The patients comprised 28 boys and 27 girls with an average age of 9.2 years (range, 3 to 16 y). The average follow-up was 76 months (range, 28 to 132 mo). The median time from biopsy to clinical recovery was 17 days [95% confidence interval (CI), 13.3-20.6] and 36 days (95% Cl, 32.8-39.1) in group 1 and group 2, respectively. MSTS scores increased progressively till the end of 12 months in both groups. The median time from biopsy to radiologic healing was 16 months (95% CI, 11.5-20.4) and 42 months (95% Cl, 39.3-44.6) in group 1 and group 2, respectively. Both clinical recovery (P=0.021) and radiologic healing (P=0.009) were significantly faster in group 1 compared with group 2. No major complication was seen after biopsy. All lesions regressed without a local recurrence. CONCLUSIONS: Unifocal osseous EGs have spontaneous healing potential and confirming the diagnosis by biopsy is enough to obtain good clinical and radiologic results without any additional surgical intervention. TYPE OF STUDY: This was a therapeutic study. LEVEL OF EVIDENCE: Level IV.

Factors affecting postmusculoskeletal tumour surgery wound problem treatment with negative pressure wound therapy.

The aim of the study is to investigate the risk factors identified in literature that have been associated with prolonged Negative Pressure Wound Therapy (NPWT). Our study included patients who developed local wound problems after bone or soft tissue sarcoma surgery with negative margin at our clinic between 2012 and 2018 and treated with NPWT. All patients were followed up of at least 6 months. Sex, albumin level, skin infiltration, type of wound problem, postoperative intensive care unit (ICU) requirement, and intraoperative blood loss were found to be influential factors on NPWT > 10 sessions. We conclude that treatment may be prolonged and the necessary precautions need to be taken in patients with an impaired preoperative nutritional condition, with intraoperative high amount of blood loss, and with long postoperative stays in the ICU as well as if the underlying cause for wound problem is an infection.

Minimal invasive intralesional excision of extremity-located osteoid osteomas in children.

In this retrospective study, we evaluated the efficiency of minimal invasive intralesional extended curettage in the treatment of osteoid osteomas of the extremities in children. Forty-seven children (29 males, 18 females; mean age 10.5 years; range 4-19 years) with osteoid osteoma of the extremities underwent minimal invasive intralesional extended curettage. The exact localization of the nidus was determined preoperatively by thin-section (1-1.5 mm) computed tomography scans, and complete excision of the nidus was performed using a modified burr-down technique. None of the procedures required bone grafting or internal fixation. The median follow-up duration was 59 months (range, 12-136 months). Histopathological confirmation of osteoid osteoma was achieved in all procedures. All patients experienced immediate and complete relief of lesional pain after surgery. Preoperative (a day before surgery) and postoperative (at the time of discharge) mean visual analogue scale scores, questioning the pain derived from osteoid osteoma, were 7.7±1.2 and 0.3±0.6, respectively, confirming complete removal of the nidus. Early motion of the involved extremities and mobilization of the patients were achieved within 2 days. The children resumed normal function within 3 weeks. Postoperative complication or recurrence was not encountered in any of the patients. Even though percutaneous radiofrequency thermoablation is accepted as the treatment of choice for extraspinal osteoid osteomas, this technique requires a regional reference institution. Minimal invasive intralesional extended curettage can be performed in conventional institutions, even those not specialized in bone tumor surgery, by orthopedic surgeons with high success and low morbidity rates, in addition to rapid functional recovery.

A treatment strategy for proximal femoral benign bone lesions in children and recommended surgical procedures: retrospective analysis of 62 patients.

PURPOSE: We aimed to develop a surgical treatment strategy for benign bone lesions of the proximal femur based upon retrospective review of our data in 62 children. METHODS: Sixty-two children [38 male, 24 female; median age 9 years (range 5-18 years)] with proximal femoral benign bone lesions were surgically treated between 2005 and 2013. Histopathological diagnoses were simple (31) or aneurysmal (27) bone cysts, and nonossifying fibromas (4). The pathological fracture rate was 77.4 %. Surgical treatment was determined due to four criteria, including patient's skeletal maturity, localization and initial diagnosis of lesion, and amount of bone loss in the femoral neck and lateral proximal femur. Surgical procedure consisted of biopsy, curettage, bone grafting, and internal fixation when required. The median follow-up was 45 months (range 25-89 months). RESULTS: Complete clinical recovery was achieved in 56 (90.3 %) patients between 4 and 8 months postoperatively; full weight-bearing and mobilization, without pain and limping, was possible. The median preoperative and postoperative last follow-up Musculoskeletal Tumor Society (MSTS) scores were 13.3 % (range 10-23.3 %) and 96.6 % (range 90-100 %), respectively (p < 0.0001). The pathological fractures were healed in 10 weeks on average (range 8-12 weeks). Fifty-seven (92 %) patients demonstrated complete or significant partial radiographic healing between 5 and 7 months that maintained throughout follow-up. Local recurrence was not observed, and only 1 (1.6 %) patient required reoperation for partial cyst healing. There were 5 (8 %) complications, 1 (1.6 %) of which required reoperation. CONCLUSIONS: This treatment strategy can provide good local control and excellent functional and radiological results in the management of benign bone lesions of the proximal femur in children.