Predicting medical complications in spine surgery: evaluation of a novel online risk calculator.

PURPOSE: The preoperative prediction of medical complications is essential to optimize perioperative management. SpineSage™ is a free of charge online calculator to predict medical complications in spine surgery. The current study utilizes it in patients undergoing spine surgery to assess whether the predicted risks would correlate with the actual complication rate in clinical practice. METHODS: A total of 273 consecutive patients who underwent spinal surgery were assessed. The risk of medical complications was predicted for each patient, and all medical complications were recorded within 30 days of surgery. Based on their predicted risk of complication, patients were divided into three risk groups (< 15, 15-30, > 30%). RESULTS: The predicted overall risk of medical complications was 14.7% and was comparable to the observed complication rate of 16.1%. The predicted risk for major medical complications (3.8%) was also similar to the observed complication rate (3.3%). Detailed analysis of the segmented risk groups suggests a close correlation between predicted and actual complication rates. Receiver operating characteristic analysis revealed an area under the curve of 0.71 (p < 0.001) for the prediction of overall medical complications and 0.85 (p < 0.001) for major complications. CONCLUSIONS: The online risk calculator predicted both overall and major medical complications. The tool can assist in preoperative planning and counseling of patients. These slides can be retrieved under Electronic Supplementary Material.

What Sport Activity Levels Are Achieved in Patients After Resection and Endoprosthetic Reconstruction for a Proximal Femur Bone Sarcoma?

BACKGROUND: Limited information is available about sports activities of survivors after resection and reconstruction of primary malignant bone tumors with megaprostheses. Because patients often ask what activities are possible after treatment, objective knowledge about sports activities is needed to help assess the risks of sports participation and to help guide patients' expectations. QUESTIONS/PURPOSES: The aims of this study were to evaluate (1) what proportion of patients with proximal-femoral megaprostheses placed as part of tumor reconstructions can perform sports; (2) what activity levels they achieved; and (3) whether sports activity levels are associated with an increased likelihood of revision. METHODS: This retrospective study considered all 27 living patients in our institutional tumor registry with enduring proximal-femoral reconstructions performed more than 5 years ago who were between the ages of 11 and 49 years at the time of the reconstruction; seven were lost to followup and one was excluded because of paraplegia as a result of a car accident and another because of senile dementia; another two were excluded from statistics because of growing prostheses and skeletal immaturity at the time of followup, leaving 16 (11 male, five female) for analysis. Their mean age was 26 ± 12 years (range, 11-49 years) at surgery, and the mean followup was 18 ± 7 years (range, 5-27 years). Types of sports, frequency per week, duration of each sports session as well as the UCLA and modified Weighted Activity Score were assessed retrospectively by an independent assessor a median of 18 years (range, 5.3-27 years) after surgery. RESULTS: Patients recalled that preoperatively 14 were practicing sports 5 (± 4) hours/week. At followup, 11 of the patients were practicing one or more sports activities 2 (± 3) hours/week on a regular basis. The preoperative UCLA and modified Weighted Activity Score levels of 9 and 6 fell to levels of 6 (p = 0.005) and 3 (p = 0.025), respectively, at followup. With the numbers of patients available for study, we could not determine that prosthetic failures were associated with sport activity levels. CONCLUSIONS: Patients who survive primary malignant bone tumors in the proximal femur reconstructed by megaprostheses are able to perform some sports activities. The estimates of activity levels made in this study probably are best-case estimates, given that some patients were lost to followup; patients unaccounted for might not be doing as well as those represented here. Also, the degree to which sports participation influences implant durability remains, for the most part, unanswered; studies with more patients and longer followup will be needed to determine to what degree prosthesis survivorship relates to sporting activity levels. Most patients perform low-impact sports and at a lower level than they had preoperatively. Because this is a preliminary study of a select group of patients, further information is necessary to weight the benefits of higher sports activity levels against potential risks. If this can be confirmed in a larger number of patients, the information may guide surgeons in their discussion with patients preoperatively and give them some objective assessment of what to expect regarding sports activities. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Computer navigation-assisted surgery for musculoskeletal tumors: a closer look into the learning curve.

BACKGROUND: Computer navigation-assisted surgery for musculoskeletal tumors has shown to reduce the risk of intra-lesional margins in resection. Experiences with this method are still limited to smaller case series. METHOD: We reviewed our first experiences in 24 patients in whom computer navigation-assisted surgery had been performed. In 7 of these patients (6 male and 1 female), this has influenced the surgical treatment plan and navigation was used for both tumor resection and reconstruction. Three of the patients suffered from a chondrosarcoma, 2 from an osteosarcoma, 1 from a fibrosarcoma and 1 from an Ewing's sarcoma. Tumors were localized in the femur (n = 2), the tibia (n = 1), the sacrum (n = 1), the humerus (n = 1), the ilium (n = 1) and in the gluteal region (n = 1). RESULTS: The mean registration error was 0.9 mm. No intra-operative complications occurred. Two postoperative complications were observed which required revision surgery. Except for one marginal resection, all tumors were excised with wide margins. One patient suffered from a local recurrence, and one patient died of disease after distant metastatic dissemination. CONCLUSION: Computer navigation-assisted surgery represents a safe and helpful tool for the resection of musculoskeletal tumors and may influence surgical treatment plans in selected cases to provide more limited resections. Surgeons should be aware of risks considering biomechanical and oncological consequences in doing so. Further investigations and the evaluation of newer techniques (e.g., computed tomography-guided navigation) are needed to assess long-term outcomes of computer navigation assistance in musculoskeletal tumor surgery.

C-reactive protein as a prognostic factor in patients with chordoma of lumbar spine and sacrum--a single center pilot study.

STUDY DESIGN: This is a retrospective, diagnostic study, level IV. BACKGROUND: It appears to be necessary to identify prognostic markers for individual risk estimation for progression and survival in patients with chordoma, a rare disease. Are pre-operative serum levels of C-reactive protein (CRP) associated with disease progression and survival? METHODS: Survival rates of 24 patients (18 males, 6 females) (mean age 67 years (SD ± 16; range 20-85 years); minimum follow-up 2 years, mean follow-up 5 years (SD ± 5; range 2-19 years)) with chordoma of the lower spine and sacrum were assessed with a focus on pre-operative CRP levels. RESULTS: The survival rate of patients with pre-operative CRP level of >1.0 mg/dl was lower than that of patients with a CRP level <1.0 mg/dl (p = 0.01). The estimated 10-year survival of patients with pre-operative CRP values <1.0 and >1.0 mg/dl was 76 and 25%, respectively. CRP remained as an independent survival factor (p = 0.025; CI 95% 1.0-2.6) in multivariable analysis. CONCLUSIONS: Pre-operative CRP levels appear to be a biomarker for disease-specific survival in patients with chordoma of the lumbar spine and sacrum. A validation of our finding with larger cohorts and integration of putative risk factor would further elucidate CRP a surrogate for tumor progression.

Does competing risk analysis give useful information about endoprosthetic survival in extremity osteosarcoma?

BACKGROUND: Conventional survival analysis for endoprosthetic complications does not consider competing events adequately. Patients who die of their disease are no longer at risk for complications; therefore, death as a competing event may alter survivorship estimates in the orthopaedic-oncological setting. QUESTIONS/PURPOSES: This investigation aimed to compare (1) endoprosthetic survivorship after osteosarcoma by Kaplan-Meier analysis; and (2) by a competing risk model. METHODS: Between 1981 and 2009, we performed 247 modular endoprostheses for patients with extremity osteosarcoma; 73 patients had a followup of less than 2 years but all patients were included in statistical analysis. No patients were lost to followup for reasons other than death. Revision-free endoprosthetic survival until soft tissue failure (Type 1), aseptic loosening (Type 2), structural failure (Type 3), infection (Type 4), and local tumor progression (Type 5) was estimated according to a Kaplan-Meier analysis and a competing risk model. Sixty-four patients died throughout followup; the 5- and 10-year overall survival and metastasis-free survival were 72% and 70% and 70% and 69%, respectively. One hundred twenty-two patients (49%) had complications. RESULTS: Competing risk analysis consistently resulted in reduced estimates of the frequency of complications and reconstructive failures compared with Kaplan-Meier analysis. Cumulative risks for complication Types 1 to 5 at 10 years without/with death as a competing event revealed a risk of 19%/16% for Type 1, 26%/20% for Type 2, 51%/38% for Type 3, 23%/20% for Type 4, and 4%/3% for Type 5. CONCLUSIONS: A competing risk model reveals considerably reduced risks for every complication compared with Kaplan-Meier analysis when death is included as a competing event. Because it more realistically represents the risks of complications, competing risk models should be used to arrive at risk estimates for purposes of counseling patients about those risks associated with modular endoprosthetic reconstruction. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

What sports activity levels are achieved in patients with modular tumor endoprostheses of osteosarcoma about the knee?

BACKGROUND: Advances in multimodal treatment have improved survival of patients with nonmetastatic osteosarcoma. At the same time, implant design has improved the outcomes of limb salvage with modular endoprostheses. However, little is known about sports activity in long-term survivors with osteosarcoma. QUESTIONS/PURPOSES: We wanted to evaluate (1) sports activity levels in long-term survivors of osteosarcoma about the knee who received a modular tumor endoprosthesis; (2) to determine if activity level changed over time from initial reconstruction or (3) was predicted from sports activity level before diagnosis; and (4) if complications that occurred affected sports or contributed to prosthetic failures. METHODS: Between 1995 and 2005, we treated 120 patients for osteosarcoma about the knee with resection and modular endoprosthetic reconstruction; of those, 25 (21%) have died, six (5%) had an amputation, 39 (32%) did not speak German and so were ineligible, and 14 (12%) were either lost to followup or refused to participate, leaving 27 patients (14 females, 13 males; median age 19 years [range, 12-60 years); average followup 11 ± 4 years) (54% of the living, German-speaking cohort) for this analysis. Tumors were located in the distal femur (n = 16) and the proximal tibia (n = 11). Sports participation as well as the UCLA Activity Score and the modified Weighted Activity Score were assessed retrospectively. Moreover, postoperative complications were evaluated. RESULTS: Before the diagnosis of osteosarcoma and 1, 3, and 5 years and at the latest followup, respectively, after their reconstructions, 24 (89%), nine (33%), 20 (74%), and 24 patients (89%) were able to perform sports activities. There was a reduction in high-impact activities. Those patients with followup longer than 5 years had no changes in sports activity at their latest followup. Patients who had higher levels of sports activity levels before surgery generally had higher levels of activity at last followup (UCLA Activity Score: r = 0.62, p < 0.0005; modified Weighted Activity Score r = 0.49, p < 0.01). Fourteen patients (51%) underwent revision surgery. With the numbers available, complications had no effect on sports activity. No sports activity-related complications were found. CONCLUSIONS: Some long-term survivors of osteosarcoma can achieve high levels of sports activity. Preoperative activity levels seem to influence the postoperative activity levels. This information is important to give realistic expectations for long-term survivors of osteosarcoma of the knee. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Tumour response of osteosarcoma to neoadjuvant chemotherapy evaluated by magnetic resonance imaging as prognostic factor for outcome.

PURPOSE: This study evaluated the feasibility of computed magnetic resonance imaging (MRI) volumetry in conventional osteosarcomas. Secondly, we investigated whether computed volumetry provides new prognostic indicators for histological response of osteosarcomas after neoadjuvant chemotherapy. METHODS: In a retrospective cohort study, data from the Vienna Bone Tumour Registry was used. MR images from 14 patients (male:female = 1.8, mean age 19 years) were analysed prior to and after neoadjuvant chemotherapy according to current therapy regimens. Histological response to chemotherapy was graded according to the Salzer-Kuntschik classification. Computed volumetry was performed for the intraosseous part, as well as the soft-tissue component and the tumour as a whole. RESULTS: In a setting of appropriate radiological equipment, the method has been considered to be well implementable into clinical routine. The mean tumour volume prior to chemotherapy was 321 (±351) ml. In good responders (n = 6), overall tumour volume decreased by 47% (p = 0.345), whereas poor responders (n = 8) showed a 19% decrease (p = 0.128). Neoadjuvant multidrug therapy remarkably changed the tumour composition. This is seen in a decrease of the mean ratio of soft-tissue to intraosseous tumour volume from 8.67 in poor responders and 1.15 in good responders to 1.26 and 0.45 (p = 0.065), respectively. Interestingly, the bony compartment of good responders showed a volume increase during neoadjuvant chemotherapy (p = 0.073). However, we did not find prognostic markers for histological tumour response to pre-operative chemotherapy. CONCLUSIONS: Separated volumetry of tumour segments revealed interesting insights into therapy-induced growth patterns. If verified in a larger study population, these results should be taken into account when planning ablative surgery.

Incidence and management of hip dislocation in tumour patients with a modular prosthesis of the proximal femur.

PURPOSE: Little data is available about the incidence and especially the management of hip dislocation following the implantation of modular tumor prostheses of the proximal femur. In this retrospective single-centre study we assessed the incidence of hip dislocation following implantation of a proximal femoral modular prosthesis as well as the success of the subsequent surgical or non-surgical treatment in tumor patients. METHODS: Between 1982 and 2008, 166 tumor patients received a modular prosthesis of the proximal femur at our institution. The average age at the time of surgery was 50 ± 20 years (range, six to 84 years). An additional pelvic reconstruction was done in 14 patients. An artificial band for soft tissue reconstruction of the hip was used in 19 patients. The average time of follow-up was 46 ± 64 months (range, one to 277 months). RESULTS: The overall dislocation rate after proximal femoral replacement was 13% after a mean time of seven ± eight months (range, 0.3-33 months) after surgery. Between 1982 and 1986 the dislocation rate was 33% and declined to 9% in subsequent years (1987-2008). Patients who had received an additional pelvic reconstruction had a three fold higher dislocation rate (p <0.05). Patients with closed reduction had a 58% (eight of 12) re-dislocation rate compared to 11% (one of nine) for open reduction (p = 0.0357). CONCLUSIONS: Dislocation of a modular prosthesis of the proximal femur is a common complication, especially in cases with additional pelvic resection with extensive bone and soft-tissue defects. Open surgical management may be more effective in preventing re-dislocation than closed reduction and bracing alone.

Primary malignant tumours of the scapula--a review of 29 cases.

PURPOSE: Primary malignant bone tumours of the scapula are very rare. Apart from limited small series and some case reports, international literature on flat bone sarcoma is exiguous and not much is known about the oncological outcome. METHODS: A retrospective analysis of 29 patients diagnosed with a primary malignant tumour of the scapula was performed. The mean age was 40 years. The average time of follow-up was 60 months. Diagnoses included chondrosarcoma in 11 patients, Ewing's sarcoma/PNET in six, osteosarcoma in three, and others in nine. RESULTS: Five patients (19%) had no surgery. Wide resection was performed in 18 patients (74%) and marginal and intralesional resection in three patients (13%) each. Fifteen patients underwent resection without bony reconstruction, seven patients underwent a Tikhoff-Linberg procedure, and two patients received a custom-made scapula prosthesis. Six patients were diagnosed with metastasis after a mean time of nine months after surgery, while three patients suffered local recurrence at an average of six months after surgery. Disease-specific survival was 70% at one year and 47% at five years. The mean MSTS score was 69% and was highest for patients with scapular prosthesis. CONCLUSION: The overall prognosis of primary malignant bone tumours of the scapula remains to be inferior compared to extremity sarcoma. Endoprosthetic reconstruction, however, shows promising functional results even in cases of total scapulectomy.

Patients' perception of changes and consequences after tumor resection : A qualitative study in Austrian patients with musculoskeletal malignancies.

OBJECTIVE: The aim of this study was to investigate the effects and consequences of surgical treatment of patients with musculoskeletal malignancies on everyday life. METHODS: A modified form of grounded theory was used for data collection and analysis. Data collection was systematic and analyzed simultaneously and 16 interviews were conducted: 2 narrative, 11 guided and 3 expert interviews (surgeon, physical therapist, support group). Data collection and analysis alternated until no new codes could be found. Once theoretical saturation was achieved, the main category was formed and described using the literature. RESULTS: The main category results from the combination of all categories and leads to the core category. In the center is the affected person and in the immediate environment are the patient's relatives/partners. In the next instance the primary care physician is necessary to establish a sense of normalcy. This depends on the individuality of the person and the restored possibilities of movement. CONCLUSION: Based on the results, the necessity of implementing psychosocial care involving the social environment is shown. The importance of relatives/partners for recovery is emphasized. Furthermore, the communication between the specialists and family physicians should be simplified.

Surgical treatment of the haemophilic pseudotumour: a single centre experience.

PURPOSE: Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour. METHODS: We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department. RESULTS: The mean age at surgery was 45.9 (range, 40-61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4-24) years, normal healing with no recurrence was observed. CONCLUSIONS: The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.

Results in the surgical treatment of aneurysmal bone cysts - A retrospective data analysis.

BACKGROUND: Aneurysmal bone cysts (ABC) are benign tumors mostly occurring in children and young adults. Different open and minimal invasive surgical approaches have been proposed for the treatment of ABCs and yet no consensus is defined to date. The aim of this study was to retrospectively review data of a large single center series of ABCs with patients treated by open curettage with or without filling of the cavity or en-bloc resection. Questions/purposes We asked: (1) What was the local recurrence rate of ABC after surgical treatment at our institution? (2) What were positive or negative predictors for local recurrence? (3) Was there a benefit from adjuvant burring, phenolization or filling, respectively? (4) Where there changes in recurrence free survival in different time periods of primary surgery? METHODS: By retrospective data analysis of the Vienna Bone and Soft Tissue Tumor Registry, 123 patients surgically treated for primary aneurysmal bone cysts were identified. After exclusion of 33 patients (27%) due to a postoperative follow up below one year, 90 patients who were treated for primary ABCs between 1986 and 2009 were evaluated. These included 50 males and 40 females with a mean age of 16 years (SD 10 years; range: 2 to 51 years). The mean follow-up was 99 months. (SD 72 months, range: 13 to 329 months) RESULTS: Curettage was performed in 84 patients, while 45 patients received adjuvant phenolization. Local recurrence occurred in 28 patients after a mean time of 16 months, with a corresponding local recurrence free survival (RFS) of 83% after one year, 77% after 2 years and 66% after 5 years. ABCs located in hands and feet (p=0.044) showed a superior RFS, while younger patients (p=0.001) displayed an inferior RFS. Regarding adjuvant surgical techniques, mechanical cavity burring (p=0.004) and filling with autologous cancellous bone graft (p=0.024) showed protective effects on RFS. Patients treated between 1986 and 1999 (n=47) had a higher RFS than patients treated between 2000 and 2009 (n=43, p=0.011), as surgeons and surgical indications changed over time. CONCLUSION: Although curettage, burring, phenolization and reconstruction with bone grafts came with a relatively high risk of local recurrence, open surgery is still justified in aggressively growing ABCs of critical localizations. LEVEL OF EVIDENCE: IV; therapeutic study.

Treatment and outcome of parosteal osteosarcoma: biological versus endoprosthetic reconstruction.

BACKGROUND AND OBJECTIVES: Due to its good prognosis despite local recurrence, more and less invasive methods for surgical treatment of parosteal osteosarcoma (POS) have been described. Aim of this retrospective single-center study was to investigate differences in outcome after biological and prosthetic reconstruction. METHODS: A total of 28 patients with POS, 14 females, 14 males, mean age of 27 years (median, 24 years; range 15-59 years), mean follow-up of 130 months (median, 104 months; range, 9-383 months), underwent wide tumor resection and prosthetic reconstruction (12 patients, 42.9%), less extensive resection and biological reconstruction (11 patients, 39.3%), rotationplasty (three patients, 10.7%), or amputation (two patients, 7.1%). RESULTS: There were two cases of local recurrence in patients with biological reconstruction and three cases of pulmonary metastases, leading to death of disease in two. Ten-year disease-specific survival was 91.1%. There was no significant difference between prosthetic and biological reconstruction in terms of local recurrence, metastasis, or functional outcome (mean MSTS Score, 85%). There were significantly more revisions in prosthetic reconstructions. CONCLUSIONS: Given that the resection of the tumor has clear margins, both prosthetic and biological reconstruction show similar results; prostheses allow better local tumor control, however, require more revisions over time.

Management of septic complications following modular endoprosthetic reconstruction of the proximal femur.

In a retrospective single-centre study 170 consecutive patients were included who received a Kotz modular prosthesis after resection of bone tumours of the proximal femur to evaluate the management of prosthetic infection. Infection occurred in 12 of 166 patients available for follow-up (six males; six females; mean age, 47 years; range, ten to 75 years) after a mean of 39 months (range, one to 166 months; infection rate, 7.2%). Mean follow-up was 54 months (range, four to 200 months). One patient died of septic shock. Two patients were treated by wound revision only. Treatment of infection in the remaining patients was one-stage revision in eight and hip disarticulation in one. Infection control by one-stage revision was achieved in five of eight patients; re-infection occurred in three patients and was successfully treated by further revision in all of them. The overall success rate for controlling infection was 83.3%.

Pre-operative serum C-reactive protein as independent prognostic factor for survival but not infection in patients with high-grade osteosarcoma.

PURPOSE: The purpose of this study was to investigate (a) whether pre-operative serum CRP is a predictor of survival in patients with high-grade osteosarcoma, (b) whether post-operative infection is a predictor of survival in these patients and (c) whether CRP is a predictor of post-operative infection, and especially deep prosthetic infection. METHODS: In this retrospective single-centre study, pre-operative serum CRP levels in 79 patients (37 females, 42 males; average age, 18 years; mean follow-up, 46 months) undergoing resection of an osteosarcoma were correlated with clinical data and survival. RESULTS: The mean pre-operative serum CRP level of all 79 patients was 0.53 mg/dl (SD, 1.27 mg/dl). Patients dying of their underlying disease had significantly higher CRP levels compared to patients surviving throughout the follow-up period (1.09 mg/dl ± 2.02 mg/dl versus 0.32 mg/dl ± 0.75 mg/dl, respectively; p = 0.015). CRP levels were significantly correlated with survival (Pearson's correlation coefficient = -0.25; p = 0.026) and histological subtype (Pearson's correlation coefficient = -0.42; p < 0.001), but not with sex, age, histological response, tumour size or metastatic disease. In uni- and multivariate survival analysis, age, response to chemotherapy and serum CRP were associated with disease-specific survival. Patients with a CRP level over 1 mg/dl had a significantly lower disease-specific five-year survival of 36.7% compared to 73.8% in patients with normal CRP values (p = 0.020). Infection was not correlated with disease-specific survival. Pre-operative serum CRP levels were not correlated with post-operative infection or deep prosthetic infection. CONCLUSIONS: Pre-operative serum CRP seems to be an independent predictor of survival in patients with high-grade osteosarcoma. Further studies are needed to confirm these results on a large-scale basis.

Low-grade chondrosarcoma of bone: experiences from the Vienna Bone and Soft Tissue Tumour Registry.

In a retrospective single-centre study, 70 low-grade chondrosarcoma (LCS) (31 female/39 male patients with a mean age of 40 years) were reviewed to evaluate surgical management. The mean overall follow-up was 81 months (median: 73 months, range: 6-317 months). Seventeen lesions (24.3%) in the trunk and 53 (75.7%) in the extremities were treated by curettage (48.6%) or resection (51.5%). Local recurrence occurred in eight patients (11.4%) 18 months postoperatively (median: 18 months, range: 0-41 months). Recurrence-free survival was significantly better for patients with extremity lesions compared to truncal lesions, but was not affected by resection margin. The anatomical site "trunk" and an "intralesional" resection margin had a significant independent prognostic influence in multivariate analysis. Curettage with local adjuvants is a viable treatment option for most extremity LCS. In truncal LCS wide resection is recommended despite a potentially higher complication rate.

Diagnostic accuracy of ultrasound-guided core needle biopsy versus incisional biopsy in soft tissue sarcoma: an institutional experience.

Core needle biopsy (CNB) is gaining in importance due to its advantages in the matter of patient morbidity, time and cost. Nevertheless, controversies still exist regarding the biopsy technique of choice for the accurate diagnosis of soft tissue sarcoma (STS). This retrospective cohort study compared the diagnostic performance between ultrasound-guided CNB and incisional biopsy (IB), both performed by orthopedic surgeons. The aims of the study were to answer the following questions: (1) Is ultrasound-guided CNB a highly reliable modality for diagnosing STSs? (2) Is CNB equally useful to IB for identifying histologic subtype? (3) Had patients who underwent CNB a reduced risk of complications? One-hundred and fifty-three patients who underwent resection of soft tissue sarcoma were classified into two groups according to biopsy technique prior to surgery; CNB group (n = 95) and IB group (n = 58). The final surgical specimens were in 40 patients liposarcoma (myxoid, pleomorphic and dedifferentiated), 39 undifferentiated pleomorphic sarcoma (UPS), 33 myxofibrosarcoma, 10 synovial sarcoma, 10 leiomyosarcoma and in the remaining 21 patients different soft tissue sarcoma entities. Sarcoma location of 71 patients was in the thigh, 19 in the lower leg, 22 in the upper arm and shoulder area; 10 in the knee and gluteal region, 9 in the thoracic region, the residual 12 in other body areas. Malignancy was correctly diagnosed in 87% (83 of 95) for the CNB group and 93% (54/58) for the IB group. Correct identification rate of histologic subtype was 80% (76 of 95) in the CNB group and 83% (48 of 58) in the IB group. There were no significant differences in the correct diagnosis rates of malignancy and subtype between the two techniques. No complications were seen in the CNB group, whereas 2 patients in whom IB was performed developed pulmonary embolism and 1 patient surgical site infection. Ultrasound-guided CNB is highly accurate and not inferior to IB in diagnosing the dignity of lesions and histologic subtype in patients with suspected STSs.

What sports activity levels are achieved in long-term survivors with modular endoprosthetic humerus reconstruction following primary bone sarcoma resection?

BACKGROUND: The aim of the study was to assess (1) sports activity, (2) sports involving the upper extremities, (3) functional outcome and (4) sports-related complications of long-term survivors of primary malignant bone tumors of the proximal humerus. METHODS: A total of 18 patients with an endoprosthetic reconstruction for primary malignant bone sarcoma of the proximal humerus (8 male, 10 female, mean age 19.9 ± 8.4 years, range 7.8-37.4 years) with an average follow-up of 18.1 ± 7.4 years (range 6.7-29.8 years) were included. The type of sport, frequency, duration of each sport session and the University of California, Los Angeles (UCLA) activity score were assessed before surgery, at 1 year, 3 years and at the latest follow-up. Functional outcome was assessed by the Toronto extremity salvage score (TESS). RESULTS: The mean UCLA activity score decreased from 8.0 (±1.3, range 5-9) preoperative to 4.2 (±1.7, range 3-8) at 1­year follow-up (p < 0.05). After 3 years it increased to 5.1 (±1.75, range 3-8) and further to 7 (±1.8, range 4-9) at the last follow-up. The mean postoperative TESS was 80.8 (±6.4, range 75.7-91.4) at the latest follow-up. Patients who were initially more active without reconstruction including a synthetic mesh were more likely to develop soft tissue complications accompanied by proximal endoprothesis migration. CONCLUSION: Patients with a modular endoprosthetic reconstruction of the humerus following primary bone sarcoma resume participation in sports. Regarding the low incidence of periprosthetic infections, utilization of a synthetic mesh for reconstruction to prevent soft tissue complications in active patients should be considered.

The impact of re-excision of inadequately resected soft tissue sarcomas on surgical therapy, results, and prognosis: A single institution experience with 682 patients.

BACKGROUND AND OBJECTIVES: Due to their rare incidence soft tissue sarcomas (STS) are often resected without clear margins. The aim of this study was to investigate the impact of re-excision of STS on survival. METHODS: Out of 752 patients with STS (406 men and 346 women, average age 51 years), 310 patients were referred after an inadequate resection, 442 patients presented for primary treatment. Six hundred eighty-two patients were compared over a mean period of 65 months (median, 36 months) according to the treatment groups regarding their survival, clinical, surgical, and pathological data. RESULTS: The 5-year survival rate of 621 surgically treated patients was 53.9%. There was a continuous improvement in survival during the whole treatment period in the respective decades. The overall survival rate in both groups was not significantly different regardless of low- or high-grade malignancies. Patients with a re-resection did not have a higher rate of local recurrences; patients with a primary resection had a worse prognosis regarding metastases. A re-resection within 12 weeks indicated a better prognosis. CONCLUSIONS: An inadequate excision of a STS does not cogently mean deterioration of overall survival but necessitates an ample and quick re-resection.