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BACKGROUND: Vacuum-assisted closure (VAC) temporization is a promising technique to achieve local control in aggressive soft tissue sarcomas. Despite its previously reported efficacy, adoption of VAC temporization remains limited, primarily due to the scarce literature on patient-reported outcomes (PROs) supporting its efficacy. This study compared the postoperative PROs after VAC temporization or single-stage (SS) excision and reconstruction for patients undergoing surgical resection for myxofibrosarcoma management. METHODS: A retrospective analysis of myxofibrosarcoma patients who underwent surgical resections at our institution from 2016 to 2022 was performed. Postoperative PROs collected prospectively for those treated with VAC temporization or SS excision/reconstruction were compared using a visual analog scale (VAS) for pain and three Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires: Global Health Short-Form Mental (SF Mental), Global Health Short-Form Physical (SF Physical), and Physical Function Short-Form 10a (SF 10a). Absolute and differential (postoperative minus preoperative) scores at the 1-month, 3-month, 6-month, 1-year, and 2-year time points were compared. RESULTS: The analysis included 79 patients (47 treated with VAC temporization and 32 treated with SS excision/reconstruction). All outcomes were similar between the groups except for physical function 1 year after surgery, in which the differential PROMIS SF 10a scores were higher in the SS group (p = 0.001). All the remaining absolute and differential PROMIS and VAS pain scores were similar between the groups at all time points. Postoperative complications did not differ between the groups. CONCLUSION: The PROs for physical and mental health, physical function, and pain were similar between the myxofibrosarcoma patients who had VAC temporization and those who had SS excision/reconstruction after surgical resection.
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Fibrossarcoma , Histiocitoma Fibroso Maligno , Tratamento de Ferimentos com Pressão Negativa , Adulto , Humanos , Tratamento de Ferimentos com Pressão Negativa/métodos , Estudos Retrospectivos , Complicações Pós-Operatórias , Fibrossarcoma/cirurgia , Medidas de Resultados Relatados pelo Paciente , Dor , Resultado do TratamentoRESUMO
INTRODUCTION: Upper extremity (UE) desmoid tumors are locally aggressive neoplasms with high recurrence rates. Our study sought to analyze the demographics and treatment strategies of UE desmoid tumors and identify risk factors for recurrence. MATERIALS AND METHODS: A retrospective review of 52 patients with histologically confirmed UE desmoid tumors treated at our institution between 1990 and 2015 was conducted. Survival was assessed using the Kaplan-Meier method and the Cox proportional hazards model was used for risk factor analysis. RESULTS: For the entire cohort, median age was 40 (29-47) years, 75% were female, and 48% had local recurrence. The median tumor size was 45 (15-111) cm3 on imaging. Twenty-two patients had a previous resection. The most common treatments were surgery alone (50%) and surgery with adjuvant radiotherapy (21%). Tumor size ≥5 cm and tumor volume ≥40 cm3 on imaging were associated with increased recurrence (p = 0.006 and p = 0.005, respectively). Age and sex were not associated with local recurrence. Patients with a tumor size ≥5 cm were 2.6 times more likely to present with recurrence. At the 10-year mark, a lower local recurrence-free survival was seen in patients with tumors ≥5 cm (72.2% vs. 36.3%, p = 0.042) or ≥40 cm3 (67.2% vs. 32.7%, p = 0.034). CONCLUSION: In our study, only tumor dimensions appeared to modify recurrence risk.
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Fibromatose Agressiva , Humanos , Feminino , Adulto , Masculino , Fibromatose Agressiva/cirurgia , Fibromatose Agressiva/patologia , Extremidade Superior/patologia , Radioterapia Adjuvante/efeitos adversos , Terapia Combinada , Fatores de Risco , Estudos Retrospectivos , Recidiva Local de Neoplasia/patologiaRESUMO
BACKGROUND: Vacuum-assisted closure (VAC) temporization is a technique associated with high local control rates used in myxofibrosarcoma. We sought to compare the costs and postoperative outcomes of VAC temporization and single-stage (SS) excision/reconstruction. METHODS: We conducted a retrospective analysis of patients with myxofibrosarcoma surgically treated at our institution between 2000 and 2022. Variables of interest included total, direct, and indirect costs for initial episode of care, 90 days and 1 year after initial admission, and postoperative outcomes. Costs were compared between the VAC temporization and SS groups. RESULTS: After matching, 13 patients in the SS group and 23 in the VAC group were analyzed. We found no difference in median and mean total inpatient costs, between the VAC temporization and SS group. While total 90-day and 1-year costs were higher in the VAC group compared to the SS group, mean costs were similar. There were no differences in postoperative complications between groups. A subanalysis of the entire cohort (n = 139) revealed lower local recurrence and overall death rates in the VAC temporization group. CONCLUSION: VAC temporization had similar inpatient costs and postoperative outcomes to SS excision/reconstruction. While median 90-day and 1-year costs were higher in the VAC group, mean costs did not differ.
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Tratamento de Ferimentos com Pressão Negativa , Pontuação de Propensão , Humanos , Masculino , Feminino , Estudos Retrospectivos , Tratamento de Ferimentos com Pressão Negativa/economia , Pessoa de Meia-Idade , Idoso , Sarcoma/cirurgia , Sarcoma/economia , Sarcoma/patologia , Custos e Análise de Custo , Seguimentos , Complicações Pós-Operatórias/economia , AdultoRESUMO
BACKGROUND AND OBJECTIVES: Undifferentiated pleomorphic sarcoma (UPS) is an aggressive type of soft tissue sarcoma (STS) with high rates of metastatic disease and local recurrence. We sought to identify risk factors for local recurrence, metastasis, and overall death, and assess their impact on overall survival (OS), local recurrence-free survival (LRFS), and metastasis-free survival (MFS). METHODS: A total of 386 cases of UPS treated at our institution from 1980 to 2020 were included. Cox proportional hazards regression was used to identifying risk factors for death, local recurrence, and/or metastasis. Using the Kaplan-Meier method, we assessed OS, LRFS, and MFS. RESULTS: Sixty-six (17%) and 121 (30%) patients with UPS developed local recurrence or metastasis, respectively. Lymph node (LN) involvement was present in 13.5% of patients. The most affected organ in patients with metastatic disease was the lungs (76.9%). Age ≥ 60 (hazard ratio [HR] = 2.42) and size ≥7 cm (HR = 1.52) were some of the significant risk factors for overall death. LN involvement was an important risk factor for both LR (HR = 2.79) and distant metastasis (HR = 5.73). CONCLUSIONS: UPS displays high rates of metastatic disease and local recurrence. Using a tumor size cutoff value of 7 cm yields superior prognostic value than the standard STS T-score thresholds. Lymphovascular invasion is an important risk factor for the development of metastasis.
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Histiocitoma Fibroso Maligno , Sarcoma , Humanos , Prognóstico , Atenção Terciária à Saúde , Histiocitoma Fibroso Maligno/patologia , Sarcoma/patologia , Modelos de Riscos Proporcionais , Recidiva Local de Neoplasia/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown. QUESTIONS/PURPOSES: (1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty? METHODS: A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive. RESULTS: The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50. CONCLUSION: The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Membros Artificiais , Neoplasias Ósseas , Masculino , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Tíbia , Estudos Retrospectivos , Recidiva Local de Neoplasia/patologia , Infecção Persistente , Resultado do Tratamento , Pé , Neoplasias Ósseas/patologiaAssuntos
Fibrossarcoma , Histiocitoma Fibroso Maligno , Adulto , Humanos , Cicatrização , Fibrossarcoma/cirurgiaRESUMO
BACKGROUND: Total humerus replacement (THR) is a reconstruction procedure performed after resection of massive humeral tumors. However, there is limited literature on the rates of failure and functional outcomes of this implant. Our study aimed to determine the main failure modes, implant survival, and postoperative functional outcomes of THR. METHODS: A comprehensive search of the PubMed and Embase databases was conducted. We registered our study on PROSPERO (448684) and used the Strengthening the Reporting of Observational Studies in Epidemiology checklist for quality assessment. The Henderson classification was used to assess endoprosthesis failure and the Musculoskeletal Tumor Society (MSTS) score for functional outcomes. Weighted means and standard deviations were calculated. RESULTS: Ten studies comprising 171 patients undergoing THR were finally included. The overall failure rate was 32.2%. Tumor progression (12.6%) and prosthetic infections (9.4%) were the most common failure modes, followed by soft-tissue failures (5.9%), aseptic loosening (3.5%), and structural failure (1.8%). Two-year, 5-year, and 10-year implant survival rates for the entire cohort were 86%, 81%, and 69.3%. Ten-year implant survival for primary THRs was 78.3%, compared with 38.6% for revision THRs (p = 0.049). The mean MSTS score at the last follow-up was 77%. Patients whose implants did not fail had a higher MSTS score (79.3%) than those with failed implants (71.4%) (p = 0.02). CONCLUSION: One-third of THR will fail, mostly due to tumor progression and prosthetic infection. Overall functional scores were acceptable, with MSTS scores displaying great hand and elbow function but limited shoulder function. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.
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Neoplasias Ósseas , Úmero , Humanos , Úmero/cirurgia , Neoplasias Ósseas/cirurgia , Resultado do Tratamento , Masculino , Procedimentos de Cirurgia Plástica/métodos , FemininoRESUMO
Myositis ossificans, a benign tumor composed of spindle cells and osteoblasts, can clinically and radiologically mimic osteosarcoma. While recognition and accurate diagnosis of myositis ossificans can be a challenge, this is critical as it may allow a conservative surgical approach to maximize functional outcomes. Herein, we present a patient with surface myositis ossificans confirmed genetically by the presence of COL1A1::USP6 gene fusion, along with a literature review. Due to the enhanced visualization of the bone matrix, computed tomography (CT) imaging may be a superior imaging modality to magnetic resonance (MR) imaging. Staged biopsies with samples obtained from the periphery and center of the lesions may allow pathologists to discern the zonal distribution histologically. Furthermore, immunohistochemistry fluorescence in situ hybridization and molecular testing can aid in the distinction of myositis ossificans from mimics. Because of their resemblance to other bone tumors, these cases of myositis ossificans highlight the importance of a multidisciplinary approach integrating clinical, radiologic, and pathologic analysis and involving serial imaging, sampling, and judicious use of ancillary immunohistochemical and molecular testing.
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Miosite Ossificante , Osteossarcoma , Humanos , Neoplasias Ósseas/patologia , Neoplasias Ósseas/diagnóstico , Neoplasias Ósseas/diagnóstico por imagem , Colágeno Tipo I/genética , Colágeno Tipo I/análise , Cadeia alfa 1 do Colágeno Tipo I , Diagnóstico Diferencial , Imuno-Histoquímica , Hibridização in Situ Fluorescente , Imageamento por Ressonância Magnética , Miosite Ossificante/diagnóstico , Miosite Ossificante/patologia , Miosite Ossificante/diagnóstico por imagem , Miosite Ossificante/genética , Osteossarcoma/diagnóstico , Osteossarcoma/patologia , Osteossarcoma/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ubiquitina TiolesteraseRESUMO
BACKGROUND: Stem fixation in reconstruction after resection of femoral tumors is debated. Cemented stems offer immediate stability but risk aseptic loosening, while press-fit stems allow bone ingrowth but risk stress shielding and subsidence. Our retrospective review aimed to determine implant failure rates and their associated factors, as well as the rates of infection, debridement, and mortality for both fixation groups (cemented or press-fit stems) used in patients undergoing resection of femoral tumor disease and subsequent arthroplasty. METHODS: We retrospectively studied 252 patients who underwent resection of femoral tumors and subsequent arthroplasty using cemented (n = 173; 69%) or press-fit (noncemented) (n = 79; 31%) stems between 1999 and 2020. Implant failure was the primary outcome, with secondary outcomes including rates of implant infection, debridement, and mortality. Multivariable regression was done to assess risk factors for implant failures. RESULTS: The study found implant failure rates of 11% and 18% for cemented stems and press-fit stems, respectively. Lower stem to diaphyseal ratios ( P = 0.024) and younger patients ( P = 0.008) were associated with a higher risk of implant failure in cemented stems. The infection rates were 14% and 10% for cemented and press-fit stems, respectively. Debridement rates were 16% and 13% for cemented and press-fit stems, respectively, while the 1-year mortality rate was 16% for cemented stems and 1.5% for press-fit stems. CONCLUSIONS: This study is the largest of its kind, providing patient characteristics and outcomes in both cemented and press-fit stems in the setting of reconstruction for femoral tumors. Both methods can be effective, with outcomes dependent on patient-specific factors, such as life expectancy, activity level, and body habitus, as well as proper implant fit. Additional studies of both implants and longer follow-up are required to elucidate the optimal fixation method for each individual patient. LEVEL OF EVIDENCE: Level III, retrospective noncomparative study.
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Cimentos Ósseos , Neoplasias Femorais , Desenho de Prótese , Falha de Prótese , Humanos , Masculino , Estudos Retrospectivos , Neoplasias Femorais/cirurgia , Feminino , Pessoa de Meia-Idade , Adulto , Prótese de Quadril , Artroplastia de Quadril/métodos , Artroplastia de Quadril/instrumentação , Fêmur/cirurgia , Idoso , Desbridamento , Adulto Jovem , Infecções Relacionadas à Prótese/etiologiaRESUMO
BACKGROUND: Fluorescence-guided surgery (FGS) is a novel technique to successfully assess surgical margins intraoperatively. Investigation and adoption of this technique in orthopaedic oncology remains limited. METHODS: The PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (380520). Studies describing the use of FGS for resection of bone and soft tissue sarcomas (STS) on humans were included. Diagnostic performance metrics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) and margin positivity rate were the outcomes assessed. RESULTS: Critical appraisal using the Joanna Brigs Institute checklists showed significant concerns for study quality. Sensitivity of FGS ranged from 22.2 % to 100 % in three of the four studies assessing his metrics; one study in appendicular tumors in the pediatric population reported 0 % sensitivity in the three cases included. Specificity ranged from 9.38 % to 100 %. PPV ranged from 14.6 % to 70 % while NPV was between 53.3 % and 100 %. The diagnostic accuracy ranged from 21.62 % to 92.31 %. Margin positivity rate ranged from 2 % to 50 %, with six of the seven studies reporting values between 20 % and 50 %. CONCLUSIONS: FSG is a feasible technique to assess tumor margins in bone and STS. Reported performance metrics and margin positivity rates vary widely between studies due to low study quality and high heterogeneity in dying protocols. LEVEL OF EVIDENCE: Level III, diagnostic study.
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Neoplasias Ósseas , Margens de Excisão , Neoplasias de Tecidos Moles , Cirurgia Assistida por Computador , Humanos , Neoplasias de Tecidos Moles/cirurgia , Neoplasias de Tecidos Moles/patologia , Fluorescência , Cirurgia Assistida por Computador/métodos , Neoplasias Ósseas/cirurgia , Neoplasias Ósseas/patologia , Prognóstico , Sarcoma/cirurgia , Sarcoma/patologia , Neoplasias do Apêndice/patologia , Neoplasias do Apêndice/cirurgiaRESUMO
BACKGROUND: Intramedullary nail fixation is commonly used for prophylactic stabilization of impending and fixation of complete pathological fractures of the long bones. However, metallic artifacts complicate imaging evaluation for bone healing or tumor progression and postoperative radiation planning. Carbon-fiber implants have gained popularity as an alternative, given their radiolucency and superior axial bending. This study evaluates incidences of mechanical and nonmechanical complications. METHODS: Adult patients (age 18 years and older) treated with carbon-fiber nails for impending/complete pathological long bone fractures secondary to metastases from 2013 to 2020 were analyzed for incidences and risk factors of mechanical and nonmechanical complications. Mechanical complications included aseptic screw loosening and structural failures of host bone and carbon-fiber implants. Deep infection and tumor progression were considered nonmechanical. Other complications/adverse events were also reported. RESULTS: A total of 239 patients were included; 47% were male, and 53% were female, with a median age of 68 (IQR, 59 to 75) years. Most common secondary metastases were related to breast cancer (19%), lung cancer (19%), multiple myeloma (18%), and sarcoma (13%). In total, 17 of 30 patients with metastatic sarcoma received palliative intramedullary nail fixation for impending/complete pathological fractures, and 13 of 30 received prophylactic nail stabilization of bone radiated preoperatively to manage juxta-osseous soft-tissue sarcomas, where partial resection of the periosteum or bone was necessary for negative margin resection. 33 (14%) patients had complications. Mechanical failures included 4 (1.7%) structural host bone failures, 7 (2.9%) implant structural failures, and 1 (0.4%) aseptic loosening of distal locking screws. Nonmechanical failures included 8 (3.3%) peri-implant infections and 15 (6.3%) tumor progressions with implant contamination. The 90-day and 1-year mortalities were 28% (61/239) and 53% (53/102), respectively. The literature reported comparable failure and mortality rates with conventional titanium treatment. CONCLUSIONS: Carbon-fiber implants might be an alternative for treating impending and sustained pathological fractures secondary to metastatic bone disease. The seemingly comparable complication profile warrants further cohort studies comparing carbon-fiber and titanium nail complications.
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Fixação Intramedular de Fraturas , Fraturas Espontâneas , Sarcoma , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pinos Ortopédicos , Fibra de Carbono , Fixação Intramedular de Fraturas/métodos , Fraturas Espontâneas/etiologia , Titânio , Resultado do TratamentoRESUMO
Introduction: The use of carbon fiber implants in orthopaedic oncology has increased within recent years. The most widely used type of polymer is carbon fiber polyether ether ketone (CF-PEEK). Its radiolucency enables targeted radiotherapy and artifact-free tumor surveillance, which provides major advantages over metallic hardware. We aim to summarize the unique benefits within orthopaedic oncology, clinical pitfalls, and recent advancements. Methods: Four representative patient cases from a single tertiary academic medical center were treated with carbon fiber implants (n = 2 nails, n = 2 plates) from 2021 to 2022. Results: There were no adverse events noted during intraoperative implantation or postoperative follow up. All patients reported improvements in pain and no difficulties in ambulation. There were no instances of catastrophic failure or implant loosening. Conclusion: CF implants offer a diverse array of advantages regarding its radiolucency, low scatter density, and bioinert profile. Nonetheless, further research is required to understand the long-term surgical outcomes and robustness of CF implants. Multi institutional trials could address important aspects of durability and stability over extended periods, feasibility and ease-of-use for different anatomical sites and bone quality, as well as cost-effectiveness in post-operative imaging, healthcare resource utilization, and revision rates. Providing orthopaedic surgeons with valuable insight will enable thorough clinically supported, informed decision making regarding optimal use of implants.
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CASE: We present the case of a 47-year-old paraplegic woman who underwent resection of an intermediate-grade chondrosarcoma in the proximal ulna, which was initially reconstructed with an osteoarticular allograft. However, after more than 25 years without complications, she sustained an intra-articular fracture of the allograft, which was then successfully treated using a vascularized medial femoral condyle (MFC) flap and anterolateral thigh flap. The patient has subsequently recovered her baseline elbow function, has no pain, and can use her wheelchair without restrictions. CONCLUSION: Free MFC flaps are viable options to salvage osteoarticular allografts that are affected by intra-articular fractures.