Comparable outcomes of recycled autografts and allografts for reconstructions in patients with high-grade osteosarcoma.

PURPOSE: This retrospective, single-centre study compares the clinical and radiographic outcomes of limb reconstruction using recycled autografts to that using allografts. METHODS: Patients with histopathologically verified high-grade osteosarcoma treated with wide bone resection and limb reconstruction using allografts or recycled autografts from January 1998 through December 2012 were retrospectively screened for enrolment eligibility. The final study cohort included 255 patients (allograft, 91; recycled autograft, 164). Data regarding post-operative complications, salvage treatment, and graft survival were collected. A modified International Society of Limb Salvage classification system was used to evaluate the radiographic findings. RESULTS: The time to graft-host union did not differ significantly between the two graft types. Patients receiving recycled autografts had fewer complications compared than did those receiving allografts (recycled autografts vs. allograft: structural failure, 4.3 vs. 13.2%; late infection, 2.4 vs. 7.7%; all p < 0.05). Complications occurred most frequently during the first three years after surgery, and the majority were manageable. The five year limb survival rate did not differ significantly between the two graft types (91.3 vs. 94.0%; p = 0.752). No local oncological recurrence was observed within the recycled autografts. CONCLUSION: Recycled autografts and allografts are feasible options for biological limb reconstructions in terms of complications and graft survival after wide resection of osteosarcoma.

Intra-articular Injection of Tranexamic Acid Reduced Postoperative Hemarthrosis in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study.

PURPOSE: To evaluate the effect of intra-articular injection of tranexamic acid (TXA) in patients receiving arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS: A total of 304 patients were included in this study, which was performed between August 2017 and April 2018. Single-bundle reconstructions using autologous hamstring tendon grafts were performed in all patients. Patients were randomized into 2 groups: Group 1 patients (TXA group) received the index procedure with a 10-mL intra-articular injection of TXA (100 mg/mL). Group 2 patients (control group) received the index procedure without TXA injections. An intra-articular suction drain was placed in the joint and clamped for 2 hours after the procedure. The volume of drainage was recorded 24 hours after surgery. Clinical evaluations using the International Knee Documentation Committee functional score, range of motion, and a visual analog scale pain score were performed on day 3 and at week 4 postoperatively. RESULTS: Twenty-four hours after surgery, a significant decrease in the amount of drainage was observed in patients receiving intra-articular injections (TXA group, 56.1 ± 34.1 mL; control group, 80.1 ± 48 mL; P < .05). On day 3 and at week 4, significantly reduced pain scores were reported in the TXA group. However, at week 4, clinical function scores did not show significant differences between the 2 groups. CONCLUSIONS: Intra-articular injection of TXA could significantly reduce postoperative intra-articular bleeding in the first 24 hours in patients receiving arthroscopic ACLR. TXA injection may also decrease pain and the grade of hemarthrosis in the early postoperative period. No systemic side effects or need for aspiration was noted during the follow-up period. Therefore, intra-articular injection of TXA could be considered an effective and relatively safe solution to reduce postoperative bleeding and pain in ACLR patients. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Comparison of Tunnel Enlargement and Clinical Outcome Between Bioabsorbable Interference Screws and Cortical Button-Post Fixation in Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study With a Minimum Follow-Up of 2 Years.

PURPOSE: To investigate the tunnel enlargement rate and clinical function by comparing double-bundle anterior cruciate ligament reconstruction (ACLR) using different fixation devices. METHODS: Patients receiving primary arthroscopic double-bundle ACLR were screened and divided into 2 groups on the basis of the method of graft fixation: bioabsorbable interference screw (BS) group and cortical button (CB) group. Bone tunnel size was assessed digitally using magnetic resonance imaging, which was performed a minimum of 2 years postoperatively. Clinical evaluations were performed using the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, and KT-1000 arthrometer 2 years postoperatively. RESULTS: Sixty patients receiving primary arthroscopic double-bundle ACLR were included. Overall, the BS group showed greater tunnel enlargement than the CB group, as well as a significantly increased rate of tunnel communication (P = .029). The average anteromedial tunnel enlargement rates for the BS and CB groups were 50% and 28%, respectively. The enlargement rate of the posterolateral (PL) femoral tunnel was similar in both groups. In the PL tibial tunnel, the CB group showed a significant increase in enlargement compared with the BS group (64% vs 45%, P = .0001). Both groups showed functional improvement in the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee score. No significant difference in postoperative functional outcomes was found between the 2 groups. CONCLUSIONS: The BS group showed significantly greater tunnel enlargement in anteromedial tunnels and an increased tunnel communication rate compared with the CB group. On the other hand, the CB group showed greater tunnel enlargement in tibial PL tunnels. Tunnel communication was observed mostly on the tibial side in the BS patients. Equivalent clinical function outcomes were noted at 2 years after surgery in both groups of patients. LEVEL OF EVIDENCE: Level II, randomized controlled clinical trial.

Intraoperative Extracorporeal Irradiation and Frozen Treatment on Tumor-bearing Autografts Show Equivalent Outcomes for Biologic Reconstruction.

BACKGROUND: Immediately recycling the resected bone segment in a biologic limb salvage reconstruction is an option after wide resection of bone. Intraoperative extracorporeal irradiation and freezing are the two major tumor-killing techniques applied on the fresh tumor-bearing autografts. However, graft-derived tumor recurrence and complications are concerns affecting graft survival. QUESTIONS/PURPOSES: We therefore asked: (1) Is there a difference in the proportion of patients achieving union by 18 months after surgery between the groups with extracorporeal-irradiated autografts and frozen-treated autografts? (2) Is there any difference in the frequency of graft-related complications for patients receiving either an extracorporeal-irradiated or a frozen-treated autograft? (3) Is there a difference between the techniques in terms of graft-derived recurrence? (4) Are there differences in failure-free grafts, and limb and overall survivorship between autografts treated by extracorporeal irradiation or by freezing? METHODS: During the study period we treated a total of 333 patients with high-grade osteosarcoma. One hundred sixty-nine patients were excluded. Overall, 79 of the enrolled 164 patients received recycled autografts treated with extracorporeal irradiation whereas the other 85 received frozen-treated autografts. The mean followup was 82 ± 54 months for the extracorporeal irradiation group and 70 ± 25 months for the frozen autograft group, and one patient was lost to followup. Complications and graft failure (revision required for primary graft removal) were characterized by adapting the International Society of Limb Society (ISOLS) system modified for inclusion of biologic and expandable reconstruction. The primary study endpoints were the proportion of patients in each group who achieved radiographic union, and had an ISOLS grade of fair or good host graft fusion at 6, 9, 12, and 18 months after surgery. Five-year survival data for graft failure and limb amputation were analyzed by a cumulative incidence function regression model whereas the Kaplan-Meier function was used to test the 5-year overall survival rate between the two techniques. RESULTS: With the numbers available, no differences were found in the accumulated proportion of patients achieving union between the groups at 6, 9, 12, and 18 months. Radiographic evaluation did not show differences in the average scores of compared criteria. However in the subchondral bone subcriterion, more patients receiving frozen-treated autografts had higher scores (p = 0.03). Complications leading to a second surgery were not different between extracorporeal irradiation and frozen autografts in aspects of soft tissue failure (Type 1B), nonunion (Type 2B), structural failure (Type 3A and Type 3B), or infection (Type 4A and Type 4B). No graft-originating tumor recurrence was found and there was no difference in Type 5A tumor progression originating from soft tissue in the groups (odds ratio, 0.8; 95% CI, 0.3-2.1; p = 0.7). Neither group showed a difference in the cumulative incidence for graft failure and limb amputation. Five-year overall survival rates were 83% and 84% (p = 0.69) for extracorporeal-irradiated and frozen autografts respectively. A decrease in survivorship was seen at 50 to 100 months after surgery for the extracorporeal irradiation group. CONCLUSION: We segregated the ISOLS criteria evaluating the graft-mediated tumor progression into host- or graft-derived complications (Types 5B and 5C) in this study. With the available data, there was no difference in the incidence of tumor recurrence derived from irradiation- or frozen-treated autografts. Ongoing evaluations comparing 10-year survivorship for both groups will be helpful to elucidate the possible difference found after 100 months. LEVEL OF EVIDENCE LEVEL: III, therapeutic study.

Pathological fractures in predicting clinical outcomes for patients with osteosarcoma.

BACKGROUND: Studies reported contradictory results for the prognostic significance of a pathological fracture in osteosarcoma patients. The aim of this study is to report the outcomes for a cohort of patients with osteosarcoma who presented with and without pathological fractures and to identify the prognostic importance of pathological fracture in predicting outcomes and influences on survival. METHODS: Data of patients with osteosarcoma were retrospectively reviewed. Between March 1992 and June 2014, a total of 268 patients with osteosarcoma were included in this analysis, of whom 34 (12.7%) with fractures at diagnosis or sustained after chemotherapy and 234 (87.3%) without fracture. All patients were treated with approaches that integrated chemotherapy and surgical resections to maximal extent of all sites whenever feasible. The association between potential prognostic factors and survival for these patients were analyzed and compared. RESULTS: No significant difference was observed in overall survival, progression free survival, and disease free survival between osteosarcoma patients with pathological fractures and without fracture. The patients without fracture had a 5-year survival of 50% and 10-year survival of 21%, in contrast to 37% (5-year) and 22% (10-year) in patients with fractures. Lung metastasis was the significant predictor for the presence of fractures. Advanced stage (III) of tumor, lung metastasis, poor response to chemotherapy, and local recurrence were associated increased risk for death in all osteosarcoma patients. CONCLUSION: Pathological fracture is not a predictor of worse survival in this study. Further studies with matched cases are needed to confirm our observations.

Bone-prosthesis composite with rotating hinged-knee prosthesis in limb salvage surgery for high-grade sarcoma around the knee.

Bone prosthesis composite (BPC) had been widely-used in reconstruction after wide excision of malignant tumors around the knee. However, implant selection for BPC remains a dilemma. Forty-one patients with high-grade malignant bone tumors around the knee who underwent excision and reconstruction with BPC and rotating hinged knee (RHK) prosthesis were included. The mean follow-up time was 54 months (range, 31-78 months). The average Musculoskeletal Tumor Society Rating score was 93.4% (range, 73-100%). The mean range of motion was 125°. Complications included 2 local recurrences, 2 nonunions, and 1 peri-prosthetic fracture. The reconstruction with BPC using the RHK prosthesis provided consistently good functional results with a low complication rate. The RHK prosthesis is a promising choice for BPC reconstruction.

Total Hip Arthroplasty for Patients Who Have Ankylosing Spondylitis: Is Postoperative Irradiation Required for Prophylaxis of Heterotopic Ossification?

Postoperative radiation for prevention of heterotopic ossification (HO) has been proven effective for the patients with ankylosing spondylitis (AS) after total hip arthroplasties (THA). This study aims to evaluate the effect of postoperative radiation in HO formation following THA in patients with AS. We retrospectively reviewed 129 hips from 91 patients with AS receiving primary THA from July 2004 to December 2012. There were total 38 patients (53 hips) did not receive postoperative prophylaxis in Group I. Moreover, 53 patients (76 hips) received postoperative single-fraction radiotherapy of 500 cGy in Group II. After a minimum 12-month follow-up, there was no significant difference in HO formation between the two groups (P=0.210). This study suggests that postoperative radiation may not be necessary in Asian patients.

Osteomyelitis of the femur mimicking bone tumors: a review of 10 cases.

BACKGROUND: The clinical symptoms and radiographic appearance of osteomyelitis can mimic those of bone tumors. METHODS: We reviewed 10 patients with osteomyelitis of the femur who were initially diagnosed as having bone tumors and were subsequently transferred to our institution. RESULTS: Nocturnal pain of moderate intensity occurred in seven patients, and all 10 patients had elevated C-reactive protein levels. The radiographic findings included the following: a permeative, moth-eaten osteolytic lesion in six patients, an osteolytic lesion with sclerotic borders in three patients, and cortical destruction with pathological fracture in one patient. Magnetic resonance imaging was performed for eight patients, and only one had a positive penumbra sign. All patients underwent a surgical biopsy to confirm the final diagnosis for histological analysis and cultures. Klebsiella pneumoniae was detected in six patients and Staphylococcus aureus, the most common organism in osteomyelitis, was detected in three. Recurrence of infection occurred in five patients following debridement surgery; of these three had a Klebsiella pneumoniae infection. All patients received antibiotic treatment for an average of 20.4 weeks (range, 4 to 44) and surgical treatment an average of 1.8 times (range, 1 to 4). At the final follow-up, all patients were fully recovered with no signs of infection. CONCLUSIONS: When used in combination, clinical examinations, laboratory data, and radiographic findings can reliably distinguishing osteomyelitis from bone tumors.

Subtalar distraction arthrodesis using fresh-frozen allogeneic femoral head augmented with local autograft.

BACKGROUND: Tricortical autograft has been commonly used in subtalar distraction arthrodesis (SDA) for severe calcaneal malunion. Structural allograft enriched with orthobiological agents is an alternative. This study was performed to evaluate the results of SDA using fresh-frozen allogeneic femoral head without the addition of orthobiological agents. MATERIALS AND METHODS: We retrospectively reviewed 15 consecutive SDA procedures (13 patients) with allogeneic femoral head augmented with local autograft for the treatment of severe calcaneal malunion. Clinical outcome was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) pain score, Short Form-12 (SF-12), range of motion (ROM) of the ankle joint, and patient satisfaction rate. Radiographic assessment included the talar declination angle (TDA), calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), heel height, calcaneal length, and union time. RESULTS: At a median follow-up of 36.0 months (range, 24-47 months), all 15 feet (100%) achieved union, at a median of 13.0 weeks (range, 12-18 weeks). The AOFAS score and VAS pain score improved significantly, with a satisfaction rate of 93.3%. The TDA, CIA, LTCA, and heel height improved significantly. The median increase in heel height was 8.6 mm (range, 1.9-20.1 mm). There was a significant reduction in calcaneal length. Complications included 1 varus malalignment, 1 complex regional pain syndrome, 1 hardware irritation, and 1 sural neuralgia. CONCLUSION: This study found that SDA using fresh-frozen femoral head allograft without an orthobiological agent was cost-effective and may have outcomes comparable to those using autograft or allograft enriched with orthobiological agents.

High-grade osteosarcoma treated with hemicortical resection and biological reconstruction.

BACKGROUND AND OBJECTIVES: Wide excision with a 2-3 cm safe margin is widely-accepted in treating high-grade osteosarcoma. However, a wider margin sacrifices more healthy bone and may jeopardize joint function. We hypothesize that our innovative hemicortical resection for such tumors leads to better joint function without higher recurrence rate. METHODS: Between August 2002 and April 2007, six patients of high-grade osteosarcoma were treated with hemicortical resection and biological reconstruction. RESULTS: Five tumors were located around the knee and one was located in the distal tibia. The mean tumor size was 20.5 cm(3). The bone defects were reconstructed using recycled autograft in four cases (one by extracorporeal irradiation; three by liquid nitrogen) and structural allograft in two. In an average follow-up of 52 months (24-96), all patients survived without local recurrence or metastasis. All bone grafts incorporated well without mechanical failure or infection. The average Musculoskeletal Tumor Society score was 97.7%. CONCLUSIONS: Hemicortical resection for high-grade osteosarcomas located eccentrically in the long bones may be a reliable technique leading to good joint function by preserving surrounding healthy tissues. The functional outcome was encouraging, although long-term follow-up is mandatory to validate. With the advancement of chemotherapy and radiographic three-dimensional imaging, the safe margin in wide excision of high-grade osteosarcoma may be narrowed down in light of joint surface preservation.