Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients.

We evaluated the long-term functional outcome in 118 patients treated for osteosarcoma or Ewing's sarcoma in the extremities a minimum of five years after treatment. We also examined if impaired function influenced their quality of life and ability to work. The function was evaluated according to the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). Quality of life was assessed by using the Short Form-36 (SF-36). The mean age at follow-up was 31 years (15 to 57) and the mean follow-up was for 13 years (6 to 22). A total of 67 patients (57%) initially had limb-sparing surgery, but four had a secondary amputation. The median MSTS score was 70% (17% to 100%) and the median TESS was 89% (43% to 100%). The amputees had a significantly lower MSTS score than those with limb-sparing surgery (p < 0.001), but there was no difference for the TESS. Tumour localisation above knee level resulted in significantly lower MSTS scores and TESS (p = 0.003 and p = 0.02, respectively). There were no significant differences in quality of life between amputees and those with limb-sparing surgery except in physical functioning. Of the patients 11% (13) did not work or study. In multivariate analysis, amputation, tumour location above the knee and having muscular pain were associated with low physical function. We conclude that most of the bone tumour survivors managed well after adjustment to their physical limitations. A total of 105 are able to work and have an overall good quality of life.

Treatment of local recurrences of giant cell tumour in long bones after curettage and cementing. A Scandinavian Sarcoma Group study.

We retrospectively studied local recurrence of giant cell tumour in long bones following treatment with curettage and cementing in 137 patients. The median follow-up time was 60 months (3 to 166). A total of 19 patients (14%) had at least one local recurrence, the first was diagnosed at a median of 17 months (3 to 29) after treatment of the primary tumour. There were 13 patients with a total of 15 local recurrences who were successfully treated by further curettage and cementing. Two patients with a second local recurrence were consequently treated twice. At the last follow-up, at a median of 53 months (3 to 128) after the most recent operation, all patients were free from disease and had good function. We concluded that local recurrence of giant cell tumour after curettage and cementing in long bones can generally be successfully treated with further curettage and cementing, with only a minor risk of increased morbidity. This suggests that more extensive surgery for the primary tumour in an attempt to obtain wide margins is not the method of choice, since it leaves the patient with higher morbidity with no significant gain with respect to cure of the disease.

Scandinavian Sarcoma Group Osteosarcoma Study SSG VIII: prognostic factors for outcome and the role of replacement salvage chemotherapy for poor histological responders.

From 1990 to 1997, 113 eligible patients with classical osteosarcoma received neo-adjuvant chemotherapy consisting of high-dose methotrexate, cisplatin and doxorubicin. Good histological responders continued to receive the same therapy postoperatively, while poor responders received salvage therapy with an etoposide/ifosfamide combination. With a median follow-up of 83 months, the projected metastasis-free and overall survival rates at 5 years are 63 and 74%, respectively. Independent favourable prognostic factors for outcome were tumour volume < 190 ml, 24-h serum methotrexate > 4.5 microM and female gender. The etoposide/ifosfamide replacement combination did not improve outcome in the poor histological responders. In conclusion, this intensive multi-agent chemotherapy results in > 70% of patients with classical osteosarcoma surviving for 5 years. The data obtained from this non-randomised study do not support discontinuation and exchange of all drugs used preoperatively in histological poor responders. As observed in previous Scandinavian osteosarcoma studies, female gender appears to be a strong predictor of a favourable outcome.

Osteosarcoma over the age of forty.

The European Musculo Skeletal Oncology Society (EMSOS) has carried out a retrospective review of patients over the age of 40 years with osteosarcoma. 481 patients from 12 centres or multicentric groups were included. 42 patients had osteosarcoma arising in Paget's disease, median survival was 9 months. Patients with axial or metastatic tumours also did badly whilst 41 patients with radiation-induced osteosarcoma had a prognosis paralleling conventional osteosarcoma matched for patient age and site of the tumour. 238 patients had high grade non-metastatic osteosarcoma and had a survival of 46% at 5 years. Older patients had less chemotherapy and fared worse. Osteosarcoma in the elderly is a curable condition and warrants intensive treatment with chemotherapy and surgical resection.

Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases.

We treated forty-eight femoral-shaft fractures in forty-seven patients with the Grosse-Kempf interlocking intramedullary nail. Fifteen fractures were transverse or short oblique, ten were long oblique or spiral, and twenty-three were comminuted. Only twenty-four (50 per cent) of the fractures were located in the middle one-third of the shaft. The median time until full weight-bearing was thirty days (range, seven to 150 days). Radiographic consolidation was seen in all fractures at a median of sixteen weeks (range, nine to fifty-six weeks). The patients were followed for one to four years, and no infections developed. The results in thirty fractures were classified as excellent; in eight, as good; in seven, as fair; and in two, as poor. We have found the Grosse-Kempf method to be useful in treating patients with high-energy fractures, multiple injuries, open fractures, and osteoporosis. Since there is a risk of rotational and longitudinal instability with the dynamic method of interlocking nailing, we recommend that the static method be used whenever there is doubt about the stability of the fracture. We did not observe any delay in bone-healing when the static method was used.

Bilateral femoral shortening for unaccepted tallness.

We performed bilateral femoral shortening operations on 15 skeletally mature patients (11 women and four men). Their mean height pre-operatively was 193.5 cm and they were shortened by 5 to 9 cm. We used a subtrochanteric Z-osteotomy with an AO condylar plate in 11 patients, and mid-diaphyseal osteotomy with an intramedullary locking nail in four. After an average follow-up of 8.1 years, isokinetic muscle testing showed that muscle strength was reduced bilaterally in five patients. The strength ratio between hamstrings and quadriceps muscles was normal in all those treated by subtrochanteric shortening; in those shortened at the mid-shaft the quadriceps was relatively weaker. The result was rated as excellent by 11 patients, very good by three, and good by one.

Locked intramedullary nailing for displaced tibial shaft fractures.

We analysed the results of 93 tibial shaft fractures treated with the Grosse-Kempf locked nail. Twenty-six fractures were comminuted, 19 were open grade I to II, and 54 were located outside the middle third of the tibia. The deep infection rate was 3.2%. There were only two poor results. The use of this method is recommended and discussed.

Muscle function after mid-shaft femoral shortening. A prospective study with a two-year follow-up.

We performed isokinetic knee testing to assess thigh muscle function in ten patients (12 legs) before and after mid-shaft femoral shortening averaging 46 mm (27 to 70). Tests were at angular velocities of 60 degrees/sec and 180 degrees/sec, and were performed preoperatively and after 3, 6, 12 and 24 months. Isokinetic tests at two years showed a significant reduction in muscle function in both quadriceps and hamstrings, but recovery of function was significantly better for the hamstrings. There was a linear relationship with correlation of r2 = 0.31 to 0.86 between loss of muscle force at two years and the magnitude of shortening. Long-term loss of muscle force should be expected after a mid-shaft shortening of the femur of more than 10%.

[Experiences with interlocking nails in the femur. A retrospective analysis of 99 operated femur shaft fractures]. / Die Erfahrungen mit der Verriegelungsnagelung am Femur. Eine retrospektive Analyse 99 operierter Femurschaft-Frakturen.

In 95 patients 99 femoral fractures treated with an intramedullary locking nail were followed-up for median 22 months (12-60). 62 results were classified as excellent, 19 as good and 16 results as fair. A poor result was registered in 2 patients. We had 13 operation-related complications. Four of these complications required a new operation and one ended up with a poor end-result. Operative-technical complications do not necessarily need to impair the result if the surgeon is aware of them and knows how they are to be handled.

Metastases from renal cell carcinoma to the humerus or the shoulder girdle.

OBJECTIVE: To discuss the clinical presentation of metastases in the scapula and/or humerus resulting from renal cell carcinoma and the courses of treatment available. PATIENTS: A series of 35 patients with humeral or scapular metastases from renal cell carcinoma, treated at The Norwegian Radium Hospital (NRH) during an 11-year period, is reviewed. Two case reports are examined in detail. RESULTS: The median survival was 12 months (range 1-88) from the time of diagnosis of metastasis. Three patients lived for more than 50 months. CONCLUSION: Owing to the relatively long survival time, especially in patients with limited tumour burden elsewhere and who are in a good general state of health, long-lasting palliative treatment of the humeral or scapular metastases is aimed for. Renal cell carcinoma tends to be resistant to radiotherapy, and early treatment, combining orthopaedic surgery and high-dose radiotherapy, is advocated.

Interlocking intramedullary nailing in the treatment of tibial fractures. A report of 45 cases.

Forty-five tibial shaft fractures in 43 patients were treated with the Grosse-Kempf interlocking intramedullary nail. The material was highly selected because 49% of the fractures were due to high-energy trauma and 62% were located at the diaphyseal-metaphyseal junctions. The median time to full weight-bearing was 30 days, and 44 fractures healed by bridging callus in a median of 16 weeks. There was one nonunion, one deep, and one superficial infection. The results of the clinical and radiologic evaluations were excellent in 29 fractures, good in 13, fair in two, and poor in one. Interlocking intramedullary nailing proved to be efficient for comminuted, segmental, and unstable tibial fractures, especially in patients with multiple injuries. Compared with conventional intramedullary nailing, the locking procedure increases the stability at the fracture site and extends the indication for nailing to fractures in the proximal and distal diaphyseal-metaphyseal junctions.

Locked intramedullary nailing of fractures of femur and tibia.

The results of 194 consecutive interlocking nailings for 95 fractures in the tibia and 99 fractures in the femur with a median observation time of 22 months are presented. Three fractures were not consolidated radiologically at follow-up; three deep infections were recorded, all of which healed. Shortening greater than 1 cm was recorded in 17 fractures, rotatory malalignment greater than 5 degrees in 21, and angular malalignment greater than 5 degrees occurred in 17. The end result was excellent in 121 fractures, good in 41, fair in 28, and poor in 4.

Extremity and non-extremity high-grade osteosarcoma -- the Norwegian Radium Hospital experience during the modern chemotherapy era.

Of 103 patients with high-grade osteosarcoma, 27% had tumours localized outside the extremities. Non-extremity patients were significantly older at diagnosis than patients with extremity tumours (median 38 vs. 17 years). More than 90% of patients with extremity tumours received adequate treatment (aggressive chemotherapy plus at least marginal surgery), compared with only 25% of patients with non-extremity tumours. Failure of adequate treatment was due to inoperable tumour, intralesional surgery and age preventing aggressive chemotherapy. There was a highly significant difference in both local tumour control and overall survival, both favouring patients with extremity tumours. Within the extremity tumour group, patients who were treated in prospective multicentre trials had a significantly better outcome than non-trial patients. Our results show that the fraction of patients with high-grade tumours that fall outside trials designed for 'classical osteosarcoma' may be larger than is usually acknowledged, and that the results reported for the classical group are by no means representative of the whole patient population. Improved and new treatment approaches are needed for patients with non-extremity tumours, particularly in the older age groups.

[Diagnostic aspects of subacute osteomyelitis in children and adolescents. Clinical and radiographic resemblance to primary malignant tumors]. / Diagnostiske aspekter ved subakutt osteomyelitt hos barn og ungdom. Klinisk og røntgenologisk likhet med primaer malign beintumor.

During a six-year period, 17 patients younger than 20 years of age, with a final diagnosis of subacute osteomyelitis, were admitted to the Norwegian Radium Hospital because of an initial suspicion of primary malignant bone tumour. The most common localizations were the metaphyses of long bones (eight patients) and the clavicle (four patients). Pain was the dominating symptom. Common radiological findings were localized osteolysis and/or sclerosis, cortical bone destruction, periosteal reaction and an adjacent, often palpable soft tissue mass. Clinical signs of infection were generally absent, and a positive bacterial culture was obtained from the biopsy material in only one patient. Following extensive investigations, a malignant bone tumour (especially Ewing's sarcoma) remained a differential diagnosis, and open biopsy was indicated in all cases. The patient material illustrates the difficulty in distinguishing between subacute osteomyelitis and malignant bone tumours, and it is stressed that diagnostic investigations for this type of patients should be performed in an oncological centre with experience of bone tumours.

[Treatment of chondrosarcoma. A retrospective study at the Norwegian Radium Hospital]. / Behandling av kondrosarkom. En retrospektiv undersøkelse ved Det Norske Radiumhospital.

The authors present a retrospective analysis of 59 chondrosarcoma patients treated at the Norwegian Radium Hospital during the period 1981 to 1993. 31 patients were admitted with untouched tumour, seven after fine needle cytology and 20 after open biopsy or partial excision. One patient had recurrent local disease. Only 20% of the tumours were of high grade malignancy. 51 patients were treated by surgery. Reconstructions were performed in 16 patients, using allografts or endoprostheses. Amputations were performed in six cases and wide excision in 12 cases. In these 18 patients local recurrence appeared in one case, and two developed lung metastases. Only one of the 18 patients operated by amputation or wide excision has since died from chondrosarcoma. Marginal excisions were performed in 26 cases. Nine of these patients developed a local recurrence, five developed metastases and three have died. Six patients had partial excisions. Postoperative radiotherapy was given to one patient only. Five of the six are alive. In one case, the quality of the margins could not be evaluated. A total of 45 of the 51 patients treated for the primary tumour by surgery are alive. The median observation time is four years. Treatment of nonmetastatic chondrosarcoma should be surgical. Chondrosarcoma patients show wider variations in age, localization of tumour and tumour growth rate than patients with other bone sarcomas. Although wide excisions provide the best local control of any grade of malignancy, the mutilation or risk involved may be so great that some patients may benefit from marginal or even partial excision.

Umbilical vein grafts and PTFE grafts for femoro-popliteal bypass. Preliminary results.

This retrospective, multiple-center study includes 172 PTFE (Gore-Tex) and 35 umbilical vein grafts (Bio-graft) used for femoro-popliteal bypass grafting. The one-year patency rate was approximately 63% in both groups. Until further experience is accumulated, autogenous saphenous vein should probably be the first choice for femoro-popliteal bypass grafting. Prosthetic grafts should preferably be used when the saphenous vein is absent or insufficient.