Intermediate to Long-Term Follow-up of Distal Femoral Replacements in the Treatment of Neoplastic Disease About the Knee.

BACKGROUND: Limb salvage procedures have become more prevalent in orthopedic oncology. Endoprostheses have been used successfully to reconstruct large skeletal deficits. The aim was to review intermediate to long-term follow-up of distal femoral replacements in the setting of neoplastic disease about the knee. METHODS: This was a single-center retrospective cohort study from 1997 to 2018 in a national referral center for oncology. The secondary objectives were to describe morbidity and mortality in this cohort. We recorded the modes of failure using Henderson classification system, complications, revisions, and all further operations. RESULTS: Seventy-two distal femoral replacements were performed. Osteosarcoma was the most common indication (55 patients). Other indications included chondrosarcoma (7 patients), giant cell tumor (5 patients), Ewing's sarcoma (2 patients), metastatic spread (2 patients), and leiomyosarcoma (1 patient). One-year mortality was 1.38% with an overall mortality of 13.8%, at the end of the study period. The 1-year revision rate was 4.2%, 30.5% for 10 years, and 38.8% for more than 15 years. The overall implant survival rate was 63.8%. The most common reasons for failure included aseptic loosening (16.6%), infection (16.6%), and local recurrence (9.7%) with an amputation rate of 6.9% in the cohort. CONCLUSION: Neoplastic disease of the lower limb is associated with significant morbidity. Aseptic loosening (16.6%) and infection (16.6%) were the most common reasons for failure in this cohort.

Primary appendicular soft-tissue sarcoma resection: What tumour parameters affect wound closure planning?

Wound closure after wide, local excision of an appendicular soft-tissue sarcoma (STS) can be challenging. This study evaluates the value of magnetic resonance imaging (MRI)-based tumour parameters in planning wound closure. A total of 71 patients with a primary limb-based STS, excluding vascular or osseous involvement, excluding the shoulder or hand and hip or foot were included. Axial MRI images were used to measure the circumferences and cross-sectional areas of the limb, bone, and tumour. The tumour diameter, length, and depth at the level of maximal tumour dimension were measured to identify the tumour's relative contribution to the planning of optimal wound closure management through primary closure (PC) or reconstructive surgery (RS). Eighteen patients required planned wound RS. Wound complications occurred in 14% overall. Tumours, which were closed by PC, were of significantly greater depth, shorter radial diameter, and shorter tumour circumference relative to those closed by RS. On multivariate analysis, tumour depth was the greatest contributory factor in predicting type of wound closure. A quantitative analysis of MRI-based tumour parameters demonstrates tumour depth as the most predictive factor in planning for the type of wound closure and may prove beneficial in providing greater insight into planned wound management of sarcoma resection.

Resection and reconstruction of pelvic and extremity soft tissue sarcomas with major vascular involvement: Current concepts.

Soft tissue sarcoma accounts for approximately 1% of all cancers diagnosed annually in the United States. When these rare malignant mesodermal tumours arise in the pelvis and extremities, they may potentially encase or invade large calibre vascular structures. This presents a major challenge in terms of safe excision while also leaving acceptable surgical margins. In recent times, the trend has been towards limb salvage with vascular reconstruction in preference to amputation. Newer orthopaedic and vascular reconstructive techniques including both synthetic and autogenous graft reconstruction have made complex limb-salvage surgery feasible. Despite this, limb-salvage surgery with concomitant vascular reconstruction remains associated with higher rates of post-operative complications including infection and amputation. In this review we describe the initial presentation and investigation of patients presenting with soft tissue sarcomas in the pelvis and extremities, which involve vascular structures. We further discuss the key surgical reconstructive principles and techniques available for the management of these complex tumours, drawn from our institution's experience as a national tertiary referral sarcoma service.

Evaluation of the incidence of pulmonary embolus in the early postoperative period following cemented hemiarthroplasty.

PURPOSE: Little is known regarding the incidence of early postoperative pulmonary embolus (PE) following hip fracture surgery. Clinical suspicion of PE mandates therapeutic anticoagulation, adding a further insult to those of trauma and surgery in a physiologically frail population. The aim of the study was to evaluate for the presence of PEs by performing postoperative CT pulmonary angiography (CTPA) in patients who demonstrated intraoperative, or early postoperative cardiorespiratory lability following surgery with a cemented prosthesis for intracapsular hip fracture. METHODS: All patients undergoing cemented hemiarthroplasty for displaced intracapsular neck of femur fracture were recruited during a 6-month period, and signed consent obtained from the patient or their next of kin for CTPA in the event of any cardiorespiratory instability. Patient demographics, comorbidities were reviewed, and premorbid mobility status documented. RESULTS: 18 of the 66 patients in the study having cemented hemiarthropalsty demonstrated intra- or early postoperative lability, all had early postoperative CTPA scans. 6 of the 18 were noted to have PE. All had more than 1 risk factor for VTE on admission (excluding their injury). Patients diagnosed with PE had a higher ASA grade, and lower mobility scores than those who did not have a PE. CONCLUSIONS: Clinical suspicion alone is inadequate to diagnosis PE in patients undergoing cemented hip arthroplasty. Only 1 in 3 patients suspected of PE on account of intraoperative or immediate postoperative cardiorespiratory lability was found to have a PE based on CTPA. Early postoperative CTPA is helpful to prevent unnecessary anticoagulation for suspected PE.

Orthopaedic perspective on bone metastasis.

The incidence of cancer is increasing worldwide, with the advent of a myriad of new treatment options, so is the overall survival of these patients. However, from an orthopaedic perspective, there comes the challenge of treating more patients with a variety of metastatic bone lesions. The consequences of such lesions can be significant to the patient, from pain and abnormal blood results, including hypercalcemia, to pathological fracture. Given the multiple options available, the treatment of bone metastasis should be based on a patient-by patient manner, as is the case with primary bone lesions. It is imperative, given the various lesion types and locations, treatment of bone metastasis should be performed in an individualised manner. We should consider the nature of the lesion, the effect of treatment on the patient and the overall outcome of our decisions. The dissemination of primary lesions to distant sites is a complex pathway involving numerous cytokines within the tumour itself and the surrounding microenvironment. To date, it is not fully understood and we still base a large section of our knowledge on Pagets historic "seed and soil" theory. As we gain further understanding of this pathway it will allow us develop more medical based treatments. The treatment of primary cancers has long been provided in a multi-disciplinary setting to achieve the best patient outcomes. This should also be true for the treatment of bone metastases. Orthopaedic surgeons should be involved in the multidisciplinary treatment of such patients given that there are a variety of both surgical fixation methods and non-operative methods at our disposal.

Pathological fracture of femur secondary to infected synovial sarcoma.

Pathological fracture is not uncommon in musculoskeletal oncological surgical practice. When complicated by infection, it is both limb- threatening and life-threatening problem. Pathological fractures require urgent investigation, not urgent treatment. We present the case of a 75-year-old man who presented with an infected sarcoma causing a pathological fracture of his right femur.

Musculoskeletal oncology training during residency.

PURPOSE: To evaluate the efficacy of a musculoskeletal oncology training module during residency. METHODS: 24 orthopaedic residents with differing years of experience were recruited. 12 of them received musculoskeletal oncology training for 6 months. The remaining 12 were controls who did not attend the training and had no clinical experience in a musculoskeletal oncology unit but had at least 3 years of postgraduate surgical training. Upon completion, residents in both groups were assessed by a knowledge test and then an objective structured clinical examination (OSCE). RESULTS: Residents who attended the training module had better mean knowledge test scores (48 vs 25 out of 58, p<0.0001) and OSCE scores (32 vs 22 out of 42, p<0.004), compared to those who did not attend. No residents who attended the training module marked an inappropriate biopsy site that would have compromised definitive surgery, compared to 5 (42%) of the untrained residents who marked an inappropriate biopsy site that may have resulted in an unnecessary amputation. All residents who attended the training module agreed that such a module should be included in the orthopaedic residency programme. CONCLUSION: Residents who attended the training module were more aware of the biopsy principles and risks. A training module for musculoskeletal oncology should be included in the orthopaedic residency programme.

Inter- and intra-observer variability associated with the use of the Mirels' scoring system for metastatic bone lesions.

Metastatic bone disease is increasing in association with ever-improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to evaluate a classic scoring system. All radiographs were examined twice by three orthopaedic oncologists and scored according to the Mirels' scoring system. The Kappa statistic was used for the purpose of statistical analysis. The results show agreement between observers (κ = 0.35-0.61) for overall scores at the two time intervals. Inter-observer agreement was also seen with subset analysis of size (κ = 0.27-0.60), site (κ = 0.77-1.0) and nature of the lesion (κ = 0.55-0.81). Similarly, low levels of intra-observer variability were noted for each of the three surgeons (κ= 0.34, 0.39, and 0.78, respectively). These results indicate a reliable, repeatable assessment of bony metastases. We continue to advocate its use in the management of patients with long bone metastases.

Chordoma and chondrosarcoma gene profile: implications for immunotherapy.

Chordoma and chondrosarcoma are malignant bone tumors characterized by the abundant production of extracellular matrix. The resistance of these tumors to conventional therapeutic modalities has prompted us to delineate the gene expression profile of these two tumor types, with the expectation to identify potential molecular therapeutic targets. Furthermore the transcriptional profile of chordomas and chrondrosarcomas was compared to a wide variety of sarcomas as well as to that of normal tissues of similar lineage, to determine whether they express unique gene signatures among other tumors of mesenchymal origin, and to identify changes associated with malignant transformation. A HG-U133A Affymetrix Chip platform was used to determine the gene expression signature in 6 chordoma and 14 chondrosarcoma lesions. Validation of selected genes was performed by qPCR and immunohistochemistry (IHC) on an extended subset of tumors. By unsupervised clustering, chordoma and chondrosarcoma tumors grouped together in a genomic cluster distinct from that of other sarcoma types. They shared overexpression of many extracellular matrix genes including aggrecan, type II & X collagen, fibronectin, matrillin 3, high molecular weight-melanoma associated antigen (HMW-MAA), matrix metalloproteinase MMP-9, and MMP-19. In contrast, T Brachyury and CD24 were selectively expressed in chordomas, as were Keratin 8,13,15,18 and 19. Chondrosarcomas are distinguished by high expression of type IX and XI collagen. Because of its potential usefulness as a target for immunotherapy, the expression of HMW-MAA was analyzed by IHC and was detected in 62% of chordomas and 48% of chondrosarcomas, respectively. Furthermore, western blotting analysis showed that HMW-MAA synthesized by chordoma cell lines has a structure similar to that of the antigen synthesized by melanoma cells. In conclusion, chordomas and chondrosarcomas share a similar gene expression profile of up-regulated extracellular matrix genes. HMW-MAA represents a potential useful target to apply immunotherapy to these tumors.

Squeaking in ceramic-on-ceramic hips: the importance of acetabular component orientation.

Audible squeaking in total hip replacements with ceramic-on-ceramic bearings is a rare problem. Acetabular component orientation was compared for 17 squeaking hips and 17 matched controls. Ninety-four percent of control hips were in a range of 25 degrees +/- 10 degrees anteversion and 45 degrees +/- 10 degrees inclination, but only 35% of squeaking hips were in this range (P = .0003). Eight hips squeak with bending. Four hips squeak with walking, and 5 hips squeak after prolonged periods of walking. Hips that squeaked with walking had acetabular components that were more anteverted (40 degrees ) than hips that squeaked with bending (19 degrees ) (P = .001) or prolonged walking (18 degrees ) (P = .020). The hips started squeaking after an average of 14 months. Patients with squeaking hips were younger, heavier, and taller than patients with silent hips.

Metastatic bone cancer pain: etiology and treatment options.

Painful metastatic bone disease remains a challenge for physicians. The treatment choices available are wide and varied, with each having its appropriate place in the management of painful bone metastases. Radiotherapy remains the mainstay of treatment with or without surgery. Advances in understanding the intricate pathway responsible for pain generation and the addition of agents such as bisphosphonates to the physician's armamentarium further assist in the management of painful bone metastases.

Positive apical surgical margins after radical retropubic prostatectomy, truth or artefact?

OBJECTIVE: The significance of a positive apical surgical margin following radical retropubic prostatectomy has been the subject of controversy. We examined the hypothesis that a positive apical margin alone is not associated with an increased probability of biochemical relapse. MATERIAL AND METHODS: A total of 162 men underwent radical prostatectomy for clinically organ-confined disease between May 1990 and December 1998. The mean follow-up period was 55 months (minimum 24 months). The mean patient age was 60.8 years. Clinical staging was 67.9% T1 and 32.1% T2. The mean preoperative prostate-specific antigen level was 11.5 ng/ml, and the mean Gleason score was 5.8. RESULTS: Overall, 5/64 patients (7.8%) with negative surgical margins and 42/98 (42.9%) with at least one positive surgical margin had biochemical recurrence (p < 0.001). Seven of 25 patients (28%) with a solitary positive apical margin relapsed. A solitary apical positive margin was associated with a statistically significant higher risk of recurrence versus controls (p < 0.05). CONCLUSION: All patients with a positive surgical margin, including those with a solitary apical margin alone, are at significantly increased risk of biochemical failure.

Bone sialoprotein-coated femoral implants are osteoinductive but mechanically compromised.

Aseptic loosening of femoral implants in total hip replacement remains an unsolved orthopaedic problem. This paper investigates the potential role of bone sialoprotein (BSP) in enhancing bone-implant adherence. As BSP is osteoinductive in rat calvarial models, we investigated whether BSP is similarly osteoinductive when coated onto intramedullary femoral implants. BSP-coated titanium implants were implanted into the femur of female 'Wistar' rats (average weight 215 g) that were sacrificed at days 10, 20 and 30. Harvested femoral implants were subjected to pullout testing and then examined histologically. BSP-coated implants demonstrate osteoinduction when examined histologically. Plugging the femoral canal with BSP prior to inserting the implant neither increased implant pullout strengths nor further increased osteoblastic activity. This study has demonstrated for the first time that BSP is osteoinductive when coated onto femoral implants and inserted into bones subjected to mechanical loading. However, we found that pullout strengths are a function of implant surface topographical characteristics and are not affected by BSP coating or histological osteoinduction.

Purulent bloody drainage after infected total hip arthroplasty: a sign of a leaking mycotic aneurysm.

An infected total hip arthroplasty remains one of the most challenging problems faced by orthopaedic surgeons from diagnosis through treatment. We present the case of a 58-year-old woman who was referred to our service with an infected revision total hip arthroplasty. The hip had migrated medially, and the patient had recently noted the presence of blood discharging through a chronic sinus. Angiography revealed a mycotic aneurysm of the external iliac artery. An emergency procedure incorporating a femorofemoral bypass graft and a Girdlestone procedure was undertaken. This is the first reported case of a leaking mycotic aneurysm presenting acutely with blood discharging through a previously chronically discharging sinus tract.