Controversies in orthopaedic oncology.

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Effects of time to treatment initiation on outcomes for soft tissue sarcomas.

BACKGROUND AND OBJECTIVES: Few studies have investigated the effects of time to treatment initiation (TTI) for soft tissue sarcomas (STS). Our objective was to investigate the risk factors for prolonged TTI and the effects of prolonged TTI on local recurrence free survival (LRFS), distant metastasis free survival (DMFS), and disease specific survival (DSS). METHOD: Patients diagnosed with high-grade STS of the extremities and trunk from 2011 to 2020 were included. TTI was grouped into two groups (treatment provided in less than vs. more than or equal to 30 days). Two-year and 5-year survival probabilities were calculated for LRFS, DMFS, and DSS. Cox regression and Kruskal-Wallis tests in univariate analysis were conducted to find risk factors affecting TTI and the survival outcomes. RESULTS: In the univariate analysis, diagnosis in the later 5-year period of the study, tumor size, and treatment modality were associated with prolonged TTI. TTI ≥30 days was associated with higher DMFS but no association was found with LRFS or DSS. Tumor size, surgical margins, and provision of surgery were associated with DSS. CONCLUSION: Despite the delay in treatment for STS patients caused by the COVID-19 pandemic, our study showed TTI of more than 30 days does not negatively impact patients.

Functional and radiologic outcomes of uncemented reverse shoulder arthroplasty in proximal humeral fractures: cementing the humeral component is not necessary.

BACKGROUND: Our aim was to determine the radiologic and functional outcomes of patients who underwent reverse shoulder arthroplasty (RSA) for proximal humeral fractures and to assess whether the uncemented humeral components put them at risk for early loosening and failure. METHODS: Thirty-three patients were identified in our hospital database (January 2004-December 2012). Twenty patients were assessed using American Shoulder Elbow Surgeons (ASES) score, Constant Shoulder Score (CSS), and the Oxford Shoulder Score (OSS). Up-to-date shoulder radiographs were evaluated for evidence of radiologic loosening. RESULTS: The mean follow-up period was 3.0 years (range, 2.5-7.8 years), and the mean age at the time of surgery was 76.5 years (range, 62-87 years). The mean ASES was 75.9 of 100 (range, 55-98.3), with a mean visual analog scale pain score of 2 of 10. The mean OSS was 42.5 of 48 (range, 35-48), and the mean CSS was 54.1 of 100 (range, 32-72). Upon radiographic assessment of the humeral component, 6 patients (30%) had 3 or more lucent zones, and 12 patients (60%) had a lucent zone measuring more than 2 mm in width; however, only 2 patients (10%) had 3 or more lucent zones measuring 2 mm or more in width and were identified as "at risk of loosening." No patients had tilt or subsidence of the humeral prosthesis. CONCLUSIONS: Our study demonstrated satisfactory functional and radiologic outcomes of patients compared with other studies, suggesting that RSA is a good management option for elderly patients with these fractures. The uncemented nature of the humeral component did not result in early loosening or failure.

A Technique of Superficial Medial Collateral Ligament Reconstruction Using an Adjustable-Loop Suspensory Fixation Device.

This report describes superficial medial collateral ligament reconstruction of the knee using a novel method of graft fixation with the ACL Tightrope RT (Arthrex, Naples, FL). After tibial fixation with either a standard interference screw or staple, femoral fixation of the semitendinosus tendon is performed with the adjustable-loop suspensory fixation device, which allows for both initial graft tensioning and re-tensioning after cyclical knee range of motion. This provides the ability for the graft to accommodate for resultant soft-tissue creep and stress relaxation, thereby allowing for optimal soft-tissue tension and reduction in laxity at the end of the procedure.

Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee.

BACKGROUND: Anatomic anterolateral ligament (ALL) reconstruction has been proposed to assist anterior cruciate ligament (ACL) reconstruction in controlling anterolateral rotational laxity of the knee. However, the biomechanical effects have not been reported. PURPOSE: (1) To investigate the effect of ALL transection on rotational knee kinematics and (2) to determine the effect on knee biomechanics of ALL reconstruction procedures compared with lateral extra-articular tenodesis (LET). STUDY DESIGN: Controlled laboratory study. METHODS: A total of 12 cadaveric knee specimens were tested in the following sequence: (1) ACLintact, (2) anteromedial bundle of ACL sectioned (ACLamb), (3) complete ACL sectioned (ACLfull), (4) ALL sectioned (ALLsec), (5) anatomic ALL reconstruction (ALLanat), and (6) LET. Biomechanical anterior drawer and Lachman tests were performed in which a 90-N load was applied to the posterior tibia, and anterior translation was measured. A combined load to simulate the early phase of the pivot-shift test was executed in which a 5-N·m internal rotation moment was applied to a fully extended knee; anterior translation and internal rotation were measured. RESULTS: Anterior translation increased across conditions for the biomechanical tests. Internal rotation during the simulated early-phase pivot-shift test was significantly different between ACLfull and ALLsec. Anatomic ALL reconstruction did not significantly reduce internal rotation or anterior translation during the simulated early-phase pivot-shift test. After LET, a significant decrease in anterior translation was found. There was no evidence of overconstraint of the knee with either anatomic ALL reconstruction or LET. CONCLUSION: The ALL demonstrated a role in controlling anterolateral laxity. LET had a composite effect in governing both anterior and rotational laxity. Anatomic ALL reconstruction did not reduce anterolateral rotational laxity. CLINICAL RELEVANCE: Profiling the biomechanical characteristics of anterolateral reconstruction is integral to understanding the implications and potential benefit of such an additional procedure to ACL reconstruction.