Rotationplasty after failed limb salvage: an alternative to amputation.

PURPOSE: Limb salvage procedures for musculoskeletal tumors have inherent complications. Though most complications can be managed with retention of the reconstructions, occasionally salvaging these reconstructions is not possible. We evaluated the outcomes of patients undergoing rotationplasty after multiple failed revisions of limb salvage surgery and document the success rate of this "salvage" technique and the subsequent functional outcome of these patients. METHOD: Between January 1, 1999, and December 31, 2018, 14 patients (12 male and 2 female) with a median age of 24 years (11-51 years) underwent rotationplasty after multiple failed revisions of limb salvage surgery. Indication for rotationplasty was infection (10 patients), failed megaprosthesis (2 patients), unstable biological reconstruction (1 patient) and local recurrence (1 patient). The mean number of surgeries done before the patient underwent rotationplasty was 5 (range 2-7). RESULTS: One patient developed a vascular complication (venous congestion) immediately after rotationplasty and underwent an early amputation. The remaining 13 patients had no surgical complications. Mean Musculo Skeletal Tumor Society score in 13 evaluable patients was 26 (23-30). CONCLUSION: Our study demonstrates the utility of rotationplasty as a "salvage" procedure after multiple failed lower limb salvage surgeries. It offers good success rates, low rates of complications and good functional outcomes in carefully selected cases.

The effect of COVID-19: Adopted changes and their impact on management of musculoskeletal oncology care at a tertiary referral centre.

BACKGROUND: COVID-19 pandemic has disrupted access to healthcare. Delay in diagnosis and onset of care increases cancer related mortality. We aim to analyse its impact on patient profile, hospital visits, morbidity in surgically treated patients and process outcomes. METHODS: We analysed an ambi-directional cohort from 16th March to June 30, 2020 (Pandemic cohort, PC) as compared to 2019 (Pre-pandemic cohort, PPC). We measured, new patient registrations, proportion of 'within state' patients vs 'rest of India', median time to treatment decision, proportion of patients seeking 'second opinions', modality of initial treatment (surgery/radiotherapy/chemotherapy), 30-day post-operative morbidity/mortality and conversion of inpatient-to 'teleconsult' in the PC. RESULTS: Between the 2 cohorts, new registrations declined from 235 to 69 (70% reduction). The percentage of 'within state' patients increased from 41.7% to 53.6% (11.9% increase). There was a decline in second opinion consults from 25% to 16%. The median time to decision-making decreased to 16 days in PC vs 20 days in PPC (20% reduction). Surgery was the first line of treatment in 40% as compared to 34% in the PPC with a mean time to surgery of 24 days in PC compared to 36 days in PPC (33% reduction). 66 surgeries were performed in the PC compared to 132 in the PPC. Thirty day post operative morbidity needing readmission remained similar (18% PC, vs 17% PPC). Perioperative intensive care remained similar in both cohorts. Teleconsultation was deemed medically safe in 92.8% (439/473 patients). CONCLUSIONS: The COVID 19 pandemic has substantially reduced access and onset to cancer care. Post operative morbidity and mortality did not seem to worsen with triage. Teleconsultation is an effective tool in optimizing follow up strategy.

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft.

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.

Is minimal reconstruction (meshplasty) adequate to restore ankle function after excision of distal fibula tumors?

BACKGROUND: Reconstruction modalities described after distal fibula resection varies from no reconstruction to size matched allograft or reconstruction with ipsilateral proximal fibula. Every procedure has their own limitation. We used Prolene mesh to reconstruct lateral restraint (Meshplasty) after distal fibulectomy. QUESTION: Is a minimal reconstruction using prolene mesh (meshplasty) adequate to restore ankle stability and function post distal fibula resection? METHOD: This retrospective analysis was performed in patients who underwent distal fibulectomy at the tertiary cancer hospital in India, between 01/01/2006 and 31/12/2016. Distal fibulectomy was performed through standard lateral approach. A prolene mesh was anchored to distal tibia and talus using screws or Ethibond sutures. Rehabilitation protocol included below knee cast for 6 weeks followed by gradual full weight bearing mobilization and ankle range of motion. Total 9 patients with mean age of 25 years (range: 13-43) got operated for distal fibulectomy during this period. Mean resection length was 13.3 cm (range: 9-20). RESULTS: Seven patients were available for final assessment at a median follow-up duration of 78 months (range: 34-161 months). Two patients developed local recurrence. Two patients developed distant recurrence both died of disease. One patient of GCT developed local recurrence in soft tissue at 30months, which was excised. Another patient of OGS developed local recurrence after 8 months along with distant recurrence. One patient of PNET developed distant recurrence at 3 months. One patient had a valgus deformity at 55 months follow up without any restriction of activity while the others had a stable ankle without any deformity. The mean MSTS score was 28 (24-29). CONCLUSION: "Meshplasty" after distal fibulectomy is an easy, reproducible, time and cost effective reconstruction modality with minimal complications. It adequately restores ankle function while providing results comparable to other procedures. LEVEL OF EVIDENCE: IV.

Outcomes of short segment distal radius resections and wrist fusion with iliac crest bone grafting for giant cell tumor.

BACKGROUND: Distal radius is third most common site for occurrence of Giant cell tumor (GCT) of bone. Most of Campanacci grade II & III cases require resection. Reconstructions of these defect are challenging. Though fibular arthroplasty provides mobility at wrist but is fraught with complications of donor site morbidity and instability with wrist pain. Wrist arthrodesis with ulna translocation provides stable reconstruction but is cosmetically less appealing. We present a series of 12 cases of GCT of distal radius treated with short segment (6 cm or less) resections and wrist fusion with iliac crest grafting. We evaluated donor site morbidity, functional and oncological outcomes. OBJECTIVES: To assess time to union, donor site morbidity, functional and oncological outcomes after wrist fusion with iliac crest bone grafting for distal radius resection (≤6 cm). METHODS: Retrospective analysis was performed from a prospectively maintained database between January 2011 and December 2017, 12 patients (7 male and 5 female; 9 primary and 3 recurrent; all Campanacci grade III) were included. Mean age was 29 years (15-41 years) with mean resection length of 5.1 cm (4.5-6 cm). The dominant hand was involved in 6 patients. Time to union, donor site morbidity, functional and oncologiacal outcomes were evaluated. Functional outcomes were evaluated using Musculo-Skeletal Tumor Society (MSTS) score and Patient Rated Wrist Evaluation (PRWE) score. Grip strength and arc of forearm rotation were also evaluated. RESULTS: All patients were available for analysis. No symptomatic donor site morbidity was observed. One patient had prominent implant following a fall and delayed union. Mean time to union for 22 osteotomy sites in rest of 11 patients (both proximal and distal) was 6 months (4-11 months). At median follow up of 45 months (18-78 months) 2 patients had soft tissue recurrence, 1 had a stable pulmonary metastasis. Local Recurrence rate was 17%. All patients returned to their pre surgery activity. Mean MSTS score was 25 (19-29) and PRWE score was 12 (6-28). Grip strength and Prono - supination measurements were available in 10 patients. Grip strength was 69% of non operated limb. Mean supination was 53° (0° to 80°) and mean protonation was 73° (40° to 80°). Mean arc of rotation was 126° (80° to 160°). CONCLUSION: Reconstruction of distal radius bone defects with Iliac crest bone grafting and wrist arthrodesis retains prono-supination while maintaining wrist girth (cosmesis). The oncologic and functional outcomes make it an acceptable modality in selected cases of distal radius tumours with short resection length (≤6 cm).