Clinical and functional results after total scapulectomy in orthopedic oncology: are custom-made scapular prostheses better than humeral suspension?

Background: In orthopedic oncology, total scapulectomy is necessary to allow a wide resection of extended malignancies of the scapula and scapular girdle. Scapular reconstruction is challenging even for the most experienced surgeon. This paper reports our experience with total scapular resections, followed by humeral suspension or custom-made prostheses. Methods: In this retrospective study, we evaluated all the oncologic patients treated in our institution between 2016 and 2023 with total scapulectomy and consequential reconstruction using humeral suspension or a custom-made prosthesis. Only cases suffering from malignant bone tumors were included. The postoperative functionality of the treated limbs was assessed using the Musculoskeletal Tumor Society (MSTS) scoring scale. Complications and local recurrences were also recorded. Results: Nine patients were enrolled. Five had custom-made implants, and four had humeral suspensions. The mean postoperative MSTS score of patients treated with custom-made prostheses was 24.0 (22-26). Globally, our cohort's mean MSTS score was 19.1 (9-26). Patients with custom-made prostheses had significantly better functional outcomes (MSTS 24 vs 13) and similar complication rates (40% vs 50%) than those who received humeral suspensions. Conclusion: Our outcomes suggest that, when feasible, custom-made scapular prostheses can represent a reliable reconstructive option after total scapulectomy for malignant scapular tumors.

Proximal Femur Megaprostheses in Orthopedic Oncology: Evaluation of a Standardized Post-operative Rehabilitation Protocol.

Background: Reconstructions of the proximal femur after massive resections represent one of the main challenges in orthopedic oncology. Among the possible treatments, megaprostheses represent one of the most used and reliable reconstructive approaches. Although literature about their outcomes has flourished through the last decades, a consensus rehabilitative treatment is still far from being established. Materials and methods: We evaluated the functional results of all our oncologic cases treated between 2016 and 2022 that could follow our standardized post-operative rehabilitative approach, consisting in progressive hip mobilization and early weight-bearing. Results: Twenty-two cases were included in our study. On average, their hospitalization lasted 15.1 days. The seated position was achieved on average within 3.7 days after surgery, the standing position reached 5.4 after surgery, while assisted deambulation was started 6.4 days after surgery. After a mean post-operative follow-up of 44.0 months, our patients' mean MSTS score was 23.2 (10-30). Our data suggested a statistically significant inverse linear correlation between post-operative functionality and patients' age, resection length, and the start of deambulation. Conclusions: A correct rehabilitation, focused on early mobilization and progressive weight-bearing, is crucial to maximize patients' post-operative functional outcomes.

Distal Femur Megaprostheses in Orthopedic Oncology: Evaluation of a Standardized Post-Operative Rehabilitation Protocol.

BACKGROUND AND OBJECTIVES: Megaprostheses are the most used reconstructive approach for patients who have undergone massive resection of their distal femurs due to bone tumors. Although the literature about their outcomes has flourished in recent decades, to date, a consensus on rehabilitative treatment is yet to be established. In this study, we report on our experience with our latest standardized rehabilitation program, evaluating our results in a mid-to-long-term scenario. MATERIALS AND METHODS: We evaluated the functional results of all our oncologic patients treated between 2016 and 2022 who could follow our standardized post-operative rehabilitative approach, consisting of progressive knee mobilization and early weight-bearing. RESULTS: Sixteen cases were included in our study. The average duration of the patients' hospitalization was 12.2 days. A standing position was reached on average 4.1 days after surgery, while assisted walking was started 4.5 days after surgery. After a mean post-operative follow-up of 46.7 months, our patients' mean MSTS score was 23.2 (10-30). Our data suggest that the sooner patients could achieve a standing position (R = -0.609; p = 0.012) and start walking (R = -0.623; p = 0.010), the better their final functional outcomes regarding their MSTS scores. CONCLUSIONS: Rehabilitation should be considered a pivotal factor in decreeing the success of distal femur megaprosthetic implants in long-surviving oncologic patients. Correct rehabilitation, focused on early mobilization and progressive weight-bearing, is crucial to maximizing the post-operative functional outcomes of these patients.

Preliminary Results of Preoperative Planning Using 3D Printing and Augmented Reality in Cryotherapy Treatment of Giant Cell Tumor of Bone-CRIO2AR Project.

Giant Cell Tumor of Bone is a benign tumor with high local aggressive expansion, which, in rare cases, spreads metastasis. Surgical treatment, which often consists of wide curettage to reduce recurrence risk, can lower the quality of life for those affected. Along with aggressive surgery, adjuvant intraoperative techniques have been implemented such as PMMA and cryotherapy. One of the most widely used cryotherapy techniques involves the use of probes to generate ice balls, which have been scientifically shown to have various impacts on the tumor. Although this has been acknowledged, no one has yet tested a way to accurately plan the positioning of cryotherapy probes before surgery, according to the research conducted by the authors. CRIO2AR is a randomized clinical prospective ongoing study by which it will be experimented via preoperative planning of ice probes placement using AR and 3D printing technologies. By studying a single clinical case with these technologies, the surgeon gains better awareness of patient's anatomy and tumor localization. Preliminary results are shown in the article. The first results are confirming that these technologies are applicable in clinical practice. Secondly, preoperative planning is proving to be reliable, easily replicable, and useful for the surgeon.

Aneurysmal Bone Cyst of the Pelvis in Children and Adolescents: Effectiveness of Surgical Treatment with Curettage, Cryotherapy and Bone Grafting.

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign but locally aggressive cystic lesions of the bone. Pelvic ABCs are extremely rare and hard to treat due to their high risk of local recurrence and the tough access to pelvic bones. METHODS: In this retrospective study, we evaluated pediatric cases with pelvic ABC treated with curettage, cryotherapy and bone grafting treated in our institution between 2016 and 2022. Complications were recorded, as well as local recurrences. Patients' post-operative functionality was assessed with the MSTS score. RESULTS: Fourteen consecutive cases were included in our study. Their mean age at surgery was 13.5 years. The mean lesion size was 55 mm. The mean follow-up was 38 months. Two cases (11.8%) had local recurrences, which were successfully treated with further curettage. At their latest FU, 13 cases were continuously disease free (CDF), and one had no evidence of disease (NED). Only one case had a post-operative compilation (wound dehiscence). Patients' mean post-operative MSTS score was 29.6. CONCLUSIONS: Pelvic ABCs are a challenge, even for the most experienced orthopedic surgeon. Our study suggests that the association of an accurate curettage, intraoperative cryotherapy and bone grafting can be a reliable and effective therapeutic option for large-sized ABCs of the pelvis.

Hemicalcaneal reconstruction with a 3D printed custom-made prosthesis after partial calcanectomy due to a malignant bone tumor.

The malignant bone tumors of the calcaneus are extremely uncommon lesions. Surgical approach can consist in either an amputation or in a limb sparing procedure, depending on the width and the location of the neoplasm. Although several reconstructive options have been proposed to fulfill the bone defect in those cases that received a selective resection, to this date a consensus reconstructive approach is far from being established. Among the alternatives described in literature, 3D printed custom-made prostheses represent one of the most intriguing and promising reconstructive options. Herein, we report our experience of a spindle cell bone sarcoma of the calcaneus treated with selective resection of the anterior segment of the calcaneus and further reconstruction with a 3D printed custom-made prosthesis, based on patients' own anatomy. The posterior calcaneus and the insertion of the Achilles tendon were preserved. The resection was performed with wide margins and no major complication occurred through the intra-operative or post-operative intercourse. At her latest follow-up, our patient showed good functional results and was continuously disease free. Our outcomes therefore suggest that a partial prosthetic replacement of the anterior calcaneus with preservation of the Achilles insertion site may represent a safe and effective solution for cases that required the resection of the anterior calcaneus due to a malignant bone tumor.

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications.

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Outcomes of Surgical Treatment for Localized Tenosynovial Giant-Cell Tumor of the Foot and Ankle: A Case Series.

Background: Giant cell tumor of the tendon sheath (GCTTS), also termed Tenosynovial giant cell tumor (TGCT), is a locally aggressive tumor which originates from tendon sheaths or bursas. Around 3-5% of these tumors arise from foot and ankle. Localized lesions in this area are often manifested as firm masses or nodules with slow but continuous progression through months and years. Pain associated with weight-bearing, as well as limitations in joint motions, may be reported, depending on tumor's location. Surgery is the treatment of choice for the definitive removal of GCTTSs with the aim to eradicate the neoplasm and restore the lower limb's functionality. Methods: Thirteen cases suffering from GCTTS of the foot and ankle underwent surgical resection at our institution between 2017 and 2022. For each case we recorded pre-operative and post-operative symptoms, as well as their pre-operative and post-operative functional status according to both MSTS and AOFAS scores. Eventual complications and local recurrences were reported. Results: Each patient experienced an at least mild pain before surgical treatment. The mean pre-operative MSTS and AOFAS scores were 22.8 and 70.7, respectively. The mean tumor size was 17.7 mm. Each patient received a resection with wide margins. Two cases (15.4%) had local recurrences. None had major complications at their latest follow-up. After the surgery, the mean post-operative MSTS and AOFAS scores increased to 28.3 and 92.2, respectively. Conclusion: Resection with wide margins for foot and ankle GCTTS is effective in restoring the patients' lower limb functionality and is associated with reasonable local recurrence rates.

Hamstring Graft Preparation for ACL Reconstruction.

Anterior cruciate ligament (ACL) reconstruction represents one of the most common procedures in orthopedic surgery. It usually involves the harvest of both gracilis and semitendinosus tendons from the ipsilateral knee. Different methods of hamstring graft preparation have been proposed in recent years, to create an adequate graft diameter reducing morbidity linked to gracilis tendon harvesting procedure. More recently, the use of only 1 of the tendons (semitendinosus) in a tripled or quadrupled arrangement has been described, especially in an all-inside type of reconstruction. Having a thicker tendon with a quadrupled semitendinosus (ST), instead of double gracilis and ST enables to have a graft with enough diameter to resemble more closely the native ACL and decreases the risk of graft re-rupture. The present study aims to describe different options of hamstring graft preparing, listing and analyzing each configuration to help surgeons to choose the most suitable graft type for their patients.

Dedifferentiated chondrosarcoma of the ring finger: a case report of an exceptional surgical treatment and review of literature.

The DDCS is a rare, highly malignant tumor characterized by two distinct histopathologic components. The diagnosis is insidious, and the prognosis is poor. The therapy is primarily surgical. It is possible to associate chemotherapy if the nonchondrogenic component is a responder. Unfortunately, very few cases of DDCS of the hand are described in the literature. Therefore, few scientific comparisons are possible regarding diagnosis and therapy. For this reason, we decided to present a sporadic case of DDCS of the fourth finger of the left hand, presented with a seven months history of pain and swelling, which appeared after the treatment of recurrent enchondroma and was treated with amputation and complex reconstruction. To our knowledge, no similar cases have been previously reported in the literature.

Synovial sarcomas: A single surgeon experience of 130 cases.

BACKGROUND: Synovial sarcoma is a rare malignant tumor that generally requires a multidisciplinary therapeutic approach. In this study we report the experience of a single surgeon, evaluating surgical and oncological outcomes of the cases he treated through his 30 years carrier. METHODS: We enrolled patients treated surgically between 1988 and 2018. Surgical and medical treatments, as well as surgical and oncological results, were investigated. RESULTS: One hundred and thirty cases were included. Surgical resection was carried out achieving wide margins in 90% of the cases. At their latest follow-up, 76 patients were continuously disease free, 16 were no evidence of disease, and other 16 were alive with disease. Twenty cases were dead of disease and two dead of other causes. Twenty-five patients (19%) had local recurrence of synovial sarcoma through their postoperative intercourse. Thirty-seven patients (28%) were diagnosed with at least a metastasis during their follow-up. The global survival of our population, at each patient's latest follow-up, was 82%. Cases with tumor size above 5 cm had a significantly higher risk to develop metastasis (p = 0.002). CONCLUSIONS: Synovial sarcoma is a threatening disease and represents a challenge for oncological physicians and surgeons. Early diagnosis and multidisciplinary approach are mandatory to limit the spread of synovial sarcomas, maximizing the effectiveness of surgery and the other treatments.

Peri-Implant Distal Radius Fracture: Proposal of a New Classification.

A peri-implant fracture near the volar plate of the distal radius represents a rarity and can be associated with a mechanical failure of the devices. A literature review was conducted including all fractures that occurred around a volar wrist plate, which could be associated with an ulna fracture. All articles published until December 2021 were considered according to the guidelines presented in the PRISMA Statement. The search was conducted with the PubMed electronic database, Cochrane Database of Systematic Reviews, Medline, Embase, and Google Scholar. Only nine cases of these fractures were reported in the literature. The causes could be due to delayed union/non-union of the old fracture after low energy traumas, high energy trauma in patients with poor bone quality, or hardware mechanical failure. Furthermore, the literature review of peri-implant radius fracture shows different level of radius fracture and types of implant failure. In accordance with these different cases, a new classification of peri-implant fracture of the distal radius is proposed.

Schwannomas of the peroneal nerves: Clinical and functional results of surgical treatment.

OBJECTIVES: Peroneal nerves Schwannomas are rare benign tumors. Literature is still poor of studies about clinical and functional outcomes after surgical treatment. We evaluated the pre-operative presentation of the disease and assessed clinical and functional outcomes after surgery. METHODS: We collected all the cases of peroneal nerves' neurinoma treated surgically between June 2016 and June 2020. We analyzed each patients' personal data and carried out accurate clinical examinations before and after surgery. MRI was performed both pre-operatively and post-operatively. RESULTS: We reported 9 cases of peroneal nerves schwannomas: five arising from the common peroneal nerve and four arising from the deep or superficial branches alone. Their mean size was 22.6 mm. Each patient showed sensation deficits before surgery; pre-operative MRC score was 4.2. Pre-Operative MSTS and LEFS scores were 23.6 and 64.4. Surgery was successful in each case. No local recurrence nor major complication occurred. Tumor size was significantly associated with both diagnostic delay and development of pre-operative deficits. Surgery was proven to be globally successful: post-operative evaluations highlighted a marked reduction of neurological signs and overall functional limitations. CONCLUSIONS: Surgical treatment at early stages of the disease represents a reliable and relatively safe therapeutic option.

Peripheral schwannomas of the tibial nerve: surgical results in a case series.

BACKGROUND AND AIM OF THE WORK: Schwannomas of the lower limb are uncommon benign tumors and those arising from Tibial Nerve are particularly rare. We report our experience on the topic, with particular attention to clinical presentation and lower limbs overall functionality before and after treatment. Our aim is to assess clinical impairment caused by the tumor and evaluate the effectiveness of surgical treatment. MATERIALS AND METHODS: Time between symptoms outbreak and diagnosis, as well as pre- operative tumor size were evaluated for each case. Pre-operative and post-operative overall lower limb functionality were assessed using both MSTS and LEFS scores. Sensitive symptoms and muscular strength were also evaluated before and after surgery. RESULTS: 7 patients were included in our study. The mean follow-up was 22.9 months. Average diagnostic delay was 8 months and tumor size was 29.3mm. Before surgery each patient had positive Hoffmann-Tinel sign and an at least mild paresthesia, 57% of our cases had slight reduction of muscular strength. Pre-operative MSTS score was 24.4 and LEFS score was 64.7. Tumor size and diagnostic delay were associated with pre-operative functionality. No major local complication was recorded during or after surgery. Each patient with pre-operative sensitive or motorial deficit benefited the effects of surgical treatment. CONCLUSIONS: Our cases suggest early diagnosis could reduce the impact of the disease on patients' activities of daily living and quality of life. Surgery, for its part, represents a safe and reliable approach to Tibial Nerve schwannomas with good chances of clinical and functional remission.

Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management.

Proximal humerus is one of the anatomical sites that are most frequently involved by bone and soft tissue malignant tumors. Alone or in association with adjuvant treatments, surgery represents the main therapeutic option to treat and eradicate these diseases. Once the first-line option, in the last decades, amputation lost its role as treatment of choice for the large majority of cases in favor of the modern limb sparing surgery that promises to preserve anatomy and-as much as possible-upper limb functionality. Currently, the main approaches used to replace proximal humerus after a wide resection in oncologic surgery can be summarized in biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions. The purpose of this overview is to present nowadays surgical options for proximal humerus reconstruction in oncological patients, with their respective advantages and disadvantages.

Acral Dedifferentiated Chondrosarcoma: Report of a Case Arising in the Proximal Phalanx of the Fourth Finger.

Dedifferentiated chondrosarcoma is a well-recognized entity, but its occurrence in the distal extremities is exceedingly rare. We present the case of a 49-year-old woman who experienced local recurrence of an "enchondroma" of the proximal phalanx of the fourth finger of the left hand, which had been initially treated with intralesional curettage at another hospital 4 years before, and 1 year before for a local recurrence. The imaging findings indicated an aggressive behavior, and an incisional biopsy showed a highly cellular proliferation of spindle and pleomorphic elements without evidence of matrix production intermixed with few fragments of a well-differentiated cartilaginous neoplasm with bland cellular atypia, focal nuclear hyperchromatism, and binucleation. An isocitrate dehydrogenase 2 R172S mutation was detected. The final diagnosis was dedifferentiated chondrosarcoma. Despite amputation of the fourth finger, the patient developed lung metastases and further local relapse. Recurrent cartilaginous tumors of the extremities should not be underestimated and should be followed in view of the possible acquisition of aggressive clinical behavior.

A rare case of peri-implant distal radius fracture.

A peri-implant fracture near the volar plate of distal radius represent a very rare injury. The main factor of this lesion is high energy trauma on the wrist. We report a case of a 61-year-old woman with a peri-implant fracture located just proximally to the plate and a fracture of the ulnar head that occurred after a simple fall. The patient was surgically treated by plate and screws removal. The fracture was fixed using a longer volar plate for the radial fracture and a plate for the head ulnar fracture. Different factors such as osteoporosis, BMI and screw position could influence the fracture pattern. However, considering growing use of plates for distal radius fracture fixation, the frequency of these kind of fracture will probably increase.

Isolated osteoblastoma of the cuboid bone: A case report and review of the literature.

Osteoblastoma is a relatively rare, benign, bone-forming tumor, commonly observed in the second and third decades of life. Spine and the long tubular bones are the most common sites of involvement. Osteoblastoma is infrequently seen in other sites, including the bones of hand and foot. A rare case of a 35-year-old man that presented an osteoblastoma of the cuboid bone is reported. The patient was treated with surgical resection and grafting. After the intervention, the patient recovered with no clinical and radiological evidence of recurrence after one year of follow-up. Several cases of osteoblastoma-like variant of osteosarcoma of the cuboid have been previously reported, but, to our knowledge, this is the first case of conventional and isolated osteoblastoma involving the cuboid bone reported in the literature.

Bone Marrow Concentrate in the Treatment of Aneurysmal Bone Cysts: A Case Series Study.

INTRODUCTION: A recent attractive option regarding mesenchymal stem cells (MSC) application is the treatment of bone cystic lesions and in particular aneurysmal bone cysts (ABC), in order to stimulate intrinsic healing. We performed a retrospective evaluation of the results obtained at our institution. METHODS: The study group consisted of 46 cases with an average follow-up of 33 months. Forty-two patients underwent percutaneous treatment as the first approach; four patients had curettage as first treatment. In all cases, autologous bone marrow concentrate (BMC) was associated too. The healing status was followed up through a plain radiograph 45 days and 2 months after the procedure. Results and Conclusions. At the final follow-up, thirty-six patients healed with a Neer type II aspect, nine healed with a type I aspect, and one patient was not classified having total hip arthroplasty. Bone marrow concentrate is easy to obtain and to manipulate and can be immediately available in a clinical setting. We can assert that the use of BMC must be encouraged being harmless and having an unquestionable high osteogenic and healing potential in bone defects.