Prognostic Factors Influencing Survival and Oncological Outcome in Patients with Parosteal Osteosarcoma.

This study aimed to evaluate the significance of radiological (magnetic resonance imaging [MRI]) findings, surgical, and previous interventions on prognosis with oncological and functional outcome in patients with parosteal osteosarcoma (POS). Twenty-seven patients (8 male/19 female) who were operated with the diagnosis of primary POS in our institution were retrospectively reviewed. The epidemiological data, biopsy method, misdiagnosis/improper interventions, and delay in diagnosis were noted. The lesions' maximum circumferential extension, maximum longitudinal extension, intramedullary involvement, and neurovascular extensions in MRI sections were evaluated, and the resection type (segmental intraarticular/segmental intercalary/hemicortical), reconstruction type (biologic/non-biologic), and surgical margins were noted. Functional and oncological results at the last follow-up were assessed. The mean age was 31.6 (12-73) years, and mean follow-up was 80.8 (24-270) months. Intramedullary involvement percentage was related with maximum circumferential extension percentage and maximum longitudinal extension. (p = 0.006, p = 0.005) The intramedullary involvement ratio of ≤ 10% suggested no recurrence or metastasis. The neurovascular encasement was related to metastatic disease, deep infections, and complication related surgeries (p = 0.017, p = 0.002, p = 0.005). The most common resection type was segmental intraarticular resection (63%). The maximum circumferential extension percentage, the maximum longitudinal extension of the lesion, intramedullary involvement percentage, and neurovascular encasement had lower MSTS scores (p = 0.003, p = 0.028, p = 0.038, p = 0.022). The mean MSTS score was 81.1% (60-100%). The 5-year overall survival was 96.3%, local recurrence-free survival was 77.2%, and metastasis-free survival was 69.4%. The lesions' extent of intramedullary involvement, neurovascular bundle proximity, and maximum periosteal circumferential extension on MRI should be considered when planning the surgery.

What factors are associated with osteoarthritis after cementation for benign aggressive bone tumor of the knee joint: a systematic review and meta-analysis.

Background: The current systematic review aimed to answer the following questions: (i) Does extended curettage combined with the PMMA technique for the treatment of aggressive bone tumors around the knee led to the development of knee osteoarthritis? (ii) What factors are associated with osteoarthritis after bone cementation around the knee joint? Methods: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All electronic searches were performed on November 20, 2022, by a single researcher who evaluated the full texts of potentially eligible studies to determine inclusion. In these patients, the presence of osteoarthritis secondary to the surgical procedure was investigated. Data extracted included study type, characteristics of participants, sample size, gender, tumor site (femur or tibia), secondary osteoarthritis, tumor volume, distance from the joint cartilage, reoperation, follow-up time, Campanacci grade, and pathological fracture. Results: In total, 11 studies comprising 204 patients were evaluated, and it was found that 61 (30%) patients developed knee osteoarthritis due to extensive curettage and bone cement application for benign aggressive tumor treatment. According to the results obtained based the random effects model with the 11 studies included in the meta-analysis, the mean odds ratio of development knee OA with the 95% CI was calculated as -2.77 (-3.711, -1.83), which was statistically significant (z = -5.79; P < 0.000). Conclusion: The association of distance between the tumor and joint cartilage and development of osteoarthritis was not shown in this meta-analysis. Level of Evidence: Level IV prognostic study.

Is higher body mass index associated with secondary osteoarthritis in patients treated with bone cement for benign aggressive bone tumors? Long-term evaluation of 43 patients.

BACKGROUND: This study was designed to investigate the secondary osteoarthritis rate in patients with benign aggressive bone tumors treated with curettage and cementing at long-term follow up. METHODS: Patients diagnosed with benign aggressive bone tumor (giant cell or aneurysmal bone cyst), treated with extended curettage and cementation with polymethylmethacrylate, who had a minimum of 60 months of follow up after surgery were included in this study. After definitive diagnoses were confirmed by a histopathologist, we decided to perform standard surgical management. Osteoarthritis was staged radiologically using the Kellgren-Lawrence scoring system, and the contralateral knees of the patients were used as the control group. Based on the Kellgren-Lawrence classification system, stages 3 and 4 were accepted as the existence of osteoarthritis. Body mass index, the distance to the subchondral joint line, tumor mass volume, the location of the tumor (i.e., femur, tibia, medial condyle, or lateral condyle), age, and sex were also investigated, all of which are factors that can affect the occurrence of osteoarthritis. RESULTS: Forty-three patients, 24 male (56%) and 19 female (44%), were included in the study. The mean age of the patients was 29.5 ± 10 years, and mean follow up duration was 128.7 months. Tumor localization was the distal femur in 20 patients (46.5%) and the proximal tibia in 23 patients (53.5%). The mean tumor mass volume was 77.84 cm3 and the distance to the knee joint subchondral line was 3.2 ± 2 mm. According to this scoring system, 14 patients were at stage 0, 10 patients were at stage 1, 10 patients were at stage 2, four patients were at stage 3, and five patients were at stage 4. When we compared osteoarthritis development, the affected knee had a significantly higher rate of osteoarthritis development than the contralateral knee. A univariate analysis demonstrated that age (P = 0.002) and body mass index (P = 0.045) were associated with secondary osteoarthritis. Moreover, multivariate analysis demonstrated that none of the variables were independently associated with secondary osteoarthritis. CONCLUSION: Patients with contralateral osteoarthritis had bilateral knee osteoarthritis, indicating that primary osteoarthritis progressed in both knees. Seven of the 43 patients (16.2%) showed secondary osteoarthritis. Although age and body mass index were associated with secondary osteoarthritis in univariate analysis, none of the variables were independently associated with secondary osteoarthritis in the multivariate analysis.

Is liquid nitrogen recycled bone and vascular fibula combination the biological reconstruction of choice in lower extremity long bone tumor-related defects?

INTRODUCTION: Combination techniques, which encompass the combined use of vascularized bone grafts with massive allografts or autografts (recycled bone grafts), are especially important in the biological reconstruction of tumor-related lower extremity long bone defects. Liquid nitrogen recycled bone (frozen autograft) and free vascular fibula graft (FVFG) combination, which was coined as the "frozen hotdog (FH)" method by the authors, has not been as widely used nor its outcomes reported for significantly sized patient groups. This study aims to provide an answer to whether FH is a safe and effective reconstructive tool for limb salvage in malignant tumors of the lower extremity regarding radiological, functional, and oncological outcomes. PATIENTS AND METHODS: Sixty-six (male/female: 33/33) patients, who underwent FH reconstruction for tumor-related massive defects of lower extremity long bones between 2006 and 2020, were retrospectively analyzed. The mean age was 15.8 (3.8-46.7) years. The most common tumor localizations were distal femur (42.4%) and proximal tibia (21.2%) while classic osteosarcoma and Ewing's sarcoma were the most common pathologies (60.6% and 22.7%, respectively). Mean resection and FVFG lengths were 160 (90-320) mm and 192 (125-350) mm, respectively. The mean follow-up was 73.9 (24-192) months. RESULTS: The mean MSTS score was 25.4 (15-30) and the mean ISOLS radiographic score was 22.6 (13-24). Mean time to full weight bearing without any assistive devices was 15.4 (6-40) months and the median time was 12 months. MSTS score negatively correlated with resected segment length and vascular fibula length (p < 0.001; p = 0.006). Although full contact apposition of the FH segment correlated with earlier full weight bearing compared to partial apposition (mean 13.7 vs. 17.9 months) (p = 0.042), the quality of reduction did not affect the ISOLS radiographic score at LFU. Overall limb survival rate was 96.3% at 5 and 10 years while FH survival rate was 91.0% and 88.1% at 5 and 10 years. Local recurrence-free survival rates were 88.8% and 85.9%, and overall survival was 89.9% and 86.1% at 5 and 10 years, respectively. Limb length discrepancy was the most common complication with 34 (51.5%) patients while shell nonunion was seen in 21 (31.8%) patients and graft fracture in 6 (9.1%). CONCLUSION: The "FH" method is a safe, effective, and extremely cost-efficient reconstructive tool for tumor-related lower extremity long bone defects. Patient compliance to protracted weight-bearing, ensuring the vitality of the FVFG, and achieving an oncologically safe resection are key factors for a successful outcome.

Treatment of neuropathic unstable knee osteoarthritis by a condylar, rotating-hinge prosthesis with cementless pentagonal stem: a case series.

INTRODUCTION AND IMPORTANCE: Total knee arthroplasty (TKA) in the neuropathic unstable knee (NUK) setting is classically a challenging orthopedic problem due to intraoperative technical difficulties and a higher frequency of periprosthetic complications. More recently, satisfactory results have been reported using improved constraints, stems and revision-type TKA components. The study aims to present long-term results of a small case series with NUK osteoarthritis reconstructed by a condylar, semi-constrained prosthesis with a polygonal, hydroxyapatite-coated (HA-coated) press-fit stem. CASE PRESENTATION: From 2009 through 2010, three knees in three patients with advanced NUK arthropathy underwent TKAs in our institution using the PENTA® prosthesis. The average age at surgery was 44 years (32-58). The patients were followed up for a mean period of 124 months (120-128). The etiology of NUK was determined to be poliomyelitis sequela in 2 cases and spinal cord injury in one case. Functional outcomes were assessed with Knee Society (KS) Knee and Function Scores, and radiological outcomes were evaluated with ISOLS radiographic implant scores. Patients were monitored for complications clinically and radiologically. CLINICAL DISCUSSION: KS knee scores improved from a mean of 12,3 (0-37) preoperatively to 71,3 (65-77) and KS function scores improved from a mean of 1,7 (0-5) preoperatively to 68,3 (55-80) at the latest follow-up. Radiological outcomes were excellent according to ISOLS scores, and no complications were observed. CONCLUSION: Although this is a small case series, the significant improvement in functional scores, excellent radiological outcome, and implant survival at the end of a long follow-up period warrants TKA with a semi-constrained hinged implant in the setting of NUK. PENTA® prosthesis offers a good choice of implant with its hydroxyapatite-coated, press-fit, pentagonal stem and precisely designed rotating hinge.

Does the technique of limb lengthening affect physeal growth in patient with achondroplasia? Comparison of the simultaneous and consecutive tibia and femur lengthening with external fixators.

We aimed to retrospectively investigate and compare patients who underwent bilateral simultaneous and consecutive lengthening surgery of the femur and tibia in terms of the effect on physeal growth. We hypothesize that compared with the sequential lengthening technique, simultaneous lengthening of the bilateral femur and tibia affects physeal growth to a greater extent. Twenty-six patients with achondroplasia who operated in our clinic between 1995 and 2015 for limb lengthening were included in the study. Fourteen patients with bilateral lengthening of the femur and tibia at the same time were named as simultaneous bilateral lengthening (SBL). Twelve patients with bilateral lengthening of the femur and then bilateral tibia lengthening in other sections or vice versa, at a different time was named consecutive bilateral lengthening (CBL). All patients were followed until at least 18 years old. The physeal arrest was measured with predicted final length at the first visit (investigated with the multiplier method), the total amount of lengthening, and final clinical, and radiological length. Mean limb lengthening was 145 mm (48.5%) and 151 mm (46.6%) for simultaneous and consecutive groups respectively. For lower extremity length, the first group reached 527.6 mm while the expected was 447.3 mm. Considering 151 mm lengthening, the mean growth disturbance for the SBL group was 70.7 mm and for the CBL group was 47.5 mm. For total height comparing between two groups, disturbance for height was 80.5 mm and 65.4 mm, respectively. Although there was no statistical difference, simultaneous bilateral femoral and tibial lengthening has more physiological physeal disturbance effects than consecutive lengthening in patients with achondroplasia.

Femoral Discrepancy After Childhood Bone Sarcoma Surgery Can Be Treated With Magnetic Intramedullary Nails.

This study aims to determine whether femoral lengthening with a magnetic motorized intramedullary nail (PRECICE; NuVasive) is safe and effective in patients with discrepancy due to limb salvage performed for bone sarcomas before skeletal maturity. Six patients (male, 4; female, 2) with a mean age of 9.3 years (range, 4.8-12.8 years) at the time of index limb salvage surgery were retrospectively analyzed. Four patients had undergone biological reconstruction with liquid-nitrogen recycled frozen autograft shell and inlaid vascular fibula combination and 2 had undergone nonbiological reconstruction with distal femur modular tumor endoprosthesis. The mean age at PRECICE operation was 16.1 years (range, 13.4-20.1 years). The mean prelengthening femoral discrepancy was measured as 60 mm (range, 39-80 mm). Lengthening was achieved in 5 of these 6 patients. Although the PRECICE nail was successfully implanted in the sixth patient, lengthening could never be performed owing to failure to overcome the chronic diaphyseal nonunion first, as intended with compressive use of the nail. For the other 5 patients, in whom lengthening was performed, the mean lengthening was 45 mm (range, 35-52 mm), the mean ratio of achieved to planned lengthening was 93% (range, 74%-100%), and the mean bone-healing index was 41 days per cm (range, 24-69 days per cm). Mean Musculoskeletal Tumor Society score improved from 25.6 to 27.2 after lengthening. No major complications occurred. The outcomes of this study demonstrate that the PRECICE implant can safely and effectively correct femoral length discrepancy caused by limb salvage performed for osteosarcoma before skeletal maturity. [Orthopedics. 2023;46(1):27-34.].

The Relationship Between Limb Lengthening Rate and Callus Quality in Patients with Achondroplasia.

Objectives: This study investigated the effect of the femur, tibia, and humeral lengthening rate in patients with achondroplasia and regenerated bone quality. Methods: The records of the patients with achondroplasia who underwent limb lengthening surgery for both upper and lower extremities between 2002 and 2019 were retrospectively reviewed. Bone formation regeneration was evaluated in each segment at anteroposterior and lateral radiographs and the callus quality was determined at the first month of the consolidation period according to Li's classification system. Results: This study included 42 (28 females and 14 males), 38 (26 females and 12 males), and 17 (11 females and 6 males) patients with bilateral femoral, bilateral tibial, and bilateral humeral lengthening. The mean lengthening rate was 0.920 ± 0.23 (range, 0.53-1.67), 0.813 ± 0.17 (range, 0.51-1.26), and 1.02 ± 0.26 (range, 0.58-150) mm/day in the femoral, tibial, humeral groups, respectively. In the femoral group, 75% femur with good morphological quality, 56.6% good morphological quality in tibial group and 55.9% good morphological quality in humeral group. Statistically significant relationships were found between femoral lengthening rate and callus quality (p < 0.001; r = 0.454). However, no significant correlation was found in the humeral and tibial groups. Moreover, the sensitivity and specificity of the lengthening rate for obtaining good morphological quality callus were 72% and 80%, respectively, with an optimum diagnostic cutoff value of 0.976 mm/day for femoral lengthening. Conclusions: A higher-rate good morphological callus was obtained in femoral lengthening compared with tibia and humerus in patients with achondroplasia.

Mid-term implant survival, functional and radiological results and mechanical complications of mega-prosthetic reconstruction around the knee with the PENTA® system.

AIM: Mega-prosthetic reconstruction is the most common treatment method for massive osteoarticular defects caused by tumor resection around the knee. The new implant is a highly modular rotational-hinged megaprosthesis system with a distinct pentagonal stem geometry and variable implantation options. The aim of this study is to present the mid-term implant survival characteristics, functional and radiological results and mechanical complication profile of the new megaprosthesis. METHODS: One hundred and one mega-prosthetic knee reconstruction procedures in 90 patients (M/F: 51/39) utilizing the new implant system were retrospectively analyzed. In 68 patients, the megaprosthesis was used for primary reconstruction following tumor resection while it was used for revision of other implants in 22. The mean age was 28.5 (7-66) years and the mean follow-up was 59.2 (24-124) months. The most common primary pathology was osteosarcoma with 63-70% patients, the most common anatomical site of involvement was the distal femur with 56-62% patients. RESULTS: Henderson Type 2 failure (aseptic loosening) was seen in only 2-2.2% patients while Type 3 (structural failure) was seen in 29-32.2% Although the 5-year anchorage survival rate was 94.3%, overall mechanical implant survival was 76.1% at 5 years due to a relatively high failure rate in the first-generation hinge mechanism of the implant. The 5-year hinge survival rate demonstrated a significant improvement rate from 61.7% to 87.2% between the first and second generations of the implant (p = 0.027). The mean MSTS score was 24 out of 30 (14-29). The mean cumulative ISOLS radiographic score for index megaprosthesis operations was 19.7 (12-24), which corresponded to excellent outcome. CONCLUSION: The new megaprosthesis system is a reliable choice for the reconstruction of tumor-related massive osteoarticular defects around the knee. Although long-term follow-up is necessary for a definitive evaluation of the implant's survival characteristics, midterm follow-up yields exceptional anchorage properties related to pentagonal stem geometry with very good functional outcomes.

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia.

PURPOSE: This study aims to evaluate the effect of lengthening speed on the quality of callus and complications during distraction osteogenesis and describe an optimal lengthening speed in patients with congenital pseudarthrosis of tibia (CPT). METHODS: Twenty-seven patients with CPT with a minimum follow-up of 36 months who underwent limb lengthening surgery between 1997 and 2016 with external fixator only were included in this study. All patients underwent lengthening procedures after achieving complete bone union in this study. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction period. Complications were noted in post-operative follow-up period. Receiver operator characteristics (ROC) curve analysis was performed to obtain optimal lengthening speed for these patients. RESULT: The mean age at the time of surgery was 5.74 years. The mean lengthening speed was 0.596 mm/day. Follow-up period of 136.14 months with a mean lengthening period of 92.4 days. Mean amount of lengthening was 5.44 cm for patients with CPT. Total rate of callus with good morphological quality was calculated as 66%. According to ROC analysis, optimal cut-off values of lengthening speed for the obtaining good morphological quality callus was 0.564 mm/day for tibial lengthening in CPT. There was a significantly positive correlation between complication rate and lengthening speed for each group. CONCLUSION: We recommend a mean lengthening rate of 0.56mm/day for the lengthening procedures with external fixator in patients with CPT who had complete bone union at the area of pseudarthrosis.

Congenital pseudarthrosis of the tibia: Results of circular external fixation treatment with intramedullary rodding and periosteal grafting technique.

OBJECTIVE: This study investigated the clinical and functional results of treating congenital pseudarthrosis of the tibia (CPT) using the combined techniques of hamartoma resection, periosteal grafting, circular external fixator application, and intramedullary rodding. METHODS: The clinical and radiological data of 17 patients (mean age at the treatment time: 7.6 months (range: 4.6-9.7 months) with CPT, treated by a single surgeon between 1997 and 2017, were retrospectively analyzed. All data regarding surgical interventions, complications, deformity analysis parameters, limb length discrepancy (LLD), ankle joint range of motion, and residual deformities were reviewed. All the patients were followed up at least two years after the last surgical intervention. The mean follow-up time was 8.5 years (range: 2.2 to 15.7 years). RESULTS: Union was achieved with the index treatment in 15 of the 17 cases (88.2%). The mean age of the patients at the last follow-up visit was 14.2 years (range: 7.6 to 22.1). The mean LLD was 2.1 cm. Nine patients had radiological ankle valgus at the last follow-up. In the entire series, eight patients did not display any complications, four cases reported minor complications, and five cases were complicated by refractures. CONCLUSION: Circular external fixator application combined with periosteal grafting is a superior method of CPT treatment. This method provides a healthy biological healing environment while correcting the mechanical problems. The combination of periosteal and cancellous bone grafts with intramedullary rods and an external fixator addresses issues that complicate obtaining and maintaining a union during the CPT treatment. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Treatment of Tibial and Femoral Bone Defects With Bone Transport Over an Intramedullary Nail.

OBJECTIVES: To evaluate the results of the bone transport over an intramedullary nail (BTON) technique for the treatment of segmental bone defects. DESIGN: Retrospective review of case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: We included 40 patients who underwent reconstruction of the lower limb with BTON technique between 2000 and 2018. The technique was performed in the tibial segments in 21 patients and in the femoral segments in 19 patients. INTERVENTION: The surgical technique was performed in 2 stages for patients with infected nonunion. Infection was eradicated in all patients at the first stage. For the BTON at the second stage, monolateral external fixators and circular external fixators were used for femoral and tibial defects, respectively. In cases of defects without any infection, debridement with a single-stage BTON was performed. MAIN OUTCOME MEASUREMENTS: Complications as well as radiological and clinical results were evaluated according to the criteria of Paley-Maar. RESULTS: Minor complications occurred in 11 patients: pin site problems (9), cellulitis (1), and skin detachment due to Schanz screw (1). Major complications occurred in 8 patients: docking site nonunion (4), early consolidation and Schanz screw failure (1), knee flexion contracture (1), and ankle equinus contracture (2). Four patients had osteomyelitis as residual sequelae. Bone score was excellent in 27 patients. Excellent functional results were obtained in 31 patients. CONCLUSIONS: The BTON technique is associated with low cost because of the short treatment period, low complication risk, and rapid rehabilitation and is not limited by the amount of bone transport. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute shortening versus bone transport for the treatment of infected femur non-unions with bone defects.

BACKGROUND: The bone transport technique has been a well-known method in the treatment of osteomyelitis of the long bones with large segmental bone defects. However, one of the major drawbacks with this traditional technique is the long-lasting consolidation period, which may entail infectious and non-infectious complications. To overcome this drawback, several techniques were developed, one of which is acute shortening and re-lengthening. The aims of this study were: 1) to present our experience with a new modified technique of acute shortening and re-lengthening using a monolateral external fixator combined with a retrograde intramedullary nail, and 2) to compare its results with the classic Ilizarov bone transport method in the management of infected non-unions of the distal femur with bone loss. METHODS: This retrospective study compared these two techniques. 17 patients were treated using our modified technique of acute shortening and re-lengthening (Group A); 15 patients were treated using segmental bone transport (Group B). The average follow-up was 66 months (range: 24-180) in Group A and 70 months (range: 24-240) in Group B. The mean bone loss was 5.5 cm (range: 3-10) in Group A and 5.9 cm (range: 3-10) in Group B. The primary outcome of the present study was to compare the external fixator time (EFT) and external fixation index (EFI) between the two groups. The bone and functional status were also assessed. RESULTS: The mean EFI was lower in Group A (mean: 31.8 days/cm; range: 24-50) than in Group B (mean 48.7 days/cm; range: 40-100) (p = 0.02). The mean EFT was shorter in Group A (mean: 120 days; range: 100-150) than in Group B (mean: 290 days; range: 100-400) (p = 0.0003). With respect to the bone and functional results, no difference was observed. CONCLUSIONS: Although both techniques could be employed safely in the treatment of infected non-union of the distal femur with size defects ranging between 3 cm and 10 cm, our modified technique of acute shortening and re-lengthening may confer greater patient satisfaction because of shorter EFI.

Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors.

OBJECTIVES: This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. METHODS: Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. RESULTS: The mean follow-up was of 39 months (range 3-120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. CONCLUSION: Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

External fixation reconstruction of the residual problems of benign bone tumours.

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7-58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier's disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35-108 months). The mean external fixation time was 159.5 days (range 27-300 days). The mean external fixation index was 67.4 days/cm (12-610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2-14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.

Knee Arthrodesis in Persistently Infected Total Knee Arthroplasty.

The reported incidence of infection in total knee arthroplasty (TKA) varies from 0.5 to 15%. The most common indication for knee arthrodesis is persistent infection after repeated staged knee replacement. The purpose of this study is to investigate the success of fusion with monoplanar fixators and eradication rates of infection, and to evaluate the satisfaction of patients who underwent a last-resort TKA due to infection.This is a retrospective review of infected knee arthroplasties that were treated with knee arthrodesis using unilateral external fixators at a single institution from 1999 through 2012. The patients' charts were analyzed for demographics, types of external fixators used, infection parameters, external fixator indexes, complications, positions of fusion, and leg length discrepancies (LLDs). Patients were called back to return for additional follow-up. A self-administered general health status questionnaire (SF-36) was assessed to evaluate life quality.There were 14 women and 3 men with an average age of 67 ± 16.6 years. Antibiotic-loaded acrylic cements were used as a spacer for an average of 3.4 ± 1.2 months in all patients. Monoplanar type of external fixator was used in all 17 patients. Fusions were achieved in all but one patient. The mean duration of fusion was 6.8 ± 2.2 months and external fixator duration was 7.6 ± 2.4 months. Average LLD was 2.9 ± 1.7 cm. The mean coronal alignment of fusion was 6.8 degrees (± 3.3 degrees, range 4-15 degrees) valgus and mean flexion was 11.3 degrees (± 6.5 degrees, range 3-30 degrees). Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (physical component score [PCS]-arthrodesis: 39.3 vs. PCS- healthy controls: 47.9, p < 0.05; mental component score [MCS]-arthrodesis: 38.6 versus MCS-healthy controls: 47.7, p < 0.05).Use of monoplanar fixators for arthrodesis in infected TKA can achieve high fusion rates with the control of infection. If fusion can be achieved, the patient satisfaction is low with acceptable pain relief and functionality. We observed that monoplanar external fixators increased patients' comfort levels compared with circular external fixators. Further studies are needed to compare different arthrodesis modalities in patients with infected TKA.

Preliminary report on amputation versus reconstruction in treatment of tibial hemimelia.

OBJECTIVE: Tibial hemimelia is a rare disorder characterized by the absence or hypoplasia of the tibia with associated rigidity. The aim of this study was to retrospectively evaluate the affectivity of reconstructive surgeries including centralization of the knee-ankle joints and lengthening with Ilizarov principles, as well as physical and functional results of amputation and reconstruction. METHODS: This is an IRB-approved retrospective review of all patients diagnosed with tibial hemimelia who required surgery at a single institution between 1998 and 2011. Charts were analyzed for clinical and radiographical findings. At final follow-up, patients underwent physical and radiographic examination. Patients and their parents were asked to complete the SF-10™ health survey (QualityMetric Inc., Lincoln, RI, USA). RESULTS: Twenty-one patients (12 male, 9 female) with 30 affected extremities were included. Mean age was 4.8±3.1 years at initial surgery. Knee level disarticulation was performed in 6 extremities of 4 patients. One patient with type III underwent transtibial amputation. Mean number of surgeries for each patient was 6.4±3.3, and mean duration of external fixator and casting was 17±6 months. Mean lengthening was 4.9±1.3 cm, and mean limb length discrepancy was 3.1±1.7 cm at 5.8±3.7 years at follow-up. SF-10™ scores were similar in disarticulated and reconstructed patients (p=0.63). All scores were significantly higher when disarticulation was performed in cases of knee instability (p<0.01). CONCLUSION: When stability of the knee joint is present, treatment modality should be chosen according to the existence of the proximal tibia. Amputation should be preferred in cases of knee joint instability.

Fourth primary malignant tumor in a patient with possible li-fraumeni syndrome: synchronous diagnosis of postirradiation sarcoma, cutaneous relapse of a previous soft tissue sarcoma, and lung adenocarcinoma.

We present a 46-year-old female patient who is diagnosed with synchronous postirradiation sarcoma, cutaneous relapse of a previous soft tissue sarcoma, and lung adenocarcinoma. More than one malignant tumor at the same time with an accompanying relapse of a previous malignant tumor is a rare entity. A relatively young patient diagnosed with adenocarcinoma of the urethra before age 40, which is an unusual tumor for that age, later three more different malignant tumors being diagnosed, two of which are synchronous, causes the suspicion of Li-Fraumeni syndrome.

A rare cause of 'drop foot' in the pediatric age group: Proximal fibular osteochondroma a report of 5 cases.

INTRODUCTION: The fibular nerve is the most frequent site of neural entrapment in the lower extremity and the third most common site in the body, following the median and ulnar nerves. The peroneal nerve is commonly injured upon trauma. Additionally, a dropped foot might be a symptom related to the central nervous system or spinal pathologies in pediatric patients. Entrapment of the peripheral nerve as an etiologic cause should be kept in mind and further analyzed in orthopedic surgery clinics. PRESENTATION OF CASE: In this study, the evaluation and treatment results of five patients with no history of trauma, who underwent diagnostic procedures and treatment in various clinics (physical therapy and rehabilitation and neurosurgery), are reported. The patients underwent several treatments without diagnosis of the primary etiology. Upon initial consultation at our department, osteochondroma at the proximal fibula was detected after physical examination and radiologic assessment. During surgery, the peroneal nerve was dissected, starting from a level above the knee joint. Following nerve release, the osteochondroma was removed, including its cartilage cap. Consequently, recovery was observed in all five cases after surgery. DISCUSSION: Many factors may cause non-traumatic neuropathies. However, due to their rare occurrence, lesions such as osteochondromas may be overlooked at non-orthopedic clinics. Nerve entrapment due to proximal fibular osteochondroma is rare. Surgical treatment planning plays a critical role in nerve entrapment cases. CONCLUSION: Despite its frequent occurrence, a drop foot associated with peroneal nerve entrapment by an osteochondroma is not easily remembered and diagnosed. Especially in pediatric cases, inadequate clinical consultation and a lack of appropriate radiologic studies may result in a delay in diagnosing peroneal nerve lesions.