Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma.

INTRODUCTION: Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications. METHODS: A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis. RESULTS: Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis. CONCLUSION: A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions. LEVEL OF EVIDENCE (OXFORD): Level 4.

Long term outcome of surgical treatment of chondroblastoma: analysis of local control and growth plate/articular cartilage related complications.

BACKGROUND: Chondroblastoma (CBL) is a rare benign chondroid producing bone tumor that typically occurs in epiphysis or apophysis of growing children and young adults. Intralesional curettage is the treatment of choice, while resection is required in selected cases, even though the use of minimally invasive ablation techniques has been advocated. Authors reviewed a series of 75 CBLs with the aim of assess risk factors for local recurrence, the growth plate related complications after epiphyseal curettage and the risk of arthritis of the adjacent joint after epiphyseal curettage. METHODS: We retrospectively review 69 CBLs treated with intralesional curettage and 6 treated with resection from March 1995 to February 2020. The median age was 18.8 years (7 to 42, median 16). The site was proximal humerus in 18 cases, proximal tibia in 17, distal femur in 16, talus in 6, femur's head in 4, calcaneus in 3, acromion in 3, trochanteric region in 2, distal tibia in 2, patella in 2, supracetabular region in 1 and distal humerus in 1 patient. RESULTS: Mean follow-up was 124.2 months (24 to 322, median 116). Among patients treated with curettage, 7.3% of local recurrence was observed and 12 (17.4%) patients developed osteoarthritis of the adjacent joint. Five patients (7.3%) presented limb length discrepancy of the operated limb ranging from 0.5 to 2 cm. Recurrence free survival rate was 94.2% at 5 and 91.6% at 10 years. A mean Musculoskeletal Tumor Society (MSTS) of 29.3 points (20 to 30, median 30) was observed. CONCLUSION: More than 90% of CBLs were successfully treated with aggressive curettage but segmental resection is required in selected cases. In a relatively small proportion of cases long term complications can occur due to growth plate damage or osteoarthritis. TRIAL REGISTRATION: Retrospectively registered.

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis.

INTRODUCTION: Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked. MATERIALS AND METHODS: We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes. RESULTS: Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections. CONCLUSION: Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.

Ewing family tumors of the appendicular skeleton: a retrospective analysis of prognostic factors.

PURPOSE: Authors retrospectively analyzed possible prognostic factors in a series of patients affected by Ewing sarcoma of extremities (eEWS) and treated over a 20-year period at a single institution. METHODS: Between 1997 and 2017, 88 bone eEWS were treated at our institution. Staging, age, gender, tumoral volume, local treatment, surgical margins, post-ChT necrosis were investigated for prognostic correlation with overall survival (OS) and event-free survival (EFS). Median follow-up was 74 months (1-236). RESULTS: Staging of disease correlated with OS (81% vs 59%, p = 0.01) and not with EFS (68% vs 57%, p = 0.28) in localized vs metastatic eEWS at presentation. Age ≥ 14 years (p = 0.002) and volume ≥ 100 cm3 (p = 0.04) were significant negative prognostic factors. No difference was found in local treatment: OS was 76% vs 63% (p = 0.33), while EFS was 68% vs 49% (p = 0.06) after surgery alone or surgery + radiotherapy, respectively. Regarding surgical margins, OS was 76% vs 38% (p = 0.14), and EFS was 65% vs 33% (p = 0.14) in adequate vs not adequate, respectively. OS was 86% and 68% in good and poor responders, respectively (p = 0.13). CONCLUSION: In eEWS, metastatic disease at presentation, age > 14 years and tumoral volume > 100 cm3 are negative prognostic factors. Intensified adjuvant ChT can improve prognosis in poor responders and metastatic patients.

Re-excision after unplanned excision of soft tissue sarcomas: Long-term results.

BACKGROUND: Unplanned excisions of soft tissue sarcomas are still not infrequent events with patients presenting to referral Centers after having received an inadequate surgical treatment. In literature, both the wait-and-see policy and the "aggressive" management with a re-excision have been advocated. The purposes of this study were to analyze the incidence of detectable residual tumor in surgical specimens following a re-excision and to verify the long-term results of patients treated with a re-excision after previous unplanned excision. METHODS: We retrospectively evaluated 131 patients affected by localized soft tissue sarcoma (95 high grade; 36 low grade) of the limbs or the superficial trunk treated at our Institution, from 2000 to 2013, with a re-excision after a previous unplanned inadequate excision. Site, size, depth, histotype, grade, adjuvant therapies, time from unplanned surgery to re-excision were recorded and evaluated in association with clinical results. We specifically evaluated the disease-specific survival, local recurrence free survival, distant metastases free survival and the event free survival. RESULTS: Mean follow-up for living patients was 10.9 years (median 11.2 years), with a follow-up ranging from 14 to 227 months. 34% of patients underwent a re-excision within the first 2 months after unplanned surgery, while 66% of patients at more than 2 months. Residual detectable tumor cells were found on histological examination in 54% of re-excisions. A wide margin was obtained in 123 cases, a persisting positive margin in 8 patients. Disease-specific survival was 93.5%, 91.6% and 89.6% at 5, 10 and 15 years for whole series and 90.9%, 88.2% and 85.7% for high grade tumors. Event-free survival in patients affected by high grade tumors rated 75.0% at 5 years, 72.4% at 10 years and 72.4% at 15 years. Local recurrence free survival in high grade tumors was 87.6%, 86.2% and 86.2% at 5, 10 and 15 years. The grade of the tumor (high grade) and the initial dimension of the tumor (≥5 cm) were associated with worst survival. High grade tumor impacted negatively also on local recurrence free survival and event free survival. Instead, the initial size of the tumor significantly affected the event free survival but not the local recurrence free survival. No significant differences of outcome were found analyzing tumor depth, time interval to re-excision, presence of residual tumor or margins. CONCLUSION: Based on our results and literature findings, we believe that surgeons should offer a re-excision procedure in those patients presenting with an inadequate excision of a high grade soft-tissue tumor, in particular with tumors larger than 5 cm before excision. Indeed, if an adequate second treatment is performed with surgery ± radiotherapy, the long-term results of patients receiving a re-excision after unplanned excision of a high grade soft tissue sarcoma seem to be comparable to the results generally reported for wide primary excisions. More debatable is whether to perform a re-excision or not in patients with low-grade tumors. Perhaps, in this latter group a wait and see policy can eventually be offered as well as in high grade tumors when a re-excision procedure could involve major surgery or significantly affect postoperative function.

The natural history of epithelioid sarcoma. A retrospective multicentre case-series within the Italian Sarcoma Group.

INTRODUCTION: This case-series is aimed to describe the natural history of epithelioid sarcoma (ES) and to provide insights into the differential clinical behaviour of its two variants ("classic-type" and "proximal-type"). The value of a subtype-adapted grading system based on pathological features is explored. METHODS: Data from consecutive, primary, localised, INI1-deleted ES operated at three Italian sarcoma reference centres (1995-2015) were included. Centralised pathological review was performed. Classic-type ES was broken down into "high-grade" and "low-grade", according to number of mitoses, evidence of necrosis and nuclear atypia. Five- and 10-year overall survival (OS) and crude cumulative incidence (CCI) of local recurrence (LR) and distant metastasis (DM) were estimated. RESULTS: Fifty-two patients were included. 5- and 10-year OS estimates were 70% and 47% in the whole series, 57% and 37% in patients with proximal-type ES, 77% and 54% in patients with classic-type ES (P = 0.02). In classic-type ES, 5- and 10-year OS was higher for low-grade (95% and 72%, respectively) than high-grade tumours (P = 0.002). 5- and 10-year CCI estimates for LR were 21% and 33% in the whole series. 5- and 10-year CCI estimates for DM were 35% and 39% in the whole series, both 28% in classic-type ES, 47% and 59% in proximal-type ES (P = 0.03). CONCLUSIONS: Suffering from a proximal- or a classic-type is the stronger predictor of outcome in patients with localised ES, with proximal-type ES patients having lower survival due to a higher tendency toward metastatic spreading. However, the "high-grade" classic-type ES was associated with outcomes close to proximal-type ES.

Clinical features, prognostic factors and outcome in a series of 29 extra-skeletal Ewing Sarcoma. Adequate margins and surgery-radiotherapy association improve overall survival.

OBJECTIVE: Authors review a series of 29 extra-skeletal Ewing Sarcoma (EES). METHODS: They analyzed characteristics, prognostic factors and outcome of EES. RESULTS: Authors report 60% Overall Survival (OS) and 56% of Event Free Survival (EFS) at 5 years. Better 5 years EFS was found in patients with localized disease (68.8%) compared to metastatic EES (33.3%) (p = 0.042). Radiotherapy + surgery offered the best local treatment (p=0.017). Volume (p = 0.032), Surgical margins (p = 0.01), metastatic disease (p = 0.0013) were a significant prognostic factor for OS at 5-yrs. CONCLUSION: Adequate margins and surgery+radiotherapy improve Overall Survival.

Total femur prosthesis in oncological and not oncological series. Survival and failures.

Total femur prosthesis (TFP) can be used in both oncological and prosthetic revision surgery. A retrospective analysis of 32 patients receiving a TFP at a single Center between 2002 and 2018 was performed. The average follow-up was 60 months. Revision implant free survival (RIFS) of the implants was 87% at 5 and 10 years and 72% at 15 years. Overall implant survival (OIS) of the prosthesis was 90% at 5, 10 and 15 years. Complications observed: two soft tissue failures, two infection failure and one tumor progression failure.

Leiomyosarcoma: Clinicopathological study and retrospective analysis of prognostic factors in a series of 100 patients.

The Authors reported a retrospective study of 100 Leiomyosarcoma (LMS), evaluating factors that may influence Overall Survival (OS), Local Recurrence Free Survival (LRFS), Metastasis Free Survival (MFS). Tumor Size (P = 0,0009), Local Recurrence (P = 0,0487), Distant relapse (P < 0,0001), Type of Presentation (P = 0,0213) were significant risk factors affecting overall survival (OS). Tumor Size (P = 0.024), age at diagnosis (P = 0,0086), type of presentation (P < 0,0001) and Local Recurrence (P = 0.0152) affected metastasis free survival (MFS). Type of presentation (P = 0,001) was an independent prognostic factor of local recurrence-free survival (LRFS).

Is Arthrodesis a Reliable Salvage Option following Two-Stage Revision for Suspected Infection in Proximal Tibial Replacements? A Multi-Institutional Study.

The aim of this multicentric retrospective study was to verify whether knee arthrodesis (KA) is a viable reconstructive option after two-stage revision for infection of proximal tibia (PT) endoprosthetic reconstruction (EPR). Sixty patients who underwent a two-stage revision were included. Definitive EPR or a KA with a modular system was performed following consideration of soft tissue and extensor mechanism conditions. Patients were evaluated with Musculoskeletal Tumor Society Score and Oxford Knee Score. Implant survival was assessed on the basis of recurrence of infection. Five patients did not receive any reconstruction after the first stage. In 14 cases, a KA was performed, and in 41, an EPR was implanted. At 5 years follow-up, reinfection rate in the KA group was lower (10 vs. 17.5% in KA and EPR groups, respectively). In reinfected patients, the KA group had a reduced rate of amputation when compared with those with EPR (50 vs. 88%). Functional evaluation did not show any significant differences between the two groups. A successful KA using a modular implant can eradicate infection and allow preservation of the limb with good function and good pain relief in after two-stage revision for an infected PT EPR.

Surgical Treatment of Sacral Chordoma: En Bloc Resection with Negative Margins is a Determinant of the Long-Term Outcome.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report the outcome of a series of patients with sacral chordoma who were surgically treated at a single center. SUMMARY: Chordomas are low-grade malignant tumors that arise from remnants of the notochord. They are most often found in the sacrum, spine and skull-base. These tumors have a slow clinical evolution and may eventually metastasize, even after adequate treatment. Rarely, they can dedifferentiate into high-grade sarcomas. Traditionally, chordomas were considered to be resistant to chemotherapy and standard radiation therapy. However, recently, adrotherapy has been shown to be effective for local and systemic control of the disease. In this study, clinical outcomes and local and systemic recurrence were reviewed to identify prognostic factors for local and systemic control. METHODS: Thirty-three patients with sacral chordoma (19 males, 14 females; median age 61 y, range 43-80) who were surgically treated at our institution between 1994 and 2015 were reviewed. In 24 patients, resection was performed above S2. No patients received pre-operative radiotherapy (RT). Three cases received RT (carbon ion therapy) as treatment for local recurrence. Wide (R0) surgical margins were achieved in 17 patients, marginal (R1) margins in 14 patients and intralesional (R2) margins in 2 patients. RESULTS: At a median follow-up of 53 months (range 0-198), 19 patients were continuously disease-free, 6 were disease-free after local recurrence (5) or metastases (1), 3 were alive with disease (2 local recurrence and 1 metastasis), 4 were dead of disease (1 patient died intraoperatively) and 1 was dead of another cause. Local recurrence was observed in 9 cases (27%); all 9 were treated surgically and 3 received carbon ion therapy after surgical intralesional excision. Overall survival at 10 years was 86.6%. Local recurrence-free survival at 10 years was 51%. A statistical analysis confirmed the importance of negative surgical margins (R0) to achieve local control of the disease (p = 0.0007). High resections (above S2) were associated with lower survival and higher risk of local recurrence. CONCLUSION: Surgical en bloc resection is the primary treatment for sacral chordoma. Carbon ion therapy is used when it is difficult to obtain wide surgical margins. Due to morbidity and the disabling sequelae of surgery, adrotherapy may be considered an alternative to high (above S2-S3) sacral chordoma resections.

Myxoid Liposarcoma: Prognostic Factors and Metastatic Pattern in a Series of 148 Patients Treated at a Single Institution.

OBJECTIVES: The authors reported a retrospective study on myxoid liposarcomas (MLs), evaluating factors that may influence overall survival (OS), local recurrence-free survival (LRFS), metastasis-free survival (MFS), and analyzing the metastatic pattern. METHODS: 148 MLs were analyzed. The sites of metastases were investigated. RESULTS: Margins (p = 0.002), grading (p = 0,0479), and metastasis (p < 0,0001) were significant risk factors affecting overall survival (OS). Type of presentation (p = 0.0243), grading (p = 0,0055), margin (p = 0.0001), and local recurrence (0.0437) were risk factors on metastasis-free survival (MFS). Authors did not observe statistically significant risk factors for local recurrence-free survival (LRFS) and reported 55% extrapulmonary metastases and 45% pulmonary metastases. CONCLUSION: Margins, grading, presentation, local recurrence, and metastasis were prognostic factors. Extrapulmonary metastases were more frequent in myxoid liposarcoma.

Liposarcoma: Clinico-pathological analysis, prognostic factors and survival in a series of 307 patients treated at a single institution.

BACKGROUND AND OBJECTIVES: Liposarcoma (LPS) is a malignant mesenchymal tumor and the most common soft tissue sarcoma. Four different subtypes are described: well differentiated (WD) LPS or atypical lipomatous tumor (ALT), dedifferentiated (DD) LPS, myxoid LPS, and pleomorphic LPS (PLS). The objective of the study was to investigate prognostic factors and clinical outcome of liposarcoma. METHODS: We retrospectively examined the clinico-pathological features of a series of 307 patients affected by Liposarcoma at a mean follow-up of 69 months (range 6-257). ALT/WD LPS were analyzed separately. The influence of site, size, type of presentation, grading, histotype and local recurrence on local and systemic control and survival was assessed. RESULTS: The statistical analysis indicated that only surgical margins represented a significant prognostic factor for local recurrence in ALT/WD LPS (P = 0.0007) and other subtypes of LPS (P = 0.0055). In myxoid, PLS and DD LPS, significant prognostic factors for metastasis free survival (MFS) were surgical margins (P = 0.0009), size of the tumor (P = 0.0358), histology (P = 0.0117) and local recurrence (P = 0.0015). In multivariate analysis, surgical margins (0.0180), size (0.0432) and local recurrence (0.0288) correlated independently with MFS. Margins (P = 0.0315), local recurrence (P = 0.0482) and metastases (P < 0.0001) were prognostic factors for overall survival (OS). CONCLUSION: Marginal surgery can be an accepted treatment for ALT/WD LPS. In other liposarcoma subtypes (Myxoid, DD, PLS) wide or radical surgery is recommended as the margins significantly influence local recurrence-free survival (LRFS), metastasis-free survival (MFS) and overall survival (OS). Local recurrence and metastases were significant prognostic factors for OS.

Modular megaprosthesis reconstruction for oncological and non-oncological resection of the elbow joint.

BACKGROUND: Reconstruction of large bone defects around the elbow joint is surgically demanding due to sparse soft tissue coverage, complex biomechanics and the close proximity to neurovascular structures. Modular megaprostheses are established reconstruction tools for the elbow, but only small case series have been reported in the literature. METHODS: Thirty-six patients who underwent reconstruction of the elbow joint with a modular megaprosthesis were reviewed retrospectively. In 31 patients (86.1%), elbow replacement was performed after resection of a bone tumour, whereas five non-oncological patients (13.9%) underwent surgery because of a previous failed elbow reconstruction. Functional outcome, rate of complications and oncological results were considered as primary endpoints. RESULTS: The mean follow-up was 25 months. The average achieved Mayo Elbow Performance Score (MEPS) was 77.08 (range 40-95) and the average Musculoskeletal Tumor Society (MSTS) score was 22.9 (range 8-30). Six complications (16.7%) were observed: two radial palsies, one temporary radial nerve dysfunction, one ulnar palsy, one disassembling of the articular prosthesis component and one deep infection necessitating the only implant removal. The overall 5-year survival rate of the patients was poor (25.1%) because of rapid systemic progression of the oncological disease in patients with metastatic lesion. However, the 5-year survival rate of the implant was very satisfactory (93%). CONCLUSIONS: Modular megaprosthesis is a reliable and effective reconstruction tool in large bone defects around the elbow joint. The complication rates are lower than seen in osteoarticular allografts and allograft-prosthesis composites while the functional outcome is equal. In palliative situations with metastatic disease involving the elbow, modular megaprosthesis enables rapid recovery and pain relief and preserves elbow function.

Levels of silver ions in body fluids and clinical results in silver-coated megaprostheses after tumour, trauma or failed arthroplasty.

INTRODUCTION: Infection in megaprostheses remains an unsolved problem, with a rate of occurrence ranging from 5% to 12%. Silver coating of medical devices has recently been proposed to reduce infection rate because of the antibacterial effect of silver. This innovation could be particularly interesting for megaprostheses, but few data have been reported in the literature. MATERIALS AND METHODS: From June 2010 to August 2014 a modified MegaC System megaprosthesis with an innovative peripheral silver-added layer of titanium alloy ('Porag') was implanted in 33 patients after previous infection (21 patients) or at high risk for infection because of local or general conditions (12 patients). Previous infection followed megaprosthesis or standard arthroplasty procedures in 14 patients and trauma surgery in seven patients. A proximal femur replacement was performed in 13 patients, distal femur replacement in 13, total femur in one, and knee arthrodesis in six. Clinical results and levels of silver in blood, urine and wound drains were examined. RESULTS: Minimum follow-up of the patients was one year (average 25.9 months). There was no infection during the first two years after surgery in the 12 patients who received a silver-coated megaprosthesis and had no previous history of infection. An infection developed in one patient at 25 months after surgery following two further surgical procedures. Infection recurred at seven months and 24 months in two out of the 21 patients (9.5%) who had received the implant because of previous septic complications. There was no clinical evidence of argyria, and no local or systemic side effects related to silver were detected. Mean levels of silver ranging from 0.41 to 5.33µg/L in blood and from 0.28 to 0.86µg/L in urine were detected at 24h to 36 months after surgery. CONCLUSIONS: Silver-coated megaprostheses showed promising results in this series in terms of prevention of infection in a high-risk group of patients, many of whom had a history of infection. No side-effects were detected. The circulating silver levels confirm both the persistence of silver-coating activity after three years and the safety of silver-coated implants. Longer follow-up and larger series are needed.

Soft tissue myxofibrosarcoma: A clinico-pathological analysis of a series of 75 patients with emphasis on the epithelioid variant.

BACKGROUND AND OBJECTIVES: The clinical course of soft tissue myxofibrosarcoma is characterized by a high incidence of recurrences and there is no agreement on how to identify patients at major risk. An epithelioid histological variant has been described, with a possible worse prognosis. We reviewed our series to identify prognostic factors and assess clinical significance of the epithelioid variant. METHODS: We examined the clinico-pathological features of a series of 75 patients affected by soft tissue myxofibrosarcoma at a mean follow-up of 63 months (range 17-132). RESULTS: Disease specific survival and local recurrence free survival were, respectively, 84.8% and 76.8% at 5 years. Seven patients (8.6%) presented with the epithelioid variant with a survival of 62.5%. High grade and epithelioid morphology were negative prognostic factors for patient survival, high grade, and inadequate surgical margins for local recurrence. Radiotherapy had a local protective effect in high grade tumors. CONCLUSIONS: Our experience confirms the difficulties in obtaining wide margins in myxofibrosarcoma and the high rate of recurrence. Local recurrences did not significantly affect survival and a limb-sparing approach can be chosen also in recurrences. Patients affected by the epithelioid variant showed a worse prognosis. Chemotherapy should be considered as adjuvant treatment in this subtype. J. Surg. Oncol. 2016;114:50-55. © 2016 Wiley Periodicals, Inc.

Modular Endoprostheses for Nonneoplastic Conditions: Midterm Complications and Survival.

The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1-167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (p = 0.921), nor to the reconstruction site (p = 0.402). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (p = 0.851). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease.

Pre-operative diclofenac HPßCD for pain control of needle biopsy in musculoskeletal neoplasm: preliminary results.

Needle biopsy is the main standard method used for diagnosis of musculoskeletal tumors of the limbs and superficial trunk. Pain control during this procedure is through the use of Local Anaestetic (L.A.). In order to achieve a complete pain control in our cases, recently we started using diclofenac HPßCD 50 mg via s.c. preoperativly. We present the clinical results of a non-randomized study of two eterogeneous groups of patients: "Experimental" Group (1): diclofenac HPßCD 50 mg via s.c. one hour before surgical procedure, local anesthesia and ev. diclofenac HPßCD 50 mg via s.c. 12 hours postoperative; "Conventional" Group (2): local anesthesia and ev. postoperative tramadol 100 mg via oral for pain control. In October 2014, at the Department of Orthopedic Oncology and Reconstructive Surgery of Florence, 37 musculoskeletal biopsies for a bone or a soft tissue lesion were performed. Exclusion criteria for this study were: known allergies to lidocaine, diclofenac, tramadol; known gastric or duodenal ulcers; known gastrointestinal bleed or perforation; refusal of the patients to collaborate. For one or more of these reasons, 6 patients were excluded from this study. In the Group 1, 10 patients (59%) referred no pain during the surgical procedure (8/14 biopsies on soft tissue and 2/3 on bone). In 5 cases (29%) no exacerbation of previous chronic pain, and in 2 cases (12%) a progression of local pain after biopsy (average 1 points higher in the VAS). In Group 2, only 6 patients (42%) did not have any pain during the procedure, 4 (29%) no exacerbation of previous chronic pain and 4 (29%) a progression of local pain (average 2 points higher in the VAS). Despite similar results in both Groups, Group 1 seemed to have a mild better control of perioperative pain. The use of diclofenac HPßCD 50 mg preoperative seems to be a rational approach for minimizing perioperative pain and the preliminary data of our study seem encouraging. Obviously many bias are present in this study (small numbers of cases, heterogeneity of diseases, association with local anesthetic, non-randomized study, comparison between preoperative versus postoperative treatment) and this cannot absolutely be considerate as definitive conclusions.

What was the survival of megaprostheses in lower limb reconstructions after tumor resections?

BACKGROUND: Prosthetic replacement is the most commonly used option for reconstruction of osteoarticular bone loss resulting from bone neoplasm resection or prosthetic failure. Starting in late 2001, we began exclusively using a single system for large-segment osteoarticular reconstruction after tumor resection; to our knowledge, there are no published series from one center evaluating the use of this implant. QUESTIONS/PURPOSES: We investigated the following issues: (1) What is the overall survival, excluding local tumor recurrence, for these endoprostheses used for tumor reconstructions of the lower extremities (knee and hip)? (2) What types of failure were observed in these reconstructions? (3) Do the survival and complications vary according to site of implant? METHODS: Between September 2001 and March 2012, we exclusively used this implant for tumor reconstructions. During that time, 278 patients underwent tumor reconstructions of the hip or knee, of whom 200 (72%) were available at a minimum 2 years followup. Seventy-eight patients were excluded from the study for insufficient followup as a result of early death (42) or loss at followup (36). The reconstruction types were the following: proximal femur (69 cases), distal femur (87), proximal tibia (32), and total knee (12). Failures were classified according to the Henderson classification. Nine patients among those with followup shorter than 2 years had presented one or more failures and they were included in our analysis but separately evaluated. RESULTS: Overall survival (no further surgical procedures of any type after primary surgery), excluding Type 5 failure (tumor recurrence), was 75.9% at 5 years and 66.2% at 10 years. Seventy-one failures occurred in 58 implants (29%). Mechanical failures accounted for 59.2% and nonmechanical failures for 40.8%. The first causes of failure of the implants were the result of soft tissue failure in 6%, aseptic loosening in 3%, structural failure in 7%, infection in 8.5%, and tumor recurrence in 4.5% of the whole series. Nine implants sustained two or more failures. Overall incidence of infection was 9.5%. No statistically significant differences were observed according to anatomical site. CONCLUSIONS: Like in the case with many such complex oncologic reconstructions, the failure rate at short- to midterm in this group was over 20%. Comparative trials are called for to ascertain whether one implant is superior to another. Infection and structural failure were the most frequent modes of failure in our experience. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.