Aims. Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. Methods. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. Results. A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Conclusion. Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group. Cite this article: Bone Joint J 2023;105-B(10):1115–1122

The October 2023 Oncology Roundup. 360. looks at: Are pathological fractures in patients with osteosarcoma associated with worse survival outcomes?; Spotting the difference: how secondary osteosarcoma manifests in retinoblastoma survivors versus conventional cases; Accuracy of MRI scans in predicting intra-articular joint involvement in high-grade sarcomas around the knee; Endoprosthetic reconstruction for lower extremity soft-tissue sarcomas with bone involvement; Local relapse of soft-tissue sarcoma of the extremities or trunk wall operated on with wide margins without radiation therapy; 3D-printed, custom-made prostheses in patients who had resection of tumours of the hand and foot; Long-term follow-up for low-grade chondrosarcoma; Evaluation of local recurrence and diagnostic discordance in chondrosarcoma patients undergoing preoperative biopsy; Radiological scoring and resection grade for intraosseous chondrosarcoma

The December 2023 Oncology Roundup. 360. looks at: A single osteotomy technique for frozen autograft; Complications, function, and survival of tumour-devitalized autografts used in patients with limb-sparing surgery; Is liquid nitrogen recycled bone and vascular fibula the biological reconstruction of choice?; Solitary pulmonary metastases at first recurrence of osteosarcoma; Is a radiological score able to predict resection-grade chondrosarcoma in primary intraosseous lesions of the long bones?; Open versus core needle biopsy in lower-limb sarcoma – current practice patterns and patient outcomes; Natural history of intraosseous low-grade chondroid lesions of the proximal humerus; Local treatment modalities and event-free survival in patients with localized Ewing’s sarcoma; Awaiting biopsy results in solitary pathological proximal femoral fractures

The June 2023 Oncology Roundup. 360. looks at: A size-based criteria for flap reconstruction after thigh-adductor soft-tissue sarcoma resection; Surgical treatment of infected massive endoprostheses implanted for musculoskeletal tumours; Free vascularized fibula for proximal humerus oncological reconstruction in children; The national incidence of chondrosarcoma of bone; a review; Bone sarcoma follow-up: when do events happen?; Osteosarcomas in older adults: a report from the Cooperative Osteosarcoma Study Group

The December 2022 Oncology Roundup. 360. looks at: Is high-dose radiation therapy associated with early revision with a cemented endoprosthesis?; Neoadjuvant chemotherapy and endoprosthetic reconstruction for lower extremity sarcomas: does timing impact complication rates?; Late amputation after treatment for lower extremity sarcoma; Osteosarcoma prediagnosed as another tumour: a report from the Cooperative Osteosarcoma Study Group; The influence of site on the incidence and diagnosis of solitary central cartilage tumours of the femur: a 21st century perspective

The June 2024 Oncology Roundup. 360. looks at: Chondrosarcoma of the femur: is local recurrence influenced by the presence of an extraosseous component?; Diagnostic challenges in low-grade central osteosarcoma; Single osteotomy technique for frozen autograft (pedicled freezing) in patients with malignant bone tumours; Unplanned resection for small superficial soft-tissue sarcomas: disastrous or simply bad?; Inactivation and replantation of the knee joint: an infeasible surgical method; Active surveillance of diffuse-type tenosynovial giant cell tumours: a retrospective, multicentre cohort study

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting. Cite this article: Bone Joint J 2024;106-B(5):425–429

The April 2024 Oncology Roundup. 360. looks at: Midterm outcomes of total hip arthroplasty after internal hemipelvectomy and iliofemoral arthrodesis; Intraosseous conventional central chondrosarcoma does not metastasize irrespective of grade in pelvis, scapula, and in long bone locations; Oncological and functional outcomes after resection of malignant tumours of the scapula; Reconstruction following oncological iliosacral resection – a comparison of techniques; Does primary tumour resection improve survival for patients with sarcomas of pelvic bones, sacrum, and coccyx who have metastasis at diagnosis?; Older patients with Ewing’s sarcoma: an analysis of the National Cancer Database; Diagnostic challenges in low-grade central osteosarcoma; Effect of radiotherapy on local recurrence, distant metastasis, and overall survival in 1,200 limb soft-tissue sarcoma patients: a retrospective analysis using inverse probability of treatment weighting-adjusted models

The August 2023 Oncology Roundup360 looks at: Giant cell tumour of bone with secondary aneurysmal bone cyst does not have a higher risk of local recurrence; Is bone marrow aspiration and biopsy helpful in initial staging of extraskeletal Ewing’s sarcoma?; Treatment outcomes of extraskeletal Ewing’s sarcoma; Pathological complete response and clinical outcomes in patients with localized soft-tissue sarcoma treated with neoadjuvant chemoradiotherapy or radiotherapy; Long-term follow-up of patients with low-grade chondrosarcoma in the appendicular skeleton treated by extended curettage and liquid nitrogen; Cancer-specific survival after limb salvage versus amputation in osteosarcoma; Outcome after surgical treatment of dermatofibrosarcoma protuberans: does it require extensive follow-up, and what is an adequate resection margin?; Management of giant cell tumours of the distal radius: a systematic review and meta-analysis

The February 2024 Oncology Roundup. 360. looks at: Does primary tumour resection improve survival for patients with sarcomas of the pelvis with metastasis at diagnosis?; Proximal femur replacements for an oncologic indication offer a durable endoprosthetic reconstruction option: a 40-year experience; The importance of awaiting biopsy results in solitary pathological proximal femoral fractures: do we need to biopsy solitary pathological fractures?; Effect of radiotherapy on local recurrence, distant metastasis, and overall survival in 1,200 extremity soft-tissue sarcoma patients; What to choose in bone tumour resections? Patient-specific instrumentation versus surgical navigation; Optimal timing of re-excision in synovial sarcoma patients: immediate intervention versus waiting for local recurrence; Survival differences of patients with resected extraskeletal osteosarcoma receiving two different (neo) adjuvant chemotherapy regimens; Solitary versus multiple bone metastases in the appendicular skeleton: should the surgical treatment be different?

The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding. Cite this article: Bone Joint J 2023;105-B(8):850–856

The April 2023 Oncology Roundup. 360. looks at: Complete tumour necrosis after neoadjuvant chemotherapy defines good responders in patients with Ewing’s sarcoma; Monitoring vascularized fibular autograft: are radiographs enough?; Examining patient perspectives on sarcoma surveillance; The management of sacral tumours; Venous thromboembolism and major bleeding in the clinical course of osteosarcoma and Ewing’s sarcoma; Secondary malignancies after Ewing’s sarcoma: what is the disease burden?; Outcomes of distal radial endoprostheses for tumour reconstruction: a single centre experience over 15 years; Is anaerobic coverage during soft-tissue sarcoma resection needed?; Is anaerobic coverage during soft-tissue sarcoma resection needed?

The August 2024 Oncology Roundup. 360. looks at: What factors are associated with osteoarthritis after cementation for benign aggressive bone tumour of the knee joint: a systematic review and meta-analysis; Recycled bone grafts treated with extracorporeal irradiation or liquid nitrogen freezing after malignant tumour resection; Intercalary resection of the tibia for primary bone tumours: are vascularized fibula autografts with or without allografts a durable reconstruction?; 3D-printed modular prostheses for the reconstruction of intercalary bone defects after joint-sparing limb salvage surgery for femoral diaphyseal tumours; Factors influencing the outcome of patients with primary Ewing’s sarcoma of the sacrum; The significance of surveillance imaging in children with Ewing’s sarcoma and osteosarcoma; Resection margin and soft-tissue sarcomas of the extremities treated with limb-sparing surgery and postoperative radiotherapy

The February 2023 Oncology Roundup. 360. looks at: Is the number of national database research studies in musculoskeletal sarcoma increasing, and are these studies reliable?; Re-excision after unplanned excision of soft-tissue sarcoma is associated with high morbidity; Adjuvant radiation in atypical lipomatous tumours; The oncological outcomes of isolated limb perfusion and neoadjuvant radiotherapy in soft-tissue sarcoma patients - a nationwide multicentre study; Can low-grade chondrosarcoma be treated with intralesional curettage and cryotherapy?; Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis; Doxorubicin-polymeric meshes prevent local recurrence after sarcoma resection while avoiding cardiotoxicity; How important are skip lesions in Ewing’s sarcoma?; Improving outcomes for amputees: the health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees

The June 2014 Oncology Roundup. 360 . looks at: Infection still a problem in endoprosthetic reconstruction; massive allografts not as successful as we perhaps think; curopsy for aneurysmal bone cysts?; lengthening prosthesis: days are numbered; new WHO classification in brief; proximal tumours and fluid levels: bad news; infection is predictable in orthopaedic oncology; psychosocial support key in oncological outcomes

The August 2014 Oncology Roundup. 360 . looks at: Anaesthesic modality does not affect outcomes in tumour surgery; infection predictors in orthopaedic oncology; sarcoma depth unimportant in survival; photon/proton radiotherapy surprisingly effective in chondrosarcoma control; total humerus replacement a success!; LDH simple predictor of survival in sarcoma; Denosumab again! and Oops procedures in triplicate

The October 2015 Oncology Roundup. 360 . looks at: Radiotherapy for the radioresistant; Multiple hereditary exostosis; The total femur as a limb salvage option; Survival prediction in osteosarcoma; What happens when chondrosarcoma recurs?; Thumbs up for vascularised fibular graft; Radiotherapy and survival; Musculoskeletal tumours in pregnancy

The April 2015 Oncology Roundup. 360 . looks at: New hope for skull base tumours; Survival but at what cost?; Synovial sarcoma beginning to be cracked?; Wound complications facing soft-tissue sarcoma surgeons; Amputation may offer no survival benefit over reconstruction; Giant cell tumour in the longer term; Intralesional treatment comparable with excision in GCT of the radius?; Imaging prior to oncological referral; And finally…

The June 2015 Oncology Roundup. 360 . looks at: Infection in megaprosthesis; Impressive results for mid femoral reconstruction; Revered teaching or old myth? Femoral neck protection in metastatic disease; Megaprosthesis about the knee; Malignant transformation in multiple hereditary exostoses; Fracture of intercalary bone allograft; Comorbidity and outcomes in sarcoma; A worrying turn? Use of denosumab for giant cell tumour of bone

The February 2015 Oncology Roundup. 360 . looks at: Achieving global collaboration; A new standard for limb salvage; Inoperable chondrosarcoma and chemotherapy; Soft-tissue sarcoma and adjuvant chemotherapy; Missed diagnoses and malpractice in sarcoma; Radiofrequency and cartilage tumours

The December 2015 Oncology Roundup. 360 . looks at: Amputation may not be the best option; Growing golf balls bad news!; How close is safe? Radiotherapy and surgery; Lymphocyte: monocyte ratio in osteosarcoma; Are borderline cartilage tumours really borderline?; Boosting algorithms improves survival estimates; CT better than Mirels?

The December 2014 Oncology Roundup. 360 . looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet

The August 2015 Oncology Roundup. 360 . looks at: Glasgow prognostic score in soft-tissue sarcoma; Denosumab in giant cell tumour; Timing, complications and radiotherapy; Pigmented villonodular synovitis and arthroscopy; PATHFx: estimating survival in pathological cancer; Prosthetic lengthening of short stumps; Chondrosarcoma and pathological fracture

The December 2013 Oncology Roundup. 360 . looks at: Peri-articular resection fraught with complications; Navigated margins; Skeletal tumours and thromboembolism; Conditional survival in Ewing’s sarcoma; Reverse shoulders and tumour; For how long should we follow up sarcoma patients?; and already metastasised?

The October 2013 Oncology Roundup. 360 . looks at: En bloc resection, irradiation and re-implantation; Metastasis and osteosarcoma; Mobile spine and osteosarcoma; Denosumab miraculous for GCT; Fevers, megaprostheses and sarcomas; PET and prognosis; Canine sarcomas not so different?; Bone cement and giant cell tumours

The October 2014 Oncology Roundup. 360 . looks at: how best to reconstruct humeral tumours; not everything is better via the arthroscope; obesity and sarcoma; frozen autograft; en-bloc resection and metastatic disease; positive margins in soft-tissue injuries; lipomatous tumours explored; and what happens with recurrence of osteosarcoma

The August 2012 Oncology Roundup. 360. looks at: prolonged symptom duration; peri-operative mortality and above-knee amputation; giant cell tumour of the spine; surgical resection for Ewing’s sarcoma; intercalary allograft reconstruction of the femur for tumour defects; and an induced membrane technique for large bone defects

The February 2014 Oncology Roundup. 360 . looks at: suspicious lesions; limb salvage in pelvic sarcomas; does infection affect oncological survival?; cancer patient pathways; radiological arthritis with cement augmentation in GCT; and post-chemotherapy increase in tumour volume as a predictor of poor prognosis

The August 2013 Oncology Roundup. 360 . looks at: spinal osteosarcoma: all hope is not lost; intralesional curettage for low-grade chondrosarcoma?; isolated limb perfusion is a salvage option; worryingly high infection rates in patients with endoprostheses; how bad is endoprosthetic infection?; operatively treated metastatic disease; and cementoplasty gives immediate pain relief

The June 2012 Oncology Roundup. 360. looks at: avoiding pelvic hemipelvectomy; proximal femoral metastasis; extendible prostheses; rotationplasty; soft-tissue sarcomas; osteosarcoma of the pelvis; recurrent chondrosarcoma ; MRI and the differentiation between benign and malignant lesions; and malignant fibrous histiocytoma

The April 2014 Oncology Roundup. 360 . looks at: Eyeball as good as microscope for tumour margins; when is best to stabilise femoral metastases?; fluorine does not cause bone tumours; whether giant cell tumour of the proximal femur ever successfully managed; extraskeletal osteosarcoma; modular lower limb tumour reconstruction; and observational studies the basis for most bone tumour treatment

The June 2013 Oncology Roundup. 360 . looks at: whether allograft composite is superior to megaprosthesis in massive reconstruction; pain from glomus tumours; thromboembolism and orthopaedic malignancy; bone marrow aspirate and cavity lesions; metastasectomy in osteosarcoma; spinal giant cell tumour; post-atomic strike sarcoma; and superficial sarcomas and post-operative infection rates

The February 2013 Oncology Roundup. 360 . looks at: proximal fibular tumours; radiotherapy-induced chondrosarcoma; mega-prosthesis; CRP predictions of sarcoma survival; predicting survival in metastatic disease; MRI for recurrence in osteoid osteoma; and a sarcoma refresher

The October 2012 Oncology Roundup. 360. looks at: the causes of primary bone tumours; adjuvant chemotherapy in the longer term; vascularised fibular grafts to salvage massive femoral allografts; a new look at old risks; reconstruction with excised irradiated bone; predicting chemosensitivity in osteosarcoma ; and chemotherapy, osteoporosis and the risk of fracture

After 25 years in orthopaedic oncology the author wishes to set a challenge for the next generation by posing 10 questions which he believes still do not have answers and which may improve outcomes for patients with sarcomas. Why are sarcomas diagnosed so late?. Can we ever decide what is a safe margin?. What is the role of neoadjuvant chemotherapy for STS?. What can we do to decrease the risk of infection after limb salvage surgery?. What is the significance of local recurrence on outcome?. What really is the best treatment for Ewing's sarcoma of the pelvis?. Is cross sectional imaging essential as part of patient follow up?. Is it possible to evaluate outcomes combining survival and function?. Why can't we run a surgical trial in orthopaedic oncology?. How can we evaluate surgical success?. The author suggests ways these questions may be answered

Aim. was to analyze infections after bone tumour surgery. Method. 1463 patients treated from 1976 to 2007 were analized: 1036 with resection and prostheses in the lower limbs, 344 with resection and prostheses in the upper limbs, 83 with surgery for sacral tumours. Infections were analyzed for time of occurrence (“postoperative” in the first 4 weeks from surgery, “early” within 6 months, and “late” after 6 months), microbic agents, treatment, outcome. Results. In lower limbs, infections occurred in 80 cases (7.7%): generally monomicrobial, caused by gram positives, postoperative in 9, early in 12, late in 59 cases. Treatment was “two stage” in 73, “one stage” in 4, primary amputation in 3. Revisions for infection were successful in 63 patients (79%), while 17 patients were amputated (21%). In upper limbs, infections occurred in 20 cases (5.8%): generally monomicrobial, caused by gram positives (88.5%), postoperative in 2 cases, early in 7, late in 11. “Two stage” treatment was attempted in all cases, but only in 3 prosthesis was re-implanted, since the cement spacer yelded similar function. No infections were observed in 28 intralesional excisions of sacral giant cell tumours. Infection occurred in 23/52 resected sacral tumours (44%) (Three patients died postoperatively were excluded from this group): postoperative in 16 cases and early in 7, caused by gram negatives in 62% and multimicrobial in 74%. Surgical debridements associated with antibiotic therapy according to coltures cured infection in all cases. Conclusion. Infection is a severe complication in orthopedic oncology. Its incidence in the extremities (7.7% and 5.8%) is lower than after sacral surgery (44%). It is influenced by chemotherapy and by the presence of foreign bodies. Infections were mostly late, monomicrobial, gram positive in extremities, while early, multimicrobial and gram negative in sacral surgery

Introduction. The use of computer navigation has a potential to allow precise tumour resection and accurate reconstruction of the resultant defect. This can be useful in difficult areas such as pelvis, diaphyseal (intercalary) resections and geometric bony resections. Methods. We have carried out resections of musculoskeletal tumours in 7 patients using an existing commercial computer navigation system (Orthomap 3D). CT & MRI scans of each patient were fused preoperatively using navigation software and the tumour margins were marked. The planes of tumour resection were defined on the 3D image generated. During surgery, trackers were attached to bone with tumour and registration performed. Instruments attached to navigation tracker were then used to identify the predetermined resection points. Of the 4 pelvic tumours, 1 had biological reconstruction with extra corporeal irradiation, 3 had endoprosthetic replacement & 1 did not need any bony reconstruction. 1 patient with proximal femur tumour needing extraarticular resection had endoprosthetic replacement. The 2 tibial diaphyseal tumours had biological reconstruction. Results. Examination of the resected specimens revealed tumour free margins. Postoperative radiographs showed resection and reconstruction as planned in all cases. In the patient with extraarticular proximal femur resection the hip joint was inadvertently exposed whilst making the acetabular osteotomy & in one patient with pelvic tumour the intra-operative registration could not be accurately performed as she was overweight and a real time matching of anatomy & virtual images was not achieved. Discussion and Conclusion. The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent and thus resection margins can be identified accurately. Our experience so far has been encouraging. Further clinical trials (multicentre) are required to evaluate its long term impact including functional & oncological outcomes

The December 2012 Trauma Roundup³⁶⁰ looks at: more is not always better, especially when its chemotherapy; new hope for skeletal metastasis; biopsy tracts; intra-operative imaging of sarcomas; curettage with adjuvant therapy; amputation and distal tibial osteosarcoma; and diaphyseal tibial tumours.

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

Aims. Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. Methods. MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. Results. In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. Conclusion. Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:–1751

Objectives. As tumours of bone and soft tissue are rare, multicentre prospective collaboration is essential for meaningful research and evidence-based advances in patient care. The aim of this study was to identify barriers and facilitators encountered in large-scale collaborative research by orthopaedic oncological surgeons involved or interested in prospective multicentre collaboration. Methods. All surgeons who were involved, or had expressed an interest, in the ongoing Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial were invited to participate in a focus group to discuss their experiences with collaborative research in this area. The discussion was digitally recorded, transcribed and anonymised. The transcript was analysed qualitatively, using an analytic approach which aims to organise the data in the language of the participants with little theoretical interpretation. Results. The 13 surgeons who participated in the discussion represented orthopaedic oncology practices from seven countries (Argentina, Brazil, Italy, Spain, Denmark, United States and Canada). Four categories and associated themes emerged from the discussion: the need for collaboration in the field of orthopaedic oncology due to the rarity of the tumours and the need for high level evidence to guide treatment; motivational factors for participating in collaborative research including establishing proof of principle, learning opportunity, answering a relevant research question and being part of a collaborative research community; barriers to participation including funding, personal barriers, institutional barriers, trial barriers, and administrative barriers and facilitators for participation including institutional facilitators, leadership, authorship, trial set-up, and the support of centralised study coordination. Conclusions. Orthopaedic surgeons involved in an ongoing international randomised controlled trial (RCT) were motivated by many factors to participate. There were a number of barriers to and facilitators for their participation. There was a collective sense of fatigue experienced in overcoming these barriers, which was mirrored by a strong collective sense of the importance of, and need for, collaborative research in this field. The experiences were described as essential educational first steps to advance collaborative studies in this area. Knowledge gained from this study will inform the development of future large-scale collaborative research projects in orthopaedic oncology. Cite this article: J. S. Rendon, M. Swinton, N. Bernthal, M. Boffano, T. Damron, N. Evaniew, P. Ferguson, M. Galli Serra, W. Hettwer, P. McKay, B. Miller, L. Nystrom, W. Parizzia, P. Schneider, A. Spiguel, R. Vélez, K. Weiss, J. P. Zumárraga, M. Ghert. Barriers and facilitators experienced in collaborative prospective research in orthopaedic oncology: A qualitative study. Bone Joint Res 2017;6:–314. DOI: 10.1302/2046-3758.65.BJR-2016-0192.R1

Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation. A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic Oncology Surgeon. We examined the rate of component revision due to infection and the rate of infection successfully treated with antibiotic therapy. We reviewed overall revision rates, sub-categorised into the Henderson groupings for endoprosthesis modes of failure (Type 1 soft tissue failure, Type 2 aseptic loosening, Type 3 Structural failure, Type 4 Infection, Type 5 tumour progression). 283 silver-coated MUTARS endoprosthetic reconstructions were performed for 229 patients from October 2012 to July 2022. The average age at time of surgery was 58.9 years and 53% of our cohort were males. 154 (71.3%) patients underwent SC-EPR for oncological reconstruction and 32 (14.8%) for reconstruction for bone loss following prosthetic joint infection(s). Proximal femur SC-EPR (82) and distal femur (90) were the most common procedures. This cohort had an overall revision rate of 21.2% (60/283 cases). Component revisions were most commonly due to Type 4 infection (19 cases), Type 2 aseptic loosening/culture negative disease (15 cases), and Type 1 dislocation/soft tissue (12 cases). Component revision rate for infection was 6.7% (19 cases). 15 underwent exchange of implants and 4 underwent transfemoral amputation due to recalcitrant infection and failure of soft tissue coverage. This equates to a limb salvage rate of 98.3%. The most common causative organisms remain staphylococcus species (47%) and polymicrobial infections (40%). We expand on the existing literature advocating for the use of silver-coated endoprosthetic reconstructions. We provide insights from the vast experience of a single surgeon when addressing patients with oncological and bone loss-related complex reconstruction problems

Given the low prevalence of sarcoma, international cooperation is necessary to recruit sufficient numbers of patients for surgical trials. The PARITY (Prophylactic Antibiotic Regimens in Tumour Surgery) trial is the first international multicentre trial in orthopedic oncology and successfully achieved target enrollment of 600 patients across 12 countries. It is important to reflect upon the challenges encountered and experiences gained to inform future trials. The objective of this study is to describe recruitment patterns and examine the differences in enrollment across different PARITY sites and identify variables associated with varying levels of recruitment. Data from this study was obtained from the PARITY trial Methods Centre and correspondence data. We performed descriptive statistics to demonstrate the recruitment patterns over time. We compared recruitment, time to set up, and time to enroll the first patient between North American and international sites, and sites that had dedicated research personnel. Two-tailed non-paired t-tests were performed to compare average monthly recruitment rates between groups with significance being set at alpha=0.05. A total of 600 patients from 48 clinical sites and 12 countries were recruited from January 2013 through to October 2019. Average monthly enrollment increased every year of the study. There were 36 North American and 12 international sites. North American sites were able to set up significantly faster than international sites (19.3 vs. 28.3 months p=0.037). However, international sites had a significantly higher recruitment rate per month once active (0.2/month vs. 0.62/month, p=0.018). Of active sites, 40 (83%) had research support personnel and 8 (17%) sites did not. Sites with research personnel were able to reach ‘enrolment ready’ status significantly faster than sites without research support (19.6 vs. 30.7 months, p=0.032). However, there was no significant difference in recruitment rate per month once the sites began enrolling (0.28/month vs. 0.2/month, p=0.63). Trial sites that took longer than 1 year to recruit their first patient had 3x lower average recruitment rate compared to sites that were able to recruit their first patient within a year of being enrolment ready. The PARITY trial is the first multicentre RCT in orthopaedic oncology. The PARITY investigators were able to increase the recruitment levels throughout the trial and generally avoid trial fatigue. This was a North American based trial which may explain the longer start up times internationally given the different regulatory bodies associated with drug-related trials. However, international sites should be considered critical as they were able to recruit significantly more patients per month once active. The absence of research support personnel should not preclude a site from inclusion. These sites took longer to setup but had no difference in monthly recruitment once active. This study will create a framework for identifying and targeting high yield sites for future randomized control trials within orthopaedic oncology to maximum recruitment and resource allocation. Data quality is another consideration that will be addressed in future analyses of the PARITY trial

Musculoskeletal tumours are relatively rare and as such, they are not well known by the population and by general practicioners. We observed that an important proportion of our patients has seen major delays at diferent stages of their referral pathway. It is well recognised that such delays can cause avoidable loss of function, local and systemic recurrence and increase in health system costs. The main objective of this study was to prospectively assess the referral paterns of our patients to pinpoint the causes of the delays. This should allow the formation of strategies to minimise delas and their impact. The secondary objective was to assess the performance of our centre in comparaison to other centre with the goal of improving quality of care. Prospective follow up data is available for 457 patient referred to our musculoskeletal oncology team between july 2011 and november 2014. Every patients filled questionnaires on their initial referral patterns. Site specific function and quality of life are evaluated at baseline and at subsequent follow-up (six months, one year, three years and five years). The average delay between the first symptoms and the first medical consultation with a general practitioner was 37 weeks (CI: 27–46). The average delay between the first medical consultation and the referral to orthopaedic oncology was 54 weeks (CI: 43–65). The delay between the first consultation with a general practitioner and the first radiologic test was 31 weeks (CI: 22–39). The delay between the first radiologic test and the referral to orthopaedic oncology was 28 weeks (CI 24–32). The delay between the referral to orthopaedic oncology and the first appointment to our centre was three weeks (CI 2–4). Before the referral to our center, 23% of the patients met two general practitioners and 10% met with 3 or more general practitioner. Fifty-two pervent of the patients had a consultation with a specialist and 19% saw two or more specialists. It is imperative to raise awareness of musculoskeletal tumours and indication for early referral in general practitioners. One of the main problems in our actual referral patern is early access to appropriate imaging. The creation of a referral program with specific guidelines is, in our opinion, the best way to significantly reduce the delays for appropriate management of patients with suspiscion of musculoskeletal tumours

Purpose. The consequences of infection in orthopedic oncology patients are well known. Methicillin sensitive- and resistant Staphylococcus aureus (MSSA and MRSA, respectively) are common infecting organisms which may colonize patients pre-operatively. The prevalence of colonization in orthopedic oncology patients is unknown. We sought to prospectively establish the prevalence of MSSA and MRSA colonization in an orthopedic oncology patient population. Method. Beginning in September 2009, all oncology patients of a single surgical service were prospectively screened pre-operatively for MSSA and MRSA colonization using PCR nasal swabs as part of an infection control protocol. Patients identified as carriers underwent decolonization treatment peri-operatively. Results. One hundred thirty-nine oncology patients underwent 143 independent procedures with orthopedics as the primary service from September 1, 2009 August 31, 2010. MSSA/MRSA screening capture rate was 93%. Prevalence of MSSA colonization was 22% and MRSA colonization was 3.8%. MSSA colonization was not associated with malignant diagnosis (p=1.0), or recent chemo- or radiotherapy treatment (p>0.50 for both). All MRSA colonized patients had undergone inpatient oncology treatment or had occupational exposure to MRSA in the last year. Post-operative infection developed in 4/124 patients with type I surgical incisions (3.2%). Infecting organisms were coagulase negative Staphylococcus (n=2), MSSA (n=1), and Streptococcus (n=1). Conclusion. MSSA colonization rates in orthopedic oncology patients are similar to reported population values. MRSA colonization rates are low. Patient diagnosis or adjuvant treatments do not appear to influence colonization rates. MRSA colonization was only seen in patients with inpatient or occupational exposure to MRSA

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery. This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS. There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS. The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients

Aim

While the association of surgery and radiation therapy in high grade Soft Tissue Sarcoma (STS) of extremities is considered the “golden standard”, there is not international agreement regarding type, timing, overall dose of radiation, and size, site and histology of tumours to be irradiated. A similar consideration is about low grade STS. The aim of our paper is critically reconsider our experience, trough a retrospective analysis of 15 years experience. This in order to propose a perspective protocol of treatment of high and low grade STS, in order to minimize the late complication rate.

The April 2013 Oncology Roundup. 360 . looks at: the margin for error; new money for old risks; hindquarter amputation; custom tumour jigs; preserving the tibial epiphysis; how long is long enough?; genomics and radiation-induced bone tumours; and India ink

The April 2012 Oncology Roundup. 360 . looks at chondrosarcoma of the cervical spine, if excision margins matter, radiation-induced sarcomas, giant cell tumours and bone cement, enchondromatosis and malignant change, axial or appendicular Ewing’s sarcoma, and diagnosing a sarcoma

Aims. Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients. Methods. Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation. Results. A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group. Amputation was also associated with longer survival times (p < 0.050). Overall median survival time was limited to 20 months (0 to 80). Conclusion. Early and aggressive treatment with appropriate oncological surgery confers the lowest LRR and a survival advantage versus conservative treatment in this cohort of patients. With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means, such as GP, local oncology, and/or patient-led follow-up. Cite this article: Bone Joint J 2022;104-B(1):177–182

We report our experience of using a computer navigation system to aid resection of malignant musculoskeletal tumours of the pelvis and limbs and, where appropriate, their subsequent reconstruction. We also highlight circumstances in which navigation should be used with caution. We resected a musculoskeletal tumour from 18 patients (15 male, three female, mean age of 30 years (13 to 75) using commercially available computer navigation software (Orthomap 3D) and assessed its impact on the accuracy of our surgery. Of nine pelvic tumours, three had a biological reconstruction with extracorporeal irradiation, four underwent endoprosthetic replacement (EPR) and two required no bony reconstruction. There were eight tumours of the bones of the limbs. Four diaphyseal tumours underwent biological reconstruction. Two patients with a sarcoma of the proximal femur and two with a sarcoma of the proximal humerus underwent extra-articular resection and, where appropriate, EPR. One soft-tissue sarcoma of the adductor compartment which involved the femur was resected and reconstructed using an EPR. Computer navigation was used to aid reconstruction in eight patients. Histological examination of the resected specimens revealed tumour-free margins in all patients. Post-operative radiographs and CT showed that the resection and reconstruction had been carried out as planned in all patients where navigation was used. In two patients, computer navigation had to be abandoned and the operation was completed under CT and radiological control. The use of computer navigation in musculoskeletal oncology allows accurate identification of the local anatomy and can define the extent of the tumour and proposed resection margins. Furthermore, it helps in reconstruction of limb length, rotation and overall alignment after resection of an appendicular tumour. . Cite this article: Bone Joint J 2015;97-B:258–64

Aims. Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas. Methods. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Results. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Conclusion. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival. Cite this article: Bone Joint J 2023;105-B(5):575–582

In orthopaedic oncology surgical precision is important and intraoperative imaging is often necessary. CAS may enhance precision and provide continuous 3D imaging without radiation. The goal of this work is to report our experience with CAS. Since 2006 we used CAS (Stryker) in 26 patients with a bone tumour: 11 chondrosarcomas, three osteosarcomas, seven osteochondromas and five miscellaneous. Twelve lesions were located in the femur, six in the pelvis, five in the lower leg and three in the upper extremity. In 18 cases a tumour was excised, in six of these a prosthesis was placed. In eight cases a curettage was done. In 23 cases the navigation was image-based (CT and/or MRI based) and in three cases image-less (no image-preparation necessary preoperatively). CAS was successfully employed in 23 cases. In three cases the procedure was aborted. In two cases, both in the ulna, we were unable to reconstruct the exact dimensions and in one case (image-less) the tracker was to far away from the work-field. There were no complications related to CAS. Mean precision is 0.5 mm. The time CAS takes is about 15 minutes during the procedure (7–60). In the eight curettages it proved helpful. We did not measure radiation time. In the six resections were tumour-prostheses were placed it was really helpful in rotation and length determination. In three of these, image-less navigation was performed (all distal femur). In osteochondroma resections it is helpful in four of seven cases. All surgical margins were adequate in the resections; after curettage, all MRI controls at three months did not show residual tumour. Oncology follow-up is too short yet; there was one local recurrence after two years in a parosteal osteosarcoma. We conclude that CAS can be our navigator in orthopaedic oncology; it is successful in providing precision and continuous 3D imaging. The indication area needs further study

Most types of bone tumor surgery require intra-operative imaging or measurement to control margins and prevent unnecessary bone loss. Computer Assisted Surgery (CAS) has been used as a replacement of fluoroscopy or direct measurement tools in four specific types of oncological orthopaedic surgical approaches. There are intralesional treatments, image-based resections, image-based resections with image-based reconstructions and image-based resections with imageless tumor prostheses reconstruction. Since 2006 we have performed 130 oncological surgeries with CAS. Most cases were excochleations, 64, where CAS replaces fluoroscopy as an intra-operative imaging modality. Advantages over fluoroscopy are real time three dimensional feedback, high-res image and no use of ionizing radiation. It is especially useful in larger lesions or lesions located in the femoral head or pelvis. Currently a study is being performed on patient satisfaction, recurrence and complications. Another application where CAS has often been used is in resections and segmental resections (together 45). These can be preplanned before surgery, incorporating the margin required, and checked intra-operatively. Coloration of the tumor, critical structures is useful to avoid these. Sometimes it's possible with careful planning to spare structures that otherwise probably would not confidently have spared. With hemicortical resection (5) it's possible to use CAS to exactly copy the shape of the resected bone to an allograft. A Ct scan of one case shows an average gap between host and graft of 0.9 mm (range 0–5.4) along the 6 cm resection. Finally in 16 cases of imageless use in placement of tumor prostheses it feels greatly helpful in reconstructing the joint line, length and correct rotation. There were 8 failures in these 130 cases with the system or software. Setup time was measured in 47 cases and was on average 6:50 (range 2:26–14:27). Indication and performance of CAS in orthopedic oncology is an under researched aspect of CAS. In our opinion CAS shows great promise in the field of orthopedic oncology and is a valuable tool in the operating room

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision. We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation; three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision and achieve pre-planned oncological margins with improved accuracy. We resected musculoskeletal tumours in ten patients using commercially available computer navigation software (Orthomap 3D, Stryker UK Ltd). Of the five pelvic tumours, two underwent biological reconstruction with extra corporeal irradiation, two endoprosthetic replacement (EPR) and one did not require bony reconstruction. Three tibial diaphyseal tumours had biological reconstruction. One patient with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging. Further clinical trials are required to evaluate its long-term impact on functional & oncological outcomes

Background. The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision. Materials and methods. We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Results. Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation, three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. Discussion. The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging

Quality outcomes from medical intervention are assumed by patients & the community. However such quality cannot be assured in every case. There are systems which can be developed which will make the safety of patients more assured. In any system of medical care, it is presumed that the practitioners who are taking care of the patient are qualified both in their basic qualification & also in their higher qualification. As well it is now accepted that appropriate credentialling occurs & that this is the purview of the hospital which will check the qualifications & currency of practice with the medical board & the higher degree & currency (participation in CPD) with the College concerned. They should also review the privileges which define the scope of practice. In orthopaedic oncology it is now essential that a practitioner has completed a higher form of training such as a Fellowship. At the current time in this country there is no process of assurance of the quality of the education program but there is continuing development in this area. Peer review & audit remains problematic. The RACS demands that surgeons participate in an appropriate audit process yearly & that this reviews outcomes rather than just complications. The participation is however voluntary. Despite this, the participation rate is greater than 94% of all surgeons. Medical boards have been requested to make participation in a quality CPD program compulsory, but have not done so, & there are no sanctions for non participation – yet. Most surgeons participate in regular morbidity & mortality meetings, but these are not truly audits of outcome. It would be wise for the Australian Sarcoma Group to develop outcome measures which could easily be collected. The desire to perform research should not be confused with audit which simply addresses quality at an appropriate expert level and which the community expects. Prospective collection & review of outcome measures will mean that trends in performance will be noted earlier. This is particularly important in adverse events. These processes have been embraced by some branches of surgery more than others. Medical outcome reviews of performance have not been developed to such an extent in most disciplines for a variety of reasons, including the fact that surgical endpoints can be more easily identified. The same principles apply, however. It is important for the profession to participate in self audit or third parties will demand it, not necessarily in a way which we might prefer

Introduction. Clear operative oncological margins are the main target in malignant bone tumour resections. Novel techniques like patient specific instruments (PSIs) are becoming more popular in orthopaedic oncology surgeries and arthroplasty in general with studies suggesting improved accuracy and reduced operating time using PSIs compared to conventional techniques and computer assisted surgery. Improved accuracy would allow preservation of more natural bone of patients with smaller tumour margin. Novel low-cost technology improving accuracy of surgical cuts, would facilitate highly delicate surgeries such as Joint Preserving Surgery (JPS) that improves quality of life for patients by preserving the tibial plateau and muscle attachments around the knee whilst removing bone tumours with adequate tumour margins. There are no universal guidelines on PSI designs and there are no studies showing how specific design of PSIs would affect accuracy of the surgical cuts. We hypothesised if an increased depth of the cutting slot guide for sawblades on the PSI would improve accuracy of cuts. Methods. A pilot drybone experiment was set up, testing 3 different designs of a PSI with changing cutting slot depth, simulating removal of a tumour on the proximal tibia (figure 1). A handheld 3D scanner (Artec Spider, Luxembourg) was used to scan tibia drybones and Computer Aided Design (CAD) software was used to simulate osteosarcoma position and plan intentioned cuts (figure 1). PSI were designed accordingly to allow sufficient tumour. The only change for the 3 designs is the cutting slot depth (10mm, 15mm & 20mm). 7 orthopaedic surgeons were recruited to participate and perform JPS on the drybones using each design 2 times. Each fragment was then scanned with the 3D scanner and were then matched onto the reference tibia with customized software to calculate how each cut (inferior-superior-vertical) deviated from plan in millimetres and degrees (figure 3). In order to tackle PSI placement error, a dedicated 3D-printed mould was used. Results. Comparing actual cuts to planned cuts, changing the height of the cutting slot guide on the designed PSI did not deviate accuracy enough to interfere with a tumour resection margin set to maximum 10mm. We have obtained very accurate cuts with the mean deviations(error) for the 3 different designs were: [10mm slot: 0.76±0.52mm, 2.37±1.26°], [15mm slot: 0.43±0.40mm, 1.89±1.04°] and [20mm: 0.74±0.65mm, 2.40±1.78°] respectively, with no significant difference between mean error for each design overall, but the inferior cuts deviation in mm did show to be more precise with 15mm cutting slot (p<0.05) (figure 2). Discussion. Simulating a cut to resect an osteosarcoma, none of the proposed designs introduced error that would interfere with the tumour margin set. Though 15mm showed increased precision on only one parameter, we concluded that 10mm cutting slot would be sufficient for the accuracy needed for this specific surgical intervention. Future work would include comparing PSI slot depth with position of knee implants after arthroplasty, and how optimisation of other design parameters of PSIs can continue to improve accuracy of orthopaedic surgery and allow increase of bone and joint preservation. For figures/tables, please contact authors directly.

Cite this article: Bone Joint Res. 2020;9(2):79–81.

Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia.

We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test.

A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals.

On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity.

To assess the performance of calcium sulphate pellets as a bone graft substitute in an Orthopaedic Oncology practice using clinical and radiological outcomes. Between 1998 and 2001, calcium sulphate pellets were used in cavitary defects in 38 procedures in 34 patients with bone tumours. In 29 calcium sulphate pellets were used alone, in 8 allograft and in 1 autograft bone was added. The diagnosis was unicameral bone cyst in 13, giant cell tumour in 11, non-ossifying fibroma in 2, chondroblastoma in 2, benign fibrous histiocytoma in 2 and another pathology in 8 procedures. The femur was involved in 12 procedures, the humerus in 8, the radius in 5, the tibia in 4, the fibula in 3, the calcaneus in 2, and one procedure each in the tarsal cuboid, a metatarsal, the talus, and the middle phalanx of a finger. Median follow up was 14 months (3 to 48). Seven patients had wound complications. Pellets had absorbed completely in 26/28 (93%) evaluable procedures by 3 months. Healing of the defect occurred in 24/28 (86%) evaluable procedures by 6 months. In 6 cases, the healed defect contained cystic areas simulating local recurrence. In 3 cases, there was collapse of the defect. In cavitary defects, calcium sulphate pellets reliably absorb. Some patients have wound complications, especially where the cavity is relatively superficial. The pellets do not provide mechanical stability where there is attenuated cortical bone. Cysts within the healed defect may simulate recurrence

The aim of this project is to test the parameters of Patient Specific Instruments (PSIs) and measuring accuracy of surgical cuts using sawblades with different depths of PSI cutting guide slot. Clear operative oncological margins are the main target in malignant bone tumour resections. Novel techniques like patient specific instruments (PSIs) are becoming more popular in orthopaedic oncology surgeries and arthroplasty in general with studies suggesting improved accuracy and reduced operating time using PSIs compared to conventional techniques and computer assisted surgery. Improved accuracy would allow preservation of more natural bone of patients with smaller tumour margin. Novel low-cost technology improving accuracy of surgical cuts, would facilitate highly delicate surgeries such as Joint Preserving Surgery (JPS) that improves quality of life for patients by preserving the tibial plateau and muscle attachments around the knee whilst removing bone tumours with adequate tumour margins. There are no universal guidelines on PSI designs and there are no studies showing how specific design of PSIs would affect accuracy of the surgical cuts. We hypothesised if an increased depth of the cutting slot guide for sawblades on the PSI would improve accuracy of cuts. A pilot drybone experiment was set up, testing 3 different designs of a PSI with changing cutting slot depth, simulating removal of a tumour on the proximal tibia. A handheld 3D scanner (Artec Spider, Luxembourg) was used to scan tibia drybones and Computer Aided Design (CAD) software was used to simulate osteosarcoma position and plan intentioned cuts. PSI were designed accordingly to allow sufficient tumour. The only change for the 3 designs is the cutting slot depth (10mm, 15mm & 20mm). 7 orthopaedic surgeons were recruited to participate and perform JPS on the drybones using each design 2 times. Each fragment was then scanned with the 3D scanner and were then matched onto the reference tibia with customized software to calculate how each cut (inferior-superior-vertical) deviated from plan in millimetres and degrees. In order to tackle PSI placement error, a dedicated 3D-printed mould was used. Comparing actual cuts to planned cuts, changing the height of the cutting slot guide on the designed PSI did not deviate accuracy enough to interfere with a tumour resection margin set to maximum 10mm. We have obtained very accurate cuts with the mean deviations(error) for the 3 different designs were: [10mm slot: 0.76 ± 0.52mm, 2.37 ± 1.26°], [15 mm slot: 0.43 ± 0.40 mm, 1.89 ± 1.04°] and [20 mm: 0.74 ± 0.65 mm, 2.40 ± 1.78°] respectively, with no significant difference between mean error for each design overall, but the inferior cuts deviation in mm did show to be more precise with 15 mm cutting slot (p<0.05). Simulating a cut to resect an osteosarcoma, none of the proposed designs introduced error that would interfere with the tumour margin set. Though 15mm showed increased precision on only one parameter, we concluded that 10mm cutting slot would be sufficient for the accuracy needed for this specific surgical intervention. Future work would include comparing PSI slot depth with position of knee implants after arthroplasty, and how optimisation of other design parameters of PSIs can continue to improve accuracy of orthopaedic surgery and allow increase of bone and joint preservation

Objective. was to review the experience of the Rizzoli with megaprosthetic reconstruction of the extremities in musculoskeletal oncology. Material and methods. Between April 1983 and December 2007, 1036 modular uncemented megaprostheses of the lower limbs were implanted in 605 males and 431 females: 160 KMFTR(r), 633 HMRS(r) prostheses, 68 HMRS(r) Rotating Hinge and 175 GMRS(r). Sites: distal femur 659, proximal tibia 198, proximal femur 145, total femur 25, distal femur and proximal tibia 9. Histology showed 612 osteosarcomas, 113 chondrosarcomas, 72 Ewing's sarcoma, 31 metastatic carcinomas, 89 GCT, 36 MFH,68 other diagnoses. Between 1975 and 2006 at Rizzoli 344 reconstructions of the humerus using prosthetic devices (alone or in association with allografts) were performed: 289 MRS(r), 37 HMRS(r), 2 Osteobridge(r), 4 composite prostheses, 8 Coonrad-Morrey(r), 4 custom made prostheses. Sites of reconstruction were: proximal humerus 311, distal humerus 19, diaphysis 5, total humerus 9. Histology showed 146 osteosarcomas, 56 chondrosarcomas, 23 Ewing's sarcoma, 67 metastatic carcinomas, 14 GCT, 10 MFH, 28 other diagnoses. Patients were followed periodically in the clinic. Information were obtained from clinical charts and imaging studies with special attention to major complications requiring revision surgery. Major prostheses-related complications were analysed and functional results evaluated according to the MSTS system. Univariate analysis by Kaplan-Meier actuarial curves was used for studying implant survival to major complications. Results. Major complications causing implants failure in lower limbs were 80 infections (7.7%), 64 aseptic loosening (6.2%) and 33 breakages (3.2%). In lower limbs infection occurred in 18 KMFTR(r), 47 HMRS(r), 5 HMRS(r) Rotating Hinge, 10 GMRS(r). Breakage of the prosthetic reconstruction occurred in 16 KMFTR(r), 16 HMRS(r), 1 HMRS(r) Rotating Hinge. Aseptic loosening occurred in 15 KMFTR(r), 28 HMRS(r), 18 HMRS(r) Rotating Hinge, 3 GMRS(r). Major complications causing implants failure in upper limbs were 15 infections (4.3%), 8 aseptic loosening (2.3%) and 4 breakages (1.2%). In upper limbs infection occurred in 14 MRS(r) and 1 Coonrad-Morrey(r). Aseptic loosening in 8 cases MRS(r). Breakage in 4 cases MRS(r) prostheses. Most patients in both lower and upper extremities series showed satisfactory function (good or excellent) according to the MSTS evaluation system. Implant survival to all major complications of lower limb megaprostheses evaluated with Kaplan-Meier curve was 80% at 10 years and 60% at 20 years. Implant survival for the newer designs (GMRS(r)) available only at middle term follow up showed an implant survival to major complications at about 90% at 5 years. Implant survival to all major complications was over 80% at 10 years and 78% at 20 years. Conclusions. Megaprostheses are the most frequently used type of reconstruction after resection of the extremities, since they provide good function and a relatively low incidence of major complications. Both function and implant survival improved in the last decades with the introduction of newer designs and materials

Introduction: Based on their experience of over 25 years in musculoskeletal oncology the Authors review indications and problems of the different types of biopsies. Methods: From the Rizzoli files and the literature most critical procedural problems and mistakes in performing biopsies are examined, with special attention to the consequences of mistakes and impact on treatment. Data of 749 consecutive cases of biopsies over a 12 year period were analysed: cases included were bone lesions with clinical and pathological features of malignancy requiring biopsy. Of these 198 had already had a biopsy elsewhere. Moreover the Rizzoli experience was reviewed in comparison to what reported in major studies in the literature. Results: Of the 551 cases primarily biopsied at the Rizzoli 28 (5%) required a repeated biopsy. Of 198 cases biopsied elsewhere in 35 cases there was a major diagnostic error and in 18 a minor error (same grade of malignancy but different histotype). Most common mistakes adversely affecting treatment were wrong skin incisions and/or surgical approach, amount and quality of the biopsy sample, infection. Discussion: the analysis as well as major series reported in literature confirm that chosing the technique of biopsy and performing is not so simple. Critical task is first of all to properly chose the best technique:fine needle, trocar, incisional, frozen and excisional biopsies have proper indications, as well radioguidance or CT guidance or ultrasound guidance. Main needs are to avoid contamination, to provide an adequate sample of viable tissue and to place the biopsy tract so that it can be removed at definitive surgery. Today CT or MRI guided trocar biopsies are preferable for most bone lesions while ultrasound guided tru-cut biopsies in most soft tissue lesions. Mistakes concern the surgical approach, the site of biopsy, the quality of sample and tissue preservation. Most common mistakes of the unexperienced surgeon are to remove a lesion without a previous histology or to inadequately excise a soft tissue lesion. Conclusions: Biopsy is the last step of staging before treatment and it is a compromise between the need of having significant tissue and the need to avoid contamination, yet this is by definition an intralesional procedure. Prof. Mario Campanacci used to say that biopsy is an important surgical procedure in the treatment of musculoskeletal tumors and it should be planned and performed by an experienced surgeon or radiologist

Objective. To evaluate functional and oncological outcomes following sacral resection. Methods. Retrospective review of 97 sacral tumours referred to spinal or oncology units between 2004 and 2009. Results. 61 males, 37 females (average age of 47 (range 3 – 82). Average duration of symptoms 13 months. 17 metastatic disease, excluded from further discussion. Of the remainder 36/81(44%) underwent surgery – 21 excision, 9 excision and instrumented stabilisation, and 6 curettage. 13(16%) patients were inoperable - 8 advanced disease, 3 unable to establish local control, 2 recurrence. Colostomy was performed in 11/21(52%) patients who underwent excision. Deep wound infections in 6/21(29%). No difference in infection rates between definitive surgery with or without colostomy – 3/11(27%) vs. 3/10(30%). In the instrumented group, no colostomies were performed due to concerns about deep infection and none resulted (0/9). Radiological failure of stabilisation was noted in 7/9(78%). However, functionally, 3/9(33%) were mobilising independently, 3/9(33%) crutches, 2/9(22%) able to transfer and 1/9(11%) undocumented. Mean follow-up 25 months (range 0-70). Local recurrence in 9/36(25%) of operated patients. Metastasis occurred in 4/36(11%) and mortality 8/36(22%) although follow-up period was noted to be short. Conclusions. Results are comparable with current literature. Mechanical stabilisation for extensive sacral lesions is challenging. Despite radiological failure in 7/9 instrumented stabilisations, patients were relatively asymptomatic and only 1/9 required revision stabilisation surgery. By design none had colostomies and there were no deep infections