Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

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Due to its indolent clinical behaviour, the treatment paradigm of atypical cartilaginous tumours (ACTs) in the long bones is slowly shifting from intralesional resection (curettage) and local adjuvants, towards active surveillance through wait-and-scan follow-up. In this retrospective cohort study performed in a tertiary referral centre, we studied the natural behaviour of ACT lesions by active surveillance with MRI. Clinical symptoms were not considered in the surveillance programme.

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Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft.

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Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS.

Introduction. Primary soft tissue sarcomas of the extremities are uncommon. Many such lesions will present to specialists in other clinics such as specialist Hand or Foot and Ankle clinics. Many are of a small size at presentation and may appear to be alternate, more common pathology. Methods. We collected data from all those patients with acral soft tissues sarcomas and referred to the Oxford Sarcoma Service, Nuffield Orthopaedic Centre, Oxford over a thirteen year period from 1997 – 2010. Data were collected regarding the primary suspected diagnosis, the final diagnosis, the referral route and whether patients had undergone previous inadvertent excision. Results. 38 patients were treated (24 foot, 14 hand tumours). The commonest histological subtype was synovial sarcoma in the foot group, and leiomyosarcoma in the hand group. 25 of the 38 patients had a lesion of less than 5cm at presentation. For those patients in whom a wide excision was performed 50% underwent complex plastic surgical reconstruction. Discussion. This study shows that 30% of patients with acral tumours required further surgery due to previous inadequate/inadvertent excision. 5cm as a benchmark for specialist referral should not be applied to lesions in the hand or feet and we recommend the use of the “marble rule” i.e. any lesion the size of a marble should be referred urgently and no patient should undergo surgery without imaging

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While a centralized system for the care of patients with a sarcoma has been advocated for decades, regional variations in survival remain unclear. The aim of this study was to investigate regional variations in survival and the impact of national policies in patients with a soft-tissue sarcoma (STS) in the UK.

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Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques.

Aims

Urgent referral to a specialist centre for patients with a soft-tissue sarcoma (STS) has been recommended by the National Institute for Health and Care Excellence (NICE) in the UK since 2006. However, the impact of this recommendation on the prognosis for these patients remains unclear. We aimed to determine the impact of the NICE guidelines on the disease-specific survival (DSS) of patients with an STS.

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The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

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Surgery is often indicated in patients with metastatic bone disease (MBD) to improve pain and maximize function. Few studies are available which report on clinically meaningful outcomes such as quality of life, function, and pain relief after surgery for MBD. This is the published protocol for the Bone Metastasis Audit — Patient Reported Outcomes (BoMA-PRO) multicentre MBD study. The primary objective is to ascertain patient-reported quality of life at three to 24 months post-surgery for MBD.

We report our early experience with the use of a non-invasive distal femoral expandable endoprosthesis in seven skeletally immature patients with osteosarcoma of the distal femur. The patients had a mean age of 12.1 years (9 to 15) at the time of surgery. The prosthesis was lengthened at appropriate intervals in outpatient clinics, without anaesthesia, using the principle of electromagnetic induction. The patients were functionally evaluated using the Musculoskeletal Tumour Society scoring system. The mean follow-up was 20.2 months (14 to 30). The prostheses were lengthened by a mean of 25 mm (4.25 to 55) and maintained a mean knee flexion of 110° (100° to 120°). The mean Musculoskeletal Tumour Society score was 68% (11 to 29). Complications developed in two patients; one developed a flexion deformity of 25° at the knee joint, which was subsequently overcome and one died of disseminated disease. The early results from patients treated with this device have been encouraging. The implant avoids multiple surgical procedures, general anaesthesia and assists in maintaining leg-length equality

Aims

For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy.

Aims

Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

Introduction. The diagnosis and subsequent management of sarcoma often requires multiple separate attendances to Hospital and often a prolonged inpatient stay post surgery. Previous research has focused on the physical and emotional aspects of a diagnosis of cancer, but little has been discussed regarding the financial costs incurred by patients and their families. Methods. 40 patients treated at our Unit were contacted and were questioned about the financial costs relating to their diagnosis and treatment. The questionnaire included distance travelled to the Unit, mode of transport, who patients were accompanied by, costs whilst at the Hospital e.g. car parking, days off work and impact on employment and career progression. Results. Patients travelled an average of 88 miles for a return journey to the Unit. They attended an average of 18 out-patient consultations during their treatment. The estimated cost of travel to consultations alone, including parking was £785. The mean length of in-patient stay was 5.4 days. Relatives visited on most days of the in-patient stay with further associated costs. 18 patients felt that progression at work i.e. promotion had been affected by their diagnosis. A further 12 patients had lost / given up their job as a result of the disease. Discussion. The diagnosis, and the subsequent treatment of, Sarcoma has a profound effect on patients. The financial strain incurred by multiple clinic visits, in-patient stays and associated costs adds to the pressure of the diagnosis. Efforts need to be made to ensure that patients are seen in a truly coordinated manner and more use made of new innovations such as web support. An outline of the anticipated financial impact for patients should be given at an earlier stage and earlier liaison with employers ensured such that employers can plan for expected absences

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus in adult patients after trans-articular tumour resection. Method. Between1985 and 2005 thirty-eight consecutive proximal humeral reconstructions using either, allograft-prosthesis composite (n=10), osteoarticular allograft (n=13) or a modular tumour prosthesis (n=14), were performed in our clinic. Their mean follow-up was ten years (nine months to 25 years). Of these, twenty-seven were disease free at latest follow-up (Mean follow-up 16.8 years) and ten had died of disease (4.2 years). Complications and implant survival with revision surgery as end-point are presented for the total group of patients, functional scores for surviving patients only. Results. The endoprosthetic group presented the smallest complication rate of 21%, compared to 40% in the allograftprosthesis- composite and 62% in the osteoarticular allograft group. Only one revision was performed in the endoprosthetic group, in a case of shoulder instability. Infection after revision (n=3), pseudoarthrosis (n=2), fracture of the allograft (n=3), and shoulder instability (n=4) were major complications of allograft use in general. Kaplan-Meier-analysis showed a significantly better implant survival for the endoprosthetic group (log-rank p=0.002). At final follow-up the MusculoSkeletal Tumour Society scores averaged at; 72% for the allograft-prosthetic-composite (n=7, mean follow-up 19 years), 76% for the osteoarticular allograft (n=3, 16 years), and 77% for the endoprosthetic reconstruction (n=10, 6 years) groups. Conclusion. An endoprosthetic reconstruction after trans-articular proximal humeral resection resulted in the lowest complication rate, highest implant survival and comparable functional results when compared to allograft-prosthesiscomposite and osteoarticular-allograft use. For all types of reconstruction, gleno-humeral instability remains a major cause of dysfunction at long-term FU. We believe that the additional use of a knitted tube surrounding the humeral prosthesis may have decreased the high incidence of this complication reported in recent literature

Aim. To report late development of sarcomas on sites of previously curetted and grafted benign tumours. Rare cases of development of sarcomas in sites of previous benign lesions are documented, and the development is generally considered secondary to progression of benign lesions, even without radiotherapy. Methods and Results. In our files, 12 cases curetted and grafted, without radiotherapy addition developed sarcomas from 6 to 28 years from curettage (median 18). Age at first diagnosis (9 GCT, 1 benign fibrous histiocytoma, ABC and solitary bone cyst) ranged from 13 to 55 (median 30). For all cases radiographic and clinic documentation was available. Histology was available for 7 of the benign lesions and for all malignant lesions. The type of bone used to fill cavities was autoplastic in 4 cases, homoplastic in 2 cases, homoplastic and tricalciumphosphate/hydrossiapatite in 1 case, autoplastic and homoplastic in 1 cases, heteroplastic in 1 case. In 3 cases the origin was not reported. Secondary sarcomas, all high grade, were 8 OS, 3 MFH, and 1 fibrosarcoma. Conclusions. It is impossible to calculate the exact incidence of this transformation, but from a comparison with 137 secondary sarcomas treated in the same years (1975-2005) at the Rizzoli Institute, it is similar to the risk of a sarcoma on fibrous dysplasia or lower than a sarcoma on bone infarcts or on Paget's disease. Recurrence with progression from benign tumours can occur, but the very long intervals reported in the present series suggest a possible different pathogenesis. Recent preclinical papers report development of sarcoma in mice after transplantation of mesenchymal stem cells, independently from the type of scaffold used. The fact that reparative proliferative changes occuring in the area of dead bone, with stimulation of mesenchymal stem cells, could cause malignant transformation, is a new hypothesis

Introduction. Following bone tumour resection, lower limb reconstruction results in leg-length discrepancy in skeletally immature patients. Previously, minimally invasive endoprostheses have been associated with a high risk of complications including joint stiffness, nerve injury, aseptic loosening and infection. The purpose of this study was to examine the outcome of the Stanmore non-invasive extendible endoprostheses used in our institution between 2002 and 2009 and compare them with implants used in the past. Methods. Fifty-five children with a mean age of 11.4 years (5 to 16) underwent limb reconstruction with thirty-three distal femoral, two total femoral, eight proximal femoral and twelve proximal tibial implants. Forty-six endoprostheses were lengthened in clinic without anaesthesia using the principle of electromagnetic induction. Patients were assessed using the Musculoskeletal Tumour Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS). Results. Ten children (18.2%) died of disseminated disease. One child underwent amputation for infected prosthesis. Forty-four patients were reviewed after a mean follow-up of 41 months (16 to 98). The mean MSTS score was 80.7% (26.7-100) and the TESS score was 92.3% (55.2-99). There was no local tumour recurrence. Complications developed in sixteen patients (29.1%). Seven patients (12.7%) underwent ten revision procedures. The mean length gained per patient was 38.6mm (3.5 to 161.5) requiring a mean of 11.3 (1-40) extensions. Ten component exchanges were performed in nine patients (16.4%) after attaining the maximum lengthening capacity of the implant. Eleven patients (20%) were skeletally mature at follow-up, of which ten had equal leg-lengths and nine had full range of hip and knee movement. Overall our outcomes compared favourably with minimal endoprostheses and other non-invasive designs. Discussion. This is the largest reported series of non-invasive extendible endoprostheses, demonstrating good functional outcome with prevention of limb-length discrepancy at skeletal maturity

Introduction. Our Unit has been treating large volume soft tissue sarcomas involving the sciatic nerve with epineurectomy for over a decade. The aim of this study was to quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy. Methods. 20 patients with soft tissue sarcomas involving the sciatic nerve were studied treated between 1997 and 2010. Nineteen underwent surgery with extended epineurectomy of the sciatic nerve and planned marginal excision. All patients underwent staging and follow up at our Sarcoma Clinic with functional assessment and TESS evaluation. Results. There were sixteen low and four high-grade posterior thigh tumours of which nineteen were liposarcomas and one haemangiopericytoma. Two were recurrent and eighteen were primary. There were seven men and thirteen women with a mean age of 77 years. Nineteen patients underwent planned marginal excision. There was soft tissue reconstruction in three cases using fascial adductor or gracilis graft for sciatic nerve cover and one with superficial femoral nerve and vein resection requiring ipsilateral saphenous reconstruction. The remainder underwent direct primary reconstruction. Eight patients underwent post operative radiotherapy. There was no local recurrence of disease. There was one patient with post radiation wound necrosis that resolved. Four patients have died of unrelated causes. Discussion. Planned marginal excision (PME) of low grade large volume posterior thigh sarcomas with extensive sciatic nerve involvement can be successfully treated with preservation of the sciatic nerve without significant morbidity and excellent resultant limb function. Even with PME of high grade disease with adjuvant radiotherapy, there was no local recurrence. Whilst the procedure is technically demanding, providing strict surgical technique is employed, damage to the sciatic nerve is rare and leaves patients with an unimpaired future lifestyle

Aim. We investigated low grade intramedullary chondrosarcomas to see if curettage and cementation remains a strong alternative treatment to local resection. Methods. 39 patients with biopsy proven low grade chondrosarcoma treated with curettage and cementation in our clinic between 1993-2009. 32 were females and 7 were males. Mean age was 44. Mean follow up was 40.5 months. Anatomical localizations were 16 proximal humerus and 16 proximal femur, 6 distal femur and 1 proximal tibia. All patients had plain X-ray, CT scan, Tc99 bone scan and MRI before open biopsy. 28 patients had frozen intraoperative biopsy. Histological diagnosis were grade I chondrosarcoma in all our patients. Curettage followed by high speed burr and cementation with high viscosity bone cement was applied without any internal fixation. Active physiotherapy began after 2 days of the operation and full weight bearing is permitted at about 2 weeks later. Results. At 72.6 months follow up 2 patients (1 proximal humerus, 1 distal femur) developed local recurrence at 3rd month and converted to local wide excision and reconstruction with tumour prosthesis. No infection occurred in the series. All patients followed by plain X-rays and if needed CT or MRI every third month in the first year and every fourth month at the second year and 6 months thereafter. Chest CT scans obtained at every 6 months for two years. No patient developed distant metastasis including recurrence cases. Conclusion. Curettage and cementation in the treatment of low grade chondrosarcomas with a local recurrence rate of 5.1 percent proved itself as a safe and function sparing surgical method. Recurred patients turned out to be Grade II chondrosarcoma at the re-examination of resected specimens. Recurrences could be easily detected around bone cement and prompt resection with prosthetic replacement seemed to be effective

Aim. Patients treated with limb salvage surgery for bone sarcomas of the extremities (upper and lower) may have physical disability as a result of treatment. Goal of this study was to evaluate the quality of life after treatment (chemotherapy and conservative surgery) at long term. Method. 208 patients resected for a bone sarcoma and with prosthetic reconstruction (45 in the upper and 163 in the lower limb) were evaluated. Assessment of results was done using the Karnofsky Scale (K.S.). Patients were followed in the clinic and functional results assessed according to the Musculoskeletal Tumour Society (MSTS) system. Moreover the Toronto Extremity Salvage Score questionnaire (TESS) was mailed to 144 patients. Results. Before treatment 157 patients had a Karnofsky index between “50%” and “70%”, 96 patients between “0%” and “40%”. After treatment 94 patients had a Karnofsky index between “80%” and “100%”, 54 between “50%” and “70%”, and 34 below “40%”. Twentysix patients died with disease. For the upper limb MSTS system showed a mean value of 80%, with excellent or good results (MSTS score between 30 and 15) in 43 patients, fair or poor results (MSTS score between 14 and 0) in 2 patients. For the lower limb MSTS system showed a mean value of 76.6%, with excellent or good results in 145 patients (89%), fair or poor results in 18 patients (11%). TESS questionnaire was sent back by eighty two patients. TESS was recorded an average of 3.7 years (upper limb) and 4.2 years (lower limb) after reconstruction. Mean TESS was similar in upper (75.3%) and lower (78.3%) limbs, but differed with age (patients older than 25 years had worse scores). Conclusion. The 3 analyzed methods showed a good quality of life after treatment. The subjective view of K.S. and TESS is aligned with the MSTS results