Aims

The aim of this study was to analyse a group of patients with non-metastatic Ewing’s sarcoma at presentation and identify prognostic factors affecting the development of local recurrence, in order to assess the role of radiotherapy.

Aims

The purpose of this study was to review a large cohort of patients and further assess the correlation between the histological response to chemotherapy in patients with Ewing’s sarcoma with the overall (OS) and event-free survival (EFS).

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy.

We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence.

Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.

Cite this article: Bone Joint J 2015;97-B:115–20.

The aim of this study was to evaluate the functional and oncological outcome of extracorporeally irradiated autografts used to reconstruct the pelvis after a P1/2 internal hemipelvectomy.

The study included 18 patients with a primary malignant bone tumour of the pelvis. There were 13 males and five females with a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a mean follow-up of 51.6 months (4 to 185), nine patients had died with metastatic disease while nine were free from disease. Local recurrence occurred in three patients all of whom eventually died of their disease. Deep infection occurred in three patients and required removal of their graft in two while the third underwent a hindquarter amputation for extensive flap necrosis.

The mean Musculoskeletal Tumor Society functional score of the 16 patients who could be followed-up for at least 12 months was 77% (50 to 90). Those 15 patients who completed the Toronto Extremity Salvage Score questionnaire had a mean score of 71% (53 to 85).

Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after an internal hemipelvectomy. It has an acceptable morbidity and a functional outcome that compares favourably with other available reconstructive techniques.

Cite this article: Bone Joint J 2014;96-B:1404–10

We retrospectively compared the outcome after the treatment of giant cell tumours of bone either with curettage alone or with adjuvant cementation. Between 1975 and 2008, 330 patients with a giant cell tumour were treated primarily by intralesional curettage, with 84 (25%) receiving adjuvant bone cement in the cavity. The local recurrence rate for curettage alone was 29.7% (73 of 246) compared with 14.3% (12 of 84) for curettage and cementation (p = 0.001). On multivariate analysis both the stage of disease and use of cement were independent significant factors associated with local recurrence. The use of cement was associated with a higher risk of the subsequent need for joint replacement. In patients without local recurrence, 18.1% (13 of 72) of those with cement needed a subsequent joint replacement compared to 2.3% (4 of 173) of those without cement (p = 0.001). In patients who developed local recurrence, 75.0% (9 of 12) of those with previous cementation required a joint replacement, compared with 45.2% (33 of 73) of those without cement (p = 0.044).

Background: And Aims Pathological fractures of the proximal femur due to primary bone sarcomas are difficult to treat. The aim of the study was to assess the factors determining the outcomes following pathological fractures of the proximal femur due to primary bone sarcomas.

Methods: 93 patients with a pathological fracture of the proximal femur due to primary bone sarcomas were studied. The patient, tumour and treatment factors in relation to overall survival were analysed.

Results: There were 55 male and 38 female patients. The mean age was 47 years. The diagnoses were Chondrosarcoma -34, Osteosarcoma – 21, spindle cell sarcoma – 25, Ewing’s sarcoma -13. 74 patients had a pathological fracture at diagnosis and 19 patients had a fracture after the diagnosis. 17 patients had metastases at diagnosis. 24 patients had an intracapsular fracture. Limb salvage was possible in 60 patients (65%), 18 patients had an amputation and 15 patients had palliative treatment. 27% of the patients were referred after an unplanned surgery. The mean follow up was 49 months [range 0–302]. Twenty one patients [23%] had a local recurrence -10 patients had a diagnosis of chondrosarcoma, four patients had osteosarcoma and seven had spindle cell sarcoma. The overall five years survival was 37% [Ewing’s sarcoma 60%, Chondrosarcoma 57%, spindle cell sarcoma 28%, osteosarcoma 13% and dedifferentiated Chondrosarcoma 0% (p-0.002)]. Metastasis at diagnosis was a significant factor (p-0.04) affecting survival.

Conclusion: We conclude that a pathological fracture of the proximal femur due to osteosarcoma and dedifferentiated chondrosarcoma. carry a poor prognosis.

Introduction: Malignant tumours of the foot and ankle are rare. The aim of the study was to document one of the largest series of malignant tumours affecting the foot and ankle and to assess the outcomes following limb salvage and amputation.

Methods: The study was a retrospective review of the patients with a malignant tumour of the foot and ankle. Demographic details, diagnosis, treatment and outcomes were retrieved from the electronic patient records containing information on over 20 000 patients seen over a 25 year period.

Results: Two hundred and twenty five patients had malignant tumours affecting the foot and ankle. It was common in the fifth decade (35 patients). The mean age was 46 years. The commonest diagnosis was synovial sarcoma (40 patients) followed by chondrosarcoma (23 patients) and Ewing’s sarcoma (21 patients). The mean tumour size was 5.6 cm (0.8 to 17.5 cm). 82 patients (37%) underwent an unplanned excision and 13% (29 patients) presented with metastases at diagnosis. Primary bone tumours were 28% (64 patients), soft tissue sarcomas were 62% and metastatic tumours were 8% while lymphoreticular malignancies were (1%). Limb salvage was possible in 71% (156 patients). 29% (65 patients) had a below knee amputation. 7% (15 patients) had a local recurrence. The 5 years survival was 63%. The 5 years survival for the patients who had limb salvage was 68% compared with 54% for the patients who had an amputation (p 0.03).

Conclusion: Though amputation can provide better local control, limb salvage surgery improves survival.

Introduction: Parosteal osteosarcoma is a rare, mostly low grade tumor arising from the surface of the bone. The aim of the study was to establish risk factors for local recurrence (LR) and death.

Method: Retrospective review of a prospectively collected database with complete up-to-date follow up.

Results: 63 patients were diagnosed and treated at our centre from 1978 to 2007. The most common site was the femur (37) followed by the tibia (10) and humerus (9). The median size was 7cm (2 – 16). At the time of diagnosis 27 (43%) were low grade, 13 (21%) were low grade but had invaded the medullary canal and 8 (13%) had a high grade component; the data was missing in 15 patients (24%). All patients were operated.

LR arose in 11 patients (17.5%) at a mean of 38 months and was related to surgical margins. There were no LR in the 26 wide resections, but the risk of LR was 20% in those with a marginal and 46% in those with an intralesional excision. LR appeared as a higher grade than the primary tumor in 3 patients (27%).

9 (14.3%) patients developed metastases at a median of 22 months (6 – 123). Five patients developed both LR and metastases. Seven patients died from the tumor, 2 patients are alive with metastatic disease.

None of the patients with a low grade tumor and wide or marginal margins died of tumor, but 2 patients (18%) operated intralesional died of tumor.

Discussion: There was a statistically significant relationship between surgical margins and LR (p< 0.001). All patients with low grade parosteal osteosarcoma operated with wide margins have been cured. LR appeared often in higher grade than the primary tumor. Patients with low grade tumor and intralesional margins had 18% risk to tumor-ralated death.

Pathological fractures due to metastasis with destruction of the acetabulum and central dislocation of the hip present a difficult surgical challenge. We describe a series using a single technique in which a stable and long-lasting reconstruction was obtained using standard primary hip replacement implants augmented by strong, fully-threaded steel rods with cement and steel mesh, where required.

Between 1997 and 2006, 19 patients with a mean age of 66 years (48 to 83) were treated using a modified Harrington technique. Acetabular destruction was graded as Harrington class II in six cases and class III in 13.

Reconstruction was achieved using three 6.5 mm rods inserted through a separate incision in the iliac crest followed by augmentation with cement and a conventional cemented Charnley or Exeter primary hip replacement. There were no peri-operative deaths. At the final follow-up (mean 25 months (5 to 110)) one rod had fractured and one construct required revision. Of the 18 patients who did not require revision, 13 had died. The mean time to death was 16 months (5 to 55). The mean follow-up of the five survivors was 31 months (18 to 47). There were no cases of dislocation, deep infection or injury to a nerve, the blood vessels or the bladder.

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the proximal tibia following resection of a tumour. Survival of the implant and ‘servicing’ procedures have been documented using a prospective database.

A total of 194 patients underwent a proximal tibial replacement, with 95 having a fixed-hinge design and 99 a rotating-hinge with a hydroxyapatite collar; their median age was 21.5 years (10 to 74). At a mean follow-up of 14.7 years (5 to 29), 115 patients remain alive. The risk of revision for any reason in the fixed-hinge group was 32% at five years, 61% at ten years and 75% at 15 and 20 years, and in the rotating-hinge group 12% at five years, 25% at ten years and 30% at 15 years. Aseptic loosening was the most common reason for revision in the fixed-hinge knees, fracture of the implant in the early design of rotating hinges and infection in the current version. The risk of revision for aseptic loosening in the fixed-hinge knees was 46% at ten years. This was reduced to 3% in the rotating-hinge knee with a hydroxyapatite collar. The cemented, rotating hinge design currently offers the best chance of long-term survival of the prosthesis.

We investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur after resection of a tumour. Survival of the implant and ‘servicing’ procedures have been documented using a prospective database, review of the design of the implant and case records. In total, 335 patients underwent a distal femoral replacement, 162 having a fixed-hinge design and 173 a rotating-hinge. The median age of the patients was 24 years (interquartile range 17 to 48).

A total of 192 patients remained alive with a mean follow-up of 12 years (5 to 30). The risk of revision for any reason was 17% at five years, 33% at ten years and 58% at 20 years. Aseptic loosening was the main reason for revision of the fixed-hinge knees while infection and fracture of the stem were the most common for the rotating-hinge implant. The risk of revision for aseptic loosening was 35% at ten years with the fixed-hinge knee, which has, however, been replaced by the rotating-hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason fell by 52% when the rotating-hinge implant was used.

Improvements in the design of distal femoral endoprostheses have significantly decreased the need for revision operations, but infection remains a serious problem. We believe that a cemented, rotating-hinge prosthesis with a hydroxyapatite collar offers the best chance of long-term survival of the prosthesis.