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.

Several methods have been used for proximal humeral reconstruction following tumour resection. None of these modalities allow the patient to regain his normal shoulder range of motion. Moreover, every modality has its advantages and disadvantages.

The aim of this study was to compare the functional outcome of 2 reconstructive modalities that we are using in our institution for proximal humeral reconstruction; endoprosthesis and shoulder arthrodesis using a vascularised autograft This study included 48 patients diagnosed with malignant or benign aggressive tumours that required resection of their proximal humerus. They were divided into 2 groups according to the method of reconstruction. Group 1 included 22 patients with an average age of 20 years were reconstructed by shoulder arthrodesis using a free vascularised fibular graft (6) or a pedicled scapular crest graft (16). Group 2 included 26 patients with an average age of 26 years were reconstructed with an endoprosthesis.

In group 1 the average follow up period was 88 months (range 12 to 184 months). The average functional outcome (according to the MSTS scoring system) was 25 points (range 19 – 28). The average abduction and forward flexion range of motion (scapulothoracic) was 40 degrees (range 20 -60). Complications included failed fixation (2), non union (1), infection (1) and temporary radial nerve palsy (2). In group 2 the average follow up period was 36 months (range 12 – 110). The average functional outcome was 24 points (range 20 – 27). The average abduction and forward flexion range of motion was 40 (range 30 –70). Complications included sublaxation (2), loosening (1) and infection (1).

Reconstruction of the proximal humerus by arthrodesis or endoprosthesis yield similar functional outcome. Although endoprosthesis is a much more expensive modality, it does not provide any superior functional outcome over shoulder arthrodesis.

Aim

To compare the functional outcome of proximal femoral reconstruction using endoprosthetic replacement and hip arthrodesis using a vascularised fibular graft

Fifteen patients (11 males, 4 females) with a median age of 16 years (range, 7–25) were treated in our centre by intra-articular resection of the proximal femur, and hip arthrodesis using a vascularized fibular graft. Eight patients had Ewing’s sarcoma, 5 osteogenic sarcoma, and 2 chondrosarcoma.

After a mean follow up of 58.2 months, 13 patients were alive with no evidence of disease. All fibular grafts united at a mean time of 7.6 months (range, 7–9 months). Four patients had stress fractures of the vascularized fibular graft, all healed after a mean period of 6.5 weeks. Failure of the fixation system occurred in two patients. Deep infection developed in one case which necessitated plate removal. Three of these patients with complications underwent a second procedure, giving a re-operation rate of 20%. The mean MSTS functional score was 85.9% at the time of the latest follow-up.

We conclude that hip arthrodesis using a vascularized fibular graft is a viable alternative to endoprosthetic replacement after proximal femoral resections. It should be considered as an effective and durable reconstructive technique in young patients with high physical demands.

Patients with high-grade osteosarcoma who have been previously misdiagnosed as benign lesions or infection and accordingly been treated by curettage, internal fixation or drainage present a challenge in deciding the most appropriate treatment plan. Since one of the contraindications of limb salvage is the inability to achieve a wide surgical margin, there has been a tendency to treat these patients by amputation. Due to contamination by previous surgeries, limb salvage surgery was thought to be associated with a higher risk of local recurrence.

The aim of this study was to evaluate the oncologic outcome following limb salvage surgery done for high-grade osteosarcoma patients who were initially treated inadequately by curettage, internal fixation or drainage.

The study included 24 patients (14 males and 10 females) with an average age of 19 years (range 7 to 39 years). All the patients had high-grade osteosarcoma of the extremities. Seven were located in proximal tibia, six distal femur, four proximal humerus, three proximal femur, two distal tibia, one distal radius and one fibula. 14 patients were previously diagnosed as benign lesions and treated by curettage. 5 patients were diagnosed as regular fracture and internally fixed. 5 patients were diagnosed as osteomyelitis and treated by drainage. The patients were staged then treated by neoadjuvant chemotherapy and limb salvage surgery. The average time between the initial procedure and the limb salvage procedure was 7 months (range 3 to 36 months). A wide resection margin was achieved in all patients.

The average follow up period was 40 months (range 18 to 110 months). Local recurrence occurred in three patients (12.5%). Three patients developed chest metastases and one patient developed bone metastases.

We conclude that patients who had an inadequate surgical procedure prior to the diagnosis of a high-grade osteosarcoma could still be treated by neoadjuvant chemotherapy and limb salvage surgery without a significant increased risk of local recurrence and chest metastases.

Osteosarcoma is the most common bone tumour of the paediatric age. Long time survival can be reached in 70% of patients when metastatic disease is absent at presentation. But in spite of aggressive chemotherapy regimens, about 30% of patients die of the disease.

This retrospective study was carried on 120 patients with primary non-metastatic osteosarcoma of the extremities, attending at Cairo University Hospitals (Faculty of Medicine and National Cancer Institute) between January 1993 and June 2006. The patients’ functional outcome was evaluated according to the Musculoskeletal Tumor Society Functional Rating System.

All patients have undergone surgical resection of the tumour and limb salvage. They have received different chemotherapy regimens depending on the time of entry to the study. Four patients were treated according the Osteosarcoma Group Study I (OSGI): six courses of adjuvant cisplatin and doxorubicin. Twenty patients received OSGII: 2 neoadjuvant and 4 adjuvant courses of cisplatin and doxorubicin. Twenty-nine patients received OSGIII: high-dose methotrexate, ifosfamide, doxorubicin, and cisplatin. Sixty-seven patients received OSGIV: high dose cisplatin, ifosfamide, doxorubicin and a cardioprotective agent. Patients with limb salvage surgery were divided into 3 groups: mobile joints (33 patients), fused joints (75 patients) and rotation plasty (12 patients).

The 5-year event free survival and overall survival for the 120 patients were 70.9 % and 71.3% respectively at median follow-up of 54.5 months and a range of 5–153 months. Functional outcome for available patients according to MST rating system was < 70% in 34 patients and > 70 % in 86 patients. There was not a statistically significant difference between survival and different prognostic factors (age, sex, tumour site, tumour size, tumour necrosis, pathology and time of chemotherapy). Only serum LDH and alkaline phosphatase were statistically significant when correlated with survival.

The results of this study seem to be in accordance with other studies in the literature.

We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma.

Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems.