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
The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19).Aims
Methods
Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment. A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients.Aims
Methods
We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone. The search terms used in combination were “multicentric”, “giant cell tumour”, and “bone”. Exclusion criteria were: reports lacking data, with only an abstract; papers not reporting data on multicentric GCT; and papers on multicentric GCT associated with other diseases. Additionally, we report three patients treated under our care.Aims
Methods
The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation. A total of 69 patients with ankle sarcomas, treated between 1981 and 2017 at two tumour centres, were retrospectively reviewed (mean age at surgery: 46.3 years (SD 22.0); 31 females (45%)). Among these 69 patients 25 were analyzed prospectively (mean age at latest follow-up: 61.2 years (SD 20.7); 11 females (44%)), and assessed for mobility using the Prosthetic Limb Users Survey of Mobility (PLUS-M; for amputees only), the Toronto Extremity Salvage Score (TESS), and the University of California, Los Angeles (UCLA) Activity Score. Individual QoL was evaluated in these 25 patients using the five-level EuroQol five-dimension (EQ-5D-5L) and Fragebogen zur Lebenszufriedenheit/Questions on Life Satisfaction (FLZ).Aims
Methods
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. Between 1989 and 2015, 32 patients underwent a Type I or Type I/IV pelvic resection without reconstruction for a primary bone tumour. There were 21 men and 11 women with a mean age of 35 years (15 to 85). The most common diagnosis was chondrosarcoma (50%, n = 16). Local recurrence-free, metastasis-free, and overall survival were assessed using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumour Society (MSTS) and Toronto Extremity Salvage Score (TESS).Aims
Methods
To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs). This is a retrospective cohort study of patients with GCT who presented between January 2011 and July 2017. Intralesional curettage was performed and patients treated from 2015 to 2017 also received denosumab therapy. The patients were divided into three groups: Cohort 1: control group (n = 36); cohort 2: adjuvant denosumab group (n = 9); and cohort 3: neo- and adjuvant-denosumab group (n = 17).Aims
Methods
The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11).Aims
Methods
The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins. A cohort of 50 consecutive patients who underwent the modified Harrington procedure for periacetabular metastasis or haematological malignancy between January 1996 and April 2018 were studied. The median follow-up time for all survivors was 3.2 years (interquartile range 0.9 to 7.6 years).Aims
Patients and Methods
The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total We retrospectively reviewed 32 patients who underwent TES in our hospital between January 2015 and December 2017. We divided the patients into three groups on the basis of the method of reconstruction: an endoprosthesis group (n = 10); a combined reconstruction group (n = 14), who underwent non-endoprosthetic combined reconstruction, including anterior spinal column fixation; and a spinopelvic fixation (SPF) group (n = 8), who underwent only SPF. Spinopelvic stability, implant survival (IS), intraoperative haemorrhage rate, and perioperative complication rate in the endoprosthesis group were documented and compared with those of other two groups.Aims
Patients and Methods
The aim of this study was to assess the current trends in the estimation of survival and the preferred forms of treatment of pathological fractures among national and international general and oncological orthopaedic surgeons, and to explore whether improvements in the management of these patients could be identified in this way. All members of the Dutch Orthopaedic Society (DOS) and the European Musculoskeletal Oncology Society (EMSOS) were invited to complete a web-based questionnaire containing 12 cases.Aims
Materials and Methods
Aims
Patients and Methods
The aim of this study was to evaluate health-related quality of life (HRQoL) and joint function in tenosynovial giant cell tumour (TGCT) patients before and after surgical treatment. This prospective cohort study run in two Dutch referral centres assessed patient-reported outcome measures (PROMs; 36-Item Short-Form Health Survey (SF-36), visual analogue scale (VAS) for pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) in 359 consecutive patients with localized- and diffuse-type TGCT of large joints. Patients with recurrent disease (n = 121) and a wait-and-see policy (n = 32) were excluded. Collected data were analyzed at specified time intervals preoperatively (baseline) and/or postoperatively up to five years.Aims
Patients and Methods
The use of a noninvasive growing endoprosthesis in the management
of primary bone tumours in children is well established. However,
the efficacy of such a prosthesis in those requiring a revision
procedure has yet to be established. The aim of this series was
to present our results using extendable prostheses for the revision
of previous endoprostheses. All patients who had a noninvasive growing endoprosthesis inserted
at the time of a revision procedure were identified from our database.
A total of 21 patients (seven female patients, 14 male) with a mean
age of 20.4 years (10 to 41) at the time of revision were included.
The indications for revision were mechanical failure, trauma or infection
with a residual leg-length discrepancy. The mean follow-up was 70
months (17 to 128). The mean shortening prior to revision was 44 mm
(10 to 100). Lengthening was performed in all but one patient with
a mean lengthening of 51 mm (5 to 140).Aims
Patients and Methods
Adjuvant treatment after intralesional curettage for atypical
cartilaginous tumours (ACTs) of long bones is widely accepted for
extending surgical margins. However, evaluating the isolated effect
of adjuvant treatment is difficult, and it is unclear whether not
using such adjuvants provides poor oncological outcomes. Hence,
we analyzed whether intralesional curettage without cryosurgery
or chemical adjuvants provides poor oncological outcomes in patients
with an ACT. A total of 24 patients (nine men, 15 women) (mean age 45 years;
18 to 62) were treated for ACTs of long bones and followed up for
a median of 66 months (interquartile range 50 to 84). All patients
were treated with extensive manual curettage and limited burring.
Bone cement and grafts were used to fill bone defects in 16 and eight
patients, respectively. No chemical adjuvants or cryosurgery were
used.Aims
Patients and Methods
Few studies dealing with chondrosarcoma of the pelvis are currently
available. Different data about the overall survival and prognostic
factors have been published but without a detailed analysis of surgery-related complications.
We aimed to analyse the outcome of a series of pelvic chondrosarcomas
treated at a single institution, with particular attention to the
prognostic factors. Based on a competing risk model, our objective
was to identify risk factors for the development of complications. In a retrospective single-centre study, 58 chondrosarcomas (26
patients alive, 32 patients dead) of the pelvis were reviewed. The
mean follow-up was 13 years (one week to 23.1 years).Aims
Patients and Methods
After intercalary resection of a bone tumour from the femur,
reconstruction with a vascularized fibular graft (VFG) and massive
allograft is considered a reliable method of treatment. However,
little is known about the long-term outcome of this procedure. The
aims of this study were to determine whether the morbidity of this
procedure was comparable to that of other reconstructive techniques,
if it was possible to achieve a satisfactory functional result, and
whether biological reconstruction with a VFG and massive allograft
could achieve a durable, long-lasting reconstruction. A total of 23 patients with a mean age of 16 years (five to 40)
who had undergone resection of an intercalary bone tumour of the
femur and reconstruction with a VFG and allograft were reviewed
clinically and radiologically. The mean follow-up was 141 months
(24 to 313). The mean length of the fibular graft was 18 cm (12 to
29). Full weight-bearing without a brace was allowed after a mean
of 13 months (seven to 26).Aims
Patients and Methods
The aim of this study was to identify any progression between
benign osteofibrous dysplasia (OFD), OFD-like adamantinoma and malignant
adamantinoma, and to investigate the rates of local recurrence,
metastases and survival, in order to develop treatment algorithms
for each. A single institution retrospective review of all patients presenting
with OFD, OFD-like adamantinoma and adamantinoma between 1973 and
2012 was undertaken. Complete data were available for 73 patients
(42 with OFD; ten with an OFD-like adamantinoma and 21 with an adamantinoma).
The mean follow-up was 10.3 years (3 to 25) for OFD, 9.2 years (3.0
to 26.3) for OFD-like and 11.6 years (0.25 to 33) for adamantinoma.Aims
Patients and Methods
Due to the complex anatomy of the pelvis, limb-sparing resections
of pelvic tumours achieving adequate surgical margins, can often
be difficult. The advent of computer navigation has improved the
precision of resection of these lesions, though there is little
evidence comparing resection with or without the assistance of navigation. Our aim was to evaluate the efficacy of navigation-assisted surgery
for the resection of pelvic bone tumours involving the posterior
ilium and sacrum. Using our prospectively updated institutional database, we conducted
a retrospective case control study of 21 patients who underwent
resection of the posterior ilium and sacrum, for the treatment of
a primary sarcoma of bone, between 1987 and 2015. The resection
was performed with the assistance of navigation in nine patients
and without navigation in 12. We assessed the accuracy of navigation-assisted
surgery, as defined by the surgical margin and how this affects
the rate of local recurrence, the disease-free survival and the
effects on peri-and post-operative morbidity. Aims
Patients and Methods
We report a prospective cohort study of the midterm results of
surgical dislocation of the hip (according to Ganz) to perform resection
of osteochondromas involving the femoral neck in patients with multiple
hereditary exostoses (MHE). Hip range of movement (ROM) was assessed pre- and post-operatively.
Patients’ judgment of post-operative reduction of pain, symptoms,
the Rand 36-item Health Survey (RAND-36) and complications were
analysed. Aims
Methods
We investigated whether the presence of a pathological
fracture increased the risk of local recurrence in patients with
a giant cell tumour (GCT) of bone. We also assessed if curettage
is still an appropriate form of treatment in the presence of a pathological
fracture. We conducted a comprehensive review and meta-analysis
of papers which reported outcomes in patients with a GCT with and
without a pathological fracture at presentation. We computed the
odds ratio (OR) of local recurrence in those with and without a
pathological fracture. We selected 19 eligible papers for final analysis. This included
3215 patients, of whom 580 (18.0%) had a pathological fracture.
The pooled OR for local recurrence between patients with and without
a pathological fracture was 1.05 (95% confidence interval (CI) 0.66
to 1.67, p = 0.854). Amongst the subgroup of patients who were treated with
curettage, the pooled OR for local recurrence was 1.23 (95% CI 0.75
to 2.01, p = 0.417). A There is no difference in local recurrence rates between patients
who have a GCT of bone with and without a pathological fracture
at the time of presentation. The presence of a pathological fracture
should not preclude the decision to perform curettage as carefully
selected patients who undergo curettage can have similar outcomes
in terms of local recurrence to those without such a fracture. Cite this article:
Clinical studies of patients with bone sarcomas have been challenged
by insufficient numbers at individual centres to draw valid conclusions.
Our objective was to assess the feasibility of conducting a definitive
multi-centre randomised controlled trial (RCT) to determine whether
a five-day regimen of post-operative antibiotics, in comparison
to a
24-hour regimen, decreases surgical site infections in patients
undergoing endoprosthetic reconstruction for lower extremity primary
bone tumours. We performed a pilot international multi-centre RCT. We used
central randomisation to conceal treatment allocation and sham antibiotics
to blind participants, surgeons, and data collectors. We determined
feasibility by measuring patient enrolment, completeness of follow-up,
and protocol deviations for the antibiotic regimens. Objective
Methods
Giant cell tumour is the most common aggressive
benign tumour of the musculoskeletal system and has a high rate of
local recurrence. When it occurs in proximity to the hip, reconstruction
of the joint is a challenge. Options for reconstruction after wide
resection include the use of a megaprosthesis or an allograft-prosthesis
composite. We performed a clinical and radiological study to evaluate
the functional results of a proximal femoral allograft-prosthesis
composite in the treatment of proximal femoral giant cell tumour
after wide resection. This was an observational study, between 2006
and 2012, of 18 patients with a mean age of 32 years (28 to 42)
and a mean follow-up of 54 months (18 to 79). We achieved excellent
outcomes using Harris Hip Score in 13 patients and a good outcome
in five. All allografts united. There were no complications such
as infection, failure, fracture or resorption of the graft, or recurrent
tumour. Resection and reconstruction of giant cell tumours with
proximal femoral allograft–prosthesis composite is a better option
than using a prosthesis considering preservation of bone stock and excellent
restoration of function. A good result requires demanding bone banking techniques, effective
measures to prevent infection and stability at the allograft-host
junction. Cite this article:
We welcome letters to the Editor concerning articles
that have recently been published. Such letters will be subject
to the usual stages of selection and editing; where appropriate the
authors of the original article will be offered the opportunity
to reply.
In 1999, we developed a technique for biological
reconstruction after excision of a bone tumour, which involved using
autografts of the bone containing the tumour treated with liquid
nitrogen. We have previously reported the use of this technique
in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction
using this technique. A total of 33 patients died and three were
lost to follow-up, at a mean of 23 months (2 to 56) post-operatively,
leaving 36 patients available for a assessment at a mean of 101
months 16 to 163) post-operatively. The methods of reconstruction included
an osteo-articular graft in 16, an intercalary in 13 and, a composite
graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%),
good in seven (19.4%), and fair in three (8.3%) according to the
functional evaluation system of Enneking. No recurrent tumour occurred
within the grafts. The autografts survived in 29 patients (80.6%),
and the rates of survival at five and ten years were 86.1% and 80.6
%, respectively. Seven of 16 osteo-articular grafts (44%) failed
because of fracture or infection, but all the composite and intercalary
grafts survived. The long-term outcomes of frozen autografting, particularly using
composite and intercalary grafts, are satisfactory and thus represent
a good method of treatment for patients with a sarcoma of bone or
soft tissue. Cite this article:
The pre-operative differentiation between enchondroma,
low-grade chondrosarcoma and high-grade chondrosarcoma remains a
diagnostic challenge. We reviewed the accuracy and safety of the
radiological grading of cartilaginous tumours through the assessment
of, first, pre-operative radiological and post-operative histological agreement,
and second the rate of recurrence in lesions confirmed as high-grade
on histology. We performed a retrospective review of major long
bone cartilaginous tumours managed by curettage as low grade between
2001 and 2012. A total of 53 patients with a mean age of 47.6 years
(8 to 71) were included. There were 23 men and 30 women. The tumours
involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula
(n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses
resulted from multidisciplinary consensus following radiological
review alone for 35 tumours, or with the addition of pre-operative
image guided needle biopsy for 18. The histologically confirmed diagnosis
was enchondroma for two (3.7%), low-grade chondrosarcoma for 49
(92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients
with a low-grade tumour developed a local recurrence at a mean of 15
months (12 to 17) post-operatively. A single high-grade recurrence
(grade II) was treated with tibial diaphyseal replacement. The overall
recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to
12.3). Cartilaginous tumours identified as low-grade on pre-operative
imaging with or without additional image-guided needle biopsy can
safely be managed as low-grade without pre-operative histological
diagnosis. A few tumours may demonstrate high-grade features histologically,
but the rates of recurrence are not affected. Cite this article:
Pathological fractures in children can occur
as a result of a variety of conditions, ranging from metabolic diseases and
infection to tumours. Fractures through benign and malignant bone
tumours should be recognised and managed appropriately by the treating
orthopaedic surgeon. The most common benign bone tumours that cause pathological
fractures in children are unicameral bone cysts, aneurysmal bone
cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological
fractures through a primary bone malignancy are rare, these should
be recognised quickly in order to achieve better outcomes. A thorough
history, physical examination and review of plain radiographs are
crucial to determine the cause and guide treatment. In most benign
cases the fracture will heal and the lesion can be addressed at
the time of the fracture, or after the fracture is healed. A step-wise
and multidisciplinary approach is necessary in caring for paediatric
patients with malignancies. Pathological fractures do not have to
be treated by amputation; these fractures can heal and limb salvage
can be performed when indicated.
The purpose of this study was to assess whether
the use of a joint-sparing technique such as curettage and grafting was
successful in eradicating giant cell tumours of the proximal femur,
or whether an alternative strategy was more appropriate. Between 1974 and 2012, 24 patients with a giant cell tumour of
the proximal femur were treated primarily at our hospital. Treatment
was either joint sparing or joint replacing. Joint-sparing treatment
was undertaken in ten patients by curettage with or without adjunctive
bone graft. Joint replacement was by total hip replacement in nine patients
and endoprosthetic replacement in five. All 11 patients who presented
with a pathological fracture were treated by replacement. Local recurrence occurred in five patients (21%): two were treated
by hip replacement, three by curettage and none with an endoprosthesis.
Of the ten patients treated initially by curettage, six had a successful
outcome without local recurrence and required no further surgery.
Three eventually needed a hip replacement for local recurrence and
one an endoprosthetic replacement for mechanical failure. Thus 18
patients had the affected joint replaced and only six (25%) retained
their native joint. Overall, 60% of patients without a pathological
fracture who were treated with curettage had a successful outcome. Cite this article:
We reviewed the outcome of patients who had been
treated operatively for symptomatic peri-acetabular metastases and
present an algorithm to guide treatment. The records of 81 patients who had been treated operatively for
symptomatic peri-acetabular metastases between 1987 and 2010 were
identified. There were 27 men and 54 women with a mean age of 61
years (15 to 87). The diagnosis, size of lesion, degree of pelvic
continuity, type of reconstruction, World Health Organization performance
status, survival time, pain, mobility and complications including
implant failure were recorded in each case. The overall patient survivorship at five years was 5%. The longest
lived patient survived 16 years from the date of diagnosis. The
mean survival was 23 months (<
1 to 16 years) and the median
was 15 months. At follow-up 14 patients remained alive. Two cementoplasties
failed because of local disease progression. Three Harrington rods broke:
one patient needed a subsequent Girdlestone procedure. One ‘ice-cream
cone’ prosthesis dislocated and was subsequently revised without
further problems. We recommend the ‘ice-cream cone’ for pelvic discontinuity
and Harrington rod reconstruction for severe bone loss. Smaller
defects can be safely managed using standard revision hip techniques. Cite this article:
The aim of this study was to assess a specific
protocol for the treatment of patients with a parosteal osteosarcoma of
the distal femur with limb salvage involving hemicortical resection
and reconstruction using recycled pasteurised autograft and internal
fixation. Between January 2000 and January 2010, 13 patients with
a mean age of 26.5 years (17 to 39) underwent this procedure. All
the tumours were staged according to Enneking’s criteria: there
were eight stage IA tumours and five stage IB tumours. The mean
follow-up was 101.6 months (58 to 142), and mean post-operative
Musculoskeletal Tumour Society functional score was 88.6% (80% to
100%) at the final follow-up. All the patients had achieved bony
union; the mean time to union was 11.2 months (6 to 18). Local recurrence
occurred in one patient 27 months post-operatively. No patient had
a pulmonary metastasis. A hemicortical procedure for the treatment of a parosteal osteosarcoma
is safe and effective. Precise pre-operative planning using MRI
is essential in order to define the margins of resection. Although
it is a technically demanding procedure, gratifying results make
it worthwhile for selected patients. Cite this article:
We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature. Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5 to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6 mm (3.5 to 161.5),
requiring a mean of 11.3 extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11 patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
There is currently no consensus about the mean
volume of blood lost during spinal tumour surgery and surgery for metastatic
spinal disease. We conducted a systematic review of papers published
in the English language between 31 January 1992 and 31 January 2012.
Only papers that clearly presented blood loss data in spinal surgery
for metastatic disease were included. The random effects model was
used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective
reviews and two prospective studies. Altogether, there were 760
patients who had undergone spinal tumour surgery and surgery for
metastatic spinal disease. The pooled estimate of peri-operative
blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic
blood loss as high as 5000 ml, which is rare. Aside from two studies
that reported large amounts of mean blood loss (>
5500 ml), the
resulting funnel plot suggested an absence of publication bias.
This was confirmed by Egger’s test, which did not show any small-study
effects
(p = 0.119). However, there was strong evidence of heterogeneity
between studies (I2 = 90%; p <
0.001). Spinal surgery for metastatic disease is associated with significant
blood loss and the possibility of catastrophic blood loss. There
is a need to establish standardised methods of calculating and reporting
this blood loss. Analysis should include assessment by area of the
spine, primary pathology and nature of surgery so that the amount
of blood loss can be predicted. Consideration should be given to
autotransfusion in these patients. Cite this article:
The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient’s life without the need for further surgical intervention. We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required. Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.
We review the treatment of pelvic Ewing’s sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods. We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100). We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing’s sarcoma.
Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87). All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance. Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.
We evaluated 31 patients who were treated with a non-vascularised fibular graft after resection of primary musculoskeletal tumours, with a median follow-up of 5.6 years (3 to 26.7 years). Primary union was achieved in 89% (41 of 46) of the grafts in a median period of 24 weeks. All 25 grafts in 18 patients without additional chemotheraphy and/or radiotherapy achieved primary union, compared with 16 of the 21 grafts (76%; 13 patients) with additional therapy (p = 0.017). Radiographs showed an increase in diameter in 70% (59) of the grafts. There were seven fatigue fractures in six patients, but only two needed treatment. Non-vascularised fibular transfer is a simpler, less expensive and a shorter procedure than the use of vascularised grafts and allows remodelling of the fibula at the donor site. It is a biological reconstruction with good long-term results, and a relatively low donor site complication rate of 16%.
We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 ( Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.
We report our experience of treating 17 patients with benign lesions of the proximal femur with non-vascularised, autologous fibular strut grafts, without osteosynthesis. The mean age of the patients at presentation was 16.5 years (5 to 33) and they were followed up for a mean of 2.9 years (0.4 to 19.5). Histological diagnoses included simple bone cyst, fibrous dysplasia, aneurysmal bone cysts and giant cell tumour. Local recurrence occurred in two patients (11.7%) and superficial wound infection, chronic hip pain and deep venous thrombosis occurred in three. Pathological fracture did not occur in any patient following the procedure. We conclude that non-vascularised fibular strut grafts are a safe and satisfactory method of treating benign lesions of the proximal femur.
Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm (5.5 to 15). All the patients were followed to bony union and 12 were available at a mean follow-up of 26 months (10 to 49). The mean time to union was four months (3 to 7) at the ulnocarpal junction and five months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of pronation and supination. The remaining patient developed a radio-ulnar synostosis. The mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients had a soft-tissue recurrence, but with no bony involvement. They underwent a further excision and are currently well and free from disease. Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. It avoids the need for a microvascular procedure while retaining rotation of the forearm and good function of the hand.
Elastofibroma dorsi is an uncommon, benign, slow-growing soft-tissue tumour of uncertain aetiology. It classically presents as an ill-defined mass at the inferior pole of the scapula with symptoms which include swelling, discomfort, snapping, stiffness and occasionally pain. We report the symptoms, function and outcome after treatment of 21 elastofibromas in 15 patients. All were diagnosed by MRI and early in the series four also underwent CT-guided biopsy to confirm the diagnosis. In all, 18 tumours were excised and three were observed. After excision, the mean visual analogue score for pain decreased from 4.6 (0 to 10) pre-operatively to 2.4 (0 to 8) post-operatively (p = 0.04). The mean shoulder function, at a mean follow-up of 4.2 years (3 months to 16 years), was 78.1% (30 to 100) using the Stanmore percentage of normal shoulder assessment scoring system. The mean range of forward flexion improved from 135° (70° to 180°) to 166° (100° to 180°) after excision (p = 0.005). In four patients a post-operative haematoma formed; one required evacuation. Three patients developed a post-operative seroma requiring needle aspiration and one developed a superficial infection which was treated with antibiotics. Our findings support previous reports suggesting that a pre-operative tissue diagnosis is not necessary in most cases since the lesion can be confidently diagnosed by MRI, when interpreted in the light of appropriate clinical findings. Surgical excision in symptomatic patients, is helpful. It has been suggested that elastofibroma is caused by a local tissue reaction and is not a true neoplastic process. A strong association has been noted between elastofibroma and repetitive use of the shoulder, which is supported by our findings.
We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes. Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid. Limb salvage can achieve good oncological and functional results with additional treatment.
We identified eight patients of 2900 with a primary malignant bone tumour who had coexisting neurofibromatosis type 1. This was a much higher incidence than would be expected by chance. The patients had a mean age of 22.4 years (9 to 54): five were male. Two patients subsequently developed a second bone sarcoma, one of which was radiation induced. Four of the primary tumours were osteosarcomas, four were spindle-cell sarcomas and one a Ewing’s sarcoma. All the patients were treated with chemotherapy and surgery: six of the eight appear to be cured. This study suggests a possible relationship between neurofibromatosis type 1 and the development of a bone sarcoma, the increased risk being estimated at eight times that of the normal population. We recommend that further research into this possible link should be considered.
We have developed a hollow perforated cannulated screw. One or more of these was implanted percutaneously in 11 patients with an osteolytic metastasis in the femoral neck and multiple metastases elsewhere. They were supplemented by one or two additional standard 6.5 mm cannulated screws in nine patients. Polymethylmethacrylate bone cement was injected through the screw into the neck of the femur using small syringes, as in vertebroplasty. The mean amount of cement injected was 23.2 ml (17 to 30). Radiotherapy was started on the fourth post-operative day and chemotherapy, on average, was resumed a day later. Good structural stability and satisfactory relief from pain were achieved in all the patients. This technique may be useful in the palliation of metastases in the femoral neck.
Skeletal metastases from hepatocellular carcinoma are highly destructive vascular lesions which severely reduce the quality of life. Pre-existing liver cirrhosis presents unique challenges during the surgical management of such lesions. We carried out a retrospective study of 42 patients who had been managed surgically for skeletal metastases from hepatocellular carcinoma affecting the appendicular skeleton between January 2000 and December 2006. There were 38 men and four women with a mean age of 60.2 years (46 to 77). Surgery for a pathological fracture was undertaken in 30 patients and because of a high risk of fracture in 12. An intralesional surgical margin was achieved in 36 and a wide margin in six. Factors influencing survival were determined by univariate and multivariate analyses. The survival rates at one, two and three years after surgery were 42.2%, 25.8% and 19.8%, respectively. The median survival time was ten months (95% confidence interval 6.29 to 13.71). The number of skeletal metastases and the Child-Pugh grade were identified as independent prognostic factors by Cox regression analysis. The method of management of the hepatocellular carcinoma, its status in the liver, the surgical margin for skeletal metastases, the presence of a pathological fracture and adjuvant radiotherapy were not found to be significantly related to the survival of the patient, which was affected by hepatic function, as represented by the Child-Pugh grade.
We evaluated the results of fibular centralisation as a stand alone technique to reconstruct defects that occurred after resection of tumours involving the tibial diaphysis and distal metaphysis. Between January 2003 and December 2006, 15 patients underwent excision of tumours of the tibial diaphysis or distal metaphysis and reconstruction by fibular centralisation. Their mean age was 17 years (7 to 40). Two patients were excluded; one died from the complications of chemotherapy and a second needed a below-knee amputation for a recurrent giant-cell tumour. A total of 13 patients were reviewed after a mean follow-up of 29 months (16 to 48). Only 16 of 26 host graft junctions united primarily. Ten junctions in ten patients needed one or more further procedure before union was achieved. At final follow-up 12 of the 13 patients had fully united grafts; 11 walked without aids. The mean time to union at the junctions that united was 12 months (3 to 36). The mean Musculoskeletal Tumor Society Score was 24.7 (16 to 30). Fibular centralisation is a durable reconstruction for defects of the tibial diaphysis and distal metaphysis with an acceptable functional outcome. Stable osteosynthesis is the key to successful union. Additional bone grafting is recommended for patients who need postoperative radiotherapy.
Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records. A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p <
0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02). Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.
We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin. We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastastic disease.
We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated. The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221). The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°). At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery.
Open surgery is rarely justified for the initial treatment of a unicameral bone cyst, but there is some debate concerning the relative effectiveness of closed methods. This study compared the results of steroid injection with those of autologous bone marrow grafting for the treatment of unicameral bone cysts. Between 1990 and 2001, 30 patients were treated by steroid injection and 28 by grafting with autologous bone marrow. The overall success rates were 86.7% and 92.0%, respectively (p >
0.05). The success rate after the initial procedure was 23.3% in the steroid group and 52.0% in those receiving autologous bone marrow (p <
0.05), and the respective cumulative success rates after second injections were 63.3% and 80.0% (p >
0.05). The mean number of procedures required was 2.19 (1 to 5) and 1.57 (1 to 3) (p <
0.05), the mean interval to healing was 12.5 months (4 to 32) and 14.3 months (7 to 36) (p >
0.05), and the rate of recurrence after the initial procedure was 41.7% and 13.3% in the steroid and in the autologous bone marrow groups, respectively (p <
0.05). Although the overall rates of success of both methods were similar, the steroid group had higher recurrence after a single procedure and required more injections to achieve healing.