Field Of Orthopaedic Oncology Research Articles

Trends in functional outcome measures in orthopedic oncology.

The purpose of this study was to identify trends in the use of functional outcome measures within orthopedic oncology. The search engine, PubMed, was reviewed for all articles over an 11-year period from 2011 to 2021 from five major journals that publish in the field of orthopedic oncology. The functional outcome measures used in the articles were recorded along with study date, study design, clinical topic/pathology, and level of evidence. Out of 5968 musculoskeletal tumor-focused articles reviewed, 293 (4.9%) included at least one outcome measure. A total of 28 different outcome tools were identified. The most popular were Musculoskeletal Tumor Society (MSTS) score (61.1%) and Toronto Extremity Salvage (TESS) score (14.0%), followed by 36-Item Short Form Survey (SF-36) (4.1%) and Patient-Reported Outcomes Measurement Information System (PROMIS) (3.8%). The use of MSTS scores decreased by 0.7% each year, whereas PROMIS increased by 1.2% each year. Seventy-four articles used more than one outcome measure. Of these 74 articles, 61 had the MSTS as one of the outcome measures. Orthopedic oncology utilizes functional outcome measures less commonly in comparison to other orthopedic subspecialties. However, this may be due in large part to orthopedic oncologists putting more emphasis on outcomes such as local recurrence, implant failure, and mortality. MSTS score is the most widely used functional outcome measure, but the utilization of PROMIS has increased recently, and could be the next step in evaluating outcomes in orthopedic oncology as it is patient-derived rather than physician-derived.

Cost-effective office 3D printing process in orthopaedics and its benefits: A case presentation and literature review

Background and objectives The advent of 3-Dimensional (3D) printing technology is one of the most revolutionising breakthroughs of the generation. Its benefits in surgical practice are undeniable, however a steep learning curve and concerns regarding costs may pose a barrier to large scale implementation. Methods We set up an in-house 3D printing facility in our institution and described our workflow. Using the described workflow, we 3D printed models which were used in the surgical management of three patients with differing conditions. Results We present three case examples to display the uses that 3D printing technology is able to provide in our experience, and show how 3D printing technology can be beneficial in the field of orthopaedic oncology and surgically complex cases. 3D printing has proven to be useful and improved quality of care in these case examples. The processes for each case were described individually. The benefits of our in-house 3D printing facility were discussed in detail. Conclusion An in-house office 3D printing facility is advantageous and cost-efficient. Its benefits can be maximised if implemented on a larger scale and has the potential to be standard of care in many institutions.

MRI-based navigated cryosurgery of extra-abdominal desmoid tumors using skin fiducial markers: a case series of 15 cases

BackgroundPrecision surgery is becoming increasingly important in the field of Orthopaedic Oncology. Image-guided percutaneous cryosurgery (CRA) has emerged as a valid treatment modality for extra-abdominal desmoid tumors (EDTs). To date, most CRA procedures use CT-based guidance which fails to properly characterize tumor segments. Computer-guided MRI navigation can address this issue however, the lack of a fixed landmark for registration remains a challenge. Successful CRA correlates directly with precision approaches facilitated by intraoperative imaging guidance. This is the first study that attempts to assess the feasibility and efficacy of a novel approach of using skin fiducial markers to overcome the challenge of a MRI-based navigation CRA for symptomatic or progressive EDTs.MethodsIn this retrospective study conducted between 2018 and 2020, 11 patients at a single center with symptomatic or progressive EDTs were treated with CRA using intraoperative MRI navigation. Fifteen cryosurgery procedures were performed, each adhering to a personalized pre-operative plan. Total tumor size, viable and non-viable portions pre- and post-operation, and SF-36 questionnaire evaluating subjective health were recorded.ResultsAll CRAs demonstrated 100% adherence to the predetermined plan. Overall, tumor size decreased Median= -56.9% [-25.6, -72.4]) with a reduction in viable tissue, (Median= -80.4% [-53.3, -95.2]). Four patients required additional CRAs. Only one patient’s tumor did not reduce in size. One patient suffered from local muscle necrosis. Pre-operation, the average physical and mental scores 41.6 [29.4, 43] and 26.3 [17.6, 40.9] respectively. Post-operation, the average physical and mental scores were 53.4[38, 59.7] and 38 [31.2, 52.7] respectively.ConclusionThese findings provide an early indication of the feasibility and efficacy of performing percutaneous cryosurgery using skin fiducial marker registration for MRI-computed navigation to treat EDTs safely. Larger cohorts and multicenter evaluations are needed to determine the efficacy of this technique.

Personalized 3D-printed guide in malignant bone tumor resection and following reconstruction – 17 cases in pelvic and extremities

IntroductionCustomized accurate tumor resection and individualized reconstruction is a challenging in treatment of malignant bone tumor. Three-dimensional (3D)-printing technique is now widely used in the resection and following reconstruction of malignant bone tumor, which included but not limited to tumor model, osteotomy guide and customized implant. MethodsWe retrospectively reviewed 17 patients, who underwent limb salvage surgery by using 3D-printed guide at a single center between August 2014 and October 2019. The median duration of follow-up was 26.5 months. Osteosarcoma (41.2%) were the predominant diagnoses. The functional outcomes were assessed by Musculoskeletal Tumor Society (MSTS) functional score. We also analyzed survival status, intraoperative data (blood loss, operation time and resection length), reconstruction method, margin outcomes and complications. ResultsWe totally performed 93 guided osteotomies on affected bone and allograft bone in 17 patients. Reconstruction in 12 cases was performed with biological technique: allograft combined with autograft was used in 7 cases. 11 of 12 (91.7%) cases showed a good bone healing in both allograft and autograft. 1 of 12 (8.3%) cases had allograft necrosis. Additional intra-operative extracorporeal radiation was performed in 3 pelvic cases for reconstruction. 63 of 64 (98%) osteotomies achieved wide resection and negative margin. All the cases had successful limb salvage result without amputation. At the latest follow up, the mean MSTS Score was 24 (range: 13–30), 12 patients alive with no evidence of disease, 1 patient alive with disease, 5 patients had died of disease and 5 years overall survival is 73.3%. The most common complications are wound healing disorder in 4 cases (23.5%) and infection in 3 cases (17.6%). ConclusionThe 3D-printed resection guide was easy to use and showed promise in the field of orthopedic oncology. It can not only used in primary malignant bone tumor personalized resection but also in shaping structural bone allograft in biological reconstruction, which can achieve a safety surgical margin and individualized resection at the same time.

What's New in Pediatric Orthopaedic Tumor Surgery.

Pediatric Orthopaedic Oncology is a developing subspecialty within the field of Pediatric Orthopaedics. Traditionally, the field of Orthopaedic Oncology has been focused on the skeletally mature individual, and the research tends to be all encompassing rather than truly evaluating isolated populations. The purpose of this review is to summarize the most clinically relevant literature in the field of Pediatric Orthopaedic Oncology over the last 6 years. We evaluated the PubMed database utilizing keywords for pediatric orthopaedic oncology: sarcoma, osteosarcoma, Ewing sarcoma, bone cyst. In additionally, we further broadened our search by searching for relevant articles in the contents sections of major orthopaedic surgery journals that routinely publish both pediatric and orthopaedic oncology literature. In keeping with "What's New," we selected the most clinically relevant articles published in the last 6 years from January 1, 2014 through February 2020. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search yielded 60 articles that met general criteria, from which 14 were determined to be most relevant to the goals of this paper. Of the papers presented in this review, there were papers related to management of benign tumors/tumor-like conditions, bone cysts, limb salvage procedures, and amputation procedures. Ultimately included in the review were 5 studies related to limb salvage, 4 related to bone cysts, 1 related to multiple hereditary exostoses, 2 related to osteofibrous dysplasia, 1 related to chondroblastoma, and 1 discussing cementation in skeletally immature patients. They were level III, IV, and V studies. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search of the basic science and systemic therapies literature yielded 19 sources were found to be pertinent to our aims and 18 of those sources were published between 2015 and 2020. There are many, varied, and creative procedures in the realm of limb salvage, though there remains a lack of high-level evidence to support some of the more novel procedures. In regards to benign bone tumors, despite a more solid base of literature, there still does not seem to be consensus as to the best treatment. In particular, there continue to be many schools of thought on the treatment of benign bone cysts. Research in the basic science arena and systemic therapies are advancing in exciting ways in regards to pediatric sarcoma. Orthopaedic oncologic research specific to the pediatric population overall continues to be impeded by low sample sizes and inadequate levels of evidence, which limits the ability of surgeons to draw definitive conclusions from the literature.

Functional outcome in endoprosthetic replacement around the knee: A narrative review

In general, most comparative studies have reported that successful limb salvage surgeries have better functional outcomes than amputations. This is largely due to the advances in surgical techniques and adjuvant therapy which allows reconstruction such as endoprosthetic replacements (EPR). Clinician-reported outcome measures and patient-reported outcome measures have been utilised to evaluate the benefits of orthopaedic surgical procedures. The most widely used measures in the field of orthopaedic oncology are the Musculoskeletal Tumour Society Score and the Toronto Extremity Salvage Score. The Jury is still out on the evidence basis for the functional outcome of EPR, especially around the knee joint. There is a need for more randomised control trials, systematic reviews or meta-analyses to critically appraise and formally synthesise the best available evidence to provide a statement of conclusion on the functional outcome of EPRs.

Biomechanical comparison of a 3D-printed sacrum prosthesis versus rod-screw systems for reconstruction after total sacrectomy: A finite element analysis

BackgroundReconstruction after total sacrectomy is a difficult problem in the field of orthopedic oncology. Current reconstruction methods have not completely solved the problems associated with instrumentation failure. The purpose of this study was to evaluate the biomechanical properties of a 3D-printed total sacrum prosthesis and to conduct biomechanical comparisons between the total sacrum prosthesis and rod-screw systems for lumbosacral reconstruction after total sacrectomy. MethodsThree types of reconstruction were explored, and corresponding finite element models were simulated: four-rod reconstruction, four-rod plus anterior column reconstruction, and 3D-printed total sacrum prosthesis reconstruction. A vertical load of 600 N was applied to the L4 vertebra, and the bilateral acetabula were set as the boundary with six degrees of freedom fixed, simulating the bipedal standing position. FindingsThe order of the reconstructions according to decreasing maximum von Mises stress was as follows: four-rod reconstruction > four-rod plus anterior column reconstruction >3D-printed total sacrum prosthesis reconstruction. The order of reconstructions according to decreasing L5 shift-down displacement was as follows: four-rod reconstruction >3D-printed total sacrum prosthesis reconstruction > four-rod plus anterior column reconstruction. InterpretationCompared with the rod-screw systems, the total sacrum prosthesis reconstruction has the biomechanical advantages of a more uniform stress distribution, a lower peak stress and better stability and can thus serve as an alternative choice for reconstruction after total sacrectomy.

Bone tumor resection guide using three-dimensional printing for limb salvage surgery.

The three-dimensional (3D)-printed bone tumor resection guide can be personalized for a specific patient and utilized for bone tumor surgery. It is noninvasive, eidetic, and easy to use. We aimed to categorize the use of the 3D-printed guide and establish in vivo accuracy data. We retrospectively reviewed 12 patients, who underwent limb salvage surgery using the 3D-printed guide at a single institution. To confirm the achievement of a safe bone margin, we compared the actual and planned distances between the cutting surface and tumor, which were reported in the final pathological report and measured from the same virtual cutting plane using graphical data of the cutting guide design, respectively. The use of the 3D-printed guide was categorized as follows: (a) wide excision only, (b) wide excision and biological reconstruction with a structural bone allograft shaped in accordance with the 3D-printed guide, and (c) wide excision and reconstruction with a 3D-printed personalized implant. The maximal cutting error was 3 mm. The 3D-printed resection guide is easy to use and shows promise in the field of orthopedic oncology, with its application in bone tumor resection and reconstruction with a structural bone allograft or 3D-printed implant.

Navigation in Musculoskeletal Oncology: An Overview.

Navigation in surgery has increasingly become more commonplace. The use of this technological advancement has enabled ever more complex and detailed surgery to be performed to the benefit of surgeons and patients alike. This is particularly so when applying the use of navigation within the field of orthopedic oncology. The developments in computer processing power coupled with the improvements in scanning technologies have permitted the incorporation of navigational procedures into day-to-day practice. A comprehensive search of PubMed using the search terms “navigation”, “orthopaedic” and “oncology” yielded 97 results. After filtering for English language papers, excluding spinal surgery and review articles, this resulted in 38 clinical studies and case reports. These were analyzed in detail by the authors (GM and JS) and the most relevant papers reviewed. We have sought to provide an overview of the main types of navigation systems currently available within orthopedic oncology and to assess some of the evidence behind its use.

Moving forward through consensus: protocol for a modified Delphi approach to determine the top research priorities in the field of orthopaedic oncology

IntroductionOrthopaedic oncology researchers face several obstacles in the design and execution of randomised controlled trials, including finite fiscal resources to support the rising costs of clinical research and insufficient patient...

Editorial: Limb Preservation: Past and Present

The International Society of Limb Salvage (ISOLS) displayed the global perspective needed to bring advances in surgery, engineering, reconstruction, biology, and clinical care to the entire international community. The 16th meeting, held in 2011 in Beijing, China, marked the 30th anniversary of the organization. Starting from humble beginnings at the Mayo Clinic in 1981, Frank Sim and Ed Chao inaugurated the Society. It has grown from a meeting of 127 participants from 23 countries to 840 participants from 44 countries, reflecting the excitement of a burgeoning field and the enthusiasm that resonates among the practitioners of musculoskeletal oncology. The fundamental philosophy of the ISOLS is that all people in the world deserve to benefit from the advances in musculoskeletal cancer care achieved in the developed countries. Affording limb preservation to all seemed to be the goal. Specialty education and sharing of experience in this niche field was the method to achieve it. ISOLS pursued this egalitarian vision long before any other organization took up the mantra. It promulgated the use of standardized staging, functional outcome, and radiographic description systems. In what was perhaps an overly zealous effort, it even normalized the nonparametric functional outcome system of the Musculoskeletal Tumor Society and imposed a 100-point normative scale that encouraged researchers to present data as a percentage of normal. The result has been the relentless improvement in survival and the reduction in amputation rates around the world. ISOLS deserves a significant amount of the credit for these extraordinary advances. How did this happen? What contributed to its successes and failures? Any short answers to these questions inevitably will fail to capture the excitement of discovery or the satisfaction of sharing the hard-won knowledge. Major contributors to the effort are forgotten as new advances take priority. Nevertheless, it is worth reflecting on the contributions that created the organization and how these have created the foundation for what we do in modern musculoskeletal oncology. It is also worth thinking of what we still have to accomplish, taking the generalized findings to the public in the individualized medicine of the future. The ISOLS organizers came together to share knowledge about clinical care and prosthetic reconstruction in the new era of limb preservation. The first meeting served to introduce titanium fiber-metal, among other advances. Major advances were presented in meetings in Kyoto such as the extracorporeal radiation and reimplantation of osseous tumors and gait analysis of periacetabular resections/reconstructions. These themes were supplemented by biological and genetic information presented in Singapore and tissue regeneration prospects in New York. We have seen how these advances are now commonplace in countries worldwide such as India. The Beijing meeting allowed Dr Sim, one of the original founders, to present an awesome display of surgical virtuosity in the resection and reconstruction of sacral tumors. Quality control strategies in these developing countries were especially impressive. The durability of the original work that spawned ISOLS was glorious to behold. It was equally inspiring to learn of the innovative ways that the information is being disseminated. The papers selected for this Symposium build on the hard work of our predecessors and the creative genius of multispecialty interaction. It is a celebration of what the field of orthopaedic oncology has to offer. At the same time, it exposes the limitations of what we do and the magnitude of what still needs to be accomplished to help our tumor patients. Fig. 1 Dr. John H. Healey is shown.

The Current Practice of Orthopaedic Oncology in North America

The field of orthopaedic oncology in North America has been formalized over the past 30 years with the development of the Musculoskeletal Tumor Society (MSTS) and fellowship education opportunities. To characterize current practices we assessed the fellowship education, practice setting, constitution of clinical practice, bone and soft tissue sarcoma treatment volume, perceived challenges and rewards of the career, and the nonclinical activities of orthopaedic oncologists. Members of the MSTS and attendees of the 2009 AAOS-MSTS Specialty Day meeting were invited to participate in a twenty-three question online survey. One hundred and four surgeons including 99 of the 192 (52%) MSTS members completed the online survey. Sixty-nine of the 104 (66%) responding surgeons completed a 1-year musculoskeletal oncology fellowship. Thirty-eight (37%) completed an additional orthopaedic subspecialty fellowship. Seventy-four (79%) work in an academic practice and 70 (+/- 16) % of clinical time is spent practicing musculoskeletal oncology. An average of 20 (+/- 16) bone and 40 (+/- 36) soft tissue sarcomas were treated annually. Insufficient institutional support, reimbursement, and emotional stresses were perceived as the most important challenges in a musculoskeletal oncology practice. Sixty-seven (64%) of the surgeons reported serving in a leadership position at the departmental or national level. Professional time distribution is similar to other academic orthopaedists. The members of the MSTS are responsible for the treatment of more than two-thirds of bone and soft tissue sarcomas in the United States. This information can assist the fellowship directors and related professional societies in tailoring their educational programs and the interested orthopaedic resident to make a more informed career choice.

Palliative care in orthopaedic surgical oncology

Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.

Radiofrequency ablation in bone neoplasia

Purpose of reviewIn the past 15 years, radiofrequency ablation has emerged as one the most exciting new technologies in the field of orthopaedic oncology. Combined with major improvements in cross-sectional imaging (i.e. computed tomography), radiofrequency ablation has developed into an important t

MULTIMODAL DISPLAY INTERFACE FOR PLANNING AND MONITORING COMPLEX SKELETAL RECONSTRUCTIONS

The aim of the present work is to present the new software Multimod Data Manager and to show applications in the planning and monitoring of complex skeletal reconstructions in orthopedic oncology. The DataManager allows the full integration of different kind of data, particularly medical imaging data, both static as CT, SPECT or MRI, or time-varying as fluoroscopy or dynamic MRI, with motion analysis data, but also 3D computer and finite element models of bones, joints and also soft tissues. All the data can be visualized with highly interactive and specialized modalities and can be integrated to offer a complete representation of the patient anatomy. Several algorithms are implemented to allow registration and synchronization of the data. A fully 3D environment is offered to the surgeon to navigate inside the medical imaging dataset. To exemplify the use of the software we document in this paper the data processing used to investigate different specific clinical cases in the field of orthopedic oncology.

The Management of Chondrosarcoma of Bone

Chondrosarcomas of bone are among the most difficult problems in diagnosis and management in the field of orthopaedic oncology. In addition to the variability of presentation of the "standard" hyaline, myxoid or fibrous types of lesion, three unusual forms of the tumor are now recognized--mesenchymal, clear cell and dedifferentiated--which show differences in their biologic behavior. Chondrosarcomas, with only rare exception, are radio-resistant and show only a limited response to adjunctive chemotherapy. The optimal therapy at present is surgical, but clearly the type of surgical procedure selected should vary with the malignity and extent of the tumor in order to avoid either undertreatment (resulting in a high rate of local recurrence and/or distant metastases) or excessive and unnecessary sacrifice of normal tissue. Patients suspected of having chondrosarcomas should be thoroughly evaluated by clinical examination, radiographic and special studies to define as fully as possible the site and extent of the local tumor, the presence or absence of a soft-tissue mass and the existence of distant metastases. A biopsy should be performed through an incision which can be subsequently excised during the definition procedure. The tissue obtained should be graded histologically and the clinical and radiologic data added to define whether the lesion is benign or a low-grade or high-grade chondrosarcoma. Using a special system recently described by Enneking and Spanier, the lesions should be evaluated on the basis of the grade (G1 or G2); the site of the lesion in relation to the anatomic compartments (T1 or T2) and the presence or absence of distant metastasis (M0 or M1). Based on a scheme presented in this article, the appropriate one of four grades of surgical procedures should be chosen. For benign tumors, Grade I procedures (intralesional curettage or excision) are generally adequate. For Stage IA tumors, occasionally a Grade II procedure, marginal excision may be sufficient, but more frequently Grade III procedures (wide intracompartmental resections) are indicated. Stage IIA and IIB lesions should be treated with Grade III or Grade IV (radical resection) surgical procedures. The treatment of inoperable or Stage IV tumors (those with metastasis) is unsatisfactory and consists of palliative resections, radiation therapy and chemotherapy.