Joint Salvage Research Articles

Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears Using a Quadricipital Tendon Allograft and a Double-Row Construct

Lower trapezius transfer is a joint salvage treatment option for irreparable posterosuperior rotator cuff tears in relatively young patients. It requires the use of a tendinous graft to bridge the gap between the lower trapezius and the greater tuberosity. Inlay fixation of hamstring autografts and onlay single-row fixation of Achilles allografts have been described in the literature. This technical note describes an arthroscopic-assisted lower trapezius transfer using a quadricipital tendon allograft fixed with an onlay knotless double-row construct.

BIOPATCH GRAFTING OF LARGE OR RECALCATRANT OSTEOCHONDRAL DEFECTS OF THE TALUS

IntroductionLarge osteochondral defects (OCD) of the talus present a difficult management conundrum. We present a series of Maioregen xenograft patches applied through an open approach, early lessons from the technique and good early outcomes, in patients who are otherwise looking at ankle salvage techniques.Results16 patients underwent open patch procedures, performed by a single surgeon, over a 30 month period. 12 males, and 4 females with age at presentation from 21–48. The majority were young, male, in physical employment with active sporting interest. MoxFQ, and E5QD were collected preop, 3, 6, 12 month postoperatively. There were significant improvements in ROM, pain, and scores in the cohort. 3 cases returned to Theatre, 1 for a concern about late infection, which settled with good outcome, and a further 2 with metalwork / adhesions.ConclusionEarly results suggest that this patch technique may be useful in prolonging the longevity of the TTJ, where micro fracture has failed, or the lesion is so large that it would likely be futile. Patients rescoped demonstrated good integration of the patch material, with stability and functional improvement. There may be a place for this technique in the management of large lesions, particularly in young patients where preservation is desired over joint salvage.

Hip Preservation and Capanna Reconstruction for Pediatric Proximal Femur Ewing Sarcoma: A Report of 2 Cases.

This is a first report describing preservation of the femoral head by transcervical resection of proximal femoral Ewing sarcoma in 2 pediatric patients. A unique Capanna reconstruction supported joint salvage. At 1 year, Pediatric Outcomes Data Collection Instrument and Pediatric Toronto Extremity Salvage Score outcomes were excellent. Surveillance magnetic resonance imaging was without evidence of recurrence or impaired perfusion to the femoral head. We demonstrate the feasibility of hip joint preservation and maintenance of femoral head viability after transcervical resection of pediatric proximal femur bone sarcomas while preserving the medial circumflex femoral artery. This technique may be a preferred option over joint sacrifice and endoprosthetic replacement in young patients when tumor margins permit.

Outcomes of Tibiotalocalcaneal Arthrodesis vs Talar Body Prosthesis as Treatment of Collapsed Avascular Necrosis of the Talus: A 10- to 13-Year-Follow-up Retrospective Comparative Study.

Joint salvage surgeries such as tibiotalocalcaneal arthrodesis and talar prosthesis are commonly used in the surgical treatment of collapsed avascular necrosis of the talus (AVNT). However, differences in outcomes of these 2 surgical treatments are still inconclusive. This study compared the 10- to 13-year outcomes and 10-year survivorship rates of tibiotalocalcaneal arthrodesis and talar body prosthesis in the surgical treatment of collapsed AVNT. A retrospective comparative study was conducted of patients who underwent either tibiotalocalcaneal arthrodesis or talar body prosthesis implantation between 2005 and 2012. The demographic matching process resulted in 24 patients per treatment group. Clinical outcomes were evaluated using a numeric rating scale (NRS) of 2 hours of activities of daily living (ADL) and Foot and Ankle Ability Measure (FAAM) for ADL. Radiographic assessments included the incidence of nonunion, adjacent joint arthritis, and prosthesis loosening. The 10-year survivorship of both surgical treatments was calculated. A P value of less than .05 was considered statistically significant. The median NRS of 2 hours of ADL and FAAM score for ADL were statistically significantly better in the talar body prosthesis group, with P values of .001 and <.001, respectively. The statistically significant differences in FAAM score for ADL exceeded the minimum clinically important difference. In the tibiotalocalcaneal arthrodesis group, nonunion was observed in 7 of 24 patients (29.2%). No prosthesis loosening was reported in the talar body prosthesis group. The 10-year survivorship was statistically significantly higher in talar body prosthesis than tibiotalocalcaneal arthrodesis (95.8% vs 70.8%), P = .023. Talar body prosthesis implantation in selected eligible patients demonstrated statistically significantly better 10- to 13-year clinical outcomes and higher 10-year survivorship compared with tibiotalocalcaneal arthrodesis in the surgical treatment of collapsed AVNT. Level III, retrospective cohort comparative study.

Arthroscopic Superior Capsular Reconstruction Using Hybrid Autologous Fascia Lata and the Long Head of Biceps Tendon Graft: the Central Beam Concept

Superior capsular reconstruction is a joint salvage treatment option for retracted irreparable rotator cuff tears in relatively young patients. Various graft options have been described in the literature, including autologous fascia lata graft, synthetic graft, and dermal patches. Superior capsular reconstruction using long head of biceps tendon autograft alone has also been described by few authors. In this technical note, we describe a modified technique of performing arthroscopic superior capsular reconstruction using both fascia lata graft and the intra articular portion of the long head of biceps tendon. Our technique resembles central beam concept over which the fascia lata graft is anchored, providing good structural support to the graft and enabling graft healing and improved clinical outcomes.

Association between radioulnar impingement and salvage surgical procedures of the distal radioulnar joint: influence of confounding variables.

We conducted an ambispective cohort study to assess the association between symptomatic radioulnar impingement syndrome (SRUIS) and distal radioulnar joint (DRUJ) salvage surgery to examine the influence of confounders on the final effect. The outcome variable was the incidence of SRUIS and the exposure variable was the surgical procedure. Seventy-two patients with median age of 48 years (IQR 25-78) were examined using bivariate and logistic regression multivariate analyses, and confounders were analysed in 15 multivariate models. Overall, SRUIS occurred in 21 patients (29%). Bivariate analysis showed a significant association between SRUIS and type of surgical procedure, observed in 71% after Sauvé-Kapandji, 50% after Bowers and 15% after Darrach procedure. When adjusted for age, aetiology and previous surgery, the significant association disappeared. Confounding is an important factor when accounting for SRUIS after DRUJ salvage surgery. The risk of SRUIS did not depend on the procedure, but rather on patient's age, aetiology and previous surgery.Level of evidence: II.

Giant cell tumour of bone.

Giant cell tumour of bone (GCTB) is a locally aggressive lesion that is difficult to treat as salvaging the joint can be associated with a high rate of local recurrence (LR). We evaluated the risk factors for tumour relapse after treatment of a GCTB of the limbs. A total of 354 consecutive patients with a GCTB underwent joint salvage by curettage and reconstruction with bone graft and/or cement or en bloc resection. Patient, tumour, and treatment factors were analyzed for their impact on LR. Patients treated with denosumab were excluded. There were 53 LRs (15%) at a mean 30.5 months (5 to 116). LR was higher after curettage (18.4%) than after resection (4.6%; p = 0.008). Neither pathological fracture (p = 0.240), Campanacci grade (p = 0.734), soft-tissue extension (p = 0.297), or tumour size (p = 0.872) affected the risk of recurrence. Joint salvage was possible in 74% of patients overall (262/354), and 98% after curettage alone (262/267). Of 49 patients with LR after curettage, 44 (90%) underwent repeated curettage and joint salvage. For patients treated by curettage, only age less than 30 years (p = 0.042) and location in the distal radius (p = 0.043) predicted higher LR. The rate of LR did not differ whether cement or bone graft was used (p = 0.753), but may have been reduced by the use of hydrogen peroxide (p = 0.069). Complications occurred in 15.3% of cases (54/354) and did not differ by treatment. Most patients with a GCTB can undergo successful joint salvage by aggressive curettage, even in the presence of a soft-tissue mass, pathological fracture, or a large lesion, with an 18.4% risk of local recurrence. However, 90% of local relapses after curettage can be treated by repeat joint salvage. Maximizing joint salvage is important to optimize long-term function since most patients with a GCTB are young adults. Younger patients and those with distal radius tumours treated with joint-sparing procedures have a higher rate of local relapse and may require more aggressive treatment and closer follow-up.

The Aggressive Open Anterior Ankle Cheilectomy as Joint Salvage for Anterior Ankle Impingement Syndrome and Arthritis.

Anterior ankle impingement syndrome can frequently present in athletes and post-traumatic patients who have osteophytes contributing to limited dorsiflexion and pain. Surgical treatment options include arthroscopy, open arthrotomy, arthrodesis, and total implant arthroplasty. For many, joint-sparing arthroscopy or arthrotomy yield satisfactory results if significant debridement is performed. If debridement is not aggressive, patients may not obtain the desired improvement. In cases where a larger amount of bone must be removed, or the patient does not have an anatomic appearing talar neck due to osteophytic changes, we have found that an open approach is necessary to achieve good results. To the best of our knowledge, no such technique has been previously published detailing a standard approach to open ankle arthrotomy. Our technique is coined the "Aggressive Open Anterior Ankle Cheilectomy" and involves a systematic 3-step approach. First, the tibial osteophytes are resected with an osteotome; second, the ankle gutters are addressed, and all hypertrophic bones removed; and third, an anatomic talar neck is fashioned. We herein describe our surgical technique and case examples.Level of Evidence: 5.

Outcome Analysis of En-bloc Excision and Endoprosthetic Replacement among the Cases Operated for Distal Femoral and Proximal Tibial Giant Cell Tumour around the Knee: A Retrospective Study

Introduction: Giant Cell Tumour (GCT) around the knee joint is the most common site for this locally malignant bone tumour and, in advanced stages, requires excision of the tumour mass. Current recommendations promote joint salvage procedures in allograft or mega prosthetic replacement. Patients undergoing this surgery need massive changes in their lifestyle to cope with their activities of daily living. The psychological and social impact following these procedures has not been extensively studied. Aim: To observe the long term functional results as well as the impact on quality of life in patients undergoing endoprosthetic replacements in GCT around the knee with emphasis on any difference in results among the cases operated for distal femoral and proximal tibial GCT. Materials and Methods: This retrospective study was conducted at Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow from June 2015 to June 2019 with a total sample size of 21 cases. The two groups formed were; one having GCT of distal end femur and the other group with GCT of proximal end tibia. The evaluation was done for outcome measures by Oxford Knee Score (OKS) and Musculo Skeletal Tumour Society score (MSTS) for their functional outcome and Short Form Health Survey (SF12) for their quality of life effect at two years postoperatively. Students unpaired t-test was performed for intergroup analysis and Analysis of Variance (ANOVA) was done for within the group analysis for subsequent follow-up visits. Data was analysed using Statistical Package for Social Sciences (SPSS) version 21. Results: The mean age of study population was 33.67±8.674 years. The male-female distribution was insignificant (p=0.673), providing us with a homogenous study group. Recurrent GCT was found significantly more commonly in the proximal tibia group than in the distal femur group (p=0.031). Comparison of OKS and MSTS preoperatively, at six months, at one year, and two years showed statistically significant improvement in successive follow-ups in both the distal femur and proximal tibia groups (p&lt;0.001 in both groups). Intergroup analysis also showed significantly better scores in the distal femur group compared to the proximal tibia group in the preoperative period and all successive follow-ups. On intergroup analysis at 2 years, both the OKS (p=0.020*) and MSTS score (p&lt;0.0001) were found to be statistically significant. SF-12 mental and physical scores preoperatively also showed statistically significant improvement in all cases (p&lt;0.001 for mental and physical components. Conclusion: Early functional outcomes of en-bloc excision and reconstruction with modular endoprosthesis are good in terms of joint function and the patient’s overall mental and physical well-being.

Elbow joint salvage in pediatric traumatic amputation with targeted muscle reinnervation, external tissue expansion, and free muscle flap – A case report

The authors report targeted muscle reinnervation (TMR) in an 11-year-old male who sustained a trans-radial amputation of the right upper extremity in an ATV accident. A combination of targeted muscle reinnervation, external tissue expansion, and free muscle transfer allowed us to preserve elbow function, prevent neuroma formation, and allow for the future use of a myoelectric prosthetic. The use of TMR in pediatrics leverages the enhanced cortical plasticity of younger patients to improve outcomes and quality of life following traumatic injury, limiting the otherwise significant financial and psychosocial impact of amputation. This report offers the first account of TMR performed on a pediatric patient with no neuroma formation or phantom limb pain. • TMR redirects severed nerves to muscular targets. • This prevents neuroma and generates neural control for myoelectric prosthetic use. • TMR aided in the salvage of the dominant elbow joint of an 11-year-old male. • This is the first report of TMR in a pediatric upper extremity traumatic amputation.

Chronic posterior dislocation of shoulder

PurposeChronic posterior dislocation of shoulder (PDS) is an uncommon injury and there are very few publications describing its different injury patterns and their treatment. This study was carried out to study the associated injuries in chronic PDS, which can help to classify and guide the treatment. MethodsWe retrospectively studied 16 chronic posterior dislocation of shoulder. CT scan was used to classify the injury based on the amount of bone loss in humeral head, malunion of greater tuberosity and malunion of proximal humerus metaphysis. Visual analogue score (VAS) for pain, university of California Los Angles (UCLA) shoulder score and American shoulder and elbow surgeon (ASES) shoulder score were recorded pre operatively and at an average of 27 months post operatively. Results– Type A1 injury was PDS with <50% humeral head bone loss with intact greater tuberosity (GT). It was managed by modified McLaughlin procedure (MMP). Type A2 injury was PDS with >50% bone loss with intact GT. It was managed by hemi-replacement (HRA). Type B1 injury was PDS with <50% bone loss with severe GT malunion. It was managed by MMP and corrective osteotomy of GT. Type B2 injury was PDS with >50% bone loss and severe GT malunion. It was managed by reverse shoulder arthroplasty (RSA). Type C1 injury was PDS with <50% bone loss and metaphyseal malunion. It was managed by MMP and osteotomy of proximal humeral metaphysis. Type C2 injury was PDS with >50% bone loss and metaphyseal malunion. It was managed by HRA. The VAS, UCLA score and ASES score improved significantly after the surgery in all cases. There was no recurrence of the instability ConclusionsWe concluded that chronic PDS could have fractures of tuberosities and/or proximal metaphysis in addition to bone loss in humeral head. The treatment is guided by all three factors-amount of bone loss in humeral head, malunion of GT and proximal humeral metaphysis. The proposed classification can help in choosing the optimum treatment out of joint salvage procedure, anatomic shoulder replacement and reverse shoulder arthroplasty

Surgical and patient-reported outcomes after total knee arthroplasty requiring soft tissue flap reconstruction – A 12-year experience from high-volume arthroplasty hospital

This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital. Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups. Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n=27; EC group n=31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p=0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p=0.36). Oxford Knee Score was 34.5vs. 25.5 (p=0.21), and range of motion was 100⁰ vs. 93⁰ (p=0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p=0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p=0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p=0.03). Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Patients with advanced lateral osteoarthritis can return to sports and work after distraction arthroplasty plus lateral meniscal allograft transplantation combined with cartilage repair.

This study aimed to report return to sports (RTS) and return to work (RTW) outcomes after distraction arthroplasty (DA) plus lateral meniscal allograft transplantation (MAT) combined with cartilage repair in active patients with advanced osteoarthritis. It was hypothesised that DA combined with lateral MAT would improve clinical and radiological outcomes and enable RTS and RTW for most patients. In total, 21 patients with advanced osteoarthritis (moderate to severe joint space narrowing at lateral edge on Rosenberg view and large cartilage defect of lateral femoral condyle) who underwent concomitant DA and MAT were retrospectively reviewed. Clinical outcomes were assessed using subjective knee scores [Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity scale (TAS)] and functional tests (isokinetic extensor muscle strength test, single-leg vertical jump test, and single-leg hop for distance test). The rates of RTS, RTW, and satisfaction were evaluated. Radiological outcomes were assessed using magnetic resonance imaging (MRI) and X-ray (Rosenberg view). The mean age at surgery and mean follow-up duration were 37.2 ± 5.9years and 37.1 ± 5.4months, respectively. All improvements in subjective scores were statistically significant (p < 0.001). The Lysholm score improved from 58.3 ± 8.1 to 84.3 ± 8.2, the IKDC subjective score from 53.9 ± 10.4 to 78.0 ± 7.7, and the TAS from 4.0 ± 0.5 to 5.1 ± 0.8. The limb symmetry index (LSI) (%) of the extensor peak torque at an angular velocity of 60°/s improved from 67.3 ± 19.2 to 88.4 ± 20.3% (p = 0.001). The LSI of the single-leg vertical jump test and single-leg hop for distance test improved from 62.8 ± 21.3 to 87.7 ± 19.5% and from 63.9 ± 20.8 to 85.5 ± 18.1%, respectively (all, p < 0.001). All patients were able to return to any sports activity and work. However, 67% and 90.5% returned to their defined or desired level of sports activity and occupation intensity, respectively. Further, 76.2% were very satisfied or somewhat satisfied with the outcome at the last follow-up. The JSW increased by 0.8 ± 0.4 to 2.3 ± 0.6mm (p = 0.005). In more than 90% of patients, > 50% of cartilage lesion was covered. The mean graft extrusion was 2.6 ± 1.0mm. All patients who underwent distraction arthroplasty plus lateral MAT combined with cartilage repair returned to any sports and work at the last follow-up. Significant improvements in clinical outcomes and the radiographic joint space width were observed. However, the activity ability was somewhat reduced compared with the best preoperative level. This one-stage joint salvage treatment is a promising option for young and active patients with advanced OA who wish to return to high levels of sports activity and occupation intensity (≥ Tegner activity scale 4). III.

Ankle joint salvage and reconstruction by limited ORIF combined with an Ilizarov external fixator for complex open tibial pilon fractures (AO 43-C3.3) with segmental bone defects

BackgroundOpen pilon fractures combined with sizeable segmental bone defects are rare, difficult to treat, and often result in the loss of ankle joint function. The purpose of this study was to determine clinical outcomes in patients with open pilon fractures and sizeable segmental bone defects treated by limited ORIF combined with an Ilizarov external fixator.MethodsWe conducted a retrospective analysis of open pilon fractures with sizeable segmental bone defects treated by limited ORIF combined with the Ilizarov external fixator strategy between July 2014 and August 2019. All patients were included for assessments of fracture healing and infection rates. Ankle functional outcomes were assessed in all patients according to the Paley criteria and American Orthopedic Foot and Ankle Society Score (AOFAS) at least 24 months post-injury.ResultsAll patients were followed up for a mean of 41.09 months. The mean bone defect size was 5.64 ± 1.21 cm. The average EFI and BTI were 1.56 ± 0.28 months/cm and 11.12 ± 0.74 days/cm, respectively. According to the Paley evaluation system, the success rate of ankle joint reconstruction was 64% (7/11). The mean score based on the AOFAS functional assessment was 77.73 ± 8.87. Five patients showed posttraumatic arthritis, one of whom required ankle arthrodesis. Three patients developed pin site infections, and one patient developed a deep infection after bone grafting.ConclusionThe strategy of limited ORIF combined with an Ilizarov external fixator can restore ankle function in most patients with complex open tibial pilon fractures. Ankle stiffness, pin tract infection, and traumatic arthritis were the most common complications associated with this therapy.

Wrist Arthrodesis with Vascularized Fibular Graft after Failed Allograft Replacement for Giant-Cell Tumor Resection

Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function. Numerous options for reconstruction are available, but in the literature there is a lack of salvage surgery data. We present a case of a 67-year-old woman who underwent complete wrist arthrodesis with vascularized fibular graft as salvage procedure for allograft necrosis, after excision of a distal radius GCT. The patient did not complain of any impairment in daily use, and the functional score was 22 points (73%) at latest follow-up of 14 months. Despite joint salvage remains the most favorable treatment with regard to functional outcome for aggressive tumors of the distal radius, vascularized fibular grafts is a valuable alternative especially in salvage procedures, where the use of another allograft could lead to higher complications rate. Keywords: Vascularized fibular graft, Wrist arthrodesis, Giant-Cell Tumor, Fibula free flap.

THE RESULTS OF TREATMENT OF GIANT CELL TUMOR OF LONG BONES WITH DENOSUMAB

Surgical intervention remains a gold standard for the treatment of giant cell tumors (GCT) of long bones. The significant risk of recurrence after the curettage and a high complication rate after radical resections is still an unsolved problem. Targeted therapy with denosumab could solve this problem in favor of curettage, but recent studies have shown negative results with denosumab in such situation. Objective. To analyze the results of the denosumab application in patients with long bone GCP with indications for joint salvage surgery. Methods. We compared the treatment results in two groupsof patients: 1st retrospective (control) group — 57 patients, who underwent curettage with surgical treatment and the 2nd prospective (main) group — 42 patients with combination of surgery with neoadjuvant and adjuvant denosumab tretment. In the 2nd group of patients received 5 neoadjuvant and 5 adjuvant cycles of denosumab. The median follow-up period was 189 months in the control group, and 45 months in the main group. Results. Disease progression which identified as a local recurrence was revealed in the control group in 15 patients (25.4 %) and in 7 patients (16.7 %) in the maingroup (p = 0.19). In the main group, the median time to relapse was 19.8 months (8–34 months) from the date of surgery, in the control group — 15.1 months (9–28 months), respectively. The statistically significant difference in relapse-free survival (RFS) between patients in the main group and in the control group (p = 0.18) was not revealed. But the 5-year RFS in the main group was higher and reached to 85 % (95 % CI 74–96 %) versus 75 % (95 % CI 64–86 %) in control group, respectively. There was no evidence of malignant transformation in the main group and one case in retrospective group. Conclusions. The application of denosumab in the regimen before and after curettage is associated with lees number of relapses — 16.7 % vs. 25.4 % without denosumab, respectively. The lack of statistically significant difference between groups does not provide the sufficient reasons for denosumab prescription in neoadjuvant regimen. But adjuvant administration of denosumab can be considered as preventing factor of recurrence after primary tumor curettage, which may be perspective for further study and optimization of indications for its application in patients with GCT.

Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young.

PurposeThe main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible.MethodsWe describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours.ResultsDifferent resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life.ConclusionSeveral biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours.Level of EvidenceLevel V Expert opinion

Joint Salvage and Biological Repair of Massive-Cavity Bone Defects After Extensive Curettage of Campanacci Grade II or III Giant Cell Tumor Around the Knee With Vascularized Fibular Autograft and Cancellous Allograft.

The aim of the study was to report the clinical outcomes of repair of massive-cavity bone defects after extensive curettage of Campanacci grade II or III giant cell tumor (GCT) around knee with vascularized fibular autograft and cancellous allograft. There were 12 consecutive patients with Campanacci grade II or III GCT around knee treated in our department between 2004 and 2016. All the patients underwent clinical evaluation, plain radiography, and/or magnetic resonance imaging of the knee right after admission. To preserve their knee function, we repaired the massive-cavity bone defects after extensive curettage of GCT by vascularized fibular autografts and cancellous allograft. All the patients were evaluated through clinical examinations, plain radiography of the knee and chest, and Musculoskeletal Tumor Society (MSTS) scores of the lower extremity in the follow-ups. The follow-up ranged from 1.5 to 12.0 years (mean, 4.2 years). There were no local recurrences or lung metastasis in any of the 12 patients at the last follow-up. Ten patients had no pain or experienced occasional pain, and 9 were able to resume their previous work. The mean range of motion of knee flexion was 117 degrees, and the extension was -6 degrees. The mean MSTS score was 24.7, and a total of 10 patients had excellent or good MSTS scores. It is reliable to achieve knee joint salvage and repair massive-cavity bone defects after extensive curettage with vascularized fibular autograft and cancellous allograft in patients with Campanacci grade II or III GCT around the knee.

Functional Outcomes for Basilar Joint Arthroplasty with Meniscus Allograft Compared with Trapeziectomy Alone.

Advanced thumb carpometacarpal (CMC) joint arthritis is widely treated with trapeziectomy. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using meniscal allograft. We hypothesize that the use of meniscus improves outcomes and subsequent functionality compared with trapeziectomy alone. Twenty-three patients with Eaton stage III-IV CMC osteoarthritis underwent arthroplasty with meniscal allograft, and 7 patients underwent trapeziectomy alone. Preoperative Disabilities of the Arm, Shoulder, and Hand (DASH), pain, grip and pinch strength, and range of motion scores were compared with postoperative scores at 6 weeks, 6 months, and 1 year. The study group consisted of 17 women and 6 men, and the control group consisted of 5 women and 2 men. The mean age was similar at 61.4 (48-72) years and 65.7 (56-78) years for the study and control groups, respectively. The DASH scores dropped by 61.8% in the study group compared with 38.8% in the control group (<0.01), whereas pain decreased 86.0% and 69.8%, respectively (P < .01). Strength and range of motion improvement was similar between the groups. Subsidence of the joint space was 1% in the study group compared with 18.4% in the control group. There were no surgical complications in either group. Joint resurfacing with meniscal allograft represents a viable joint salvage option in severe cases of CMC arthritis. Early results suggest that, compared with trapeziectomy alone, the approach results in greater reduction in subjective pain and disability scores, similar improvement in strength measures and range of motion, and less subsidence.

The use of denosumab in the setting of acute pathological fracture through giant cell tumour of bone

BackgroundDenosumab (XgevaTM) is a fully human antibody to RANK-Ligand, an important signal mediator in the pathogenesis of giant cell tumour of bone (GCTB). The use of denosumab in the treatment of GCTB has changed the way in which these tumours are managed over the past years.Case presentationDescribed is the case of an acute fracture through a GCTB of the distal radius of a fit and well 32-year-old, non-smoking, female patient following a simple fall onto her outstretched, dominant hand. The aim was to enable joint sparing management for the patient, as opposed to an acute fusion procedure of the carpus. The patient underwent percutaneous k-wire fixation with application of plaster and immediate commencement with denosumab to halt the activity of the GCTB. Bone healing was rapid; plaster and k-wires were removed after 6 weeks. At 6 months denosumab, was ceased and an open curettage and grafting procedure of the tumour bed was undertaken (using MIIG X3, Wright Medical, aqueous calcium sulphate as graft material).ConclusionsThe use of denosumab in the acute setting of pathological fracture through giant cell tumour of bone allowing joint salvage has not been previously described. The treatment was well tolerated and functional outcomes are excellent, with very promising 4-year follow-up.This novel approach may allow for more joint sparing strategies in the future for other patients in this difficult situation. Further cases will need to be gathered to establish this technique as a suitable treatment pathway.