Limb-preserving Surgery Research Articles

Lower extremity osteotomies for limb preservation: Indications, outcomes, and risk factors

ObjectivesTo delineate the key factors associated with treatment success or failure for patients undergoing lower extremity osteotomies to address a spectrum of lower extremity joint and limb deformities at an Integrated Limb Preservation Center (ILPC). MethodsDesign: Retrospective cohort study.Setting: Level I Academic Trauma Center.Patient selection criteria: Patients of the ILPC with at least 1-year of follow-up data regarding previous surgery to correct trauma-or developmental-related deformities between January 1, 2005, and October 1, 2022.Outcome measures and comparisons: Patients were categorized first based on etiology (developmental vs. traumatic) and then based on the nature of deformity (joint, limb, nonunion). Treatment data, demographics including age, sex, body mass index (BMI), tobacco use history, insurance status, marital status, mental health history, and history of comorbidities, concurrent procedures, and post-operative infection, revision, reoperation, and bone healing status were extracted from the medical record and compared. Treatment failure was defined as conversion of the limb preservation surgery (ies) to amputation of any type. Results139 patients were included for analysis; 47 patients in the developmental-related cohort, and 92 patients in the trauma-related cohort. The treatment success rate in terms of preserving the affected limb for patients undergoing lower extremity osteotomies was 94.7 % for the developmental-related cohort and 92.4 % for the traumatic-related cohort. 57.4 % of patients in the developmental-related cohort and 59.8 % of patients in the trauma-related underwent unplanned secondary procedures Concurrent osteomyelitis debridement (p = 0.01) and postoperative infection (p = 0.049) were the only factors measured significantly associated with conversion to amputation. ConclusionsPatients undergoing osteotomies at an ILPC to address developmental-related or trauma-related joint and/or limb deformities experienced high short-term success (>90 %) with respect to preserving the affected limb. However, 56 % of patients required subsequent unplanned surgeries and improvements in PROMs were only statistically significant in patients with trauma-related deformities. Level of evidenceIII.

Postoperative Opioid-Prescribing Practice in Limb Preservation Surgery.

Limb preservation surgery affects more than 100,000 Americans annually. Current postoperative pain management prescribing practices of podiatric physicians in the United States are understudied. We examined prescribing practices for limb preservation surgery to identify prescriber characteristics' that may be associated with postoperative opioid-prescribing practices. We administered an anonymous online questionnaire consisting of five patient scenarios with limb preservation surgery commonly performed by podiatric physicians. Respondents provided information about their prescription choice for each surgery. Basic provider demographics were collected. We developed linear regression models to identify the strength and direction of association between prescriber characteristics and quantity of postoperative opioid "pills" (dosage units) prescribed at surgery. Logistic regression models were used to identify the odds of prescribing opioids for each scenario. One hundred fifteen podiatric physicians completed the survey. Podiatric physicians reported using regional nerve blocks 70% to 88% of the time and prescribing opioids 43% to 67% of the time across all scenarios. Opioids were more commonly prescribed than nonsteroidal anti-inflammatory drugs and anticonvulsants. Practicing in the Northeast United States was a significant variable in linear regression (P = .009, a decrease of 9-10 dosage units) and logistic regression (odds ratio, 0.23; 95% confidence interval, 0.07-0.68; P = .008) models for the transmetatarsal amputation scenario. Prescribing practice variation exists in limb preservation surgery by region. Podiatric physicians reported using preoperative regional nerve blocks more than prescribing postoperative opioids for limb preservation surgeries. Through excess opioid prescribing, the diabetes pandemic has likely contributed to the US opioid epidemic. Podiatric physicians stand at the intersection of these two public health crises and are equipped to reduce their impact via preventive foot care and prescribing nonopioid analgesics when warranted.

Neoadjuvant Radiotherapy Is Associated with Fewer Acute Adverse Skin Reactions Without Increased Risk of Postoperative Wound Complications in High-Grade Extremity Soft Tissue Sarcoma - A Retrospective Comparative Study with A Mean Follow-Up of 7 Years

Aim: In this study, we aim to compare the adverse effects and oncological outcomes of patients with high-grade extremity soft tissue sarcoma receiving neoadjuvant or adjuvant RT. Methods: From 2008 to 2022, Sixty-four patients underwent limb-preserving surgery in our institute for localized high-grade extremity soft tissue sarcoma were included. Thirty-nine patients received adjuvant radiotherapy while twenty-five patients received neoadjuvant RT before surgery if the soft tissue sarcomas were close to the neurovascular bundles, bones or histological types of myxoid liposarcoma or rhabdomyosarcoma. Primary outcomes were acute RT-related skin adverse reactions and significant side effects comprising postoperative wound complications, pathological fractures and RT-induced sarcoma. Secondary outcomes included surgical margin quality, Local-Recurrence (LR)-free survival, metastasis-free survival and overall survivorship. Results and Discussion: Patients in the neoadjuvant RT group had significantly fewer acute RT-induced adverse skin reactions than the adjuvant RT group (p=0.044, Table 2). None in the neoadjuvant RT group suffered severe acute skin reaction (RTOG grade 3-4). Wound infection (n=2) and pathological fracture (n=1) were rare in both adjuvant and neoadjuvant RT groups (P=0.640 & 1.000 respectively). Survival curves for local-recurrence-free survival, metastasis-free survival and overall survivorship of both neoadjuvant and adjuvant groups were analyzed via Kaplan-Meier Curve. All results are statistically insignificant, with p=0.835, 0.948 and 0.540, respectively. Presence of metastasis was the only statistically significant predictor of the overall survival-adjusted hazard ratio of 8.7 (95%CI 2.7-28), p<0.001. Conclusion: Patients with neoadjuvant RT had lower cumulative radiation doses and fewer acute adverse skin reactions. There was no increased risk of postoperative wound complication compared to adjuvant RT. The LR-free survival, metastasis-free survival and overall survival were comparable in both groups. Our results suggested that postponing surgery to eight weeks after neoadjuvant RT and primary wound closure were associated with fewer wound complications, but further studies were warranted.

Targeting signaling pathways in osteosarcoma: Mechanisms and clinical studies.

Osteosarcoma (OS) is a highly prevalent bone malignancy among adolescents, accounting for 40% of all primary malignant bone tumors. Neoadjuvant chemotherapy combined with limb-preserving surgery has effectively reduced patient disability and mortality, but pulmonary metastases and OS cells' resistance to chemotherapeutic agents are pressing challenges in the clinical management of OS. There has been an urgent need to identify new biomarkers for OS to develop specific targeted therapies. Recently, the continued advancements in genomic analysis have contributed to the identification of clinically significant molecular biomarkers for diagnosing OS, acting as therapeutic targets, and predicting prognosis. Additionally, the contemporary molecular classifications have revealed that the signaling pathways, including Wnt/β-catenin, PI3K/AKT/mTOR, JAK/STAT3, Hippo, Notch, PD-1/PD-L1, MAPK, and NF-κB, have an integral role in OS onset, progression, metastasis, and treatment response. These molecular classifications and biological markers have created new avenues for more accurate OS diagnosis and relevant treatment. We herein present a review of the recent findings for the modulatory role of signaling pathways as possible biological markers and treatment targets for OS. This review also discusses current OS therapeutic approaches, including signaling pathway-based therapies developed over the past decade. Additionally, the review covers the signaling targets involved in the curative effects of traditional Chinese medicines in the context of expression regulation of relevant genes and proteins through the signaling pathways to inhibit OS cell growth. These findings are expected to provide directions for integrating genomic, molecular, and clinical profiles to enhance OS diagnosis and treatment.

Midterm Results of High-Dose-Rate Intraoperative Brachytherapy in the Treatment of Soft Tissue Sarcomas.

According to the literature only sparse data are available on the use of high-dose-rate intraoperative brachytherapy (IOHDR-BT) as a boost to external-beam irradiation (EBRT) in combination with a wide resection in patients with high-grade soft tissue sarcomas (STS). Applying a retrospective study design, we investigated all patients who between 2010 and 2016 underwent marginal resection of a high-grade STS and intraoperative radiotherapy, followed by EBRT. We included only patients with a traceable follow-up time of at least two years. Of 89 patients, 35 met our inclusion criteria and showed an average follow-up of four years. We found an overall 2-year local control rate of 94.3%. The local recurrence rate for R0 resections was 6%, whereas recurrences occurred in 13% of R1 resections and in 100% of R2 resections. One affected patient received only intraoperative radiotherapy. The recurrence rate by tumour entity was 36% for LPS, 11% for myxofibrosarcoma and 17% for undifferentiated pleomorphic sarcoma. The treatment regimen consisting of limb-preserving surgery, IORT and pre- or postoperative radiotherapy consistently shows excellent local control rates.

Cancer-Specific Survival after Limb Salvage versus Amputation in Children and Adolescents with Osteosarcoma: A Population-Based Analysis with Propensity Score Matching.

The study aims to identify whether osteosarcoma patients of children and young adults will benefit from a survival profit from the choice of the operation method. The National Cancer Institute SEER database from 2000 to 2018 was selected for a retrospective analysis of 1630 children and young adults with a primary diagnosis of osteosarcoma, 1222 who underwent limb-preserving surgery, and 408 who underwent amputation. Confounders were controlled for by propensity score matching (PSM), cancer-specific survival (CSS) was analyzed using the Kaplan-Meier method, and univariate and multivariate Cox regression was used to analyze the factors influencing the prognosis of children and young osteosarcoma patients after surgery. A nomogram plot predicted 1-, 3-, and 5- survival rate in osteosarcoma. The model's accuracy was validated by the area under the ROC and calibration curves. After PSM, multifactor Cox regression analysis found AJCC Stage III-IV (CSS : HR = 5.26, 95% CI 1.95-14.18, p=0. 001; HR = 5.54, 95% CI 2.56-12.01, p < 0. 001. Limb salvage surgery (CSS : HR = 0.58, 95% CI 0.44-0.77, p < 0. 001) has independent impact factors for CSS prognosis. The survival curve before and after PSM showed that patients with osteosarcoma of children and young adults who underwent limb salvage surgery had a survival benefit compared with those who underwent amputation surgery. Gender, chemotherapy, histology, primary tumor site, stage, and surgical modality were modeled in a total of six variables in the nomogram. The model exhibited good predictive performance. The AUC were 0.823, 0.74, and 0.757 for training set at 1, 3, and 5 years, respectively. The AUC of validation set 0.666, 0.722, and 0.699 at 1, 3, and 5 years, respectively. The model also predicted CSS with good fidelity for both datasets. This model was significantly superior to the 8th edition of the AJCC TNM staging system, with a better net benefit in predicting CSS in children and young adults with osteosarcoma. Limb salvage surgery is an option for children and young adults with osteosarcoma and cancer-specific survival rates can be improved by receiving limb salvage surgery.

MUTARS® Humero pro Femur replacement: A novel reconstructive procedure after malignant bone tumor resection of the femur in young children

Limb-preserving surgery in young children suffering malignant bone tumor of the femur is challenging due to the specific anatomical conditions. Extendable tumor endoprostheses are often oversized, while custom-made endoprostheses do not provide the intraoperatively required variability regarding reconstruction length. Allo- and autograft replacements, on the other hand, show high complication and revision rates. We report a novel reconstructive procedure after resection of malignant bone tumors of the femur in young children, and present our preliminary results of this technique.

Neoadjuvant stereotactic ablative radiotherapy (SABR) for soft tissue sarcomas of the extremities

BackgroundSoft tissue sarcomas (STS) comprise a diverse group of mesenchymal malignancies that require multidisciplinary care. Although surgery remains the primary form of treatment for those with localized disease, radiation therapy (RT) is often incorporated either in the neo- or adjuvant setting. Given the development of modern RT techniques and alternative dosing schedules, stereotactic ablative radiotherapy (SABR) has emerged as a promising technique. However, the current role of SABR in the treatment of STS of the extremities remains uncertain. Methods and MaterialsThis was a single-center, prospective, single-arm phase II trial. Patients with localized STS who were candidates for limb-preservation surgery were included. Experimental treatment consisted of SABR with 40 Gy in 5 fractions, administered on alternate days, followed by surgery after a minimum interval of 4 weeks. The primary outcome was the rate of wound complication. Secondary outcomes included 2-year local control (LC), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) rates (and other toxicities). ResultsTwenty-five patients were enrolled between October 2015 and November 2019 and completed the treatment protocol. The median rate of histopathologic regression was 65% (range 0–100) and 20.8% of tumors presented pathologic complete response (pCR). Wound complications were observed in 7/25 patients (28%). Three patients underwent disarticulation by vascular occlusion after plastic reconstruction and one patient was amputated by grade 3 limb dysfunction. After a median follow up of 20.7 months, the 2-year estimated risk of local recurrence, distant metastasis and cause-specific death were 0%, 44.7% and 10.6% respectively. ConclusionsNeoadjuvant SABR appears to improve the pCR for patients with eSTS, with acceptable rate of wound complications. Nevertheless, this benefit should be weighed against the risk of late of vascular toxicity with SABR regimen since, even in a short median follow-up, a higher rate of amputation than expected was observed. A larger sample size with longer follow-up is necessary to conclude the overall safety of this strategy.

Surgical Advances in Osteosarcoma

Simple SummaryOsteosarcoma (OS) is the most common bone cancer in children. OS most commonly arises in the legs, but can arise in any bone, including the spine, head or neck. Along with chemotherapy, surgery is a mainstay of OS treatment and in the 1990s, surgeons began to shift from amputation to limb-preserving surgery. Since then, improvements in imaging, surgical techniques and implant design have led to improvements in functional outcomes without compromising on the cancer outcomes for these patients. This paper summarises these advances, along with a brief discussion of future technologies currently in development.Osteosarcoma (OS) is the most common primary bone cancer in children and, unfortunately, is associated with poor survival rates. OS most commonly arises around the knee joint, and was traditionally treated with amputation until surgeons began to favour limb-preserving surgery in the 1990s. Whilst improving functional outcomes, this was not without problems, such as implant failure and limb length discrepancies. OS can also arise in areas such as the pelvis, spine, head, and neck, which creates additional technical difficulty given the anatomical complexity of the areas. We reviewed the literature and summarised the recent advances in OS surgery. Improvements have been made in many areas; developments in pre-operative imaging technology have allowed improved planning, whilst the ongoing development of intraoperative imaging techniques, such as fluorescent dyes, offer the possibility of improved surgical margins. Technological developments, such as computer navigation, patient specific instruments, and improved implant design similarly provide the opportunity to improve patient outcomes. Going forward, there are a number of promising avenues currently being pursued, such as targeted fluorescent dyes, robotics, and augmented reality, which bring the prospect of improving these outcomes further.

Safety of limb-salvaging surgery for sarcomas compromising major vessels: A 15-year single-centre outcomes study.

Limb-threatening sarcomas invading major vessels present an oncological and reconstructive challenge. Curative resection involves either performing an amputation or an immediate reconstruction of the invaded vessels. We present our 15-year experience of these cases at the North of England Bone and Soft Tissue Tumour Service. A Strengthening the Reporting of Observational studies in Epidemiology (STROBE) compliant retrospective review of our prospective database was performed including patients who required major vessel reconstruction following sarcoma excision from 2003 until 2018. Patient demographic data along with tumour and histological subtypes, treatment modality, complications and outcomes were inquired. Autologous and prosthetic vessel reconstruction approaches were compared. Nineteen patients were identified with the most common tumour locations being the thigh and groin areas. Five cases involved recurrent tumours. Clear resection margins were obtained in 15 cases. Autologous vein grafts were preferred over polytetrafluoroethylene (PTFE) prosthesis in 17 cases. A pedicled flap or free flap was required to achieve adequate soft tissue cover in six patients, while the rest underwent primary closure. Five patients lost the patency of the reconstructed vessels with one of these requiring an amputation. The estimated disease-specific survival at 5 years was 58%. Limb-preservation surgery in the context of vessel compromise is not only safe, but also a functionally and psychosocially beneficial means of avoiding an amputation. We believe that careful pre-operative planning and discussion in a multidisciplinary setting is key for obtaining positive outcomes.

Intraoperative Radiotherapy Without External Beam Radiotherapy in the Management of Primary Soft Tissue Sarcomas of the Extremities

Intraoperative radiation therapy (IORT) is frequently used in conjunction with conventional external-beam radiation therapy (EBRT) to treat soft tissue sarcomas (STS) of the extremities as part of a limb sparing approach. We sought to investigate the efficacy of limb preservation surgery and IORT alone in the management of primary extremity STS. This is a single institutional retrospective study of patients diagnosed with primary STS of the extremity who received surgery and IORT without neoadjuvant or adjuvant EBRT between January 2008 and April 2018. Survival analyses were performed using the Kaplan-Meier method with log-rank testing for significance. Adverse event data were assessed per CTCAE v5 guidelines. Thirty-two patients were diagnosed with primary extremity STS and underwent limb sparing surgery and IORT without neoadjuvant or adjuvant radiotherapy. Four (12.5%) patients received neoadjuvant chemotherapy and two (6.3%) received chemotherapy in the postoperative setting. Twenty-five patients (78%) had Stage I-II disease, 63% of tumors were intermediate or high grade, and 91% had negative resection margins. With a median follow up of 5.3 years, the 5-year local recurrence rate was 9.1%, and the 5-year overall survival rate was 97%. Overall, treatment was well tolerated: the most common adverse effects included postoperative infections (12.5%), grade 1 neuropathies (9.4%), and delayed wound healing (9.4%). With respect to Grade 3-5 toxicities, one Grade 3 (infection) and one Grade 5 toxicity (in a 95-year-old patient with unfavorable preoperative performance status) were observed. Limb preservation surgery and IORT alone may provide adequate local control in the management of select primary extremity STS, with acceptable toxicity.

Outcomes of Elderly Patients with Soft Tissue Sarcoma of the Extremities

Current standard of care for management of localized soft tissue sarcoma (STS) of the extremity includes aggressive local therapy including limb-salvage surgery with radiotherapy and/or chemotherapy. STS has a high incidence rate in the elderly. However, due to comorbidities associated with advanced aged, elderly patients with soft tissue sarcoma of the extremities may receive de-intensified therapy leading to adverse outcomes. We performed a single tertiary-care institution review of patients age 70 or above treated for STS to identify patient, disease, and treatment factors associated with outcomes, with a focus on the impact of treatment de-intensification in this population. Patients age 70 or older at time of biopsy-proven STS sarcoma diagnosis were identified from a single institution electronic health record from 1991-2015. Local control was calculated from time of completion of upfront local therapy (surgery and/or radiotherapy) to recurrence or last follow up. Associations between patient, disease, and treatment factors with outcome were interrogated with Fisher exact and log-rank tests. We identified 126 patients with median age of 79 (IQR 74-85) at diagnosis. The most common histologic subtypes included undifferentiated pleomorphic sarcoma (40%), liposarcoma (16%), and myxofibrosarcoma (14%). Grade distribution was 9%, 17%, and 74% for grade 1, 2, 3, respectively. Stage distribution (AJCC 7th edition) was 14%, 33%, 52% for stage I, II and III, respectively. 47% had a documented significant cardiovascular, pulmonary, or cognitive comorbidity. Among patients with high-grade (3) disease (88 patients), 93% underwent limb preservation (LP) surgery and 7% underwent amputation. In the LP subgroup, 38% had positive margins (< 1 mm). 70% of LP patients received pre- or post-operative adjuvant radiotherapy. 9% received chemotherapy. Median follow up was 17.6 months (IQR 4.4-58.2 months). Actuarial local control at one and five years was 91.9% (95% CI 79.7-96.9%) and 66.3% (95% CI 45.8-80.6%). 35% of patients developed distant recurrences. 26% of patients had late complications following combined modality therapy, predominantly lymphedema. Median overall survival was 2.8 years. On multivariate analysis, only radiotherapy was associated with local control and chemotherapy with distant control (p<0.05). While almost half of all patients had significant comorbidities, aggressive multimodal therapy for appropriately selected patients was associated with improved survival outcomes. Our institutional series affirmed the association of radiotherapy with local control in elderly patients with high-grade STS of the extremities treated with limb preservation therapy. Moreover, a high rate of distant metastases was observed potentially related to limited use of chemotherapy in patients at-risk for distant recurrences.

Relationship Between Clinicopathological Features and Prognosis in Appendicular Osteosarcoma in Dogs

Osteosarcoma is the most common primary bone neoplasm in dogs and often involves the appendicular skeleton. We report the clinicopathological and prognostic features of appendicular osteosarcomas diagnosed in 153 dogs from 2008 to 2018. The survival data for 22 dogs that underwent surgery and chemotherapy were statistically compared with the clinical, histopathological and immunohistochemical data for correlation with prognosis. The affected dogs had a mean age of 9.1 years and a mean body weight of 33.4kg. No sex predilection was detected, although the incidence was slightly higher in females (52%). Large mixed and purebred dogs were most commonly affected. Long bones were affected in 124 cases (92.5%; 124/134). The extremities affected within long bones were the metaphysis of the proximal humerus (29%), distal radius (17.7%), distal femur (15.3%) and proximal tibia (7.2%). Histologically, osteoblastic osteosarcoma was most commonly detected (56.9%), followed by chondroblastic (13.7%), telangiectatic (11.8%), fibroblastic (7.8%), giant cell-rich (5.2%) and poorly differentiated neoplasms (4.6%). Regional lymph nodes were available for analysis in 28 out of 70 excisional biopsies from amputated entire limbs. Metastases to regional lymph nodes were observed in 14.3% (4/28) of these cases. Distant metastases were found in 75% (39/52) of cases in which diagnostic imaging or necropsy was carried out. The lungs were the most common site of metastasis (87.2%; 34/39 cases). Weight, age, sex, affected limb or bone, histological classification, mitotic count or histological grade did not influence survival (P>0.05). Neoplasms located at proximal extremities (n=7) of affected limbs had a tendency for a poorer prognosis than those at distal extremities (n=15) (P=0.06). For these cases, the 1-year survival rate was 14.3% compared with 40% for neoplasms at distal extremities. There was no significant difference in the survival rate when amputation (n=16) or limb preservation (n=6) techniques were employed with chemotherapy (P=0.20). The survival period of dogs that had undergone limb amputation, or limb preservation surgery, and chemotherapy was 73-1,185 days, with a mean and median of 376 and 256 days, respectively. Mild to marked cytoplasmic immunolabelling of osteopontin was found in all cases but the intensity (P=0.66) and percentage of neoplastic cells labelled (P=0.49) did not influence survival.

Soft tissue sarcomas in the elbow region and influence of their anatomical features in their treatment. Experience in the Unit of Musculoskeletal Tumours

Background and aimSoft tissue sarcomas are exceptionally located in the elbow region. The aim of this work was to study the soft tissue sarcomas of the elbow region, their epidemiological and histopathological characteristics, anatomical features, the treatment performed, and the results obtained, in a unit of musculoskeletal tumours. MethodsRetrospective review of ten patients with a mean follow-up of 65.0 ± 11.9 (range 21–132) months with soft tissue sarcomas located in the elbow region operated in our centre between 2008 and 2016. ResultsMean age was 60.8 ± 6.7 years. Undifferentiated pleomorphic sarcoma was the most frequent histological diagnosis. Limb preservation surgery was performed in 90% of patients. Three patients were previously operated without following surgical oncology guidelines in another hospital, and this was statistically related to the need for more than one surgery to control the disease. R1 margin was obtained in 5 patients and R0 in another 5. Adjuvant radiotherapy was used in 7 cases. In 4 patients, subsequent surgery was performed for local or systemic control of the disease. Local recurrence occurred in 3 cases and in 5 there was distant disease. ConclusionThe elbow region presents difficulty in achieving wide margins due to the proximity of neurovascular structures, adjuvant and/or neoadjuvant therapies could play an important role in performing limb preservation surgery. It would be advisable to refer these tumours to specialized units with multidisciplinary teams.

Sarcomas de partes blandas en la región del codo e influencia de sus particularidades anatómicas en su tratamiento. Experiencia en una Unidad de Tumores musculoesqueléticos

Background and aimSoft tissue sarcomas are exceptionally located in the elbow region. The aim of this work was to study the soft tissue sarcomas of the elbow region, their epidemiological and histopathological characteristics, anatomical features, the treatment performed, and the results obtained, in a unit of musculoskeletal tumours. MethodsRetrospective review of ten patients with a mean follow-up of 65.0 ± 11.9 (range 21-132) months with soft tissue sarcomas located in the elbow region operated in our centre between 2008 and 2016. ResultsMean age was 60.8 ± 6.7 years. Undifferentiated pleomorphic sarcoma was the most frequent histological diagnosis. Limb preservation surgery was performed in 90% of patients. Three patients were previously operated without following surgical oncology guidelines in another hospital, and this was statistically related to the need for more than one surgery to control the disease. R1 margin was obtained in 5 patients and R0 in another 5. Adjuvant radiotherapy was used in 7 cases. In 4 patients, subsequent surgery was performed for local or systemic control of the disease. Local recurrence occurred in 3 cases and in 5 there was distant disease. ConclusionThe elbow region presents difficulty in achieving wide margins due to the proximity of neurovascular structures, adjuvant and / or neoadjuvant therapies could play an important role in performing limb preservation surgery. It would be advisable to refer these tumours to specialized units with multidisciplinary teams.

Is bone morphogenetic protein 2 effective, safe and cost-efficient in nonunion surgery of long bones

Background: The prevalence of fracture nonunion surgery is increasing in the general population with greater advancement in trauma surgery. Increasingly complex injuries involving the limbs are now amenable for limb preservation surgery, where in the past amputations would have been common place. Aims and Objectives: We carried out a literature review on the evidence available on the use of Bone Morphogenetic Protein 2 (BMP-2) for long bone nonunion surgery. Methods: This literature review was initially undertaken for a systematic review using PRISMA guidelines, however due to lack of high-quality published literature, we present a narrative review instead. The abstracts of the articles obtained on Medline and Embase database were scrutinised according to the inclusion and exclusion criterions. The primary endpoint was union rates, and secondary end points were time to union, re-operation and post op infection rates. Results: A total of 240 titles were obtained, and after review, 3 articles were selected for final analysis. There were no statistically significant differences noted between the primary and secondary endpoints in the autologous bone graft (ABG) group when compared against the BMP-2 with allograft group. An additional review of the literature suggests that BMP-2 is cost neutral to the healthcare system. Conclusion: Although no firm conclusions can be drawn due to lack of power, the trend suggests no significant difference in union rates between autograft or BMP-2 with allograft, with comparable results to each other in all measurable end-points.

Analysis of vascularized fibula graft integration to the extracorporeal irradiated bone after replantation: 2-year follow-up

Background: Major bone segmental defects in oncologic patients continue as a therapeutic challenge to orthopedic surgeons. The few alternatives for its management and the relationship between functional outcome and surgical complications remain among the main restrictions for the indication of different techniques. One of these alternatives is the vascularized fibular graft in association with the creation of a bone channel made from resection of the tumor bone segment after being submitted to the extracorporeal irradiation technique. There is little subject information about long-term follow-up either prospective than retrospective studies. Aim of the study: Retrospective evaluation of vascularized fibular graft union capacity from diaphysis and metaphysis and its integration to the irradiated bone after transplantation. Methods: Eleven patients submitted to extracorporeal irradiation technique and replantation with vascularized fibular graft had their radiographic images on 6, 12 and 24 months of postoperative period evaluated. Results: We observed 45,4% in diaphysis integration in the first year and 72,7% in the second year of follow-up, progressive in the diaphysis focus, and maintenance of the metaphysis focus (33,3%). Conclusion: The fibula has a good capacity for bone integration, showing less influence on the union of the metaphysis portion.Descriptors: Bone Transplantation; Osteosarcoma; Microsurgery; Surgical Oncology.ReferencesMyers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89(12):1632-37.Muscolo DL, Ayerza MA, Aponte-Tinao L, Farfalli G. Allograft reconstruction after sarcoma resection in children younger than 10 years old. Clin Orthop Relat Res. 2008;466(8):1856-62.Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br. 2012;94(7):982-88.Hong AM, Millington S, Ahern V, McCowage G, Boyle R, Tatersall M et al. Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients. Ann Oncol. 2013;24(10):2676-80.Manfrini M, Vanel D, De Paolis M, Malaguti C, Innocenti M, Ceruso M et al. Imaging of vascularized fibula autograft placed inside a massive allograft in reconstruction of lower limb bone tumors. AJR Am J Roentgenol. 2004;182(4):963-70.Spira E, Lubin E. Extracorporeal irradiation of bone tumor. A preliminary report. Isr J Med Sci. 1968;4(5):1015-19.Krieg AH, Davidson, AW, Stalley PD. Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery. J Bone Joint Surg Br. 2007;89(3):366-71.Ceruso M, Falcone C, Innocenti M, Delcroix L, Capanna R, Manfrini M. Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir. 2001;33(4):277-82.Ortiz-Cruz E, Gebhardt MC, Jennings LC, Springfield DS, Mankin HJ. The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study. J Bone Joint Surg Am. 1997;79(1):97-106.Farfalli GL, Aponte-Tinao L, Lopez-Millán L, Averza MA, Muscolo DL. Clinical and functional outcomes of tibial intercalary allografts after tumor resection. Orthopedics. 2012;35(3):e391-96.Aponte-Tinao L, Farfalli GL, Ritacco LE, Averza MA, Muscolo DL. Intercalary femur allografts are an acceptable alternative after tumor resection. Cln Orthop Relat Res. 2012;470(3):728-34.

IMPACT OF TREATMENT DELAYS IN EWINGS SARCOMA IN A LOW RESOURSE SETTING

Abstract Background Ewing’s sarcoma is the second most common primary malignant bone cancer in children and adolescents. Outcome of the children with Ewing sarcoma (ES) is worse in Low and Middle Income Countries (LMIC) compared to High Income Countries (HIC). In HIC only factor that had a significant impact on outcome was the presence of metastasis at presentation whereas treatment delay is a recognized factor contributing to poorer outcome evident by the studies especially done in LMIC. The situation in Sri Lanka has not been described before. We analyzed the clinical features and the impact of treatment delays on 5 year Event Free Survival (EFS) in Sri Lanka. Method All children with histologically proven Ewing sarcoma registered at the paediatric department from 01.01.2006 to 31.12.2011 were included. Demographic data, dates of first registration,chemotherapy, surgery, last contact and date of an event (Death, recurrence, progressive disease)were extracted from clinic records. EFS was calculated with Kaplan Meir curves and log rank test were used to calculate the level of significance. Results Out of 49 patients commonest site of presentation was leg (n = 19) followed by chest wall (n = 16). 10% had metastasis (n = 5) at presentation. 65% (n = 32) had surgery as local treatment (LT) and rest had radiotherapy while 4 defaulted treatment before LT. Out of extremity tumours only 21% (5/23) had limb preservation surgery. 5 year EFS in the entire cohort were 23.8%. Mean delay in neoadjuvant chemotherapy (NAC), LT and adjuvant chemotherapy (AC) were 6, 5.59 and 9.69 weeks respectively. NAC (p = 0.035) and LT(p = 0.004) delays significantly impacted EFS. Conclusions In spite of demographic and pathological data are similar to published data, 5 year EFS was is inferior to the accepted international standards. Delays in NAC and LT is the likely reason for inferior outcome.

IP215. Mature Radiocephalic Fistula as Conduit for Bypass of a Mycotic Common Femoral Artery Pseudoaneurysm: A Case Report

Mycotic common femoral artery pseudoaneurysms are a challenging entity with high morbidity. Surgical intervention has been described in intravenous drug abusers. Ligation of the infected pseudoaneurysm and revascularization often result in limb amputation or other complications. This case report describes the safety and efficacy of novel limb preservation surgery using an arteriovenous fistula as a robust conduit. A 59-year-old woman with history of end-stage renal disease, diabetes mellitus, and peripheral vascular disease presented status post cardiac catheterization with a right mycotic common femoral artery pseudoaneurysm measuring 2.3 × 1.8 × 2.3 cm. Preoperative vein mapping revealed no suitable superficial veins for graft harvesting, given the need to support a high-flow area. Blood culture specimens grew Pseudomonas aeruginosa, and antibiotics were initiated. Taking into account the need for permanent vascular access for dialysis in the future, deep veins were not harvested. The patient's radiocephalic fistula was created 6 months earlier and was functioning well as access for dialysis. A tunneled dialysis catheter was placed in preparation for ligation of the patient's fistula. During the procedure, the distal common iliac was exposed through a retroperitoneal approach with a longitudinal groin incision to expose the distal anastomosis site. The pseudoaneurysm was incised and oversewn. Proximal and distal anastomoses were made using the patient's arteriovenous fistula. The groin incision was closed with a sartorius muscle flap. On postoperative day (POD) 2, the patient developed a non-ST-segment elevation myocardial infarction, which was managed conservatively without further cardiac catheterization, and the patient was discharged on POD 6. On POD 16, the patient was readmitted for a groin abscess, which was treated with antibiotics and negative pressure wound therapy. No vascular or limb complications have been observed at the time of this report 2 months after the procedure. Infected pseudoaneurysms in drug abusers involving the common femoral artery have previously been treated with ligation and excision of the pseudoaneurysm with autogenous vascular reconstruction. No deaths were reported in this cohort, but patients who underwent ligation and excision only experienced significant claudication, and 33% resulted in amputation of the limb. We wished to avoid the likely complication of lower extremity amputation if our patient's pseudoaneurysm was treated with conventional methods. Prosthetic grafts would have been inappropriate with active Pseudomonas infection. Use of a mature, patent arteriovenous fistula graft as a conduit for bypass of a common femoral artery pseudoaneurysm appears to be a safe and effective option for revascularization.

Case Report: Use Of Structural Bone Allograft In Giant Cell Tumor Of The Femur

BACKGROUND: Bone giant cell tumor (GCT) is one of the least frequent, most controversial and least predictable tumors in its behavior. We present a case of GCT in the lower limb, which implied the distal femur. The diagnosis required a previous biopsy before proceeding with its en bloc resection, and treatment based on bone allograft. CASE REPORT: Male patient of 43 years of age, mestizo, with no relevant personal or family history. He went to the oncology orthopedics outpatient clinic for presenting a hard and painful mass with gradual increase in size at the level of the right knee, deformity, functional limitation and crepitus in that region, which is why he attends his assessment. EVOLUTION: The patient underwent a lesion biopsy at the level of the distal femur with a pathological anatomy report of giant cell tumor. Bone resection was performed at the tumor level and treatment was performed by allografting the bone structural allograft. A 2-year follow-up was performed and a score of 14/15 according to the Makin scale was obtained as functional results. Osteointegration of the graft to autogenous bone was also evidenced. Excellently at 15 months. We did not find infection, graft resorption or fatigue of the material. CONCLUSIONS: Limb preservation surgery represented by structural allografts is a favorable technique with adequate functionality and osteoingration, increasing the life expectancy of our patients and future revision possibilities. Avoiding amputations, arthrodesis or tumor prosthesis whose cost benefit with the subsequent years end up being high and deteriorating the quality of life in the patient.