Mean Musculoskeletal Tumor Society Score Research Articles

Revision surgery for periprosthetic fracture of distal femur after endoprosthetic replacement of knee joint following resection of osteosarcoma.

Periprosthetic fracture (PPF) is one of the severe complications in patients with osteosarcoma and carries the risk of limb loss. This study describes the characteristics, treatment strategies, and outcomes of this complication. Patients were consecutively included who were treated at our institution between 2016 and 2020 with a PPF of distal femur. The treatment strategies included two types: 1) open reduction and internal fixation with plates and screws and 2) replacement with long-stem endoprosthesis and reinforcement with wire rope if necessary. A total of 11 patients (mean age 12.2 years (9-14)) were included, and the mean follow-up period was 36.5 (21-54) months. Most fractures were caused by direct or indirect trauma (n = 8), and others (n = 3) underwent PPF without obvious cause. The first type of treatment was performed on four patients, and the second type was performed on seven patients. The mean Musculoskeletal Tumor Society (MSTS) score was 20 (17-23). All patients recovered from the complication, and limb preservation could be achieved. PPF is a big challenge for musculoskeletal oncologists, particularly in younger patients. Additionally, PPF poses a challenge for orthopedic surgeons, as limb preservation should be an important goal. Hence, internal fixation with plates and endoprosthetic replacement are optional treatment strategies based on fracture type and patient needs.

Does the intercondylar approach provide a better outcome for chondroblastoma of the distal femur in skeletally immature patients?

The epiphyseal approach to a chondroblastoma of the intercondylar notch of a child's distal femur does not provide adequate exposure, thereby necessitating the removal of a substantial amount of unaffected bone to expose the lesion. In this study, we compared the functional outcomes, local recurrence, and surgical complications of treating a chondroblastoma of the distal femoral epiphysis by either an intercondylar or an epiphyseal approach. A total of 30 children with a chondroblastoma of the distal femur who had been treated by intraregional curettage and bone grafting were retrospectively reviewed. An intercondylar approach was used in 16 patients (group A) and an epiphyseal approach in 14 (group B). Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system and Sailhan's functional criteria. At final follow-up, the mean MSTS score was 29.1 (SD 0.9) in group A and 26.7 (SD 1.5) in group B (p = 0.006). According to Sailhan's criteria, the knee function was good and fair in 14 (87.5%) and two (12.5%) patients of group A, and eight (57.1%) and six (42.9%) patients of group B, respectively (p = 0.062). The lesion had recurred in one patient (6.2%) in group A and four patients (28.6%) in group B. Limb shortening > 1 cm was recorded in one patient (6.2%) from group A and six patients (42.8%) from group B. Joint degeneration was noted in one patient from group A and three patients from group B. An intercondylar approach to a chondroblastoma of the middle two-quarters of the distal femoral epiphysis results in better outcomes than a medial or lateral epiphyseal approach: specifically, better limb function, a lower rate of recurrence, and a lower rate of physeal damage and joint degeneration.

An innovative staged prosthetic lengthening reconstruction strategy for osteosarcoma-related leg discrepancy

Correction of leg length discrepancy (LLD) in skeletally mature patients with osteosarcoma was rarely reported and quite challenging. This study aimed to propose a treatment strategy of staged lengthening and reconstruction with a standard static prosthesis to address LLD and restore limb function. It also evaluated the effectiveness of the strategy in terms of leg lengthening, functional outcomes, and complications. The strategy for lengthening included three stages. In stage 1, the previous prosthesis was removed and an external fixator with a temporary rod-cement spacer was placed. In this stage, the external fixator was used to lengthen the limb to the appropriate length. In stage 2, the external fixator was removed and the old rod-cement spacer was replaced with a new one. In stage 3, the rod-cement spacer was removed and the standard static prosthesis was planted. Nine skeletally mature distal femoral osteosarcoma patients with unacceptable LLD were treated in our institution from 2019 to 2021. We performed a chart review on nine patients for the clinical and radiographic assessment of functional outcomes, LLD, and complications. The mean (range) leg lengthening was 7.3 cm (3.6–15.6). The mean (range) LLD of the lower limbs decreased from 7.6 cm (4.1–14.2) before the lengthening to 0.3 cm (− 0.3 to 2.1) at the final follow-up with statistical significance (P = 0.000). The mean (range) Musculoskeletal Tumor Society score improved from 30.3% (16.7%–53.3%) before the lengthening to 96.3% (86.7%–100%) at the final follow-up with statistical significance (P = 0.000). Three patients (33.3%) had a minor complication; none needed additional surgical intervention. In the short term, the current staged lengthening and reconstruction with standard static prosthesis provided satisfactory functional outcomes and LLD correction with few complications. The long-term effects of this method need further exploration.

Outcomes of Megaprosthesis ‎Reconstruction for the Salvage of ‎Failed Osteoarticular Allograft ‎‎Around the Knee implanted before ‎Skeletal Maturity in Primary Bone ‎Sarcoma: A Case-Series.

Functional expectations following the salvage of a failed osteoarticular allograft are poorly described. In this study, we aim to evaluate functional outcomes, implant survival, and complications of the megaprosthesis in salvaging a failed osteoarticular allograft around the knee. We retrospectively reviewed the medical profiles of 21 skeletally mature patients who underwent megaprosthesis reconstruction to salvage a failed osteoarticular allograft around the knee implanted before skeletal maturity. The location of reconstruction was the proximal tibia in 13 patients and the distal femur in eight patients. Knee function was evaluated by the Musculoskeletal Tumor Society (MSTS) ‎score and the Toronto Extremity Salvage Score (TESS). The mean age of patients was 16±1.7 years. The mean interval between the primary (allograft) and secondary (megaprosthesis) reconstructions was 59.4±23.6 months. At an average follow-up of 51.2 months, the mean knee range of motion was 101.2±15.6°. The mean MSTS score and TESS were 83.6±7 and 86.6±7.9, respectively. The mean limb length discrepancy was 2.5±1 cm before and 0.36±0.74 cm after the operation (P<0.001). Six postoperative complications (28.6%) occurred in this series, including one wound dehiscence, one periprosthetic fracture, two acute infections, one aseptic loosening, and one delayed periprosthetic infection. Only the last two complications required revision. Accordingly, the two- and five-year implant survivals were 95.7% and 90%, respectively. Megaprosthesis is a viable option for salvaging failed osteoarticular allografts around the knee. It also provides the opportunity to correct the limb length discrepancy.

Complications and Outcome of Bone Sarcoma Patients with Limb Salvage using Liquid Nitrogen-treated Bone for Reconstruction.

The recommended treatment method for bone sarcoma is wide local excision and reconstruction to preserve limb function. Established methods of reconstruction are mega prosthesis or biological reconstruction. This study aimed to determine the complications and functional outcomes associated with limb salvage surgery using liquid nitrogen-treated bone. We retrospectively observed the short-term outcome of limb salvage surgeries where liquid nitrogen bone was used for reconstruction. A total of 15 patients underwent reconstruction with liquid nitrogen auto graft from January 2018 to December 2020. We used the free freezing method of liquid nitrogen treatment after wide local excision of sarcoma. We observed short-term outcomes after liquid nitrogen-treated bone reconstruction in limb salvage surgery. Survival of the auto grafts was recorded using the Kaplan-Meier method with a 95% confidence interval. The mean follow-up was 19.83 ± 4.5 months. The mean musculoskeletal tumor society score was 62.4 ± 7.9%, while the average Toronto extremity score was 59.6 ± 5.7%. Three patients died during the study duration due to visceral metastasis. Skin necrosis and wound breakdown were major complications in 9 (60%) patients. Deep infection was observed in 4 (26.7%). Similarly, 4 (26.7%) patients had non-union at either the proximal or distal osteotomy site, while the average time of bone union in the rest of the patients was 6.3 ± 1.7 months. A total of 6 (40%) patients underwent reoperation after liquid nitrogen treatment, either due to infection or non-union at the osteotomy site. Recurrence was observed in 3 (20%) of patients. We observed a high complication rate with liquid nitrogen-treated autograft reconstruction. Vascularized fibula with liquid nitrogen-treated autograft or endoprosthesis should be encouraged.

Reconstruction following oncological iliosacral resection.

The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19). Overall, 27 patients (45%) were reconstructed, while 33 (55%) had no formal reconstruction. There was no difference in the use of chemotherapy (p = 1.000) or radiotherapy (p = 0.292) between the groups. Patients with no reconstruction had a mean larger tumour (11 cm (SD 5) vs 8 cm (SD 4); p = 0.014), mean shorter operating times (664 mins (SD 195) vs 1,324 mins (SD 381); p = 0.012), and required fewer blood units (8 (SD 7) vs 14 (SD 11); p = 0.012). Patients undergoing a reconstruction were more likely to have a deep infection (48% vs 12%; p = 0.003). Nine reconstructed patients had a hardware failure, with five requiring revision. Postoperatively 55 (92%) patients were ambulatory, with no difference in the proportion of ambulatory patients (89% vs 94%; p = 0.649) or mean Musculoskeletal Tumor Society Score (59% vs 65%; p = 0.349) score between patients who did or did not have a reconstruction. The ten-year disease-specific survival was 69%, with no difference between patients who were reconstructed and those who were not (78% vs 45%; p = 0.316). There was no difference in the rate of metastasis between the two groups (hazard ratio (HR) 2.78; p = 0.102). Our results demonstrate that SIJ reconstruction is associated with longer operating times, greater need for blood transfusion, and more postoperative infections, without any improvement in functional outcomes when compared to patients who did not have formal SIJ reconstruction.

Oncological and functional outcomes after resection of malignant tumours of the scapula.

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification. The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05). Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence.

Outcomes of proximal humeral reconstruction with cemented osteoarticular allograft in pediatric patients: a retrospective cohort study.

There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft. Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88±31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records. Mean active forward flexion of the shoulder was 38°±18°. Mean active abduction was 48°±18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4%±11.2%. The mean Toronto Extremity Salvage Score was 75.6%±12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal. In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques.

Reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection: case series

Giant cell tumor of bone (GCTB) (Campanacci III) or malignant tumors extend to the epiphyseal region, and intra-articular resection of the proximal radius is often needed. In the present study, we present the patients who underwent reconstruction of the proximal radius with 3D-printed personalized prosthesis after tumor resection, aiming to describe the prosthesis design and surgical technique and evaluate the clinical outcomes of this method. Between November 2018 and January 2021, nine patients received radial hemiarthroplasty with 3D-printed personalized prostheses after tumor resection. The pathological diagnosis was GCTB (Campanacci III) in seven patients, osteosarcoma (IIB) in one patient, and synovial sarcoma (IIB) in one patient. The range of motion (ROM) and strength in terms of elbow flexion/extension and forearm supination/pronation were evaluated. Pain was assessed by the visual analog scale (VAS) preoperatively and at each follow-up visit. To evaluate the functional outcome, the Mayo Elbow Performance Score (MEPS) system and the Musculoskeletal Tumor Society (MSTS) scoring system were administered at each follow-up visit. Complications and oncological outcomes were recorded. The patients were followed from 24 to 51 months, with a median follow-up of 35 months. No patients were lost to follow-up. During the follow-up, local recurrence and metastasis were not observed. The VAS score improved from a median of 5 points (range 4 to 7) preoperatively to 1 point (range 0 to 2) at the last follow-up visit. The mean MEPS score was 88.5% (83 to 93), and the mean MSTS score was 25.3 (24 to 27) at the last follow-up visit. No complications such as infection and aseptic loosening were detected. The implantation of a 3D-printed personalized prosthesis after proximal radial resection showed excellent oncologic outcomes and postoperative function at short-term follow-up and is a viable alternative method for reconstruction of the proximal radius bone defect after tumor resection.

Cemented K-wire external fixation in juxta-articular enchondroma-related phalangeal pathological fracture

PurposeThis study aimed to introduce a technique of external fixation using a combination of bone cement and K-wires, to treat pathological fractures related to solitary digital enchondroma close to the finger joints. MethodsFrom October 2015 to January 2021, 21 patients (8 males and 13 females) with acute pathological fracture due to solitary digital enchondroma close to the finger joints were treated with cemented K-wire external fixators. Mean age was 32 (19–51) years. The digits involved were the index (n = 4), long (n = 4), ring (n = 6), and little (n = 7) fingers. Time to bone healing and complications were assessed. At final follow-up, active range of motion, grip strength and key pinch strength of the tumor-involved and contralateral healthy digits were measured and compared. Functional outcomes were evaluated on Takigawa criteria. Pain was measured on a 10-cm visual analog scale. We assessed the affected upper extremity on the Musculoskeletal Tumor Society score questionnaire. ResultsMean bone healing time was 5.5 (4–8) weeks. Pin site infection was observed in 1 patient and cured with dressing changes. Mean follow-up was 34 months, with no recurrences or refractures. Mean active range of motion of the proximal interphalangeal joint, grip and key pinch strength of the involved digits reached 92%, 97%, and 99% of the contralateral digits, respectively. On Takigawa criteria, 20 functional results were excellent and 1 good. Mean pain score was 1 (0–3) cm. Mean Musculoskeletal Tumor Society score was 95 (80–100). ConclusionThe combination of bone cement and K-wires is a reliable technique for pathological fracture related to solitary enchondroma close to the joints of the digits, leading to good functional outcomes. Level of evidenceTherapeutic study, Level IVa.

Durability of intercalary endoprosthesis for humeral reconstruction.

The humerus is a common site of metastases and primary tumors. For some patients with a segmental defect and/or diaphyseal cortical destruction a cemented intercalary device may provide a more reliable construct, however data on their use is limited. We reviewed 43 (28 male and 15 female) patients treated with an intercalary humeral spacer at a single tertiary referral center between 1989 and 2022. Humeral lesions were most commonly secondary to metastatic disease (n = 29, 68%), with 25 (58%) patients presenting with a pathologic fracture. Mean age and body mass index were 66 years and 27.9 kg/m2 . First generation taper joint device were used in 22 patients and second-generation lap device in 21 patients. Following reconstruction the 2-year overall survival was 30%. Mechanical complications occurred in 11 patients, most commonly aseptic loosening (n = 6, 14%). With death as a competing risk, the cumulative incidence of mechanical failure was 28% at 2-years postoperative. Following the procedure, mean Musculoskeletal Tumor Society scores was 70% and mean shoulder elevation was 87°. Reconstruction of the humeral diaphysis with an intercalary endoprosthesis provides restoration of function of the upper extremity, however, is associated with one in four patients having mechanical failure.

Distal Tibia Endoprosthesis Reconstruction after Resection of Aggressive Bone Tumors: Is it a Reliable Treatment Option?

Introduction: Primary bone tumours of the distal tibia are rare, and amputation was the treatment of choice in the past. Custom-made endoprosthesis reconstruction of the distal tibia has become a viable option in selected patients as a form of limb salvage for better function and cosmesis. It provides similar functional outcomes to below-knee amputation with a below-knee prosthesis. We investigated our cases' reliability, functional and oncological outcomes with distal tibia endoprosthesis reconstruction done for aggressive bone tumours. Methods: This is a retrospective review of 10 patients who underwent distal tibia endoprosthesis reconstruction at our centre from December 2007 to December 2021. This study aims to determine the clinical, oncological and functional outcomes using the Musculoskeletal Tumor Society (MSTS) Score and Toronto Extremity Salvage Score (TESS) and the survivorship of these implants. Results: The mean age of our patients is 29 years (range 12 to 53), with 60% males. The mean follow-up was 39.3 months (range 12 to 112). 50% of our cases were giant cell tumour of bone, 20% were osteosarcoma, and 10% were ewing’s, PVNS and pleomorphic sarcoma of the bone, respectively. Two patients passed away from advanced disease, where one was associated with local recurrence. The other case with local recurrence developed an acute infection post-resection of the recurrence. The infection resolved after repeated debridement and free muscle transfer. One patient had septic loosening of the implant and underwent below-knee amputation. Two-thirds of the patients remained disease free. The mean MSTS score for the 9 patients during their last follow-up is 87.8% (range 73.3 to 100). The mean TESS score for the 6 patients during their last follow-up is 84.4% (range 69.2 to 100). Conclusion: Our study concludes that distal tibia endoprosthesis reconstruction is a reliable treatment option for aggressive bone tumours and provides good function outcomes.

A 3D-printed patient-specific modular implants for pelvic reconstruction of bone tumors involving the sacroiliac joint.

Background: Current reconstruction methods of the pelvic ring after extensive resection of tumors involving the sacroiliac joint have a high incidence of failure. We aimed to study the effect of 3D-printed patient-specific implant reconstruction to show that this method is stable and has a low risk of failure. Methods: Between February 2017 and November 2021, six patients with bone tumors involving the sacroiliac joint (Enneking I + IV) who received 3D-printed patient-specific implants for pelvic reconstructive surgery were retrospectively analyzed. Two female and four male patients with a mean age of 41.83years (range 25-65years) were included. Two were osteosarcomas, two chondrosarcomas, one malignant fibrous histiocytoma, and one giant cell tumor of bone. For each patient, preoperative osteotomy guides were designed to ensure accurate tumor resection and individualized prostheses were designed to ensure a perfect fit of the bone defect. General, oncologic, and functional outcomes, implant status, and complications were retrospectively analyzed. The Visual Analog Scale (VAS) was used to assess pain and the Musculoskeletal Tumor Society (MSTS) score was used to assess hip function. Osseointegration was assessed by CT. Results: According to the preoperative design, complete resection of the entire tumor and reconstruction with a custom 3D-printed sacroiliac joint implant was completed without perioperative severe complications or deaths. Relatively satisfactory surgical margins were achieved. The mean operative time and intraoperative blood loss were 495min (420-600min) and 2533.33mL (range, 1,200-3,500mL), respectively. The mean follow-up was 49.83months (range, 18-75months). At the last follow-up, all four patients were disease-free, and the two patients who developed lung metastases were alive with tumors. All patients could walk unassisted. The mean VAS was 1.33 (range, 0-2). The mean MSTS score was 25.33 (range, 24-27). CT showed complete osseointegration of the implant to the ilium and sacrum. Conclusion: The 3D-printed custom prosthesis can effectively reconstruct pelvic stability after total sacroiliac joint resection with satisfactory clinical results.

Ten-year retrospect of the investigation of proximal limbs metastasis in cancer: a multi-center study on survival outcome, limb function status and surgical procedures analysis

BackgroundThe aim of study was to evaluate survival outcome and limb function in cancer patients with proximal limbs metastasis. Associated factors on survival outcome and limb function were identified. The comparative analysis between intramedullary nailing and prosthesis surgery in cancer patients with proximal limb metastasis was performed.MethodsIn this five-center retrospective study, patients diagnosed with limbs metastasis were collected. Descriptive statistics was used and log-rank test was performed to analyze the survival in subgroups. The Cox proportional hazards regression analysis was performed to identify the independent prognostic factors. The Musculoskeletal Tumor Society (MSTS) scoring system was used to evaluate limb function after surgery, and t test or analysis of variance (ANOVA) was utilized in subgroup analysis.ResultsA total of 316 patients with limb metastasis were included with mean age at 61.0 years. The most common primary tumor was breast, followed by renal cancer and lung cancer. The median overall survival was 24.0 months and the 1-, 3- and 5-year survival rates were 86.9%, 34.7% and 6.8%, respectively. Primary tumor type, visceral metastasis and chemotherapy were proved to be the independent prognostic factors. The mean Musculoskeletal Tumor Society (MSTS) score was 20.5, significant difference was observed in subgroup of solitary/multiple bone metastasis, with/without pathological fracture, and type of surgery.ConclusionThe present study concluded that primary tumor type, visceral metastasis and chemotherapy were three factors affecting the survival of patients. Compared with intramedullary nailing, the patients underwent prosthesis surgery showed better limb function, this procedure should be encouraged in patients with indication.

Limb-sparing resection of axillary soft tissue sarcomas

For patients with soft tissue sarcoma, surgical resection is akey element of curative therapy. Surgery is performed as awide resection with microscopically negative margins (R0resection) and as limb-sparing procedure whenever possible to preserve maximum function. Soft tissue sarcoma, metastases. Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care. Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus. Shoulder abduction brace for 6weeks, passive mobilization for 6-12weeks followed by active mobilization. Compression sleeve. Oncological follow-up. Between 2017 and 2022, wide resection was performed in 6consecutive cases including 4 primary soft tissue sarcomas and 2metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5months (3-60months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.

Intramedullary Nailing with and without the Use of Bone Cement for Impending and Pathologic Fractures of the Humerus in Multiple Myeloma and Metastatic Disease.

Although intramedullary nailing (IMN) is considered the standard of care for the surgical management of most femur metastatic diseases, the optimal treatment of metastatic humeral impending and/or pathologic fractures is still debatable. Moreover, the use of cemented humeral nails has not been thoroughly studied, and only a few small series have compared their results with uncemented nails. The purpose of this study was to compare the (1) survivorship, (2) functional outcomes, and (3) perioperative complications in patients receiving cemented versus uncemented humerus IMN for impending or complete pathologic fractures resulting from metastatic disease or multiple myeloma. We retrospectively reviewed 100 IMNs in 82 patients, of which 53 were cemented and 47 were uncemented. With a mean survival of 10 months (Cemented: 8.3 months vs. Uncemented: 11.6 months, p = 0.34), the mean Musculoskeletal Tumor Society (MSTS) scores increased from 42.4% preoperatively (Cemented: 40.2% vs. Uncemented: 66.7%, p = 0.01) to 89.2% at 3 months postoperatively (Cemented: 89.8% vs. Uncemented: 90.9%, p = 0.72) for the overall group (p < 0.001). Both cohorts yielded comparable complication rates (overall [22.6% vs. 19.1%)], surgical ([11.3% vs. 4.3%], and medical [13.2% vs. 14.9%], all p > 0.05), but estimated blood loss was significantly higher in the cemented group (203 mL vs. 126 mL, p = 0.003). Thus, intramedullary nailing, with and without cement augmentation in select patients, is a relatively safe and effective therapeutic modality for metastatic humeral disease with similar clinical outcomes and acceptable complication rates. While controlling for possible selection bias, larger-scale, higher-level studies are warranted to validate our results.

Outcome of Limb Salvaging Procedure for Bone Tumor Using Liquid Nitrogen Technique: A Case Series of 21 Patients

Abstract Introduction and importance: Autologous bone graft treated with liquid nitrogen is an option for biological reconstruction of bone defects in patients receiving tumor resection. This is the first report in Hong Kong on the outcome of this biological reconstruction in terms of functional outcome, local recurrence rate, and prognosis. Case presentation: From 2015 to 2021, 21 patients with bone tumor resection and reconstruction using liquid nitrogen treated autologous bone graft were recruited. The medical records and radiological images were retrieved for retrospective review. After delivery of the specimen, all the soft tissue of the excised bone was removed at the back table before cryotherapy. The auto graft was immersed in liquid nitrogen for 20 minutes, and thawed at room temperature for 10 minutes. After that the autograft was immersed in distilled water for 15 minutes before being incorporated into the reconstruction. All of them were followed up for at least one year post-operation. Clinical discussion: The mean union time was 13.3 months (from 4 to 31 months). The mean Musculoskeletal Tumor Society (MSTS) score was 22.6 (from 12 to 30). The mean follow up time was 38.2 months (from 12 to 64 months). There were two local soft tissue recurrences and one local recurrence from host bone. Conclusion: Autologous bone graft treated with liquid nitrogen is a safe option for biological reconstruction of bone defects after tumor resection. It provides satisfactory outcomes with low local recurrence rate, as well as comparable complications with other reconstruction methods.

A Retrospective Study of the Functional Outcomes in Patients with Proximal Humeral Bone Defect after Shoulder Fusion or Prosthetic Replacement.

The reconstruction of proximal humeral defects resulting from tumor resection is challenging. The purpose of this work was to retrospectively study the functional outcomes in patients with large bone defects after the resection of proximal humeral tumors. We performed a retrospective analysis of 49 patients with malignant or aggressive benign tumors in the proximal humerus at our institution between 2010 and 2021. Forty-nine patients were included in the study (prosthetic replacement, n = 27; shoulder arthrodesis, n = 22). The mean follow-up was 52.8 months (range, 14-129 months). The factors evaluated included the Musculoskeletal Tumor Society (MSTS) functional score, Constant Murley Score (CMS), and complications. Of the 49 patients enrolled in the study, 35 were disease-free by the time of the latest follow-up, and 14 died because of the disease. Adjuvant therapies and medical comorbidities were similar between the two groups. Osteosarcoma was the most common abnormality among all the patients. The mean MSTS scores for surviving patients in the prosthesis and arthrodesis groups were 57.4% and 80.9%, respectively. The mean CMS score for the surviving patients in the prosthesis group was 43.47, and it was 61.44 for arthrodesis cases. Patients with shoulder arthrodesis demonstrated evidence of bony union at a mean of 4.5 months. Shoulder arthrodesis is a reliable reconstructive procedure in patients with large bone defects after the resection of proximal humeral tumors for pediatric osteosarcoma patients. Moreover, prosthetic replacement with anatomical implants results in poor function in older metastasis patients with large bone defects and resection of the deltoid muscle.

Incidence and progression of osteoarthritis following curettage and cementation of giant cell tumor of bone around the knee: long-term follow-up

BackgroundGiant cell tumor of bone (GCTB) is a benign locally aggressive tumor frequently treated with intralesional curettage and cementation. The aim of this study was to investigate the long-term incidence of arthritic changes following curettage and cementation of GCTB around the knee.Materials and methodsThis study was a retrospective review of patients with GCTB around the knee treated with curettage and cementation with a minimum follow-up of 10 years. The functional results were assessed using the Musculoskeletal Tumor Society (MSTS) score. The arthritic changes were classified using the Kellgren–Lawrence (KL) classification system of osteoarthritis.ResultsThis study included 119 patients, 54 males and 65 females, with a mean age of 29.4 ± 9.2 years. There were 35 (29.4%) patients with pathological fractures. There were 84 (70.6%) patients with de novo lesions and 35 (29.4%) with recurrent lesions. The mean follow-up period was 13.2 ± 3.16 years. The mean MSTS score was 28.5 ± 1.9. Overall, 25 (21%) patients developed variable degrees of arthritis of KL grade 1 (n = 7), KL grade 2 (n = 11), KL grade 3 (n = 4), and KL grade 4 (n = 3). Ten patients showed progression of arthritis during the follow-up period. Age at presentation, gender, presence of pathological fracture, whether the tumor was de novo or recurrent, and tumor location were not associated with arthritis incidence.ConclusionsCurettage and cementation can be used safely to treat GCTB around the knee. Arthritis of the knee is a possible complication, but mild grades are expected in most cases. There was no association between arthritis incidence and age, gender, pathological fractures, tumor location, or recurrent tumors.Level of evidenceLevel IV.

Improved functional status in patients undergoing cement and rebar reconstruction with total hip arthroplasty for uncontained metastatic tumors of the acetabulum.

Metastatic cancer of the acetabulum can produce marked pain and disability for patients. Several reconstruction techniques for such lesions have been described, with variable outcomes. The purpose of this study was to determine functional outcomes and complication rate for patients undergoing cement rebar reconstruction using posterior column screws with total hip arthroplasty for large, uncontained lesions of the acetabulum. Twenty-two consecutive patients who underwent cement rebar reconstruction with posterior column screws and total hip arthroplasty for metastatic tumors of the acetabulum between 2014 and 2017 were identified. All cases were reviewed for patient demographics, surgical parameters, implant survival, complications, and functional status following these procedures. There was a significant increase in the proportion of patients able to ambulate post-surgery (95.5%) compared withpresurgery (22.7%) (p < 0.001). Mean musculoskeletal tumor society score postoperatively was 17.9 (60%). Average operative time was 174 min and average estimated blood loss was 689 mL. Seven patients required an intraoperative or postoperative blood transfusion. Three patients had postoperative complications (14%), two of whom required revision (9%). Reconstruction using cement rebar with posterior column screws and total hip arthroplasty is a safe, reproducible approach that may greatly improve functional outcomes with a low rate of intraoperative or postoperative complications.