Musculoskeletal Tumor Society Rating Scale Research Articles

Aneurysmal bone cyst of the greater trochanter: evaluation of surgical outcome of 17 cases

Background: Aneurysmal bone cyst is a benign, aggressive lesion that occurs in childhood and early adulthood. It usually affects the metaphysis of long bones. The aims of this study were to report clinical and radiological outcome following operative treatment of aneurysmal bone cyst of greater trochanter of femur and asses functional outcome by the Musculoskeletal Tumour Society (MSTS) Rating scale for the lower extremity. Methods: This Quasi-experimental study included 17 patients radiologically and histologically diagnosed as having aneurysmal bone cyst involving the greater trochanter of femur from 2015 to 2022. All cases were curetted, chemical cauterization with 5% phenol done and autogenous cortico-cancellous bone graft were added to fill the osseous defect. The patients were followed-up at 6 weeks and then 3 monthly for 1st year, 6 monthly for 2nd and 3rd year and yearly thereafter. In each follow-up, the recurrence, post-operative complications were documented and MSTS scoring was done. Results: The mean age of the patients were 14.5 years; 9 (53%) were female and 8 (47%) were male. The mean follow-up period for the patients was 3.6 years. There were 3 (18%) recurrences and 2 (11.8%) cases developed superficial surgical site infection. The average MSTS score on final follow-up was 22.6. Conclusion: Aneurysmal bone cyst of the greater trochanter is common in second decade among females. Treatment with extended intralesional curettage, chemical cauterization with 5% phenol and application of autogenous bone graft has less than 18% chance of recurrence. Furthermore, there is acceptable radiological bone graft incorporation and average MSTS score on final follow-up suggest a good functional outcome. BIRDEM Med J 2024; 14(3): 124-130

Moderately hypofractionated, preoperative radiotherapy in patients with soft tissue sarcomas (HYPORT-STS): Updated local control, late toxicities, and patient-reported outcomes.

Moderately hypofractionated, preoperative radiotherapy in patients with soft tissue sarcomas (HYPORT-STS; ClinicalTrials.gov identifier NCT03819985) investigated a radiobiologically equivalent, moderately hypofractionated course of preoperative radiotherapy (RT) 15×2.85 Gy in patients with soft tissue sarcoma (STS). Here, the authors report longer term follow-up to update local control and report late toxicities, as well as functional and patient-reported outcomes. HYPORT-STS was a single-center, open-label, single-arm, prospective phase 2 clinical trial that enrolled 120 eligible adult patients with localized STS of the extremities or superficial trunk between 2018 and 2021. Patients received a 3-week course of preoperative RT followed by surgery 4-8 weeks later. End points and follow-up were analyzed from the date of surgery. The median follow-up was 43 months (interquartile range, 37-52 months), and the 4-year local recurrence-free survival rate was 93%. Overall RT-related late toxicities improved with time from local therapy (p<.001), and few patients had grade ≥2 toxicities (9%; n=8 of 88) at 2 years. These included: 2% grade ≥2 skin toxicity, 2% fibrosis, 3% lymphedema, and 1% joint stiffness. Four patients (3%) had bone fractures. Both functional outcomes, as measured by the Musculoskeletal Tumor Society Rating Scale (p<.001), and quality of life, as measured by the Functional Assessment of Cancer Therapy-General (p<.001), improved with time from treatment, and both measures were better in follow-up at 2 years compared with baseline. Long-term follow up suggests that moderately hypofractionated preoperative RT for patients with STS is safe and effective. Higher grade late toxicities affect a minority of patients. Late toxicities decrease over time, whereas functional outcomes and health-related quality of life seem to improve with more time from combined modality treatment.

Results of resection of forearm soft tissue sarcoma

PurposeSoft tissue sarcomas (STS) of the forearm are rare. We aim to assess their oncological and functional outcomes.MethodsWe retrospectively evaluated 34 patients who underwent surgical excision for forearm STS at our institution between 1993 and 2020. We analyzed postoperative Musculoskeletal Tumor Society rating scale (MSTS) and local recurrence-free survival (LRFS), metastasis-free survival, and overall survival (OS) rates. The significance of the following variables was determined: age, sex, histology, tumor size, Fédération Nationale des Centres de Lutte contre le Cancer grade, American Joint Committee on Cancer stage, surgical margin, unplanned excision, metastases upon initial presentation, receipt of chemotherapy, and radiotherapy (RT).ResultsThe postoperative median MSTS score was 28. Bone resection or major nerve palsy was the only factor that influenced MSTS scores. The median MSTS scores in patients with or without bone resection or major nerve palsy were 24 and 29, respectively (P < 0.001). The 5-year LRFS rates was 87%. Univariate analysis revealed that the histological diagnosis of myxofibrosarcoma was the only factor that influenced LRFS (P = 0.047). The 5-year MFS rates was 71%. In univariate analysis, no factors were associated with MFS. The 5-year OS rates was 79%. Age was the only factor that influenced OS (P = 0.01).ConclusionIn the treatment of forearm STS, reconstruction of the skin and tendon can compensate for function, while bone resection and major nerve disturbance cannot. Careful follow-up is important, especially in patients with myxofibrosarcoma, due to its likelihood of local recurrence.

Preserving the rectus femoris and improving limb function after total femoral prosthesis replacement following resection of femoral malignant tumors.

Current research is focused on the factors that influence the maintenance of limb function after total femoral replacement. This retrospective study investigated the difference in functional outcomes in patients with invasion of the rectus femoris vs. an intact rectus femoris that underwent total femoral replacement with a modular total femur prosthesis. The medical records of patients who underwent total femoral replacement with a modular total femur prosthesis between July 2010 and March 2017 at our institute were retrospectively reviewed. The patients were divided into two groups: group A had invasion of the rectus femoris and group B had an intact rectus femoris. Functional status was assessed using the Musculoskeletal Tumor Society Rating Scale (MSTS) and the Harris Hip Score (HHS). Complications were assessed using the International Society of Limb Salvage classification that was published in 2011 and modified in 2014. The mean total MSTS score (23.0 ± 4.8 vs. 17.6 ± 3.1; P = 0.02) and the mean total HHS score (80.17 ± 6.24 vs. 55.38 ± 13.30; P = 0.001) were significantly higher in patients with intact rectus femoris compared with patients with invasion of the rectus femoris. Patients with an intact rectus femoris achieved significantly better limb function (support and gait) and active range of motion (P < 0.05). The overall complication rate was 35.7%. Functional outcomes after total femoral replacement were significantly better in patients with an intact rectus femoris compared with patients with invasion of the rectus femoris, possibly because more muscle mass can be preserved around the femur in patients with an intact rectus femoris.

French translation and validation of the cross-cultural adaptation of the MSTS functional assessment questionnaire completed after tumor surgery

IntroductionMalignant tumors of the extremities are uncommon. Their surgical treatment, whether conservative or not, may cause sequelae. Functional assessment of patients is essential for research purposes, but also follow-ups and adaptation of treatments. The Musculoskeletal Tumor Society Rating Scale (MSTS) is a disease-specific functional scoring system often used in English literature. Currently, no studies have been published on a valid French translation of the MSTS, whether for the lower or upper extremities. We, therefore, conducted a prospective study to answer the following questions: (1) Are the proposed adapted French versions of the MSTS valid? (2) Do the psychometric properties of the two versions obtained make their use relevant? Materials and methodsThe translation and cross-cultural adaptation were carried out following the recommendations of Beaton and Guillemin to obtain two versions: one for patients who had undergone upper extremity surgery (MSTS-UE) and one for those who had undergone lower extremity surgery (MSTS-LE). A prospective multicenter cohort study was then carried out to analyze the psychometric properties of these two versions. ResultsA total of 250 patients from 3 referral centers were enrolled in this study. A confirmatory factor analysis (CFA) demonstrated that the two French versions of the MSTS (MSTS-LE and MSTS-UE) were a good fit with a root mean square error of approximation (RMSEA)<0.08 and a comparative fit index (CFI)>0.90. The psychometric properties of the two versions were validated with internal consistency (Cronbach alpha>0.7), convergent validity of each item with its score (> 0.4), and sufficient criterion validity (Pearson correlation coefficient>0.4). The discriminant validity analysis showed that there was a significant correlation between each version and the performance status (PS) (p<0.05). ConclusionThis study produced a French version of the MSTS scoring system and validated the psychometric properties of the two versions obtained (MSTS-UE and MSTS-LE). Therefore, the French MSTS scoring system is a valid measurement that can be used in international studies. Level of evidenceI.

Various treatment options for the management of Campanacci III giant cell bone tumor.

e23509 Background: To assess the treatment effectiveness of Campanacci III giant cell bone tumours. Methods: This prospective cohort study was done using a non-probability purposive sampling technique in the orthopaedic surgery and traumatology unit-I department from February 2013 to October 2017. The sample size of 21 patients aged 33 to 60year Campanacci III giant cell bone tumour diagnosed on biopsy were included, and all patients with uncontrolled diabetes mellitus, decompensated liver disease, chronic renal failure, previously treated for giant cell tumours and malignant transformation were excluded. Treatment options included wide margin excision with fibular vascular graft with plating, mega prosthesis, and chirolin prosthesis. Treatment effectiveness was observed in terms of superficial &amp; deep infection, limb length discrepancy, implant failure and function using musculoskeletal tumour society rating scale (MSTS). Follow-p of the patients was five years. All patients were followed up for six months in the first year and yearly till five years. Results: Out of the total 21 patients, male were 11 (52.4%) and female were 10 (47.6%). The mean age of the patients was 34.8±14.6 years, with a median age was 30year. Four (19.1%) had proximal humerus, o5 (23.8% had distal radius, 09 (42.8% had distal femur, and 03 (14.3%) had proximal thigh involvement. The MSTS was 21.8±6.8 with a median score of 22 till the last follow-up. Kaplan Meier curve was plotted, and median survival rate was 50% at 54 months for the patients treated with fibular vascular graft, 57 months for mega prosthesis and 58 months for the patients treated with chirolin prosthesis. Conclusions: Treatment of Campanacci III with mega prosthesis, fibular vascular graft and chirolin prosthesis is a good outcome except with implant failure in mega prosthesis and limb length inequality with fibular vascular grafts. [Table: see text]

Pedicled fibular graft in knee-sparing tumor resection surgery: a retrospective case series

Background: Several viable options have been discussed in the literature for management of bone defects that result from resection of proximal tibial sarcomas. Pedicled vascularized fibular graft alone as a reconstructive technique can be considered as an alternative method that needs to be evaluated regarding adequacy, safety, and applicability for these situations. Methods: This is a retrospective case series study of 23 patients (14 male and nine female) aged from 7 yr to 40 yr with proximal tibial sarcomas that were managed from 1999 through 2017 by a knee-sparing limb salvage technique. Routine clinical and radiographic examinations were performed with histopathologic diagnosis that found 16 patients who had conventional osteosarcoma, three patients who had parosteal osteosarcoma, three patients who had Ewing sarcoma, and one patient who had fibrosarcoma. One patient had initial lung metastasis. Results: The average functional score from the revised Musculoskeletal Tumor Society rating scale (MSTS) was 26 (86.6%). Local recurrence occurred in two patients who were managed by amputation. Overall survival in our study was 91.4% with mortality of two patients. Conclusions: Pedicled vascularized fibular graft alone as a novel reconstructive technique after knee-sparing limb salvage surgery for juxtaarticular proximal tibial sarcoma is an effective technique with overall good oncologic and functional results. Level of Evidence: Level IV

Autografts, Allografts and Bone Substitutes in Lytic benign Bone Tumors and Tumour Like Lesions: A Comparative Study of Filling Defects and Healing in 90 Patients

Background: Extended curettage is treatment of choice for most benign lesions. To fill the defect after curettage remains a major problem particularly in children and in large cavities. We compared the results of allografts, autografts and bone substitutes in patients with benign bone tumors and tumour like conditions after curettage in view of healing of the lesion and their complications. Material and Methods: Total 90 patients (54 males and36 females) of benign lytic bone tumors in extremities and amenable to curettage were included in this prospective study. Extended curettage was done using the sharp curettes and high-speed burr. The age of patient ranged from 6 years to 62 years. Giant cell tumor 33.3% (n=30) and aneurismal bone cyst 30% (n=27) were the most common type of tumors in our series. There were twelve patients (13.3%) of enchondroma and ten patients each (11% each) of simple bone cyst and chondroblastoma. One patient had chondromyxoid fibroma. Mean tumor volume was 29.88 cm3 (range 2.7 to 168.48). The defects were filled by either autograft, allograft or bone substitutes making the comparative groups. The mean follow up period was 46months (range 24–70). Results: Autografts were used in 32 patients (35.6%) allografts in 28 (31.1%) and in remaining 30 cases (33.3%) bone substitutes were used. Autografts had shortest healing time with mean value of 6.77 ± 3.2 weeks (4–16 weeks) followed by bone substitutes 10.0± 2.4weeks (8-14 weeks). Allograft demonstrated maximum healing time with mean 11.25 ± 2.6weeks (range 8-16 weeks). Additional scar 100% (n=32), cosmetic deformity 6.25% (n=2), recurrence 6.25%(n=2) and infection 3.13%(n=1) were chief complications in autograft group. Serous discharge was observed in 64.3% (n=18) patients of allograft and in 23.3% (n=7) of bone substitute groups and one patient each in these two groups had infection respectively. There was one recurrence each in allograft and bone substitute groups respectively. Cost was big limiting factor for usage of bone substitutes in large cavities. Functional assessment was done by Musculoskeletal Tumor Society Rating Scale (MSTS) score while radiographic assessment of graft uptake by Irwin grading. The overall average Musculoskeletal Tumor Society (MSTS) score was 26.75 (range 24-30). Conclusion: Autograft is the best material to fill the defect after extended curettage of benign lytic lesions of bone. Bone substitutes and allografts are the options if autograft not available like in children. We observed that in small cavities bone substitutes can be an effective alternative and in large cavities it is better to use either allograft alone or a combination of autograft.

The effects of surgical treatment with chondroblastoma in children and adolescents in open epiphyseal plate of long bones

BackgroundChondroblastoma is a rare benign cartilaginous tumor, which primarily occurs in children and adolescents. Chondroblastoma commonly originates in the epiphyseal plate of long bones. An aggressive curettage treatment is recommended to manage lesion, which may jeopardize an open epiphyseal plate and result in limb shortening and deformity as the limb grows and develops. The purpose is to observe surgical effects of chondroblastoma on open epiphyseal plate of long bones in children and adolescents and explore influences on limb growth and development.MethodsWe retrospectively reviewed 18 cases of long bone chondroblastoma with open epiphyseal growth plate during March 2004 to October 2010 in our center. Seven females and 11 males with mean age of 11.6 ± 2.0 years old (8–15 years) were included. Patients, who suffered from trauma and pathological fracture of the epiphyseal plate or congenital diseases such as poliomyelitis, congenital dementia, and cartilage malnutrition, were excluded. All patients were treated with meticulous intralesional curettage and inactivity with alcohol followed by bone grafts. All cases were followed up 8.2 ± 1.7 years (5–11.5 years).ResultsAll had no local recurrence and distance metastasis. The length of the affected limb was short, 18.47 ± 7.22 mm (1.5–30 mm). There was no obvious relativity with tumor activity (P = 0.061). Meanwhile, there were obvious relativity with the greatest dimension of the lesion (TGD) (P = 0.003), the vertical dimension between edge of lesion and epiphyseal line (TVD) (P = 0.010), and area ratio of lesion to local epiphysis (lesion/growth plate) (P = 0.015). The MSTS93 (Revised Musculoskeletal Tumor Society Rating Scale 93) and SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey) had been significantly improved (P < 0.01).ConclusionManaging of chondroblastoma located in open epiphyseal plate of a long bone with meticulous curettage, inactivity, and bone grafts can control tumor progression and recurrence effectively. Meanwhile, early detection and prompt surgical treatment intervention, which reduced significantly the tumor to influence limb growth and development, get encouraging limb function.Trial registrationThis is a retrospective study, which was not registered in any trial registry.

All-endoscopic management of benign bone lesions; a case series of 26 cases with minimum of 2 years follow-up.

Purpose: Assessment of the functional and oncologic outcomes regarding endoscopic curettage of different benign bone tumor types within variable anatomic locations.Patients and methods: During the period between February 2012 and December 2016, 26 patients with symptomatic intra-osseous benign bony lesions were included. The age ranged from 3 up to 49 years (mean 20), of 14 females and 12 males. The follow-up duration ranged from 26 up to 58 months (mean 41). Functional scoring was done according to the Revised Musculoskeletal Tumour Society Rating Scale. Anatomic locations of the lesions included: 6 cases in the proximal tibia, 6 cases in the distal femur, 4 cases in the calcaneus, 3 cases in the proximal humerus, 3 cases in the distal tibia, 2 cases in the talus, 1 case in the proximal femur, and 1 case in the distal fibula. The procedure used 4 mm 30° scope for endoscopy, and high speed burrs 3.5–5 mm for extended curettage. Autogenous bone grafting was done in 5 cases, and adjuvant material (polymethylmethacrylate) was needed in 7 cases.Results: After exclusion of one case that was lost in the follow-up, the remaining 25 cases showed full functional recovery at a period of 8–12 weeks, and improved mean functional scores from 20.2 to 28.6/30 post-operatively, with p value <0.001 which was considered as a statistically significant result. The oncologic outcome showed 24 cases with adequate healing, while 1 case developed recurrence (aneurysmal bone cyst in the proximal tibia) for which, an open revision surgery was performed. Intra-operative fracture occurred in another case with aneurysmal bone cyst of the proximal femur, which was fixed by flexible nails with complete healing.Conclusion: Endoscopic curettage of different types of intra-osseous benign bony lesions proved to be an effective treatment modality with promising oncologic outcome, improved functional scores, and fast functional recovery.

PERİASETABULAR EWİNG SARKOMU OLGU SUNUMU: CERRAHİ TEKNİK VE LUMIC ASETABULAR İMPLANT İLE REKONSTRÜKSİYON

Reconstruction of periacetabular defects following pelvic tumor resection is a demanding procedure in orthopaedic surgical oncology. Conventional reconstruction procedures have dissatisfying mechanical and functional results. Therefore, more recently, to reduce risk of dislocation, aseptic loosening, infection, and achieve better functional results, endoprosthetic implants such as LUMIC® have been more preferred to reconstruct following pelvic resections. We presented a 28-year-old female patient who underwent a reconstruction surgery with a modular acetabular implant LUMIC® following a type-II pelvic resection due to periacetabular Ewing’s sarcoma. In the second postoperative year, with active hip abduction, good hip functions were observed, according to Musculoskeletal Tumor Society Rating Scale. Moreover, the radiographs displayed no aseptic loosening. Literature shows that Lumic® endoprosthetic reconstruction implant is an advantageous procedure with its satisfactory functional and mechanical results, as it is seen in our case. However, there is no case report and a limited number of clinical studies addressing this new technique and its results. In this issue, It is seen that more studies are required to achieve more definitive results in terms of function and mechanic. Keywords: Ewing's sarcoma ; reconstruction ; periacetabular ; hip ; prosthesis

Distal tibial osteosarcoma: A technique of custom mega prostheses reconstruction

Primary malignant bone tumours of the distal tibia are very rare. Amputation was the standard surgical treatment with satisfactory functional results obtained using an appropriate prosthesis [1]. But in the era of limb salvage, tumours of distal tibia are being dealt with limb salvage surgery to provide patients with a better quality of life [2]. We report a case of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection and reconstruction with custom mega prostheses and ankle arthrodesis [3] Osteosarcomas of the distal tibia are rare. These tumours are usually treated with amputation [2]. We report a case of osteosarcoma of distal tibia in a 13year old female. The patient presented with complaints of pain and limping gait of 6 months’ duration. Imaging revealed a mixed lesion predominantly sclerotic with moth-eaten appearance, aggressive periosteal reaction in distal tibia. MRI revealed soft tissue involvement.The patient received four cycles of neoadjuvant chemotherapy [4] she had a good clinical response by clinical and imaging evaluation. A distal tibial resection with custom mega prostheses reconstruction was done. The post-operative histopathology revealed an osteoblastic variant of osteosarcoma with 60% of necrosis. The patient completed two more cycles of same chemotherapy [4] the patient was on follow up since four months. The post-treatment functional evaluation was done with “Revised Musculoskeletal Tumour Society Rating Scale [5]. And patient had a score of 26 of 30. The patient was able to walk without crutches

Surgical treatment of patients with lung cancer and bone metastases: a prospective, observational study

BackgroundAs life expectancy improves in patients with lung cancer and bone metastases, effective surgical treatment to relieve pain and improve quality of life and neurological function is increasingly needed. Indications for surgery in patients with bone metastases are controversial. We aimed to assess a protocol for the surgery of patients with lung cancer and bone metastases. MethodsWe developed a surgical protocol for both spinal and appendicular metastases. According to the aim of surgery, eligible patients were placed into four classes (class 1: solitary metastatic bone lesion; class 2: spinal cord compression or pathological fracture; class 3: impending fracture; and class 4: severe pain after medical treatment or radiation). We assessed mobility and neurological functions 1 day before and 1 week, 1 month, 3 months, and 6 months after surgery with the visual analog scale for pain (VAS; scale 1–10), Karnofsky performance status scale (KPS), mobility scale with a score of 0 representing no limitation, a score of 1 representing limitation without the need for orthopaedic aids, a score of 2 representing limitation necessitating orthopaedic aids, and a score of 3 representing bedridden operative technique. Kaplan-Meier analysis was used to calculate survival. This study was approved by the ethics committee of the Sixth People's Hospital, Shanghai Jiao Tong University. Written informed consent was provided by the patient or their legal guardian. FindingsBetween Jan 1, 2005 and Jan 1, 2014, 134 patients underwent surgery (49 spine lesions and 86 appendicular skeleton lesions; one patient was operated in both lumbar and pelvis). VAS decreased after surgery (mean score 6·58 [SD 1·12] before vs 5·33 [1·38] at 1 week, 4·39 [1·35] at 1 month, 3·71 [1·29] at 3 months, and 3·99 [1·02] at 6 months, all p<0·0001 vs baseline). KPS and mobility scale scores were decreased 1 week after surgery (KPS 69·2 [SD 8·8] vs 65·4 [9·1], p=0·0012; mobility scale score (0/1/2/3) 32/47/34/21 vs 19/43/48/23, p<0·0001), and returned to preoperative levels at 1 month for appendicular surgery (KPS 67·2 [10·1] and mobility 21/34/19/11) or 3 months for spinal surgery (KPS 70·8 [11·7] and mobility 21/13/11/4). Mobility scale scores increased at 3 months and 6 months after surgery (48/46/26/12 at 3 months, p<0·0001; 54/39/21/6 at 6 months, p<0·0001). Frankel classification in patients with spinal metastases also improved at 3 months and 6 months after surgery (D/C/B/A from 17/5/3/4 to 12/4/3/2 and 19/0/0/1; p=0·0234 and p=0·0114), as did Musculo-Skeletal Tumor Society rating scale (MSTS) scores in patients with appendicular metastases (from 14·8 [6·1] 1 week after surgery to 20·3 [5·8] at 1 month, 24·1 [4·3] at 3 months, and 22·6 [5·5] at 6 months; all p<0·05 vs 1 week postoperative). The amounts of blood loss in spinal surgery were larger than appendicular surgery (mean 1620 mL [SD 1078] vs 571 mL [775]; p<0·0001). Median overall survival time after surgery was 13·5 months [SD 0·8]. Survival time in the group aimed at radical cure (Class 1: 27·0 months [3·5]) was significantly longer than the other three group (Class 2: 12·6 months [1·0]; Class 3: 13·1 months [1·0]; Class 4: 9·6 months [0·7]; p<0·0001). InterpretationAppropriate surgery provides pain relief, improvement of quality-of-life, and increased neurological function with an acceptably low rate of complications. Our protocol enabled physicians to identify patients with lung cancer and bone metastases who might be candidates for radical surgery. FundingNational Natural Science Foundation of China Grant (81201628).

Long-Term Outcome of Endoprosthetic Replacement for Proximal Femur Giant Cell Tumor.

Introduction:Giant cell tumor (GCT) of bone is locally aggressive benign tumor involving the epiphysis of long bones in young adults. Various treatment options include intralesional curettage, extended curettage, wide resection, resection and reconstruction and amputation. The main variables to be considered for planning treatment include the site of involvement and Campanacci stage of the tumor. Functional and oncological outcomes of these treatment options vary widely, the predominant detrimental factor being tumor recurrence rate.Aim:A study was conducted to evaluate the long-term oncological and functional outcome of patients with GCT of the proximal femur that underwent tumor resection and endoprosthetic replacement.Materials and Methods:Eleven patients with Campanacci stage-III GCT of proximal femur who underwent wide excision of tumor and endoprosthesis replacement with a mean follow-up the duration of 10.6 years were assessed using standard proforma. The treatment outcome was evaluated using the Revised Musculoskeletal Tumor Society Rating Scale for the lower extremity.Results:At mean follow-up the duration of 10.6 years, none of the cases had tumor recurrence, infection, prosthesis loosening or dislocation. All the patients were community ambulators among whom eight patients were walking without support while three patients were using a cane for support. The mean total Musculoskeletal Tumor Society Score was 26.8 out of 30 indicating the good outcome.Conclusions:The authors recommend that wide resection and endoprosthetic replacement should be considered as a preferred treatment option for proximal femur GCT as the functional, and oncological outcome is satisfactory with this modality of treatment.

Validation of the Brazilian Version of the Musculoskeletal Tumor Society Rating Scale for Lower Extremity Bone Sarcoma

The Musculoskeletal Tumor Society (MSTS) rating scale is an English-language instrument used worldwide to assess functional evaluation of patients with musculoskeletal cancer. Despite its use in several studies in English-speaking countries, its validity for assessing patients in other languages is unknown. The translation and validation of widely used scales can facilitate the comparison across international patient samples. The objectives of this study were (1) to translate and culturally adapt the MSTS rating scale for functional evaluation in patients with lower extremity bone sarcomas to Brazilian Portuguese; (2) analyze its factor structure; and (3) test the reliability and (4) validity of this instrument. The MSTS rating scale for lower limbs was translated from English into Brazilian Portuguese. Translations were synthesized, translated back into English, and reviewed by a multidisciplinary committee for further implementation. The questionnaire was administered to 67 patients treated for malignant lower extremity bone tumors who were submitted to limb salvage surgery or amputation. They also completed a Brazilian version of the Toronto Extremity Salvage Score (TESS). Psychometric properties were analyzed including factor structure analysis, internal consistency, interobserver reliability, test-retest reliability, and construct validity (by comparing the adapted MSTS with TESS and discriminant validity). The MSTS rating scale for lower limbs was translated and culturally adapted to Brazilian Portuguese. The MSTS-BR proved to be adequate with only one latent dimension. The scale was also found to be reliable in a population that speaks Brazilian Portuguese showing good internal consistency (Cronbach's alpha = 0.84) and reliability (test-retest reliability and interobserver agreement of 0.92 and 0.98, respectively). Validity of the Brazilian MSTS rating scale was proved by moderate with TESS and good discriminant validity. The Brazilian version of the MSTS rating scale was translated and validated. It is a reliable tool to assess functional outcome in patients with lower extremity bone sarcomas. It can be used for functional evaluation of Brazilian patients and crosscultural comparisons.

Reconstruction of sarcoma defects following pre-operative radiation: Free tissue transfer is safe and reliable

Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects. A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups. Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups. Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.

Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction

Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap. Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores. Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection. Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.

Sandwich reconstruction technique for subchondral giant cell tumors around the knee

Background Curettage followed by cementation is a commonly accepted treatment modality for giant cell tumors of bone. However, concerns regarding articular cartilage damage related to the exothermic reaction during polymerization and the change in stress distribution in the subchondral region have been reported to occur within 5 years following cementation. Methods Twelve patients (five men, seven women) presenting with giant cell tumor of the distal femur were treated with the “sandwich technique” of subchondral bone grafting and cavity filling cementation after extensive intralesional curettage. The average age of the patients was 26.5 years. The mean duration of follow-up was 44.8 months. All lesions were found to extend within 3 mm of the subchondral bone. Results: All patients had an uneventful recovery and regained an average range of motion of 122.9° in the knee. The average revised Musculoskeletal Tumor Society Rating Scale for the lower extremity was 26. One patient had a local recurrence within the first 2 years of the procedure and was treated with a resection arthrodesis. None of the patients developed signs of articular cartilage degeneration at final follow-up. Conclusions The “sandwich technique” of reconstruction of the subchondral bone after extended curettage produces good functional results with a low recurrence rate. Insertion of a corticocancellous bridge between the subchondral bone and the cement layer may retard the progression of early cartilage degeneration.

Quality of life following limb-salvage surgery for bone sarcomas

Limb-salvage surgery and reconstruction of bone defects is challenging in orthopedic oncology. Evaluation and improvement of the quality of life in these patients is difficult. Currently available metrics of function include clinical measures such as range of motion and muscle strength, measures of activities of daily living, scales that combine both clinical measures and activities of daily living, the original and the revised version of the Musculoskeletal Tumor Society Rating Scale, which includes symptoms, mobility and use of assistive devices, generic health status measures such as the Sickness Impact Profile, and the Reintegration to Normal Living, a measure of handicap. Most bone sarcoma survivors manage well; they are able to work and have an overall good quality of life, having adjusted to their physical limitations. To enhance the literature, we summarize the results of previous studies reporting on the quality of life after limb-salvage surgery of the upper and lower limb, discuss the complications and outcomes, and present our long-term experience and future view.

54 INVITED Long-term cancer survivorship issues: Is there a role for CAM?

Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap.Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores.Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection.Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.