Benign aggressive tumors are common and can be debilitating for patients especially if they are in peri-articular regions or cause pathological fracture as is common for giant cell tumor of bone (GCT). Although GCT rarely metastasize, the literature reports many series with high rates of local recurrence, and evidence about which risk factors influence recurrence is lacking. This study aims to evaluate the recurrence rate and identify local recurrence risk factors by reviewing patient data from a single high-volume orthopedic oncology center.

A retrospective analysis of all patients treated for GCT at a tertiary orthopedic oncology center was conducted. In total 413 patients were treated for GCT between 1989 and 2017. Multiple patient and tumour characteristics were analysed to determine if they influenced local recurrence including: age, gender, anatomical site, Campanacci stage, soft tissue extension, presence of metastasis, pathologic fractures, and prior local recurrence. Additional variables that were analysed included type of treatment (en bloc resection or aggressive intralesional curettage) and use of local adjuvants. The main outcome parameters were local recurrence- free survival, metastasis-free survival and complications. Patients treated with Denosumab were excluded from analysis given its recently documented association with high rates of local recurrence.

“There were 63/413 local recurrences (15.3%) at a mean follow-up of 30.5 months. The metastatic rate was 2.2% at a mean 50.6 months follow-up and did not vary based on type of treatment. Overall complication rate of 14.3% was not related to treatment modality. Local recurrence was higher (p=0.019) following curettage (55/310; 17.7%) compared to resection (8/103; 7.8%) however, joint salvage was possible in 87% of patients (270/310) in the curettage group. Use of adjuvant therapy including liquid nitrogen, peroxide, phenol, water versus none did not show any effect on local recurrence rates (p= 0.104). Pathological fracture did not affect local recurrence rates regardless of treatment modality (p= 0.260). Local recurrence at presentation was present in 16.3% (58/356) patients and did not show any significance for further local recurrence (p= 0.396). Gender was not associated with local recurrence (p=0.508) but younger patient age, below 20 years (p = 0.047) or below 30 years (p = 0.015) was associated with higher local recurrence rates. GCT in distal radius demonstrated the highest rate of local recurrence at 31.6% compared to other sites, although this was not significant (p=0.098). In addition, Campanacci stage and soft tissue extension were not risk factors for recurrence.

The overall GCT local recurrence rate was 15.3%, but varied based on the type of resection: 17.7% following joint sparing curettage compared to 7.8% following resection. Local recurrence was also higher with younger patient age (30 years or less) and in distal radius lesions. In addition, neither Campanacci stage, soft tissue extension or presence of a pathologic fracture affected local recurrence. Most patients with GCT can undergo successful curettage and joint sparing, while only a minority require resection +/− prosthetic reconstruction. Even in the presence of soft tissue extension or a pathologic fracture, most joints can be salvaged with curettage.

Myxofibrosarcoma (MFS) is the second most common subtype of soft tissue sarcoma (STS) and is associated with a high rate of local recurrence after resection. These tumours frequently present with peri-lesional edema, termed “tumour tails” on staging MRI scans [1]. Tumour tails(TT) may contain satellite neoplastic cells or can represent benign reactive edema. There are no clear radiological features to distinguish malignant from reactive peri-lesional edema which limits accurate surgical planning, resulting in either high rates of inadvertently positive resection margins and local recurrences or overly-aggressive resections which negatively impact function and increase morbidity [2]. The objective of this pilot study was to prospectively study a cohort of MFS patients with TTs in an attempt to identify radiological features that predict which type of edema is malignant and requires resection together with the main tumour mass.

Patients diagnosed with MFS on biopsy at an orthopaedic oncology referral centre between January 1-December 31 2018 who also had TTs on staging MRI scans were prospectively recruited for the study. Tumours were treated with wide surgical excision, including the TTs, and (neo)adjuvant radiotherapy as per institutional protocol. Staging MRI scans were reviewed in a blinded fashion by two musculoskeletal radiologists to distinguish malignant from reactive TTs. The main tumour mass underwent standard histological evaluation while the regions encompassing the TTs were photographed and sectioned into grids. Each tissue section was examined histologically for the presence of satellite neoplastic cells based on morphological criteria. Radiological and histological findings were compared.

Six patients met the inclusion criteria and underwent analysis. All tumours were located in the extremities and were deep to fascia. Mean age at presentation was 67 years (range 51 – 85), with a male:female ratio of 4:2. All patients received radiotherapy (50 Gy), either pre- (n=4) or post-operatively (n=2) based on multidisciplinary tumor board discussion or enrolment in a prospective clinical trial. Radiologically, TTs were labelled as malignant in four patients (66.7%) and as benign TTs in two others. The tails were recognised to be malignant due to the differing signal characteristics to reactive edema on mixed MRI sequences. The radiological evaluation correlated exactly with histological analysis, as satellite neoplastic cells were identified microscopically in the same four cases in which the TTs were designated to be malignant by MRI (specificity&sensitivity=100%). Surgical resection margins were microscopically positive in 50% of cases in the TTs themselves, and 75% of cases in which TTs were designated as malignant on staging MRI.

“The malignant nature of peri-lesional edema in MFS, also known as the TT, was accurately predicted in this small pilot study based on specific radiological features which correlated exactly with histologic identification of isolated tumor cells. These findings validate development of a larger prospective study to recruit additional patients with tumor tails beyond just MFS, in order to more robustly study the correlation between the MRI appearance and histological distribution of satellite sarcoma cells in peri-lesional edema in STS. We are already recruiting to this expanded radiological-histological investigation including evaluation of additional novel MRI sequences.

Myxoid or Myxoid Round Cell liposarcoma (MLS) is a mesenchymal malignancy with adipocyte differentiation accounting for 15–20% of liposarcomas and 5% of all adult soft tissue sarcomas (STS). Like other STS, treatment of MLS is generally by wide surgical resection in conjunction with radiotherapy and this approach is associated with low rates of local recurrence [1]. However, most MLS are located between muscles so wide local excision(WLE) can be quite morbid with adverse functional results. MLS are known to be extremely sensitive to radiotherapy which has led to development of treatment protocols utilizing neoadjuvant radiation. Given the radiosensitivity of MLS, we hypothesize that resection with marginal margins (1mm) does not result in higher rates of local recurrence or disease-free survival if performed following pre-operative radiotherapy.

We identified all patients with localized MLS who underwent preoperative radiation and surgical resection between January 2000 and January 2018 from a prospectively collected sarcoma database. We calculated the ellipsoid tumour volume(ETV=h x w x d x ()) at diagnosis and after radiation, and documented the necrosis percentage of the tumour and margin status following resection based on histological analysis [2]. Marginal resection was identified by the operative report describing no or only very minimal resection of muscle surrounding the tumour, and a negative surgical margin 0.1cm/1mm as defined histologically. In comparison, WLE was defined if the operative note described an attempt to remove the tumour with a cuff of surrounding muscle, and the final histology reported a negative margin 0.1cm/1mm which included skeletal muscle. The third group for analysis included patients with positive resection margins.

There were 91 patients with MLS of mean age 48 years (range 18–88) with 69% male and 31% female. The mean pre-radiotherapy ETV was 507cm³(16.1cm³ to 6961cm³) and decreased to 361cm³(8.7cm³ to 5695cm³) following radiation, with an average percentage reduction in ETV of −45%(+129%to-99%). Mean patient follow-up was 7.3 years (0.2–18) with no differences between margin groups(p=0.284). Only 10(11%) patients had positive margins, of which 43(47%) underwent marginal resection and 38(42%) WLE. Overall the mean necrosis as measured histologically following preoperative radiation was 69% (range 0–100%) with no differences between the 3 resection groups(p-0.151). Similarly, there was no significant difference in reduction in mean ETV between the three resection groups(p=0.311), there was no significant difference between the three treatment groups in 5-year LR-free survival (p=0.469), metastasis-free survival (p=0.841) or overall survival (p=0.873).

Most patients with MLS experienced significant reduction in tumour size and necrosis following preoperative radiation. We found no differences in the risk of local recurrence or survival based on the type of surgical approach for patients with MLS. Based on these results, we conclude that MLS can be safely removed by marginal resection following preoperative radiotherapy with high rates of local tumour control. Even following a positive margin resection, local recurrence remains uncommon after preoperative radiation. A marginal surgical approach for patients with MLS reduces the need for major muscle resection and is associated with improved functional outcomes with less complications.

Ewing Sarcoma is the second most common primary bone sarcoma in young patients, however, there remains geographical variation in the treatment of these tumours. All patients receive neoadjuvant chemotherapy and, in most cases, the soft tissue mass diminishes significantly in volume. Controversy surrounds whether to then treat the pre- or post-chemotherapy tumour volume. Many centres advocate either (1) resection of the pre-chemotherapy volume or (2) treatment of the pre-chemotherapy volume with radiation followed by resection of the post-chemotherapy volume. These approaches increase both the short and long-term morbidity for this young patient population. In this study, we retrospectively reviewed our experience resecting only the post-chemotherapy volume without the use of (neo)adjuvant radiotherapy.

A retrospective analysis of all patients with Ewing Sarcoma treated at a tertiary orthopaedic oncology centre was conducted. All patients were treated as per the consensus opinion of the multidisciplinary tumour board. Demographic and oncological variables were collected from our institutional database. Presentation and re-staging MRI scans were reviewed to evaluate pre- and post-chemotherapy tumour volumes. Operative and pathology reports were utilized to determine the extent of the surgical resection. Outcome variables included local recurrence free-, metastasis free- and overall survival.

Sixty-five patients were identified in our institutional database of which 56 did not receive (neo)adjuvant radiotherapy. Median age at diagnosis was 24 years (range 13–64), 60% of patients were male and 67.6% of tumours were located in the appendicular skeleton. All 56 patients not treated with radiotherapy had resection of the post-chemotherapy tumour volume. There were 3 local recurrences in this group with a mean follow-up of 70.8 months (range 2 to 328). The median overall survival was 47 months and the mean of 70.8months.

The rate of local recurrence is comparable to reports in the literature in which patients had their entire pre-chemotherapy tumour volume treated by radiation and/or surgery. Similarly, two-year overall survival for our patient cohort is not significantly different from previous studies in which more aggressive local control measures were employed. Resecting the post-chemotherapy tumour volume in Ewing Sarcoma without the use of (neo)adjuvant radiotherapy does not appear to increase the risk of local recurrence or negatively impact overall survival. This approach should be studied further as it reduces the risk of short and long-term complications for this patient population.”

Aims

Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

Biological reconstruction techniques after diaphyseal tumour resection have increased in popularity in recent years. High complication and failure rates have been reported with intercalary allografts, with recent studies questioning their role in limb-salvage surgery. We developed a technique in which large segment allografts are augmented with intramedullary cement and fixed using compression plating. The goal of this study was to evaluate the survivorship, complications and functional outcomes of these intercalary reconstructions.

Forty-two patients who had reconstruction with an intercalary allograft following tumour resection between 1989 and 2010 were identified from our prospectively collected database. Allograft survival, local recurrence-free, disease-free and overall survival were assessed using the Kaplan-Meier method. Patient function was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS).

The 23 women and 19 men had a mean age of 33 years (14–77). The most common diagnoses were osteosarcoma (n=16) and chondrosarcoma (n=9). There were 9 humerus, 18 femur and 15 tibia reconstructions. At a mean follow-up of 95 months (5–288), 31 patients were alive without disease, 10 were dead of disease and 1 was deceased of other causes. There were 4 local recurrences and 11 patients developed metastatic disease. 5-year local recurrence free survival was 92%, 5-year disease-free survival was 70% and overall survival was 75%. Fourteen of 42 patients (33%) experienced complications: 5 wound healing complications, 4 infections, 2 non-unions, 2 fractures and 1 nerve palsy. Four allografts (9.5%) were revised for complications and 2 (5%) for local recurrence. Mean allograft survival was 85 months (4–288). Mean time to union was 8.2 (3–36) months for the proximal osteotomy site and 8.1 (3–23) months for the distal osteotomy site. The mean score for MSTS 87 was 29.4 (+/− 4.4), MSTS 93 was 83.7 (+/−14.8) and TESS was 81.6 (+/−16.9).

An intercalary allograft augmented with intramedullary cement and compression plate fixation provides a reliable and durable method of reconstruction after tumour resection. Complication rates are comparable to the literature and are associated with high levels of patient function and satisfaction.

Hindquarter amputations for bone or soft tissue sarcoma cause a high degree of disability in patients and are associated with high morbidity rates. The goal of this study is to determine prognostic factors for outcome and analyse quality of life after resection, in order to better select patients who are more likely to benefit from a hindquarter amputation.

Our prospectively collected database was searched for all patients treated with a hindquarter amputation between 1989 and 2015. Clinical and histopathological features were analysed for their prognostic value using Kaplan-Meier and Cox proportional hazard analysis. Endpoints were set at recurrent disease and death. Also, functional and social outcome as well as pain was assessed from the hospital charts in the patients that are still alive.

82 patients underwent a hindquarter resection in the given time frame. Of these patients, 63 were treated with a curative intent. The median hospital stay was 25 days, and 49% of the patients had wound complications. The in-hospital mortality was 6%. The 5-year overall survival in the whole group was 31%, while disease free survival was 26%. As expected, patients with metastases at presentation had a significantly worse outcome, while patients with locally recurrent sarcoma had the same outcome as patients with primary sarcoma. For those patients treated with curative intent, younger age was correlated with better survival, while higher histological grade was correlated with worse disease free survival. The functional and social outcome for patients who survived more then one year varied widely, with about 50% of the patients living an acceptable social life with reasonable pain levels and mobility status.

Hindquarter amputations for sarcoma patients are still indicated for a select group of patients. Younger patients and/or patients with low grade sarcomas are more likely to benefit form this resection in terms of survival and long term function. However, for patients with less favourable prognostic factors a hindquarter operation might be an unreasonable palliative option.

Objectives

The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial.

Introduction

Fibromatosis is a disorder characterised by a spectrum of biological behaviour from relative indolence to aggressive local infiltration. With aimed to describe the pre and post-operative functional status of these patients managed with surgery and analyse the effect of radiotherapy on functional outcome.

Fibromatosis represent a highly heterogeneous group of tumours in growth pattern, location and management. Our aim was to describe the demographics of the patient population who had undergone surgical resection and to identify predictors of local recurrence. Any lesion that was infiltrating the chest or abdominal cavity was excluded. Patients were also not included if they had a plantar or palmar lesions or had received hormonal or chemotherapy.

67 men and 88 women aged from 16 to 77 with a median age of 39 were analyzed. 121 patients had no prior resective operative intervention. 34 patients had undergone an attempted resection procedure at another unit of which 30 had locally recurred. 3 were located in the abdominal wall, 5 chest wall, 15 paraspinal, 56 lower and 76 upper limb. 40 patients did not receive XRT, 18 in the post-operative period and 97 in the pre-operative period. 67 operations produced margin negative resection, 85 were positive and 3 in which the margin status was unknown. Follow-up ranged from 1 day post op to 23.3 years. 23 patients had a local recurrence. Following subsequent re-resections, the total number of patients who were alive with evidence of disease was 16.

6 pts had deceased. 149 were alive with no evidence of disease. No factors were found to be statistically significant for predicting local recurrence, including the use of radiation (0.06) and margin status (0.81). Although radiation, given either pre or post-operatively did trend towards preventing local recurrence (HR 0.40; 95% CI 0.15 to 1.06; p = 0.06).

Soft tissue sarcomas (STS) arising in the adductor compartment of the thigh are frequently large before clinical detection, posing particular challenges with surgical resection and associated with a high risk of wound complications. This study compares oncological and functional outcomes and complications following treatment of adductor compartment soft tissue sarcomas from three international centres with different treatment philosophies.

184 patients with new primary, non-metastatic, deep STS in the adductor compartment diagnosed between 1990 and 2001 were identified from the centres' local databases. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients.

There were 94 male and 90 female patients, with ages ranging from 13 to 88 years (median age 57 years). The period of follow-up ranged from 1 to 162 months. The overall survival was 65% at 5 years and related to grade and size of the tumour. There was no difference in overall survival or systemic relapse between the three centres. There was however a significant difference in local control (28% LR in centre 1 compared to 10% in centre 2 and 5% in centre 3, which appeared to be principally related to the use of radiotherapy and surgical margins.)

66 patients (36%) from the three centres developed wound complications post-operatively and it was shown to be associated with high grade and large tumours (>10cm).

Functional scores averaged 78% but were significantly worse for patients with wound complications or high-grade tumours; however, they were not affected by timing of radiotherapy or use of prophylactic free muscle flaps.

This study examines the biomechanical performance of five types of fixation techniques in a model of pathological fracture of the diaphyseal humerus.

In forty synthetic humeri, a hemi cylindrical defect centered in the middle third of the diaphysis was created. A transverse fracture was created through the centre of each defect. The bones were randomly assigned to five groups. Group A was fixed with standard ten hole DCP plates centered over the defect with five screws inserted on either end. In group B, the screw holes were injected with bone cement and then the screws and plate were reapplied while the cement was still soft. The defect was also filled with cement. Group C was fixed by injecting the cement into the entire intramedullary canal. The fracture was then reduced and the screws and plate were applied once the cement had hardened. In group D, the specimens were fixed with locked antegrade IM nail with one proximal and one distal interlocking screw. Group E was same as D except that the defect was filled with cement. Each specimen was tested in external rotation to failure by fracture.

There was no significant difference in torsional stiffness between groups B, C, and E (P> 0.16), whereas there were differences between all other groups using pairwise comparisons(p< 0.001). Groups B, C, and E were of highest stiffness followed by A and then D. Group C had the highest torque to failure, followed by groups A/B and then D/E. Total cumulative energy to failure for group C was statistically greater than each of B, D, and E (p< 0.005), but not different from A, though it approached significance (p=0.057).

This study demonstrates that, in a model of a fracture through a hemicylindrical defect in the middiaphysis of the humerus, fixation with a broad ten-hole dynamic compression plate after filling the entire medullary canal with cement is associated with the highest torque to failure and energy to failure with torsional forces. This fixation technique may best accomplish the clinical goal of maximal initial stability.

The outcome of complex acetabular reconstruction was evaluated in twenty-one patients who were confined to a wheelchair or bed because of pain from acetabular metastases. Reconstruction rings were used where bone loss exceeded 50% of the acetabulum. Six roof reinforcement-rings, eight ilioischial-rings and eight Harrington reconstructions were performed. All but two patients(90%) became ambulatory without pain. Median survival was nine months. Two patients underwent acetabular revision for recurrence. These results support the role of acetabular reconstruction for palliation of pain in appropriate patients with acetabular metastases.

Metastatic disease of the acetabulum is painful and disabling. Operative intervention is indicated in certain patients with pathologic fractures, and non-responders to adjuvant treatment. The functional outcome of hip arthroplasty with reconstruction rings was evaluated in twenty-one patients with acetabular metastases between 1989 and 2001. Preoperatively all patients were confined to a wheelchair or bed and used significant narcotic medications. Preoperative radiotherapy was employed in eighteen cases (90%) and 30% had undergone chemotherapy.

AAOS classification of the acetabular lesion revealed: six-type II, seven-type III and eight-type IV deficiencies. All cases required a reconstruction ring due to bone loss exceeding 50% of the acetabular dome. Six roof reinforcement rings, eight ilioischial rings and eight Harrington reconstructions with rings were performed in this group. Determination of the reconstructive technique was based on preoperative computerized tomography and intraoperative examination of the acetabular deficiency.

All but two patients (90%) became ambulatory without significant pain. Eleven patients used a walker or two canes and nine walked with one or no canes. Median survival was nine months and patients with visceral involvement had a shorter duration. Eight early post-operative complications developed in six patients (29%). In two patients the acetabular construct failed with cup migration due to locally recurrent disease; both were successfully revised.

The results of complex acetabular reconstruction for metastatic disease validate its role for palliation of pain and to improve ambulatory status. Preoperative planning with computerized tomography can assist in classifying acetabular bone loss and determining optimal reconstruction technique.

Many authors believe that size, histological grade and depth are the best predictors of outcome in soft tissue sarcoma. Enneking’s surgical staging system included compartmental status, and was intended to guide surgical intervention as well as provide prognostic information. Advances in surgical and radiotherapy techniques may mean that extracompartmental status is no longer a poor prognostic factor. We compared a group of popliteal fossa sarcomas with a group from the posterior thigh, and found that although the former group required more extensive surgery to obtain wide margins, their functional and survival outcomes were similar.

No single staging system has been generally accepted for extremity soft tissue sarcoma, although histologic grade, size and depth are widely accepted as prognostic indicators. Enneking outlined a surgical staging system which used compartmental status as a predictor of outcome. However, surgical reconstruction and adjuvant radiotherapy have advanced considerably. We wanted to know if a tumour arising in the popliteal fossa still had poorer survival or functional outcome in the light of these advances.

We identified twenty-three patients who had sarcomas of the popliteal fossa and forty-six patients who had sarcomas of the nearby posterior thigh compartment. Popliteal sarcomas were not of a different size or more likely to present with metastasis. Popliteal tumours more frequently required reconstructive techniques such as local or free tissue transfer and skin grafting than posterior thigh tumours (39.1% v 4.3% respectively). Popliteal tumours were also more likely to undergo a dissection or reconstruction of the major neurovascular structures of the lower limb (30.4% v 0% respectively). There was no difference in local or systemic recurrence rates between the groups. TESS and MSTS 1987 functional scores also showed no difference between the groups.

We conclude that popliteal fossa sarcomas require a greater level of surgical intervention to follow sound principles of sarcoma resection and achieve reconstruction of the ensuing soft tissue defect. However, if these principles are followed in a planned multidisciplinary setting, then survival and functional results similar to the posterior thigh can be expected.

A retrospective review of our prospectively collected database was undertaken and the functional and oncologic outcomes after Type One pelvic resections for bone tumours of the ilium and sacrum were analyzed. Seventeen patients were identified with a minimum followup after resection of twelve months. In seven patients the bone defect was reconstructed, with no reconstruction in the remaining ten patients. The functional/oncologic outcomes of the two groups are similar, however patients without reconstruction had fewer complications and less dependence on walking aids suggesting that reconstruction may not be justified.

Management of defects created by Type One pelvic resections of large iliac bone tumours remains controversial. We reviewed the functional/oncologic outcome following resection with and without reconstruction.

Similar functional/oncologic outcome was achieved in both groups suggesting that reconstruction is not justified.

A retrospective review of our prospectively collected database was undertaken analyzing functional/oncological outcome of seventeen patients with Type One pelvic resection. Minimum follow up was twelve months (12–96). Outcome data was available on 8/10 patients managed without reconstruction (WOR), with residual ilium collapsing back onto sacrum, and on 5/7 patients with bone graft reconstruction (WR).

Average age thirty-three years (WOR) and 48yrs (WR), (p=0.04), with average maximal tumour dimensions of 12cm and 9cm (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (24–96) compared to 69%, 21/35 and 51% at an average of 37 months (12–60) for the WR group. 33% of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 57% of WR patients. No local recurrences.

The perceived advantages of no reconstruction are shorter operating times, reduced incidence of complications and improved functional outcome due to medialization of the weightbearing axis in the absence of hip abductors. The oncologic/functional outcomes of both groups were similar but in those not reconstructed there was a lower incidence of complications and walking aids.

A retrospective review of our prospectively collected database was undertaken to determine the functional and oncologic outcome following combined pelvic allograft and total hip arthroplasty (THA) reconstruction of large pelvic bone defects following tumour resection. There were twenty-four patients with a minimum followup of fifteen months. The complication rate following hemipel-vic allograft and THA reconstruction of resection Types I+II and I+II+III was high, but when successful this reconstruction resulted in reasonable functional outcome. In comparison, the functional outcome after allograft and THA reconstruction of isolated Type II acetabular resections was better and more predictable.

Resection of large pelvic bone tumours often results in segmental defects with pelvic discontinuity and loss of the acetabulum. We reviewed the functional and oncologic outcomes following pelvic allograft and total hip arthroplasty (THA) reconstruction.

Reconstruction of large pelvic defects including the acetabulum using hemipelvic allograft and THA is associated with high complication rates, however when successful provides reasonable function. In comparison, the outcomes of allograft and THA for acetabular defects alone are better and more predictable.

A retrospective review of our prospectively collected database was undertaken. Minimum followup was fifteen months (15–167). Nineteen patients were hemipel-vic resections (twelve Type I+II and seven Type I+II+III, eleven cases including partial sacral resection) reconstructed by hemipelvic allograft and THA. Five patients had Type II acetabular resections, reconstructed with structural allograft, roof ring and THA.

Osteosarcoma and chondrosarcoma were the most frequent tumours. All patients required walking aids. In the hemipelvic group there were two early deaths (peri-operative haemorrhage and aplastic anaemia). In seven patients (37%) the allograft remained intact without infection but three required revision THA for loosening. For these seven patients the functional outcome scores were TESS 64%, MSTS87 17/35 and MSTS93 of 45% (mean fifty-two months.). There were nine cases of deep infection (47%) with three patients maintaining a functional implant. The nineteenth patient was revised following allograft fracture.

In the Type II acetabular group, three patients had no complications, and two patients dislocated. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean fifty-five months).

Forty-six patients with an uncemented proximal tibial endoprosthesis were reviewed following resection of a proximal tibial tumor. The mean age was thirty-four years and the majority were male. The most common malignant diagnosis was osteosarcoma. Oncologic and functional analysis was performed on these cases. At latest follow-up thirty of the patients remain alive with no evidence of disease and eleven had died. The most common complication was deep infection (7/46). Only six patients had mechanical prosthesis related complications. At latest follow up the average TESS score was 76.3 and MSTS score 75.5 with an average extensor lag of 6.5o.

To review the oncologic and functional results of a series of forty-six uncemented proximal tibia tumour replacements.

A retrospective review of our prospectively collected database revealed forty-six patients with an uncemented proximal tibial replacement following tumour excision. The data was analysed with respect to patient demographics, operative and prosthetic complications. Oncologic diagnosis and results and functional results were also reviewed.

The average age of the forty-six patients was thirty-four years (14–73) with thirty-three males and thirteen females. The most common diagnosis was osteosarcoma. There were four cases of benign GCT. At an average follow-up of 85.8 months (11–170), thirty were alive with no evidence of disease while eleven patients had died of their disease. Four patients were alive with evidence of disease at latest follow-up and one patient had died of unrelated causes.

The most common operative complication was infection (9/46) with seven of these being deep infections requiring prosthesis removal, followed by mechanical problems including stem fracture (3/46) and bushing failure (3/46) also requiring operative intervention.

Functional assessment revealed an average extensor lag of 6.5o with an average ROM of 83.6o, average TESS scores of 76.3 and MSTS 93 scores of 75.5.

Large series of uncemented proximal tibial endoprostheses are uncommon in the literature. In our series there is a low rate of aseptic loosening at an average seven year follow-up, but this is offset by problems including infection and prosthetic fracture. Overall the functional and oncologic results remain satisfactory.

Purpose: To determine the outcome of patients 80 years old and greater that were diagnosed with a primary soft tissue sarcoma and if these patients should be treated as aggressively as younger patients.

Methods: One-hundred two patients were retrospectively reviewed.Well differentiated liposarcoma and der-matofibrosarcoma were excluded.

Results: There were 52 males. Average age was 84 years (80–94). Malignant fibrous histiocytoma was most common (36 patients) followed by leiomyosarcoma (22 pts) and liposarcoma (17 pts). Tumors were superficial in 25 patients and deep in 75. The lower extremity was most frequent site(70 patients), 27 patients had upper extremity involvement and 9 had a back lesion. MSTS stages were IA 6 patients, IB 22 patients, IIA 55 patients, IIB 9 patients, III 1 patient, and was unknown for 9 cases. Lesions were larger than 5cm in 80%. Four patients had no surgery, 89 patients had limb salvage, and 8 patients underwent amputation. Thirty-two patients had pre-operative radiotherapy, 30 patients had post-operative radiation, and 3 patients received both. No patients were given chemotherapy. The average follow up was 24 months (0–107months). Seventeen patients experienced local recurrence. Thirty-one patients developed metastatic disease. At latest follow-up 49 patients were alive without disease, 21 patients were alive with disease, 22 patients died of their disease, 8 patients died of another cause and the final status was unknown for 2 patients.. The MSTS functional score pre-treatment was 24 (11–72) and 31 (20–77) one year following treatment.

Conclusions: Elderly patients with soft tissue sarcoma have a poor outcome. Taking into account their associated medical condition, this group should likely be managed as younger patients although chemotherapy has no role according to our experience Funding: Other Education Grant Funding Parties: CIHR,|Stryker Canada

As patients live longer following treatment for soft tissue sarcomas, complications from treatment will continue to emerge. Predicting which patients are at risk allows for improved preoperative planning, treatment, and surveillance. The data presented here suggests that females greater than fifty-five years of age treated with high dose, postoperative radiotherapy in combination with limb salvage surgery for soft tissue sarcomas are at an increased risk of post irradiation fractures. Unlike previous reports, a significantly higher rate of fracture occurred in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy).

This retrospective study was performed to determine if the timing and dosage of radiotherapy are related to the risk of post radiation pathologic fracture following combined therapy for lower extremity soft tissue sarcomas. Three hundred sixty-four patients with sarcomas treated with external beam radiation therapy and limb salvage surgery were evaluated. High dose radiation was defined as 60 Gy or 66 Gy; low dose as 50Gy. Radiation timing schedules were preoperative, postoperative, or preoperative with a postoperative boost. Univariate and multivariate analysis was used to determine which factors were associated with fracture risk. Twenty- seven pathologic fractures occurred in twenty-three patients. Twenty- four fractures occurred in twenty patients who were treated with high dose radiation. Sixteen of these patients had postoperative radiation (fourteen patients received 66Gy, two received 60Gy), and four had pre-operative radiation with a postoperative boost (total dose = 66Gy). Three fractures occurred in three patients who received low dose preoperative radiation (50Gy). Both high dose radiation (versus low dose) (p=.001) and preoperative radiation (versus postoperative) (p =0.002) were associated with a risk of fracture. Findings in this study were consistent with previous reports in that females over fifty-five years of age who undergo removal of a thigh sarcoma combined with radiation therapy are at a higher risk of a pathologic fracture, and differs in that there was a significantly higher rate of fracture in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy), and when radiation therapy was given postoperatively versus preoperatively.

Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36).

To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture.

There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease.

Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival.

Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002.

There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36).

Purpose: Endoprosthetic reconstruction of the distal femur is the preferred approach for patients undergoing resection of bone sarcomas. The traditional How-medica Modular Resection System, using a press-fit stem (HMRS or Kotz prosthesis, Stryker Orthopaedics, Mahwah, New Jersey, USA) has shown good long-term clinical success, but has also been known to incur complications such as stem fracture. The Restoration stem, as a part of the new Global Modular Resection System (GMRS, Stryker Orthopaedics, Mahwah, NJ, USA), is currently proposed for this same application. This stem has a different geometry and provides the advantage of decreased risk of fracture of the component. The goal of this study was to compare the HMRS and Restoration press-fit stems in terms of initial mechanical stability.

Methods: Six matching pairs fresh frozen adult femora were obtained and prepared using a flexible canal reamer and fitted with either a Restoration or HMRS press-fit stem distally. All constructs were mechanically tested in axial compression, lateral bending, and torsion to obtain mechanical stiffness. Torque-to-failure was finally performed to determine the offset force required to clinically fail the specimen by either incurring damage to the femur, the stem, or the femur-stem interface.

Results: Restoration press-fit stems results were: axial stiffness (average=1871.1 N/mm, SD=431.2), lateral stiffness (average=508.0 N/mm, SD=179.6), and torsional stiffness (average=262.3 N/mm, SD=53.2). HMRS stems achieved comparable levels: axial stiffness (average=1867.9 N/mm, SD=392.0), lateral bending stiffness (average=468.5 N/mm, SD=115.3), and torsional stiffness (average=234.9 N/mm, SD=62.4). For torque-to-failure, the applied offset forces on Restoration (average=876.3 N, SD=449.6) and HMRS (aver-age=690.5 N, SD=142.0) stems were similar. There were no statistical differences in performance between the two stem types regarding axial compression (p=0.97), lateral bending (p=0.45), or torsional stiffnesses (p=0.07). Moreover, no differences were detected between the groups when tested in torque-to-failure (p=0.37). The mechanism of torsional failure for all specimens was “spinning” (i.e. surface sliding) at the femur-stem interface. No significant damage was detected to any bones or stem devices.

Conclusions: These results suggest that the Restoration and HMRS press-fit stems may be equivalent clinically in the immediate post-operative situation. Funding: Commerical funding Funding Parties: Stryker Orthopaedics

In this paper, a retrospective review was undertaken of a large musculoskeletal tumour database to identify patients who presented with tumours of the foot and ankle. Soft tissue tumours occurred more frequently than bone tumours, and were also more frequently malignant than bone tumours. In contrast to the more recent trend towards limb-preserving surgery in other anatomic areas, malignant tumours of the foot and ankle were frequently unresectable and were treated with amputation.

Although the majority of extremity tumours that present to the orthopaedic surgeon are found in the proximal limbs or around the knee, tumours of the ankle and foot are also relatively common. The purpose of this study is to identify the frequency with which benign and malignant bone and soft tissue tumours occur in the foot and ankle and the oncologic and surgical outcomes of these patients.

A retrospective review of a large musculoskeletal tumor database in a tertiary referral center from the years 1986–2002 was undertaken. For oncologic outcomes, a minimum two-year follow up was considered.

A total of one hundred and sixteen bone and one hundred and seventy-one soft tissue tumours were identified. Seventy-seven bone tumours were benign and thirty-nine were malignant. Sixty-six soft tissue tumours were benign and one hundred and five were malignant. The most common benign bone tumour was giant cell tumour and osteosarcoma was the most common malignancy. Malignant fibrous histiocytoma was common in the distal leg but synovial sarcoma and clear cell sarcoma were more common in the foot. Twenty patients with bone malignancies (51%) and twenty-four with soft tissue sarcomas (23%) had amputation as definitive surgical management. Death from metastases occurred in 25% of patients with bone malignancies and 10% of soft tissue sarcomas.

At this center, the majority of bone tumours treated are benign but the majority of soft tissue tumours are malignant. Limb salvage is often not possible and amputation for local tumour control is necessary far more often than in other anatomic sites.

Twenty-three patients with scapular chondrosarcomas presented to our institution between 1989 and 2003. Twenty-two were treated surgically while one presented with metastases and was treated palliatively. Fourteen patients underwent partial scapulectomy and eight had a Tikhoff-Linberg procedure. There were no local recurrences and only two patients have suffered a systemic recurrence at mean follow-up of fifty-two months. Mean functional scores were: TESS – 88, MSTS 1987 – 27 and MSTS 1993 – 84. Overall, the oncologic and functional outcome for these patients was excellent.

To examine the oncologic and functional outcome of patients treated for chondrosarcoma of the scapula.

Rates of local recurrence and metastasis for adequately treated chondrosarcomas of the scapula were very low and patient function was quite good.

Unlike previous reports in the literature, we found that scapular chondrosarcomas are highly amenable to limb salvage surgery and the oncologic and functional outcomes are excellent.

Retrospective review of our prospectively collected database for all patients treated surgically at our institution for scapular chondrosarcoma between 1989 and 2003.

Twenty-three patients presented with scapular chondrosarcoma, but one had spine metastases and was treated palliatively. Thus twenty-two patients were treated with limb salvage surgery. There were fourteen males and eight females. One patient presented as a local recurrence. Four tumors were grade one, sixteen grade two and two grade three. Eight were secondary to a primary benign primary tumor of bone. There were fourteen partial scapulectomies and eight Tikhoff-Linberg procedures. Surgical margins were positive in three cases. two patients received post-operative radiation and no patients received adjuvant chemotherapy. At last follow-up, twenty patients were alive with no evidence of disease (90.9%), one was alive with disease and one was dead of disease. There were two systemic recurrences and no local recurrences at an average follow-up of fifty-two months (range 12–113). Mean functional scores were: TESS – 88, MSTS – 1987 27 and MSTS 1993 – 84.

Introduction and Aims: Resection of large pelvic bone tumors often results in segmental defects with pelvic discontinuity and loss of the acetabulum. We reviewed the functional and oncologic outcomes following pelvic allograft and total hip arthroplasty (THA) reconstruction.

Method: A retrospective review of our prospectively collected database was undertaken. Minimum follow-up was 15 months (range 15–167 months). Nineteen patients were hemipelvic resections (12 Type I+II and seven Type I+II+III, 11 of these cases included partial sacral resection) reconstructed by hemipelvic allograft and THA. In comparison, five patients had Type II acetabular resections, reconstructed with structural allograft, roof ring and THA. Functional outcome was assessed by the Toronto Extremity Salvage score (TESS) and the Musculoskeletal Tumor Society scores (MSTS87 and MSTS93).

Results: Osteosarcoma and chondrosarcoma were the most frequent tumors. All patients required walking aids. In the hemipelvic group there were two early deaths (peri-operative haemorrhage and aplastic anaemia). In seven patients (37%), the allograft remained intact without infection but three required revision THA for component loosening. For these seven patients, the functional outcome scores were TESS 64%, MSTS87 17/35 and MSTS93 45% (mean follow-up 52 months). There were nine cases of deep infection (47%) with three patients maintaining a functional implant with antibiotic suppression. Of the remaining six patients with infection, four patients required hindquarter amputation, one patient required allograft removal and the allograft fragmented in the remaining patient. The 19th patient was revised following allograft fracture. Five patients sustained at least one allograft fracture.

In the Type II acetabular group, three patients had no complications, and two patients sustained dislocations. The average scores were TESS 78%, MSTS87 21/35 and MSTS93 64% (mean follow-up 55 months).

Conclusion: Reconstruction of large pelvic defects including the acetabulum using hemipelvic allograft and THA is associated with high complication rates, however when successful provides reasonable function. In comparison, the functional outcome after allograft and THA reconstruction of isolated Type II acetabular resections was better and more predictable.

Introduction and Aims: The management of bone defects created by Type 1 pelvic resections of large iliac bone tumors remains controversial. We reviewed the functional and oncologic outcome following Type I resection with and without bone reconstruction.

Method: A retrospective review of our prospectively collected database was undertaken analysing functional and oncological outcome of 16 patients with Type I pelvic resections. Minimum follow-up was 12 months (range 12–96 months). Outcome data was available on eight of 10 patients managed without reconstruction (WOR), with the residual ilium allowed to collapse back onto the sacrum, and on five of six patients with bone graft reconstruction (WR). Functional outcome was assessed by the Toronto Extremity Salvage score (TESS) and the Musculoskeletal Tumor Society scores (MSTS87 and MSTS93).

Results: Average age at surgery was 33 years (WOR) and 48 years (WR), (p=0.04), with average maximal tumor dimensions of 12cm and 9cm respectively (p=0.1). The most frequent diagnosis was chondrosarcoma. The WOR group average TESS, MSTS 87 and MSTS 93 scores were respectively 73%, 18/35 and 58% at an average of 50 months (range 24–96 months) compared to 69%, 21/35 and 51% at an average of 37 months (range 12–60 months) for the WR group. Thirty-three percent of WOR and 20% of WR patients did not require walking aids. Infection or wound necrosis occurred in 40% of WOR patients and 50% of WR patients. No local recurrences were identified.

Conclusion: Similar functional and oncologic outcome was achieved in both groups suggesting that bone reconstruction is not justified following Type I pelvic resection.

Aim: To explore the relationship between anatomical location in lower extremity soft tissue sarcoma and function as measured by the Musculoskeletal Tumour Society (MSTS 93) rating and Toronto Extremity Salvage Score (TESS).

Methods: 207 patients of median age 54 years (15 to 89) were reviewed. 58 tumours were superficial and 149 deep. Deep tumours were allocated to one of 9 locations based on anatomical compartments.

Results: Treatment of superficial tumours did not lead to significant changes in MSTS (mean 90.6% vs 93.0%, p=0.566) or TESS (mean 86.4% vs 90.9%, p=0.059). Treatment of deep tumours lead to significant reductions in MSTS and TESS (mean 86.9% vs. 83.0%, p=0.001. mean 83.0% vs. 79.4%, p=0.015). There were no significant differences in MSTS and TESS when overall scores were compared by anatomical location. Exploratory analysis of MSTS subscales showed groin tumours were more painful than others, and posterior calf tumours had the lowest scores for gait. TESS subscales analysis suggested groin and buttock tumours were associated with difficulty sitting, and groin tumours were associated with difficulty dressing. Further exploratory analysis suggested “conservative” surgical excision of low-grade liposarcomas in all locations was associated with a significant decrease in functional scores.

Conclusion: There is significant variation in MSTS and TESS subscale scores when anatomical locations are compared. The “conservative” surgery used in the treatment of low-grade fatty tumours in all locations has a significant impact on functional scores.

Introduction Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing pre-operative versus post-operative RT is described.

Methods One hundred and ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, six weeks, and three, six, 12, and 24 months after surgery. One hundred and eighty-five patients had function data.

Results Patients treated with post-operative RT had better function with higher MSTS (25.8 v 21.3, P < .01), TESS (69.8 v 60.6, P =.01), and SF-36 bodily pain (67.7 v 58.5, P =.03) scores at six weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health sub-scales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first two years after treatment.

Conclusions The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.

Introduction Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine.

Methods We followed-up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature.

Results No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery.

Conclusions This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.

Introduciton In our experience, amputation is rarely indicated in osteosarcoma. Amputation is more frequently required in soft tissue sarcoma for the following reasons: 1) recurrent tumour in previously radiated field; 2) composite tissue involvement of soft tissue, bone, vessels and nerves; 3) size of lesion. We have measured functional outcome in bone and soft tissue sarcoma using a combination of clinimetric measures describing impairment and patient determined measures assessing disability (1,2).

Methods In a matched case-control study (3), 12 patients with amputation were matched with 24 patients treated by limb-sparing surgery on the following variables: age, gender, length of follow-up, bone versus soft-tissue tumor, anatomic site, and treatment with adjuvant chemotherapy. End points included the Toronto Extremity Salvage Score (TESS), a measure of physical disability; the Shortform-36 (SF-36), a generic health status measure; and the Reintegration to Normal Living (RNL), a measure of handicap.

Results Mean TESS score for the patients with amputations was 74.5 versus 85.1 for the limb-sparing patients. (p = .15). Only the physical function subscale of the SF-36 showed statistically significant differences, with means of 45 and 71.1 for the amputation versus limb-sparing groups, respectively (p = .03). The RNL for the amputation group was 84.4 versus 97 for the limb-sparing group (p = .05). Seven of the 12 patients with amputations experienced ongoing difficulty with the soft tissues overlying their stumps. There was a trend toward increased disability for those in the amputation group versus those in the limb-sparing group, with the amputation group showing significantly higher levels of handicap.

Conclusions These data suggest that the differences in disability between amputation and limb-sparing patients are smaller than anticipated. The differences may be more notable in measuring handicap.

113 consecutive patients with soft tissue sarcoma treated by excision and reconstructive flaps were studied to assess the risk of complications and to compare local tumour control with those in whom primary wound closure was possible.

Minimum follow-up was 24 months and mean age was 55 years (16–95). The sarcoma was located in the lower extremity in 83 and upper extremity 30 patients. Significant wound complications developed in 37 patients (33%). The most common complications were wound infections or partial necrosis occurring in 16% (18/113) and 13% (15/113) respectively. Complete flap necrosis requiring flap removal occurred in 6 patients (5%). Three patients (2.3%) required amputation as a result of complications. Significant risk factors for development of wound complications include location of tumour in the lower limb compared to upper limb (relative risk 2.3, p=0.02) and use of pre-operative radiotherapy compared to no or post-operative radiotherapy (relative risk 2.05, p=0.02). There was no difference in rates of complications in patients with free or pedicled flaps, tumours < or > 5cm, distal or proximal location of tumour.

The rates of negative excision margins (80%) and wound complications in patients who required reconstructive flaps were not different from that for the other patients treated at our centre who did not require reconstructive flaps.

The use of soft tissue reconstructive flaps did not reduce the risk of positive excision margins or the rates of wound complications. The risk of amputation secondary to flap complication or failure is low.