Although the recurrence rate of giant cell tumors of bone (GCTB) is relatively high exact data on treatment options for the recurrent cases is lacking. The possible surgical procedures range from repeated intralesional curettage to wide resection. 214 patients with histologically certified GCTB have been treated at the authors department from 1980 to 2007. 67 patients with at least one local recurrence were included in this study. The mean follow-up was 77.3 months. The data was evaluated according the re-recurrence rate with regard to the surgical procedure for the recurrence. The mean time until the first local recurrence was 22.0 months; the mean number of recurrences per patient was 1.4. The recurrence occurred in 69.7 % (46 out of 66 patients) within the first two years. If after intralesional procedures (curettage or intralesional resection) no adjunct was used the re-recurrence rate was 58.8 % (10 out of 17 patients) and decreased to 21.7 % (5 out of 23 patients) if a combination of all adjuncts (PMMA + burring) was used. The likelihood of re-recurrence was reduced by the factor 5.508 which was clearly significant (p = 0.016). In case of wide resection no re-recurrence occurred. Seven patients (10.5 %) developed pulmonary metastases. Fourteen patients (20.9 %) finally received an endoprosthesis; 12 due to tumor recurrence, 2 due to secondary arthritis. Recurrent GCTB can be treated by further curettage with additional burring and cementing with an acceptable re-recurrence rate of 21.7 %. The rate of patients finally needing an endoprosthesis is 20.9 %. Due to the high rate of pulmonary metastases recurrent GCTB may be considered as a severe disease.
The development of local recurrence after multimodal treatment of osteosarcoma is associated with a very poor prognosis. The importance of clear surgical margins has been demonstrated in multiple studies, however up to date there are no studies defining which margin width is safe from an oncological perspective. The purpose of this retrospective analysis was to evaluate whether margin width or other surgical and tumour-related factors influence the development of local recurrence in osteosarcoma patients. The files of 1867 consecutive patients with high-grade central osteosarcoma of the extremities, the pelvic bones and the shoulder girdle, who had achieved a complete surgical remission during combined-modality therapy on neoadjuvant Cooperative Osteosarcoma Study Group (COSS) protocols between 1986 and 2005, were reviewed. Of those, the data required were available for 1369 patients, who were the subject of this analysis. Eighty of these patients developed a local recurrence during the course of their illness. The median surgical margin width amounted to 45 mm (range, 0 to 140 mm) in the local recurrence (LR) group and 50 mm (range, 0 to 350 mm) in the non-local recurrence (NLR) group (p=0.106). No statistically significant difference between the two groups was found regarding tumour size (mean, 10.38 cm and 9.53 cm respectively, p=0.169), T-status (p=0.225) and presence of pathological fracture (p=0.231). However infiltration of the soft tissue beyond the periosteum was documented in 58.8% of the patients with local recurrence and only in 36.9% of the rest (p=0.003). Furthermore, in 50% of the LR group the biopsy had been performed in a centre other than the one performing the definitive tumour resection, compared to 30.2% of the NRL group (p=0.001). In conclusion, the absolute metric width of surgical margins does not define oncological safety. Local recurrence is more likely to develop in patients with soft tissue infiltration beyond the periosteum or those biopsied in a centre other than the one performing the tumour resection.
78 patients (41 male and 37 female) with a revision total knee or hip arthroplasty were enrolled in this prospective study to evaluate the role of new laboratory markers in the diagnostic of deep implant infection. The average age at the time of surgery was 64 years. Based on intraoperative cultures, 21 patients had a septic and 57 patients had an aseptic revision total joint arthroplasty. White blood cell counts, erythrocyte sedimentation rate, C-reactive protein levels, interleukin-6, procalcito-nin and TNF-alpha were measured in preoperative blood samples. Diagnostic cut of values were determined by Receiver Operating Characteristic curve analysis. If patients with rheumatoid arthritis and other concomitant infections are excluded the C-reactive protein (>
3.2md/dl) and interleukin 6 (>
12 pg/ml) have the highest sensitivity (0.95). Interleukin 6 is less specific than the C-reactive protein (0.87 versus 0.96). Combining C-reactive protein and interleukin identifies all patients with deep implant infection. Procalcitonin (>
0.3 ng/ml) and TNF-alpha (>
40 ng/ml) are very specific (0.98 versus 0.94)) but have a low sensitivity (0.33 versus 0.43). The combination of C-reactive protein and interleu-kin 6 is an excellent screening tests for deep implant infection. Highly specific marker like procalcitoninn as well as preoperative joint aspiration might be useful to identify patients with true positive CRP and/or interleu-kin 6 levels.
This prospective study evaluates the role of new laboratory markers in the diagnosis of deep implant infection in 78 patients (41 men and 37 women) with a revision total knee or hip replacement. The mean age at the time of operation was 64.0 years (19 to 90). Intra-operative cultures showed that 21 patients had a septic and 57 an aseptic total joint replacement. The white blood cell count, the erythrocyte sedimentation rate and levels of C-reactive protein, interleukin-6, procalcitonin and tumour necrosis factor (TNF)-α were measured in blood samples before operation. The diagnostic cut-off values were determined by Received Operating Characteristic curve analysis. C-reactive protein (>
3.2 md/dl) and interleukin-6 (>
12 pg/ml) have the highest sensitivity (0.95). Interleukin-6 is less specific than C-reactive protein (0.87 The combination of C-reactive protein and interleukin-6 measurement provide excellent screening tests for infection of a deep implant. A highly specific marker such as procalcitonin and pre-operative aspiration of the joint might be useful in identifying patients with true positive C-reactive protein and/or interleukin-6 levels.
Type BI rotationplasty is currently indicated for children with tumours of the proximal femur whereas type BIIIa rotationplasty is reserved for those in which the entire femur has to be removed. Our aim was to compare these two types of rotationplasty and determine whether the knee should be preserved in children with tumours of the proximal femur. We compared the post-operative complications, oncological outcome, range of movement, Enneking score and radiographs of six children, who had undergone type BI rotationplasty with those of 12 who had undergone type BIIIa rotationplasty. Patients with type BI rotationplasty had a mean Enneking score of 21.6 compared with 24.4 in those with type BIIIa rotationplasty, and worse mean results in all of the parameters investigated. We conclude that type BI rotationplasty has a worse functional outcome and more complications than type BIIIa rotationplasty in children under the age of ten years.
Our aim was to investigate the outcome of excision of osteochondromas. Between 1994 and 1998, 92 symptomatic osteochondromas in 86 patients were excised. There were 40 women and 46 men with a mean age of 20 years (3 to 62). Of these, 56 had a solitary osteochondroma and 30 had multiple hereditary tumours. The presenting symptoms were pain (79.1%), swelling (23.3%), reduced range of movement (19.8%), cosmetic abnormalities (17.4%), and bursitis (12.8%). The most common site (37.6%) was around the knee. Four patients had major complications (4.7%) including one intra-operative fracture of the femoral neck and three nerve palsies which resolved after decompression. Six patients had minor complications. Overall, 93.4% of the preoperative symptoms resolved after excision of the tumours. Excision is a successful form of treatment for symptomatic osteochondromas with a low morbidity.
In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumors of the proximal humerus. An osteoarticular allograft was used in 11, a The complication rate was lowest after reconstruction with a tumour prosthesis. The At follow-up at two years the functional results for the three reconstructive procedures were the same with a mean functional rating of 79% (Musculoskeletal Tumor Society). Excision of the glenoid had no influence on the functional result. Our findings indicate that the use of a tumour prosthesis is the most reliable limb-salvage procedure for the proximal humerus. The
We treated 58 patients with osteoid osteoma by CT-guided radiofrequency ablation (RF). In 16 it followed one or two unsuccessful open procedures. It was performed under general anaesthesia in 48, and spinal anaesthesia in ten. The nidus was first located by thin-cut CT (2 to 3 mm) sections. In hard bony areas a 2 mm coaxial drill system was applied. In softer areas an 11-gauge Jamshidi needle was inserted to allow the passage of a 1 mm RF probe into the centre of the nidus. RF ablation was administered at 90°C for a period of four to five minutes. Three patients had recurrence of pain three, five and seven months after treatment, respectively, and a second percutaneous procedure was successful. Thus, the primary rate of success for all patients was 95% and the secondary rate was 100%. One minor complication was encountered. CT-guided RF ablation is a safe, simple and effective method of treatment for osteoid osteoma.
We assessed the results of 17 limb-salvage procedures using osteoarticular allografts after wide resection of high-grade malignant bone tumours. All patients received chemotherapy. At the five-year follow-up, three patients had died from metastases. The allografts survived for five years in only seven patients all of whom had good function, ranging from 73% to 90% of normal. The allografts were removed because of fracture in seven patients and infection in one, and in all of these a second limb-salvage procedure was undertaken. With such a low rate of survival of osteoarticular allografts, we believe that their use in the management of high-grade malignant bone tumours should, at best, be considered a temporary solution.
Bone tumours may recur locally even after wide surgical excision and systemic chemotherapy. Local control of growth may be accomplished by the addition of cytostatic drugs such as methotrexate (MTX) to bone cement used to fill the defect after surgery and to stabilise the reconstructive prosthesis. We have studied the elution kinetics of MTX and its solvent N-methyl-pyrrolidone (NMP) from bone cement and their biological activities in five cell lines of osteosarcoma and in osteoblasts, and compared them with the effects of the parent compounds alone and in combination. Our findings show that MTX is released continuously over months at concentrations highly cytotoxic to osteosarcoma cells and suggest that the impregnated bone cement would be effective in the long term. Proliferating osteoblasts, however, were much less sensitive towards MTX. The dose-response relationship for NMP and experiments with MTX/NMP-mixtures show that the eluted concentrations of solvent are not toxic and do not influence the effects of MTX. We suggest that bone cement containing MTX dissolved in NMP releases the drug in a suitable and effective way and may be of value in the treatment of bone tumours.
