What’s New in Musculoskeletal Tumor Surgery

Orthopaedic surgeons continued to be faced by novel challenges related to the COVID-19 pandemic over the past year. Nevertheless, inquiry into the treatment of tumors of the musculoskeletal system continued to result in a proliferation of available information to help to guide clinical practice. As in the past, the vast majority of published studies were retrospective in nature, likely due to the rarity and expansive range of the diseases treated by orthopaedic oncologists. Therefore, the new information described in this Guest Editorial, albeit robust, should be considered in the context of the limitations of the evidence. We conclude this article with studies by musculoskeletal oncologists that are unique in that they are prospective collaborative endeavors. Primary Bone Tumors Table I shows a number of recent studies on bone tumors1-45. TABLE I - Studies on Bone Tumors Study Article Title Key Findings Bone: pelvis and spine Liang 1 (2021) Venous Tumor Thrombus in Primary Bone Sarcomas in the Pelvis. A Clinical and Radiographic Study of 451 Cases A venous tumor thrombus is most common in patients with pelvic osteosarcoma (23%) compared with patients with other primary bone sarcomas and is a negative prognostic factor. Erol 2 (2021) Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma. Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation Double-barreled free vascularized fibular graft after iliosacral resection for Ewing sarcoma in children resulted in the need for reoperation in 3 of 16 patients. Union rates were high in this cohort, with good functional outcomes. Kurisunkal 3 (2021) Is 2 mm a Wide Margin in High-Grade Conventional Chondrosarcomas of the Pelvis? In a series of 105 patients with pelvic chondrosarcoma, a margin of >2 mm was a significant predictor of increased local recurrence-free survival. Jamshidi 4 (2021) Type III Internal Hemipelvectomy for Primary Bone Tumors with and without Allograft Reconstruction: A Comparison of Outcomes In a retrospective cohort of 32 patients who underwent a Type-III pelvic resection, those who underwent allograft reconstruction fared better than those who did not undergo reconstruction with regard to functional outcomes, pain, and limp. Xie 5 (2022) A Novel Limb-Salvage Reconstruction Strategy with a Custom Hemipelvic Endoprosthesis and Preserved Femoral Head Following the Resection of Periacetabular Tumors: A Preliminary Study In 14 patients who underwent acetabular resection, reconstruction with an individualized hemipelvic prosthesis and preservation of the femoral head showed acceptable early functional and oncological outcomes and a 35.7% complication rate. Jawad 6 (2022) Impact of Local Treatment Modality on Overall- and Disease-Specific Survival for Nonmetastatic Pelvic and Sacral Ewing Sarcoma Data from the ACS National Cancer Database and the SEER database on patients treated in the United States for Ewing sarcoma of the sacrum or pelvis indicate that radiation therapy is the most common local modality and has similar efficacy as surgery and surgery with radiation therapy. Kapoor 7 (2022) Leaving Half the Acetabulum in Pelvic Resections Improves Hip Function. Is There a Need to Revisit Conventional Pelvic Resections? Transacetabular resections, where feasible, result in better functional outcomes than full acetabular resections. Brinkmann 8 (2022) Impact of Preoperative Sarcopenia in Patients Undergoing Sacral Tumor Resection In a series of 48 patients undergoing sacrectomy, central sarcopenia was not predictive of wound complications or infection but was an independent risk factor for local tumor recurrence. Jawad 9 (2021) Primary Mobile Vertebral Column Sarcomas: Prognostic Factors Vary by Histologic Subtypes The SEER database was used to identify 712 patients with mobile vertebral column sarcomas. The 5-year, disease-specific survival was 56%, with worse survival for osteosarcoma. Wu 10 (2021) Three-Dimensional Printing-Based Personalized Limb Salvage and Reconstruction Treatment of Pelvic Tumors In a series of 28 patients who underwent personalized 3D printing-based limb salvage and reconstruction for pelvic tumors, at a median follow-up of 32 months, 9 patients had died and 9 patients had complications (infection, dislocation). Functional outcomes were good. Stroud 11 (2022) Survival of Patients with Primary Osseous Malignancies of the Mobile Spine Is Associated with Access to “Standard Treatment” Protocols The California Cancer Registry identified 484 patients with malignancies of the mobile spine. Medicaid and public insurance and Medicare were associated with higher mortality compared with private insurance. The authors concluded that patients with public insurance are vulnerable to worse outcomes, even if they receive standard treatment. Fujiwara 12 (2021) Limb-Salvage Reconstruction Following Resection of Pelvic Bone Sarcomas Involving the Acetabulum The authors reviewed a series of 122 patients with a periacetabular bone sarcoma who underwent internal hemipelvectomy and various forms of reconstruction or no reconstruction. Functional outcomes scores were worse in those who had a major complication. If the ilium can be maintained, an ice-cream cone prosthesis with antibiotic-laden cement is a reasonable option. Court 13 (2021) Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors. Technique and Outcomes in a Series of 33 Patients There were 33 patients who underwent video-assisted thoracoscopic surgery for resection of a vertebral tumor. There were 18 complications (55%), mostly pulmonary. The authors recommended the technique for smaller tumors without substantial chest wall and/or mediastinal invasion. Wellings 14 (2021) Comparison of Free Vascularized Fibular Flaps and Allograft Fibular Strut Grafts to Supplement Spinopelvic Reconstruction for Sacral Malignancies The authors reviewed 44 cases of en bloc resection of the pelvis for a malignant tumor and concluded that supplementation of spinopelvic reconstruction with a free vascularized fibula was associated with a shorter time to union compared with reconstruction with an allograft fibular strut graft. Bone: lower extremity Ogura 15 (2021) Finn/Orthopaedic Salvage System Distal Femoral Rotating-Hinge Megaprostheses in Oncologic Patients. Long-Term Complications, Reoperations, and Amputations The authors reviewed 214 patients treated with a Finn/Orthopaedic Salvage System (OSS) knee prosthesis (Zimmer Biomet) after distal femoral resection over a 26-year period. There were 312 reoperations, and the cumulative incidence of implant removal or revision for any reason at 10 years was 30.1%, with a continued risk of 1.24% per year. El Ghoneimy 16 (2022) What Is the Cumulative Incidence of Revision Surgery and What Are the Complications Associated with Stemmed Cementless Nonextendable Endoprostheses in Patients 18 Years or Younger with Primary Bone Sarcomas About the Knee The authors reviewed 328 patients who were <18 years of age and were treated for a bone sarcoma around the knee with resection and endoprosthetic reconstruction. The 8-year cumulative incidence of revision surgery for any cause was 32%. The mean leg-length discrepancy for those who were skeletally immature at the time of surgery was 3.5 cm. Functional scores were excellent in those who retained the prosthesis. Geiger 17 (2022) What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report Data from the Childhood Cancer Survivor Study were used to determine the risk of late amputation following limb-salvage surgery in children. The cumulative incidence of amputation at 25 years after limb salvage was 18%. Risk factors for amputation were male gender and history of periprosthetic joint infection. Groundland 18 (2022) What Are the Long-Term Surgical Outcomes of Compressive Endoprosthetic Osseointegration of the Femur with a Minimum 10-Year Follow-up Period? This was a retrospective series of 110 patients with primary bone sarcoma of the proximal or distal femur. Of the 110 patients, 25 were treated with a compressive osseointegration implant and 85 were treated with conventional stemmed implants or amputation. Of the 25 patients, 20 were alive at 10 years. The rate of mechanical failure related to the compression device was 12%, and all failures occurred in the first 29 months. Fernandes 19 (2021) Clinically Important Reductions in Physical Function and Quality of Life in Adults with Tumor Prostheses in the Hip and Knee: A Cross-Sectional Study The authors assessed 30 patients who underwent endoprosthetic reconstruction of the hip or knee and compared them with 30 age-matched controls with regard to physical function and quality of life. Pain and objective functional limitations were common in the surgical group, even in the contralateral limb. Döring 20 (2021) How Common Are Chronic Residual Limb Pain, Phantom Pain, and Back Pain More Than 20 Years After Lower Limb Amputation for Malignant Tumors? There were 21 patients with a median follow-up of 41 years who completed a standardized questionnaire to assess pain and daily prosthesis use; 17 of the 21 patients reported phantom limb pain and back pain. However, the 21 patients represented a small number of those who had undergone amputation (124), due to death, loss to follow-up, and declining to participate. Nevertheless, residual functional impairment appears to be common. Hindiskere 21 (2021) What Is the Survival of the Telescope Allograft Technique to Augment a Short Proximal Femur Segment in Children After Resection and Distal Femur Endoprosthesis Reconstruction for a Bone Sarcoma? The authors reviewed 14 patients who underwent telescopic allograft augmentation of the femur due to a short residual bone segment. There were 3 delayed unions (14%), but no nonunions. The survivorship of the implant at 7 years was 80%. The authors concluded that telescopic allograft is a helpful method to provide adequate bone length to preserve the hip joint. Christ 22 (2021) Compliant Compression Reconstruction of the Proximal Femur Is Durable Despite Minimal Bone Formation in the Compression Segment This was a retrospective case series of 12 patients who underwent proximal femoral reconstruction with compliant compression fixation. In contrast to distal femoral compliant compression implants, there was minimal bone formation at the compression segment. However, there was only 1 implant failure during a median follow-up of 6 years. Jamshidi 23 (2021) How Can We Differentiate Local Recurrence from Heterotopic Ossification After Resection and Implantation of an Oncologic Knee Prosthesis in Patients with a Bone Sarcoma? Heterotopic ossification after the use of oncologic knee prostheses for reconstruction after tumor resection occurred in 8% of patients. Local recurrence occurred in 10%. Heterotopic ossification occurred earlier than local recurrence and was associated with well-defined borders. Jamshidi 24 (2022) Fibular Strut Allograft or Bone Cement for Reconstruction After Curettage of a Giant Cell Tumour of the Proximal Femur: A Retrospective Cohort Study The authors reviewed 26 patients with a giant cell tumor of the proximal femur. Recurrence was similar between the allograft-strut reconstruction group (25%) and the cement reconstruction group (21%). Osteoarthritis was more common in the cement group. Lex 25 (2021) Acetabular Complications Are the Most Common Cause for Revision Surgery Following Proximal Femoral Endoprosthetic Replacement: What Is the Best Bearing Option in the Primary and Revision Setting? The authors reviewed 233 patients who underwent proximal femoral endoprosthetic replacement for oncologic reconstruction. The revision rate was 15% at a mean follow-up of 74 months. Acetabular revisions were the most common reoperation in both the hemiarthroplasty and arthroplasty groups. Re-revision rates were lower with dual-mobility bearings, constrained bearings, or large-diameter heads (>32 mm). Ogura 26 (2021) Long-Term Competing Risks for Overall and Cause-Specific Failure of Rotating-Hinge Distal Femoral Arthroplasty for Tumour Reconstruction A review of 209 patients who underwent resection of the distal femur for tumor and reconstruction using a rotating-hinge knee prosthesis between 1991 and 2016 was performed. Risk factors for implant failure were the percentage of femoral resection and extent of quadriceps resection. The type of joint resection was associated with the risk for infection, and a bone-stem ratio of >2.5 was predictive of aseptic loosening. Jawad 27 (2021) Malignant Neoplasms Originating from the Bones of the Foot: Predilection of Hematological Malignancies and Sex-Related and Ethnic Disparities in Amputation The authors queried the National Cancer Institute’s SEER database and identified 514 patients diagnosed with a malignancy of the small bones of the lower limb. Disease-specific survival was 73% at 5 years, and male gender and Hispanic race were associated with amputation. Labott 28 (2021) Utility of the ACS-NSQIP Surgical Risk Calculator in Predicting Postoperative Complications in Patients Undergoing Oncologic Proximal Femoral Replacement The authors used the online ACS-NSQIP surgical risk calculator to predict complications for 103 proximal femoral replacements. They found that the calculator significantly underestimated the actual risk of 54%. Groundland 29 (2021) Is Osseous Reattachment of the Greater Trochanter Necessary Compared to Soft-Tissue-Only Abductor Repair in Proximal Femoral Megaprosthesis Reconstruction? The authors reviewed 53 patients who underwent proximal femoral endoprosthetic reconstruction and found that salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function compared with soft-tissue-only abductor repair. Errani 30 (2021) Does the Addition of a Vascularized Fibula Improve the Results of a Massive Bone Allograft Alone for Intercalary Femur Reconstruction of Malignant Bone Tumors in Children? The authors reviewed 60 pediatric patients with diaphyseal tumors undergoing intercalary resection and reconstruction with massive allograft with or without vascularized free fibula. No differences in union rates, complications, or functional outcomes were found. Bone: upper extremity Schneider 31 (2021) What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors? The authors reviewed 31 patients who underwent total humeral endoprosthetic reconstruction for a primary bone malignancy. The revision-free implant survivorship was 77% at 1 year and 74% at 5 years. At a mean follow-up of 75 months, only 13 patients were still alive, and these patients had good functional outcomes. Liang 32 (2022) Elbow Hemiarthroplasty with a 3D-Printed Megaprosthesis for Defects of the Distal Humerus or Proximal Ulna After Tumour Resection: A Preliminary Report There were 13 patients with aggressive or malignant tumors of the distal humerus or proximal ulna who underwent en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty. The preparation of the prosthesis took a mean of 8.0 days. Apart from 1 dislocation, there were no failures related to the implant at a mean follow-up of 25.7 months. Functional outcomes were excellent. Houdek 33 (2022) Allograft Prosthetic Composite Reconstruction Using a Reverse Total Shoulder Arthroplasty for Failed Oncologic Proximal Humerus Reconstruction There were 11 patients with failure of a previous proximal humeral reconstruction treated with a reverse shoulder arthroplasty with an allograft-prosthetic composite. Re-revisions were required for 2 patients with allograft complications. Overall function improved significantly. Kruckeberg 34 (2021) Total Elbow Arthroplasty for Tumors of the Distal Humerus and Elbow The authors reported on 33 patients who underwent elbow arthroplasty for oncologic reconstruction. Postoperative complications were common (45%), with the most common being periprosthetic fracture. The 5-year implant survival was 88%. Jawad 35 (2021) Prognostic Factors, Disparity, and Equity Variables Impacting Prognosis in Bone Sarcomas of the Hand: SEER Database Review The authors queried the National Cancer Institute’s SEER database for patients diagnosed with primary sarcomas originating from the bones of the hand and the wrist. Disease-specific survival was 90% at 5 years and 84% at 10 years. Imaging and perioperative management Cranmer 36 (2022) Is Chemotherapy Associated with Improved Overall Survival in Patients with Dedifferentiated Chondrosarcoma? A SEER Database Analysis The authors queried the SEER database for patients diagnosed with non-metastatic dedifferentiated chondrosarcoma and found that, in 185 patients, chemotherapy did not improve survival. Kiatisevi 37 (2022) Does Local Zoledronate Applied to Pasteurized Bone Autografts Improve the Likelihood of Union of Graft-Host Junctions After Limb-Sparing Surgery? The authors reviewed 73 patients who underwent oncologic reconstruction with pasteurized bone autograft with follow-up of at least 2 years. There were 8 metaphyseal fractures and 7 nonunions. Local zoledronate application did not improve union rates. Holzer 38 (2021) Is There an Association Between Bone Microarchitecture and Fracture in Patients Who Were Treated for High-Grade Osteosarcoma? A Controlled Study at Long-Term Follow-up Using High-Resolution Peripheral Quantitative CT Nineteen patients treated for osteosarcoma at least 20 years previously were assessed with dual x-ray absorptiometry and high-resolution peripheral quantitative CT; they were also queried with regard to fracture history. The authors found that a high proportion had osteopenia or osteoporosis and experienced fractures. However, the authors did not find differences in microarchitectural bone parameters. Aryal 39 (2021) What Is the Comparative Ability of 18F-FDG PET/CT, 99mTc-MDP Skeletal Scintigraphy, and Whole-Body MRI as a Staging Investigation to Detect Skeletal Metastases in Patients with Osteosarcoma and Ewing Sarcoma? The authors prospectively recruited 54 patients who were diagnosed with osteosarcoma or Ewing sarcoma. The presence of skeletal metastases was assessed with 18F-FDG PET/CT, whole-body MRI, and 99mTc-MDP skeletal scintigraphy. There was no difference found in the sensitivity, specificity, negative predictive value, or positive predictive value among the 3 staging modalities. Laitinen 40 (2021) Clinical Differences Between Central and Peripheral Chondrosarcomas There were 714 patients treated surgically at 2 centers for chondrosarcoma of the extremities or pelvis. Oncologic outcomes were similar between the central and peripheral locations. In patients with hereditary multiple exostosis, the most common locations were the pelvis and scapula. Tsagkozis 41 (2022) Intralesional Margin After Excision of a High-Grade Osteosarcoma: Is It a Catastrophe? In this small series, oncologic outcomes were improved in intralesional resections of osteosarcoma in cases in which there was a good response to chemotherapy. Lazarides 42 (2022) Investigating Readmission Rates for Patients Undergoing Oncologic Resection and Endoprosthetic Reconstruction for Primary Sarcomas and Tumors Involving Bone In a retrospective review of 149 patients who underwent surgery for a primary bone tumor or a soft-tissue tumor invading bone, the readmission rate within 90 days was 28.3% and was associated with female sex, higher tumor grade, and longer procedure duration. Haase 43 (2022) Tranexamic Acid Improves Early Postoperative Mobilization in Cancer Patients Undergoing Endoprosthetic Reconstruction In this comparative retrospective cohort study, the authors found that patients who underwent oncologic endoprosthetic reconstruction were more likely to walk and had longer endurance if tranexamic acid was administered perioperatively. Schumacher 44 (2022) Evaluation of Triage Tool for Tumors: A retrospective cohort with was used to determine that a that and is a in from (2021) Osteosarcoma: of Outcomes The authors reviewed patients treated at a for a osteosarcoma. a median follow-up of 6 years, 3 patients a local recurrence and 5 patients and Spine The reconstruction of the pelvis following internal hemipelvectomy has an of clinical Reconstruction that reported to reasonable surgical outcomes, albeit with high complication rates, free vascularized fibular individualized hemipelvic an ice-cream cone and personalized printing-based limb salvage and reconstruction A studies identified risk factors for oncologic and surgical outcomes in pelvic a venous tumor a margin of acetabular resection compared with resection, and The National Cancer Institute’s and Results the of National Cancer and the California Cancer Registry were queried by authors who concluded that radiation therapy is the most common local modality used in the United States for Ewing sarcoma of the sacrum or pelvis and has similar efficacy to surgical resection with or without radiation that 5-year disease-specific survival in patients with mobile vertebral column sarcomas was 56%, with worse survival for and that patients with malignancies of the mobile spine with public insurance are vulnerable to worse outcomes, even if they receive standard Lower Extremity Reconstruction of the femur and is of in the with to review of the outcomes of endoprosthetic reconstruction. the Finn/Orthopaedic Salvage System distal femoral rotating-hinge and compliant compressive The of the in these retrospective series from 12 to 328 patients, all with to follow-up cumulative revision rates were around the failures in compliant compressive which for shorter residual bone were with However, these prostheses are is Hindiskere described the outcomes of telescopic allograft augmentation to residual femoral with implant survivorship of at 7 outcomes of for oncologic also an of Geiger and Döring published functional and outcomes 20 to 40 years after the treatment for a limb sarcoma. The authors found that the cumulative incidence of amputation at 25 years after limb salvage was with periprosthetic joint infection as a risk factor for failure of limb Phantom limb pain and functional impairment are even after amputation. It is that, the high incidence of complications with limb-salvage all should be feasible, to limb in patients. The reconstruction of the proximal femur has a of Jamshidi reported that patients with a giant cell tumor of the proximal femur are more likely to if they undergo reconstruction with cement than strut In a retrospective from the United Lex found that, in patients with proximal femoral endoprosthetic acetabular revisions were the most common reoperation following both hemiarthroplasty and and rates were lower with dual-mobility bearings, constrained bearings, or large-diameter heads (>32 Christ reported on a small series of 12 patients who underwent proximal femoral reconstruction with compliant compression and found that bone at the was not as is in distal femoral Groundland reported that, in patients who underwent proximal femoral endoprosthetic salvage of the greater trochanter for reattachment to the endoprosthesis did not lead to improved function compared with soft-tissue-only abductor Extremity The upper extremity is by bone sarcomas and bone However, there studies the oncologic and surgical outcomes of reconstruction of the shoulder and Schneider reviewed 31 patients who underwent total humeral endoprosthetic The revision-free implant survivorship was 77% at 1 year and 74% at 5 years. However, only 13 patients were still alive for the functional Liang and Kruckeberg reviewed the outcomes of patients who underwent elbow arthroplasty with or standard prostheses and reported that, a high risk of complications, implant survival at 2 and 5 years was to with excellent functional outcomes. regard to the proximal Houdek reviewed 11 patients with a previous proximal humeral reconstruction who were treated with reverse shoulder arthroplasty with an allograft-prosthetic composite. Re-revisions were required for 2 patients with complications. The function improved Jawad queried the SEER database for patients diagnosed with primary sarcomas originating from the bones of the hand and the and reported that disease-specific survival was 90% at 5 years and 84% at 10 Imaging and In studies in the recent authors reported on perioperative management and for bone In a SEER database study, Cranmer reported that chemotherapy did not improve survival for dedifferentiated In a comparative retrospective cohort study, Haase found that patients who underwent oncologic endoprosthetic reconstruction were more likely to walk and had longer endurance if tranexamic acid was administered In a retrospective review by Lazarides 149 patients were identified who underwent a surgical procedure for a primary bone tumor or a soft-tissue the readmission rate within 90 days was 28.3% and was associated with female sex, higher tumor grade, and longer procedure in an prospective study, Aryal assessed 54 patients with osteosarcoma or Ewing sarcoma for the presence of skeletal metastases with whole-body and skeletal scintigraphy. The authors found no difference in the sensitivity, specificity, negative predictive value, or positive predictive value among the 3 staging Tumors Table shows a number of recent studies on soft-tissue TABLE - Studies on Tumors Study Article Title Key Findings (2022) Is Use Associated with Overall Survival in Patients with Sarcoma? A Study The database was queried and the authors found that that, even after for a number of there was an between use and increased survival in patients with soft-tissue sarcoma. However, the authors did not (2022) Outcomes of Sarcoma in In a retrospective review of patients treated at a 48 patients who were years of age and were diagnosed with a soft-tissue sarcoma over 23 years had a median survival of 20 months. The authors recommended management for patients on a 48 (2022) Does the Prognostic in the of Patients Undergoing Surgery for a Sarcoma? Study The authors of this retrospective review of patients with soft-tissue sarcoma treated at 6 in 3 found that the Prognostic and among other factors as tumor and grade, was predictive of survival. (2021) A Comparison of Clinical Outcomes Between Excision After and in Patients with Sarcoma of the A Cohort Study In this database study, the authors used to outcomes between patients with a soft-tissue sarcoma