Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Selected Papers Presented at the 2007 Meeting of the Musculoskeletal Tumor Society 9 articles


Intraarterial Chemotherapy for Extremity Osteosarcoma and MFH in Adults

Ronald R. Hugate MD, Ross M. Wilkins MD, Cynthia M. Kelly MD, Walt Madsen MD, Ioana Hinshaw MD, Anne B. Camozzi BA The neoadjuvant treatment of osteosarcoma using intravenous agents has resulted in survival rates of 55% to 77% [3, 5, 6, 20, 22, 35]. We designed a neoadjuvant chemotherapy protocol using combined intraarterial and intravenous agents to treat high-grade osteosarcoma and malignant fibrous histiocytoma of bone in an attempt to improve survival. We report the results of treating 53 adults (age 18–77 years) diagnosed with nonmetastatic extremity osteosarcoma or malignant fibrous histiocytoma. Preoperative chemotherapy consisted of intravenous doxorubicin followed by intraarterial cisplatinum administered repetitively every 3 weeks for three to five cycles, depending on tumor response assessed by serial arteriography. Dose and duration of cisplatin were adjusted for tumor size. After resection, good responders (90% or greater necrosis) underwent treatment with the same agents and poor responders were treated with alternative agents for longer duration. Minimum followup was 24 months (mean, 111 months; range, 24–235 months). Estimated Kaplan-Meier survival at 10 years was 82% and event-free survival was 79%. Forty-one patients (77%) had a good histologic response and 92% (49 of 53) underwent limb-sparing procedures. Local recurrence occurred in two patients (4%). These results compared favorably with those reported in the current literature.,[object Object]

A Comparison of Intramedullary and Juxtacortical Low-grade Osteogenic Sarcoma

Joseph H. Schwab MD, Cristina R. Antonescu MD, Edward A. Athanasian MD, Patrick J. Boland MD, John H. Healey MD, Carol D. Morris MD, MS While low-grade juxtacortical and low-grade intramedullary osteogenic sarcomas are histologically indistinguishable, they have been studied as separate entities. We retrospectively reviewed the clinical, radiographic, histologic features and treatment of 59 patients treated surgically to compare the rate of local recurrence, grade progression, and survival between low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma. Forty-five (76%) patients were treated for low-grade juxtacortical osteogenic sarcoma and 14 (24%) were treated for low-grade intramedullary osteogenic sarcoma. Local recurrence rates of 7% were similar for both groups studied. The rate of distant metastases was also similar for both groups. . The rate of dedifferentiation for the entire group was 29%. Dedifferentiated lesions were treated with adjuvant chemotherapy in 16 of 17 cases. Recurrence preceded dedifferentiation in four cases. Five-year survival was over 90% in both groups. Low-grade intramedullary and low-grade juxtacortical osteogenic sarcoma were clinically indistinguishable with identical rates of local recurrence, distant metastases, dedifferentiation, and survival.,[object Object]

Does the Second-generation Intercalary Humeral Spacer Improve on the First?

Timothy A. Damron MD, Taninnit Leerapun MD, Ronald R. Hugate MD, Thomas C. Shives MD, Franklin H. Sim MD Since publication of the results of a first-generation intercalary humeral spacer, a newer design has been available that addressed the weaknesses of the first. This study evaluated the hypothesis that the second-generation lap joint junction intercalary humeral spacer reduced complications compared with the original male-female taper design. We retrospectively reviewed the charts of 32 consecutive patients who had undergone placement of an intercalary humeral spacer. Twenty-one with the male-female taper (minimum followup 0 months, mean 19.2 months) were compared with 11 with the lap joint configuration (minimum followup 0 months, mean 20.3 months). Demographic, tumor, treatment, and radiographic variables were similar between groups. We observed a lower complication rate in the lap joint group (three of 11 versus 11 of 21). The most common complications in the male-female group, neuropraxia, periprosthetic fracture, and disengagement, were not seen in the lap joint group. Aseptic loosening was more frequent in the lap joint group. There were no differences in blood loss, operative time, or Musculoskeletal Tumor Society scores between groups. We noted improvement in Musculoskeletal Tumor Society scores from preoperatively to postoperatively in both groups. Use of these implants should be reserved for patients with limited life expectancy.,[object Object]

Attenuated Salmonella typhimurium with IL-2 Gene Reduces Pulmonary Metastases in Murine Osteosarcoma

Brent S. Sorenson BS, MS, Kaysie L. Banton MD, Natalie L. Frykman BS, Arnold S. Leonard MD, PhD, Daniel A. Saltzman MD, PhD [object Object]

Predicting Distal Femur Bone Strength in a Murine Model of Tumor Osteolysis

Kenneth A. Mann PhD, John Lee MS, Sarah A. Arrington BS, Timothy A. Damron MD, Matthew J. Allen VetMB, PhD [object Object]

Analysis of the Pathology Section of the OITE Will Aid in Trainee Preparation

Frank J. Frassica MD, Derek Papp MD, Edward McCarthy MD, Kristy Weber MD We analyzed the tumor-related questions on the Orthopaedic In-Training Examinations (OITE) over a 5-year period (2002–2006). Each year approximately 27 of the 275 examination questions (10%) are tumor-related. Malignant conditions are tested more than benign ones (1.2:1). Approximately nine questions per year are immediate recall of specific entities, while eight questions tested the examinees’ ability to establish a diagnosis from imaging studies with or without biopsy material. Participants were required to establish a diagnosis from imaging studies and/or biopsy material and then choose treatment an average of seven times per examination. The examinees’ abilities in evaluation and decision making of patients was only tested an average of twice during each examination. Analysis of the content and type of question on the OITE might enable trainees to prepare more systematically. We determined the content, classified the questions, and quantified the interpretive material.

Complications and Risk Factors for Failure of Rotationplasty: Review of 25 Patients

Chigusa Sawamura MD, Francis J. Hornicek MD, PhD, Mark C. Gebhardt MD Rotationplasty is one treatment option for femoral bone sarcomas in skeletally immature patients. This procedure enables patients to avoid phantom pain, limb length discrepancy, or loosening of an endoprosthesis, and good functional outcome has been reported. However, rotationplasty is only rarely indicated and the surgical complications or risk factors for failure of the procedure that might influence choices of treatment or patient counseling have not been well described. We reviewed 25 patients who underwent rotationplasty focusing on risk factors for failure and postoperative complications. Three of 25 patients had vascular compromise resulting in amputation. All three had vascular anastomosis and were resistant to chemotherapy with less than 95% of tumor necrosis. Two of the three patients who underwent amputation had a pathologic fracture before surgery. Late complications included one patient with a tibial fracture, two with wound complications treated with skin grafts, one with nonunion, and one with subsequent slipped capital femoral epiphysis. Rotationplasty was successfully accomplished in 22 of the 25 patients. Patients with large tumors unresponsive to chemotherapy or preoperative pathologic fracture appear at higher risk for failure of rotationplasty presumably as a result of compromise of venous drainage of the leg.,[object Object]

Mirels’ Rating for Humerus Lesions is Both Reproducible and Valid

Andrew R. Evans MD, John Bottros MD, William Grant EdD, Benjamin Y. Chen BS, Timothy A. Damron MD Mirels’ rating system is commonly used to predict risk of fracture in patients with metastatic bone lesions to long bones, but it has not been independently validated for use in humeral bone lesions. We asked whether this system was a valid and reproducible instrument for predicting impending pathologic fractures in the humerus. We presented 17 case histories and plain radiographs of 16 patients with humeral metastases through a web-based survey to 39 physicians with varying training and experience. Participants scored each case using Mirels’ criteria and provided a fracture prediction, which was compared with actual outcome in the subset of 12 patients with three fractures not treated prophylactically. Using Mirels’ definition of impending pathologic fracture (nine points or greater), the sensitivity and specificity for determining the likelihood of pathologic humeral fracture were 14.5% and 82.9%, respectively. When we used seven or more points as the definition of impending pathologic humeral fracture, sensitivity improved to 81% but specificity was reduced to 32%. Kappa analysis suggested moderate reproducibility across groups for prediction of pathologic fracture. The Mirels rating system for humeral lesions is reproducible and valid, but low specificity at acceptable sensitivity levels as reported remains a problem as for femoral lesions.,[object Object]