Houdek, Matthew T.

AbstractIntroductionThe proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft‐prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies.MethodsA total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10).ResultsReverse reconstructions had improved forward elevation (85° vs. 44°, p < .001) and external rotation (30° vs. 21°; p < .001) versus a hemiarthroplasty. Reverse reconstructions had improved American Shoulder and Elbow Surgeons scores (65 vs. 57; p = .01) and Musculoskeletal Tumor Society 93 scores (72 vs. 63; p < .001) versus hemiarthroplasty. Subluxation of the reconstruction was a common (n = 23, 27%), only occurring in hemiarthroplasty patients (EPR [n = 13, 36%] and APC [n = 10, 59%]).ConclusionThe current series highlights the improved functional outcome in patients undergoing reconstruction with a reverse arthroplasty compared to the traditional hemiarthroplasty. Currently reverse shoulder arthroplasty (APC or EPR) is our preferred methods of reconstruction in this patient population.

AbstractBackgroundNonuterine leiomyosarcomas (LMS) are common extremity soft‐tissue sarcomas. Deep LMS are at an increased risk for recurrence; however, few studies have focused on superficial LMS.MethodsWe reviewed the clinicopathological features of 82 patients with a primary superficial LMS. The mean age and follow‐up were 57 ± 15 and 7 ± 5 years. Depth was classified as dermal (based in the skin; n = 35, 43%) and subcutaneous (based below the dermis, above the fascia; n = 47, 57%) on the final resection specimen. Dermal cases were treated with negative margin resection, while subcutaneous tumors were evaluated by a multidisciplinary team for consideration of possible adjuvant therapy.ResultsThe 10‐year disease‐specific survival (DSS) for superficial LMS was 90% with no difference (p = .18) in the 10‐year DSS between patients with dermal (100%) and subcutaneous (86%) LMS. All disease recurrences occurred in subcutaneous LMS (17% vs. 0%, p = .02) and subcutaneous tumors had a worse10‐year metastatic free survival (81% vs. 100%, p = .03).ConclusionsThe results of this study suggest that dermal LMS can be managed with a negative margin resection alone. Although the prognosis for patients with subcutaneous LMS is quite favorable, there is some risk for local and distant recurrence, and such patients will benefit from multidisciplinary care.

Background: Sacral tumor resections require a multidisciplinary approach to achieve a cure and a functional outcome. Currently, there is no accepted classification system that provides a means to communicate among the multidisciplinary teams in terms of approach, osseous resection, reconstruction, and acceptable functional outcome. The purpose of this study was to report the outcome of sacral tumor resection based on our classification system. Methods: In this study, 196 patients (71 female and 125 male) undergoing an oncologic en bloc sacrectomy were reviewed. The mean age (and standard deviation) was 49 ± 16 years, and the mean body mass index was 27.2 ± 6.4 kg/m 2 . The resections included 130 sarcomas (66%). The mean follow-up was 7 ± 5 years. Results: Resections included total sacrectomy (Type 1A: 20 patients [10%]) requiring reconstruction, subtotal sacrectomy (Type 1B: 5 patients [3%]) requiring reconstruction, subtotal sacrectomy (Type 1C: 104 patients [53%]) not requiring reconstruction, hemisacrectomy (Type 2: 29 patients [15%]), external hemipelvectomy and hemisacrectomy (Type 3: 32 patients [16%]), total sacrectomy and external hemipelvectomy (Type 4: 5 patients [3%]), and hemicorporectomy (Type 5: 1 patient [1%]). The disease-specific survival was 66% at 5 years and 52% at 10 years. Based on the classification, the 5-year disease-specific survival was 34% for Type 1A, 100% for Type 1B, 71% for Type 1C, 65% for Type 2, 57% for Type 3, 100% for Type 4, and 100% for Type 5 (p < 0.001). Tumor recurrence occurred in 67 patients, including isolated local recurrence (14 patients), isolated metastatic disease (31 patients), and combined local and metastatic disease (22 patients). At 5 years, the local recurrence-free survival was 77% and the metastasis-free survival was 68%. Complications occurred in 153 patients (78%), most commonly wound complications (95 patients [48%]). Following the procedure, 154 patients (79%) were ambulatory, and the mean Musculoskeletal Tumor Society (MSTS93) score was 60% ± 23%. Conclusions: Although resections of sacral malignancies are associated with complications, they can be curative in a majority of patients, with a majority of patients ambulatory with an acceptable functional outcome considering the extent of the resection. At our institution, this classification allows for communication between surgical teams and implies a surgical approach, staging, reconstruction, and potential functional outcomes. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

» Oncologic sacrectomy is used in the curative treatment of patients with primary sacral malignancies or select locally invasive visceral malignancies. » A systematic surgical approach involves preoperative imaging, diagnosis, and multidisciplinary surgical execution. » Close collaboration with pediatric, medical, and radiation oncology colleagues is often necessary to individualize treatment plans.

AbstractBackgroundExtraskeletal myxoid chondrosarcoma (ESMC) is a rare type of soft‐tissue sarcoma with limited series reporting outcome of treatment. Currently there is limited data on the incidence and impact on patient outcome in those with metastatic disease to lymph nodes in ESMC.MethodsThirty (21 males, 9 females) patients, mean age 50 ± 16 years, with ESMC were reviewed. The tumors were most commonly located in the lower extremity (n = 23, 77%) and the mean tumor size and volume were 9 ± 5 cm and 490 ± 833 cm3. Mean follow up was 7 ± 4 years.ResultsSix (20%) patients either presented (n = 3, 10%) or developed (n = 3, 10%) lymph node metastatic disease. When comparing patients without, with lymph node metastasis and metastasis elsewhere, patients with lymph nodes metastasis had worse survival than those without metastasis, however better 10‐year disease specific survival than those with metastasis elsewhere (100% vs 62% vs 0%; P < .001).ConclusionThere is a high incidence of lymph node metastatic disease in patients with ESMC. Although survival in these patients is worse compared to those without metastasis, their survival is better than those with metastasis elsewhere. Due to the high incidence of lymph node metastatic disease, preoperative staging of the lymph node should be considered.

AbstractIntroductionTreatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.MethodsData from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.ResultsOf 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).ConclusionOne in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow‐up to minimize readmission.

Background: Limb salvage of the proximal tibia can be difficult due to the growth potential of and functional demands of the pediatric patients. Multiple reconstruction techniques exist, however, the ideal form of reconstruction is yet to be elucidated. The purpose of the current study is to evaluate outcomes in patients with an intercalary resection of the proximal tibia reconstructed with an allograft with or without a free vascularized fibula flap (FVF). Methods: Seventeen pediatric patients (9 males, 8 females) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12±4 years. The most common diagnoses were osteosarcoma (n=6) and Ewing sarcoma (n=6). Patients were reconstructed with an allograft alone (n=6) or supplemented with an FVF (n=11). Results: All surviving patients had at least 2 years of clinical follow-up, with the mean follow-up of 12±7 years. The mean time to union of the allograft was 11±4 months, with 6 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (odds ratio=1.14, P=1.0) between patients with an FVF and those without. Four patients underwent an amputation, all with an allograft alone, due to disease recurrence (n=2) and due to infection (n=2). As such, there was a higher 10-year overall limb-salvage rate when the allograft was combined with an FVF compared with an allograft alone (100% vs. 33%, P=0.001). At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 86%, with a higher mean score in patients reconstructed with an FVF (94% vs. 70%, P=0.002). Conclusion: Use of an intercalary allograft supplemented with an FVF to reconstruct the proximal tibia provides a durable means of reconstruction with an excellent functional outcome following oncologic proximal tibia resection in a pediatric population. Level of Evidence: Level III—therapeutic level.

Background: The periacetabular region is a common location for metastatic disease. Although large lytic acetabular defects are commonly treated with a hip arthroplasty with a cemented component according to a Harrington-style reconstruction, the use of highly porous uncemented tantalum acetabular components has been described. Currently, there are no direct comparisons of these reconstructive techniques. The purpose of this study was to compare the outcomes of the Harrington technique and tantalum acetabular component reconstruction for periacetabular metastases. Methods: From 2 tertiary sarcoma centers, we retrospectively reviewed 115 patients (70 female and 45 male) with an acetabular metastatic defect who had been treated between 2002 and 2015 with a total hip arthroplasty using either the cemented Harrington technique (78 patients) or a tantalum acetabular reconstruction (37 patients). The mean patient age was 61 years, and the most common Eastern Cooperative Oncology Group status was 3 (39 patients). The mean follow-up for surviving patients was 4 years. Results: An additional surgical procedure was performed in 24 patients (21%). Harrington-style reconstructions were more likely to require a reoperation compared with tantalum reconstructions (hazard ratio [HR], 4.59; p = 0.003). The acetabular component was revised in 13 patients (11%); 5 patients (4%) underwent revisions that were due to loosening of the acetabular component. The 10-year cumulative incidence of revision of the acetabular component for loosening was 9.6% in the Harrington group and 0% in the tantalum group (p = 0.09). The mean Harris hip score significantly improved following reconstruction (31 to 67 points; p < 0.001), with no significant difference (p = 0.29) between groups. Conclusions: In patients with periacetabular metastatic disease treated with total hip arthroplasty, an acetabular reconstruction strategy utilizing highly porous tantalum acetabular components and augments successfully provided patients with a more durable construct with fewer complications compared with the cemented Harrington-style technique. Levels of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

AbstractBackground and ObjectivesThe ACS‐NSQIP surgical risk calculator is an online tool that estimates the risk of postoperative complications. Sacrectomies for chordoma are associated with a high rate of complications. This study was to determine if the ACS‐NSQIP calculator can predict postoperative complications following sacrectomy.MethodsSixty‐five (42 male, 23 female) patients who underwent sacrectomy were analyzed using the Current Procedural Terminology (CPT) codes: 49215 (excision of presacral/sacral tumor), 63001 (laminectomy of sacral vertebrae), 63728 (laminectomy for biopsy/excision of sacral neoplasm) and 63307 (sacral vertebral corpectomy for intraspinal lesion). The predicted rates of complications were compared to the observed rates.ResultsComplications were noted in 44 (68%) patients. Of the risk factors available to input to the ACS‐NSQIP calculator, tobacco use (OR, 20.4; P < .001) was predictive of complications. The predicted risk of complications based off the CPT codes were: 49215 (16%); 63011 (6%); 63278 (11%) and 63307 (15%). Based on ROC curves, the use of the ACS‐NSQIP score were poor predictors of complications (49215, AUC 0.65); (63011, AUC 0.66); (63307, AUC 0.67); (63278, AUC 0.64).ConclusionThe ACS‐NSQIP calculator was a poor predictor of complications and was marginally better than a coin flip in its ability to predict complications following sacrectomy for chordoma.

AbstractBackgroundConventional primary pelvic chondrosarcoma often presents as a low‐ or intermediate‐grade tumor in older patients. Although this is the most common variant of pelvic chondrosarcoma, studies examining treatment outcomes are lacking. The purpose of this study was to evaluate patients with these tumors to determine their outcomes of treatment.MethodsSeventy‐three patients (grade I [n = 19, 26%] and grade II [n = 54, 74%]) were reviewed including 55 (75%) males and 18 (25%) females, with a mean age of 51 (range, 17‐81) years and follow‐up of 9 ± 5 years.ResultsThe 10‐year disease‐specific survival was 71%. Grade II disease (hazard ratio [HR], 6.74; P = .04) and age ≥50 years (HR, 3.97; P = .02) was associated with death due to disease. The 10‐year local recurrence‐ and metastatic‐free survival were 79% and 72%. Of the patients with a local recurrence (n = 11), 7 (64%) recurred at a higher histological grade. Patient age ≥50 years was associated with local recurrence (HR, 10.03; P = .02) and metastatic disease (HR, 4.20; P = .02).ConclusionAdvancing patient age was an independent risk factor for worse survival and disease recurrence. Tumors often recurred locally at a higher grade and as such wide local excision remains the treatment of choice for these tumors.