Rose, Peter S.

Background. Limb-salvage surgery combined with radiotherapy has become the primary treatment for soft tissue sarcomas of the extremity. Free functional latissimus flaps (FFLF) are an option to restore function in the setting of volumetric muscle loss. The purpose of the current study was to examine the use of FFLF in patients undergoing resection of thigh sarcoma. Methods. Twelve patients with a sarcoma involving the hamstring (n = 6), quadriceps (n = 5), or combined (n = 1) defects which included multiple muscle groups were reviewed. This included 9 males and 3 females with a mean age and body mass index of 56 ± 12 years and 31.3 ± 5.7 kg/m2. Results. The mean defect volume and operative time was 3,689 ± 2,314 cm3 and 587 ± 73 minutes. Following reconstruction, the mean knee range of motion (ROM), MSTS93 score, and muscle strength was 89 ± 24°, 90 ± 15%, and 4 ± 1; with 75% of patients ambulating without gait aids. Seven (58%) patients sustained a complication, namely, delayed wound healing (n = 2). Conclusion. Although there was a high incidence of complications, FFLF can restore active knee ROM and function, with most patients ambulating without gait aids following reconstruction of large oncologic defects in the thigh.

Abstract PURPOSE Vertebral compression fracture (VCF) is a potential adverse effect following stereotactic body radiation therapy (SBRT) for spinal metastases. In this analysis, we developed and internally validated a risk stratification model for VCF. METHODS From an initial set of 680 treatments, we excluded those with proton therapy, prior surgical intervention, or missing data. The final dataset had 464 treatments in 313 patients. Delineations of VCF and all radiographic components of the spinal instability neoplastic score (SINS) were determined by a radiologist. Recursive partitioning analysis (RPA) was conducted using separate training (70%), internal validation (15%), and test (15%) sets. The log-rank test was used as the criterion for node splitting. RESULTS With a median follow-up of 21 months, we identified 84 VCF (18%), including 65 (77%) de novo and 19 (23%) progressive fractures. There was a median 9 months (IQR: 3 – 21) to VCF. From an initial set of 15 candidate variables, six were identified using the backwards selection method, feature importance testing, and a correlation heatmap. Four were then selected in the highest-fidelity RPA models: epidural tumor extension, lumbar location, gross tumor volume > 10 cc, and SINS > 6. One point was assigned to each variable, and the resulting multivariate Cox model had a concordance of 0.760. Each one point increase in score was associated with increasing rates of VCF. Low-risk lesions (score: 0-1, n=273) had 2-year freedom from VCF of 92%, compared to 80% for intermediate-risk (score: 2, n=99) and 56% (score: 3-4, n=92) for high-risk lesions (p < 0.0001). Cumulative incidence curves with death as a competing risk showed increased VCF with higher scores via Gray’s test (p < 0.001). CONCLUSIONS Our internally-validated model identifies a subgroup of patients with high risk for VCF who may benefit from prophylactic surgical stabilization or vertebroplasty.

AbstractIntroductionThe elbow is a rare location for primary and metastatic tumors in the upper extremity. The goal of reconstruction is to provide painless motion and stability for hand function. Total elbow arthroplasty (TEA) is commonly utilized, with either off‐the‐self components, modular segmental endoprosthesis, or allograft‐prosthesis composites (APC). The purpose of this study was to analyze and compare commonly utilized elbow reconstructions and report outcomes of (1) patient function and (2) implant survival and complications.MethodsWe reviewed 33 patients (18 females and 15 males) undergoing elbow arthroplasty for reconstruction of an underlying oncologic process including linked TEA (n = 22, 67%), APC (n = 9, 27%), and endoprosthesis (n = 2, 6%). The most common indication was metastatic disease (n = 17, 52%), with 24 patients (73%) presenting with a pathologic fracture.ResultsFive‐year implant survival was following elbow reconstruction was 88%. The mean most recent Mayo Elbow Performance Score and Musculoskeletal Tumor Society Score were 84 ± 18 and 78 ± 15%. Postoperative complications occurred in 15 elbows (45%), most commonly periprosthetic fracture (n = 5, 15%), leading to reoperation in six elbows (18%).ConclusionAlthough elbow arthroplasty is associated with a high incidence of complications, it provides a stable platform for upper extremity function in patients with oncologic processes of the elbow.

AimsOrthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques.MethodsWe reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5).ResultsThere was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003).ConclusionSupplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414–1420.

AbstractBackgroundCoverage of posterior trunk defects after tumor resection can be challenging due to the intricate anatomy. The keystone perforator island flap (KPIF) provides coverage of the defect without the need for distant flap coverage or microsurgery, matches the recipient's skin color and contour, and requires a short operative time.MethodsA retrospective review of all oncological back reconstructions with KPIF was performed at our institution. The patient comorbidities and surgical outcomes were collected.ResultsA total of 17 patients underwent 20 KPIF (15 single and 2 double) for back reconstruction. Surgical indications were sarcoma (n = 12) and melanoma (n = 5). The mean age at surgery was 47.3 years (SD 23.3). The flaps were located in the upper back (n = 8), paraspinal (n = 4), middle back (n = 6), and lower back (n = 2). The average wound size after sarcoma and melanoma excision were 231.6 ± 297.4 and 156.7 ± 269.7 cm2, respectively. Four patients required an additional planned skin graft and one patient underwent a simultaneous myocutaneous latissimus dorsi flap. The mean operative time, including tumor resection, was 256 min (SD 118). The median length‐of‐hospital stay was 3 days (Q1–3: 1–6.5) and the median follow‐up time was 35.3 months (Q1–3: 13.3–53.1). All flaps survived with minor surgical complications which included hematoma (n = 1), surgical site infection requiring debridement (n = 1), superficial wound dehiscence (n = 1), cellulitis (n = 1), and seroma (n = 1). The reconstructions were successful in 100% of patients.ConclusionsThe KPIF is a reliable and safe option for reconstruction of oncological back defects with minimal perioperative complications. This flap option avoids the use of free flaps and myocutaneous flaps for moderate‐sized back defects.

Abstract Background Foot and ankle soft tissue sarcomas (STS) are challenging for reconstruction due to limited surrounding soft tissue and weight‐bearing requirements. Currently, there is a paucity of data examining the outcome of flap reconstruction following resection of a foot and ankle sarcoma. Methods We reviewed 44 (31 female, 13 male) patients with STS arising from the ankle or foot which required coverage in the form of a free ( n = 21), pedicled ( n = 13), or rotational perforator flap ( n = 10). The mean tumor size was 6 ± 5 cm, with 39 (89%) patients receiving radiotherapy. The mean follow‐up was 10 ± 7 years. Results There were no cases of amputation due to flap failure, with a 10‐year limb salvage rate of 84%. Complications occurred in 19 (43%) patients, most commonly wound infections. There was no difference in the incidence of complications between patients undergoing a free flap and pedicled or perforator flap (odds ratio = 0.97, p = 1.0); with no difference in the mean Musculoskeletal Tumor Society (MSTS) score between patients with a free flap versus a pedicled/perforator flap (84% vs. 76%, p = 0.11). Conclusion Flap reconstruction is an essential part of limb salvage for foot and ankle STS. At final follow‐up nearly all the patients are ambulatory with an acceptable MSTS score.

AbstractIntroductionProximal femur replacement (PFR) in the setting of tumor resection is associated with a high rate of postoperative complication. The online American College of Surgeons‐National Surgical Quality Improvement Program (ACS‐NSQIP) surgical risk calculator is approved by the Center of Medicare and Medicaid services to estimate 30‐day postoperative complications. This study was to determine if the ACS‐NSQIP can predict postoperative complications following PFR.MethodsWe reviewed 103 (61 male and 42 female) patients undergoing PFR using the Current Procedural Terminology (CPT) codes available in the calculator: 27125 (hemiarthroplasty), 27130 (total hip), 27132 (conversion to total hip), 27134 (revision total hip), 27137 (revision acetabulum), 27138 (revision femur), and 27365 (excision tumor hip). The predicted rates of complications were compared with the observed rates.ResultsComplications occurred in 54 (52%) of patients, with the predicted risk based on CPT codes: 27125 (21.5%); 27130 (7.8%); 27132 (16.6%), 27134 (17.8%), 27137 (14.4%), 274138 (22.7%), and 27365 (16.2%). The calculator was a poor predictor of complications (27125, area under the curve [AUC] 0.576); (27130, AUC 0.489); (27132, AUC 0.490); (27134, AUC 00.489); (27137, AUC 0.489); (27138, AUC 0.471); and (27365, AUC 0.538).ConclusionOncologic PFR is known for complications. The ACS‐NSQIP does not adequately predict the incidence of complications, and therefore cannot reliably be used in their shared decision‐making process preoperative.

INTRODUCTION: Using standard anterior-only or anterior then posterior approaches can make an R0 resection difficult to achieve in patients with pelvic sidewall recurrences because of confined working spaces and poor visibility. TECHNIQUE: Given the limitations of standard approaches, we have used a novel posterior-first then anterior 2-stage approach allowing us to widely expose and secure deep margins and control vessels under direct visualization. RESULTS: We present a technical note describing this approach in patients with recurrent rectal cancer involving the pelvic sidewall with extrapelvic extension. CONCLUSION: The posterior-first approach may assist in achieving a higher number of R0 resections in patients with locally recurrent rectal cancer involving the pelvic sidewall.