Citations

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.

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm which typically originates from liver, lung, or bone. Due to the low incidence of disease, the most effective treatment is not easily studied and much of the information known about EHE has been learned through case reports and case series. In this case, we will present an uncommon form of primary soft tissue EHE with local recurrence, bone metastasis, and lymphangitic spread to the lungs leading to respiratory failure. Imaging of the chest was atypical for EHE with intraseptal thickening and hilar lymphadenopathy. Respiratory failure was progressive despite aggressive multimodal treatment. This case highlights an unusually aggressive recurrence and metastasis of primary soft tissue EHE with atypical pulmonary imaging findings.

AbstractBackground and ObjectivesChordomas of the mobile spine (C1–L5) are rare malignant tumors. The purpose of this study was to review the outcome of surgical treatment for patients with primary mobile spine chordomas.MethodsThe oncologic outcomes and survival of 26 patients undergoing surgical resection for a primary mobile spine chordoma were assessed over a 25‐year period. The mean follow‐up was 12 ± 6 years.ResultsThe 2‐, 5‐, and 10‐year disease‐free survivals were 95%, 61%, and 55%. The local recurrence‐free survival was improved in patients receiving en bloc resection with negative margins (83% vs. 35%, p = 0.02) and similar in patients receiving adjuvant radiation therapy (43% vs. 45%, p = 0.30) at 10 years. Debulking of the tumor (hazard ratio [HR] = 6.41, p = 0.01) and a local recurrence (HR = 9.52, p = 0.005) were associated with death due to disease. Complications occurred in 19 (73%) patients, leading to reoperation in 9 (35%) patients; this rate was similar in intralesional and en bloc procedures.ConclusionSurgical resection of mobile spine chordomas is associated with a high rate of complications; however, en bloc resection can provide a hope for cure and appears to confer better oncologic outcomes for these tumors without an increase in complications compared to lesser resections.

AimsHip reconstruction after resection of a periacetabular chondrosarcoma is complex and associated with a high rate of complications. Previous reports have compared no reconstruction with historical techniques that are no longer used. The aim of this study was to compare the results of tantalum acetabular reconstruction to both historical techniques and no reconstruction.MethodsWe reviewed 66 patients (45 males and 21 females) with a mean age of 53 years (24 to 81) who had undergone acetabular resection for chondrosarcoma. A total of 36 patients (54%) underwent acetabular reconstruction, most commonly with a saddle prosthesis (n = 13; 36%) or a tantalum total hip arthroplasty (THA) (n = 10; 28%). Mean follow-up was nine years (SD 4).ResultsThere was no difference in the mean age (p = 0.63), sex (p = 0.110), tumour volume (p = 0.646), or type of resection carried out (p > 0.05) between patients with and without reconstruction. Of the original 66 patients, 61 (92%) were ambulant at final follow-up. There was no difference in the proportion of patients who could walk in the reconstruction and 'no reconstruction' groups (p = 0.649). There was no difference in the mean Musculoskeletal Tumor Society (MSTS) score between patients who were reconstructed and those who were not (61% vs 56%; p = 0.378). Patients with a tantalum THA had a significantly (p = 0.015) higher mean MSTS score (78%) than those who were reconstructed with a saddle prosthesis (47%) or who had not been reconstructed (56%). Patients who had undergone reconstruction were more likely to have complications (81% vs 53%; p = 0.033).ConclusionReconstruction after resection of the acetabulum is technically demanding. In selected cases, reconstruction is of benefit, especially when reconstruction is by tantalum THA; however, the follow-up for these patients remains mid-term. When not feasible, patients with no reconstruction have an acceptable functional outcome. Level of Evidence: Level III Therapeutic. Cite this article: Bone Joint J 2021;103-B(2):391–397.

Objective To describe the natural history, reconstructive solutions, and functional outcomes of those men undergoing pubectomy and urinary reconstruction after prostate cancer treatment. Patients and Methods This study retrospectively identified 25 patients with a diagnosis of urosymphyseal fistula (UF) following prostate cancer therapy who were treated with urinary reconstruction with pubectomy. This study describes the natural history, reconstructive solutions, and functional outcomes of this cohort. Results All 25 patients had a history of pelvic radiotherapy for prostate cancer. The median (interquartile range [IQR]) time from prostate cancer treatment to diagnosis of UF was 11 (6, 16.5) years. The vast majority of men (24/25; 96%) presented with debilitating groin pain during ambulation. Posterior urethral stenosis was common (20/25; 80%), with 60% having repetitive endoscopic treatments. Culture of pubic bone specimens demonstrated active infection in 80%. Discordance between preoperative urine and intraoperative bone cultures was common, 21/22 (95.5%). After surgery, major 90‐day complications (Clavien–Dindo Grade III and IV) occurred in eight (32%) patients. Pain was significantly improved, with resolution of pain (24/25; 96%) and restoration of function, the median (IQR) preoperative Eastern Cooperative Oncology Group Performance Status (ECOG PS) was 3 (2, 3) vs median postoperative ECOG PS score of 0 (0, 1). Conclusion Endoscopic urethral manipulation after radiation for prostate cancer is a risk factor for UF. Conservative management will not provide symptom resolution. Fistula decompression, bone resection, and urinary reconstruction effectively treats chronic infection, improves pain and ECOG PS scores.

AbstractIntroductionAll‐polyethylene (AP) tibial components have demonstrated equivalent or improved long‐term survivorship and reduced cost compared with metal‐backed (MB) components in primary total knee arthroplasty; however, there is a lack of data comparing these outcomes in the setting of an oncologic endoprosthetic reconstruction.MethodsA total of 115 (88 AP:27 MB) patients undergoing cemented distal femur endoprosthetic reconstruction following oncologic resection were reviewed. Mean age was 40 years and 51% were females. Cumulative incidences of all‐cause revision, tibial component revision, reoperation, and infection were calculated utilizing a competing risk analysis with death as the competitor. Mean follow‐up was 14 years.ResultsThe 10‐year cumulative incidence of all‐cause revision was 19.9% in the AP group and 16.3% in the MB group (hazard ratio [HR] = 0.93, p = 0.88). The cumulative incidence of tibial component revision was significantly lower in AP compared with MB at 10 years (1.1% vs. 12.5%, HR = 0.18, p = 0.03). There was no difference in infection‐free survival when comparing the two groups (p = 0.72).ConclusionsReconstruction utilizing an MB or AP tibia component resulted in equivalent overall outcome; however, the tibial component in the AP group was less likely to be revised. AP tibial component should be considered for all primary oncologic reconstructions in the distal femur.Level of EvidenceLevel III Therapeutic.

AbstractIntroductionAdvances in the care of cancer patients have resulted in increased survival. The proximal femur is a common site for metastatic disease, often requiring surgical intervention. Tranexamic acid (TXA) has proven to be safe in elective and traumatic femoral hemiarthroplasty; however, its use has not been investigated in oncologic patients.MethodWe reviewed 66 patients (37 males) with a mean age of 64 ± 3 years undergoing a hemiarthroplasty for metastatic disease in the femoral neck. A total of 22 (33%) patients received intraoperative TXA. Primary outcomes included postoperative blood loss, intraoperative and postoperative transfusion requirement, and postoperative complications.ResultsThere was no difference in the baseline characteristics between the TXA and non‐TXA groups. When comparing the TXA and non‐TXA groups, there were no differences in 72 h postoperative blood loss between groups (1.21 L vs. 1.33 L, p = 0.61), percentage of patients requiring transfusion (36.4% vs. 36.4%, p = 1.0), or the incidence of postoperative complications including venous thromboembolism (14% vs. 11%, p = 0.70) and pulmonary embolism (0% vs. 5%, p = 1.0).ConclusionOncology patients are a high‐risk population for thromboembolic events. This initial study supports the safe use of TXA intraoperatively in femoral hemiarthroplasty performed for metastatic disease.