Aim

A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI.

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age.

The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery.

Aims

Delays to diagnosis and management of soft tissue sarcomas are preventable but still occur. The introduction of a referral proforma to the Thames Valley Cancer Network in 2005 and National guidelines in 2006 aimed to decrease the incidence of partially and inadequately managed soft tissue sarcomas. This study aims to assess referrals for partially or inadequately managed soft tissue sarcomas and their subsequent management.

Introduction

Our Unit has been treating large volume soft tissue sarcomas involving the sciatic nerve with epineurectomy for over a decade. The aim of this study was to quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy.

Introduction: Acral sarcomas present as small tumours to specialised orthopaedic services. There is a high incidence of inadequate resection compromising clinical and functional outcome.

It is advised that lumps which are greater than 5cm should be referred to a sarcoma centre for management and that small lesions cause less harm with unplanned excision.

Method: Data from the Oxford Registry was collated of all those patients with acral sarcomas who underwent surgery in a period from 1997 – 2008 at The Nuffield Orthopaedic Centre including site, size, histological subtype, of tumours, history of previous surgical excisions, staging, and functional scores.

Results: 27 patients were treated (17 foot and ankle cases, 10 hand tumours). The commonest acral lesions were synovial sarcomas (30%).

Of the hand patients 7 of the 10 patients had wide excision of the lesion with 3 an amputation. 5 of the cases were for inadequate previous excision (50%).

7 of the 17 in the foot and ankle group underwent amputation (41%) the rest wide excision. 29% of cases were for second time surgery due to inadequate previous excision.

Discussion: Our study shows that up to 50% of patients with acral tumours are undergoing further surgery due to previous inadequate excision. The belief that 5cm should be a benchmark for specialist referral should not be applied to such lesions.

Introduction: Young active patients with malignant tumours arising in the distal fibula, requiring bone and soft tissue excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Method: Excision of the distal fibula lesion followed by rotation of the proximal fibula on its vascular pedicle recreates the ankle mortise with consequent restoration of ankle stability and retaining ankle movement.

Results: Between 2000 and 2008, we have performed this technique on four patients, (2F, 2M) mean age 21 (13–33). Diagnoses were that of chondrosarcoma, parosteal osteosarcoma, Ewings sarcoma and osteofibrodysplasia. Follow up at 5 years (18m-8 year) with no evidence of local or distant recurrence. One case was complicated by deep infection requiring surgical debridement and antibiotic therapy. In all cases the fibula grafts survived. Good to excellent functional results were achieved (Toronto Extremity Salvage Scores, mean 88 range 82–94).

Discussion: We will present the technical aspects of this procedure with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients required distal fibula excisions for sarcoma.

Young active patients with malignant tumours arising in the distal fibula, requiring excision, present a challenge to the treating surgeon. Wide local excision is advocated, to achieve clearance, however, disruption of the ankle mortise results and fusion is often required to restore stability. The loss of movement is poorly tolerated in the younger patient and leads to progressive degenerative changes in surrounding joints.

Excision of the distal fibula lesion followed by harvesting of the proximal fibula and using this graft to recreate the ankle mortise restores ankle stability and retains ankle movement.

Between 1998 and 2007, we have performed this technique on 4 patients. Diagnoses were Ewing’s sarcoma, chondrosarcoma, parosteal osteosarcoma and osteofibrous dysplasia. To date there has been no evidence of distant or local recurrence. One case was complicated by infection, which resolved with radical debridement and antibiotics; the other three fibula grafts survived. Good to excellent results were achieved.

We will present the technical aspects of this procedure, with particular reference to the most recent case, performed on a young female patient with parosteal osteosarcoma.

We believe this technique provides good oncological and functional results and recommend this treatment option is considered in young active patients requiring distal fibula excisions for sarcoma.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Aim of Study: Assess clinical outcome and function of planned marginal excision of low grade liposarcoma of the forearm.

Material and Methods: Between 1997 and 2005 15 of 27 soft tissue sarcomas of the forearm were liposarcoma.

13 presented in the extensor compartment and 2 flexor compartment at the level of the distal radius. All presented with a painless mass. 5 patients with neurological symptoms. 4 involving the post interosseus nerve and 1 radial nerve. MRI was the diagnostic imaging technique of choice, 2 had biopsies where there was atypical imaging features.

Treatment and Results: All treated by planned marginal excision in view of proximity of neurovascular structures. The majority of tumours of the extensor compartment of the forearm were either involving or abutting the post interosseus nerve or neurovascular conduit.

All underwent planned marginal excision preserving juxtaposed peripheral nerve. There were no radial, spiral or PIN nerve palsies. One patient presented with PIN palsy had partial resolution of symptoms and function. I wound infection

Conclusion: Low grade lipoma-like liposarcomas have low metastatic potential. In the forearm a wide margin would mean ablation of critical neurological structures and planned marginal excision results in good function and to date no evidence of local recurrence at 2–9 year follow up.

Aim: To review a series of 30 tumours affecting the Brachial plexus for the purposes of analysing the presentation, pathology, indication, surgical approach and outcome of these tumours. We describe a modification of an approach to such tumours.

Method: A personal series of 30 cases of tumours affecting the Brachial Plexus were identified, and their notes reviewed. 30 patients with a slight predominance of females, and an average age of 43 were reviewed. The presenting complaints (in order of decreasing frequency) were mass, pain, motor dysfunction, sensory dysfunction and Horner’s syndrome. Previous operation was common. There was significant past history of neurofibromatosis, radiotherapy and other malignancy.

The supra-clavicular approach was most commonly used, however infra-clavicular, trans-clavicular, trans-manubrial, trans-thoracic, axillary and combined approaches were all used when necessary. A modification of the trans-manubrial approach is described preserving the continuity of the clavicle.

The histology of the tumours was extremely varied, with half being benign and half malignant. The incidence of marginal and incomplete excision was higher then other tumour sites, due presumably to the proximity of vital structures.

Post-operatively there was good resolution of pain and recovery of motor dysfunction, but poor recovery of sensory loss and Horner’s syndrome. At follow up most were alive, 5 had lung metastases, 3 local recurrence, 4 metastases else where and 5 dead of their disease.

Conclusion: Tumours affecting the Brachial plexus are rare. Only 3 previous series have been published. The adjacent structures and the morbidity complicate tumour clearance, however, outcomes suggest that excision is worthwhile.

Introduction: Osseous metastases from melanoma are relatively common (7% of cases), and occur most often in the axial skeleton. Bone destruction in skeletal metastases of solid tumours is due to stimulation of osteoclast formation and bone resorption. Osteoclasts are formed by the fusion of marrow-derived mononuclear phagocyte precursors which express RANK (receptor activator of nuclear factor κB) which interacts with RANKL expressed by osteoblasts/bone stromal cells in the presence of macrophage colony-stimulating factor (M-CSF). Osteoclast formation by a RANKL-independent, tumour necrosis factor α (TNFα)-induced mechanism has also been reported. Tumour-associated macrophages (TAMs) are present in both primary and secondary tumours and TAMs are known to be capable of osteoclast differentiation. Our aim in this study was to determine the role of TAMs and the humoral mechanisms of osteolysis associated with melanoma metastases.

Materials and Method: In this study we isolated TAMs from extraskeletal primary melanomas and lymph node metastases. TAMs were cultured for up to 21 days in the presence and absence of M-CSF and RANKL or TNF. In a separate experiment, conditioned medium was extracted from the melanoma cell line, SK-Mel-29, and cultured with human peripheral blood mononuclear cells in the presence of M-CSF.

Results: TAM-osteoclast differentiation, as evidenced by the expression of tartrate-resistant acid phosphatase, vitronectin receptor and lacunar resorption pit formation, occurred by both RANKL-dependent and RANKL-independent mechanisms. Osteoclast formation induced by RANKL-independent mechanism was not abolished by the addition of osteoprotegerin or RANK:Fc, decoy receptors for RANK. Conditioned medium from SK-Mel-29 could support osteoclast differentiation in the absence of RANKL. This effect was not abolished by antibodies to RANKL, TNFα, TGFβ, IL-8 or gp130.

Discussion: These results indicate that melanoma TAMs are capable of differentiation into osteoclasts and that both RANKL-dependent and RANKL-independent (TNFα) mechanisms are involved. Melanoma tumour cells also secrete a soluble factor that supports osteoclastogenesis.

Conclusion: Inhibitors of osteoclast formation targeting TAM-osteoclast differentiation and osteoclast activity and identification of the osteoclastogenic factor produced by melanoma cells may have a therapeutic potential in controlling tumour osteolysis.

We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft.

An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement.

The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect.

Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection.

Purpose: To assess the functional outcome of patients who pre-operatively, were known to have sciatic nerve tumour involvement and proceeded to have nerve-preserving planned marginal excision with epineurectomy.

Methods: We identified patients who had surgery between 1997 and 2004, for soft tissue sarcomas in the posterior thigh with known sciatic nerve involvement. During this period it was the practice of the senior authors (MG & HG) to apply a nerve-preserving epineurectomy approach as part of their planned marginal excision of these tumours.

The identified patients had their notes reviewed, and were contacted by post to complete a Toronto Extremity Severity Score (TESS) questionnaire to assess lower limb function in day-to-day life. Details of their presenting features, oncological work-up, surgical intervention and adjuvant therapy was established and correlated to the TESS score.

Conclusion: This study demonstrates that a careful epineurectomy can preserve sciatic nerve function and allow tumour excision with no increase in local recurrence rate. With good soft tissue cover it appears nerve function can be maintained, even in cases where adjuvant radiotherapy is indicated.

Purpose: To quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy.

Materials and Methods: Ten patients with large volume posterior thigh soft tissue sarcoma with known sciatic nerve involvement were reviewed between 1997 and 2004. Nine underwent surgery with extended epineurectomy of the sciatic nerve and planned marginal excision.

All patients underwent staging and follow up at Sarcoma Clinic with functional assessment and TESS evaluation.

Results: There were seven low and two high grade posterior thigh tumours of which nine were liposarcoma and 1 haemangiopericytoma. Two were recurrent and eight primary. There were five men and five women with a mean age of 77.

Nine patients underwent planned marginal excision. Sciatic nerve involvement was 13–30cm in eight cases and in one case the sciatic nerve was abutting the tumour throughout its length. There was soft tissue reconstruction in three cases using fascial adductor or gracilis graft for sciatic nerve cover and one with superficial femoral nerve and vein resection requiring ipsilateral saphenous reconstruction. The remainder underwent direct primary reconstruction.

Four patients underwent radiotherapy 46–60 Gy.

There was no local recurrence of disease within 14 – 96m follow-up. There was one patient with post radiation wound breakdown that resolved.

Three patients have died of unrelated causes. To date there has been no evidence of local recurrence of disease at FU.

Conclusion: Planned marginal excision of low grade large volume posterior thigh sarcomas with extensive sciatic nerve involvement can be successfully treated with preservation of the sciatic nerve without significant morbidity and resultant good limb function.

Aim: To review our series of mid foot sarcomas with regard to excision of tumour, tolerance of radiotherapy and preservation of function.

Methods and results: We identified 6 patients with mid foot sarcomas treated in our unit. Synovial sarcoma was the commonest diagnosis. All the patients had stage 1 disease with no evidence of pulmonary metastases at presentation. Patients judged to have resectable tumour but preserving sufficient foot to be functional were spared amputation. They had excision of the sarcoma and immediate reconstruction using fascio-cutaneous free flaps. Complete excision was achieved in all cases. One flap was lost and repeated. In all patients, subsequent radiotherapy was well tolerated without significant complications. All patients remain disease free. All patients have returned to pre-operative functioning including walking and jogging. All except one have returned to work.

Conclusion: Patients and feet treated by wide local excision of mid foot sarcomas and reconstructed by free fascio-cutaneous flaps tolerate post-operative radio-therapy well, and return to near normal function.

Aim: To assess the functional outcomes for patients treated by limb salvage surgery for sarcomas of the upper limb and shoulder girdle.

Materials and methods: Patients who had undergone limb salvage surgery for upper limb sarcoma between 1997 and 2004 were entered into the study. The operation notes were used to obtain details of the surgery. Pathology reports were consulted to identify the type, grade and margins of the tumour. The Toronto Extremity Salvage Score (TESS) questionnaire was used to assess post-operative function, in a postal survey.

Results: A total of 62 patients were identified. Liposarcoma was most common histological diagnosis, and “low” the most common grade (27). Histologically clear margins were achieved in 28 (44%) cases, marginal in 2 (3%), incomplete in 13 (21%) and indeterminate in 20 (32%). 30% had received adjuvant radiotherapy with or without chemotherapy as indicated. A total of 48 (76%) had been treated with excision and primary closure, 7 (11%) with local flaps, and 4 (6%) with endoprostheses. 10 patients had died, and 1 was untraceable. 29 completed TESS questionnaires were returned; with an average follow-up of 33 months post-resection (range 4 to 83). 11 female (38%), 18 male (62%), with an average age at surgery of 55. The average TESS score was 77 +/−10 with a range of 18–100. For the different regions, forearm sarcomas had an average TESS of 81 +/−17, upper arm 76 +/−19 and shoulder 81 +/−14.

Discussion: Surgical excision of soft tissue tumours with limb salvage aims to balance morbidity and mortality. Upper limb amputation has greater morbidity than lower limb and thus the argument for limb salvage should be stronger. A limb-salvage procedure should be considered preferable to amputation provided oncological outcomes are not compromised, and the resulting functional outcome is worth the oncological risk. In this cohort, patients had good functional outcomes, as described by the TESS functional assessment score, with no evidence of compromised oncological outcome during the follow up period.

Over a five year period 50 patients required combined orthoplastic care out of 987 patients presenting with bone and soft tissue tumours. Thirty men, mean age 51 years, had their treatment reviewed at a mean follow up of 23 months (3–54 months) post surgery. All surviving patients completed the Toronto Extremity Salvage Score.

There were 23 bone and 27 soft tissue sarcomas, 4 were Enneking stage I, 41 stage II and 5 stage III. All tumours were removed by wide resection to achieve microscopically clear margins in 49. 9 endoprostheses were inserted. Soft tissue reconstruction involved 9 local flaps, 13 distant flaps (mainly muscle) and 8 free flaps (including 3 composite osseous flaps). 20 patients received adjuvant radiotherapy and 14 patients received chemotherapy.

Two endoprosthetic replacements required surgery for infection, one distant lap and one free flap required further surgery (6%). The mean disease free interval was 29 months (2–49 months). There were 6 deaths and pulmonary metastases occurred in a further 8 patients. Within this study period there was one episode of local recurrence, but no local recurrence in the group that had radiotherapy. 77% of surviving patients completed the Toronto Extremity Salvage Score and good to excellent function was seen in most cases.

Combined orthoplastic approach facilitates limb sparing surgery and early adjuvant radiotherapy.