Expandable prostheses were designed to allow progressive growth after tumour resection in children. The aim of this study was to report the late results of the non-invasive growing prostheses designed by A Soubeyran (Phenix prosthesis or Wright Repiphysis).

From 1994 to January 2006, 27 children aged 4 to 12 (mean 8.5), underwent a resection of the knee for a bone tumour, with reconstruction by a non invasive expandable prosthesis. There were 16 boys and 11 girls. The tumours were 25 osteosarcomas and 2 Ewing tumours. All patients received pre and post-operative chemotherapy. There were 18 distal femur, 7 proximal tibia, and 2 femur + tibia resections.

There were different successive designs based on the same electro-magnetic growing mechanism using a pre bent spring, released by eating in an induction coil.

After, 7.2 years mean follow-up (4 months to 15 years), 20 patients had no evidence of disease and 7 were deceased. Two with a local recurrence were amputated. Mean lengthening was 5.1 centimeters (0 to 8), after 3 to 11 lengthening procedures. Mean limb-length discrepancy was 1.8 cm. Two patients had a secondary infection. Eleven had a revision for arthrofibrosis. All surviving patients were revised to a conventional hinged prosthesis. The mean MSTS functional score of the definitive prosthesis was 82% (63 to 96%).

Theses prostheses showed many mechanical complications as loosening, fracture of the growing mechanism, and arthrofibrosis. The positive outcome was the possibility to perform a progressive lengthening, without surgery limiting the risk of infection. Theses prostheses should be considered as temporary until reconstruction with a conventional hinged prosthesis. Patients with multiple revisions had a tendency to show less favourable late functional results than with primary implanted hinged prosthesis.

Aims. The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone. . Patients and Methods. We conducted a retrospective analysis of a prospectively maintained database to identify all patients who had undergone an endoprosthetic replacement more than 25 years ago and who were still alive. Their outcomes were investigated with reference to their complications and need for further surgery. A total of 230 patients were identified. Their mean age at diagnosis was 20.7 years (five to 62). The most common diagnosis was osteosarcoma (132). The most common site was the distal femur (102). . Results. The mean follow-up was 29.4 years (25 to 43). A total of 610 further operations were undertaken, an average of 2.7 further operations per patient. A total of 42 patients (18%) still had the original prosthesis in place. The risk of amputation was 16% at 30 years (31 patients). Those without infection had a mean of 2.1 further operations (one to nine) while those with infection had a mean of 4.6 further operations (two to 11). The risk of infection persisted throughout the life of the prosthesis with a mean of 1% per year becoming infected. Of the 60 patients who developed an infection, 21 (35%) developed this following the primary procedure at a mean of 50 months, but another 19 developed this within a year of another surgical procedure. The risk of infection after any further surgery was 2.7%. The site with the highest risk of infection was the proximal tibia (43.3%). Take home message: This study highlights the inevitable need for further surgery following first-generation endoprosthetic reconstruction, although in most cases, limb salvage is maintained. Late complications, especially infection, continue for the lifetime of the implant. Cite this article: Bone Joint J 2016;98-B:857–64

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Endoprosthetic reconstruction following distal femur tumour resection has been widely advocated. In this paper, we present the design of an uncemented endoprosthesis system featuring a short, curved stem, with the goal of enhancing long-term survivorship and functional outcomes.

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Limb salvage surgery (LSS) is the primary treatment option for primary bone malignancy. It involves the removal of bone and tissue, followed by reconstruction with endoprosthetic replacements (EPRs) to prevent amputation. Trabecular metal (TM) collars have been developed to encourage bone ingrowth (osseointegration (OI)) into EPRs. The primary aim of this study was to assess whether OI occurs when TM collars are used in EPRs for tumour.

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Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients.

Introduction. Enchondromas located in the phalangeal bones may be more cellular than non-digital locations necessitating clinical and radiological correlation to determine diagnosis. Atypical enchondromas have increased cellularity and atypia relative to simple enchondromas but no evidence of permeation. Chondrosarcomas of the phalanges are thought to have a more indolent course than chondrosarcomas in other locations. The aim of the study was to determine the outcome of atypical enchondromas and grade 1 chondrosarcomas of the phalanges treated surgically. Methods. Data was collected prospectively on patients with a cartilage lesion of the phalanges. Typical enchondromas, grade 2 or 3 chondrosarcomas and patients with Ollier's disease were excluded. Results. There were twenty two cases of atypical enchondroma or grade 1 chondrosarcoma. Ten of the patients were female and twelve male with a mean age of 41. There were fourteen atypical enchondromas and eight grade 1 chondrosarcomas. Sixteen of the lesions were in the hand and six were in the foot. Seventeen tumours, including four cases of grade 1 chondrosarcoma, were treated with extended curettage utilising a high speed burr. Five cases were managed by digital amputation as the degree of bone loss precluded retention of the phalanx. At a mean follow up of 30 months there has been one case of local recurrence occurring in an atypical enchondroma of the foot. There have been no cases of local recurrence in the four cases of grade 1 chondrosarcoma treated by curettage. There have been no cases of distant metastasis. All patients remain under long term clinical review. Discussion. There are few published results on the treatment of atypical enchondromata and low-grade chondrosarcomas of the phalanges. In selected cases extended curettage has a low recurrence rate in the treatment of atypical enchondromata and grade 1 chondrosarcomas of the phalanges

Aim. In osteosarcoma, local control of the tumour is absolutely critical otherwise the chances of long term survival are <10% and may effectively approach zero. Radiotherapy is used in case of non-resectable tumours. Histone deacetylase inhibitors (HDACIs) can enhance the sensitivity of cells to photon radiation (XRT) by altering numerous molecular pathways. Therefore, we investigated the effect of the pan-HDAC inhibitor suberoylanilide hydroxamic acid (SAHA) on radiation response in osteosarcoma (OS) and rhabdomyosarcoma (RMS) cell lines. Methods. Clonogenic survival, cell cycle analysis, apoptosis and gammaH2AX phosphorylation as a marker of DNA double strand breaks (DSBs) were examined in two OS (KHOS-24OS, SAOS2) and two RMS (A-204, RD) cell lines treated with SAHA alone and SAHA plus XRT, respectively. Protein expression was investigated via immunoblot analysis, cell cycle analysis, measurement of apoptosis and gammaH2AX expression were performed using flow cytometry. Results. In the sarcoma cell lines, SAHA induced an inhibition of cell proliferation and clonogenic survival and lead to a significant radiosensitization. Furthermore, SAHA significantly increased radiation-induced apoptosis in the OS cell lines, whereas in the RMS cell lines radiation-induced apoptosis was insignificant with and without SAHA. In both tumour entities, gammaH2AX expression was significantly increased when XRT was combined with SAHA treatment which was correlated with attenuation of radiation-induced DNA repair protein expression. Conclusion. Our results show that HDACIs enhance radiation action in OS and RMS cell lines. Inhibition of DNA repair rather than increased apoptosis induction after exposure to HDACIs could be one key mechanism of radiosensitization by HDACIs

Introduction. The use of computer navigation has a potential to allow precise tumour resection and accurate reconstruction of the resultant defect. This can be useful in difficult areas such as pelvis, diaphyseal (intercalary) resections and geometric bony resections. Methods. We have carried out resections of musculoskeletal tumours in 7 patients using an existing commercial computer navigation system (Orthomap 3D). CT & MRI scans of each patient were fused preoperatively using navigation software and the tumour margins were marked. The planes of tumour resection were defined on the 3D image generated. During surgery, trackers were attached to bone with tumour and registration performed. Instruments attached to navigation tracker were then used to identify the predetermined resection points. Of the 4 pelvic tumours, 1 had biological reconstruction with extra corporeal irradiation, 3 had endoprosthetic replacement & 1 did not need any bony reconstruction. 1 patient with proximal femur tumour needing extraarticular resection had endoprosthetic replacement. The 2 tibial diaphyseal tumours had biological reconstruction. Results. Examination of the resected specimens revealed tumour free margins. Postoperative radiographs showed resection and reconstruction as planned in all cases. In the patient with extraarticular proximal femur resection the hip joint was inadvertently exposed whilst making the acetabular osteotomy & in one patient with pelvic tumour the intra-operative registration could not be accurately performed as she was overweight and a real time matching of anatomy & virtual images was not achieved. Discussion and Conclusion. The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent and thus resection margins can be identified accurately. Our experience so far has been encouraging. Further clinical trials (multicentre) are required to evaluate its long term impact including functional & oncological outcomes

In proximal humerus reconstructions, osteoarticular massive allograft (OA) allows a biologic reattachment of tendineous structures of the host providing stability and functional recovery. Allograft-prosthesis composites (APC) are more technically demanding, but functional advantages with new prosthetic design are expected with lower fracture and failure rate with time. We compared the outcome of patients treated with OA reconstruction (group A) and patients treated with an APC (group B) after humerus resection for bone tumours. Thirty six patients treated between 1996 and 2009 were included in the study (18 group A; 18 group B). The diagnosis was a malignant bone tumour in 28 cases, an aggressive benign bone tumour in 6 and a bone metastasis in 2. Three total humerus resections were performed (two in group A and one in group B). Three different type of prosthesis were used (conventional, reverse and resurfacing). In group A, at an average follow-up of 66 months (2-116), 16 patients were continuously disease free. Ten patients (56%) had no complication; in 6 cases (33%) we observed a fracture of the graft and in 3 cases (17%) a pseudoarthrosis. In group B, at an average follow up of 44 months (3-164), 16 patients were continuously disease free. Thirteen patients (72%) had no complication, in 2 cases (11%) stem loosening, in 2 cases (11%) dislocation, in 1 case pseudoarthrosis and in 1 case resorption and detachment of allograft's great tuberosity was observed. Functional outcome was evaluated using MSTS scoring system: a mean score of 24 (13-30) in group A and 23 (15-27) in group B was observed. In our experience, proximal humerus APC showed functional results comparable to OA allograft with lower complication rate. In conclusion, in biologic reconstruction of the proximal humerus, APC seems to provide a more reliable solution than OA allograft at long term

Aim. The saddle prosthesis was originally developed for reconstruction of large acetabular defects in hip revision arthroplasty. Later on the saddle prosthesis was also used for hip reconstruction after resection of peri-acetabular tumours. In case of patient survival a long-term good hip function is required of the saddle prosthesis. The goal of this study is the measurement of long-term clinical results of saddle prosthesis after reconstruction of peri-acetabular tumours. Method. Between 1987 and 2003 a total of 17 patients were treated in the Leiden University Medical Center with saddle prosthesis after resection of peri-acetabular tumours (12 chondrosarcoma, 3 osteosarcoma, 1 malignant fibrous histiocytoma, 1 metastasis). 11 of the 17 patients died, the mean survival was 37 months (range 2-59 months), and 6 patients were still alive (follow-up 12.1 year, range 8.3–16.8 year). The outcome was measured with the SF-36 questionnaire, the Toronto Extrimity Salvage Score (TESS) and the Musculo Skeletal Tumour Society (MSTS) score. In 1 patient the saddle prosthesis was removed already after 3 months because of luxation and infection. Results. In 13 of the 17 patients the use of walking devices was known: 54% required two crutches, 38% one crutch, and 8% no walking aids. The mean hip flexion was 60 degrees (range 40-100 degrees). Local complications were seen in 14 of the 17 patients: 9 wound infections, 7 luxations, and 2 leg length discrepancies requiring additional surgery. In the 5 surviving patients the MSTS score at long-term follow up was 47%, the mean TESS score was 53%, the mean composite SF-36 physical and mental scores were 43.92 and 50.64 respectively. Conclusion. Reconstruction with saddle prosthesis after peri-acetabular tumour surgery has a high risk of complications, and poor long term functional outcome with limited flexion of the hip

Aim. Patients treated with limb salvage surgery for bone sarcomas of the extremities (upper and lower) may have physical disability as a result of treatment. Goal of this study was to evaluate the quality of life after treatment (chemotherapy and conservative surgery) at long term. Method. 208 patients resected for a bone sarcoma and with prosthetic reconstruction (45 in the upper and 163 in the lower limb) were evaluated. Assessment of results was done using the Karnofsky Scale (K.S.). Patients were followed in the clinic and functional results assessed according to the Musculoskeletal Tumour Society (MSTS) system. Moreover the Toronto Extremity Salvage Score questionnaire (TESS) was mailed to 144 patients. Results. Before treatment 157 patients had a Karnofsky index between “50%” and “70%”, 96 patients between “0%” and “40%”. After treatment 94 patients had a Karnofsky index between “80%” and “100%”, 54 between “50%” and “70%”, and 34 below “40%”. Twentysix patients died with disease. For the upper limb MSTS system showed a mean value of 80%, with excellent or good results (MSTS score between 30 and 15) in 43 patients, fair or poor results (MSTS score between 14 and 0) in 2 patients. For the lower limb MSTS system showed a mean value of 76.6%, with excellent or good results in 145 patients (89%), fair or poor results in 18 patients (11%). TESS questionnaire was sent back by eighty two patients. TESS was recorded an average of 3.7 years (upper limb) and 4.2 years (lower limb) after reconstruction. Mean TESS was similar in upper (75.3%) and lower (78.3%) limbs, but differed with age (patients older than 25 years had worse scores). Conclusion. The 3 analyzed methods showed a good quality of life after treatment. The subjective view of K.S. and TESS is aligned with the MSTS results

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We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.

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Local recurrence remains a challenging and common problem following curettage and joint-sparing surgery for giant cell tumour of bone (GCTB). We previously reported a 15% local recurrence rate at a median follow-up of 30 months in 20 patients with high-risk GCTB treated with neoadjuvant Denosumab. The aim of this study was to determine if this initial favourable outcome following the use of Denosumab was maintained with longer follow-up.

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We analyzed the long-term outcomes of patients observed over ten years after resection en bloc and reconstruction with extracorporeal irradiated autografts

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Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

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The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins.

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The aim of this study was to evaluate the prosthesis characteristics and associated conditions that may modify the survival of total femoral endoprosthetic replacements (TFEPR).

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The aim of this study was to describe, analyze, and compare the survival, functional outcome, and complications of minimally invasive (MI) and non-invasive (NI) lengthening total femoral prostheses.

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The aims of this study were to evaluate the long-term outcome of surgery for bone or soft-tissue metastases from renal cell carcinoma (RCC) and to determine factors that affect prognosis.

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Dislocation rates are reportedly lower in patients requiring proximal femoral hemiarthroplasty than for patients undergoing hip arthroplasty for neoplasia. Without acetabular replacement, pain due to acetabular wear necessitating revision surgery has been described. We aimed to determine whether wear of the native acetabulum following hemiarthroplasty necessitates revision surgery with secondary replacement of the acetabulum after proximal femoral replacement (PFR) for tumour reconstruction.