Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.
This month, author Peter S. Rose, MD summarized the 5 most compelling findings from the 40 studies highlighted in the December 16, 2020 “What’s New in Musculoskeletal Tumor Surgery.”
Primary Bone Tumors
–A retrospective analysis of data from the Euro-EWING99 trial1 is probably the most thorough examination to date of local tumor-control options in Ewing’s sarcoma of the pelvis–a difficult and controversial condition. The authors conclude with a recommendation for aggressive surgery and radiation in many patients, which goes beyond what most North American centers provide.
–Anderson et al. validate a fracture-risk calculating app2 that provides immediate clinical guidance on the risk of fracture and the role for surgery in patients with skeletal metastases. It is an early example of applying digital technology to provide real-time, individualized clinical guidance.
Phantom Limb Pain
–Alexander et al. provide an excellent early report of a new surgical technique3 (targeted muscle reinnervation) and a focused rehabilitation protocol to decrease phantom limb pain and maximize function after oncologic amputations.
–After analyzing >1,600 patients treated for a soft-tissue sarcoma, Bedi et al. put forth a nomogram4 to predict postoperative wound complications, the single most frequent surgical complication in this population. The finding that BMI, tumor location, and timing of radiation are associated with the risk of wound complications is clinically relevant to all surgeons who treat these patients.
Carcinogenesis from Radiation Exposure
–This thought-provoking study predicted a lifetime fatal cancer risk of 3.5% from medical imaging studies used in the care of polytrauma patients. While the study focused on trauma patients rather than oncology patients, the striking results may have implications for how we use CT imaging to follow tumor patients as well.
- Andreou D, Ranft A, Gosheger G, Timmermann B, Ladenstein R, Hartmann W, Bauer S, Baumhoer D, van den Berg H, Dijkstra PDS, Dürr HR, Gelderblom H, Hardes J, Hjorth L, Kreyer J, Kruseova J, Leithner A, Scobioala S, Streitbürger A, Tunn PU, Wardelmann E, Windhager R, Jürgens H, Dirksen U; GPOH-Euro-EWING99 Consortium. Which factors are associated with local control and survival of patients with localized pelvic Ewing’s sarcoma? A retrospective analysis of data from the Euro-EWING99 trial. Clin Orthop Relat Res.2020 Feb;478(2):290-302.
- Anderson AB, Wedin R, Fabbri N, Boland P, Healey J, Forsberg JA. External validation of PATHFx version 3.0 in patients treated surgically and nonsurgically for symptomatic skeletal metastases. Clin Orthop Relat Res.2020 Apr;478(4):808-18.
- Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: early experience of a novel institutional protocol. J Surg Oncol.2019 Sep;120(3):348-58. Epub 2019 Jun 13.
- Bedi M, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Cardona K, King DM. Is a nomogram able to predict postoperative wound complications in localized soft-tissue sarcomas of the extremity? Clin Orthop Relat Res.2020 Mar;478(3):550-9.
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Peter S. Rose, MD selected the most clinically compelling findings from the 40 studies summarized in the December 18, 2019 “What’s New in Musculoskeletal Tumor Surgery.”
Staging Primary Bone Tumors
–The American Joint Committee on Cancer (AJCC) issued new staging criteria for primary bone tumors,1 largely in response to clinician reports that pelvic and spinal bone tumors have adverse clinical outcomes compared with extremity tumors. In the AJCC staging system, different criteria are applied to extremity, pelvic (inclusive of the sacrum), and mobile spinal tumors—an important step toward gathering data to better define the prognosis of these tumors.
–The skeletal system is the third most common site of metastatic disease, and the most common location of symptomatic skeletal metastases is about the hip. In a risk-adjusted analysis of US Veterans Administration data, Philipp et al. showed that patients with femoral metastases treated prophylactically have a lower risk of death (hazard ratio, 0.75) than similar patients treated after pathological fracture.2
–Aponte-Tinao et al. investigated the ≥10-year survival of bulk allografts for the femur and tibia, demonstrating 60% graft survival in 166 patients.3 However, proximal tibial osteoarticular grafts fared poorly.
–An analysis of the impact of obesity on soft-tissue sarcoma presentation and management4 arrived at 3 conclusions. Relative to non-obese patients,
- Obese patients presented with larger tumors (presumably because of difficulty detecting them).
- Obese patients required more complex wound closures.
- Obese patients experienced more complications.
–A retrospective analysis of the value of radiotherapy and chemotherapy in treating different subtypes of soft-tissue sarcomas5 revealed that myxoid liposarcomas, vascular sarcomas, and myxofibrosarcomas had the greatest benefit from radiation in terms of local control rates, although there was no difference in overall survival. Chemotherapy resulted in a 5% survival benefit.
- Kniesl JS, Rosenberg AE, Anderson PM, Antonescu C, Bruland O, Cooper K, Horvai A, Holt G, O’Sullivan B, Patel S, Rose P. Bone. In: Amin M.B., Edge S.B., Greene F.L., Byrd D.R., Brookland R.K., Washington M.K., Gershenwald J.E., Compton C.C., Hess K.R., Sullivan D.C., Jessup J.M., Brierley J.D., Gaspar L.E., Schilsky R.L., Balch C.M.,Winchester D.P., Asare E.A., Madera M., Gress D.M., Vega L.M., editors. AJCC cancer staging manual. 8th ed. Springer; 2018. p 471-86.
- Philipp T, Mikula J, Doung Y-C, Gundle K. Is there an association between prophylactic femur stabilization and survival in patients with metastatic bone disease? Clin Orthop Relat Res. 2019 May 17. [Epub ahead of print.]
- Aponte-Tinao L, Ayerza M, Albergo J, Farfalli GL. Do massive allograft reconstructions for tumors of the femur and tibia survive 10 or more years after implantation? Clin Orthop Relat Res. 2019 May 17. [Epub ahead of print.]
- Montgomery C, Harris J, Siegel E, Suva L, Wilson M, Morell S, Nicholas R. Obesity is associated with larger soft-tissue sarcomas, more surgical complications, and more complex wound closures (obesity leads to larger soft-tissue sarcomas). J Surg Oncol. 2018 Jul;118(1):184-91. Epub 2018 Jun 7.
- Callegaro D, Miceli R, Bonvalot S, Ferguson P, Strauss DC, Levy A, Griffin A, Hayes AJ, Stacchiotti S, Le P`echoux C, Smith MJ, Fiore M, Dei Tos AP, Smith HG, Catton C, Casali PG, Wunder JS, Gronchi A. Impact of perioperative chemotherapy and radiotherapy in patients with primary extremity soft tissue sarcoma: retrospective analysis across major histological subtypes and major reference centres. Eur J Cancer. 2018 Dec;105:19-27. Epub 2018 Oct 29.