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Background Compliant, self-adjusting compression technology is a novel approach for durable prosthetic fixation of the knee. However, the long-term survival of these constructs is unknown. Questions/purposes We therefore determined the survival of the Compress ® prosthesis (Biomet Inc, Warsaw, IN, USA) at 5 and 10 actuarial years and identified the failure modes for this form of prosthetic fixation. Methods We retrospectively reviewed clinical and radiographic records for all 82 patients who underwent Compress ® knee arthroplasty from 1998 to 2008, as well as one patient who received the device elsewhere but was followed at our institution. Prosthesis survivorship and modes of failure were determined. Followup was for a minimum of 12 months or until implant removal (median, 43 months; range, 6–131 months); 28 patients were followed for more than 5 years. Results We found a survivorship of 85% at 5 years and 80% at 10 years. Eight patients required prosthetic revision after interface failure due to aseptic loosening alone (n = 3) or aseptic loosening with periprosthetic fracture (n = 5). Additionally, five periprosthetic bone failures occurred that did not require revision: three patients had periprosthetic bone failure without fixation compromise and two exhibited irregular prosthetic osteointegration patterns with concomitant fracture due to mechanical insufficiency. Conclusions Compress ® prosthetic fixation after distal femoral tumor resection exhibits long-term survivorship. Implant failure was associated with patient nonadherence to the recommended weightbearing proscription or with bone necrosis and fracture. We conclude this is the most durable FDA-approved fixation method for distal femoral megaprostheses. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Joint-preserving surgery is performed in select patients with bone sarcomas of extremities and allows patients to retain the native joint with better joint function. However, recurrences may relate to achieving adequate margins and there is frequently little room for error in tumors close to the joint surface. Further, the tumor margin on preoperative CT and/or MR images is difficult to transpose to the actual extent of tumor in the bone in the operating room. Questions/purposes We therefore determined whether joint-preserving tumor surgery could be performed accurately under image-guided computer navigation and determined local recurrences, function, and complications. Methods We retrospectively studied eight patients with bone sarcoma of extremities treated surgically by navigation with fused CT-MR images. We assessed the accuracy of resection in six patients by comparing the cross sections at the resection plane with complementary prosthesis templates. Mean age was 17 years (range, 6–46 years). Minimum followup was 25 months (mean, 41 months; range, 25–60 months). Results The achieved resection was accurate, with a difference of 2 mm or less in any dimension compared to that planned in patients with custom prostheses. We noted no local recurrence at latest followup. The mean Musculoskeletal Tumor Society score was 29 (range, 28–30). There were no complications related to navigation planning and procedures. There was no failure of fixation at the remaining epiphysis. Conclusions In selected patients, the computer-assisted approach facilitates precise planning and execution of joint-preserving tumor resection and reconstruction. Further followup assessment in a larger study population is required in these patients. Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Small recent case series using CT-based navigation suggest such approaches may aid in surgical planning and improve accuracy of intended resections, but the accuracy and clinical use have not been confirmed. Questions/purposes We therefore evaluated (1) the accuracy; (2) recurrences; and (3) function in patients treated by computer-assisted tumor surgery (CATS). Methods From 2006 to 2009, we performed CATS in 20 patients with 21 malignant tumors. The mean age was 31 years (range, 6–80 years). CT and MR images for 18 cases were fused using the navigation software. Reconstructed two-dimensional/three-dimensional images were used to plan the bone resection. The achieved bone resection was compared with the planned one by assessing margins, dimensions at the level of bone resection, or fitting of CAD custom prostheses. Function was assessed with the Musculoskeletal Tumor Society (MSTS) score. The minimum followup was 31 months (mean, 39 months; range, 5–69 months). Results Histological examination of all resected specimens showed a clear tumor margin. The achieved bone resection matched the planned with a difference of ≤ 2 mm. The achieved positions of custom prostheses were comparable to the planned positions when merging postoperative with preoperative CT images in five cases. Three of the four patients with local recurrence had tumors at the sacral region. The mean MSTS score was 28 (range, 23–30). Conclusion CATS with image fusion allows accurate execution of the intended bone resection. It may be beneficial to resection and reconstruction in pelvic, sacral tumors and more difficult joint-preserving intercalated tumor surgery. Comparative clinical studies with long-term followup are necessary to confirm its efficacy. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture. Questions/Purposes We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture. Methods We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27–293 months). Results Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23–30; n = 18) when compared with resection (mean, 25; range, 13–30; n = 25). Conclusions Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Limb-salvage reconstruction for periacetabular malignant tumors is one of the most challenging problems in orthopaedic oncology. Reconstructive options include resection arthroplasty, endoprosthesis, allograft, recycled autobone graft, arthrodesis, and pseudarthrosis. However, no standard procedure exists because of rarity and clinical variability of the disease. We previously developed a megaprosthetic system with a constrained total hip mechanism (C-THA). Questions/purposes We evaluated (1) survival of patients and C-THA; (2) postoperative function; and (3) complications. Methods We retrospectively reviewed 25 patients with primary periacetabular tumors treated using C-THA between 1985 and 2009. There were 18 male and seven female patients with a median age of 44 years (range, 16–72 years). They included 11 chondrosarcomas, eight osteosarcomas, two giant cell tumors of bone (one locally aggressive benign, one malignant), and others in four. Surgical margin was wide in 18 patients, marginal in five, and intralesional in two. The minimum postoperative followup for survivors was 32 months (median, 163 months; range, 32–285 months). Results The 10-year overall survival rate of all patients was 47%. C-THA implants survived in 19 of 25 patients at last followup. Twenty-one patients acquired ambulatory activity. There were seven local recurrences, resulting in hemipelvectomy in one patient. Postoperative complications included deep infection in eight of the 25 patients, dislocation in four, and aseptic loosening in two, necessitating five revision surgeries and three implant removals. Conclusions Our observations suggest C-THA using an acetabular reconstruction cup is a useful reconstructive option after resection of periacetabular malignant tumors despite frequent postoperative complications. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Successful treatment of pathologic femur fractures can preserve a patient’s independence and quality of life. The choice of implant depends on several disease- and patient-specific variables; however, its durability must generally match the patient’s estimated life expectancy. Failures do occur, however, it is unclear which implants are associated with greater risk of failure. Questions/Purposes We evaluated patients with femoral metastases in whom implants failed to determine (1) the rate of reoperation; (2) the timing of and most common causes for failure; and (3) incidence of perioperative complications and death. Methods From a prospectively collected registry, we identified 93 patients operated on for failed treatment of femoral metastases from 1990 to 2010. We excluded five patients who subsequently underwent amputations leaving 88 who underwent salvage procedures. These included intramedullary nails (n = 11), endoprostheses (n = 61), and plate fixation (n = 16). The primary outcome was reoperation after salvage treatment. Results Seventeen of the 88 patients (19%) required subsequent reoperation a median of 10 months (interquartile range, 4–14) from the time of salvage surgery: 15 for material failure, one for local progression of tumor, and one for a combination of these. Five patients died within 4 weeks of surgery. Although perioperative complications were higher in the endoprosthesis group and dislocations occurred, overall treatment failures after salvage surgery were lower in the that group (four of 61) compared the group with plate fixation (eight of 16) and intramedullary nail groups (five of 11). Conclusions Despite relatively common perioperative complications, salvage using endoprostheses may be associated with fewer treatment failures as compared with internal fixation. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Distal radius reconstruction after en bloc tumor resection remains a surgical challenge. Although several surgical techniques, either reconstructing the wrist or achieving a stable arthrodesis, have been described, it is unclear to what degree these restore function. Description of Technique We describe an updated technique making use of a tibia cortical strut autograft (TCSA) to perform a functional arthrodesis from the remaining radius to the first carpal row. This, in theory, could lead to less donor site morbidity while resulting in a stable but functional and pain-free arthrodesis of the wrist. Methods Between 1987 and 2010 we reconstructed the wrists of 17 patients using a TCSA arthrodesis (six primary and three revisions), seven with an osteoarticular allograft, three using an ulnar translocation, and one with a fibula autograft. Median age at diagnosis was 24 years (range, 9–58 years) and minimum followup was 2.7 years (median, 13.8 years; range, 2.7–24.5 years). Patients were evaluated using radiographs and clinical examination. We used Musculoskeletal Tumor Society (MSTS), Disabilities of the Arm, Shoulder, and Hand (DASH), and SF-36 questionnaires to assess function and quality of life. Results All TCSA reconstructions fused; one patient had a second surgery to expedite union with the carpal row. After osteoarticular allograft, five patients were revised (three to a TCSA) for nonunion, fracture, or joint collapse. ROM and grip strength were comparable in both AO and TCSA, all above 60% of the contralateral side. Median MSTS and DASH scores were 73% and 6, respectively, and did not differ between the groups. The SF-36 scores showed less pain after TCSA; otherwise, all patients presented with comparable function. Conclusions TCSA wrist arthrodesis resulted in a functional and painless wrist reconstruction with a relatively low complication and donor site morbidity rate and comparable functional results as other techniques. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background The literature on osteosarcoma survival generally focuses on tumor and treatment variables, although it is unclear whether and how ethnic and socioeconomic factors might influence survival. Questions/purposes We therefore investigated the relative contribution of socioeconomic influences together with more traditional tumor-specific factors on osteosarcoma survival. Methods We performed survival analyses on two national databases in two countries. Using multivariable analyses, we compared these with corresponding institution-specific survival to determine if socioeconomic factors might impact osteosarcoma survival. Results East Asian descent, state-specific treatment, female sex, treatment in the 1990s, low-grade disease, intracompartmental disease, small size, wide resections as opposed to forequarter or hindquarter amputations, and single primaries were good prognostic factors. Survival was better in the more affluent states. Males were affected at an older age than females. Blacks tended to have larger tumors, although their overall survival was similar to whites. East Asians were more likely to be treated in the 1990s with wide resections for smaller tumors and were located around states associated with good treatment. East Asians in Singapore and the United States had the same survival. Survival in East Asians in Singapore was similar to that of other races. The provision of health care for osteosarcoma varies greatly across the United States but is uniform in the socialized medical system in Singapore. Hence, the observed differences in the United States were likely the result of socioeconomic factors. Conclusions Our analysis suggests ethnic and economic bias may influence survival in osteosarcoma and should receive greater attention in the collective literature on survival analyses. Level of Evidence Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background Despite neoadjuvant chemotherapy and wide surgical ablation, 15% to 25% of patients with primary osteosarcoma will relapse (local recurrence or metastases). Neither chemotherapy nor radiation therapy alone will render a patient disease-free without concomitant surgical ablation of relapse. We prefer excision of relapse when possible. However, it is unclear whether excision enhances survival. Questions/purposes We therefore determined (1) onset, location, and treatments for relapse; (2) postrelapse disease-free survival of patients who underwent surgical ablation and those who did not; and (3) relapse-free interval between initial diagnosis and first relapse in survivors and in those who died of their disease. Methods We retrospectively reviewed 15 children who initially presented with localized, nonmetastatic extremity osteosarcoma and attained initial complete remission after neoadjuvant chemotherapy, wide local resection, postoperative chemotherapy, and subsequently developed disease relapse. Relapse occurred at a median of 28 months, although late relapse after 5 years occurred in three. We resected the recurrent tumor in nine patients and treated six nonoperatively. Results Seven of nine surgically treated patients had a postrelapse disease-free survival ranging from 3 to 14 years and an overall survival ranging from 7 to 16 years. Patients not surgically treated all died within 40 months of their relapse. The median relapse-free interval in patients who survived was longer 34 months (range, 17–152 months) as compared with 17 months (range, 7–40 months) in those who died of their disease. Conclusions Our data confirm the importance of surgery in patients with relapsed osteosarcoma. Disease-free survival in patients with relapsed osteosarcoma is only possible if complete remission is attained. Patients with late relapse may have a better chance of survival. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Wide-margin resections are an accepted method for treating soft tissue sarcoma. However, a wide-margin resection sometimes impairs function because of the lack of normal tissue. To preserve the normal tissue surrounding a tumor, we developed a less radical (ie, without a wide margin) surgical procedure using adjunctive photodynamic therapy and acridine orange for treating soft tissue sarcoma. However, whether this less radical surgical approach increases or decreases survival or whether it increases the risk of local recurrence remains uncertain. Questions/purposes We determined the survival, local recurrence, and limb function outcomes in patients treated with a less radical approach and adjunctive acridine orange therapy compared with those who underwent a conventional wide-margin resection. Methods We treated 170 patients with high-grade soft tissue sarcoma between 1999 and 2009. Fifty-one of these patients underwent acridine orange therapy. The remaining 119 patients underwent a conventional wide-margin resection for limb salvage surgery. We recorded the survival, local recurrence, and functional score (International Society of Limb Salvage [ISOLS]) score) for all the patients. Results The 10-year overall survival rates in the acridine orange therapy group and the conventional surgery group were 68% and 63%, respectively. The 10-year local recurrence rate was 29% for each group. The 5-year local recurrence rates for Stages II, III, and IV were 8%, 36%, and 40%, respectively, for the acridine orange group and 13%, 27%, and 33%, respectively, for the conventional surgery group. The average ISOLS score was 93% for the acridine orange group and 83% for the conventional therapy group. Conclusion Acridine orange therapy has the potential to preserve limb function without increasing the rate of local recurrence. This therapy may be useful for eliminating tumor cells with minimal damage to the normal tissue in patients with soft tissue sarcoma. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of the levels of evidence.