Osteosarcoma is the most common primary osseous malignancy excluding malignant neoplasms of marrow origin (myeloma, lymphoma and leukemia) and accounts for approximately 20% of bone cancers. It predominantly affects patients younger than 20 years and mainly occurs in the long bones of the extremities, the most common being the metaphyseal area around the knee. These are classified as primary (central or surface) and secondary osteosarcomas arising in preexisting conditions. The conventional plain radiograph is the best for probable diagnosis as it describes features like sun burst appearance, Codman's triangle, new bone formation in soft tissues along with permeative pattern of destruction of the bone and other characteristics for specific subtypes of osteosarcomas. X-ray chest can detect metastasis in the lungs, but computerized tomography (CT) scan of the thorax is more helpful. Magnetic resonance imaging (MRI) of the lesion delineates its extent into the soft tissues, the medullary canal, the joint, skip lesions and the proximity of the tumor to the neurovascular structures. Tc99 bone scan detects the osseous metastases. Positron Emission Tomography (PET) is used for metastatic workup and/or local recurrence after resection. The role of biochemical markers like alkaline phosphatase and lactate dehydrogenase is pertinent for prognosis and treatment response. The biopsy confirms the diagnosis and reveals the grade of the tumor. Enneking system for staging malignant musculoskeletal tumors and American Joint Committee on Cancer (AJCC) staging systems are most commonly used for extremity sarcomas.
Osteosarcoma; imaging; biopsy; Enneking staging
Osteosarcoma (OS), the commonest malignancy of osteoarticular origin, is a very aggressive neoplasm. Divergent histologic differentiation is common in OS; hence triple diagnostic approach is essential in all cases. 20% cases are atypical owing to lack of concurrence among clinicoradiologic and pathologic features necessitating resampling. Recognition of specific anatomic and histologic variants is essential in view of better outcome. Traditional prognostic factors of OS do stratify patients for short term outcome, but often fail to predict their long term outcome. Considering the negligible improvement in the patient outcome during the last 20 years, search for novel prognostic factors is in progress like ezrin vascular endothelial growth factor, chemokine receptors, dysregulation of various micro ribonucleic acid are potentially promising. Their utility needs to be validated by long term followup studies before they are incorporated in routine clinical practice.
Osteosarcoma; prognostic factors; vascular endothelial growth factor; ezrin
Surface osteosarcomas are a rare form of osteosarcomas accounting for around 3-6% of all osteosarcomas. Three major groups of surface osteosarcomas are parosteal, periosteal and the high grade surface osteosarcomas. Of these, the parosteal osteosarcoma is the most common. Parosteal and periosteal osteosarcomas are distinct clinical entities and it is important to identify the clinicoradiological differences between the two types. Surface osteosarcomas occur at a later age as compared to conventional osteosarcomas. The classical site is the lower end of the femur followed by the upper end of the tibia and upper end of humerus, in that order. The periosteal variant affects the tibia more commonly than the parosteal variety. Neo-adjuvant chemotherapy is the standard of care for high grade surface osteosarcomas. Parosteal osteosarcomas, being low grade lesions, can be treated by upfront wide excision without adjuvant systemic therapy. Controversy prevails over the need for chemotherapy in periosteal osteosarcomas, which are intermediate grade lesions.
High grade; parosteal; periosteal; surface osteosarcoma
Dedifferentiated chondrosarcomas are cartilaginous tumors that consist of two distinguishable components, a lowgrade chondrosarcoma (chondrogenic) component and a highgrade dedifferentiated (anaplastic) component. The tumor cells in both components seem to originate from a single precursor, but there are a substantial number of genetic alterations in the anaplastic component. The underlying mechanism of dedifferentiation is unknown, but cell cycle regulators p16, p53 and retinoblastoma appear to have important roles in tumor development and dedifferentiation. In this article, molecular pathogenesis of dedifferentiated chondrosarcomas is reviewed.
Dedifferentiated chondrosarcoma; dedifferentiation; pathogenesis
While limb salvage surgery has long been established as the standard of care for osteosarcoma, large studies from Indian centers are few. Given the diverse socio economic milieu of our patients, it becomes significant to determine the feasibility and outcome of management of osteosarcoma in our population. We analyzed the early outcome of limb salvage surgery with multimodality treatment of osteosarcoma of the extremity/girdle bones at a tertiary North Indian Cancer Centre.
Materials and Methods:
A total of 51 limb salvage surgeries performed during the months between November 2008 and November 2012 were studied. Neoadjuvant/adjuvant chemotherapy was given by the pediatric/adult medical oncology teams as applicable. The mean followup was 19.45 months (range 2-50 months). The oncological outcome was correlated with age, sex, size of tumor, stage at presentation, site, histological subtype, type of chemotherapy protocol followed and necrosis seen on postoperative examination of resected specimen. The functional outcome of the patients was evaluated using the musculoskeletal tumor society (MSTS) scoring system.
Out of a total of 37 males and 14 females with an average age of 18.8 years, the 3 year overall survival was 66% and 3 year event free survival was 61.8%. In this group of patients with a short followup, a better oncological outcome was associated with good postoperative tumor necrosis, nonchondroblastic histology and age <14 years. The average MSTS score was highest in patients with proximal or distal femur prosthesis and the lowest in patients undergoing a knee arthrodesis.
The present study shows oncological and functional outcomes of limb salvage combined with chemotherapy in Indian patients with osteosarcoma comparable to those in world literature. Larger studies on Indian population with longer followup are recommended.
Limb salvage surgery; osteosarcoma; oncological outcome; neoadjuvant chemotherapy
The aim of the following study is to evaluate the morbidity, oncologic results and functional outcome in nonmetastatic patients with primary osteosarcoma of the pelvis treated with surgical resection.
Materials and Methods:
Twelve cases of nonmetastatic osteosarcoma of pelvis were operated as part of their multimodality treatment regime between November 2003 and May 2011. There were 5 males and 7 females with a median age of 22 years (range 8-39 years). Ten patients underwent limb sparing resections while 2 had a hindquarter amputation. All 10 cases of limb sparing surgery included resection of the acetabulum. A pseudarthrosis was carried out in 7 cases. Extracorporeal radiation therapy and reimplantation of the bone followed by fixation with plates was used in 1 case and an ischiofemoral arthrodesis was carried out in 2 cases.
Surgical margins were free in 11 patients. Seven patients had a poor histological response to chemotherapy while 4 patients had a good response to chemotherapy. In the patient reconstructed with radiated auto bone graft, the histological response to chemotherapy could not be assessed. Surgery related complications were seen in 8 out of 12 patients (67%). Three of these patients (25%) required additional surgical intervention for their complications. All patients were available for followup. The median followup of survivors was 56 months (range 24-102 months). Four patients (33%) developed a local recurrence. At 5 years, overall survival was 67%. Patients with a good response to chemotherapy had a better overall survival when compared with patients with a poor response to chemotherapy. The mean Musculoskeletal Tumor Society functional score was 22 (range12-27).
Though complex and challenging, surgery provides good local control and oncologic outcomes with acceptable function in patients with osteosarcoma of the pelvis treated with appropriate surgical resection as part of their multimodality treatment.
Hindquarter; limb salvage; pseudarthrosis; resection
Periosteal osteosarcoma is an uncommon variant of osteosarcoma which constitutes less than 2% of all osteosarcomas. Whereas adequate surgical excision remains the cornerstone of treatment, the role of chemotherapy in this tumor is still unclear. Existing literature contains very few single center studies on the outcomes for periosteal osteosarcomas and any additional information will help in better understanding of these uncommon lesions. This study aims to evaluate the oncologic and functional outcomes of treatment of periosteal osteosarcoma treated at our institute.
Materials and Methods:
A retrospective analysis of 18 cases of periosteal osteosarcoma treated between January 2001 and December 2010 was carried out. There were 12 males and 6 females. The mean age at presentation was 16.3 years (range 5-26 years). Tibia and femur were the most common sites (n = 8). 16 of 18 patients received chemotherapy, 16 had limb sparing resection, one had an amputation and one had rotationplasty. Of the 16 patients with limb salvage, conventional wide excision was done in 11 cases. In 5 cases tumor was excised with hemicortical excision. Of the 11 cases treated with wide excisions, 4 patients underwent an osteoarticular resection and in 7 patients a joint preserving segmental intercalary resection was done.
All patients were available for followup. Surgical margins were free in all patients. A good response to chemotherapy was seen in 4/11 cases and poor in 6/11 cases. In one case the histological response was not discernible due to predominant chondromyxoid nature of the tumor. The median followup was 61 months (range: 18-130 months). There were two local recurrences (11%) at 9 and 18 months postsurgery. Pulmonary metastasis subsequently occurred in 4 cases (22%). Fourteen patients are currently alive and continuously disease free. Disease free survival at 5 years was 77.8% and overall survival (OVS) was 83.3%. Patients without marrow involvement had a better OVS at 5 years when compared with patients with marrow involvement (90% vs. 75%) (P = 0.23).
Surgical excision remains the mainstay of treatment. Intramedullary involvement may suggest aggressive disease biology. The role of chemotherapy is still debatable and multicenter studies are needed to provide guidelines.
Hemicortical; intercalary; limb salvage; periosteal osteosarcoma; resection
Osteosarcoma is a high grade malignant, osteoid forming, primary bone tumor affecting the metaphysis of long bones. Local recurrence (LR) in osteosarcomas is a sinister. Theoretically, a high tumor volume at the time of presentation will limit surgical margins, involve vital neurovascular bundles and show poor response to chemotherapy thereby causing high rates of amputations (as against limb salvage surgery) and should be associated with poor survival rates. This study evaluated objectively if high tumor volume is a significant predictor of local recurrence (LR) in operated cases of osteosarcomas.
Materials and Methods:
Operated cases of osteosarcoma (presenting to the Orthopedic outpatient or the Medical Oncology outpatient between January 1, 2004 and January 1, 2011 were included in the study. Their preoperative clinical data and investigations along with the operative notes were traced from the medical/departmental records. Details of chemotherapy received in the neo-adjuvant and postoperative periods were noted. Besides, all demographic data were also noted. Tumor volume was calculated using the available magnetic resonance images using the formula: ([π/6] × length × width × depth). Post data extraction, patients were divided in two groups, Groups I (without LR) and Group II (with LR).
A total of 95 cases of biopsy proven osteosarcomas were identified. Of which 64 were male and 31 females. There were 15 (15.8%) local recurrences. 71% (57/80) patients without LR fell in the age group of 10-20 years, while 66% (10/15) patients with LR were in the age group of 10-20 years. Limb salvage surgery was done in 81.05% (77/95) patients while a total of 18 patients underwent amputation. Of the 80 cases in Group I (without LR), 40 (50%) patients had tumor volume >200 c.c., 30 patients (37.5%) had tumor volume between 50 and 200 c.c. while only 10 patients had tumor volumes <50 c.c. This was in contrast to the tumor volume noted in Group II (with LR) of 15 patients where 8 patients had a tumor volume between 50 and 200 c.c., five had bigger tumor volumes of >200 c.c. and only two patients were smaller in size, with a tumor volume <50 c.c. The mean tumor volume in the group without LR was 406.74 ± 771.67 c.c. as compared with 195.77 ± 226.8 c.c. in the group with local recurrence. Using Mann-Whitney test, the difference between the two groups was found to be statistically insignificant (P = 1.403).
We conclude that high tumor volume is not a significant predictor of LR in osteosarcomas thus patients with high tumor masses should not be denied limb salvage. However, we recommend that the decision on attempting limb salvage should not only be based on the tumor volume alone.
Local recurrence; osteosarcoma; tumor volume
Allograft–prosthetic composite can be divided into three groups names cemented, uncemented, and partially cemented. Previous studies have mainly reported outcomes in cemented and partially cemented allograft–prosthetic composites, but have rarely focused on the uncemented allograft–prosthetic composites. The objectives of our study were to describe a surgical technique for using proximal femoral uncemented allograft–prosthetic composite and to present the radiographic and clinical results.
Materials and Methods:
Twelve patients who underwent uncemented allograft–prosthetic composite reconstruction of the proximal femur after bone tumor resection were retrospectively evaluated at an average followup of 24.0 months. Clinical records and radiographs were evaluated.
In our series, union occurred in all the patients (100%; range 5-9 months). Until the most recent followup, there were no cases with infection, nonunion of the greater trochanter, junctional bone resorption, dislocation, allergic reaction, wear of acetabulum socket, recurrence, and metastasis. But there were three periprosthetic fractures which were fixed using cerclage wire during surgery. Five cases had bone resorption in and around the greater trochanter. The average Musculoskeletal Tumor Society (MSTS) score and Harris hip score (HHS) were 26.2 points (range 24-29 points) and 80.6 points (range 66.2-92.7 points), respectively.
These results showed that uncemented allograft–prosthetic composite could promote bone union through compression at the host–allograft junction and is a good choice for proximal femoral resection. Although this technology has its own merits, long term outcomes are yet not validated.
Bone tumor; uncemented allograft prosthetic composite; proximal femur
Due to its anatomical location, the upper end of the tibia poses unique problems while attempting limb salvage and appropriate reconstruction. This article attempts to highlight a few of the key steps, pearls and pitfalls while attempting this challenging procedure.
Arthrodesis; megaprosthesis; osteosarcoma; proximal tibia
Volar and/or dorsal surgical approaches are used for surgical treatment of perilunate and lunate dislocations. There are no accepted approaches for treatment in the literature. We evaluated the functional results of isolated volar surgical approach for the treatment of perilunate and lunate dislocation injuries.
Materials and Methods:
9 patients (6 male and 3 female patients average age 34.5 ± 3.6 years) diagnosed with perilunate or lunate dislocations between January 2000 and January 2009 were involved in the study. The reduction was performed through isolated volar surgical approach and K-wire fixation, fracture stabilization with volar ligament repair was performed. Range of wrist joint motion, fracture healing, carpal stability, grip strength, return to work were evaluated and also direct radiographs were taken routinely at each control. The scapholunate interval and the scapholunate angle were evaluated radiographically. Evaluations of the clinical results were done using the DASH, VAS and Modified Mayo Wrist Scores.
The physical rehabilitation was started at 6th week, after the K-wires were removed. The average followup was 18.2 months (range 12-28 months). At the final followup, the average flexion extension arc was 105.0 ± 9.6° (74.6% of the other side), the average rotation arc was 138.8 ± 7.8° (81.5% of the other side) and the average radioulnar arc was 56.1 ± 9.9° (86.4% of the other side). The grip strength was 0.55 bar; 83.2% that the uninjured arm. According to the Mayo Modified Wrist score, the functional result was excellent in five patients and good in four and the average DASH score was 22.8. The scapholunate interval was 2.1 mm and scapholunate angle was 51°.
The clinical and radiological results of the isolated volar surgical approach were satisfactory. The dorsal approach was not needed for reduction of dislocations during operations. Our results showed that an isolated volar approach was adequate.
Carpal instability; lunate dislocation; perilunate dislocation; volar surgical approach
The purpose of this study was to compare the resistance of intramedullary single screw device (Gamma nail) and double screw device proximal femoral nail (PFN) in unstable trochanteric fractures in terms of the number of cycles sustained, subsidence and implant failure in an axial loading test in cadaveric femora.
Materials and Methods:
The study was conducted on 18 dry cadaveric femoral specimens, 9 of these were implanted with a Gamma nail and 9 with PFN. There was no significant difference found in average dual energy X-ray absorptiometry value between both groups. The construct was made unstable (AO type 31A3.3) by removing a standard sized posteromedial wedge. These were tested on a cyclic physiological loading machine at 1 cycle/s with a load of 200 kg. The test was observed for 50,000 loading cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine construct stiffness and gap micromotion in axial loading.
It was observed that there was statistically significant difference in terms of displacement at the fracture gap and overall construct stiffness of specimens of both groups. PFN construct group showed a mean subsidence of 1.02 mm and Gamma nail construct group showed mean subsidence of 2.36 mm after cycling. The average stiffness of Gamma nail group was 62.8 ± 8.4 N/mm which was significantly lower than average stiffness of the PFN group (80.4 ± 5.9 N/mm) (P = 0.03). In fatigue testing, 1 out of 9 PFN bone construct failed, while 5 of 9 Gamma nail bone construct failed.
When considering micromotion (subsidence) and incidence of implant/screw failure, double screw device (PFN) had statistically significant lower micromotion across the fracture gap with axial compression and lower incidence of implant failure. Hence, double screw device (PFN) construct had higher stability compared to single screw device (GN) in an unstable trochanteric fracture femur model.
Cyclic loading; Gamma nail; proximal femoral nail; subsidence
Large posteromedial defects encountered in severe varus knees during primary total knee arthroplasty can be treated by cementoplasty, structural bone grafts or metallic wedges. The option is selected depending upon the size of the defect. We studied the outcome of autograft (structural and impaction bone grafting) reconstruction of medial tibial bone defects encountered during primary total knee replacement in severe varus knees.
Materials and Methods:
Out of 675 primary varus knees operated, bone defects in proximal tibia were encountered in 54 knees. Posteromedial defects involving 25-40% of the tibial condyle cut surface and measuring more than 5 mm in depth were grafted using a structural graft obtained from cut distal femur or proximal tibia in 48 knees. For larger, peripheral uncontained vertical defects in six cases, measuring >25 mm in depth and involving >40% cut surface of proximal tibial condyle, impaction bone grafting with a mesh support was used.
Bone grafts incorporated in 54 knees in 6 months. There was no graft collapse or stress fractures, loosening or nonunion. The average followup period was 7.8 years (range 5-10 years). We observed an average postoperative increase in the Knee Society Score from 40 to 90 points. There was improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in terms of pain, stiffness and physical function during activities of daily living.
Bone grafting for defects in primary total knee is justified as it is biological, available then and is cost effective besides preserving bone stock for future revisions. Structural grafts should be used in defects >5 mm deep and involving 25-40% of the cut proximal tibial condyle surface. For larger peripheral vertical defects, impaction bone grafting contained in a mesh should be done.
Osteoarthritis knee; autografting; bone defects; primary total knee replacement; severe varus deformity
The biological effects of hemostatic agends on the physiological healing process need to be tested. The aim of this study was to assess the effects of oxidized cellulose (surgicel) and bone wax on bone healing in goats’ feet.
Materials and Methods:
Three congruent circular bone defects were created on the lateral aspects of the right and left metacarpal bones of ten goats. One defect was left unfilled and acted as a control; the remaining two defects were filled with bone wax and surgicel respectively. The 10 animals were divided into two groups of 5 animals each, to be sacrificed at the 3rd and 5th week postoperatively. Histological analysis assessing quality of bone formed and micro-computed tomography (MCT) measuring the quantities of bone volume (BV) and bone density (BD) were performed. The results of MCT analysis pertaining to BV and BD were statistically analyzed using two-way analysis of variance (ANOVA) and posthoc least significant difference tests.
Histological analysis at 3 weeks showed granulation tissue with new bone formation in the control defects, active bone formation only at the borders for surgicel filled defects and fibrous encapsulation with foreign body reaction in the bone wax filled defects. At 5 weeks, the control and surgicel filled defects showed greater bone formation; however the control defects had the greatest amount of new bone. Bone wax filled defects showed very little bone formation. The two-way ANOVA for MCT results showed significant differences for BV and BD between the different hemostatic agents during the two examination periods.
Surgicel has superiority over bone wax in terms of osseous healing. Bone wax significantly hinders osteogenesis and induces inflammation.
Bone defects; bone wax; oxidized cellulose; goat; histology; micro-computed tomography
We present a patient with dermal argyria as a cutaneous manifestation of a silver-coated megaprosthesis used for a distal femoral osteosarcoma. Histological and electron microscopic analyses also showed silver deposition in the dermis.
Dermal argyria; distal femur; osteosarcoma; silver
Vascular complications in closed clavicular fractures are uncommon, with an incidence of only 0.4%. Subclavian artery injury can present acutely or can have a delayed presentation with arm ischemia. We report the case of an undetected subclavian pseudoaneurysm in a patient with a nonunion fracture clavicle who was referred with persistent ischemia following attempted brachial embolectomy at another center, along with a review of literature to support the hypothesis that in addition to repair of the aneurysm, treatment of the psuedarthrosis by fixation of the clavicle is essential.
Clavicle nonunion; subclavian pseudoaneurysm; thoracic outlet syndrome; thromboembolism
Osteochondromas are usually extra articular and grow away from the joint towards the diaphysis. Intraarticular osteochondromas are very rare and often misdiagnosed. We report a case of 16-year-old boy who presented with pain and clicking sound in the right knee for last 6 months. On examination, click was felt at the terminal flexion of the knee. The lateral radiograph of the right knee showed a radio opaque shadow at the posterior aspect of the distal end of femur, which was further evaluated with an MRI. Arthroscopy showed a hard lesion arising from the roof of the intercondylar notch of femur. It was excised arthroscopically. Histopathology revealed it to be an osteochondroma. Thus, intraarticular osteochondroma of the knee can be considered as a rare cause of pain in young patients.
Arthroscopy; intraarticular; knee; osteochondroma
Problems of the proximal tibiofibular joint (pTFj) after high tibial osteotomy (HTO) are rare. With this case report, we strive to highlight the importance of investigating the pTFj in patients with unexplained knee pain after HTO. A 44 year old male patient presented with diffuse pain on his left knee 3 years after medial opening wedge HTO due to medial compartment overloading in a varus knee. Patient described persistent anterior tibial and lateral knee pain. 2 years after HTO, patient underwent implant removal but the knee pain persisted. As the reason for the persistent pain was not identified, further radiological evaluation was done. Single photon emission computerized tomography/computerized tomography (SPECT/CT) revealed that there was no increased uptake within the tibiofemoral joint, indicating a biologically well performed correction of the varus deformity. However, markedly increased tracer uptake was found at the pTFj. On the inherent axial CT scans, it was seen that the proximal screws were too long and placed within the pTFj. Along with this a severe osteoarthritis of the pTFj was identified. The cause of the patient's pain was then confirmed by a CT guided infiltration of local anesthetic. An arthrodesis of the pTFj was performed and at 12 months followup after the arthrodesis the patient was pain free. This case highlights how important it is to evaluate the pTFj in patients with unexplained pain after HTO. SPECT/CT was helpful in identifying the patient's problem in this challenging case.
Arthrodesis; high tibial osteotomy; proximal tibiofibular joint; medial compartment arthrosis
Fungal arthritis is an uncommon yet serious disorder in the newborn. Delay in diagnosis and management can lead to significant morbidity. We report our experience with management of two such cases. Two preterm neonates with multifocal arthritis caused by Candida were studied. Diagnosis was made by clinical examination, laboratory investigations, radiological investigations and culture. Both were treated by aspiration, arthrotomy and antifungal therapy. One patient recovered fully from the infection while the other had growth disturbances resulting in limb length inequality at recent followup. Prompt and expeditious evacuation of pus from joints and antifungal therapy is imperative for treatment. Associated osteomyelitis leads to further difficulty in treatment.
Arthritis; candidiasis; neonates