Osteosarcoma is the most common primary malignant bone tumor. The long-term outcome is poor for patients with metastatic disease. From June 1989 to January 2008, 202 patients (128 males and 74 females) with high-grade osteosarcoma of the extremities were treated at our institution. Patients were divided into three groups depending on the time of identification of pulmonary metastasis: group A, identified with primary tumor diagnosis; group B, during whole treatment course; and group C, after completion of treatment. Long-term survival was calculated and factors related to metastases were analyzed. Ninety-one patients developed pulmonary metastases; 21 in group A, 18 in group B and 52 in group C. The mean period from initial diagnosis to lung metastases in groups B and C was 22.2 months (±20.6). Five-year survival rates were 82.0% and 38.3% in the non-metastasis group and metastasis group, respectively (P < 0.001). The 5-year survival rate was significantly worse in group A than in group B or C (0%, 7.4%, 59.5%, P < 0.001), in patient with more than one lobe involved (27.0%, P = 0.006) and more than three pulmonary nodule metastases (21.3%, P = 0.002). Factors related to the pulmonary metastasis were: old age (65.5% in older than 27.5 years old and 41.6% in younger, P = 0.017), large tumor volume (54.4% in larger than 202.5 ml and 33.7% in smaller, P = 0.005) and elevated lactodehydrogenase (LDH; 55.1% vs.31.0% in normal, P = 0.001). The prognosis of osteosarcoma with pulmonary metastases is dismal, especially for patients who have primary pulmonary metastases, more than three pulmonary metastatic nodules or involvement of more than one lobe. Factors such as older age, larger tumor volume and elevated LDH may reflect high metastatic rate.

Background: Immediately recycling the resected bone segment in a biologic limb salvage reconstruction is an option after wide resection of bone. Intraoperative extracorporeal irradiation and freezing are the two major tumor-killing techniques applied on the fresh tumor-bearing autografts. However, graft-derived tumor recurrence and complications are concerns affecting graft survival. Questions/Purposes: We therefore asked: (1) Is there a difference in the proportion of patients achieving union by 18 months after surgery between the groups with extracorporeal-irradiated autografts and frozen-treated autografts? (2) Is there any difference in the frequency of graft-related complications for patients receiving either an extracorporeal-irradiated or a frozen-treated autograft? (3) Is there a difference between the techniques in terms of graft-derived recurrence? (4) Are there differences in failure-free grafts, and limb and overall survivorship between autografts treated by extracorporeal irradiation or by freezing? Methods: During the study period we treated a total of 333 patients with high-grade osteosarcoma. One hundred sixty-nine patients were excluded. Overall, 79 of the enrolled 164 patients received recycled autografts treated with extracorporeal irradiation whereas the other 85 received frozen-treated autografts. The mean followup was 82 ± 54 months for the extracorporeal irradiation group and 70 ± 25 months for the frozen autograft group, and one patient was lost to followup. Complications and graft failure (revision required for primary graft removal) were characterized by adapting the International Society of Limb Society (ISOLS) system modified for inclusion of biologic and expandable reconstruction. The primary study endpoints were the proportion of patients in each group who achieved radiographic union, and had an ISOLS grade of fair or good host graft fusion at 6, 9, 12, and 18 months after surgery. Five-year survival data for graft failure and limb amputation were analyzed by a cumulative incidence function regression model whereas the Kaplan-Meier function was used to test the 5-year overall survival rate between the two techniques. Results: With the numbers available, no differences were found in the accumulated proportion of patients achieving union between the groups at 6, 9, 12, and 18 months. Radiographic evaluation did not show differences in the average scores of compared criteria. However in the subchondral bone subcriterion, more patients receiving frozen-treated autografts had higher scores (p = 0.03). Complications leading to a second surgery were not different between extracorporeal irradiation and frozen autografts in aspects of soft tissue failure (Type 1B), nonunion (Type 2B), structural failure (Type 3A and Type 3B), or infection (Type 4A and Type 4B). No graft-originating tumor recurrence was found and there was no difference in Type 5A tumor progression originating from soft tissue in the groups (odds ratio, 0.8; 95% CI, 0.3-2.1; p = 0.7). Neither group showed a difference in the cumulative incidence for graft failure and limb amputation. Five-year overall survival rates were 83% and 84% (p = 0.69) for extracorporeal-irradiated and frozen autografts respectively. A decrease in survivorship was seen at 50 to 100 months after surgery for the extracorporeal irradiation group. Conclusion: We segregated the ISOLS criteria evaluating the graft-mediated tumor progression into host- or graft-derived complications (Types 5B and 5C) in this study. With the available data, there was no difference in the incidence of tumor recurrence derived from irradiation- or frozen-treated autografts. Ongoing evaluations comparing 10-year survivorship for both groups will be helpful to elucidate the possible difference found after 100 months. Level of Evidence Level: III, therapeutic study

Total knee arthroplasty (TKA) improves the patient's quality of life by relieving pain, correcting the deformity, and helping the patient resume normal activities. However, post-TKA prosthetic joint infection leads to implant failure, is difficult to treat, and causes a significant burden both economically and health-wise. Therefore, an understanding of the current trends in this infection and microbiology data is essential for preventing and treating it. A retrospective study was conducted on 10,768 patients who underwent primary TKA at Taipei Veterans General Hospital, Taiwan, from 2002 to 2014. The incidence of post-TKA prosthetic joint infection in different time periods was investigated, and microbiological results in early- (<3 months post-TKA) and delay-onset prosthetic joint infection were analyzed. The 2 years incidence of post-TKA prosthetic joint infection was 1.93% (2002-2006), 1.05% (2007-2010), and 0.76% (2011-2014). The incidence of post-TKA prosthetic joint infection decreased significantly from 2002 to 2014. Although Staphylococcus species was most commonly isolated, a significantly higher proportion of gram-negative bacteria were isolated from early-onset compared with delay-onset post-TKA prosthetic joint infection patients: 9/29 (31.0%) versus 13/100 (13%); p = 0.023. The results showed that the risk of post-TKA prosthetic joint infection is decreasing. Microbiology results showed that early-onset post-TKA prosthetic joint infection is associated with a higher risk of gram-negative bacterial infection. Physicians should be aware of this risk in order to correctly select empirical agents.

Purpose. High tibial osteotomy (HTO) has been adopted as an effective surgery for medial degeneration of the osteoarthritis (OA) knee. However, satisfactory outcomes necessitate the precise creation and distraction of osteotomized wedges and the use of intraoperative X-ray images to continually monitor the wedge-related manipulation. Thus HTO is highly technique-demanding and has a high radiation exposure. We report a patient-specific instrument (PSI) guide for the precise creation and distraction of HTO wedge. Methods. This study first parameterized five HTO procedures to serve as a design rationale for an innovative PSI guide. Preoperative X-ray and computed tomography- (CT-) scanning images were used to design and fabricate PSI guides for clinical use. The weight-bearing line (WBL) of the ten patients was shifted to the Fujisawa’s point and instrumented using the TomoFix system. The radiological results of the PSI-guided HTO surgery were evaluated by the WBL percentage and tibial slope. Results. All patients consistently showed an increased range of motion and a decrease in pain and discomfort at about three-month follow-up. This study demonstrates the satisfactory accuracy of the WBL adjustment and tibial slope maintenance after HTO with PSI guide. For all patients, the average pre- and postoperative WBL are, respectively, 14.2% and 60.2%, while the tibial slopes are 9.9 and 10.1 degrees. The standard deviations are 2.78 and 0.36, respectively, in postoperative WBL and tibial slope. The relative errors of the pre- and postoperative WBL percentage and tibial slope averaged 4.9% and 4.1%, respectively. Conclusion. Instead of using navigator systems, this study integrated 2D and 3D preoperative planning to create a PSI guide that could most likely render the outcomes close to the planning. The PSI guide is a precise procedure that is time-saving, radiation-reducing, and relatively easy to use. Precise osteotomy and good short-term results were achieved with the PSI guide.

Chondrosarcoma is a type of highly malignant tumor with a potent capacity to invade locally and cause distant metastasis. Chondrosarcoma shows a predilection for metastasis to the lungs. IL-6 is a multifunctional cytokine that is associated with the disease status and outcomes of cancers. However, the effect of IL-6 on the migration activity of human chondrosarcoma cells is mostly unknown. Here, we found that IL-6 increased the migration and expression of MMP-13 in human chondrosarcoma cells. We also found that human chondrosarcoma tissues had significant expression of IL-6, which was higher than that in normal cartilage. IL-6-mediated migration and MMP-13 up-regulation were attenuated by anti-IL-6 receptor antibody, Ras, Raf-1, and a MEK inhibitor. Activation of the Ras, Raf-1, MEK, ERK, and NF-κB signaling pathways after IL-6 treatment was demonstrated, and IL-6-induced MMP-13 expression and migration activity were inhibited by the specific inhibitor and mutant Ras, Raf-1, MEK, ERK, and NF-κB cascades. In addition, migration-prone sublines demonstrated that cells with increasing migration ability had greater expression of IL-6 and MMP-13. Taken together, these results indicate that IL-6 and IL-6 receptor interaction enhances migration of chondrosarcoma through an increase in MMP-13 production.