The use of a pedicled latissimus dorsi flap for reconstruction of large soft-tissue defects following musculoskeletal tumor excision around the shoulder provides adequate well-vascularized and healthy tissue to maximize the chances of successful limb salvage and minimize the risks of wound problems and deep infection1-5. Verify the adequacy of the latissimus dorsi, confirm the feasibility of the flap in relation to the extent of the defect, and use a laparotomy pad to simulate the arc of flap rotation. At the time of surgery, proper flap design and markings are critical for successful tumor excision and flap rotation. Confirm adequate tumor removal, prepare the recipient site for the flap, ensure the proper size and shape of the skin island, deepen the dissection circumferentially around the skin paddle, divide the latissimus from the thoracolumbar fascia, develop the natural plane of the flap, divide the branch for the serratus to increase rotation if necessary, and release the humeral insertion to further increase rotation if necessary. Be sure to create an adequately sized tunnel and, when passing the flap through the tunnel, to avoid tension on the vascular pedicle and the skin island. Proper postoperative care includes monitoring the flap blood supply and output of drains, removing sutures, and ensuring satisfactory healing overall. The preoperative evaluation, positioning, and preparation are identical to those for the posterior clockwise rotation technique described above. Make sure you understand the regional anatomy, ensure appropriate anterior flap rotation, and use the laparotomy pad technique to the simulate arc of rotation. The surgical principles of flap elevation and transfer are the same regardless of the location of the recipient site (see Step 3 for the posterior technique above). Elevate the flap, create a large subcutaneous tunnel for anterior transfer, and ensure optimal flap inset into the shoulder defect. Perform as for the posterior technique. In 2007, we reported on a series of 33 consecutive patients treated from 1994 to 2004 with a pedicled latissimus dorsi flap following sarcoma excision in the shoulder region1.

Background: Compliant compression fixation was developed to promote permanent bone-prosthesis osteointegration while preserving bone stock in patients needing endoprosthetic reconstructions. This has demonstrated durability in the distal femur, with reliable cortical hypertrophy adjacent to the implant. However, the extent of bone formation and prosthetic survivorship of proximal femoral replacements with compliant compression fixation has not been established. Questions/purposes: (1) How much bone formation occurs across the compression segment in patients treated with a proximal femoral replacement implant using compliant compression fixation? (2) What were the Musculoskeletal Tumor Society (MSTS) scores at minimum 24-month follow-up of patients who received this reconstruction? (3) What is the implant survivorship free from implant removal or revision for any reason at final follow-up? Methods: From 2006 to 2018, we performed 213 proximal femoral replacements in patients with oncologic conditions of the proximal femur where the trochanters could not be preserved. Of these, 6% (12 of 213) were performed with an implant that used compliant compression fixation. We used this device in primary oncologic reconstructions in patients younger than 65 years of age without metastases who had nonirradiated bone with the requisite ≥ 2.5 mm of cortical thickness in the hope that it would provide more durable fixation and bone stock preservation than conventional reconstructions. All patients were followed for longer than 2 years except one who died in that interval. Median (range) follow-up was 6 years (2 to 10 years). Seven patients received diagnosis-specific chemotherapy in a consistent manner based on Children’s Oncology Group chemotherapy protocols. Using the NIH-developed ImageJ open-access software, we measured the area of bone under compression on 3-, 6-, 9-, 12-, 18-, and 24-month radiographs and the length of the traction bar potential-compression distance, reconciling independent measures from two investigators using the identical method as published for the distal femur with compression fixation. The duration of prosthesis retention was evaluated using a competing risk analysis for the 11 surviving patients. Results: Bone hypertrophy in the compression segment was scant. At the final analysis, cortical bone formation was a median (range) of 4 (-7 to 14) above baseline. The median (range) MSTS score was 27 (19 to 30). One implant failed after trauma, and the patient underwent revision of the implant. Conclusion: Despite scant bone formation across the compression segment and drastically less formation than reported for distal femoral replacements, compliant compression fixation of the proximal femur demonstrated good survivorship in patients 65 years or younger with localized sarcoma and nonirradiated, adequate bone stock in this small, retrospective series. Patients achieved good functional outcomes at final follow-up. The potential benefit of this reconstruction method should be weighed against the initial period of limited weightbearing and the life expectancy of the patient. Level of Evidence: Level IV, cohort study.

The purpose of this study is to assess the impact of MRI findings on management of symptomatic patients following RFA of OO. Retrospective review of 43 patients with RFA for OO between June 2010 and June 2017 was performed. Patient, nidus, and ablation data were reviewed. Pre- and 6–8 weeks post-procedural MRI (n = 32) were compared for coverage of nidus by ablation zone, bone marrow edema, nidus hyperintensity, and other findings. Baseline pain levels and analgesic use were compared with post-procedural follow-up visit at 6–8 weeks. Three groups of clinical and MRI outcomes of complete (CR), partial (PR), and no response (NR) were defined. A weighted kappa statistic was used to assess for agreement. Clinical responses were CR in 34/43 (79.1%, 95% CI: 64.0–90.0%), PR in 8/43 (18.6%), and NR in 1/43 (2.3%) patients. All 19/32 patients with MRI CR experienced clinical CR. One patient with MRI NR had clinical NR. All 7/32 patients with clinical PR had MRI PR. All 4/43 complications were in MRI PR or NR groups. Substantial agreement was observed between MRI and clinical outcomes (kappa: 0.69, 95% CI: 0.45–0.95). MRI helped determine etiologies in all symptomatic patients and their management (n = 8). MRI is recommended for symptomatic patients after ablation.