Al tibia reconstructions with allograft-prosthesis composites to ascertain the complications and functional outcomes. By combining an allograft with a prosthesis, placing cement in the graft, and press-fitting the prosthesis in the tibial diaphysis, we obtained satisfactory Musculoskeletal Tumor Society scores in 90.4% of patients, with a 5-year survival rate (73.4%) comparable to that of reconstruction with a modular prosthesis. However, we observed high infection rates (24.2%) and rotation of the medial gastrocnemius seemed not to reduce this complication. For this reason, we do not recommend using this reconstructive technique in patients who will receive postoperative chemotherapy or in patients in whom a previous reconstructive method failed. We believe the ideal candidate is the young patient with a benign aggressive or malignant low-grade tumor who has not undergone previous surgery. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence....

So could be extended to Grade I chondrosarcomas without an increase in recurrence. We retrospectively reviewed 31 patients with Grade I chondrosarcomas of the limbs. The minimum followup was 66 months (mean, 157 months; range, 66-296 months). None of the 16 patients treated by resection had recurrences during the followup and two of the 15 patients with intralesional excision had recurrences, both of which resolved with resection of the site involved by the recurrence without progression of the disease. The Musculoskeletal Tumor Society scores averaged 72% in patients treated with wide resection compared with 89% in the 15 patients treated by intralesional surgery. The two recurrences occurred in patients whose radiographs showed thinning of the cortex combined with bone enlargement and marked endosteal scalloping; histologic examination in these two patients also showed a correlation between radiographic aggressiveness and the presence of myxoid areas and hypercellularity. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence....

Reconstruction of distal femur or proximal tibia in growing patients is a challenge for the high rate of complications and limb length discrepancy at the end of growth. The purpose of this study was to evaluate the long-term outcome of children affected by high-grade osteosarcoma of the knee region, reconstructed by osteoarticular bone allograft of distal femur, and proximal tibia. We retrospectively reviewed 25 patients treated for high-grade osteosarcoma, 13 in the distal femur and 12 in the proximal tibia. The mean follow-up was 124 months. Clinical and radiologic evaluation was carried out in the 20 long-term survivors with a minimum follow-up of 7 years from surgery. The rates of survival of the implants were estimated with use of the Kaplan-Meier method. Functional and radiographic evaluation was done according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up in all the patients that still had the allograft. Five patients died during the first 2 years of follow-up for disease-related causes. Of the remaining 20 osteoarticular allografts (10 of the distal femur and 10 of the proximal tibia), 12 failed: 4 in the distal femur and 8 in the proximal tibia. All the failures were related to a graft fracture, but in 4 patients with subchondral collapse the graft was maintained and converted into an allograft prosthetic composite. No deep infection of the primary reconstruction was observed. The overall rate of allograft survival was 70% at 5 years and 58% at 10 years in the distal femur, and 45% at 5 years and 20% at 10 years in the proximal tibia. At final follow-up, 8 patients still walked on the primary implant, 6 in the distal femur, and 2 in the proximal tibia. The functional outcome of these patients was evaluated as good in 5 patients (3 with distal femoral and 2 with proximal tibial allograft), and poor in 3. Although mechanical complications significantly affect the outcome, osteoarticular allografts may represent a viable option for reconstruction in children older than 8 with high-grade sarcomas about the knee. Level IV.

Purpose The histological response to neoadjuvant chemotherapy is an important prognostic factor in patients with osteosarcoma (OS) and Ewing sarcoma (EWS). The aim of this study was to assess baseline primary tumour FDG uptake on PET/CT, and serum values of alkaline phosphatase (ALP) and lactate dehydrogenase (LDH), to establish whether these factors are correlated with tumour necrosis and prognosis. Methods Patients treated between 2009 and 2014 for localized EWS and OS, who underwent FDG PET/CT as part of their staging work-up, were included. The relationships between primary tumour SUVmax at baseline (SUV1), SUVmax after induction chemotherapy (SUV2), metabolic response calculated as [(SUV1 − SUV2)/SUV1)] × 100, LDH and ALP and tumour response/survival were analysed. A good response (GR) was defined as tumour necrosis >90 % in patients with OS, and grade II-III Picci necrosis (persitence of microscopic foci only or no viable tumor) in patients with Ewing sarcoma. Results The study included 77 patients, 45 with EWS and 32 with OS. A good histological response was achieved in 53 % of EWS patients, and 41 % of OS patients. The 3-year event-free survival (EFS) was 57 % in EWS patients and 48 % OS patients. The median SUV1 was 5.6 (range 0 – 17) in EWS patients and 7.9 (range 0 – 24) in OS patients (p = 0.006). In EWS patients the GR rate was 30 % in those with a high SUV1 (≥6) and 72 % in those with a lower SUV1 (p = 0.0004), and in OS patients the GR rate was 29 % in those with SUV1 ≥6 and 64 % in those with a lower SUV1 (p = 0.05). In the univariate analysis the 3-year EFS was significantly better in patients with a low ALP level (59 %) than in those with a high ALP level (22 %, p = 0.02) and in patients with a low LDH level (62 %) than in those with a high LDH level (37 %, p = 0.004). In EWS patients the 3-year EFS was 37 % in those with a high SUV1 and 75 % in those with a low SUV1 (p = 0.004), and in OS patients the 3-year EFS was 32 % in those with a high SUV1 and 66 % in those with a low SUV1 (p = 0.1). Histology, age and gender were not associated with survival. In the multivariate analysis, SUV1 was the only independent pretreatment prognostic factor to retain statistical significance (p = 0.017). SUV2 was assessed in 25 EWS patients: the median SUV2 was 1.9 (range 1 – 8). The GR rate was 20 % in patients with a high SUV2, and 67 % in those with a low SUV2 (p = 0.02). A good metabolic response (SUV reduction of ≥55 %) was associated with a 3-year EFS of 80 % and a poor metabolic response with a 3-year EFS of 20 % (p = 0.05). In the OS patients the median SUV2 was 2.7 (range 0 – 4.5). Neither SUV2 nor the metabolic response was associated with outcome in OS patients. Conclusion FDG PET/CT is a useful and noninvasive tool for identifying patients who are more likely to be resistant to chemotherapy. If this finding is confirmed in a larger series, SUV1, SUV2 and metabolic response could be proposed as factors for stratifying EWS patients to identify those with high-grade localized bone EWS who would benefit from risk-adapted induction chemotherapy.

Intercalary reconstruction of tibial sarcomas with vascularized fibula autografts and massive bone allografts is reliable with predictable long-term results. However, inadequate data exist comparing free and pedicled vascularized fibula autografts in combination with a massive bone allograft in patients undergoing intercalary tibia reconstructions. Among patients undergoing large-segment intercalary allografting, we sought to compare supplemental free vascularized fibular autografts with supplemental pedicled vascularized fibular autografts, in terms of (1) oncologic results, (2) complications associated with surgery, (3) Musculoskeletal Tumor Society (MSTS) scores, and (4) surgical time. Between 1994 and 2013, we treated 320 patients, younger than 40 years, with tibial sarcomas. Thirty-five patients (11%) underwent amputations. One hundred ninety-five patients (61%) were treated with intraarticular resection of the tibia, which constituted 104 tumor endoprostheses, 63 proximal tibia allograft prosthetic composites, 21 osteoarticular allografts, and seven arthrodeses with allografts. Ninety patients (28%) underwent joint-sparing intercalary reconstruction. Forty-one (13%) of these 90 patients were treated with allografts alone, two (1%) with vascularized fibula grafts, and 47 (15%) with intercalary allografts supplemented by autografts (free fibular autografts, 22 patients, 7%; pedicled fibular autografts, 25 patients, 8%). During the study period, we used free vascularized fibular autografts in association with massive bone allograft for a resection longer than 12 cm with a very small periarticular residual segment. The choice for using a pedicled fibula harvested in the ipsilateral leg initially was for patients having only diaphyseal resections and the indication was later extended to intraepiphyseal osteotomies with a small periarticular residual segment. The goals of this study are to present the long-term results in this group of patients and compare their results based on the type of vascularized fibula harvest. There were 33 male and 14 female patients with mean age of 14 ± 6 years. The median followup was 84 months (range, 7–231 months). No patients were lost to followup before 1 year. Four patients died and were not available for followup after 18 months. The mean tibia resection length was 15 ± 4 cm and mean length of the harvested vascularized fibula was 18 ± 4 cm. Overall 5- and 10-year oncologic survival rates in this study were 87% ± 5% and 83% ± 6% respectively. With the numbers available, we observed no difference in survivorship free from death from disease between the study groups (85% ± 8% [95% CI, 174–232 months] of the free vascularized group versus 82% ± 8% [95% CI, 148–206 months] of the pedicled fibula graft group; p = 0.741). At last followup, 40 patients had no evidence of disease and seven had died of disease. Local recurrence was observed in two patients in the supplemental free vascularized fibula group and three patients in the supplemental pedicled vascularized fibula group, whereas metastases was observed in eight patients. With the numbers available, we observed no difference in the proportion of patients experiencing surgical complications between those treated with free vascularized fibula grafts and those treated with pedicled grafts (eight of 22 [36%] versus nine of 25 [36%] respectively; p = 0.605). With the numbers available, we observed no difference in mean MSTS scores between patients treated with free vascularized fibula grafts and those treated with pedicled grafts (24 ± 9 versus 25 ± 8; mean difference, 0.48; 95% CI, 0.54–4.6; p = 0.858). Mean surgical time was longer in the free vascularized fibula and massive bone allograft group at 9.4 ± 1.7 hours compared with that of the pedicled vascularized fibula and massive bone allograft group at 5.7 ± 1.3 hours (mean difference, 3.73 hours; 95% CI, 2.8–4.6 hours; p ≤ 0.001). Intercalary reconstruction of tibia sarcomas with massive bone allografts supplemented with vascularized fibula grafts provide predictable results. Complications occur as expected in a biologic reconstruction, but are salvageable, preserving the original construct. The pedicled fibula can be an alternative to a free contralateral fibula for intraepiphyseal resections. Comparative technical ease, shorter surgical time, avoidance of additional microvascular anastomosis, and avoidance of surgery on the contralateral leg are notable advantages of pedicled vascularized fibula over free fibula grafts to supplement allografts when indicated in intercalary tibia resections. Level III, therapeutic study.