Aneurysmal bone cysts (ABC) are benign tumors mostly occurring in children and young adults. Different open and minimal invasive surgical approaches have been proposed for the treatment of ABCs and yet no consensus is defined to date. The aim of this study was to retrospectively review data of a large single center series of ABCs with patients treated by open curettage with or without filling of the cavity or en-bloc resection. Questions/purposes We asked: (1) What was the local recurrence rate of ABC after surgical treatment at our institution? (2) What were positive or negative predictors for local recurrence? (3) Was there a benefit from adjuvant burring, phenolization or filling, respectively? (4) Where there changes in recurrence free survival in different time periods of primary surgery? By retrospective data analysis of the Vienna Bone and Soft Tissue Tumor Registry, 123 patients surgically treated for primary aneurysmal bone cysts were identified. After exclusion of 33 patients (27%) due to a postoperative follow up below one year, 90 patients who were treated for primary ABCs between 1986 and 2009 were evaluated. These included 50 males and 40 females with a mean age of 16 years (SD 10 years; range: 2 to 51 years). The mean follow-up was 99 months. (SD 72 months, range: 13 to 329 months) RESULTS: Curettage was performed in 84 patients, while 45 patients received adjuvant phenolization. Local recurrence occurred in 28 patients after a mean time of 16 months, with a corresponding local recurrence free survival (RFS) of 83% after one year, 77% after 2 years and 66% after 5 years. ABCs located in hands and feet (p=0.044) showed a superior RFS, while younger patients (p=0.001) displayed an inferior RFS. Regarding adjuvant surgical techniques, mechanical cavity burring (p=0.004) and filling with autologous cancellous bone graft (p=0.024) showed protective effects on RFS. Patients treated between 1986 and 1999 (n=47) had a higher RFS than patients treated between 2000 and 2009 (n=43, p=0.011), as surgeons and surgical indications changed over time. Although curettage, burring, phenolization and reconstruction with bone grafts came with a relatively high risk of local recurrence, open surgery is still justified in aggressively growing ABCs of critical localizations. IV; therapeutic study.

Introduction: Multiple revision hip arthroplasties and critical trauma might cause severe bone loss that requires proximal femoral replacement (PFR). The aim of this retrospective study was to analyse complication- and revision-free survivals of patients who received modular megaprostheses in an attempt to reconstruct massive non-neoplastic bone defects of the proximal femur.Questions/purposes(1) What were general complication rates and revision-free survivals following PFR? (2) What is the incidence of complication specific survivals? (3) What were risk factors leading to a diminished PFR survival?Materials and methods: Twenty-eight patients with sufficient follow-up after receiving a modular proximal femoral megaprosthesis were identified. The indications for PFR included prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, non-union and critical femoral fracture. Complications were grouped according to the ISOLS-classification of segmental endoprosthetic failure by Henderson et al.Results: Overall, the complication-free survival was 64.3% at one year, 43.2% at five years and 38.4% at ten years, with 16 patients (57%) suffering at least one complication. Complications were dislocation in eight patients (29%), PJI in 6 patients (21%), periprosthetic fracture in five patients (18%), and aseptic loosening in six patients (21%). Prosthesis stem cementation showed a lower risk for revision in a cox proportional hazard model (95% CI 0.04–0.93, HR 0.2, p = 0.04).Conclusion: PFR with modular megaprostheses represents a viable last resort treatment with high complication rates for patients with severe proximal femoral bone loss due to failed arthroplasty or critical fractures. In revision arthroplasty settings, PFR cementation should be advocated in cases of impaired bone quality.

Background: After major lower limb amputation, persistent pain is common, with up to 85% of patients reporting recurring phantom or residual-limb pain. Although pain management is an important factor of quality of life in patients with lower limb amputations, there are few long-term data regarding the frequency of persistent pain and how it impacts prosthesis use. Questions/purposes: (1) How prevalent are different types of pain at long-term follow-up after amputation for malignant tumors? (2) What association do different pain types have with daily prosthesis use? Methods: Between 1961 and 1995, 124 major amputations for malignant tumors were performed at one center in Austria in patients (1) who spoke German and (2) whose surgical date resulted in the possibility of a minimum follow-up time of 20 years at the time of this survey; those patients were considered potentially eligible for this retrospective study. The indications for major amputation were to achieve local tumor control in limbs that the surgeon deemed unsalvageable without amputation. Of those 124 patients, 71% (88) had died, 9% (11) could not be reached, and 3% (4) declined to participate. Thus, 58% (21 of 36) of those living at the time of this study and who underwent lower limb amputation between 1961 and 1993 with a median (range) follow-up duration of 41 years (23 to 55) completed a standardized questionnaire, including an assessment of pain and daily prosthesis use during the year before the survey. Phantom pain, residual limb pain, and back pain were each further subclassified into pain frequency, intensity, and restrictions in activities of daily living (ADL) due to the specific pain form and rated on a 5- (pain frequency) and 10-point (pain intensity, restrictions in ADL) numerical rating scale. Before multivariate regression analysis, daily prosthesis use was correlated with pain parameters using Spearman correlation testing. Results: Seventeen of 21 patients reported phantom limb and back pain, and 15 patients reported residual limb pain in the past year. Median (range) phantom pain intensity was 7 (1 to 10) points, median residual limb pain intensity was 4 (1 to 9) points, and median back pain intensity was 5 (1 to 10) points. After controlling for relevant confounding variables such as age at amputation, age at survey, and stump length, we found that less intense residual limb pain (defined on a 10-point scale with 1 representing no pain at all and 10 representing extremely strong pain [95% CI 0.3 to 1.0]; r = 0.8; p = 0.003) was associated with greater daily prosthesis use. Higher amputation levels showed a decreased daily prosthesis use compared with patients with lower amputation levels (defined as transfemoral amputation versus knee disarticulation versus transtibial amputation [95% CI 0.3 to 5.1]; r = 0.5; p = 0.03). Conclusion: Decades after surgery, many patients with lower limb amputations experience pain that restricts them in terms of ADLs and decreases their daily prosthesis use. This information supports the need for regular residual limb inspections and careful prosthesis fitting even at long-term follow-up, as effective prosthesis fitting is a modifiable cause of residual limb pain. Future studies evaluating long-term treatment effects of pain relief surgery and therapeutic alternatives to conservative pain treatments should be performed, as these approaches may help alleviate pain in patients with refractory postamputation pain. Level of Evidence: Level IV, therapeutic study.

Introduction Limb salvage surgery for periacetabular malignancies is technically demanding and associated with a considerable likelihood of postoperative complications and surgical revision. Reconstruction using custom-made implants represents the treatment of choice. This study was conducted to analyze treatment outcomes of custom-made implants in a single orthopaedic tumor center. Patients and Methods Twenty patients with a histologically verified periacetabular malignancy and a median follow up time of 5 (1–17) years were included. Results The median number of revision surgeries per patient was 1.5 (0–7). Complications were dislocations in 3 patients, aseptic loosening in 4 patients, deep infections in 9 patients, thromboembolic events in 5 patients and sciatic nerve lesions in 4 patients. Overall survival was 77% after one year, 69% after two years and 46% after five years. Median Harris Hip Score was 81 (37–92) points at last follow up. Conclusion Although internal hemipelvectomy and reconstruction using custom-made implants is linked with a high risk of postoperative complications, good functional outcomes can be regularly achieved. This information may help treating surgeons to find adequate indications, as eligible patients need to be critically selected and integrated into the decision-making process.

Background: Rotationplasty was first introduced as an alternative to above-the-knee amputation after resection of bone sarcomas of the distal femur by Salzer in 1974. Although the procedure involves a substantial body image issue, it has many advantages such as durability of the reconstruction (compared with limb salvage procedures) and avoidance of phantom pain (compared with amputation). Although several reports have shown intermediate outcomes of rotationplasty, very long-term results in terms of function, activity levels, and quality of life (QoL) in comparison with above-the-knee amputation have not been reported. This work aims to fill this gap left by prior reports. Questions/purposes: (1) Is there a difference in revision-free survival in very long-term follow-up after rotationplasty and transfemoral amputation or knee disarticulation? (2) Are patient activity levels after rotationplasty comparable with those after transfemoral amputation or knee disarticulation in the very long term? (3) Do activity levels differ in terms of QoL? (4) Within the group of patients who have undergone rotationplasty, is the ROM in the neo-knee associated with QoL 20 to 40 years later? Methods: Between 1961 and 1995, a total of 360 patients were treated for bone and soft tissue sarcoma of the lower extremity. Fifty-four patients were treated with A1 rotationplasty, 124 were treated with an amputation, and 182 were treated with a limb salvage procedure. Of those who underwent amputation or rotationplasty, 9% (11 of 124) and 15% (8 of 54), respectively, were lost to follow-up before a period of 20 years without meeting a study endpoint, and another 71% (88 of 124) and 44% (24 of 54), respectively, died prior to 20 years with intact residual limbs, leaving 20% (25 of 124) and 41% (22 of 54), respectively, of the original group who had a follow-up time of at least 20 years. Four patients with amputations declined to participate in the study, while three patients with transtibial amputations and one patient with a complete language barrier after rotationplasty were excluded. These 39 patients with a minimum follow-up time of 20 years (mean [range] 36 years [23 to 55]) were available and gave their consent to this retrospective comparative study at the local orthopaedic department. The decision between rotationplasty and endoprosthetic replacement was made after thorough consultation and according to the patient’s choice. As general guidance, Salzer’s idea was to provide rotationplasty to patients who had a strong desire for higher levels of activity. Endoprosthetic reconstructions were more likely indicated given a patient’s preference for a cosmetically uncompromised limb. Amputation was primarily performed one decade before the availability of rotationplasty and was mostly an alternative to rotationplasty because of patient refusal or surgical limitations. Therefore, the two groups differed in age at follow-up; however, they did not differ in age at surgery, BMI, gender ratio, tumor entities, or tumor localization. All-cause revisions presented in Kaplan-Meier curves, pain sensation, and functional and QoL outcomes, such as ROM, University of California Los Angeles (UCLA) activity scores, 5-level EuroQol 5-domain (EQ-5D-5L) scores, and 36-Item Short Form survey scores, were assessed. Results: There was no difference between patients after rotationplasty and amputation in terms of survivorship free from revision of unpredictable events at 20 years (86% [95% confidence interval (CI) 85% to 95%] versus 67% [95% CI 64% to 94%]; p = 0.27). There was no difference in median UCLA activity scores between the groups (rotationplasty 6 versus amputation 5; p = 0.18). Patients treated with a rotationplasty had less pain than those treated with amputation (EQ-5D-5L pain/discomfort, p < 0.01). The EuroQol (EQ) index was higher in patients who had rotationplasty in comparison with patients who underwent amputation (0.92 versus 0.81; p = 0.01). A linear regression model that controlled for length of follow-up, gender, age, and type of surgery found that having rotationplasty was associated with a better EQ index than undergoing amputation (R = 0.538, R² corrected = 0.212; p = 0.011). There were positive correlations between the EQ index and both flexion (ρ = 0.53 [95% CI 0.03 to 0.82]; p = 0.03) and ROM (ρ = 0.54 [95% CI 0.05 to 0.82]; p = 0.03) in the neo-knee. Conclusion: After rotationplasty and amputation, patients show similarities at long-term follow-up in the use of external prostheses and in cosmetic issues after limb loss. Both groups might have benefitted from the advancements in prosthetics that have occurred and will continue to do so; however, in this study, patients seem to have better QoL after rotationplasty compared with those with amputation. This study intentionally did not compare outcomes after an extendible or modular endoprosthesis with outcomes after rotationplasty. However, failures after endoprosthetic reconstructions occur frequently in the long term, whereas they rarely exist after rotationplasty. The use of rotationplasty, therefore, might be a benefit not only to individual patients but also to stakeholders in healthcare systems. Furthermore, this study emphasizes the benefit of rotationplasty as a durable surgical method that enables patients for high physical performance. Therefore, tumor centers around the world should be aware of these benefits, and patients must be given the opportunity to receive information about it. Currently, rotationplasty might be beneficial in certain situations, at least when patients and/or parents accept this kind of reconstruction. Children younger than 5 to 7 years and small in height, patients considered for megaprostheses with borderline or insufficient soft tissue coverage, and even patients who are highly active and feel that sporting activities are most important for their lifestyle are potential candidates for rotationplasty. Furthermore, rotationplasty might be an option after failed limb salvage surgery. Level of Evidence: Level III, therapeutic study.