To evaluate a strategy that used thermal-ablation of vertebral metastases (VM) to prevent vertebral related events (VRE) in patients with differentiated thyroid cancer (DTC).This single center study retrospectively reviewed records and post-operative imaging of all DTC patients treated with thermal-ablation for asymptomatic VMs. Rate of local tumor control at first post-operative imaging, 12 and 24 months after thermal-ablation and rate of VREs at 12 and 24 months among the treated VMs were reported. New VMs that occurred during the follow-up and were not considered for additional thermal-ablation were moniroted and VREs were reported.Thermal-ablation was used to achieve local control of 41 VMs in 28 patients. Median post-treatment follow-up was 22 months [range: 12–80] and the mean delay for first post-operative imaging was 2 months [range: 0.6–7.5]. Local control at first post-operative imaging, 12 and 24 months was achieved in 87.8%, 82.9% and 75.6%, respectively. Among the treated VMs the rates of VRE was 7.3% at 2 years, significantly lower if local control was achieved at first post-operative imaging than if it was not (0% vs 30%, p = 0.011, OR = 0.184 [95%CI = 0.094–0.360]). After thermal-ablation procedures, 19 news VMs occurred in 11 patients (39.2%) with a median interval of 8 months [range 1–26] and remained untreated. Among these untreated VMs, the rate of VREs at 2 years was significantly higher compared to the treated VMs: (36.8% vs. 7.3%, p = 0.008, OR = 0.135, [95%CI = 0.030-0.607]).local tumor control of VMs using thermal-ablation decreases the risk of VREs in DTC patients.

Objectives Mirels’ score is known for its low sensitivity in identifying impending fracture risk in patients with metastatic tumors in the femur. CT-based finite element analysis (CTFEA) is an emerging alternative as a patient specific quantitative decision support tool. Patient’s femurs are automatically segmented from the CT scan, material properties are assigned and a stance position load is applied according to patient’s weight. The CTFEA was validated in a retrospective study on the largest cohort of patients to date (50). Using a quantitative measure, strain fold ratio, it distinguishes between high and low risk of fracture.

AIMS Accurate estimations of the risk of fracture due to metastatic bone disease in the femur is essential in order to avoid both under-treatment and over-treatment of patients with an impending pathological fracture. The purpose of the current retrospective in vivo study was to use CT-based finite element analyses (CTFEA) to identify a clear quantitative differentiating factor between patients who are at imminent risk of fracturing their femur and those who are not, and to identify the exact location of maximal weakness where the fracture is most likely to occur. METHODS Data were collected on 82 patients with femoral metastatic bone disease, 41 of whom did not undergo prophylactic fixation. A total of 15 had a pathological fracture within six months following the CT scan, and 26 were fracture-free during the five months following the scan. The Mirels score and strain fold ratio (SFR) based on CTFEA was computed for all patients. A SFR value of 1.48 was used as the threshold for a pathological fracture. The sensitivity, specificity, positive, and negative predicted values for Mirels score and SFR predictions were computed for nine patients who fractured and 24 who did not, as well as a comparison of areas under the receiver operating characteristic curves (AUC of the ROC curves). RESULTS The sensitivity of SFR was 100% compared with 88% for the Mirels score, and the specificity of SFR was 67% compared with 38% for the Mirels score. The AUC was 0.905 for SFR compared with 0.578 for the Mirels score (p = 0.008). CONCLUSION All the patients who sustained a pathological fracture of the femur had an SFR of > 1.48. CTFEA was far better at predicting the risk of fracture and its location accurately compared with the Mirels score. CTFEA is quick and automated and can be incorporated into the protocol of CT scanners. Cite this article: Bone Joint J 2020;102-B(5):638-645.

Background Osteoid osteomas are benign bone neoplasms that may cause severe pain and limit function. They are commonly treated by radiofrequency ablation (RFA) through a needle inserted into the nidus of the lesion under CT guidance, which is associated with exposure of young patients to relatively high dose of radiation. The objective of this study was to investigate the amount of radiation, effectiveness and safety of an alternative imaging approach, the 3D image-guided (O-arm) technology and the Stealth navigation. Methods We retrospectively reviewed 52 electronic medical files of patients (mean age 24.7 years, range 8–59 years) who were treated with thermal ablation of benign osteoid osteomas guided by the navigated O-arm-assisted technique in our institution between 2015 and 2017. Data were extracted on the associated complications, the reduction in pain at 3 months and one year postoperatively, and the amount of radiation administered during the procedure. Results The level of pain on a visual analogue scale decreased from the preoperative average of 7.73 to 0 at the 3-month follow-up. The mean dose-length product was 544.7 mGycm 2 compared to the reported radiation exposure of 1971–7946 mGycm 2 of CT-guided radio ablations. The one intra-operative complication was a superficial burn in the subcutaneous lesion in a tibia that was treated locally with no major influence on recovery. Conclusions RFA ablation guided by 3D O-arm stealth navigation is as effective as the traditional CT-guided technique with the advantage of lower radiation exposure. Trial registration Retrospective study number 0388–17-TLV at Tel Aviv Sourasky Medical Center IRB, approved at 25.10.17.

Aims Intra-articular (90)Yttrium (Y-90) is an adjunct to surgical treatment by synovectomy for patients with diffuse-type tenosynovial giant-cell tumour (dtTGCT) of the knee, with variable success rates. Clinical information is, however, sparse and its value remains unclear. We investigated the long-term outcome of patients who underwent synovectomy with and without adjuvant treatment with (90)Yttrium. Patients and Methods \All patients with dtTGCT of the knee who underwent synovectomy between 1991 and 2014 were included in the study. Group A patients underwent synovectomy and an intra-articular injection of (90)Yttrium between six and eight weeks after surgery. Group B patients underwent surgery alone. Results There were 34 patients in group A and 22 in group B. Recurrence of dtTGCT was identified by MRI, which was undertaken in patients with further symptoms. At a mean follow-up of 7.3 years (2.5 to 25.4), there was residual disease in 15 patients in group A and 11 in group B (p < 0.363). The mean Musculoskeletal Tumor Society (MSTS) score at final follow-up was 85% and 83%, respectively (p < 0.91). Conclusion There were no significant differences in outcome between patients treated surgically for dtTGCT of the knee with or without an adjuvant intra-articular injection of (90)Yttrium. We were unable to provide conclusive evidence of any benefits derived from the adjuvant treatment.

The article describes a unique clinical case of multifocal synchronous osteosarcoma patient 10 years old with the defeat of the right femur and humerus identified in a clinic in Israel in 2014. The patient was conducted a combined treatment including arthroplasty. At the time of this writing, the patient is alive without evidence of disease manifestations and can independently move without crutches.

Distal tibial tumor ablation results in combined soft tissue and bone defect that involves the ankle joint. This area is unique and problematic because it combines low caliber limb size, relatively soft tissue deficiency, suboptimal bone and soft tissue healing ability, and the need to sustain increased mechanical loads. The management is difficult, controversial, and traditionally was treated by primary amputation. We present our experience with a limb sparing surgery using biological reconstruction.Between 2004 and 2007, 5 patients with malignant bone tumors of the distal tibia underwent tumor resection and reconstruction with free vascularized osteoseptocutaneous fibula flap. The average age was 33.2 years (range, 11-62 years). In all cases, a skin island was harvested and used for wound closure. Arthrodesis of the ankle joint was preformed in all patients. Double fixation system was used to provide stability and avoid flap rotation.All flaps survived. There were no major complications. One patient had partial loss of the skin paddle that was treated conservatively. Callous formation was documented after an average time of 4 months, partial weight bearing after an average time of 4 months, and full weight bearing after an average time of 11.5 months. All patients regained almost normal ambulation within a year.

ВВЕДЕНИЕ Остеосаркома — первично злокачественная опухоль костей, которая развивается из примитивных мезенхимальных стволовых клеток, способных дифференцироваться в костную, хрящевую или фиброзную ткани; составляет 3% всех злокачественных опухолей у детей и подростков. Частота встречаемости — 4 случая на 1 млн детского населения в год, что составляет 35–50% всех злокачественных опухолей костей в детском возрасте [1, 2]. DOI: 10.15690/onco.v2.i4.1467 А. Штернхайм , Д. Левин , М. Министерский , А. Ниркин , Дж. Бикелс , С. Дадиа , Е. Коллендер , Е. Гортзак , М.Ю. Рыков, Э.Р. Сенжапова, А.З. Дзампаев, В.Г. Поляков 4 1 Клинический центр педиатрии Дана-Дуэк, Тель-Авив, Израиль 2 Медицинский центр им. Э. Сураски, Тель-Авив, Израиль 3 Российский онкологический научный центр им. Н.Н. Блохина Минздрава России, Москва, Российская Федерация 4 Российская медицинская академия последипломного образования Минздрава России, Москва, Российская Федерация

Reconstruction of the posterior neck is one of the rarer procedures performed by plastic surgeons; we used free flaps for the closure of defects in this area in six cases over the past 4 years. Six patients were located requiring posterior neck reconstruction between the years 2007 and 2013. Five of these patients required reconstruction due to oncologic resections, while one underwent serial removal of a giant congenital nevus. Five of these reconstructions involved the use of a free anterolateral thigh/vastus lateralis flap, and the sixth received a pre-expanded deep inferior epigastric perforator flap. Satisfactory dorsal neck reconstruction was achieved with the free flap approach: it produced excellent healing, contour and coverage of hardware. There was only one early minor complication, allowing early return to daily activities and continuation of planned oncologic treatment. Free flap reconstruction of the posterior neck area is a safe and relatively rapidly performed procedure that yields good results both functionally and aesthetically. In this article, we review the literature on the options available for reconstruction of the posterior neck, describe our surgical experience in such cases, and suggest an algorithm to guide in choosing the optimal approach for a given patient.

Introduction and aim: Endoprosthetic reconstruction is considered the mainstay of limb salvage in periarticular bone tumours. However, this procedure has limited durability especially when performed in young patients. The free fibula head flap including the proximal articular surface represents one option for hemiarthroplasty reconstruction. The aim of this study was to investigate the role of the fibula head flap for joint reconstruction after osteoarticular resections.Patients and methods: All patients who underwent hemiarthroplasty procedures between 2000 and 2006 using the free fibula head flap were included in the study. Functional assessments were performed using the American Musculoskeletal Tumor Society (AMTS) classification.Results: There were five males and two females (mean age: 22.6 +/- 15.9 years). Five patients underwent reconstruction following resection of malignant bone tumours and two for chronic osteomyelitis of the distal humerus. In three patients, the fibula was used for distal radius and wrist joint reconstruction, and the remaining four patients for reconstruction of the distal humerus and elbow joint. A vascularised growth plate transfer based on the lateral geniculate vessels was performed in two patients. Atechnetium-bone scan confirmed viability of all flaps 10 days after surgery, and radiographic bony union was confirmed on average 5 months following surgery. There were no complications with the recipient or donor site after a median follow-up of 71 months (range: 12 months to 10 years). All patients achieved reasonable return of function and were able to perform all activities of daily living.Conclusions: We demonstrate that the hemiarthroplasty procedure using the free fibula flap with its proximal head is a safe procedure with good functional results. Performing autologous arthroplasty using a free fibula head flap may be a promising alternative to an endoprosthesis or alloplastic reconstruction with a low risk of complications and morbidity. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Objective: Adjuvant radiation therapy (RT) is an essential part of combined limb-sparing treatment of soft-tissue sarcoma (STS). Elderly or medically unfit patients often have difficulty in completing 6-7 weeks of standard fractionated daily treatment. Our aim was to evaluate the efficacy of a hypofractionated adjuvant approach with RT for STS in elderly and debilitated patients.Methods: 21 elderly patients were treated with a short course of adjuvant RT (39-48Gy, 3Gy per fraction) for STS. The medical records of the patients were retrospectively reviewed for local or distant recurrence and side effects of RT.Results: At a mean 26 months of follow-up, three local recurrences (14%) were detected. Eight patients (38%) had lung metastases during the observed period. Three of them died from metastatic disease. The hypofractionated radiation was well tolerated with minimum long-term side effects.Conclusion: Hypofractionated adjuvant radiation appears to be an effective treatment in terms of local control in elderly and debilitated patients.Advances in knowledge: The results of this study might provide an alternative to commonly used standard fractionation of radiotherapy in sarcoma patients.

10043 Background: Chondrosarcomas (CS) represent a heterogeneous group of rare sarcomas, poorly responsive to chemotherapy or radiotherapy. When local therapies in recurrent or metastatic disease are exhausted, chemotherapy plays a marginal role. Different molecular pathways have been shown to be activated in CS. In this retrospective study we summarize our experience in treating a cohort of patients with recurrent nonresectable CS with a combination of sirolimus and cyclophosphamide. Methods: Nine consecutive patients with nonresectable CS were offered off-label treatment with sirolimus and cyclophosphamide between 2007-2011. Tumor response, progression-free survival (PFS), adverse events and other relevant clinical data were analyzed. Results: The median patients’ age was 52 (range, 35-68). Median disease-free interval (DFI) since the primary diagnosis was 24 months. Median time from the disease recurrence to initiation of sirolimus and cyclophosphamide treatment was 20.9 months due to additional local surgical treatments/excision of metastases/slow and asymptomatic progression. One (11%) objective response was observed and five (56%) patients had stabilization of disease for at least 6 months. One patient has been treated for only 3.5 months and reported symptomatic improvement at this stage, two patients had progressive disease. Median time to treatment failure (TTF) was 15 months (range, 2.8-30.3). No significant adverse events were observed. Conclusions: Although advanced CS remains an incurable disease, our experience suggests that a combination of sirolimus and cyclophosphamide is well-tolerated and has meaningful clinical activity with clinical benefit rate of 67%. Further prospective studies are warranted.

INTRODUCTION: Allograft reconstruction after resection of primary bone sarcomas has a non-union rate of approximately 20%. Achieving a wide surface area of contact between host and allograft bone is one of the most important factors to help reduce the non-union rate. We developed a novel technique of haptic robot-assisted surgery to reconstruct bone defects left after primary bone sarcoma resection with structural allograft. METHODS: Using a sawbone distal femur joint-sparing hemimetaphyseal resection/reconstruction model, an identical bone defect was created in six sawbone distal femur specimens. A tumor-fellowship trained orthopedic surgeon reconstructed the defect using a simulated sawbone allograft femur. First, a standard, ‘all-manual’ technique was used to cut and prepare the allograft to best fit the defect. Then, using an identical sawbone copy of the allograft, the novel haptic-robot technique was used to prepare the allograft to best fit the defect. The robotic software was programmed to ensure that the robot-assisted cuts for the structural allograft would result in a block of bone that perfectly fit the defect in the host bone. All specimens were scanned via CT. Using a separately validated technique, the surface area of contact between host and allograft was measured for both (1) the all-manual reconstruction and (2) the robot-assisted reconstruction. All contact surface areas were normalized by dividing absolute contact area by the available surface area on the exposed cut surface of host bone. RESULTS: The mean area of contact between host and allograft bone was 24% (of the available host surface area) for the all-manual group and 76% for the haptic robot-assisted group (p=0.004). Figures 1 and 2 depict representative coronal CT reconstructions of the final host-allograft reconstruction for a manually reconstructed specimen and a robotically reconstructed specimen, respectively. DISCUSSION AND CONCLUSION: This is the first report to our knowledge of using haptic robot technology to assist in structural bone allograft reconstruction of defects left after primary bone tumor resection. The findings strongly indicate that this technology has the potential to be of substantial clinical benefit. Further studies are warranted. TUMOR AND METABOLIC DISEASE

This review describes the kinds of skeletal bone defects in bones which develop through enchondral ossification. It focuses on the biological reconstruction of those defects according to the two main subtypes, intercalary and osteoarticular. We list the causes of bone defects and outline the different types and configurations that result from them. We then review the currently available reconstructive options according to the patient's age and describe the theoretical options as well. Finally, the history, surgical anatomy and clinical use of the free fibula flap will be reviewed. From our own clinical experience and review of the literature, we conclude that biological reconstruction is, in many ways, superior to alloplastic materials, especially in children, adolescents and young adults.

Purpose Most children today with bone sarcomas undergo limb-sparing surgery. When treating children younger than 12 years of age, the result is significant limb length discrepancy (LLD). One of the solutions is the use of an expandable endoprosthesis.Methods A retrospective analysis of 38 skeletally immature patients with bone sarcoma of the lower limb in whom different types of expandable endoprostheses were used from January 1988 to December 2005 were included. All patients were under the age of 14 years. There were 26 osteosarcoma and 12 Ewing's sarcomas. The data collected included the tumor characteristics, the surgical and other treatment modalities, complications and their treatment, and the final LLD and functional results.Results Fifty-five percent of the patients survived and had a mean follow-up of 113 months. All survivors reached skeletal maturity at the time of last follow-up. Seventy-one percent of the survivors had satisfactory function and 29% had a poor result. There were three secondary amputations due to local recurrence. Complications were documented in 58% of patients; the most common was infection that was diagnosed 56 times (primary 16% and secondary 84%). A significant correlation was found between function and final LLD (greater than 5 cm = inferior function), the number of complications, and the number of surgical procedures performed other than prosthesis elongation. The younger the patient was at definitive surgery, the shorter the time it took for the prosthesis to fail.Conclusion In order to improve results, the number of operations must be reduced. This can be achieved by the use of novel non-invasive expandable endoprostheses or biological reconstruction.

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Background: This summary of a single center's extensive cumulative experience in bone tumor cryosurgery assesses the long-term outcome of bone conservation surgery in which adjuvant cryosurgery plays a pivotal role.Materials and methods: We performed 440 cryosurgical procedures between January 1988 and December 2002. Two-thirds of the series comprised a variety of primary benign-aggressive and low-grade malignant lesions, and one-third were primary high-grade and metastatic bone tumors. The anatomical locations included almost every bone of the skeleton. Two methods of bone cryosurgery were used: Marcove's "open" direct-pour system using liquid nitrogen (1988-1997) and Meller's "closed" argon-based system (1998 to the present).Results: The study cohort consisted of 214 males and 191 females (age range 5-82 years). The median follow-up was 7 years (range 3-18). The overall local recurrence rate was 8%: fractures = 1%, infections = 2% and skin burns = 1.3%. There were three cases of transient nerve palsies in areas other than the sacrum, and four cases of late osteoarthritis of an adjacent joint. The functional outcome for the 372 patients with no evidence of disease was almost 100% "good" and "excellent" (American Musculo-skeletal Tumor Society System). Only two patients needed secondary amputations.Conclusions: Bone cryosurgery is a safe and effective limb-, joint- and even epiphysis-sparing surgical technique in suitable types of bone tumors, temporarily or permanently obviating the need for resection surgery. (c) 2007 Elsevier Ltd. All rights reserved.

Synovial sarcoma (SS) of an extremity or trunk is relatively rare and is approached by limb sparing surgery (LSS), radiation therapy (RT) and chemotherapy. We conducted a retrospective analysis of the clinical and histopathological data of 73 patients with proven SS. At a median follow-up time of 6 years, local recurrence was seen in 17.8 and systemic recurrence 35.6% of patients (local-only, 6.8; systemic-only, 24.6; combined, 11%). The 10-year local recurrence-free survival (LRFS), systemic recurrence-free survival (SRFS) and overall survival (OS) rates were 78, 68 and 61%, respectively. LRFS was significantly better in patients treated with isolated limb perfusion (ILP); SRFS was influenced by the delay until diagnosis. The practical aspects of our observations are the need for long-term follow-up in order to diagnose recurrences, the fact that not all local or distant recurrences are necessarily associated with a shortening of OS time and the important role of induction ILP with TNF in cases of extremity SS.