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Donati, Davide Maria/0000-0002-9170-0576; Campanacci, Laura/0000-0002-4734-6741; Bindiganavile Srinivas, Srimanth/0000-0003-0458-7331; MANFRINI, MARCO/0000-0003-2961-0171 WOS: 000399195300009 PubMed: 27995558 Background 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. Questions/Purpose 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. Methods 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. Results 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 ae 0.001). Conclusions 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. Italian Ministry of HealthMinistry of Health, Italy [RF-2010-2321501] This study was supported by Italian Ministry of Health (Grant Minsal RF-2010-2321501).

Background The Musculoskeletal Tumor Society (MSTS) scoring system is a widely used functional evaluation tool for patients treated for musculoskeletal tumors. Although the MSTS scoring system has been validated in English and Brazilian Portuguese, a Japanese version of the MSTS scoring system has not yet been validated.

Inappropriate MRI use has been targeted as a particular area of concern in orthopaedics, but it is unclear whether and to what extent its use is inappropriate in musculoskeletal oncology.We therefore evaluated the incidence and cost of inappropriate prereferral MRI among patients with musculoskeletal tumors.We retrospectively identified 920 patients treated in a musculoskeletal oncology clinic between 2009 and 2010. We accepted as necessary any MRI for a primary bone sarcoma, for biopsy-proven soft tissue sarcomas, for soft tissue masses greater than 5 cm in diameter, for soft tissue masses deep to the fascia, for painful soft tissue masses, and for growing soft tissue masses. Patients without these criteria were reviewed by a team of musculoskeletal oncologists to determine the necessity. The criteria for a repeat MRI were failure to show the tumor, lack of gadolinium contrast, lack of T1 or T2 MRI sequence, or poor image quality. Cost was determined using 2010 Medicare reimbursement rates.Of 920 patients, 320 (35%) arrived with a prereferral MRI study. Eight of the 320 (3%) studies were unnecessary, and 12 (4%) were necessary but were repeated. The cost was $11,474, which averages to $574 per study and $36 of waste per patient referred with an MRI study.Based on our data, we judged MRI use before referral to our tertiary center as not excessive. This is likely attributable, in part, to the relatively low use of MRI in our referral base. Inappropriate MRI use in patients with tumors may not be as widespread as previously reported.Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Humeral suspension was the most popular reconstructive procedure after total scapulectomy until the early 1990s. Since 1992 the senior author has been performing scapular endoprosthetic reconstruction after total scapulectomy whenever the rhomboids, latissimus dorsi, deltoid, and trapezius were preserved. We hypothesized that scapular endoprosthetic reconstruction resulted in better functional and cosmetic results than humeral suspension. From 1979 to 2003, 32 consecutive patients had total scapulectomies. Reconstructions included humeral suspensions in 16 patients and scapular endoprostheses in 16 patients. Functional and cosmetic results were compared retrospectively between the two groups. Patients with scapular endoprostheses had better functional results and superior cosmesis as compared with patients with humeral suspension. The mean Musculoskeletal Tumor Society scores for patients with scapular endoprostheses and humeral suspensions were 78.5% and 58.5% respectively. Seven patients with scapular endoprostheses had greater than 40 degrees abduction and 11 patients with humeral suspensions could not abduct the shoulder greater than 20 degrees. Twelve patients with humeral suspensions and none with scapular endoprostheses wore shoulder pads or customized orthoses for cosmetic purposes. After total scapulectomy, scapular endoprosthetic reconstruction led to better functional and cosmetic results than humeral suspension and therefore we recommend performing this reconstructive procedure whenever the rhomboids, latissimus dorsi, deltoid, and trapezius are preserved.

Treatment of giant cell tumor of bone ranges from intralesional curettage to en bloc resection. We think that intralesional treatment can be done with low recurrence and complication rates and that these patients have good functional results. The results for 40 patients treated by one surgeon with one technique for giant cell tumor of bone between 1985-1999 were reviewed. All patients were treated with intralesional excision of the tumor with adjunctive cautery, phenol, and methylmethacrylate. All patients had been followed up for a minimum of 2 years with the mean followup of 76 months (range, 26-178 months). In addition, recent functional evaluations were done on 23 patients at a mean followup of 90 months (range, 28-175 months). The local recurrence rate was 12.5%. The nononcologic complication rate was 7.5%. Using the Musculoskeletal Tumor Society functional evaluation, 93% of the patients had excellent results. This long-term followup study on patients treated with intralesional excision and methacrylate showed a low recurrence rate similar to those cited in the literature. Additionally, the complication rate was low and the function results were excellent.

With the increasing reliance of patients on the Internet for medical information, accessible and comprehensive resources are important. We retrieved orthopaedic oncology information sites for patients and professionals from three search engines. We evaluated 70 sites with two raters, plus an additional nine sites suggested by Musculoskeletal Tumor Society members. Only five patient sites and seven provider sites met our inclusion criteria. Of these, only one of each was peer-reviewed. In contrast to other disease states such as melanoma or bladder cancer, there are relatively few orthopaedic oncology sites available on the Web.

The author certifies that he, or any members of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®.

We are proud to publish the papers presented at the 2013 Annual Meeting of The Knee Society in this issue of Clinical Orthopaedics and Related Research®. As always, this group of thoughtful investigators has presented a robust body of work, with more than 30 important manuscripts. Year after year, the papers we receive from the meetings of our affiliated societies — in sections we call “proceedings” — represent some of the most-cited, best-read papers that we publish. We look forward to the Proceedings of the 2013 Hip Society meeting, coming next month, and those from the Annual Meeting of the Musculskeletal Tumor Society in March. They promise to be just as timely and relevant. In the months that CORR® does not present the proceedings of a major society, we typically publish symposia, groups of papers we solicit on important contemporary topics. Symposia have international reach and interest. Recent symposia have included Childhood Obesity and Musculoskeletal Problems, Special Considerations for TKA in Asian Patients, Tscherne Festschrift, and Evolving Medicolegal Concepts. These have included numerous manuscripts that are among the best-cited and most-downloaded papers in CORR®. Although proceedings and symposia are familiar and important parts of our Journal, some readers and even authors, find them confusing. Here are the four most common questions about proceedings and symposia, along with their answers: How does CORR®decide what symposia and proceedings to run? Sometimes, thought leaders in the orthopaedic community contact the Journal with ideas for a symposium. We evaluate these based on whether the topic is important, whether it is interesting to a sufficient number of readers, and whether we have produced a symposium on a related topic recently (or if one is in the pipeline). From time to time, a member of our Senior Editor panel will develop an idea, and then we will look for an outside “Guest Editor” to produce the symposium. We are as interested in basic science symposia as clinical topics, although the former are somewhat harder to produce, and so there have been fewer of them. Any of our affiliated societies may, in principle, produce a proceedings issue; in reality, only a few of them generate a sufficient volume of articles of interest to the broad readership on a regular basis. In recent years, four societies have produced annual proceedings: The Hip Society, The Knee Society, The Musculoskeletal Infection Society, and the Musculoskeletal Tumor Society. Others, such as the International Hip Society and the International Society of Limb Salvage, have done so on alternate years when they conduct their meetings. We continue to work with our smaller affiliates to evaluate options like “Mini-proceedings” and publication of awards papers from society meetings. If the content for symposia is solicited, and proceedings articles are invited after a meeting, are those articles peer reviewed further by CORR®? All scientific content in CORR®, including all scientific content in symposia and proceedings, is peer reviewed using the same high standards. We use the same processes for all articles in proceedings and symposia as we use for unsolicited manuscript submissions, including review by referees from our Journal’s extensive database of subject-matter experts, and evaluation and editing by one or more of our Journal’s Senior Editors and me (independent from the evaluation of the Guest Editor). The exception is some awards papers, most notably the Hip and Knee Society awards papers, which are peer reviewed and edited for clarity, but which we have agreed in advance to publish; these are clearly marked as awards papers. Editorials, columns, and commentaries — again, all clearly marked as such — generally are edited for clarity, but are not usually peer reviewed. Importantly, accepting an invitation to submit a scientific manuscript for a symposium or proceedings issue in CORR® is no guarantee of publication; manuscripts are rejected from every symposium and proceedings issue. Peer review is the cornerstone of what we do, and we take it seriously. Although it is harder to reject an article that we have solicited, our greatest duty is to uphold the high quality of the science we publish for our readers and ultimately to the patients whom they treat. What kinds of articles are suitable for these sections, and what kinds are not? As with other sections of our journal, we are interested in original research, both clinical and basic science, as well as surgical techniques. We rarely publish case reports in these sections. In terms of content that synthesizes, we are enthusiastic about meta-analyses, decision analyses, economic analyses, and systematic reviews. Other than historical reviews, we generally do not publish selective review articles (monographs or “book-chapter-style” reviews), as it can be very difficult to keep these articles balanced and free from bias. We may occasionally publish selective reviews on basic science topics if there is an important didactic principle at stake or a story that needs to be told that cannot be told in some other way. If I have an idea for a symposium, whether or not I want to be the guest editor, how do I get started? By all means please contact me directly, at eic@clinorthop.org.

This CORR Insights™ is a commentary on the article “High Infection Rate Outcomes in Long-bone Tumor Surgery with Endoprosthetic Reconstruction in Adults: A Systematic Review” by Racano and colleagues available at DOI 10.1007/s11999-013-2842-9. The author certifies that he, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. The author is the President of the Musculoskeletal Tumor Society, the sponsor of the Parity clinical trial referred to in this commentary, and a coauthor of an article referenced that describes the methodology for developing that trial. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. This CORR Insights™ comment refers to the article available at DOI: 10.1007/s11999-013-2842-9

Cooperation. Collaboration. Working together. When we strive to embody these values, we are better. When we do not, we are less. Our patients are our joint responsibility. When we collaborate, caring for them together, they do better. When we do not, they do less well. Sarcomas are a threat to life and limb, and surgery is our most effective treatment. In many ways, it is the ultimate targeted therapy. In most localized tumors, we can achieve a complete response much more effectively than by any other modality. As surgeons, we strategically remove tumors, preserving as much function as possible, and hope for the best. The best does not always come. Often, the complete responses are not sufficiently durable. Whenever possible, we look to our colleagues in other specialties to improve the results from surgery alone. In certain types of sarcomas, there is a role reversal: chemotherapy is the backbone of treatment, with surgery as the adjuvant for local cleanup. For example, with systemic chemotherapy, we tripled the survival rate in osteosarcoma, Ewing’s sarcoma, and rhabdomyosarcoma, compared to the rate achieved with local control alone. Similarly, in a majority of soft tissue sarcomas, we rely on the expertise of our radiation oncology colleagues to improve our ability to control the local tumor. All too often our local and systemic tools are limited, and we are left hoping for the best. New tools to enhance the impact of our care are a necessity. Enter the molecular scalpel. Biotargeting, in the form of directed monoclonal antibodies and small molecule inhibitors, to name just two, have helped save lives and move the hope curve to advantage the survival of more patients with sarcoma. Without the efforts of our research colleagues, such tools would not be available to our patients. The conditions we treat are rare. Consequently, it is only through analysis of our combined experience that we can establish reliable outcome data to determine whether our treatments are effective. This requires cooperation. Leading the way toward this goal are the Radiation Therapy Oncology Group (RTOG), Eastern Cooperative Oncology Group (ECOG), SWOG (formerly the Southwest Oncology Group), Children’s Oncology Group (COG), and the Sarcoma Alliance for Research through Collaboration (SARC), to name a few. Some of us are active in these groups; more of us should be. The Musculoskeletal Tumor Society (MSTS) has convened numerous combined meetings with the International Society of Limb Salvage (ISOLS), the European Musculo-Skeletal Oncology Society (EMSOS), and now the Connective Tissue Oncology Society (CTOS). These combined meetings bring out the best from our learned societies as we search to better understand the pathophysiology of sarcomas and treat them more successfully. We hope you enjoy reading these select symposium papers from the 2011 MSTS/CTOS combined meeting. As you read them, we hope two common themes will resonate: (1) cooperation across disciplines stimulates new ways of thinking and (2) interdisciplinary approaches enhance outcomes. A commitment to transdisciplinary cooperation will promote the synergies that we need to move beyond hope and cure more patients. On behalf of both societies, we trust you will enjoy this symposium. Fig. 1 R. Lor Randall, MD, FACS, Past President, CTOS, and Chair, Orthopaedic Committee, COG, is shown. Fig. 2 John H. Healey, MD, FACS, President, MSTS, and Past Chair, Orthopaedic Committee, COG, is shown.

Clinical Orthopaedics and Related Research (CORR) has a long record of accomplishment in publishing oncologic work. It has published many focused symposia regarding specific topics (eg, bone and cartilage transplantation [Volume 174, 1983]; neurofibromatosis [Volume 245, 1989]; osteosarcoma [Volume 270, 1991]). Since 1999 when CORR became the official organ for the Musculoskeletal Tumor Society (MSTS), the journal has published a symposium of the best selected articles from the annual meeting of the MSTS. The relationship between the journal and the society has promoted the interests of both organizations. The journal gets dependable high-quality content, and the society gets high-quality editing and dissemination of its aggregated best work. Each organization achieved its goals due to this mutually beneficial arrangement. The successful relationship should continue. MSTS, “Who’s your daddy?” It is CORR. CORR is the clarion voice for musculoskeletal oncology. The data speak. CORR publishes more articles with higher citation index than any other journal dealing with musculoskeletal oncology (Table 1). This includes all surgical and orthopaedic specialties. Indeed, CORR publishes more than all the other journals combined when it comes to bone tumors. For example, it dwarfs others in publications regarding osteosarcoma and giant cell tumor, the leading primary malignant and benign conditions that require orthopaedic surgery. Even in the domain of soft tissue sarcoma, orthopaedic surgeons have made the greatest contributions to the surgical literature, and CORR has led the way. CORR is clearly the best international forum for musculoskeletal tumor scholarly work. Table 1 Number of musculoskeletal tumor articles published by leading journals Investigator-initiated research was the basis of the 2010 Musculoskeletal Tumor Society Meeting. Thus, there was no specific focus, but a broad range of topics was covered. The program committee identified the best presentations for inclusion in this symposium. Included are papers dealing with complications of medical, radiation, and surgical treatment, examination of how surgical margin affects recurrence and outcome of soft tissue sarcoma, the management of several different benign and malignant tumors, followup of various reconstructive procedures, and difficulty dealing with certain anatomic sites such as the pelvis. These papers provide a balanced view of modern work done in the field of musculoskeletal oncology. Notably missing, however, was significant work dealing with tumor biology. Perhaps authors present their biologic work at other meetings and submit it to other journals. Hopefully it does not reflect orthopaedic surgeons abjuring biology. Regardless, biology is the inexorable force behind cancer, and the meeting should strive for balance between the biologic and mechanical aspects of oncologic practice. In the long run, the MSTS must focus more on biology if we are to make progress against musculoskeletal cancers. The MSTS, our members, and our patients owe a debt of gratitude to CORR for promoting research and clinical improvement in oncology and disseminating the knowledge internationally (Fig. ​(Fig.11). Fig. 1 Dr. John H. Healey is shown.