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Background: Patellar resurfacing after routine arthroplasty remains controversial. Few studies have specifically examined the effect of patellar resurfacing on outcomes after resection of the distal part of the femur and reconstruction with a megaprosthesis. Our objective was to compare the outcomes of megaprosthesis reconstructions of the distal part of the femur with and without patellar resurfacing after resection of a distal femoral tumor., Methods: We retrospectively reviewed the clinical records of patients with a femoral tumor who underwent resection of the distal part of the femur and endoprosthetic reconstruction between 1993 and 2013. We excluded patients who had had extra-articular knee resection, patellectomy, revision, reconstruction with an expandable prosthesis, or a proximal tibial replacement associated with the distal femoral replacement. We compared demographic characteristics, surgical variables, anterior knee pain, range of motion, extensor lag, Insall-Salvati ratio, Insall-Salvati patellar tendon insertion ratio, impingement, patellar degenerative disease, additional patellar procedures, complications, and Musculoskeletal Tumor Society (MSTS) score between the patellar resurfacing and nonresurfacing groups., Results: One hundred and eight patients--sixty without patellar resurfacing and forty-eight with patellar resurfacing--were included in the study. The mean age was 33.9 years (range, twelve to seventy-five years). There were fifty-four men and fifty-four women. The mean duration of follow-up was 4.5 years (range, 0.7 to twenty years). There was no significant difference in anterior knee pain between the groups (p = 0.51). Anterior knee pain did not significantly affect the range of motion, extensor lag, or reoperation or complication rate. Patellar degenerative disease occurred in 48% of the nonresurfaced knees but was not associated with focal pain. Complication rates were similar in the two groups, although peripatellar calcifications were significantly more common in the resurfacing group (19% versus 2%; p = 0.005). There was no significant difference in the mean MSTS score between the nonresurfacing (81%) and resurfacing (71%) groups (p = 0.34)., Conclusions: There were no differences in anterior knee pain, range of motion, extensor lag, or MSTS score between the patients with and those without patellar resurfacing. There were no cases of patellar component loosening or revision. In light of the similar outcomes in the two groups, the decision to resurface should be left up to the individual surgeon, who should take into account preoperative peripatellar pain and the status of the patella at the time of resection., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: In growing children, an expandable endoprosthesis is commonly used after distal femoral resection to compensate for loss of the distal femoral physis. Our hypothesis was that such prostheses can affect proximal tibial growth, which would contribute to an overall leg-length discrepancy and cause angular deformity., Methods: Twenty-three skeletally immature patients underwent the placement of a distal femoral expandable endoprosthesis between 1994 and 2012. Tibial length, femoral length, and mechanical axis were measured radiographically to determine the growth rate., Results: No patient had radiographic evidence of injury to the proximal tibial physis at the time of surgery other than insertion of the tibial stem. Fifteen (65%) of the patients experienced less proximal tibial growth in the operative compared with the contralateral limb. In ten (43%) of the patients, the discrepancy progressively worsened, whereas in five (22%) of the patients, the discrepancy stabilized. Seven patients did not develop tibial length discrepancy, and one patient had overgrowth of the tibia. For the ten patients with progressive shortening, the proximal tibial physis grew an average of 4.0 mm less per year in the operative limb. Five (22%) of the patients had ≥ 20 mm of tibial length discrepancy at last follow-up. Three of these patients underwent contralateral tibial epiphysiodesis. Three patients required corrective surgery for angular deformity., Conclusions: The tibial growth plate may not resume normal growth after implantation of a distal femoral prosthesis. Physeal bar resection, prosthesis revision, and contralateral tibial epiphysiodesis may be needed to address tibial growth abnormalities., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

An enchondroma with complex cystic changes of the proximal femur is described in a 13-year-old male. The case illustrates a unique presentation of an enchondroma and reinforces the importance of considering the presence of secondary aneurysmal bone cysts in both benign and malignant lesions of bone.

Background Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival. Questions/purposes (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score? Methods We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system. Results Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22%(95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 6 8.1 (42% 6 27%) preoperatively to 21.5 6 5.0 (72% 6 17%) at 3 months postoperatively (p < 0.001) and 21.6 6 8.5 (72% 6 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years). Conclusion Resection of diaphyseal metastases with intercalary reconstruction can provide stability and shortterm improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision. Level of Evidence Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Patients with primary bone and soft tissue sarcoma are at risk for skeletal metastases. Although uncommon, these metastases can result in impending or pathologic fractures. Intramedullary nailing traditionally has been an accepted form of palliative treatment for patients with metastatic carcinoma, but we could find no studies that report specifically on intramedullary nailing of metastatic sarcoma lesions.Questions/purposes: We asked: (1) What is the survival of patients with an impending or pathologic fracture from a sarcoma metastasis? (2) What proportion of patients treated with intramedullary nailing subsequently underwent a revision procedure or nail removal during their lifetimes?Methods: Between 1996 and 2014, we performed 40 intramedullary nailing procedures in 34 patients with multifocal metastases from sarcomas who showed signs or symptoms of impending fracture or who presented with a pathologic fracture. All of these patients are accounted for, either through the time of death or to the present, and all are included at a mean of 13 months (range, 0.3-86 months) in this retrospective study. During the study period, we generally applied the same surgical indications for patients with nailing of metastatic sarcoma lesions as we did for patients with metastatic carcinoma; in general, we used intramedullary nailing (with or without cement) rather than resection for diaphyseal lesions with less cortical destruction and no substantial soft tissue mass or metadiaphyseal lesions that could be adequately supplemented with cementation. The goal was to use this approach when it would allow immediate weightbearing, or in patients whose medical conditions were such that a more-extensive procedure seemed unsafe. During the same period, an additional 58 patients underwent resection procedures for metastatic sarcomas to long bones because they either did not meet the above indications, had a solitary resectable metastasis, or because of surgeon preference; these patients were excluded from this study. The median age of the patients was 52 years (range, 27-81 years). Eleven patients with 11 impending or pathologic fractures were documented to have received either preoperative or postoperative radiation therapy and 29 patients received some form of chemotherapy.Results: Thirty (88%) patients died during the period of observation, at a median of 5 months (range, 0.3-80 months) after surgery. Twenty-nine patients (85%) underwent no additional surgery and retained their original intramedullary nail. One patient (3%) underwent nail removal for infection, and four patients (12%) underwent further surgical revision secondary to local progression.Conclusions: Patients with an impending or pathologic fracture from multifocal metastatic sarcoma to a long bone have a dismal prognosis, but they may gain short-term benefit from surgical fixation with the goal of reducing pain and maintaining mobility. Although we have no group for comparison, such as treating with radiotherapy alone or resection and an endoprosthesis, our findings suggest that use of intramedullary nails is helpful for providing fixation that in most instances lasts for the lifetime of patients with multifocal bone metastases from sarcomas.Level Of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]