Surgical resection margins are reportedly the most important predictor of survival and local recurrence with sacral chordomas. We examined the relevance of invasion of the surrounding posterior ...pelvic musculature (piriformis and gluteus maximus) at initial diagnosis to local recurrence after sacrectomy. We retrospectively reviewed 18 patients with histologically verified sacral chordoma seen at our institution between 1998 and 2005. There were 14 men and four women with a mean age of 65.1 years (range, 31–78 years). The average overall followup was 4.4 years (range, 0.5–10 years), 5.4 years for the living patients (range, 3–10 years), and 2.8 years for the deceased (range, 0.5–5.4 years). Local recurrence occurred in 12 patients (66%) 29 months postoperatively (range, 2–84 months). Six of these patients had wide excisions at initial surgery, five had marginal excisions, and one had an intralesional excision. Ten patients had wide surgical margins, six of whom (60%) had local recurrences. Tumor invasion of adjacent muscles at presentation was present in 14 patients, 12 of whom (85%) had local recurrences. Sacroiliac joint involvement was seen in 10 patients, nine of whom (90%) had local recurrences. The findings suggest obtaining wide surgical margins posteriorly, by excising parts of the piriformis, gluteus maximus, and sacroiliac joints, may result in better local disease control in patients with sacral chordoma.
Level of Evidence:
Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Aims Pigmented villonodular synovitis (PVNS) is a rare, locally aggressive and potentially recurrent synovial disease. We present the largest single-centre experience of knee PVNS. Our aim ...was to evaluate our tertiary hospital's experience in the management of knee PVNS. Patients and methods Retrospective data collection of consecutive cases of knee PVNS from 2002 to 2015. Results In total, 214 cases of knee PVNS were identified which represented 53.4% of all PVNS (12.1% were recurrent at presentation). 100 were localised PVNS (LPVNS), 114 diffuse PVNS (DPVNS) and two malignant PVNS. Knee PVNS was more likely to occur in females with a mean age of 39. Following surgery, 47.6% had recurrence with DPVNS as opposed to 8.6% with LPVNS. In LPVNS, there was no significant difference in recurrence between open and arthroscopic synovectomy (8.7% vs 9.1%, P > 0.05). However, in DPVNS, there was a significantly higher risk of recurrence with arthroscopic compared to open synovectomy (83.3% vs 44.8%, RR = 1.86 95% CI 1.32–2.62, P = 0.0004). Conclusion PVNS can be difficult to treat. We found no difference in local recurrence rates between open and arthroscopic treatment of LPVNS but significantly increased rates of recurrence for DPVNS following arthroscopic treatment. We would therefore recommend open synovectomy for DPVNS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with ...TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.
This was a retrospective observational study of all adults with positive TB cultures on specimens taken at a tertiary orthopaedic centre between June 2012 and May 2014. A laboratory information system search identified the patients. The demographics, clinical presentation, radiology, histopathology and key clinical dates were obtained from medical records.
A total of 31 adult patients were identified. Their median age was 37 years (interquartile range (IQR): 29 to 53); 21 (68%) were male; 89% were migrants. The main sites affected were joints (10, 32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocal disease. The most common presenting symptoms were pain (29/31, 94%) and swelling (26/28, 93%). 'Typical' symptoms of TB, such as fever, sweats and weight loss, were uncommon. Patients waited a median of seven months (IQR 3 to 13.5) between the onset of symptoms and referral to the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) between referral and starting treatment. Radiology suggested TB in 26 (84%), but in seven patients (23%) the initial biopsy specimens were not sent for mycobacterial culture, necessitating a second biopsy. Rapid Polymerase Chain Reaction-based testing for TB using Xpert MTB/RIF was performed in five patients; 4 (80%) tested positive for TB. These patients had a reduced time between the diagnostic biopsy and starting treatment than those whose samples were not tested (median eight days
36 days, p = 0.016).
Patients with bone and joint TB experience delays in diagnosis and treatment, some of which are avoidable. Maintaining a high index of clinical suspicion and sending specimens for mycobacterial culture are crucial to avoid missing cases. Rapid diagnostic tests reduce delays and should be performed on patients with radiological features of TB. Cite this article:
2018;100-B:119-24.
Background
Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft ...potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions are durable.
Questions/purposes
We therefore sought to determine (1) survivorship and complications, (2) function, and (3) radiographic findings of cementless revision TKA in combination with loosely-packed morselized bone graft to reconstruct osseous defects at revision TKA.
Patients and Methods
We retrospectively reviewed 56 patients who had undergone revision TKAs using cementless long-stemmed components in combination with morselized loose bone graft at our institution. There were 26 men and 30 women with a mean age of 68.3 years (range, 56–89 years). Patients were followed to assess symptoms and function and to detect radiographic loosening, component migration, and graft incorporation. The minimum followup was 4 years (mean, 7.3 years; range, 4–10 years).
Results
Cumulative prosthesis survival, with revision as an end point, was 98% at 10 years. The mean Oxford Knee Scores improved from 21 (36%) preoperatively to 41 (68%) at final followup. Five patients (9%) had reoperations for complications.
Conclusions
Our observations suggest this technique is reproducible and obviates the need for excessive bone resection, use of large metal augments, mass allografts, or custom prostheses. It allows for bone stock to be reconstructed reliably with durable midterm component fixation.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
The pre-operative differentiation between enchondroma, low-grade chondrosarcoma and high-grade chondrosarcoma remains a diagnostic challenge. We reviewed the accuracy and safety of the radiological ...grading of cartilaginous tumours through the assessment of, first, pre-operative radiological and post-operative histological agreement, and second the rate of recurrence in lesions confirmed as high-grade on histology. We performed a retrospective review of major long bone cartilaginous tumours managed by curettage as low grade between 2001 and 2012. A total of 53 patients with a mean age of 47.6 years (8 to 71) were included. There were 23 men and 30 women. The tumours involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula (n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses resulted from multidisciplinary consensus following radiological review alone for 35 tumours, or with the addition of pre-operative image guided needle biopsy for 18. The histologically confirmed diagnosis was enchondroma for two (3.7%), low-grade chondrosarcoma for 49 (92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients with a low-grade tumour developed a local recurrence at a mean of 15 months (12 to 17) post-operatively. A single high-grade recurrence (grade II) was treated with tibial diaphyseal replacement. The overall recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to 12.3). Cartilaginous tumours identified as low-grade on pre-operative imaging with or without additional image-guided needle biopsy can safely be managed as low-grade without pre-operative histological diagnosis. A few tumours may demonstrate high-grade features histologically, but the rates of recurrence are not affected.
Hydrophobins are remarkable proteins due to their ability to self-assemble into amphipathic coatings that reverse surface wettability. Here, the versatility of the Class I hydrophobins EASΔ15 and ...DewY in diverse nanosuspension and coating applications is demonstrated. The hydrophobins are shown to coat or emulsify a range of substrates including oil, hydrophobic drugs, and nanodiamonds and alter their solution and surface behavior. Surprisingly, while the coatings confer new properties, only a subset is found to be resistant to hot detergent treatment, a feature previously thought to be characteristic of the functional amyloid form of Class I hydrophobins. These results demonstrate that substrate surface properties can influence the molecular structures and physiochemical properties of hydrophobin and possibly other functional amyloids. Functional amyloid assembly with different substrates and conditions may be analogous to the propagation of different polymorphs of disease-associated amyloid fibrils with distinct structures, stability, and clinical phenotypes. Given that amyloid formation is not required for Class I hydrophobins to serve diverse applications, our findings open up new opportunities for their use in applications requiring a range of chemical and physical properties. In hydrophobin nanotechnological applications where high stability of assemblies is required, simultaneous structural and functional characterization should be carried out. Finally, while results in this study pertain to synthetic substrates, they raise the possibility that at least some members of the pseudo-Class I and Class III hydrophobins, reported to form assemblies with noncanonical properties, may be Class I hydrophobins adopting alternative structures in response to environmental cues.
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IJS, KILJ, NUK, PNG, UL, UM
The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) offers transfemoral amputees an ambulatory method potentially reducing soft tissue complications seen with socket and stump devices. This ...study validated a finite element (
in silico
) model based on an ITAP design and investigated implant stem stiffness influence on periprosthetic femoral bone strain. Results showed good agreement in the validation of the
in silico
model against the
in vitro
results using uniaxial strain gauges and Digital Image Correlation (DIC). Using Strain Energy Density (SED) thresholds as the stimulus for adaptive bone remodelling, the validated model illustrated that: (a) bone apposition increased and resorption decreased with increasing implant stem flexibility in early stance; (b) bone apposition decreased (mean change = − 9.8%) and resorption increased (mean change = 20.3%) from distal to proximal in most stem stiffness models in early stance. By engineering the flow of force through the implant/bone (e.g. by changing material properties) these results demonstrate how periprosthetic bone remodelling, thus aseptic loosening, can be managed. This paper finds that future implant designs should be optimised for bone strain under a variety of relevant loading conditions using finite element models to maximise the chances of clinical success.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
This paper first presents the results of an experimental study into the damage tolerance of AA7075-T6, which is widely used in both fixed- and rotary-wing aircraft, space structures, and laser bed ...powder fusion (LBPF) Scalmalloy specimens built by Boeing Space, Intelligence, and Weapons Systems. To this end, four single edge notch AA7075-T6 specimens and four identical single edge notch LBPF Scalmalloy specimens were tested. The resultant crack growth curves reveal that Boeing Space, Intelligence, and Weapons Systems AM-built Scalmalloy is more damage tolerant than conventionally built AA7075-T6. This finding leads to the observation that the da/dN versus ΔK curves associated with Scalmalloy and conventionally manufactured AA2024-T3 are similar. These findings highlight the potential for Boeing Space, Intelligence, and Weapons Systems AM-built Scalmalloy to be used to extend the operational lives of military aircraft by the on-demand printing of limited-life Scalmalloy replacement parts.
This article was updated on April 9, 2020, because of a previous error. On page 1309, in the list of Tenosynovial Giant Cell Tumors (TGCT) Study Group members, the contributor name that had read “M. ...Wook Joo” should have read “M.W. Joo.”An erratum has been publishedJ Bone Joint Surg Am. 2020 May 20;102(10):e49.
BACKGROUND:Localized-type tenosynovial giant cell tumor (TGCT) is a rare, neoplastic disease with only limited data supporting treatment protocols. We describe treatment protocols and evaluate their oncological outcome, complications, and functional results in a large multicenter cohort of patients. A secondary study aim was to identify factors associated with local recurrence after surgical treatment.
METHODS:Patients with histologically proven localized TGCT of a large joint were included if they had been treated between 1990 and 2017 in 1 of 31 tertiary sarcoma centers. Of 941 patients with localized TGCT, 62% were female. The median age at initial treatment was 39 years, and the median duration of follow-up was 34 months. Sixty-seven percent of the tumors affected the knee, and the primary treatment at the tertiary center was 1-stage open resection in 73% of the patients. Proposed factors for predicting a first local recurrence after treatment in the tertiary center were tested in a univariate analysis, and those that demonstrated significance were subsequently included in a multivariate analysis.
RESULTS:The localized TGCT recurred in 12% of all cases, with local-recurrence-free rates at 3, 5, and 10 years of 88%, 83%, and 79%, respectively. The strongest factor for predicting recurrent disease was a prior recurrence (p < 0.001). Surgical treatment decreased pain and swelling in 71% and 85% of the patients, respectively, and such treatment was associated with complications in 4% of the patients. Univariate and multivariate analyses of the patients who had not undergone therapy previously yielded positive associations between local recurrence and a tumor size of ≥5 cm versus <5 cm (hazard ratio HR = 2.50; 95% confidence interval CI = 1.32 to 4.74; p = 0.005). Arthroscopy (versus open surgery) was significantly associated with tumor recurrence in the univariate analysis (p = 0.04) but not in the multivariate analysis (p = 0.056).
CONCLUSIONS:Factors associated with recurrence after resection of localized-type TGCT were larger tumor size and initial treatment with arthroscopy. Relatively low complication rates and good functional outcomes warrant an open approach with complete resection when possible to reduce recurrence rates in high-risk patients.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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