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Background: The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers., Questions/purposes: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results., Methods: Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system., Results: With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4)., Conclusions: Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous., Level of Evidence: Level III, therapeutic study.

Background: Primary aneurysmal bone cysts (ABCs) are benign, expansile bone lesions commonly treated with aggressive curettage with or without adjuvants such as cryotherapy, methacrylate cement, or phenol. It has been reported that occasionally these lesions heal spontaneously or after a pathologic fracture, and we observed that some ABCs treated at our center healed after biopsy alone. Because of this, we introduced a novel biopsy technique we call "curopsy," which is a percutaneous limited curettage at the time of biopsy, obtaining the lining membrane from various quadrants of the cyst leading to consolidation (curopsy = biopsy with intention to cure)., Questions/purposes: We asked whether (1) a curopsy results in comparable likelihood of healing of the ABC compared with more aggressive approaches involving curettage, (2) the two approaches differ in terms of the likelihood of recurrence after treatment, and (3) the two approaches differ in terms of complications after surgery., Methods: Between January 1, 1999 and June 30, 2012, 221 patients with a diagnosis of primary ABC were registered in our oncology database. Patients presenting with a pathologic fracture and those seeking a second opinion were excluded. One hundred ninety patients were included in the study. One hundred two (54%) were treated with curopsy and 88 (46%) were treated with curettage after a core needle biopsy. Complete followups were available for 88% (90 of 102) and 93% (80 of 88) of patients in those groups, respectively. During that period, a curopsy was performed for all patients with benign bone lesions with imaging suggestive of classic primary ABCs and for whom the core needle biopsy simply showed blood with no solid component. Curettage after a core needle biopsy was reserved for histologically confirmed primary ABCs, lesions with impending fractures, large lesions, if the ABC was thought to be a secondary disorder, and patients for whom the curopsy failed. All patients were followed up until consolidation of the lesion (mean, 9.6 weeks, range, 3-25 weeks, 95% CI, 8.32-10.9 for curopsy; mean, 11.4 weeks, range, 8-32 weeks, 95% CI, 10.6-12.3 for curettage). The median followup for all patients was 14 months (range, 6-36 months)., Results: Of the 102 patients who had curopsy and observation, 83 (81%) required no additional treatment and the lesion resolved. Of the 88 patients who underwent curettage (with or without adjuvant therapy) after core needle biopsy, the success rate was 90% (79 of 88). Local recurrences in both groups (curopsy or curettage) were treated successfully with additional curettage in all but one case. Curopsy in comparison to curettage provided a mean shorter healing time (9.6 versus 11.4, p = 0.01) but there was a higher local recurrence and need for additional intervention rate (18.6% versus 10.2%, p = 0.04). There were no differences in the complications between the treatment groups., Conclusions: A curopsy is a novel biopsy technique that was successful in resolving ABCs in 81% of the patients in our study. Curopsy, as a biopsy technique, for ABCs needs consideration as it potentially minimizes the number of patients needing a second procedure (a core needle biopsy being the first) as is the current practice. Furthermore, it does not disadvantage the patient or surgeon should additional intervention be needed in the form of curettage with or without adjuvants., Level of Evidence: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Unlabelled: Giant cell tumor of bone sometimes is an aggressive benign skeletal tumor. Historically, curettage and bone grafting have a high recurrence with satisfactory function whereas wide resection has a reduced recurrence rate with compromise of limb function. Thus, maintaining joint function and achieving adequately wide resection introduces contradictory surgical goals. We developed a method for achieving both goals for giant cell tumors located in only one lateral plateau of the proximal tibia. We reconstructed 13 knees preserving the meniscus and reconstructing the tibial plateau with an iliac plate autograft after resection of a giant cell tumor involving one tibial plateau. Four patients had primary tumors and nine had recurrences after curettage. The minimum followup was 5 years (mean, 9.1 years; range, 5-12.75 years). We used the system of Enneking et al. to evaluate function. One patient had recurrence and underwent prosthesis replacement. No patient experienced collapse, instability, or pain, and knee function was restored to near normal. The mean functional score was 95%. While resecting the tumor, the normal anatomic structures of the knee can be preserved or restored in many patients. This method can be used in selected patients to reconstruct the knee after resection of tumors involving one tibial plateau., Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Unlabelled: Adjuvant treatment or filling agents have been recommended for reducing recurrence rates of giant-cell tumors of bone. However, reports of low recurrence rates without either caused us to question this concept. We retrospectively reviewed 193 patients treated during a 27-year period, comparing our results with historic controls. One hundred thirty-seven patients had curettage as a primary treatment, and of these, 26 (19%) had local recurrences. The local recurrence rate of giant-cell tumors confined to bone (Campanacci Grades I and II) was only 7% compared with 29% in tumors with extraosseous extension (Campanacci Grade III). Six patients (4%) had a fracture after curettage. Twenty-nine patients who were referred to us with local recurrences after treatment elsewhere had curettage, and 10 (34%) of these patients had local recurrences develop. Twenty-seven patients had excision as their primary treatment, and two (7%) of these patients had local recurrence develop. We recommend primary curettage for intraosseous giant-cell tumors without adjuvant treatment or filling agents, but tumors with soft tissue extension or with local recurrence require more aggressive treatment., Level of Evidence: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Thirty-four patients with infected massive endoprostheses had two-stage revision procedures to cure the infection and retain a useful functioning limb. An antibiotic impregnated cement spacer constructed with two cement gun liners and a Kuntscher nail provided temporary stability and also allowed a high dose of local antibiotic concentration. In three patients the infection never was controlled, and one of these patients had a successful second revision surgery. Six other patients had reinfection varying from 14 to 92 months after surgery. Risk factors for reinfection were previous radiotherapy and any additional operative intervention. The overall success rate for controlling infection was 91% at 1 year and 74% at 5 years. Six patients required amputation. The mean functional outcome for the retained limbs using the Musculoskeletal Tumor Society scoring system was 77%. Two-stage revisions seem almost as effective at controlling infection in massive endoprostheses as in conventional joint replacements, particularly if additional surgical interventions can be avoided.

Fifty-four patients had endoprosthetic replacement of the proximal femur after resection of primary malignant or aggressive bone tumors. The mean age of the patients was 41 years. The average duration of followup was 9 years (range, 5-24 years). At the time of this review 35 patients are surviving. There were six revisions of the acetabulum and seven revisions of the femoral component. The survivorship of the prostheses without revision was 77% at 10 years falling to 57% at 20 years. There was a 13% risk of amputation and a 1.8% incidence of infection. The mean of the functional scores of the 35 living patients was 83% (range, 60%-97%). This study showed that successful long term results can be obtained with cemented massive endoprostheses despite the incidence of recognized complications including polyethylene wear and aseptic loosening.

Since the inception of the authors' facility, 365 patients with osteogenic sarcoma have been treated. While other facilities were surgically treating patients with primary amputation, this facility attempted limb-salvage surgery. The majority of patients being treated with limb-salvage surgery had the resected bone replaced by a metallic endoprosthetic replacement. The emphasis on conservative surgery led to the development of growing endoprosthetic replacements with the first being used in 1975. The cumulative survival of those patients with Stage 2 osteosarcoma treated at this facility between 1977 and 1984 is 48% at five years.