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Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour. The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195). In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients. In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%). VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Purpose: Elderly patients with bone cancer are thought to have poorer access to specialist treatment and therefore suboptimal outcome. The aim of this study was to review the clinical course, outcome and survivorship in geriatric patients with primary bone tumours., Methods: We analysed 66 consecutive patients aged 60 years or older who were surgically treated for primary bone tumours between 1997 and 2012. The cohort was divided into two groups: elderly (60-70 years, n = 31) and very elderly (>70 years, n = 35). Clinicopathologic characteristics, treatment, outcome and survival were analysed. The mean follow up was 58.5 months (range two to 188)., Results: There were 51 chondrosarcomas (grade I, n = 29; grade II, n = 15; grade III, n = 7), ten osteosarcomas and four of other primary malignant bone tumours. Twenty-three prostheses for joint reconstruction were implanted; procedures involving the transposition of free vascularised flaps were performed in six patients. Seven patients had amputation as a primary procedure, four in the elderly and three in the very elderly group. Local recurrence was recorded in eight cases (12.1%). Secondary surgery was performed in nine (13.6%) patients (six recurrences, two haematomas, one deep infection). At final follow up, 77.3% of patients were alive (elderly 83.9%, very elderly 71.4%) and there was no significant difference in the five-year survival rates between both groups., Conclusions: Elderly and very elderly patients with bone tumours receive satisfactory treatment and achieve good surgical outcome. Treatment decisions in the geriatric population should not be influenced by age alone.

The surgical treatment of upper limb sarcoma poses an oncological and reconstructive challenge. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of all important structures to retain maximum function. Reported here is an assessment of the functional and oncological outcomes of limb salvage surgery for primary sarcoma of the upper limb and limb girdle in 72 patients referred to a specialist musculoskeletal tumour unit over 9 years. All patients underwent excision of the sarcoma with reconstruction and adjuvant treatment as needed. Functional outcome was assessed using the Toronto Extremity Salvage Score (TESS) after discharge from hospital. The upper limb sarcomas treated by limb-salvage surgery achieved planned margins of excision in 85% of cases with primary surgery. This increased to 100% with re-excision, resulting in local recurrence in 15% and survival of 75% among those at 5 years or more after surgery, while retaining good to excellent function (TESS mean of 87 out of 100). A total of 38 patients completed TESS questionnaires and, as a single group, had a mean TESS of 87. Patient age, anatomical site of tumour and adjuvant treatment made no significant difference to TESS. Liposarcomas had a significantly better TESS than leiomyosarcomas, chondrosarcomas and malignant peripheral nerve sheath tumours. Oncological outcome was assessed in terms of excision margins achieved, local recurrence, re-excision and disease-free survival. Eight patients died of disease, all with high-grade primary tumours. Fourteen had local recurrence, four low-grade disease and the remaining high-grade disease. All four low-grade recurrences were successfully re-excised, as were five of the high-grade recurrences. The remaining five died of disease, with or without further recurrences. Consistently good functional results as measured by TESS were reported by responders, but high-grade disease and early recurrence were identified as predictors of recurrence and death from disease, respectively.

Cellular mechanisms that account for tumour osteolysis associated with Ewing's sarcoma are uncertain. Osteoclasts are marrow-derived multinucleated cells (MNCs) that effect tumour osteolysis. Osteoclasts are known to form from macrophages by both receptor activator for nuclear factor-kappaB (RANK) ligand (RANKL)-dependent and -independent mechanisms. In this study, our aim has been to determine whether tumour-associated macrophages (TAMs) isolated from Ewing's sarcoma are capable of differentiating into osteoclasts and to characterise the cellular and humoral mechanisms whereby this occurs. Tumour-associated macrophages were isolated from two Ewing's sarcomas and cultured on both coverslips and dentine slices for up to 21 days with soluble RANKL and macrophage colony stimulating factor (M-CSF). Osteoclast formation from TAMs (CD14+) was evidenced by the formation of tartrate-resistant acid phosphatase (TRAP) and vitronectin receptor (VNR)-positive MNCs, which were capable of carrying out lacunar resorption. This osteoclast formation was inhibited by the addition of bisphosphonates. Both Ewing's sarcoma-derived fibroblasts and some bone stromal cells expressed RANKL and supported osteoclast formation by a contact-dependent mechanism. We also found that osteoclast differentiation occurred when Ewing's TAMs were cultured with tumour necrosis factor (TNF)-alpha in the presence of M-CSF and that TC71 Ewing's sarcoma cells stimulated osteoclast formation through the release of a soluble factor, the action of which was abolished by an antibody to TNF-alpha. These results indicate that TAMs in Ewing's sarcoma are capable of osteoclast differentiation by both RANKL-dependent and TNF-alpha-dependent mechanisms and that Ewing's sarcoma cells produce osteoclastogenic factor(s). Our findings suggest that anti-resorptive and anti-osteoclastogenic therapies may be useful in inhibiting the osteolysis of Ewing's sarcoma.

Osteocartilaginous metaplasia is known to occur rarely in melanomas, particularly in subungual melanomas. We present a case of a calcified subungual soft tissue tumour in which biopsy of the lesion showed malignant round and spindle-shaped tumour cells, many of which were associated with the formation of cartilage and osteoid-like material. Subsequent resection showed clear histological evidence of a subungual melanoma. Tumour cells expressed S100, melan-A and neurone-specific enolase but were negative for HMB45. Diagnostic radiological and histological features and the nature of the osteocartilaginous differentiation within this lesion is discussed.