Santiago A. Lozano Calderon

Background: Pediatric giant cell tumor (GCT) of bone is rare and remains poorly characterized. Skeletally immature patients may demonstrate increased metaphyseal involvement and higher recurrence rates, but existing data are limited to small single-institution series. We evaluated the clinical and surgical characteristics of pediatric GCT and compared recurrence by physeal status. Methods: A retrospective review of patients younger than 19 years of age with histologically confirmed GCT of bone treated surgically at 3 tertiary centers from 1997 to 2022 was performed. Clinical, radiographic, and surgical data, including physeal status, were collected. Local recurrence-free survival (LRFS) was estimated using Kaplan-Meier analysis and compared by physeal status using the log-rank test. Recurrence rates were compared using the Fisher exact test, with significance set at P P =0.50). Preoperative magnetic resonance imaging (MRI) was available in 27 patients, including 15 (56%) with tumors demonstrating bone marrow edema (BME). BME was associated with a higher recurrence (67% vs. 17%; P =0.019). Metastatic disease was rare (5%). LRFS rates at 12, 24, and 60 months were 71.4%, 61.7%, and 52.6%, respectively. Patients with closed physes demonstrated higher LRFS across all time points compared to those with open physes, though these differences did not reach statistical significance. Conclusions: Local recurrence rates were high in pediatric GCT and numerically higher in patients with open physes, although the difference did not reach statistical significance. BME on preoperative MRI was associated with higher recurrence and warrants further study. Individualized treatment and vigilant early surveillance may improve local control while preserving growth potential. Levels of Evidence: Level IV.

Background: Calcific myonecrosis is a benign sequela of limb trauma most commonly affecting the lower leg decades after initial injury. This study aimed to systematically review the literature published on the topic and add another case to the existing body. Methods: A search of the PubMed, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies were assessed for quality, and data on study characteristics, patient information, and outcomes were collected. Results: Forty studies were included in the final review, comprising data from 61 patients with 65 total masses. The mean age at presentation was 63.0 ± 12.5 years with a male predominance (80.3%). Most lesions (n = 56) occurred in the lower leg, and 90% of patients had a prior trauma with average latency of 39.4 ± 15.6 years. Of the 65 masses, 16 were treated non-operatively, 4 with biopsy only, 22 with surgery only, and 23 with biopsy and surgery. Common presenting symptoms were a progressively enlarging (n = 39) or stable (n = 8) mass, pain (n = 22), or infection-associated symptoms (n = 24). The complication rate was 40.7% after biopsy and 28.9% after surgery. Non-operative management was not associated with complications. Conclusions: Nonoperative management is recommended for asymptomatic calcific myonecrosis, and biopsy should be avoided due to high associated complication rate. Further research should aim to build the body of literature on this rare condition to enable high quality statistical analyses in the future.

Background: Soft tissue sarcomas are a heterogeneous group of malignancies with varied clinical outcomes. Existing prognostic calculators do not capture their complete risk profile. Lymphovascular invasion, a well-known adverse prognostic marker in several other cancers, has been proposed as a risk factor in soft tissue sarcoma. However, whether it is associated with outcomes independent of and incremental to established clinicopathologic variables remains unclear. Questions/purposes: (1) Is lymphovascular invasion independently associated with distant metastatic disease, local recurrence, and overall survival? (2) Does lymphovascular invasion improve the classification of patients with distant metastasis beyond established clinicopathologic associated factors? (3) Which clinicopathologic characteristics are associated with the detection of lymphovascular invasion in a resected soft tissue sarcoma specimen? Methods: Between March 1993 and December 2025, subspecialty surgeons at two urban referral centers treated 1196 patients with primary soft tissue sarcomas. The exclusion criteria were as follows: no primary resection (11% [134]), metastatic at presentation (8% [92]), missing follow-up data (7% [84]), ineligible histology (1% [6]), and undocumented lymphovascular invasion status (20% [235]). After applying the inclusion and exclusion criteria, 645 patients were analyzed. Undocumented patients were not found to have worse outcomes than those with known lymphovascular invasion status; nevertheless, two sensitivity analyses were performed. The first analysis coded all missing patients as negative, and the second analysis imputed the lymphovascular invasion status for these patients. The presence of lymphovascular invasion was determined histologically, with 7% (42 of 645) of patients testing positive. We evaluated survivorship using a Kaplan-Meier analysis and identified independently associated factors using multivariable Fine-Gray competing risks regression and Cox proportional hazards testing. The classification performance of adding lymphovascular invasion to a baseline clinicopathologic model was assessed using the Akaike information criterion (AIC), time-dependent area under the curve (AUC), Brier scores, decision curve analysis, and calibration curves. Logistic regression was used to identify characteristics associated with lymphovascular invasion positivity. Results: After controlling for potentially confounding variables such as tumor size, chemotherapy, tumor grade, and positive margins, the presence of lymphovascular invasion was independently associated with distant metastasis (SHR 3.13 [95% confidence interval (CI) 1.88 to 5.21]; p < 0.001). Lymphovascular invasion was not independently associated with increased odds of local recurrence, although an initial association was borderline in the primary cohort (SHR 2.04 [95% CI 1.00 to 4.21]; p = 0.05), this signal was lost after excluding tumor bed excisions (SHR 1.61 [95% CI 0.73 to 3.52]; p = 0.24). Lymphovascular invasion was not independently associated with overall survival (HR 0.77 [95% CI 0.43 to 1.37]; p = 0.37). The model with lymphovascular invasion added an explicit incremental contribution to the classification value using the AIC, time-dependent AUC, and Brier scores, even though the absolute gain in discrimination remains modest. For the time-dependent AUC, at 2 years there was an increase of 3.1% (0.70 to 0.73 [95% CI 0.01 to 0.06]; p = 0.02), and at 5 years there was an increase of 2.3% (0.70 to 0.73 [95% CI 0.001 to 0.04]; p = 0.04) when adding lymphovascular invasion to the baseline model. Leiomyosarcoma histology (OR 7.44 [95% CI 2.90 to 19.1]; p < 0.001) and positive surgical margins (OR 2.54 [95% CI 1.21 to 5.18]; p = 0.01) were independently associated with higher odds of lymphovascular invasion positivity, but liposarcoma histology decreased the odds (OR 0.19 [95% CI 0.03 to 0.68]; p = 0.03). Conclusion: Lymphovascular invasion was independently associated with distant metastatic progression in patients with soft tissue sarcoma. Although the absolute gain in discrimination with the addition of lymphovascular invasion was modest and is not sufficient to guide treatment decisions, we now increase the frequency of chest CT for the first 5 years after surgery among patients with lymphovascular invasion. We believe that the cost-benefit of increased surveillance is justified in this setting, although future studies should evaluate this more formally. In our cohort, lymphovascular invasion was not consistently independently associated with local recurrence and was not associated with survival. These findings support consistent reporting of lymphovascular invasion, further evaluation of its incorporation into soft tissue sarcoma prognostic models to refine early metastatic risk stratification, and more frequent chest CTs for the first 5 years after surgery in patients with lymphovascular invasion. Level of Evidence: Level III, therapeutic study.

Orthopaedic surgeons frequently treat patients on antirheumatic medications for rheumatoid arthritis, psoriatic arthritis, lupus, and other inflammatory conditions. When these patients require surgery, surgeons face competing therapeutic priorities: continuing medications risks impaired wound healing and infection, whereas discontinuing them may trigger disease flares and functional decline. Management decisions are further complicated by inconsistent guidelines and limited data on newer biological therapies. Antirheumatic medications disrupt wound healing at multiple stages,some affect early inflammatory responses, whereas others interfere with collagen remodeling. These wound healing disruptions are especially concerning in high-risk patients, such as those with cancer, where complications can derail overall treatment plans. Current knowledge is largely limited to joint arthroplasty in rheumatoid arthritis patients, leaving notable gaps for other procedures and newer medications. This review addresses these gaps by providing evidence-based guidance for medication timing, dosing adjustments, and monitoring strategies, emphasizing multidisciplinary approaches to optimize surgical outcomes.

Background/Objectives: Staged resection with temporizing vacuum-assisted closure (VAC) has been adopted to facilitate margin assessment and local control of soft tissue sarcomas (STS). Accordingly, the objective of this study is to compare rates of local recurrence (LR) among superficial STS patients treated with and without temporizing VAC therapy. Methods: We conducted a multi-institutional retrospective cohort study of superficial STS patients treated at three tertiary care centers. Patients were matched by grade, and descriptive statistics and multivariate binary logistic regression were performed. Results: After matching, 314 superficial STS patients were included in analysis. VAC patients were more likely to present with a history of prior unplanned excision (p = 0.024), with recurrent disease (p = 0.004), harbor a diagnosis of myxofibrosarcoma (p < 0.001), and have positive initial surgical margins (p < 0.001). After multivariate analysis, VAC use remained independently associated with increased LR rates (OR = 4.117; p = 0.003). Conclusions: In this multi-institutional analysis of superficial STS patients, staged resection with temporizing VAC was not associated with improved LR rates. Rather, the VAC cohort represented distinctly higher-risk tumor biology and complex oncologic presentations, in whom the risk of LR may not be fully mitigated by surgical staging alone.

Aims: Despite the benefits of carbon fiber (CF) implants, concerns over their higher cost relative to titanium implants have limited their broader adoption in orthopaedic oncology. Our study compared the costs and postoperative complications associated with titanium and CF intramedullary nails (IMNs) in patients with femoral bone metastases. Methods: We conducted a retrospective analysis of patients treated with titanium or CF IMNs for impending or completed pathologic femoral fractures due to metastatic bone disease between 2016 and 2023. Inpatient costs, 30-day costs, and 30-day postoperative complications were assessed. Mean and median total, direct, and indirect costs were evaluated using cost units. Propensity-score matching was conducted to minimize potential confounders. Results: After propensity-score matching, we included 91 and 45 patients treated with titanium and CF femur IMNs, respectively. No differences in age, sex, primary tumor, or comorbidity profile were found between groups. Mean and median total costs, direct costs, and indirect costs during the inpatient stay and at 30 days postoperatively were similar between the titanium and CF groups. The mean length of stay was 8 days in both groups ( P = 0.70). Thirty-day complication rates were 25% and 20% in the titanium and CF group, respectively ( P = 0.50). No differences in 30-day readmission (25% in both; P = 0.35), mortality (4% versus 9%; P = 0.29), and revision surgery (1% versus 2%; P = 0.61) rates were observed between the titanium and CF groups. Conclusion: We found comparable inpatient costs, 30-day costs, and short-term postoperative complications between titanium and CF IMNs for impending or completed pathologic femoral fractures. Level of Evidence: III

Background: Local recurrence remains the main challenge in the surgical management of myxofibrosarcoma (MFS), due to its infiltrative growth pattern and difficulty achieving clear margins. Wound VAC temporization has been proposed to address this by deferring reconstruction until definitive margin status is confirmed, though supporting evidence derives from small cohorts.Methods: In our retrospective cohort study, across two tertiary sarcoma referral centers, we included 113 patients with suprafascial MFS of the extremities or trunk treated with surgery and external beam radiotherapy between 2000 and 2024. Patients underwent either single-stage resection with immediate reconstruction (n = 69) or VAC temporization pending permanent margin confirmation (n = 44). The primary outcome was local recurrence, confirmed clinically or radiologically. Local recurrence-free survival was analyzed using the Kaplan-Meier method, with a pre-specified sensitivity analysis restricted to patients undergoing primary surgery (n = 55) and stratification by radiotherapy timing.Findings: VAC temporization was associated with significantly fewer positive margins (4.5% vs. 21.7%; p = 0.01). Two-year local recurrence-free survival was 100% versus 91.2% (log-rank p = 0.05). In the primary surgery subgroup, local recurrence rates were 0% versus 21.6% (p = 0.043), with the greatest difference in patients receiving postoperative radiotherapy (0% vs. 45.5%; p = 0.007). Complications, distant metastasis, and mortality did not differ between groups.Interpretation: VAC temporization was associated with lower local recurrence and higher rates of negative margins, particularly in primary surgery with postoperative radiotherapy. These findings suggest that margin clearance before definitive reconstruction may be a prerequisite for adjuvant radiotherapy to achieve its intended local control effect. Prospective studies are warranted.