Impact of unplanned excision on prognosis of patients with extremity soft tissue sarcoma

Unplanned excision of soft tissue sarcomas (STSs) outside comprehensive tumor management centers necessitates the need for wide reexcision to achieve adequate margins. We retrospectively reviewed medical records of 135 patients with STS operated at our hospital with the goal of examining outcomes, in terms of local recurrence (LR) and metastasis rate (MR), of reexcision following unplanned excision of STS and comparing results with those of first-time planned surgery. Eighty-four patients had their first-time surgery and 51 patients had come to us following unplanned excision at prereferral hospital. Mean age of all patients was 41.8 ± 21.9 years. The LR and MR was 14.3% and 8.3%, respectively, in patients undergoing first resection, whereas it was 21.4% and 13.7%, respectively, in patients undergoing revision surgery. Average duration from previous unplanned excision was 8 months. Twelve patients were referred immediately after excised specimen revealed STS, while 39 patients presented after evident local recurrence. Wide reexcision was attempted in 48 patients while three patients need amputation. Adjuvant radiotherapy was administered in all patients undergoing limb-sparing surgery. Ten patients needed adjuvant chemotherapy.We conclude that wide reexcision of STS has poorer outcomes compared to planned excision. Therefore, patients with soft tissue masses should be managed by multidisciplinary oncology team at specialized cancer centers

Arthroscopic repair of meniscal tears with inside-out technique

Objective: To review the clinical results of arthroscopic meniscal repair and to identify factors that may affect the outcome. Methods: A total of 15 arthroscopic meniscal repairs with inside-out in 14 patients over a 7-year period were evaluated retrospectively. The mean age was 41.2 +/- 11.5 years with a range of 26-64 years. Eleven patients underwent repair for medial meniscal tear, two patients for lateral meniscus and one patient for both in the same knee. All patients were functionally evaluated by Lysholm functional knee scores over an average follow-up of 1 year and 5 months (range: 0.5-7 years). Results: The mean Lysholm score was 84 out of a maximum of 100. Functional outcome was excellent in 6 patients, good in 5, fair in 2 and poor in one patient. The patient with poor outcome was young with a chronic tear; she had concomitant ipsi-lateral radiculopathy and also had signs of reflex sympathetic dystrophy. One 64 year old patient with fair outcome developed a post-operative flexion contracture of 15 degrees. She also had moderate osteoarthritis of the medial compartment. One patient developed saphenous nerve neuralgia which was relieved spontaneously after a few months. Conclusion: All patients with excellent results were relatively younger with an acute tear. Elderly patients with concomitant osteoarthritis of the knee joint did not have a satisfactory outcome even if the tear was acute

Single stage oncologic resection and reconstruction: A step toward development of sarcoma service in resource constrained country

Tumor free-margin surgical resection remains the single most important treatment in the curative therapy of musculoskeletal tumor of limbs. Refinements in surgical techniques have led to increased function preservation and limb salvage. Patients and Methods: The records of patients (n = 24) who underwent microsurgical soft tissue reconstruction subsequent to resection of limb tumour during the period 2006 to 2011 were reviewed. Primary outcome i.e. uptake of the flap was evaluated. Perioperative morbidities were also noted including donor as well as recipient site complications. Assessment of Functional outcome (Musculoskeletal Tumor Society score, MSTS) local recurrence, free survival, and disease-specific survival was also made. Results: Twenty four patients (age range: 7 - 72 years) who have undergone tumor resection followed by flap coverage were identified. Lower limb reconstruction outnumbered upper limb by 6:1. Complications included, one complete failure of free vascularized iliac crest flap done for reconstruction of a heel defect. One of the patients had secondary hemorrhage 10 days after surgery. Another patient with internal hemipelvectomy for Ewing’s sarcoma had a dura puncture during resection of sacrum. Partial epidermal necrosis was evident in four cases. Eighty three percent of the patients remained alive (n = 20), 19 of whom currently have no evidence of disease (NED) Disease recurrence was noted in three patients. Overall MSTS score was 73.5%. Conclusion: The microsurgical repair of defects is a reliable option that, though not free of complications, is necessary in selected cases. The procedure enables both adequate oncosurgical resection and function preservation

Effect of early release of tourniquet in total knee arthroplasty

Objective: To evaluate whether tourniquet release intraoperatively is better than postoperative release in reducing overall blood loss, duration of surgery, duration of tourniquet, length of hospital stay, wound related complications and transfusion requirement. Study Design: Comparative study. Place and Duration of Study: Department of Surgery, The Aga Khan University Hospital, Karachi, from January 2004 to June 2007. Methodology: One hundred and thirty patient files were reviewed retrospectively. Patients were divided into two groups. Group-A consisted of 65 patients with early deflation of tourniquet and group-B comprised of 65 patients with the release of tourniquet after applying compressive dressing. Total blood loss (determined by Gross method) and other study variables were noted as per objective and computed.Results: There were 22 males and 108 females with comparable BMI. All had undergone posterior stabilized cemented total knee replacement. Calculated blood loss was 1.208 L and 1.108 L in group-A and B respectively (p = 0.27). Significant increase in duration of surgery was noted in group-A patients. Four patients in group-B showed complication related to wound with 3 being minor and 1 requiring additional operation room visit. Mean length of hospital stay was 9 days. Transfusion frequency was higher in group-B despite comparable postoperative haemoglobin values. Conclusion: Intraoperative tourniquet release does not reduce overall blood loss with no effect in conserving blood after total knee replacement, however, this group had relatively shorter hospital stay

Complex biological reconstruction after wide excision of osteogenic sarcoma in lower extremities

Wide margin resection of extremity tumor sometimes leaves a huge soft tissue and bony defects in limb salvage surgery. Adequate management of these defects is an absolute requirement when aiming for functional limb. Multidisciplinary management in such cases is an answer when complex biologic reconstruction is desired. We aim to present cases of osteogenic sarcoma of lower extremity requiring combined surgical approach to achieve effective musculoskeletal reconstruction. Patients and Methods. From 2006 to 2010 ten patients were operated on for osteogenic sarcoma of lower extremity requiring complex musculoskeletal reconstruction. Results. Six patients had pathology around knee joint, whereas one each with mid tibia, mid femur, proximal femur, and heel bone. Locking compression plate was used in 7 patients including six with periarticular disease. Eight out of ten patients underwent biologic reconstruction using autograft; endoprosthetic reconstruction and hindquarter amputation were done in the remaining two patients. Vascularized fibula was done in five patients, sural artery flap which was primarily done in three patients, spare part fillet flap, free iliac crest flap, and Gastrocnemius flap was done in one patient each. Secondary hemorrhage, infection, nonunion, wound dehiscence, and flap failure were notable complications in four patients. The Average Musculoskeletal Tumor Society score was 89%. Conclusion. Combined surgical approach results in cosmetically acceptable and functional limb

Managing soft tissue sarcomas in a developing country: Are prognostic factors similar to those of developed world?

Background: Managing soft tissue sarcomas (STS) in a developing country with limited financial resources and a poor health referral system is a challenge. Presenting late, these extremity STS are prone to recurrence despite apparently complete resection. This study aimed to explore and compare the impact of clinico-pathological factors on recurrence and survival in Pakistan with the corresponding figures quoted from the developed world. Methods: An institutional review was performed on all patients with primary STS of the extremities operated on between 1994 and 2008. The prognostic influence of clinical, pathologic, and treatment variables on local recurrence free survival (LRFS), metastasis free survival (MFS) and overall survival (OS) were analyzed by univariate and multivariate Cox regression analysis and Kaplan Meier survival curves. Results: A total of 84 patients with a mean age of 41.8 ± 21.9 years were included in the study. The local recurrence rate was 14.3% after a median of 6 (mean 7.4) months. Metastases occurred in 7 patients (8.3%) and 65 patients were alive without evidence of disease after a mean follow-up of 52.6 ± 39.8 months. Tumor size \u3e 5 cm, grade 3 tumors and margin \u3c 10 mm significantly increased local recurrence rates. A margin ≥ 10 mm and age \u3c 45 years significantly enhanced cumulative survival. Significant multivariate risk factors for metastases were margin \u3c 10 mm and tumor grade G3. Conclusions: Despite a poor health referral system in our country, our results are no different from those reported from the developed world. Surgical margins and tumor grade prognostically influenced LRFS, MFS and OS

Predictors of length of hospital stay after total hip replacement

Purpose: To identify variables affecting length of hospital stay after total hip replacement (THR) while controlling for potential confounders. Methods: Records of 199 consecutive elective unilateral THRs were reviewed. Clinical and demographic data including age, gender, body mass index, comorbidities, surgical factors (surgical approach, type of prosthesis, use of cement, operating time), anaesthetic factors (type of anaesthesia, ASA physical status), and length of hospital stay were recorded. Results: 64% of Patients left hospital within 12 days, 28% within 3 weeks, and 8% after 3 weeks. The median length of hospital stay was longer in women than men (11.5 vs. 9 days, p=0.009), in Patients aged \u3e65 years than those younger (13 vs. 9 days, p65 years than those younger (61% vs. 37% or 24%, p65 years (pConclusions: Prolonged hospital stay after THR is largely predetermined by case mix. Our study helps to identify individuals who need longer rehabilitation and more care

First successful autologous chondrocyte implantation in Pakistan

Osteochondritis dissecans entails a hyaline cartilage defect of the articular surface causing pain and functional restriction in young adults, sometimes resulting in early degenerative arthritis. Conventional treatment methods such as abrasion chondroplasty and mosaicplasty have limitations in terms of quality of the resultant cartilage and donor site morbidity. A more recent technique, autologous chondrocyte implantation (ACI) results in hyaline cartilage formation and gives good long-term outcome, but requires a high-level cell culture facility and two surgical procedures. The patient was a young female with knee pain, intermittent locking and feeling of joint mouse . MRI scan and arthroscopy showed a 2 x 2 cm full thickness osteochondral defect in the medial femoral condyle. A free fragment of articular cartilage was found, which was extracted arthroscopically, and chondrocytes were cultured from it in the Juma laboratory. Subsequently, patient underwent surgery whereby the chondrocytes were injected under a periosteal patch sewn over the defect. Over six months, patient\u27s symptoms completely resolved and she returned to full function. A repeat arthroscopy after one year revealed complete filling of the previous defect with normal appearing cartilage indicating success of the procedure. This technology can be utilized for treating patients with a variety of conditions affecting hyaline cartilage of joints

Complications of total hip replacement

Objective: To determine the factors causing complications in unilateral total hip replacement. Study Design: Analytical study. Place and Duration of Study: The Aga Khan University Hospital, Karachi, between 2000 and 2010. Methodology: During the study period, 199 patients underwent elective unilateral total hip replacement at the Aga Khan University Hospital. Patients were divided into two groups on the basis of postoperative complications within 30 days of surgery. Significant factors at 5% significance level on univariate analysis were further analyzed by multivariate logistic regression. Results: Postoperative complications occurred in 39 patients (19.6%); dislocation being most common in 13 patients (6.5%), followed by wound infection in four (2%), all of these patients required intervention. Other minor complications which were managed conservatively included wound infection (2.5%), urinary tract infection (2.5%), dislocation (1%), pleural effusion and pneumonia (2%), deep venous thrombosis (0.5%) and myocardial infarction (0.5%). On univariate analysis, patients with ASA III and IV, peri-operative blood transfusion, pre-operative hip deformity and post-operative bisphosphonate use were significantly associated with complications. On multi-variate analysis, adjusted odd\u27s ratio for perioperative transfusion (3; 95% CI: 1.17-7.7) and hip deformity (3.2, 95% CI: 1.4-3.4) was found statistically significant. Conclusion: Pre-operative hip deformity and perioperative blood transfusion significantly influence the rates of complication after unilateral THR

Morphology of the proximal femur in a Pakistani population

Purpose: To measure the morphology of the proximal femur in a Pakistani population. Methods: Standardised anteroposterior pelvic radiographs of 116 male and 20 female healthy volunteers aged 20 to 50 (mean, 33) years were taken. Morphologic dimensions of the proximal femur were measured, including canal flare index (CFI), morphological cortical index (MCI), femoral head offset, femoral head diameter, and femoral head position. Results: Based on the CFI, 67% of the subjects had normal canal shapes (CFI, 3.0-4.7), whereas 1% and 33% of the subjects had stovepipe shapes (CFI,2.7). Conclusions: Morphology of the proximal femur in our study population differed significantly from those in western populations, indicating regional variation. It could also be due to the younger age of our population