Elastic intramedullary nailing and DBM-Bone marrow injection for the treatment of simple bone cysts

<p>Abstract</p> <p>Background</p> <p>Simple or unicameral bone cysts are common benign fluid-filled lesions usually located at the long bones of children before skeletal maturity.</p> <p>Methods</p> <p>We performed demineralized bone matrix and iliac crest bone marrow injection combined with elastic intramedullary nailing for the treatment of simple bone cysts in long bones of 9 children with a mean age of 12.6 years (range, 4 to 15 years).</p> <p>Results</p> <p>Two of the 9 patients presented with a pathological fracture. Three patients had been referred after the failure of previous treatments. Four patients had large lesions with impending pathological fractures that interfered with daily living activities. We employed a ratio to ascertain the severity of the lesion. The extent of the lesion on the longitudinal axis was divided with the normal expected diameter of the long bone at the site of the lesion. The mean follow-up was 77 months (range, 5 to 8 years). All patients were pain free and had full range of motion of the adjacent joints at 6 weeks postoperatively. Review radiographs showed that all 7 cysts had consolidated completely (Neer stage I) and 2 cysts had consolidated partially (Neer stage II). Until the latest examination there was no evidence of fracture or re-fracture.</p> <p>Conclusion</p> <p>Elastic intramedullary nailing has the twofold benefits of continuous cyst decompression, and early immediate stability to the involved bone segment, which permits early mobilization and return to the normal activities of the pre-teen patients.</p

Wear debris pseudotumor following total knee arthroplasty: a case report

<p>Abstract</p> <p>Introduction</p> <p>In patients who have undergone a total joint replacement, any mass occurring in or adjacent to the joint needs thorough investigation and a wear debris-induced cyst should be suspected.</p> <p>Case presentation</p> <p>An 81-year-old man presented with a painful and enlarging mass at the popliteal fossa and calf of his right knee. He had had a total right knee replacement seven years previously. Plain radiographs showed narrowing of the medial compartment. Magnetic resonance imaging showed a cystic lesion at the postero-medial aspect of the knee joint mimicking popliteal cyst or soft tissue sarcoma. Fine needle aspiration was non-diagnostic. A core-needle biopsy showed metallosis. Intraoperative findings revealed massive metallosis related to extensive polyethylene wear, delamination and deformation. Revision knee and patella arthroplasty was carried out after a thorough debridement of the knee joint.</p> <p>Conclusion</p> <p>Long-term follow-up is critical for patients with total joint replacement for early detection of occult polyethylene wear and prosthesis loosening. In these cases, revision arthroplasty may provide a satisfactory knee function.</p

Spinal Infections: An Update

Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. The most common route for spinal infection is through hematogenous spread of the microorganism from a distant infected area. Most patients with spinal infections diagnosed in early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. In either case, close monitoring of the patients with spinal infection with serial neurological examinations and imaging studies is necessary

Immunohistochemical evaluation of bone metastases

  Introduction. Metastases are the most common type of malignancy involving the bone, while bone is the third most frequent site for metastases, after the lung and liver. In some patients, medical history, physical and laboratory exami­nation are not conclusive to identify the primary tumor site. In such cases a bone biopsy and immunohistochemical analysis may contribute to the diagnosis, determination of appropriate treatment and evaluation of prognosis. In this study, we tried to evaluate the imunochistochemical expression in bone metastases. Material and methods. We reviewed 125 patients, with a mean age of 63 years, treated for bone metastases in our institution. All patients received palliative orthopaedic surgery for bone metastatic carcinoma. Fifty-eight patients had already an established diagnosis of the primary tumor, while 67 patients presented metastases with an unknown primary tumor origin. Immunohistochemical analysis was performed to intra-operative bone biopsy specimens. The expression of cytokeratine 7, cytokeratin 20 and the expression of a panel of other organ-specific markers were re­corded. In patients with a known primary tumor, we examined the relationship between the origin of metastases, as suggested by the cytokeratin phenotype, compared with the one indicated by the initial histological diagnosis. We also recorded the efficacy of organ-specific markers to identify the primary tumor origin in epithelial bone metastases and we evaluated the prognosis between patients with a immunohistologically determined primary tumor origin, with those with an undetermined one. Results. Associations of cytokeratine 7 and cytokeratine 20 expression confirmed diagnosis in 51 out of the 58 patients (88%) with a known primary tumor (Cohen’s K test 0.79 SE 0.80, P &lt; 0.0005). Immunohistochemical analysis also contributed to establish the diagnosis of patients with an unknown primary tumor, yielding diagnosis in 35 out of the 67 cases (52%). Patients with an immunochistologically undetermined primary tumor site presented a statisti­cally significant poorer prognosis. Conclusions. Cytokeratine 7 and cytokeratine20 are useful immunochistochemical markers in determining a pre­liminary evaluation of bone metastases. Organ-specific immunohistochemical markers have a reliable role in either suggesting or confirming the possible origin of metastases. An indeterminate immunohistochemical phenotype seems to relate to a less differentiated lesion, with a worse prognosis

Arthroplasty versus internal fixation for femoral neck fractures in the elderly

We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60–80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time

Current trends in the management of extra-abdominal desmoid tumours

Extra-abdominal desmoid tumours are slow-growing, histologically benign tumours of fibroblastic origin with variable biologic behaviour. They are locally aggressive and invasive to surrounding anatomic structures. Magnetic resonance imaging is the modality of choice for the diagnosis and the evaluation of the tumours. Current management of desmoids involves a multidisciplinary approach. Wide margin surgical resection remains the main treatment modality for local control of the tumour. Amputation should not be the initial treatment, and function-preserving procedures should be the primary treatment goal. Adjuvant radiation therapy is recommended both for primary and recurrent lesions. Chemotherapy may be used for recurrent or unresectable disease. Overall local recurrence rates vary and depend on patient's age, tumour location and margins at resection

Chondrosarcoma of the Chest Wall: A Review of 53 Cases from Two Institutions

Background/Aim: Chondrosarcomas (CS) of the chest wall are rare, but present an aggressive biological behavior compared to CS of the extremities. The aims of the present study were to determine factors associated with oncological outcomes as well as complications. Patients and Methods: We retrospectively analyzed 53 patients (42 primary, 11 recurrent tumors). In total, 39 central CS, 10 peripheral CS, 3 dedifferentiated CS and 1 mesenchymal CS were included. The ribs were most commonly affected (68%). Overall survival and disease-free survival were estimated with Kaplan-Meier analyses and compared with log-rank test. Results: Mean follow-up was 7 years. Negative margins were achieved in 87% of patients. Thirty patients (57%) remained continuously disease-free (NED), three (5%) NED after treatment of relapse, seven (13%) were alive with disease, twelve (23%) were dead with disease and one of other cause. The 10-year survival rate was 81% and 45% in primary and recurrent tumors, respectively. Survival was significantly affected by tumor stage (p<0.001), local recurrence (p=0.025) and metastases (p=0.002). Six complications (16%) were observed. Conclusion: The outcome is rather poor, especially in patients with local recurrence. Presumably due to a high biological aggressiveness, a stricter definition of surgical margins should be considered for this location

A classification method for neurogenic heterotopic ossification of the hip

Background: Existing classifications for heterotopic ossification (HO) do not include all HO types; nor do they consider the anatomy of the involved joint or the neurological injury. Therefore, we performed this study to propose and evaluate a classification according to the location of neurogenic HO and the neurological injury. Materials and methods: We studied the files of 24 patients/33 hips with brain or spinal cord injury and neurogenic HO of the hip treated with excision, indomethacin, and radiation therapy. We classified patients according to the Brooker classification scheme as well as ours. Four types of neurogenic HO were distinguished according to the anatomical location of HO: type 1, anterior; type 2, posterior; type 3, anteromedial; type 4, circumferential. Subtypes of each type were added based on the neurological injury: a, spinal cord; b, brain injury. Mean follow-up was 2.5 years (1-8 years). Results: The Brooker classification scheme was misleading - all hips were class III or IV, corresponding to ankylosis, even though only 14 hips had ankylosis. On the other hand, our classification was straightforward and easy to assign in all cases. It corresponded better to the location of the heterotopic bone, and allowed for preoperative planning of the appropriate surgical approach and evaluation of the prognosis; recurrence of neurogenic HO was significantly higher in patients with brain injury (subtype b), while blood loss was higher for patients with anteromedial (type 3) and circumferential (type 4) neurogenic HO. Conclusions: Our proposed classification may improve the management and evaluation of the prognosis for patients with neurogenic HO