Elastic Stable Intramedullary Nailing (ESIN), Orthoss® and Gravitational Platelet Separation - System (GPS®): An effective method of treatment for pathologic fractures of bone cysts in children

<p>Abstract</p> <p>Background</p> <p>The different treatment strategies for bone cysts in children are often associated with persistence and high recurrence rates of the lesions. The safety and clinical outcomes of a combined mechanical and biological treatment with elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma are evaluated.</p> <p>Methods</p> <p>From 02/07 to 01/09 we offered all children with bone cysts the treatment combination of elastic intramedullary nailing (ESIN), artificial bone substitute (Orthoss^®) and autologous platelet rich plasma, concentrated by the Gravitational Platelet Separation (GPS^®) - System. All patients were reviewed radiologically for one year following the removal of the intramedullary nailing, which was possible because of cyst obliteration.</p> <p>Results</p> <p>A cohort of 12 children (4 girls, 8 boys) was recruited. The mean patient age was 11.4 years (range 7-15 years). The bone defects (ten humeral, two femoral) included eight juvenile and four aneurysmal bone cysts. Five patients suffered from persistent cysts following earlier unsuccessful treatment of humeral bone cyst after pathologic fracture; the other seven presented with acute pathologic fractures. No peri- or postoperative complications occurred. The radiographic findings showed a total resolution of the cysts in ten cases (Capanna Grade 1); in two cases a small residual cyst remained (Capanna Grade 2). The intramedullary nails were removed six to twelve months (mean 7.7) after the operation; in one case, a fourteen year old boy (Capanna Grade 2), required a further application of GPS^®and Orthoss^®to reach a total resolution of the cyst. At follow-up (20-41 months, mean 31.8 months) all patients showed very good functional results and had returned to sporting activity. No refracture occurred, no further procedure was necessary.</p> <p>Conclusions</p> <p>The combination of elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma (GPS^®) enhances the treatment of bone cysts in children, with no resulting complications.</p

Navigation in pelvic tumour surgery

Computer-assisted surgery (CAS) is the term used to describe a relatively new concept of application of computers to enable pre-operative planning and provide continuous intraoperative orientation, instrument feedback and guidance. This concept enables surgeons to objectify the spatial position of anatomical locations, instruments or implants.</p

Computer-assisted and patient-specific 3-D planning and evaluation of a single-cut rotational osteotomy for complex long-bone deformities

Malunion after long bone fracture results in an incorrect position of the distal bone segment. This misalignment may lead to reduced function of the limb, early osteoarthritis and chronic pain. An established treatment option is a corrective osteotomy. For complex malunions, a single-cut rotational osteotomy is sometimes preferred in cases of angular deformity in three dimensions. However, planning and performing this type of osteotomy is relatively complex. This report describes a computer-assisted method for 3-D planning and realizing a single-cut rotational osteotomy with a patient-specific cutting guide for orienting the osteotomy and an angled jig for adjusting the rotation angle. The accuracy and reproducibility of the method is evaluated experimentally using plastic bones. In addition, complex rotational deformities are simulated by a computer to investigate the relation between deformity and correction parameters. The computed relation between deformity and correction parameters enables the surgeon to judge the feasibility of a single-cut rotational osteotomy. This appears possible for deformities combining axial misalignment with sufficient axial rotation. The proposed 3-D method of preoperative planning and transfer with a patient-specific cutting guide and angled jig renders the osteotomy procedure easily applicable, accurate, reproducible, and is a good alternative for complex and expensive navigation systems

Mid- and long-term clinical results of surgical therapy in unicameral bone cysts

<p>Abstract</p> <p>Background</p> <p>Unicameral (or simple) bone cysts (UBC) are benign tumours most often located in long bones of children and adolescents. Pathological fractures are common, and due to high recurrence rates, these lesions remain a challenge to treat. Numerous surgical procedures have been proposed, but there is no general consensus of the ideal treatment. The aim of this investigation therefore was to study the long-term outcome after surgical treatment in UBC.</p> <p>Methods</p> <p>A retrospective analysis of 46 patients surgically treated for UBC was performed for short and mid-term outcome. Clinical and radiological outcome parameters were studied according to a modified Neer classification system. Long-term clinical information was retrieved via a questionnaire at a minimum follow-up of 10 years after surgery.</p> <p>Results</p> <p>Forty-six patients (17 female, 29 male) with a mean age of 10.0 ± 4.8 years and with histopathologically confirmed diagnosis of UBC were included. Pathological fractures were observed in 21 cases (46%). All patients underwent surgery for UBC (35 patients underwent curettage and bone grafting as a primary therapy, 4 curettage alone, 3 received corticoid instillation and 4 decompression by cannulated screws). Overall recurrence rate after the first surgical treatment was 39% (18/46), second (17.4% of all patients) and third recurrence (4.3%) were frequently observed and were addressed by revision surgery. Recurrence was significantly higher in young and in male patients as well as in active cysts. After a mean of 52 months, 40 out of 46 cysts were considered healed. Prognosis was significantly better when recurrence was observed later than 30 months after therapy. After a mean follow-up of 15.5 ± 6.2 years, 40 patients acknowledged clinically excellent results, while five reported mild and casual pain. Only one patient reported a mild limitation of range of motion.</p> <p>Conclusions</p> <p>Our results suggest satisfactory overall long-term outcome for the surgical treatment of UBC, although short-and mid-term observation show a considerable rate of recurrence independent of the surgical technique.</p

Pathogenesis of adolescent idiopathic scoliosis in girls - a double neuro-osseous theory involving disharmony between two nervous systems, somatic and autonomic expressed in the spine and trunk: possible dependency on sympathetic nervous system and hormones with implications for medical therapy

Anthropometric data from three groups of adolescent girls - preoperative adolescent idiopathic scoliosis (AIS), screened for scoliosis and normals were analysed by comparing skeletal data between higher and lower body mass index subsets. Unexpected findings for each of skeletal maturation, asymmetries and overgrowth are not explained by prevailing theories of AIS pathogenesis. A speculative pathogenetic theory for girls is formulated after surveying evidence including: (1) the thoracospinal concept for right thoracic AIS in girls; (2) the new neuroskeletal biology relating the sympathetic nervous system to bone formation/resorption and bone growth; (3) white adipose tissue storing triglycerides and the adiposity hormone leptin which functions as satiety hormone and sentinel of energy balance to the hypothalamus for long-term adiposity; and (4) central leptin resistance in obesity and possibly in healthy females. The new theory states that AIS in girls results from developmental disharmony expressed in spine and trunk between autonomic and somatic nervous systems. The autonomic component of this double neuro-osseous theory for AIS pathogenesis in girls involves selectively increased sensitivity of the hypothalamus to circulating leptin (genetically-determined up-regulation possibly involving inhibitory or sensitizing intracellular molecules, such as SOC3, PTP-1B and SH2B1 respectively), with asymmetry as an adverse response (hormesis); this asymmetry is routed bilaterally via the sympathetic nervous system to the growing axial skeleton where it may initiate the scoliosis deformity (leptin-hypothalamic-sympathetic nervous system concept = LHS concept). In some younger preoperative AIS girls, the hypothalamic up-regulation to circulating leptin also involves the somatotropic (growth hormone/IGF) axis which exaggerates the sympathetically-induced asymmetric skeletal effects and contributes to curve progression, a concept with therapeutic implications. In the somatic nervous system, dysfunction of a postural mechanism involving the CNS body schema fails to control, or may induce, the spinal deformity of AIS in girls (escalator concept). Biomechanical factors affecting ribs and/or vertebrae and spinal cord during growth may localize AIS to the thoracic spine and contribute to sagittal spinal shape alterations. The developmental disharmony in spine and trunk is compounded by any osteopenia, biomechanical spinal growth modulation, disc degeneration and platelet calmodulin dysfunction. Methods for testing the theory are outlined. Implications are discussed for neuroendocrine dysfunctions, osteopontin, sympathoactivation, medical therapy, Rett and Prader-Willi syndromes, infantile idiopathic scoliosis, and human evolution. AIS pathogenesis in girls is predicated on two putative normal mechanisms involved in trunk growth, each acquired in evolution and unique to humans

Histology can be predictive of the clinical course of a primary aneurysmal bone cyst.

INTRODUCTION: Aneurysmal bone cyst is a benign lesion occurring in young patients which frequently recurs after treatment. Biopsy is mandatory for the diagnosis of a putative aneurysmal bone cyst as this lesion can be secondary to another underlying process including a malignant bone tumour. The histopathological features of aneurysmal bone cysts have been examined with the goal of finding relevant criteria for predicting favourable evolution or recurrence of the disease. PATIENTS AND METHODS: Twenty-one biopsies of surgically treated aneurysmal bone cysts, from 21 patients, were analysed. Histomorphometry by two different methods (3,000- and 200-point-counting) and by two observers was performed to quantify the percentage of each tissue type in the cyst (cellular, fibrillar, osteoid). A healing index was developed by calculating a ratio of osteoid and fibrillar material divided by cellular tissue. Biopsies were also examined using two immunostains, cluster of differentiation 68 (CD68) and proliferating cell nuclear antigen (PCNA). RESULTS: The final outcome was healing for 16 aneurysmal bone cysts (healing group) and recurrence for the five others (recurrence group), after a mean follow-up of 4.43 years. The two groups differed significantly in the proportion of their cellular content and their healing index. The ratio of CD68 negative to CD68 positive cells was also significantly different between the two groups. CONCLUSION: Biopsy should be considered as a helpful prognostic factor for aneurysmal bone cyst