Resection of thumb metacarpal Ewing Sarcoma and primary reconstruction with non-Vascularized osteoarticular metatarsal autograft

Ewing sarcoma is a primary bone malignancy that rarely occurs in the hand. Resection and reconstruction will usually result in reduced or loss of thumb function. We describe a case of successful transplantation of non- vascularized osteoarticular second metatarsal autograft following wide resection of Ewing sarcoma of first metacarpal in an 11-year-old girl. The capsule of the graft’s metatarso-phalangeal joint was repaired to achieve mobility of the joint. This enabled preservation of thumb function by a relatively simple surgical technique. Detailed surgical procedures and excellence function after 2 years following surgery are described

The controversial role of ct angiogram in paediatric supracondylar humeral fracture with pulseless, perfused limb

Introduction: Almost 20% of displaced supracondylar humerus fractures in children are complicated by vascular compromise. At present, there is no clear consensus on the management of a persistent pulseless but well-perfused hand after a satisfactory closed reduction of the fracture. The role of angiography in such cases has been a source of controversy and debate. Case Report: An 18-month–old girl was referred to us with a closed, displaced, supracondylar fracture in her left humerus after a fall. She had an impalpable radial pulse but her hand looked pink with a capillary refilling time of less than 2 seconds. She underwent an emergency closed reduction and percutaneous pinning. Post-reduction, her hand remained persistently pulseless but well-perfused. A multi-disciplinary decision was made more than 24 hours after the initial surgery. The medical team decided to proceed with a computerized tomographic (CT) angiogram followed by surgical exploration and release of her left brachial artery, which was completely occluded by compression of the surrounding soft tissues. The procedure proceeded smoothly and the patient showed remarkable immediate and long term outcomes. There was no further complications observed as a result of the delay in surgical treatment. Discussion/ Conclusion:We believe that the decision to manage such cases should be made on based on appropriacy in each case. A CT angiogram is helpful in objectively determining the level of occlusion and the possible risk of proximal migration of thrombus which may eventually affect the available collaterals. A well-perfused limb may allow adequate time for a proper decision to be made for surgical intervention

Functional outcomes after internal and external hemipelvectomy in HUSM

Background: Although great advancements have been made in survival rates over the last half century with adjuvant therapies and current surgical techniques, hemipelvectomy as the surgical treatment for pelvic tumours continue to have significant associations with morbidity and complications. Using the Enneking’s criteria as adopted by the Musculoskeletal Tumor Society (MSTS), we evaluated the functional outcomes of patients who have had an internal hemipelvectomy with and without reconstruction, and external hemipelvectomy. Method: We evaluated patients who underwent hemipelvectomy in our institution between 2001 and 2010. Patients who had had an internal or external hemipelvectomy surgery at any point in their clinical course were included in the study. Patients with follow up periods of less than four months were not included. MSTS scores were obtained at various times after the surgery. Results: A total of 50 patients who had undergone various types of resection and reconstruction techniques were included in this study. The average age is 40.1 years (range 12-79). Average duration of follow up is 10 months. The average MSTS percentage score was 44.32% (range: 6.67%-100%). Results show that external hemipelvectomy in our patients have a high morbidity and mortality rate. Various techniques of resection and reconstruction give different functional scores. Conclusion: Hemipelvectomies have a profound impact on patients’ lives as illustrated by their low MSTS scores. Proper patient selection is crucial to obtain the best outcome. This study is an effort to obtain a proper reference for preoperative discussion with patients and relatives regarding expected outcomes following such a procedure

Functional outcomes after internal and external hemipelvectomy in HUSM

Background: Although great advancements have been made in survival rates over the last half century with adjuvant therapies and current surgical techniques, hemipelvectomy as the surgical treatment for pelvic tumours continue to have significant associations with morbidity and complications. Using the Enneking’s criteria as adopted by the Musculoskeletal Tumor Society (MSTS), we evaluated the functional outcomes of patients who have had an internal hemipelvectomy with and without reconstruction, and external hemipelvectomy. Method: We evaluated patients who underwent hemipelvectomy in our institution between 2001 and 2010. Patients who had had an internal or external hemipelvectomy surgery at any point in their clinical course were included in the study. Patients with follow up periods of less than four months were not included. MSTS scores were obtained at various times after the surgery. Results: A total of 50 patients who had undergone various types of resection and reconstruction techniques were included in this study. The average age is 40.1 years (range 12-79). Average duration of follow up is 10 months. The average MSTS percentage score was 44.32% (range: 6.67%-100%). Results show that external hemipelvectomy in our patients have a high morbidity and mortality rate. Various techniques of resection and reconstruction give different functional scores. Conclusion: Hemipelvectomies have a profound impact on patients’ lives as illustrated by their low MSTS scores. Proper patient selection is crucial to obtain the best outcome. This study is an effort to obtain a proper reference for preoperative discussion with patients and relatives regarding expected outcomes following such a procedure

Functional outcomes after internal and external hemipelvectomy in HUSM

Background: Although great advancements have been made in survival rates over the last half century with adjuvant therapies and current surgical techniques, hemipelvectomy as the surgical treatment for pelvic tumours continue to have significant associations with morbidity and complications. Using the Enneking’s criteria as adopted by the Musculoskeletal Tumor Society (MSTS), we evaluated the functional outcomes of patients who have had an internal hemipelvectomy with and without reconstruction, and external hemipelvectomy. Method: We evaluated patients who underwent hemipelvectomy in our institution between 2001 and 2010. Patients who had had an internal or external hemipelvectomy surgery at any point in their clinical course were included in the study. Patients with follow up periods of less than four months were not included. MSTS scores were obtained at various times after the surgery. Results: A total of 50 patients who had undergone various types of resection and reconstruction techniques were included in this study. The average age is 40.1 years (range 12-79). Average duration of follow up is 10 months. The average MSTS percentage score was 44.32% (range: 6.67%-100%). Results show that external hemipelvectomy in our patients have a high morbidity and mortality rate. Various techniques of resection and reconstruction give different functional scores. Conclusion: Hemipelvectomies have a profound impact on patients’ lives as illustrated by their low MSTS scores. Proper patient selection is crucial to obtain the best outcome. This study is an effort to obtain a proper reference for preoperative discussion with patients and relatives regarding expected outcomes following such a procedure

Evaluation of blood loss during internal (limb-salvage) hemipelvectomy for pelvic tumours : what have we learned so far?

Introduction: Pelvic tumour resections are complex and associated with extensive bleeding. Despite various blood management options in orthopaedic surgery, their used are limited particularly for pelvic tumour resections. Identifying predictive factors for a large amount of blood loss during surgery is essential. Objective: To evaluate the volume of blood loss in limb salvage pelvic resections and identify the risk factors for large amount of perioperative blood loss. Methodology: We retrospectively reviewed 25 patients underwent pelvic tumour resections performed between 2000 and 2010 in a single institution. Tumours originating from the sacrum were excluded. Total blood volume loss consisted of estimated intra-operative blood loss and the drainage volume on the first day after surgery. Loss of more than 3000ml of blood was classified as large amount of blood loss. Statistical analysis performed using Fisher’s exact test. Results: Six (24.0%) patients had total blood loss greater than 3000ml. Resections of primary bone sarcomas (osteosarcoma and chondrosarcoma) have the highest mean blood loss volume (6556.67ml and 1768.57ml, respectively). Most important factor associated with large amount of blood loss is the involvement of the acetabulum. Neo-adjuvant therapies and pre-operative embolization were not shown to be associated with extensive blood loss.. Conclusion: Resections of pelvic tumours involving the acetabular region are likely to have a large amount of blood loss perioperatively and should be anticipated. Radiation therapy prior to surgery was believed to increase the risk of bleeding intra-operatively, was not observed in this study

Resection of thumb metacarpal Ewings Sarcoma and primary reconstruction with a non-vascularized, autologous, osteoarticular metatarsal graft

Introduction: Ewings sarcoma is a rare, malignant neoplasm; rarely originates in the bones of the hand. Historically, treatment involves a combination of chemotherapy and radiotherapy. The role of surgical intervention remains limited, depending on the anatomic location. Resection and reconstruction will usually result in reduced or loss of function. Methodology: We reviewed a case of an 11-year girl with Ewings sarcoma of the first metacarpal bone of her dominant right hand with a solitary lung metastasis. Results: Treatment consisted of neo- and adjuvant chemotherapy, and wide resection of the first metacarpal followed by reconstruction of her thumb with a non-vascularised, intercalated, autologous second metatarsal graft. The capsule of the graft’s metatarso-phalangeal joint was repaired to achieve mobility of the joint. Her donor site was reconstructed with an autologous tricortical iliac bone graft. Two years following surgery, she achieved near normal functioning of her dominant hand, with no donor site morbidity and local recurrence. The surgical techniques are described together with the excellent functional outcomes in the patient. Conclusion: The use of non-vascularised, autologous metatarsal bone graft to reconstruct the thumb following tumour resection is an excellent option available. It is relatively simple and can be performed as a single resection and reconstruction procedure

Outcomes following total femur resection and modular endoprosthetic replacement for primary bone tumours

Introduction: Total femur endoprosthesis is an alternative reconstruction option following resection for massive malignant bone tumour with intramedullary extension or skip lesions. Methodology: We reviewed cases with primary bone tumours underwent total femur resection and replacement with megaprosthesis at our centre for the past 15 years. Results: Nine patients were included in our review. Mean age of patients was 21.3 years (range 12 to 35 years old). Seven had osteosarcoma of the femur and two were results of salvage procedure for implant loosening following distal femoral replacement. Another patient underwent surgery for revision of total femur allograft. Free oncologic margins were achieved in all patients. Four patients required vascularised latissimus dorsi free flaps cover for reconstruction of soft tissue defects. The average follow-up was 137 months, ranging from 24 to 180 months. Seven patients were still alive on their last follow up. Six of them being disease free and one survived with presence of pulmonary and contralateral femur metastases. Two patients were complicated with infections, two had stiff knee joint, and one case of peroneal nerve palsy. Excellent or good functional outcomes obtained in all patients on their last follow up in accordance to Musculoskeletal Tumor Society (MSTS) Scoring System. Conclusion: Modular endoprosthetic replacement is a good reconstruction option in selected cases. It provides early stability and good functional outcomes. However, it is a technically demanding procedure

The controversial role of ct angiogram in paediatric supracondylar humeral fracture with pulseless, perfused limb.

Introduction: Almost 20% of displaced supracondylar humerus fractures in children are complicated by vascular compromise. At present, there is no clear consensus on the management of a persistent pulseless but well-perfused hand after a satisfactory closed reduction of the fracture. The role of angiography in such cases has been a source of controversy and debate. Case Report: An 18-month–old girl was referred to us with a closed, displaced, supracondylar fracture in her left humerus after a fall. She had an impalpable radial pulse but her hand looked pink with a capillary refilling time of less than 2 seconds. She underwent an emergency closed reduction and percutaneous pinning. Post-reduction, her hand remained persistently pulseless but well-perfused. A multi-disciplinary decision was made more than 24 hours after the initial surgery. The medical team decided to proceed with a computerized tomographic (CT) angiogram followed by surgical exploration and release of her left brachial artery, which was completely occluded by compression of the surrounding soft tissues. The procedure proceeded smoothly and the patient showed remarkable immediate and long term outcomes. There was no further complications observed as a result of the delay in surgical treatment. Discussion/ Conclusion:We believe that the decision to manage such cases should be made on based on appropriacy in each case. A CT angiogram is helpful in objectively determining the level of occlusion and the possible risk of proximal migration of thrombus which may eventually affect the available collaterals. A well-perfused limb may allow adequate time for a proper decision to be made for surgical intervention