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AIMS: Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). METHODS: We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. RESULTS: A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. CONCLUSION: This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients.Level of evidence: IVCite this article: Bone Joint Open 2020;2(1):3-8.
RESUMEN
BACKGROUND: The treatment of locally aggressive bone tumors is a balance between achieving local tumor control and surgical morbidity. Wide resection decreases the likelihood of local recurrence, although wide resection may result in more complications than would happen after curettage. Navigation-assisted surgery may allow more precise resection, perhaps making it possible to expand the procedure's indications and decrease the likelihood of recurrence; however, to our knowledge, comparative studies have not been performed. QUESTIONS/PURPOSES: The purpose of this study was to compare curettage plus phenol as a local adjuvant with navigation-guided en bloc resection in terms of (1) local recurrence; (2) nononcologic complications; and (3) function as measured by revised Musculoskeletal Tumor Society (MSTS) scores. METHODS: Patients with a metaphyseal and/or epiphyseal locally aggressive primary bone tumor treated by curettage and adjuvant therapy or en bloc resection assisted by navigation between 2010 and 2014 were considered for this retrospective study. Patients with a histologic diagnosis of a primary aggressive benign bone tumor or low-grade chondrosarcoma were included. During this time period, we treated 45 patients with curettage of whom 43 (95%) were available for followup at a minimum of 24 months (mean, 37 months; range, 24-61 months), and we treated 26 patients with navigation-guided en bloc resection, of whom all (100%) were available for study. During this period, we generally performed curettage with phenol when the lesion was in contact with subchondral bone. We treated tumors that were at least 5 mm from the subchondral bone, such that en bloc resection was considered possible with computer-assisted block resection. There were no differences in terms of age, gender, tumor type, or tumor location between the groups. Outcomes, including allograft healing, nonunion, tumor recurrence, fracture, hardware failure, infection, and revised MSTS score, were recorded. Bone consolidation was defined as complete periosteal and endosteal bridging visible between the allograft-host junctions in at least two different radiographic views and the absence of pain and instability in the union site. All study data were obtained from our longitudinally maintained oncology database. RESULTS: In the curettage group, two patients developed a local recurrence, and no local recurrences were recorded in patients treated with en bloc resection. All patients who underwent navigation-guided resection achieved tumor-free margins. Intraoperative navigation was performed successfully in all patients and there were no failures in registration. Postoperative complications did not differ between the groups: in patients undergoing curettage, 7% (three of 43) and in patients undergoing navigation, 4% (one of 26) had a complication. There was no difference in functional scores: mean MSTS score for patients undergoing curettage was 28 points (range, 27-30 points) and for patients undergoing navigation, 29 (range, 27-30 points; p = 0.10). CONCLUSIONS: In this small comparative series, navigation-assisted resection techniques allowed conservative en bloc resection of locally aggressive primary bone tumors with no local recurrence. Nevertheless, with the numbers available, we saw no difference between the groups in terms of local recurrence risk, complications, or function. Until or unless studies demonstrate an advantage to navigation-guided en bloc resection, we cannot recommend wide use of this novel technique because it adds surgical time and expense. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Neoplasias Óseas/cirugía , Legrado/métodos , Procedimientos Ortopédicos/métodos , Cirugía Asistida por Computador/métodos , Adolescente , Adulto , Anciano , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/patología , Legrado/efectos adversos , Bases de Datos Factuales , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Recurrencia Local de Neoplasia , Neoplasia Residual , Procedimientos Ortopédicos/efectos adversos , Modelación Específica para el Paciente , Fenol/administración & dosificación , Estudios Retrospectivos , Cirugía Asistida por Computador/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Preservation of limb function after resection of malignant bone tumors in skeletally immature children is challenging. Resection of bone sarcomas and reconstruction with an allograft in patients younger than 10 years old is one reconstructive alternative. However, long-term studies analyzing late complications and limb length discrepancy at skeletal maturity are scarce; this information would be important, because growth potential is altered in these patients owing to the loss of one physis during tumor resection. QUESTIONS/PURPOSES: At a minimum followup of 10 years after reconstructions in children younger than 10 years of age at the time of reconstruction, we asked what is (1) the limb length discrepancy at skeletal maturity and how was it managed; (2) the risk of amputation; (3) the risk of allograft removal; and (4) the risk of second surgery resulting from complications? METHODS: Between 1994 and 2006, we performed 22 bone allografts after bone sarcoma resections in children younger than 10 years of age. Of those, none were lost to followup before the minimum followup of 10 years was reached, and an additional six had died of disease (of whom three died since our last report on this group of patients), leaving 16 patients whom we studied here. Followup on these patients was at a mean of 13.5 years (range, 10-22 years). During the period in question, no other treatments (such as extendible prostheses, amputations, etc) were used. The mean age at the time of the original surgery was 7 years (range, 2-10 years), and the mean age of the 16 alive patients at last followup was 20 years (range, 15-28 years). This series included 10 boys and six girls with 14 osteosarcomas and two Ewing sarcomas. Ten reconstructions were performed with an intercalary allograft and six with an osteoarticular allograft. The growth plate was uninvolved in three patients, whereas in the remaining 13, the growth plate was included in the resection (seven intercalary and six osteoarticular allografts). Limb length discrepancy at skeletal maturity was measured with full-length standing radiographs, and data were collected by retrospective study of a longitudinally maintained institutional database. The risk of amputation, allograft removal, and secondary surgery resulting from a complication was calculated by a competing-risk analysis method. RESULTS: We observed no limb length discrepancy at skeletal maturity in the three patients with intercalary resections in whom we preserved the physes on both sides of the joint (two femurs and one tibia); however, one patient developed malalignment that was treated with corrective osteotomy of the tibia. The remaining 13 patients developed limb length discrepancy as a result of loss of one physis. Seven patients (four femurs, two tibias, and one humerus) developed shortening of ≤ 3 cm (mean, 2.4 cm; range, 1-3 cm) and no lengthening was performed. Six patients developed > 3 cm of limb discrepancy at skeletal maturity (all distal femoral reconstructions). In four patients this was treated with femoral lengthening, whereas two declined this procedure (each with 6 cm of shortening). In the four patients who had a lengthening procedure, one patient had a final discrepancy of 4 cm, whereas the other three had equal limb lengths at followup. The risk of amputation was 4% (95% confidence interval [CI], 0-15) and none occurred since our previous report. The risk of allograft removal was 15% (95% CI, 1-29) and none occurred since our previous report on this group of patients. The risk of other operations resulting from a complication was 38% (95% CI, 19-57). Eleven patients underwent a second operation resulting from a complication (three local recurrences, five fractures, one infection, one nonunion, and one tibial deformity), of which three were performed since our last report on this group of patients. CONCLUSIONS: Limb length inequalities and subsequent procedures to correct them were common in this small series of very young patients as were complications resulting in operative procedures, but overall most allografts remained in place at long-term followup. In skeletally immature children, bone allograft is one alternative among several that are available (such as rotationplasty and endoprosthesis), and future studies with long followup may be able to compare the available options with one another. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Neoplasias Óseas/cirugía , Trasplante Óseo/efectos adversos , Diferencia de Longitud de las Piernas/etiología , Osteosarcoma/cirugía , Osteotomía/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Complicaciones Posoperatorias/etiología , Sarcoma de Ewing/cirugía , Adolescente , Desarrollo del Adolescente , Adulto , Factores de Edad , Aloinjertos , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/patología , Niño , Desarrollo Infantil , Femenino , Estudios de Seguimiento , Humanos , Diferencia de Longitud de las Piernas/diagnóstico por imagen , Diferencia de Longitud de las Piernas/fisiopatología , Diferencia de Longitud de las Piernas/cirugía , Masculino , Osteosarcoma/diagnóstico por imagen , Osteosarcoma/patología , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/cirugía , Factores de Riesgo , Sarcoma de Ewing/patología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Chondroblastoma is an uncommon, benign, but locally aggressive bone tumor that occurs in the apophyses or epiphyses of long bones, primarily in young patients. Although some are treated with large resections, aggressive curettage and bone grafting are more commonly performed to preserve the involved joint. Such intralesional resection may result in damage to the growth plate and articular cartilage, which can result in painful arthritis. Prior studies have focused primarily on oncologic outcomes rather than long-term joint status and functional outcomes. QUESTIONS/PURPOSES: (1) What local complications can be expected after aggressive intralesional curettage of epiphyseal chondroblastoma? (2) What is the joint survival of a joint treated in this way for chondroblastoma? (3) What additional procedures are used in treating symptomatic joint osteoarthritis after treatment of the chondroblastoma? (4) What are the functional outcomes in this group of patients? METHODS: A retrospective study of our prospectively collected database between 1975 and 2013 was done. We found 64 patients with a diagnosis of chondroblastoma of bone. After applying our selection criteria, 53 patients were involved in this study. We excluded seven patients with tumors initially treated with en bloc resection (five located in the extremities and two in the axial skeleton) and two patients with apophyseal tumors. One patient who underwent nonsurgical treatment and one patient lost to followup were also excluded. The mean age was 18 years (range, 11-39 years); the minimum followup was 2 years with a mean followup 77 months (range, 24-213 months). We analyzed all patients with a diagnosis of epiphyseal chondroblastoma of the limb treated with aggressive curettage and joint preservation surgery. During the period in question, our general indications for curettage were patients with active, painful tumors and those with more aggressive ones that remained intracompartmental, whereas initial wide en bloc resection was indicated in patients who had tumors with an extracompartmental extension breaching the adjacent joint cartilage and massive articular destruction. The tumor location was the distal femur in 14 patients, proximal tibia in 11, proximal humerus in 10, proximal femur in eight, the talus in seven, and elsewhere in the lower extremity in three. Local complications including joint degeneration and tumor recurrence were evaluated. Based on radiographic analysis, secondary osteoarthritis was classified by using the Kellgren-Lawrence grading system from Grade 0 to Grade IV. Patients who underwent joint replacement resulting from advanced symptomatic osteoarthritis were considered to have had joint failure for purposes of survivorship analysis, which was estimated using the Kaplan-Meier method. Functional results were evaluated with the Musculoskeletal Tumor Society functional score by the treating surgeon, who transcribed the results on the digital records every 6 months of followup. RESULTS: Twenty-two patients (42%) developed 26 local complications. The most common local complication was osteoarthritis in 20 patients (77% [20 of 26 complications]); tumor recurrence was observed in four patients; an intraarticular fracture and superficial infection treated with surgical débridement and antibiotics developed in one patient each. Joint survival was 90% at 5 years (95% confidence interval [CI], 76%-100%) and 74% at 10 years (95% CI, 48%-100%). Proximal femoral tumor location was associated with lower survivorship of the joint than other locations showing a 5-year survival rate of 44% (95% CI, 0%-88%; p = 0.000). Of the 20 patients with osteoarthritis, four were symptomatic enough to undergo joint replacement, all of which were for tumors in the proximal femur. The mean Musculoskeletal Tumor Society functional score was 28 of 30 points (93%). CONCLUSIONS: Osteoarthritis was a frequent complication of aggressive curettage of epiphyseal chondroblastoma, and tumors located in the proximal femur appeared to be at particular risk of secondary osteoarthritis and prosthetic replacement. Because chondroblastoma is a tumor that disproportionately affects younger patients, the patient and surgeon should be aware that arthroplasty at a young age is a potential outcome for treatment of proximal femoral chondroblastomas. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Reemplazo de Cadera , Condrosarcoma/cirugía , Legrado/efectos adversos , Neoplasias Femorales/cirugía , Húmero/cirugía , Procedimientos Ortopédicos/efectos adversos , Osteoartritis de la Cadera/cirugía , Astrágalo/cirugía , Tibia/cirugía , Adolescente , Adulto , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/instrumentación , Niño , Condrosarcoma/diagnóstico por imagen , Condrosarcoma/patología , Bases de Datos Factuales , Epífisis/patología , Epífisis/cirugía , Femenino , Neoplasias Femorales/diagnóstico por imagen , Neoplasias Femorales/patología , Prótesis de Cadera , Humanos , Húmero/patología , Estimación de Kaplan-Meier , Imagen por Resonancia Magnética , Masculino , Recurrencia Local de Neoplasia , Procedimientos Ortopédicos/métodos , Osteoartritis de la Cadera/diagnóstico , Osteoartritis de la Cadera/etiología , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Astrágalo/patología , Tibia/diagnóstico por imagen , Tibia/patología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Central chondrosarcoma of bone is graded on a scale of 1 to 3 according to histological criteria. Clinically, these tumors can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. Although en bloc resection has been the most widely used treatment, it has become generally accepted that in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment, but prior reports have indicated that both imaging and biopsy do not always give an accurate prediction of grade. QUESTIONS/PURPOSES: (1) What is the concordance of image-guided needle preoperative biopsy and postoperative grading in central (intramedullary) chondrosarcomas of long bones, and how does this compare with the concordance of image-guided needle preoperative biopsy and postoperative grading in central pelvic chondrosarcomas? (2) What is the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones, and how does this compare with the concordance in central pelvic chondrosarcomas? METHODS: Between 1997 and 2014, in our institution, we treated 126 patients for central chondrosarcomas located in long bones and the pelvis. Of these 126 cases, 41 were located in the pelvis and the remaining 85 cases were located in long bones. This study considers 39 (95%) and 40 (47%) of them, respectively. We included all cases in which histological information was complete regarding preoperative and postoperative tumor grading. We excluded all cases with incomplete data sets or nondiagnostic preoperative biopsies. To evaluate the needle biopsy accuracy, we compared the histological tumor grade, obtained from the preoperative biopsy, with the final histological grade obtained from the postoperative surgical specimen. The weighted and nonweighted kappa statistics were used to evaluate the agreement. RESULTS: Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]; odds ratio, 8, 48). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma for the determination of histological grade (0.63; 95% confidence interval [CI], 0.34-0.91 versus 0.12; -0.32 to 0.57; p < 0.001). When categorizing the lesions as low grade or high grade, concordance between the preoperative biopsy and the final pathological analysis was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (90% [36 of 40] versus 67% [26 of 39]; odds ratio, 4, 5). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (0.73; 95% CI, 0.51-0.94 versus 0.26; 0.04-0.48; p < 0.001). CONCLUSIONS: Image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The histological grade should be correlated with imaging and the clinical presentation, but under these circumstances, experienced tumor surgeons may use this information in planning surgical treatment. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution. LEVEL OF EVIDENCE: Level III, diagnostic study.
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Biopsia con Aguja , Condrosarcoma/patología , Neoplasias Femorales/patología , Peroné/cirugía , Húmero/cirugía , Biopsia Guiada por Imagen , Neoplasias Pélvicas/patología , Tibia/cirugía , Adolescente , Adulto , Anciano , Argentina , Diferenciación Celular , Condrosarcoma/cirugía , Legrado , Femenino , Neoplasias Femorales/cirugía , Peroné/patología , Humanos , Húmero/patología , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Oportunidad Relativa , Osteotomía , Neoplasias Pélvicas/cirugía , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Tibia/patología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers. QUESTIONS/PURPOSES: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results. METHODS: Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system. RESULTS: With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4). CONCLUSIONS: Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Artroplastia de Reemplazo de Rodilla/instrumentación , Neoplasias Óseas/cirugía , Trasplante Óseo/métodos , Prótesis de la Rodilla , Osteotomía , Tibia/cirugía , Adolescente , Adulto , Amputación Quirúrgica , Argentina , Artroplastia de Reemplazo de Rodilla/efectos adversos , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/patología , Trasplante Óseo/efectos adversos , Bases de Datos Factuales , Inglaterra , Femenino , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Osteotomía/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Tibia/diagnóstico por imagen , Tibia/patología , Factores de Tiempo , Trasplante Homólogo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprosthesis, although they have different outcomes and risks. The use of massive bone allografts has been thought to be associated with a high risk for infection, and there is no general consensus on the management of this complication and final outcome. Because infection is such a devastating complication of limb salvage, at times leading to loss of a limb, recognizing the risk factors for infection and the results of treatment is important. QUESTIONS/PURPOSES: The purposes of this study were (1) to analyze the frequency of infection in a group of patients treated with massive bone allografts; (2) to analyze risk factors such as age, sex, affected bone, type of reconstruction, operative room used, primary or revision procedure, length of postoperative antibiotic administration, and use of chemotherapy; and (3) to determine the likelihood that treatment of an infected allograft will result in a successful reconstruction. METHODS: We retrospectively analyzed the records of patients treated with massive bone allografts for a benign or malignant bone tumor or as a revision for a previous limb salvage procedure between 1985 and 2011. During this period, 673 patients were reconstructed with massive bone allografts in long bones, which included 272 osteoarticular, 246 intercalary, and 155 allograft-prosthetic composite reconstructions. Using a chart review, we ascertained the frequency of infection and reoperations after the treatment of infected allografts. Minimum followup was 2 years unless death occurred earlier (mean, 106 months; range, 6-360 months), and no patient was lost to followup. The selected variables were analyzed using multivariate logistic regression to identify risk factors for infection. We analyzed survivorship free of infection as the endpoint. RESULTS: During followup, 60 patients (9%) had a bacterial infection of the allograft with a survivorship free from infection of 92% at 5 years (95% confidence interval [CI], 90%-94%) and 91% at 10 years (95% CI, 89%-93%). We found that tibia allografts (p < 0.001; odds ratio [OR], 3.17; 95% CI, 1.80-5.60), male patients (p < 0.029; OR, 1.92; 95% CI, 1.08-3.49), procedures performed in a conventional operating room (p < 0.002; OR, 3.15; 95% CI, 1.58-6.62), and the use of longer periods of postoperative antibiotics (p < 0.041; OR, 2.25; 95% CI, 1.02-4.88) were patient factors associated with a greater risk of infection. In 11 patients (18%, 11 of 60 infections) the infection was controlled with antibiotics and surgical débridement; however, in 49 patients (82%, 49 of 60 infections), this approach failed, so the allograft was removed and a temporary cement spacer with antibiotic was implanted to control the infection. Forty-one patients subsequently had the spacer removed and were reconstructed after infection control with another bone allograft in 24 and an endoprostheses in 17. Four patients underwent an amputation for infection and four died of disease with the spacer in place. When we analyzed the 41 patients with a second reconstruction, 14 failed with a new infection (34%, 14 of 41 secondary reconstructed) of whom 12 had been reconstructed with bone allograft (29%) and two had endoprostheses (5%). CONCLUSIONS: Management of infections of massive bone allografts with antibiotics and surgical débridement usually resulted in failure. Infections could be treated with resection of the allograft, antibiotics, a temporary cement spacer with antibiotics, and a repeat reconstruction; however, this approach is unlikely to be successful if a second bone allograft is used. Infections are difficult to treat, and more studies are needed, but we propose that it might be preferable to use endoprosthesis reconstruction for salvage of an infected allograft. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Neoplasias Óseas/cirugía , Trasplante Óseo/métodos , Recuperación del Miembro/métodos , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aloinjertos , Neoplasias Óseas/diagnóstico por imagen , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico por imagenRESUMEN
Allograft transplantation is a biologic reconstruction option for massive bone defects after resection of bone sarcomas. This type of reconstruction not only restores bone stock but it also allows us to reconstruct the joint anatomically. These factors are a major concern, especially in a young and active population.We are describing indications, surgical techniques, pearls and pitfalls, and outcomes of proximal humeral osteoarticular allografts, done at present time in our institution.We found that allograft fractures and articular complications, as epiphyseal resorption and subchondral fracture, are the main complications observed in proximal humerus osteoarticular allograft reconstructions. Nevertheless, only fractures need a reconstruction revision. Joint complications may adversely affect the limb function, but for this reason, an allograft revision is rarely performed.
RESUMEN
Objetivo: Analizar una serie de pacientes con osteotomías varizante de fémur distal y evaluar los resultados, tanto clínicos como radiográficos. Material y Métodos: Se analizaron retrospectivamente 11 pacientes con osteotomía varizante de fémur realizada en nuestra institución, entre los años 2005 y 2013. En 7 casos se realizó una osteotomía aditiva externa y en 4 sustractiva interna. Como procedimientos asociados se realizaron: 1 trasplante meniscal, 4 mosaicoplastias, 1 reconstrucción del LCP y en 1 caso microperforaciones. El promedio de seguimiento fue de 39 meses (rango de 12-102 meses). Se midieron el eje, la consolidación ósea y la progresión de la artrosis del compartimento lateral (Score de Kellgren-Lawrence). Se realizaron las siguientes evaluaciones funcionales: IKDC subjetivo, Lysholm y Tegner. Resultados: El Promedio de corrección del eje fue de 12,6°, no se observó modificación del mismo durante el seguimiento. Todas las osteotomías consolidaron y no se observó progresión de la artrosis en el compartimento externo. El IKDC subjetivo promedio fue de 70,5, el Lysholm promedio de 83,1 y el Tegner de 4. Dos pacientes evolucionaron con rigidez articular y 1 presento molestias a nivel de la placa, por lo que se realizaron 2 movilizaciones bajo anestesia y 1 retiro de material de osteosintesis. Ninguno de los pacientes fue sometido a una artroplastia hasta la fecha. Conclusión: Se logró corregir la mala alineación en valgo que presentaban los pacientes, con buenos escores funcionales y baja tasa de complicaciones, ubicando la osteotomía de fémur distal para genu valgo como una alternativa válida en casos bien seleccionados. Nivel de Evidencia: IV. Tipo de Estudio: Serie de Casos.
Objective: To analyze a series of patients who underwent varus osteotomy of distal femur and evaluate both clinical and radiographic results. Method: We retrospectively analyzed 11 patients with distal femoral varus osteotomy performed at our institution between 2005 and 2013. 7 of these were open wedge osteotomies, whereas the remaining 4 were closing wedge ones. Associated procedures were performed as follows: 1 meniscal transplant, 4 mosaicplasties, 1 LCP reconstruction and in 1 case microfractures. The mean follow-up was 39 months (range 12 to 102 months). Pre- and postoperative radiographs were evaluated for tibiofemoral angle, bone healing and progression of lateral compartment osereoarthritis (Kellgren-Lawrence Score). The IKDC, Lysholm and Tegner scores assessed clinical outcomes. Results: The average correction of the femorotibial angle was of 12.6°, there were no changes evidenced along the follow up. Union of the osteotomy site was achieved in all cases. Osteoarthritis of the lateral compartment did not show progression. The mean results of the clinical scores were: IKDC 70.5, Lysholm 83.1, and Tegner 4. Two patients revealed joint stiffness and 1 complained about discomfort at the plate site. For these reasons, two mobilizations under anesthesia and 1 material removal were performed. To the date, none of the patients required an arthroplasty. Conclusion: We were able to correct the valgus malalignment in all patients, with good functional outcomes and low complication rate, placing the distal femoral osteotomy for valgus arthritic knees as a valid alternative in well-selected cases. Level of Evidence: IV. Type of study: Case Series.
Asunto(s)
Adulto , Articulación de la Rodilla/cirugía , Articulación de la Rodilla/patología , Fémur/cirugía , Genu Valgum/cirugía , Osteotomía/métodos , Estudios Retrospectivos , Recuperación de la Función , Resultado del TratamientoRESUMEN
BACKGROUND: Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed. QUESTIONS/PURPOSES: We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection. METHODS: We analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system. RESULTS: Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup. CONCLUSIONS: Although the recurrence rate was high in this series, the small sample size means that even one or two fewer recurrences might have resulted in a much more favorable percentage. Because of this, future, larger studies will need to determine whether this is a safe approach, and perhaps should compare epiphyseal preservation with other possible approaches, including endoprosthetic reconstruction and/or osteoarticular allografts. LEVEL OF EVIDENCE: Level IV, therapeutic study.
Asunto(s)
Neoplasias Óseas/cirugía , Trasplante Óseo , Epífisis/cirugía , Neoplasias Femorales/cirugía , Recurrencia Local de Neoplasia , Osteosarcoma/cirugía , Osteotomía , Procedimientos de Cirugía Plástica , Tibia/cirugía , Adolescente , Adulto , Aloinjertos , Argentina , Fenómenos Biomecánicos , Neoplasias Óseas/mortalidad , Neoplasias Óseas/patología , Neoplasias Óseas/fisiopatología , Trasplante Óseo/efectos adversos , Trasplante Óseo/mortalidad , Niño , Preescolar , Epífisis/patología , Epífisis/fisiopatología , Femenino , Neoplasias Femorales/mortalidad , Neoplasias Femorales/patología , Neoplasias Femorales/fisiopatología , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Osteosarcoma/mortalidad , Osteosarcoma/patología , Osteosarcoma/fisiopatología , Osteotomía/efectos adversos , Osteotomía/métodos , Osteotomía/mortalidad , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/mortalidad , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Tibia/patología , Tibia/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Se ha descripto que los tumores de la rodilla pueden ser inicialmente mal diagnosticados como lesiones deportivas o viceversa, con consecuencias dramáticas potenciales. Otro diagnóstico aún más conflictivo puede suceder cuando ambas patologías ocurren en forma simultánea. La ruptura del ligamento cruzado anterior está dentro de las lesiones deportivas más frecuentes, con una incidencia en EEUU de 150.000 a 200.000 por año. En contraste, los tumores musculo-esqueléticos de rodilla son relativamente infrecuentes. A pesar de esto, las lesiones deportivas y las lesiones tumorales presentan una estricta relación ya que exhiben un mismo grupo etario con similar sintomatología y localización anatómica, pudiendo generar problemas en el diagnóstico. El objetivo del trabajo fue describir tres pacientes con lesiones simultáneas en la rodilla: una ruptura traumática del ligamento cruzado anterior (LCA) y un tumor musculo-esquelético que puede ser particularmente confuso para el cirujano tratante. Nivel de evidencia: IV...(AU)
It has been reported that tumors about the knee may be initially misdiagnosed as athletic injuries or vice versa, with potentially dramatic consequences. An even more conflicting diagnostic situation might happen when both pathologies occur simultaneously. Anterior cruciate ligament ruptures are among the most frequent athletic injuries, with an incidence of 150.000-200.000 per year in the USA. On the other side, musculoskeletal tumors about the knee are much less common. However, they frequently occur in the same age group with symptoms that overlap, making it difficult to have a precise diagnosis. We report three patients with simultaneous lesions about the knee: A traumatic anterior cruciate ligament (ACL) rupture and a musculoskeletal tumor, which may be confusing for the treating surgeon. Level of evidence: IV...(AU)
Asunto(s)
Adulto , Ligamento Cruzado Anterior/patología , Ligamento Cruzado Anterior/cirugía , Neoplasias Óseas/cirugía , Neoplasias Óseas/diagnóstico , Articulación de la Rodilla/patología , Articulación de la Rodilla/cirugía , Rotura , Traumatismos en Atletas/patología , Resultado del TratamientoRESUMEN
Se ha descripto que los tumores de la rodilla pueden ser inicialmente mal diagnosticados como lesiones deportivas o viceversa, con consecuencias dramáticas potenciales. Otro diagnóstico aún más conflictivo puede suceder cuando ambas patologías ocurren en forma simultánea. La ruptura del ligamento cruzado anterior está dentro de las lesiones deportivas más frecuentes, con una incidencia en EEUU de 150.000 a 200.000 por año. En contraste, los tumores musculo-esqueléticos de rodilla son relativamente infrecuentes. A pesar de esto, las lesiones deportivas y las lesiones tumorales presentan una estricta relación ya que exhiben un mismo grupo etario con similar sintomatología y localización anatómica, pudiendo generar problemas en el diagnóstico. El objetivo del trabajo fue describir tres pacientes con lesiones simultáneas en la rodilla: una ruptura traumática del ligamento cruzado anterior (LCA) y un tumor musculo-esquelético que puede ser particularmente confuso para el cirujano tratante. Nivel de evidencia: IV...
It has been reported that tumors about the knee may be initially misdiagnosed as athletic injuries or vice versa, with potentially dramatic consequences. An even more conflicting diagnostic situation might happen when both pathologies occur simultaneously. Anterior cruciate ligament ruptures are among the most frequent athletic injuries, with an incidence of 150.000-200.000 per year in the USA. On the other side, musculoskeletal tumors about the knee are much less common. However, they frequently occur in the same age group with symptoms that overlap, making it difficult to have a precise diagnosis. We report three patients with simultaneous lesions about the knee: A traumatic anterior cruciate ligament (ACL) rupture and a musculoskeletal tumor, which may be confusing for the treating surgeon. Level of evidence: IV...
Asunto(s)
Adulto , Articulación de la Rodilla/cirugía , Articulación de la Rodilla/patología , Ligamento Cruzado Anterior/cirugía , Ligamento Cruzado Anterior/patología , Neoplasias Óseas/cirugía , Neoplasias Óseas/diagnóstico , Resultado del Tratamiento , Rotura , Traumatismos en Atletas/patologíaRESUMEN
Surgical precision in oncologic surgery is essential to achieve adequate margins in bone tumor resections. Three-dimensional preoperative planning and bone tumor resection by navigation have been introduced to orthopedic oncology in recent years. However, the accuracy of preoperative planning and navigation is unclear. The purpose of this study was to evaluate the accuracy of preoperative planning and the navigation system. A total of 28 patients were evaluated between May 2010 and February 2011. Tumor locations were the femur (n=17), pelvis (n=6), sacrum (n=2), tibia (n=2), and humerus (n=1). All resections were planned in a virtual scenario using computed tomography and magnetic resonance imaging fusion. A total of 61 planes or osteotomies were performed to resect the tumors. Postoperatively, computed tomography scans were obtained for all surgical specimens, and the specimens were 3-dimensionally reconstructed from the scans. Differences were determined by finding the distances between the osteotomies virtually programmed and those performed. The global mean of the quantitative comparisons between the osteotomies programmed and those obtained through the resected specimen was 2.52±2.32 mm for all patients. Differences between osteotomies virtually programmed and those achieved by navigation intraoperatively were minimal.
Asunto(s)
Neoplasias Óseas/diagnóstico , Neoplasias Óseas/cirugía , Imagenología Tridimensional/métodos , Imagen por Resonancia Magnética/métodos , Imagen Multimodal/métodos , Cirugía Asistida por Computador/métodos , Tomografía Computarizada por Rayos X/métodos , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios/métodos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del Tratamiento , Adulto JovenRESUMEN
Surgical resection with adequate margins is the treatment of choice in chondrosarcoma. However, well-circumscribed lesions can be completely resected by performing multi-planar osteotomies guided by computer-assisted navigation. This type of resection had been recently described in select patients with sarcomas; however, these osteotomies are technically demanding to plan and perform intraoperatively. The use of navigation to assist in surgery is becoming more frequently described in orthopedic oncology.The authors performed multiplanar osteotomy resections guided by navigation and reconstruction with intercalary allografts in 5 patients with chondrosarcoma around the knee. All the patients were women, with a mean age of 56 years. Four tumors were located in the distal femur and 1 in the proximal tibia. The 5 surgical anatomic specimens were 3-dimensionally reconstructed postoperatively and superimposed on a preoperative plan to check whether the resected specimen was consistent with the preoperative planned resection. At final follow-up, no patient experienced a local recurrence or metastasis. Four osteotomies each were performed in 3 patients, and 3 osteotomies each were performed in 2 patients, so 18 planes were evaluated. Mean difference in distance between preoperative vs final planes was 2.43 mm. Average functional score was 29 points. All patients resumed activities of daily living without restriction. This study's results show that navigation with adequate preoperative planning allows surgeons to intraoperatively reproduce the planned resection with accuracy in complex multiplanary resections.
Asunto(s)
Neoplasias Óseas/cirugía , Condrosarcoma/cirugía , Fémur , Tibia , Adulto , Anciano , Femenino , Humanos , Rodilla , Persona de Mediana Edad , Osteotomía , Técnicas Estereotáxicas , Cirugía Asistida por Computador , Trasplante HomólogoRESUMEN
Allograft-prosthesis composite (APC) can restore capsular and ligamentous tissues of the knee sacrificed in a tumor extirpation. We asked if performing APC would restore knee stability and allow the use of nonconstrained arthroplasty while preventing aseptic loosening. We retrospectively compared 50 knee APCs performed with non-constrained revision knee prosthesis (Group 1) with 36 matched APCs performed with a constrained prosthesis (Group 2). In Group 1, the survival rate was 69% at five and 62% at ten years. Sixteen reconstructions were removed due to complications: eight deep infections, three fractures, two instabilities, one aseptic loosening, one local recurrence, and one nonunion. In Group 2, the survival rate was 80% at five and 53% at ten years. Nine reconstructions were removed: 3 due to deep infections, 3 to fractures, and 3 to aseptic loosening. In both groups, we observed more allograft fractures when the prosthetic stem does not bypass the host-donor osteotomy (P > 0.05). Both groups had mainly good or excellent MSTS functional results. Survival rate and functional scores and aseptic loosening were similar in both groups. A rotating-hinge APC is recommended when host-donor soft tissue reconstruction fails to restore knee instability. The use of a short prosthetic stem has a statistical relationship with APC fractures.
RESUMEN
In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions after excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. Kaplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. The function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at five years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at five years and 54% at ten years. The limb salvage rate was 98% at five and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. The best functional score was observed in the intercalary humeral allograft.