Implant survival and functional results of endoprosthetic reconstruction for proximal femoral metastases with pathological fractures

BACKGROUND

This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures.

METHODS

A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated.

RESULTS

The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95-0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30-56.6%) and the median KPS score was 40 (30-50). Postoperative third month, the median MSTS score was 56.6 (53.3-86.6%) and the median KPS score was 60 (40-70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure.

CONCLUSION

Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.

Is bipolar hemiarthroplasty an appropriate type of hip articulation following proximal femoral or total femoral resections for musculoskeletal malignancies?

BACKGROUND

Different approaches are applied for reconstruction in patients with a musculoskeletal malignancy which require a proximal femoral or total femoral resection. We aimed to evaluate the treatment outcomes of patients who underwent a proximal femoral or total femoral resection due to bone and soft tissue tumors and had an endoprosthetic reconstruction by a bipolar hemiarthroplasty type of hip articulation.

METHODS

We retrospectively identified 133 patients who underwent a proximal femoral or total femoral endoprosthetic replacement after resection of a bone or soft tissue malignancy. There were 74 male and 59 female patients, with a mean age of 55.02 ± 16.92 years (range 11-84 years) and a median follow-up of 24.47 ± 24.45 months (range 6-164 months). Patient demographics, surgical, and oncological data were recorded. Acetabular wear was measured using the classification proposed by Baker. Functional assessment was performed using the Musculoskeletal Tumor Society (MSTS) functional score.

RESULTS

There was no statistically significant difference among primary diagnostic groups in terms of gender, prosthesis type, trochanter major resection, local recurrence, complication/revision rate, and MSTS Score (p > 0.05, for each parameter). On the other hand, a statistically significant difference was detected in terms of degree of acetabular erosion among diagnostic groups (p < 0.001); the acetabular erosion rate (AER) was found to be lower in patients with metastatic carcinoma than in patients with a diagnosis of primary bone or soft tissue sarcoma. The univariable analysis revealed that the effect of age, primary diagnosis, localization, follow-up time, and presence and number of distant organ metastasis variables on AER were found to be statistically significant (p = 0.018, p = 0.035, p = 0.002, p = 0.007, p = 0.031, p = 0.040, respectively).

CONCLUSION

In patients who undergo a proximal femoral or a total femoral resection due to a musculoskeletal tumor, bipolar hemiarthroplasty is an adequate type of hip articulation method, since it does not affect the revision requirements and functional outcomes of patients with acetabular erosion.

Evaluation of patella alta using MRI measurements in adolescents

PURPOSE

To determine whether or not there were any differences in the measurement techniques used by orthopedic and radiology specialists in the evaluation of magnetic resonance (MR) images for the diagnosis of patella alta in adolescents.

MATERIALS AND METHODS

Evaluations were performed by three orthopedic specialists (Group I) and three radiology specialists (Group II) regarding the presence of patella alta in 40 adolescents cases using the Insall-Salvati, Caton-Deschamps, Blackburne-Peel, and modified Insall-Salvati indices on MR images obtained to diagnose patellar instability.

RESULTS

The Fleiss Kappa conformity levels for Insall-Salvati, Caton-Deschamps, Blackburne-Peel, and modified Insall-Salvati measurements were 0.531, 0.559, 0.246, and 0.272, respectively, in Group I, and 0.699, 0.346, 0.516, and 0.394, respectively, in Group II.

CONCLUSION

The radiology specialists were found to have greater conformity in the evaluation of all patella alta indices, which was probably due to their greater familiarity with radiological measurements than that of the orthopedic specialists.

Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation

BACKGROUND

In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children.

METHODS

We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation.

RESULTS

Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases.

CONCLUSIONS

This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Heterotopic ossification on the volar surface of the distal radius in a child with fibrodysplasia ossificans progressiva: challenges in surgical excision of a rare condition

Fibrodysplasia ossificans progressiva (FOP) is one of the genetic and developmental forms of heterotopic ossification. We report a case of FOP on the volar surface of the distal radius, located close to the median nerve and radial artery with neurologic symptoms secondary to median nerve entrapment. The patient underwent surgical excision of the heterotopic lesion followed by radiation therapy. He had no signs of recurrence with more than 1 year of follow-up. Careful microsurgical dissection of the heterotopic mass must be performed to prevent the formation of new painful lesions and iatrogenic neurovascular injury. In this syndrome, the possibility of nerve entrapment due to the heterotopic lesion should be considered as the cause of neuropathic pain. Early genetic testing for confirmation of the suspected diagnosis can avoid having to do an unnecessary biopsy.

Reconstruction after periacetabular tumor resection with Lumic® endoprosthesis: What are the midterm results?

INTRODUCTION

This study aimed to analyze the midterm outcomes of LUMiC® endoprosthetic reconstruction following periacetabular resection of primary bone sarcomas and carcinoma metastases.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 21 patients (11 male [52.3%], 10 female [47.6%]; mean age 47 ± 16 years) for whom a LUMiC® endoprosthesis (Implantcast) was used to reconstruct a periacetabular defect after internal hemipelvectomy. The tumor was pathologically diagnosed as Ewing's sarcoma in six (28.5%), chondrosarcoma in 10 (47.6%), and bone metastasis from carcinoma in five (23.8%) patients.

RESULTS

The median follow-up of patients was 57.8 months (95% confidence interval: 51.9-63.7). The implant survival rate at 1, 2, and 5 years were 95.2%, 85.7%, and 80.9%, respectively. The overall complication rate was 33.3% (n = 7). Four (19%) complications resulted in reconstruction failure. Total reoperation rate was 28.5% (n = 6). The complications were soft tissue failure/dislocation in two patients, aseptic loosening in one, infection in two, and local recurrence in two. At the time of study, seven patients were alive with no evidence of disease, seven were alive with disease, and seven died of disease. The 5-year overall survival rate and local recurrence-free survival rates were 67% and 76%, respectively. The median Musculoskeletal Tumor Society score at final follow-up was 70% (range: 50%-86.6%).

CONCLUSION

We conclude that LUMiC® endoprosthesis provides good functional outcomes and a durable reconstruct. Even though this reconstruction method presents some complications, it provides a stable pelvis in the management of periacetabular malignant tumors.

Investigation of the Optimal Interval for Staged Total Knee Arthroplasty for the Treatment of Advanced Bilateral Gonarthrosis

PURPOSE OF THE STUDY This study investigated whether there was an optimal interval between two operations for total knee arthroplasties in patients with advanced bilateral gonarthrosis scheduled to undergo staged total knee arthroplasty (TKA). MATERIAL AND METHODS A prospective cohort of 219 patients (136 females, 83 males) undergoing staged total knee arthroplasty for the treatment of advanced bilateral gonarthrosis were followed for up to 12 months. The mean was 69.51±5.02 (56-80) years. Patients were categorized into five groups based on the time between the first and second operations; Group I (21-90 days), Group II (91-180 days), Group III (181-270 days), Group IV (271-360 days), and Group V (more than 360 days). Patients were evaluated based on time from surgery and were assigned to corresponding groups. The data recorded included age, body mass index (BMI), side of operated knee, complications, and radiological and clinical findings. Visual analog scale (VAS) for non-operated knees was applied. Activities of Daily Living Score (ADLS) was applied to the patients at last follow-up. RESULTS No statistically significant difference was noted in BMI values (p=0.634), range of joint motion (RJM) (p=0.940) and age (p=0.785) distribution between the five groups. In Group I, the mean VAS score increased by 7.83 to 7.98, 7.86 to 8.53 in Group II, by 7.85 to 8.54 in Group III, 7.85 to 8.59 in Group IV, and 7.88 to 8.64 in Group V. There was no statistically significant difference in preoperative ADLS between the groups (p=0.064), but there was a statistically significant difference in postoperative ADLS (p=0.001). Group I patients had significantly lower postoperative ADLS compared to the other groups (p=0.001). The mean increase in postoperative ADLS versus preoperative scores of all groups were statistically significant The most significant improvements occurred in Groups II and III. Similarly, preexisting pain in the non-operated knee started to increase in Group II and continued in all groups. DISCUSSION Given all these findings, we believe that it is reasonable to advise patients to receive their second TKA, 3-6 months after their initial TKA, as this interval will allow for the greatest improvements in functional and daily living activities, and pain in the non-operated knee simultaneously becomes more severe. This recommended interval would minimize both the functional problems with the operated extremity due to pain, and deformity and dysfunction in the non-operated knee and the subsequent overloading. CONCLUSIONS Even though a number of factors influence the optimal interval for staged TKAs in bilateral gonarthrosis, an interval of 91-270 days appears to be the optimal interval between surgeries in terms of minimizing pain and maximizing ADL s and knee scores. Key words: bilateral total knee arthroplasty, optimal interval, knee society scores, activities of daily living.

Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures

Acromioclavicular (AC) joint injury is a frequent diagnosis after an acute shoulder trauma – often found among athletes and people involved in contact sports.

This injury occurs five times more frequently in men than in women, with the highest incidence in the 20- to 30-year-old age group. Patients usually complain of pain and tenderness over the shoulder, particularly over the AC joint.

Depending on the degree of injury, the clavicle may become prominent on the injured site.

The original classification was described by Rockwood and Green according to the injured ligament complex and degree and direction of clavicular displacement.

Many surgical procedures have been described; among these are screws, plates, muscle transfer, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.

With the advancement of shoulder arthroscopy, surgeons are much more capable of performing mini-open or arthroscopically-assisted procedures, allowing patients an earlier return to their daily living activities. However, the results of conventional open techniques are still comparable.

The introduction of new arthroscopic equipment provides a great variety of surgical procedures, though every new technique has its own advantages and pitfalls. Currently there is no gold standard for the surgical treatment of any type of AC injury, though it should be remembered that whenever an arthroscopic technique is chosen, the surgeon’s expertise is likely to be the most significant factor affecting outcome.

Cite this article: EFORT Open Rev 2018;3:426-433. DOI: 10.1302/2058-5241.3.170027

Lateral Antebrachial Cutaneous Nerve as a Donor Source for Digital Nerve Grafting: A Concept Revisited

Objective:

The main objective of this study is to evaluate the availability of lateral antebrachial cutaneous nerve (LACN) autograft for acute or delayed repair of segmented digital nerve injuries.

Patients and Methods:

13 digital nerve defects of 11 patients; treated with interposition of LACN graft that harvested from ipsilateral extremity were included in the study. Mean follow up period was 35, 7 months. The mean time from injury to grafting is 53, 3 days. The results of the mean 2PDT and SWMT values of injured /uninjured finger at the end of follow up period were evaluated with Paired T test. The correlation between the defect length and the difference of 2PDT, SWMT values between the uninjured and injured finger at the end of follow up period; were evaluated with Pearson - correlation analysis.

Results:

The mean value of our 2PDT and SWMT results are ~5,923, ~3, 52, respectively in which can be interpreted between the normal and diminished light touch. The defect length and difference percentage of SWMT values is positively and significantly correlated statistically. Mean length of interposed nerve grafts was 18.5 mm. The age of the patient and the mean values of 2PDT and SWMT with the difference % of 2PDT and % of SWMT are not statistically correlated.

Conclusion:

Based on results regarding sensory regaining at recipient side and negligible sensory deficit at harvesting side, we suggest that lateral antebrachial cutaneous nerve might be a valuable graft option for digital nerve defects.

Comparison of different femoral fixation implants and fit techniques for tunnel widening and clinical outcome in ACL reconstruction using hamstring autograft

PURPOSE

The purpose of the current study is to investigate in different femoral fixation devices whether tight (undersize drilled) fit technique decreases the tunnel widening and improves the clinical outcome compared to conventional technique in ACL reconstruction using hamstring tendon autograft.

METHODS

93 patients, who underwent Arthroscopic ACL reconstruction whether cortical-cancellous suspension (CP) or cortical suspension (BF) used as fixation device for the hamstring tendon autograft, were included in the study. The cases also grouped as undersize drilled (tight fit) and normal drilled (normal fit) according to their autograft size. There was no difference in demographic data of these four subgroups (CP-TF, CP-NF, BF-TF, and BF-NF) preoperatively.

RESULTS

The patients, who had been followed for at least 2 years were included in the study. They were looked for their clinical outcome (Lysholm and IKDC scoring), tunnel widening (on AP and lateral radiographs), and also anterior translation. The BF-TF subgroup showed significantly the best clinical results compared to other three subgroups. There was no difference between BF-TF, CP-TF, and CP-NF in terms of tunnel widening.

CONCLUSION

Button fixation of femoral side in ACL reconstruction surgery has good clinical outcome and lower complication rate. Undersize drilling might be preferred in button fixation in order to reduce TW and improve stability and clinical satisfaction.

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

The effect of maternal nutrition level during mid-gestation on postnatal muscle fibre composition and meat quality in lambs

Maternal nutrient intake during early- and mid-gestation can alter fetal growth and development with long-term consequences on the postnatal productivity and health of offspring. The aim of this study was to investigate the effects of maternal nutrition level during mid-gestation on postnatal growth rate, carcass composition, muscle fibre characteristics and meat quality in lambs. Ewes were fed from Days 30 to 80 of gestation as follows: 100% (control group, C), 50% (undernutrition, UN) or 175% (overnutrition, ON) of their daily requirement. During the rest of the gestation, the ewes in all groups were fed 100% of their daily requirements. Birth and weaning (at Day 90) weights of lambs born to ewes in nutritional groups were similar, but slaughter weights (at Day 150) and daily weight gain during finishing period of lambs born to the UN group were lower (P < 0.05). Similarly, a decrease in weights of semitendinosus (ST), semimembranosus and gastrocnemius muscles was observed in the lambs born to the UN group (P < 0.05). Lambs born to the ON group had a higher (P < 0.05) concentration of DNA in longissimus dorsi (LD) and ST muscles than UN groups, but they had a lower (P < 0.05) total protein and other proteins concentrations in LD and ST muscles than those to C and UN groups. Protein to DNA ratio in LD and ST muscles of lambs born to ON group were lower than those to C and UN groups (P < 0.05). However, lambs born to the ON group had a higher number of Type IIA and IIB muscle fibres in ST muscles but not in LD muscles than those in the C and UN groups (P < 0.05). Additionally an increase in the number of fibres/mm2 muscle area in lambs born to the ON group was observed in LD and ST muscles (P < 0.05). There were no significant differences between treatment groups in terms of meat quality parameters studied. This study confirms that maternal nutrition level during mid-gestation alters the postnatal growth and muscle fibre development of lambs.

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.

[Treatment of comminuted intra-articular fractures of the distal radius by open reduction and volar plating in adults]

BACKGROUND

We herein present the mid-term results of the adult patients with comminuted intra-articular fractures of the distal radius who were treated by palmar plating.

METHODS

Between 1999 and 2003, open reduction and palmar plating were performed in 23 of the patients who had surgical treatment for comminuted intra-articular fractures of the distal radius. Nineteen patients (11 females, 8 males; mean age 34; range 22 to 54 years) with regular follow-up were included in the study. In the majority of patients only one wrist was involved (7 dominant - 12 nondominant). Preoperative evaluation included patient's history, physical examination, and radiological studies (plain radiographs, computed tomography). The patients were classified according to AO classification as 7 type B [B1 (1); B2 (3); B3 (3)] and 12 type C [C1 (7); C2 (5)]. The surgical procedure included internal fixation by using plates and screws with palmar approach. Range of motion exercises were started immediately after the operations. The patients were followed clinically and radiographically, with an average follow-up time of 28 months (range, 13-47 months). Complications were recorded.

RESULTS

Union was achieved in all patients. Radiographic parameters including the radial height, radial inclination, palmar tilt, and articular congruency have been corrected in the operation and remained unchanged until the last follow-up. According to the Gartland and Werley's classification, there were 9 (47%) excellent, 7 (37%) good, and 3 (16%) fair results. No perioperative and postoperative complications were recorded, except for three wound problems and one prolonged scar tenderness.

CONCLUSION

Palmar plating is a safe and effective treatment for comminuted intraarticular fractures of the distal radius, regardless of direction of displacement of the distal fragment.

[Surgical treatment of hand deformities in multiple enchondromatosis: a case report]

Multiple enchondromatosis (Ollier's disease) is a rare disease characterized by widespread enchondromas. In general, the short tubular bones of the hand are involved, with progressive lesions resulting in cosmetic problems and functional deformities. Diaphysectomy and reconstruction with structural autografts or allografts are usually recommended in the treatment of extensive enchondromas involving the fingers. Curettage and grafting and ray amputation are other surgical procedures that can be applied depending on the severity of involvement. A 25-year-old woman with enchondromatosis presented with severe swelling and deformities on her fingers in both hands. The majority of the lesions were managed by diaphysectomy and reconstruction with structural grafts; ray amputation, curettage and grafting were performed for more severe lesions. During a long-term follow-up (left hand 6 years, right hand 5.5 years) cosmetic and functional results were acceptable.

[The mid-term results of minimal medial epicondylectomy and decompression for cubital tunnel syndrome]

OBJECTIVES

We evaluated the mid-term follow-up results of patients who were treated by minimal epicondylectomy and decompression for cubital tunnel syndrome.

METHODS

The study included 17 elbows of 15 patients (9 females, 6 males; mean age 45 years; range 35 to 63 years) who underwent minimal medial epicondylectomy and in situ decompression for cubital tunnel syndrome, which was diagnosed through history, physical examination, and electrodiagnostic tests. Before surgery, all the patients received various conservative treatments for at least six months, with no beneficial effect. Thirteen patients had unilateral, two patients had bilateral involvement, with 11 elbows on the dominant side. The mean duration of symptoms was 14 months (range 3 to 36 months). Preoperative grading of nerve compression according to the McGowan system was as follows: three patients (20%) grade I, 11 patients (73.3%) grade II, and one patient (6.7%) grade III. The results of surgical treatment was evaluated according to the Wilson-Krout criteria. The mean follow-up was 32 months (range 25 to 64 months).

RESULTS

Symptomatic improvement was achieved in all the patients. The results were excellent in 11 elbows (64.7%), good in five elbows (29.4%), and fair in one elbow (5.9%). None of the patients developed ulnar nerve palsy or subluxation, medial elbow instability, or weakness of the flexor-pronator origin. Pain and tenderness detected at the osteotomy site in four elbows disappeared after a mean of three months.

CONCLUSION

Minimal medial epicondylectomy and decompression was found to be a safe and effective method with a low complication rate in the treatment of cubital tunnel syndrome.