Retrospective clinicopathological study of malignant bone tumors in children and adolescents in Romania - single center experience

RATIONALE

There is few data on epidemiology or clinico-pathology of malignant bone tumors in children and adolescents in Romania. These tumors are very rare compared to other malignancies, yet they account for a major source of mortality and morbidity among patients with cancer. Bone tumors often have a similar presentation and clinical approach, but they present individual characteristics that are important for treatment and prognosis.

OBJECTIVE

To describe the characteristics of primary malignant bone tumors in children and adolescents in Romania.

METHODS AND RESULTS

A retrospective analysis of all malignant bone tumors registered at a large referral center, "Maria Sklodowska Curie" Emergency Hospital for Children, between 2005 and 2013 was presented. A total of 146 biopsies and surgical resection specimens were reviewed during this period, and were classified as malignant bone tumors. There were 91 boys and 55 girls in the series, with a male-female ratio of 1.65:1. The average patient age was 13.32 years (2 to 19). The most common anatomical distribution of the tumors was femur - 32.19%, tibia - 25.34% and humerus - 11.64%. Histologically, we found osteosarcoma in 54.1% of all bone tumors, followed by Ewing's sarcoma - 30.82% and chondrosarcoma - 8.9%.

DISCUSSION

Geographic location did not appear to represent a risk factor for any particular type of bone tumor. Our results were parallel to the findings previously reported in the general literature; the distribution and the epidemiology were similar to those in the other developed and underdeveloped countries. Malignant bone tumors in our country have a high mortality rate, because of the late diagnosis.

Hip dysplasia screening - epidemiological data from Valcea County

RATIONALE

:In its most severe form, developmental dysplasia of the hip (DDH) is one of the most common congenital malformations. Uncorrected developmental dysplasia of the hip is associated with long-term morbidity such as gait abnormalities, chronic pain, and degenerative arthritis.

AIMS

(1) to identify the risks and predisposing factors involved in DDH (2) to define the incidence of the disease locally; (3) to emphasize the importance of ultrasonography in early diagnosis of DDH.

METHODS AND RESULTS

1021 newborns in the Neonatal Department of Valcea County Emergency Hospital were analyzed. The information contained in the observation sheets was collected and upon this, the ultrasound was performed accordingly to Graf's classification. The following parameters were analyzed: sex, area of origin, gestational age, birthweight, type of delivery, parturition. Out of 1021 newborns, 27 had an abnormal ultrasound examination. 20 infants were diagnosed with DDH. Regarding the risk factors: cephalic delivery was associated with a lower risk/ the lowest of DDH (with p=0.045 for the right hip and p=0.001 for the left hip). Increased gestational age and increased birthweight were incriminating factors in the occurrence of DDH.

DISCUSSION

Ultrasound imaging has become an accepted tool for accurately diagnosing DDH.

Congenital scoliosis: an up-to-date

Congenital scoliosis represents a spinal malformation due to defects of formation, segmentation or mixed ones. It is characterized by a longitudinal and rotational imbalance. 54 patients were analyzed and 39 out of them were operated by various approaches with anterior and posterior instrumentations during 2000 and 2012. The impossibility to appoint some patients encountered in the daily practice into the known classifications, allowed us to purpose two categories of congenital scoliosis related to the predominance of spinal deviances in the coronal and transversal views. No certain etiology of congenital scoliosis has been identified until today. The susceptibility of some polygenic defects is obvious due to the presence of a sum of defects associated to most of the congenital scoliosis cases and the rarity of the presence of a unique defect. The diagnosis requires a thorough clinical and imaging examination in order to establish an individualized therapeutic strategy. The treatment of congenital scoliosis is different from the adolescent idiopathic one. Therapeutic criteria are significantly different. It is essential to assess the difference in growth of the concavity related to the convexity when choosing a particular procedure. The magnitude of the curve and the progressive rate are fundamental issues to the surgeon.

Pesamosca osteoplasty: surgical procedure for the spatial correction of cubitus varus or valgus post malunited supracondylar fractures of the humerus

INTRODUCTION

Supracondylar fractures of the humerus represent a current concern in the child's and adolescent's osteo-articular pathology. Even though orthopedic reductions are made correctly, fractures can become displaced when managed only by cast immobilization and complications may arise. The most frequent complications encountered in "Prof. Dr. Alexandru Pesamosca" Clinique, Bucharest, Romania, due to supracondylar humeral fractures, are valgus or varus deviations with angles that can sometimes exceed 40 degrees as a result of malunion. Varus or valgus deformations were rarely encountered after surgical treatment. The goal of this study is to present an alternative surgical technique to correct varus and valgus deformations as well as malrotation.

MATERIAL AND METHOD

The study is a retrospective analysis of a 96 children study group surgically managed during 1985 and 2013. In the first period, various surgical techniques have been performed: cuneiform resections, step-cut osteotomies, open wedge osteotomies with external fixation, epiphysiodesis, hemichondrodiatasis and Pesamosca metaphyseal diaphyseal osteoplasty. Starting with 2005, all the cases that presented such complications--28 out of 96 (29.1%)--were managed with the Pesamosca procedure. Due to the malunion of supracondylar humeral fractures only varus or valgus deformities were admitted in the study. The malunion due to the pathologic fractures encountered in osteogenesis imperfecta or fibrous dysplasia was precluded. The experience accumulated with the other surgical techniques used in 68 out of 96 patients (70.9%) determined us to exclusively use the Pesamosca osteoplasty following the year 2005, seeing the simplicity and the efficiency of this procedure.

RESULTS

The outcome was very good. In 5 cases out of the 28 (17%) an apparent residual elbow was encountered and one case of relapse (3%) was noted due to inadequate term of cast immobilization. The elbow's mobility was completely recovered, the thoracic member's axis was appropriate and the metaphyseal diaphyseal osteotomy site healed completely in 3 months' time.

CONCLUSIONS

Compared to other surgical techniques, the Pesamosca technique offers to the surgeon the possibility of correcting the varus or the valgus deformity as well as the malrotation in a simple, secure and efficient manner.

Proteus Syndrome: a difficult diagnosis and management plan

RATIONALE

Proteus Syndrome (PS) is an extremely rare congenital pathology that causes overgrowth of multiple tissues, in particular bone and fat, following a mosaic pattern. The estimated incidence is of less than 1 per 1,000.000 live births and represents a significant challenge to the pediatric and orthopedic surgeons in order to establish a diagnosis and to elaborate a management plan.

OBJECTIVES

We had the opportunity of treating many children who were afflicted by overgrowth syndromes and have been previously misdiagnosed as Proteus Syndrome in our department of pediatric and orthopedic surgery of "Maria Sklodowska Curie" Clinical Emergency Hospital for Children. This study helped us develop a diagnostic for these patients and report the first case of a confirmed PS in Romania.

METHODS AND RESULTS

We report the case of a 5-year-old white male who is in the attention of the clinic since birth. He presented with multiple overgrowth bone segments, fatty subcutaneous or intraabdominal tumors and other connective tissues abnormalities. All the tests performed confirmed the diagnosis of PS at the age of 4 and the management is still to be decided.

DISCUSSIONS

We followed the latest diagnostic indications and the patient fulfilled the general and specific criteria. The treatment is still in progress and it represents a challenge for the multidisciplinary medical team.

Proximal congenital radial-ulnar synostosis and synchondrosis; pathogenic concept and a new therapeutic method

BACKGROUND CONTEXT

Proximal congenital radial-ulnar synostosis (PCRUS) is defined by the development before birth of a bony bridge between the radius and ulna, usually at the proximal level, which blocks forearm rotation. This anomaly is rarely reported in the medical literature, because of its low prevalence, and treatment usually yields unsatisfactory results. The most commonly used surgical interventions are: forearm repositioning osteotomies with derotation of the radius and ulna, segmental resections of the middle third of the radius with muscular interposition, resection of the synostosis with the interposition of fatty tissue, tendons or fascia lata and resection of the proximal radius along with the transfer of the distal extensor carpi ulnaris tendon on the lateral edge of the radius.

PURPOSE

To describe a new treatment method for PCRUS, which we based on a new pathogenic concept, and to present our preliminary results.

MATERIALS AND METHOD

Between 2011 and 2013 our team performed two myo-osteo-arthroplastic reconstructions of the elbow and forearm for PCRUS. The intervention involves the extraperiosteal stripping of the origins of the ventral forearm musculature, release of the interosseous membrane, resection of the proximal two thirds of the radius, reshaping of the synostosis, a double osteotomy of the ulna and the transfer and fixation of a proximal fibular graft, including the head with its articular cartilage, in place of the resected segment of the radius.

RESULTS

Our preliminary study reveals favorable postoperative results, in comparison with other published methods. At the latest follow-up, one case had -10 degrees of pronation and 68 degrees of supination, and the other had 10 degrees of pronation and 66 degrees of supination.

CONCLUSIONS

Compared with other techniques, myo-osteo-arthroplastic reconstruction may seem overly invasive. However, the extent of this intervention is mandated by the pathogenic concepts of helical distortion, muscular retraction and anomalous configuration of the interosseous membrane. Benign cases do not require surgery. When there is no helical distortion, the intervention may be limited to the transfer of the proximal extremity of the fibula for the infant and small child.

The electromagnetic bio-field: clinical experiments and interferences

INTRODUCTION

One of the most important factors is the technical and scientifically rapid development that is continually modifying the world we live in and polluting it with electromagnetic radiations. A functional and structural influence of magnetic and electromagnetic field on living organisms is presented in the literature by many performed experiments.

MATERIAL AND METHODS

The notion of bio-field represents the electromagnetic field generated by the bio-structures, not only in their normal physiological activities but also in their pathological states. There is a tight interdependency between the bio-field and the bio-structure, which respects the primary notion of an electromagnetic field given by the Maxwell-Faraday laws, in which, the electromagnetic phenomena are simplified to the field variations. These variations can be expressed in a coherent differential equation system that bounds the field vectors to different space points at different time moments.

RESULTS

The living organisms cannot contain electrostatic and magneto-static fields due to the intense activity of the bio-structures. The biochemical reactions that have high rhythms and speeds always impose the electrodynamics character of the biologic field that also corresponds to the stability of the protein molecule that can be explained only through a dynamic way. The existent energy is not considered an exciting agent, and it does not lead to any effects.

CONCLUSIONS

The parameters of these elementary bio-fields cannot yet be fully known due to technical reasons. The biological structures are very complex ones and undergo continuous dynamical activity. That is why the calculus model should be related to the constant dynamics, nowadays being very difficult to express.

Molecular basis of vascular events following spinal cord injury

The aim of this article is to analyze the effects of the molecular basis of vascular events following spinal cord injury and their contribution in pathogenesis. First of all, we reviewed the anatomy of spinal cord vessels. The pathophysiology of spinal cord injuries revealed two types of pathogenic mechanisms. The primary event, the mechanic trauma, results in a disruption of neural and vascular structures into the spinal cord. It is followed by secondary pathogenesis that leads to the progression of the initial lesion. We reviewed vascular responses following spinal cord injury, focusing on both primary and secondary events. The intraparenchymal hemorrhage is a direct consequence of trauma; it has a typical pattem of distribution into the contused spinal cord, inside the gray matter and, it is radially extended into the white matter. The intraparenchymal hemorrhage is restricted to the dorsal columns, into adjacent rostral and caudal spinal segments. Distribution of chronic lesions overlaps the pattern of the early intraparenchymal hemorrhage. We described the mechanisms of action, role, induction and distribution of the heme oxygenase isoenzymes 1 and 2. Posttraumatic inflammatory response contributes to secondary pathogenesis. We analyzed the types of cells participating in the inflammatory response, the moment of appearance after the injury, the decrease in number, and the nature of their actions. The disruption of the blood-spinal cord barrier is biphasic. It exposes the spinal cord to inflammatory cells and to toxic effects of other molecules. Endothelin 1 mediates oxidative stress into the spinal cord through the modulation of spinal cord blood flow. The role of matrix metalloproteinases in blood-spinal cord barrier disruption, inflammation, and angiogenesis are reviewed.

Vascular dysfunctions following spinal cord injury

The aim of this article is to analyze the vascular dysfunctions occurring after spinal cord injury (SCI). Vascular dysfunctions are common complications of SCI. Cardiovascular disturbances are the leading causes of morbidity and mortality in both acute and chronic stages of SCI. Neuroanatomy and physiology of autonomic nervous system, sympathetic and parasympathetic, is reviewed. SCI implies disruption of descendent pathways from central centers to spinal sympathetic neurons, originating in intermediolateral nuclei of T1-L2 cord segments. Loss of supraspinal control over sympathetic nervous system results in reduced overall sympathetic activity below the level of injury and unopposed parasympathetic outflow through intact vagal nerve. SCI associates significant vascular dysfunction. Spinal shock occurs during the acute phase following SCI and it is a transitory suspension of function and reflexes below the level of the injury. Neurogenic shock, part of spinal shock, consists of severe arterial hypotension and bradycardia. Autonomic dysreflexia appears during the chronic phase, after spinal shock resolution, and it is a life-threatening syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5-T6). Arterial hypotension with orthostatic hypotension occurs in both acute and chronic phases. The etiology is multifactorial. We described a few factors influencing the orthostatic hypotension occurrence in SCI: sympathetic nervous system dysfunction, low plasma catecholamine levels, rennin-angiotensin-aldosterone activity, peripheral alpha-adrenoceptor hyperresponsiveness, impaired function of baroreceptors, hyponatremia and low plasmatic volume, cardiovascular deconditioning, morphologic changes in sympathetic neurons, plasticity within spinal circuits, and motor deficit leading to loss of skeletal muscle pumping activity. Additional associated cardiovascular concerns in SCI, such as deep vein thrombosis and long-term risk for coronary heart disease and systemic atherosclerosis are also described. Proper prophylaxis, including non-pharmacologic and pharmacological strategies, diminishes the occurrence of the vascular dysfunction following SCI. Each vascular disturbance requires a specific treatment.

Discal hernia in children and teenagers: medical, surgical and recovery treatment

Lumbar disc hernia represents a rare situation for the physician. The first intervention in disc hernia was performed during the '40. The rate of surgery needing lumbar hernia is about 1-2%. Lumbar disc hernia in children and teenagers has 4 main causes: familial history, trauma, congenital malformation of the spine and disc degeneration. The symptoms in young patients are dominated by local or ischiadic irradiated pain, but neurological discrepancies rarely occur.

Von Recklinghausen's disease--elements of clinical practice

Neurofibromatosis is a condition described for the first time by Von Recklingahausen in 1882. This disease is one of the most common genetic disorders and is characterized by multiple tumors of the central and peripheral nervous system, brown macules on the skin, bone deformities, and by vascular and visceral disorders. Despite extensive basic science research, the diagnosis is still based largely on clinical criteria, which often present gradually during childhood.