Soft Tissue Metastasis from Carcinoma. A Case Report

The authors report a case of a man who developed soft tissue metastasis to the thigh from pulmonary carcinoma. In the preoperative staging, computerized tomograms and magnetic resonance imaging allowed to identify and characterize the features of soft tissue masses; these studies, however, must be always completed with needle (tru-cut) or incisional biopsy.

Neglected rupture of the Achilles tendon treated with a percutaneous technique

INTRODUCTION

Neglected rupture of Achilles tendon is an infrequent but debilitating injury. Several surgical methods of treatment have been described to repair neglected Achilles tendon rupture.

MATERIAL AND METHODS

In our study we reviewed 20 patients (18 male and 2 female). We describe a new surgical technique using percutaneous repair of the neglected Achilles tendon ruptures. It consists of 10 micro-incisions, five lateral and five medial to the posterior aspect of the Achilles tendon, the suture is performed using an absorbable number 1 Vicryl (Ethicon, Edinburgh UK) inserted percutaneously in a figure of eight fashion.

RESULTS

The advantages of this procedure are a short time immobilization, an early weight bearing and a return to complete ankle range of motion. The mean AOFAS score was 99.0, no re-ruptures or sural nerve damage were observed. In all the treated patients the results obtained were rated from good to excellent.

CONCLUSION

We would like to encourage this technique as being fast, inexpensive and very satisfactory both to the patient and to the surgeon.

Total hip arthroplasty revision in elderly people with cement and Burch-Schneider anti-protrusio cage

Total hip arthroplasty revision is increasingly becoming a common procedure, but the acetabular bone loss and the advanced age of the patients make revision procedures extremely complex and technically demanding. The aim of the present work is to examine the clinical and radiological results of the Burch-Schneider anti-protrusio cage (APC) implanted in revision hip arthroplasty with severe acetabular bone deficiency in elderly people. Between February 1994 and November 2005, a total of 60 revision operations of acetabular components were performed in 60 select patients (42 females and 18 males), using the Burch-Schneider APC. The indication for the Burch-Schneider APC use was massive pelvic bone loss with migration of the prosthesis cup and high-grade acetabular defects (type III or IV AAOS). The mean age at the time of surgery was 82 years (range 78-85 years). Polymethylmetacrylate cement (PMMA) was used to fill bony deficiencies in all the procedures. No graft was used. The average Harris Hip Score had improved from 28.2 preoperatively to 82.5 points at the time of follow-up. According to the classification of Gill et al., we have seen no Burch-Schneider cages definitely loose or probably. Only one acetabular component has been revised (for recurrent dislocation). Acetabular reconstruction with the use of cement and an acetabular support ring appears to have a useful role in the treatment of severe acetabular bony deficiency in elderly patients and may provide a definitive reconstruction.

Gastrocnemius flaps in the surgical treatment of sarcomas of the knee

The authors discuss their experience with the pediculated gastrocnemius flap used in the oncological surgery of the knee, in 27 patients. Three groups of patients are evaluated: in one group the method was used in patients affected with bone sarcoma and associated with reconstruction of the resected bone segment; in another group the method was used after infection had occurred as a result of reconstructive surgery; in the third group the method was used at the same time as excision of sarcomas of the soft tissues. The gastrocnemius flap may be used to cover sufficiently wide areas of loss of skin and muscular substance around the knee, and may be effectively used to cover metallic prostheses or composite reconstructive implants (bone-cement-metal). We recommend using the covering technique at the same time as resection and reconstruction are performed in order to avoid the risk of infection, and thus reduce any changes in chemotherapy protocols that postoperative infection would require in these patients. The use of the gastrocnemius flap associated with excision of sarcomas of the soft tissues must be reserved for selected cases. The high incidence of local recurrence after such excisions indicates that either wider excisions using distant free flaps or the association of radiotherapy should be considered.

[Magnetic resonance for the study of osteosarcoma]

The authors report their experience with MR imaging in the study of osteosarcoma. Two main elements were evaluated: signal characteristics and loco-regional staging. Seventy-one patients were studied: 65 of them had central long-bone osteosarcoma, and 6 had telangiectatic long-bone osteosarcoma. T1- and T2-weighted spin-echo sequences were employed and all cases were scanned on 3 planes (sagittal, coronal, and axial). In 28 patients MR imaging was performed both before and after preoperative chemotherapy. The obtained data were compared to surgical and pathological findings. With the exception of the typical signal patterns of quite-osteoblastic osteosarcoma (which presents with low signal on both T1- and T2-weighted sequences), no particular signal features were observed which could help distinguish the different types of osteosarcoma. MR imaging is the method of choice in loco-regional staging for, in our series, it allowed a rational and adequate surgical planning. For this purpose, at least a longitudinal T1- and an axial T2-weighted images are required.

Total body bone scan in the evaluation of tumor response to preoperative chemotherapy in the treatment of osteosarcoma

With the introduction of preoperative (neoadjuvant) chemotherapy in the treatment of osteosarcoma, an early preoperative evaluation of the effectiveness of chemotherapy is essential, so that treatment may be modified in cases which are not responsive, and so that the surgical margin may be planned. The authors evaluate the accuracy of total body bone scan with Tc99m MDP in determining response to chemotherapy in 43 patients affected with osteosarcoma of the limbs, and preoperatively submitted to two cycles of chemotherapy with MTX i.v. and CDP i.a. All of the cases were submitted to a double bone scan examination, before and after preoperative chemotherapy. A bone scan evaluation using a qualitative method was compared to the percentage of necrosis observed in the tumorous tissue by histological examination carried out after surgery. In 58% of the cases the two values corresponded perfectly, in 28% of the cases bone scan evaluation overestimated response, and in 14% it underestimated it. In order to obtain quantitative preoperative data on response to chemotherapy in osteosarcoma, orientation towards the use of more sophisticated bone scan methods seems to be necessary, with computerized analysis of captation by dynamic measurement after infusion of Tc99m MDP or by radiocompounds with intracellular fixation such as Ga 67.