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CORR Insights®: Does the Addition of a Vascularized Fibula Improve the Results of a Massive Bone Allograft Alone for Intercalary Femur Reconstruction of Malignant Bone Tumors in Children? Clin Orthop Relat Res 2021; 479:1309-1310. [PMID: 33635284 PMCID: PMC8133106 DOI: 10.1097/corr.0000000000001701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/04/2021] [Indexed: 01/31/2023]
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Abstract
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: IV Cite this article: Bone Joint Open 2020;2(1):3–8.
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Knee-related quality of life, functional results and osteoarthritis at a minimum of 20 years' follow-up after anterior cruciate ligament reconstruction. Knee 2019; 26:666-672. [PMID: 31103415 DOI: 10.1016/j.knee.2019.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 03/18/2019] [Accepted: 04/14/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Few studies in the literature show results with more than 20 years of follow-up after anterior cruciate ligament reconstruction (ACLR). The main purpose of this retrospective study was to describe knee-specific quality of life, functional results and prevalence of osteoarthritis (OA) of the knee in patients with ACLR using bone-patellar tendon-bone (BPTB) autograft with ultra-long-term follow-up. METHODS Prospective analyzed data included demographics, meniscus status, radiographic OA, KT-1000 arthrometer measurements and physical examinations. KOOS, Lysholm and IKDC subjective surveys were conducted. Multivariate and univariate logistic models were used to determine the effect of potential predictors of OA and symptomatic knees. RESULTS Seventy-two knees were included at a median follow-up of 22 (IQR 21-25) years postoperatively. Radiographic scores were normal in 15%, nearly normal in 57%, abnormal in 18% and severely abnormal in 10%. Multivariate analysis showed that the predictive factor for the presence of OA in the long-term was an associated meniscal lesion; patients with meniscal lesions were 3.9 times as likely to develop OA in comparison with those without meniscal injury. The subjective scores were progressively and significantly lower as the level of OA was greater. CONCLUSION At a median of 22 years of follow-up, this study shows that patellar tendon autograft ACL reconstruction provides good clinical outcomes, with clinically objective knee stability and a 28% prevalence of OA. Additionally, we identified that meniscal injury at time of surgery was an independent predictor of OA. LEVEL OF EVIDENCE Level IV; case series.
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What Are the Complications of Allograft Reconstructions for Sarcoma Resection in Children Younger Than 10 Years at Long-term Followup? Clin Orthop Relat Res 2018. [PMID: 29529639 PMCID: PMC6260017 DOI: 10.1007/s11999.0000000000000055] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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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Is Navigation-guided En Bloc Resection Advantageous Compared With Intralesional Curettage for Locally Aggressive Bone Tumors? Clin Orthop Relat Res 2018. [PMID: 29529633 PMCID: PMC6260034 DOI: 10.1007/s11999.0000000000000054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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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Proximal Tibia Reconstruction After Bone Tumor Resection: Are Survivorship and Outcomes of Endoprosthetic Replacement and Osteoarticular Allograft Similar? Clin Orthop Relat Res 2017; 475:676-682. [PMID: 27103142 PMCID: PMC5289179 DOI: 10.1007/s11999-016-4843-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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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What Happens to the Articular Surface After Curettage for Epiphyseal Chondroblastoma? A Report on Functional Results, Arthritis, and Arthroplasty. Clin Orthop Relat Res 2017; 475:760-766. [PMID: 26831477 PMCID: PMC5289155 DOI: 10.1007/s11999-016-4715-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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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MESH Headings
- Adolescent
- Adult
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/instrumentation
- Child
- Chondrosarcoma/diagnostic imaging
- Chondrosarcoma/pathology
- Chondrosarcoma/surgery
- Curettage/adverse effects
- Databases, Factual
- Epiphyses/pathology
- Epiphyses/surgery
- Female
- Femoral Neoplasms/diagnostic imaging
- Femoral Neoplasms/pathology
- Femoral Neoplasms/surgery
- Hip Prosthesis
- Humans
- Humerus/pathology
- Humerus/surgery
- Kaplan-Meier Estimate
- Magnetic Resonance Imaging
- Male
- Neoplasm Recurrence, Local
- Orthopedic Procedures/adverse effects
- Orthopedic Procedures/methods
- Osteoarthritis, Hip/diagnosis
- Osteoarthritis, Hip/etiology
- Osteoarthritis, Hip/surgery
- Reoperation
- Retrospective Studies
- Risk Factors
- Talus/pathology
- Talus/surgery
- Tibia/diagnostic imaging
- Tibia/pathology
- Tibia/surgery
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Young Adult
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In Vitro Comparative Study Between Conventional and Computer-Assisted Surgery Methods for Planning and Resection of Bone Sarcomas. Stud Health Technol Inform 2017; 245:1375. [PMID: 29295454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This poster aims to achieve an "in vitro" comparative study between three methods: 2D digital images planning and execution without navigation (freehand with ruler and caliper), 3D planning and execution without navigation (freehand with ruler and caliper) and 3D planning and execution guided with navigation. 3D planning and navigated procedures potentially improve sarcoma resection.
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Structural allograft reconstruction of the foot and ankle after tumor resections. Musculoskelet Surg 2016; 100:149-156. [PMID: 27324025 DOI: 10.1007/s12306-016-0413-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Structural allografts have been used to correct deformities or to fill bone defects secondary to tumor excisions, trauma, osteochondral lesions, or intercalary arthrodesis. However, the quality of published evidence supporting the use of allograft transplantation in foot and ankle surgery has been reported as fair. The purpose of this study was to report the overall survival of structural allograft in the foot and ankle after tumor resection, and the survival according to the type of allograft and the complication rates in the medium to long term. MATERIALS AND METHODS From January 1989 to June 2011, 44 structural allograft reconstructions of the foot and ankle were performed in 42 patients (28 men and 14 women) due to musculoskeletal tumor resections. Mean age at presentation was 27 years. Mean follow-up was 53 months. Demographic data, diagnosis, site of the neoplasm, operations performed, operative complications, outcomes after surgery, date of last follow-up evaluation, and local recurrences were reviewed for all patients. Regarding the type of 44 allograft reconstructions, 16 were hemicylindrical allografts (HA), 12 intercalary allografts (IA), 10 osteoarticular allografts (OA), and 6 were total calcaneal allograft (CA). RESULTS The overall allograft survival rate, as calculated with the Kaplan-Meier method, at 5 and 10 years was 79 % (95 % CI 64-93 %). When allocated by type of allograft reconstruction the specific allograft survival at 5 and 10 years was: 83 % for CA, 80 % for HA, 77 % for OA, and 75 % for IA. The complications rate for this series was 36 % including: articular failure, local recurrence, infection, fracture and nonunion. CONCLUSION This study showed that structural allograft reconstruction in the foot and ankle after tumor resection may be durable with a 79 % survival rate at 5 and 10 years. The two types of allografts that showed better survival rate were hemicylindrical allografts (80 %) and calcaneus allografts (83 %). The highest complication rates occurred after calcaneus allografts and osteoarticular allografts. LEVEL OF EVIDENCE IV.
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Abstract
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.
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Oncologic and clinical outcomes in pelvic primary bone sarcomas treated with limb salvage surgery. Musculoskelet Surg 2015; 99:237-242. [PMID: 26238978 DOI: 10.1007/s12306-015-0379-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/16/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE We propose to study a group of patients with primary bone sarcoma of the pelvis treated with limb salvage surgery and analyze overall survival, local recurrence rates and functional outcomes. METHODS A retrospective review was performed, and all patients diagnosed with pelvic primary bone sarcomas between 1990 and 2012 were analyzed. Patients treated with limb salvage surgery and with a minimum of 12-month follow-up for patients alive were included. The overall survival and the local recurrence rate were calculated for the assessment of oncological results. The associations with gender, age, histological grade, type of surgery, margins chemotherapy response and use of navigation were examined. RESULTS Fifty-two patients were included in the study. The mean age was 37 years (range 10-82), and mean follow-up was 44 months (range 8-189). Forty-five (86 %) tumors were histologically classified as high-grade sarcomas, four (8 %) as low-grade sarcomas and three (6 %) as dedifferentiated sarcomas. Cancer-specific overall survival was 37.5 % for 5 years and 31 % for 10 years. Local recurrence rate was 30 %. High-grade tumors and chemotherapy necrosis below 90 % were negative prognosis factor. Postoperative complication rate was 34.5 % (n:18), being deep infection the most prevalent (n:13). Reconstruction of the pelvis after an oncology resection for primary pelvic sarcomas increased the incidence of complication significantly (p < 0.001). CONCLUSION Primary bone sarcomas involving the pelvis are suggestive of a high-grade tumor and present poor oncologic outcomes. Pelvic reconstruction after a limb salvage surgery is associated with a high risk of complication. LEVEL OF EVIDENCE Case series, Level IV.
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The principles and applications of fresh frozen allografts to bone and joint reconstruction. Orthop Clin North Am 2014; 45:257-69. [PMID: 24684919 DOI: 10.1016/j.ocl.2013.12.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fresh frozen allograft reconstruction has been used for a long time in massive bone loss in orthopedic surgery. Allografts have the advantage of being biologic reconstructions, which gives them durability. Despite a greater number of complications in the short term, after 5 years these stabilize with high rates of survival after 10 years. The rate of early complications and the need for careful management in the first years has led the orthopedic surgeon to the use of other options. However, the potential durability of this reconstruction makes this one of the best options for younger patients with high life expectancy.
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[Surgical treatment of locally aggressive and malignant tumors of the proximal third of the fibula. Oncology results and functional evaluation]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014; 58:212-6. [PMID: 24461350 DOI: 10.1016/j.recot.2013.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/18/2013] [Accepted: 11/19/2013] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Proximal fibula malignant and locally aggressive benign bone tumors are uncommon and usually treat by surgery. Bloc resection of the knee can compromise knee stability due to of the resection of the posterolateral ligament complex. MATERIAL AND METHODS We analyzed 28 consecutive patients treated for a proximal fibula bone tumor between 1980 and 2006 (osteosarcoma: 9, giant cell tumor: 9, Ewing sarcoma: 8 and chondrosarcoma: 2). Sixty-one percent were male and the median age was 21 years (range: 8-60). The mean follow-up was 86 months. The posterolateral complex was reinserted at tibial metaphyseal level. Patients were evaluated functionally using the Musculoskeletal Tumor Society scale (MSTS). RESULTS Overall survival rate was 89%, local recurrence rate was 11%, and secondary amputation rate was 6% at 7 years of median follow-up. The average MSTS score was 93%. Five patients had neurological complications. No patient experienced subjective instability or vascular insufficiency. CONCLUSIONS Bloc resection of the proximal fibula for the treatment of aggressive or malignant primary bone tumors allowed us to obtain local tumor control, and overall survival rate for sarcomas of 89% at 7 years. The posterolateral ligament complex tibial reinsertion provided functional knee stability without major functional consequences in the medium term.
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Abstract
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.
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Abstract
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.
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Bone tumor resection: analysis about 3D preoperative planning and navigation method using a virtual specimen. Stud Health Technol Inform 2013; 192:1162. [PMID: 23920936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The use of three-dimensional preoperative planning and bone tumor resection guided by navigation has increased in the last ten years. However, no study to date, as far as we know, has directly provided evidence of accuracy of this method. The objective of this study was to describe a method capable of determining the accuracy of osteotomies performed for tumor resection planned and guided by navigation. We hypothesize that matching the 3D reconstructed surgical specimen is an acceptable method to determine the accuracy of virtual planning and navigation. A total of seven patients and 14 osteotomies were evaluated. After surgery, all surgical specimens were 3D reconstructed from CT images. The mean of quantitative comparisons between osteotomies planned and osteotomies obtained through the resected specimen was in a global mean of 1.56 millimeters (SD: 2.91) for all the cases. Based on our observations, a three-dimensional model obtained from the tumor surgical specimen is a useful tool to determine accuracy of 3D planning and surgical navigation.
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Abstract
Reconstruction after intercalary resection of the tibia is demanding due to subcutaneous location, poor vascularity of the tibia, and high infection rate. The purpose of this study was to evaluate the survivorship, complications, and functional outcome of intercalary tibial allograft reconstructions following tumor resections. Intercalary tibia segmental allografts were implanted in 26 consecutive patients after segmental resections. Patients were followed for an average of 6 years. Allograft survival was determined with the Kaplan-Meier method. Patient function was evaluated with the Musculoskeletal Tumor Society (MSTS) scoring system. Survivorship was 84% (95% confidence interval [CI], 98%-70%) at 5 years and 79% (95% CI, 63%-95%) at 10 years. Allografts were removed in 5 patients due to 3 infections and 2 local recurrences. Two patients showed diaphyseal nonunion, and 3 patients underwent an incomplete fracture; no allografts were removed in these patients. Average MSTS functional score was 29 points (range, 27-30 points). Despite the incidence of complications, this analysis showed an acceptable survivor-ship with excellent functional scores. The use of intercalary allograft has a place in the reconstruction of a segmental defect created by the resection of a tumor in the diaphyseal or metaphyseal portion of the tibia.
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19
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Abstract
Intraoperative ultrasonography is a useful tool for the detection and extirpation of liver metastases, breast masses, and melanoma. However, the efficacy of this technology in intraoperative localization and resection of small soft tissue tumors has not been addressed. The purpose of this study is to report on the efficacy of intraoperative ultrasound assistance in excising impalpable musculoskeletal soft tissue tumors. Twenty-two soft tissue tumors <3 cm (range, 0.7-3 cm) were resected with intraoperative ultrasound assistance. All tumors were localized in the deep panniculus, fascia, or muscle. Surgical time and length of incisions was recorded in all the cases. Intra- and postoperative reregistration was made to confirm the tumor resection. Ultrasound assistance was successful in obtaining an accurate localization in all treated cases. Mean surgical time was 30 minutes (range, 13-87 minutes). Average incision length was 5.7 cm (range, 2.5-10.6 cm). Reregistration allowed intraoperative confirmation of the adequacy of the excision. The procedure allowed recognized and excised additional nodules not previously diagnosed in 3 cases. Postoperative echography done in all patients confirmed complete extirpation of the tumors, and histopathology confirmed adequate margins obtained. Intraoperative ultrasound can be used as an efficient tool to localize and treat impalpable small soft tissue tumors.
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Case report: Common femoral artery ligation after sarcoma resection in an infant. Clin Orthop Relat Res 2011; 469:609-12. [PMID: 20668968 PMCID: PMC3018193 DOI: 10.1007/s11999-010-1494-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 07/16/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vascular reconstruction in infants constitutes a surgical challenge and is indicated frequently for acute occlusions. With the presence of a subacute vascular occlusion, including that produced by tumor resection, collateral circulation develops quickly. Thus a surgeon can consider tumor and vessel resection, without the need for vascular reconstruction. CASE DESCRIPTION We report the 2-year postoperative outcome of a 2-month-old boy who had a groin synovial cell sarcoma with vascular involvement, treated using limb salvage surgery with resection of the femoral vessels and without performing vascular reconstruction. LITERATURE REVIEW In adults with military wounds, ligation of the superficial femoral artery and common femoral artery reportedly result in amputation rates of 54% and 86%, respectively. Infants with a common femoral artery ligation may have a lower amputation rate because of some congenital collateral vessels, such as the sciatic artery. Further, when tumors involve major peripheral vessels, subacute or chronic vascular compression likely would facilitate development of collateral circulation. Similar chronic situations have been described in adults treated with debridement and common femoral artery ligation, after infected femoral artery pseudoaneurysms. PURPOSES AND CLINICAL RELEVANCE Considering our patient's history and clinical and radiographic findings, infants with musculoskeletal sarcomas involving vascular structures can be treated selectively with tumor and vessel resection without the need for vascular reconstruction if distal limb perfusion is detected intraoperatively.
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Abstract
BACKGROUND The emergence of limb salvage surgery as an option for patients with osteosarcoma is attributable to preoperative chemotherapy and advancements in musculoskeletal imaging and surgical technique. While the indications for limb salvage have greatly expanded it is unclear whether limb salvage affects overall survival. QUESTIONS/PURPOSES We asked whether over the past three decades limb-sparing procedures in high-grade osteosarcoma had increased, and whether this affected survival and ultimate amputation. METHODS We retrospectively reviewed 251 patients with high-grade osteosarcoma treated from 1980 to 2004 with a multidisciplinary approach, including neoadjuvant chemotherapy. We compared survival rates, limb-salvage treatment, and amputation after limb-sparing procedure during three different periods of time. Fifty-three patients were treated from 1980 to 1989, 97 from 1990 to 1999, and 101 from 2000 to 2004. Thirty-seven patients were treated with primary amputations and 214 with primary limb salvage. RESULTS The 5-year survival rate in the first period was 36%, whereas in the 1990 s, it was 60% and 67% from 2000-2004. Limb salvage surgery rate in the 1980s was 53% (28 of 53), whereas in the 1990 s, it was 91% (88 of 97) and 97% from 2000-2004 (98 of 101). In the limb salvage group, 22 of the 214 patients (10%) required secondary amputation; the final limb salvage rate in the first period was 36% (19 of 53), whereas in the 1990 s, it was 81% (79 of 97) and 93% from 2000-2004 (94 of 101). CONCLUSIONS Patients with osteosarcoma treated in the last two periods had higher rates of limb salvage treatment and survival, with lower secondary amputation.
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Proximal tibia osteoarticular allografts in tumor limb salvage surgery. Clin Orthop Relat Res 2010; 468:1396-404. [PMID: 20020336 PMCID: PMC2853677 DOI: 10.1007/s11999-009-1186-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Accepted: 11/23/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Resection of large tumors of the proximal tibia may be reconstructed with endoprostheses or allografts with fixation. Endoprosthetic replacement is associated with high failure rates and complications. Proximal tibia osteoarticular allografts after tumor resection allows restoration of bone stock and reconstruction of the extensor mechanism, but the long-term failure rates and complications are not known. QUESTIONS/PURPOSES We therefore determined (1) the middle- and long-term survival of proximal tibia osteoarticular allografts, (2) their complications, and (3) functional (Musculoskeletal Tumor Society score) and radiographic (International Society of Limb Salvage) outcomes in patients treated with this reconstruction. PATIENTS AND METHODS We retrospectively reviewed 52 patients (58 reconstructions including six repeat reconstructions) who underwent osteoarticular proximal tibia allograft reconstructions after resection of a bone tumor. The minimum followup of the 46 surviving patients was 72 months (mean, 123 months; range, 10-250 months). Survival of the allograft was estimated using the Kaplan-Meier method. We documented outcomes using the Musculoskeletal Tumor Society functional scoring system and the International Society of Limb Salvage radiographic scoring system. RESULTS Six patients died from tumor-related causes without allograft failure before the 5-year radiographic followup. At last followup, 32 of the 52 remaining allografts were still in place; 20 failed owing to infections, local recurrences, or fractures. Overall allograft survival was 65% at 5 and 10 years, with an average Musculoskeletal Tumor Society functional score of 26 points and an average radiographic result of 87%. CONCLUSIONS Based on these data we believe proximal tibia osteoarticular allograft is a valuable reconstructive procedure for large defects after resection of bone tumors. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Proximal femur allograft-prosthesis with compression plates and a short stem. Clin Orthop Relat Res 2010; 468:224-30. [PMID: 19488824 PMCID: PMC2795834 DOI: 10.1007/s11999-009-0903-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 05/11/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Proximal femur allograft-prosthesis composites (APCs) performed with compression plates and a short stem theoretically could minimize the resorption or nonunion that reportedly occurs with long stems bypassing the diaphyseal osteotomy. To confirm this theoretical consideration, we retrospectively reviewed 34 patients with 38 proximal femoral APCs using a short-cemented femoral stem and compression plates for diaphyseal osteotomy fixation. In 26 patients, the plate fixation extended over at least half the femoral stem and in 12, it did not. We reinserted the abductor mechanism with two techniques: in 10 cases the host trochanter was reattached to the APC, and in 28 the host tendons were sutured to the tendinous insertion of the allograft. The overall survival of the entire series was 72% at 5 years and 69% at 10 years. Eleven of the 38 (29%) APCs were removed: three for infection, one for local recurrence of tumor, and seven for fractures. Trendelenburg gait occurred in four of 21 patients with direct tendon-to-tendon suture of the abductor mechanism and in three of six patients with trochanteric osteotomy. The overall APC survival rate was greater in patients in whom the allograft was adequately protected with internal fixation than in patients in whom it was not. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Massive bone loss from fungal infection after anterior cruciate ligament arthroscopic reconstruction. Clin Orthop Relat Res 2009; 467:2420-5. [PMID: 19190972 PMCID: PMC2866916 DOI: 10.1007/s11999-009-0714-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 01/12/2009] [Indexed: 01/31/2023]
Abstract
Although there are numerous reports of septic pyogenic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction, there is limited information regarding the outcomes of fungal infection. We determined the outcomes of six patients with mycotic infection after regular ACL reconstruction. There were four males and two females with a mean age of 33 years. We determined the number of procedures performed, bone loss originating to control infection, and final reconstruction in these patients. An average of five arthroscopic lavage procedures had been performed at the referring centers. Fungal infection was diagnosed based on pathologic samples; five infections were the result of mucormycosis and one was Candida. After final débridement, the mean segmental bone loss was 12.8 cm. All patients were treated with intravenous antifungal coverage and cement spacers before final reconstruction. At final followup, all patients were free of clinical infection. Three had reconstruction with an allograft-prosthesis composite, two with hemicylindrical allografts, and one with an intercalary allograft arthrodesis. Despite the extremely unusual presentation of this complication, surgeons should be aware of potential and catastrophic consequences of this severe complication after ACL reconstruction.
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Abstract
BACKGROUND In the management of a resected distal femoral or proximal tibial condyle as the result of tumor or trauma, a unicondylar osteoarticular allograft is currently the only reconstructive option that avoids the sacrifice of the unaffected condyle. The purposes of this study were to perform a survival analysis of unicondylar osteoarticular allografts of the knee and to evaluate the complications. METHODS We retrospectively reviewed the results of forty large unicondylar osteoarticular allograft procedures in thirty-eight patients who were followed for a mean of eleven years. Twenty-nine allografts were femoral transplants and included eleven medial and eighteen lateral femoral condyles. Eleven allografts were tibial transplants, including four medial and seven lateral tibial condyles. The procedure was performed after a tumor resection in thirty-six patients and to replace condylar loss after a severe open fracture in the remaining two patients. Complications were analyzed, and allograft survival from the date of implantation to the date of revision or the time of the latest follow-up was determined. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS One patient died of tumor-related causes without allograft failure before the two-year follow-up evaluation. The global rate of allograft survival at both five and ten years was 85%, with a mean follow-up of 148 months. In six patients, the allografts were removed at an average of twenty-six months (range, six to forty-eight months) and these were considered failures. All six patients underwent a second allograft procedure including two new unicondylar and four bicondylar reconstructions. The mean radiographic score for the thirty-three surviving allografts evaluated was 89%, with an average functional score of 27 of a possible 30 points. CONCLUSIONS Unicondylar osteoarticular allografts of the knee appear to be a reliable alternative for patients in whom reconstruction of massive osteoarticular bone loss is limited to one condyle of the femur or tibia.
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Allograft reconstruction after sarcoma resection in children younger than 10 years old. Clin Orthop Relat Res 2008; 466:1856-62. [PMID: 18506559 PMCID: PMC2584248 DOI: 10.1007/s11999-008-0303-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 04/30/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Preservation of limb function in pediatric oncology patients is challenging with the ongoing growth of limbs contralateral to reconstructed limbs. We analyzed 22 patients younger than 10 years old who received an allograft after resection of a bone sarcoma with a minimum followup of 2 years (mean, 4 years; range, 2-14 years). The mean age was 7 years (range, 2-10 years). There were 16 boys and six girls with 17 osteosarcomas and five Ewing's sarcomas. Thirteen reconstructions were performed with an intercalary allograft and nine with an osteoarticular allograft. Physes were uninvolved in five patients and one physis in 17. We documented outcomes using the Musculoskeletal Tumor Society functional and the International Society of Limb Salvage radiographic scoring systems. At last followup, three of the 22 patients died of their tumor, one was alive but with an amputation, and 18 retained their limbs. These 18 patients had an average functional score of 27 points and a mean radiographic score of 94%. Eight complications required a second surgery; in four, the allograft was removed (one infection, one local recurrence, two fractures) and in four, the allograft was preserved (two local recurrences, one fracture, one nonunion). We consider biologic reconstruction with allografts after sarcoma resection an appropriate reconstructive procedure in young children. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Abstract
BACKGROUND In the management of a resected distal femoral or proximal tibial condyle as the result of tumor or trauma, a unicondylar osteoarticular allograft is currently the only reconstructive option that avoids the sacrifice of the unaffected condyle. The purposes of this study were to perform a survival analysis of unicondylar osteoarticular allografts of the knee and to evaluate the complications. METHODS We retrospectively reviewed the results of forty large unicondylar osteoarticular allograft procedures in thirty-eight patients who were followed for a mean of eleven years. Twenty-nine allografts were femoral transplants and included eleven medial and eighteen lateral femoral condyles. Eleven allografts were tibial transplants, including four medial and seven lateral tibial condyles. The procedure was performed after a tumor resection in thirty-six patients and to replace condylar loss after a severe open fracture in the remaining two patients. Complications were analyzed, and allograft survival from the date of implantation to the date of revision or the time of the latest follow-up was determined. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS One patient died of tumor-related causes without allograft failure before the two-year follow-up evaluation. The global rate of allograft survival at both five and ten years was 85%, with a mean follow-up of 148 months. In six patients, the allografts were removed at an average of twenty-six months (range, six to forty-eight months) and these were considered failures. All six patients underwent a second allograft procedure including two new unicondylar and four bicondylar reconstructions. The mean radiographic score for the thirty-three surviving allografts evaluated was 89%, with an average functional score of 27 of a possible 30 points. CONCLUSIONS Unicondylar osteoarticular allografts of the knee appear to be a reliable alternative for patients in whom reconstruction of massive osteoarticular bone loss is limited to one condyle of the femur or the tibia.
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Abstract
The surgical risk and complication rates for an open excision of a benign osteochondroma have been reported as high as 13%. The advent of minimally invasive techniques allows a surgical resection with a smaller incision and a potential for less postoperative morbidity. We presumed endoscopic resection of symptomatic osteochondroma of the distal femur would decrease postoperative morbidity of open surgery and improve functional outcome. We performed endoscopic resection of a symptomatic osteochondroma in seven patients among 24 who had surgical excision. Preoperative studies include radiographs and computed tomography scans. At a mean followup of 33 months, patients were functionally evaluated according to the Lysholm score and the International Knee Documentation Committee scale. Four exostoses were located at the anterolateral femoral cortex, one at the trochlea, and two at the anteromedial cortex. Histologic diagnosis of an osteochondroma was confirmed in all cases. The average Lysholm score improved 22 points from a mean of 74 preoperatively to 96 postoperatively, and according to the International Knee Documentation Committee scale, all patients showed a normal knee. In 7 of 24 patients with a symptomatic osteochondroma of the distal femur close to the knee, we performed endoscopic resection with low morbidity and prompt functional recovery.
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Abstract
To determine whether inappropriate surgical procedures based on an initial misdiagnosis affected recurrence and survival rates, we retrospectively reviewed the surgical treatment and results of 117 patients with high-grade osteosarcomas treated from January 1, 1990 to December 31, 2000. Nine patients had intralesional curettage performed at other institutions based on an erroneous diagnosis of a benign lesion. Two of the nine patients had amputations and seven patients had limb-salvage procedures. Of the 108 patients who were not misdiagnosed, six patients had amputations and 102 patients had limb-salvage procedures. All patients received neoadjuvant therapy. Fifteen of the 117 patients had local recurrences. Patients who had erroneous surgical procedures based on the initial misdiagnosis of osteosarcoma had an increased risk of local recurrence and decreased 10-year survival rate. Response to adjuvant therapy and the amount of previous violation of natural tumor barriers should be evaluated carefully before deciding surgical treatment.
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Abstract
UNLABELLED Reconstruction of extensor mechanism after proximal tibia tumor resection is a major concern, especially in young and physically active patients. We evaluated patellar tendon host-donor reattachments in 42 consecutive proximal tibia allo- graft reconstructions after bone tumor resection to determine if patellar tendon length and integrity was maintained, and if active knee extension and adequate function was achieved. Patellar tendon length was radiographically measured in all patients by the Insall-Salvati index while magnetic resonance was available in 19 patients to evaluate imaging integrity. Eight patients were not available for functional assessment, leaving 34 patients for clinical evaluation with the Musculoskeletal Tumor Society scoring system. According to the Insall-Salvati index evaluation, the reconstructed patellar tendon remained stable with no elongation between preoperative and postoperative measurements (1.15 versus 1.13). Postoperative magnetic resonance images showed a continuous patellar host-donor tendon in all. Active knee extension was restored in all functionally evaluated patients with an average functional score of 26.6 points. Twenty-four patients had no extensor lag, while ten had an average residual extensor lag of 6.5 degrees . Our findings suggest patellar tendon reconstruction with allogeneic tissue from the proximal tibia allograft sutured to the recipient's remnant patellar tendon can restore and stabilize active knee extension. LEVEL OF EVIDENCE Therapeutic study, level IV (case series).
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Use of distal femoral osteoarticular allografts in limb salvage surgery. Surgical technique. J Bone Joint Surg Am 2006; 88 Suppl 1 Pt 2:305-21. [PMID: 16951102 DOI: 10.2106/jbjs.f.00324] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As diagnostic and therapeutic techniques improve, patients with a musculoskeletal sarcoma should expect longer survival, fewer complications and side effects, and an improved quality of life. Functional longevity of the reconstruction after resection of the tumor becomes a major concern, especially in young and physically active patients. The purpose of this study was to analyze the mid-term and long-term survival of reconstructions with a distal femoral osteoarticular allograft in a series of patients. METHODS We retrospectively reviewed the results of eighty reconstructions with a distal femoral osteoarticular allograft following resection of a bone tumor in seventy-six patients. The mean duration of follow-up was eighty-two months. The rates of survival of the allograft and the joint surface were estimated with use of the Kaplan-Meier method. Cox regression analysis was performed to determine whether age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were independent prognostic factors. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS Five patients were lost to follow-up, leaving seventy-five allografts in seventy-one patients available for study. Thirteen patients (thirteen allografts) died of tumor-related causes without allograft failure before a two-year radiographic follow-up could be performed. Of the remaining sixty-two allografts, fourteen failed: six failed as a result of infection; four, because of local recurrence; one, because of massive resorption; and three, as a result of fracture. At the time of final follow-up, at a mean of 125 months, forty-eight allografts were still in place. The overall rate of allograft survival was 78% at both five and ten years, and the rate of allograft survival without the need for resurfacing with a knee prosthesis was 71% at both five and ten years. With the numbers available, age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were not found to have a significant effect on the overall allograft survival rates. The patients who retained the original allograft had good or excellent functional and radiographic results. CONCLUSIONS The life expectancy for most patients with a highly aggressive or malignant tumor in the distal part of the femur is now several decades. In this study, we found a high rate of survival of distal femoral allograft reconstructions at both five and ten years.
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Morselized and structural cortical allograft reconstruction after intralesional curettage of a distal femoral giant-cell tumor. Orthopedics 2006; 29:679-82. [PMID: 16924858 DOI: 10.3928/01477447-20060801-09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
We report on a series of 5 patients over 60 years of age who had a symptomatic medial meniscus degenerative tear followed-up with magnetic resonance imaging (MRI) sequence without arthroscopic surgery who developed spontaneous osteonecrosis of the knee. The average patients age was 68 years. Clinically, all 5 patients had tenderness at the medial joint line. At initial evaluation, MRI studies showed degenerative tears of the posterior horn of the medial meniscus with no evidence of osteonecrosis. After a mean time of 2.7 months, all patients had increased pain and were re-evaluated with a second MRI study that showed images compatible with osteonecrosis. The size of the osteonecrotic image shown on the MRI was measured, and values obtained averaged 21% of the femoral condyle with a range from 17% to 26%. Development of osteonecrosis after arthroscopic partial meniscectomy has been previously reported as a rare and unexpected complication. We report an MRI sequence between medial meniscus degenerative tears and the development of spontaneous osteonecrosis without any arthroscopic procedure. Elderly patients with medial meniscal tears should be alerted of this potential sequence of events and the impossibility for the surgeon to predict or prevent this situation at this stage, especially before performing an arthroscopic meniscectomy.
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Abstract
Allograft transplantation is a functional reconstructive option for large-extremity osseous defects. Improvements in anatomic matching, infection prevention, allograft fixation, soft tissue reconstructions, and rehabilitation protocols have greatly influenced predictability and longevity of massive allografts. These demanding reconstructions require time, an experienced group of orthopedic surgeons working at an institution with access to a large volume of patients, and a reliable, modern bone bank to select the appropriate graft for each individual under safe conditions. This article discusses the current use of total condylar osteoarticular allografts, hemicondylar allografts, allograft arthrodesis, intercalary segmental allografts, hemicylindric intercalary allografts, and allograft-prosthesis composites.
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Abstract
BACKGROUND As diagnostic and therapeutic techniques improve, patients with a musculoskeletal sarcoma should expect longer survival, fewer complications and side effects, and an improved quality of life. Functional longevity of the reconstruction after resection of the tumor becomes a major concern, especially in young and physically active patients. The purpose of this study was to analyze the mid-term and long-term survival of reconstructions with a distal femoral osteoarticular allograft in a series of patients. METHODS We retrospectively reviewed the results of eighty reconstructions with a distal femoral osteoarticular allograft following resection of a bone tumor in seventy-six patients. The mean duration of follow-up was eighty-two months. The rates of survival of the allograft and the joint surface were estimated with use of the Kaplan-Meier method. Cox regression analysis was performed to determine whether age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were independent prognostic factors. Functional and radiographic results were documented according to the Musculoskeletal Tumor Society scoring system at the time of the latest follow-up. RESULTS Five patients were lost to follow-up, leaving seventy-five allografts in seventy-one patients available for study. Thirteen patients (thirteen allografts) died of tumor-related causes without allograft failure before a two-year radiographic follow-up could be performed. Of the remaining sixty-two allografts, fourteen failed: six failed as a result of infection; four, because of local recurrence; one, because of massive resorption; and three, as a result of fracture. At the time of final follow-up, at a mean of 125 months, forty-eight allografts were still in place. The overall rate of allograft survival was 78% at both five and ten years, and the rate of allograft survival without the need for resurfacing with a knee prosthesis was 71% at both five and ten years. With the numbers available, age, gender, the percentage of the femur that had been resected, and the use of chemotherapy were not found to have a significant effect on the overall allograft survival rates. The patients who retained the original allograft had good or excellent functional and radiographic results. CONCLUSIONS The life expectancy for most patients with a highly aggressive or malignant tumor in the distal part of the femur is now several decades. In this study, we found a high rate of survival of distal femoral allograft reconstructions at both five and ten years.
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Abstract
We report a case of acute laceration of the popliteal artery during an arthroscopic posterior cruciate ligament reconstruction. This injury can occur during the creation of the posteromedial portal, the manipulation of the tissues in the posterior part of the capsule of the knee joint, or when drilling the tibial hole. We recommend that a qualified vascular surgeon should be immediately available at the time of the surgery. In case of suspecting the occurrence of a popliteal artery injury, the vascular surgeon should be immediately consulted and arteriography and vascular repair should be performed.
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Arthroscopic fixation of osteochondritis dissecans of the knee: clinical, magnetic resonance imaging, and arthroscopic follow-up. Am J Sports Med 2005; 33:1499-504. [PMID: 16009988 DOI: 10.1177/0363546505274717] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Optimal treatment of osteochondritis dissecans of the knee is still controversial. PURPOSE To review a group of patients with osteochondritis dissecans of the knee who were treated with arthroscopic compressive screw fixation and who were evaluated with magnetic resonance imaging studies and a second-look arthroscopic procedure at follow-up. STUDY DESIGN Case series; level of evidence, 4. METHODS A total of 14 patients (15 knees) with osteochondritis dissecans of the knee were treated with arthroscopic titanium Herbert screw fixation of the osteochondral fragment. A second-look arthroscopic procedure was performed to remove hardware and to evaluate fragment stability. At final follow-up, magnetic resonance imaging studies were used to evaluate potential healing of the subchondral bone. Outcomes were clinically evaluated at a mean follow-up of 50 months (range, 25-104 months) by the Lysholm score and by the International Knee Documentation Committee score. RESULTS At second-look arthroscopy, 14 of 15 knees showed evidence of a stable fragment with an intact smooth surface. According to magnetic resonance imaging parameters, 14 knees showed evidence of a healing process of the osteochondral fragment. The average Lysholm score improved 18 points from a mean of 79 preoperatively to 97 postoperatively, and according to the International Knee Documentation Committee score, 13 of 15 knees showed a normal result. CONCLUSION This study suggests that magnetic resonance imaging parameters of a healed osteochondral fragment and patients with satisfactory functional results correspond with arthroscopic evidence of fragment stability. According to this study, arthroscopic fixation with compressive screws is an effective method of repair for osteochondritis dissecans of the knee.
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Abstract
We present 3 cases of simultaneous rupture of the patellar tendon and the anterior cruciate ligament (ACL) and discuss the diagnosis and treatment of this infrequent association. Between 1997 and 2000, 3 patients with a mean age of 37 years were treated with an ACL reconstruction and repair of the patellar tendon. The average follow-up was 3 years. Two of them were initially misdiagnosed. At follow-up, all patients had stable knees and the average Lysholm score was 95. In acute knee injuries with gross anteroposterior instability and a huge hematoma, the occurrence of this complex lesion should be considered. A careful clinical evaluation may be correlated with magnetic resonance imaging findings to provide the orthopaedic surgeon with the appropriate information for planning the timing and surgical treatment.
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Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee. J Bone Joint Surg Am 2005; 87 Suppl 1:226-36. [PMID: 16140796 DOI: 10.2106/jbjs.e.00253] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction. METHODS The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up. RESULTS At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points). CONCLUSIONS Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts.
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Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee. J Bone Joint Surg Am 2004; 86:2686-93. [PMID: 15590854 DOI: 10.2106/00004623-200412000-00015] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction. METHODS The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up. RESULTS At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points). CONCLUSIONS Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
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Intercalary femur and tibia segmental allografts provide an acceptable alternative in reconstructing tumor resections. Clin Orthop Relat Res 2004:97-102. [PMID: 15346058 DOI: 10.1097/01.blo.0000141652.93178.10] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intercalary femur and tibia segmental allografts were implanted in 59 consecutive patients after segmental resection-52 for malignant and seven for benign aggressive bone tumors. The patients were followed up for an average of 5 years. Allograft survival was determined with the Kaplan-Meier method. Infection, fracture, and nonunion rates were determined. The overall 5-year survivorship for the 59 intercalary allografts was 79%, and we found no significant differences between allograft survival in patients receiving or not receiving adjuvant chemotherapy. Infection and fracture rates were 5% and 7% respectively. From 118 host-donor junctions, 11 did not initially heal (9%). The nonunion rate (10 of 69 osteotomies) for diaphyseal junctions was higher than the rate (one of 49 osteotomies) for metaphyseal junctions. Although some patients required reoperations because of allograft complications, it seems that the use of intercalary allograft clearly has a place in the reconstruction of a segmental defect created by the resection of a tumor in the diaphyseal and /or metaphyseal portion of the femur or tibia.
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Abstract
Even though massive osteoarticular allografts have been reported to restore function successfully after tumor resection, little has been published about this procedure in post-traumatic joint reconstruction. We report two pediatric patients who sustained a grade III open fracture of the distal femur and were treated with osteoarticular allografts as a salvage procedure. In each patient, a femoral condyle was inserted to treat the bone and cartilage defect, and a 4.5 dynamic compressive plate was applied to fix the graft to the host bone. There were no complications after the reconstructive procedure. At 2 and 10 years of follow-up, both patients showed a favorable functional and radiographic outcome using the scoring instruments of the Musculo-skeletal Tumor Society and the International Symposium on Limb Salvage.
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Abstract
The authors describe two children with a history of pain and limping who showed a solitary extensive diaphyseal lesion of the femur. A needle biopsy confirmed the diagnosis of eosinophilic granuloma. Without any treatment, both patients went into spontaneous total remission after the percutaneous biopsy. At last follow-up (after 4 years), there was no clinical evidence of disease, and a femur x-ray appeared normal. These two cases suggest that until additional biologic parameters of disease behavior are clarified, some patients with eosinophilic granuloma might be grossly overtreated due to misinterpretation of radiographic images.
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Abstract
BACKGROUND Musculoskeletal tumors may originally mimic a traumatic condition, and, on the basis of an erroneous diagnosis of an athletic injury, an invasive diagnostic or therapeutic procedure may be performed. We determined the number of such cases treated at our institution, and we analyzed the initial and final diagnoses as well as the changes in the indicated oncologic surgical technique due to the initial erroneous diagnosis. METHODS Twenty-five patients who had a bone or soft-tissue tumor about the knee that originally had been diagnosed as an athletic injury were referred to our institution. The complete clinical, radiographic, and pathological records were reviewed. Studies that had been performed prior to the invasive procedure and at the time of admission to our institution were evaluated to determine differences in the tumor stage and the oncologic treatment that was indicated at each time. RESULTS Of 667 knee tumors diagnosed in our institution, twenty-five (3.7%) previously had been treated with an intra-articular procedure as a result of a misdiagnosis of an athletic injury. The final diagnoses made at our institution were a benign tumor in eleven patients and a malignant tumor in fourteen. Oncologic surgical treatment was affected in fifteen of the twenty-five patients. CONCLUSIONS When a knee tumor is initially misdiagnosed as an athletic injury, treatment may be adversely affected by the delay in diagnosis or an inappropriate invasive procedure that results in extension of the tumor. Initial poor-quality radiographs and an unquestioned original diagnosis despite persistent symptoms were the most frequent causes of an erroneous diagnosis.
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Epiphyseal primary location for osteosarcoma and Ewing sarcoma in patients with open physis. J Pediatr Orthop 2003; 23:542-5. [PMID: 12826957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Conventional osteosarcoma and Ewing sarcoma are the most common childhood malignant tumors of bone. These tumors arise in the metaphysis and diaphysis of long bones and may extend secondarily into the epiphysis. Primary epiphyseal location for these tumors is rare and may constitute a diagnostic and therapeutic challenge. The authors report two skeletally immature patients with an osteosarcoma and Ewing sarcoma limited to the epiphysis. Clinical, radiographic and histopathologic findings are discussed.
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Abstract
The purpose of this study was to describe and report preliminary results of an arthroscopic-assisted surgical technique for the treatment of displaced transverse patella fractures with percutaneous internal fixation. We applied this technique in 5 patients who presented a displaced transverse patella fracture and were followed-up for an average of 18 months. Under an image-intensifier fluoroscope, the fracture was closely reduced with a percutaneously reduction clamp while the congruence of the articular surface was monitored arthroscopically. Two Kirschner wires were inserted perpendicular to the fracture line followed by 2 cannulated lag screws obtaining interfragmentary compression. By using a cannulated guide, 2 wires were threaded through both cannulated screws and percutaneously were crossed over the top of the patella creating a figure-8 pattern tension band. At final follow-up, radiographic consolidation was achieved in all patients obtaining full range of motion and returning to the activity level previous to the fracture. Arthroscopic internal fixation is a valid alternative for the treatment of intra-articular displaced and noncomminuted patella fractures. This technique allows healing of the fracture with low patient morbidity, a short hospitalization period, and an accelerated rehabilitation of the affected knee.
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Abstract
PURPOSE The objective of this prospective study was to evaluate preliminary results of an endoscopic-assisted surgical technique for patients suffering from chronic Achilles tendinopathies. TYPE OF STUDY Case series. METHODS Endoscopic operations were performed on 7 consecutive patients involved in recreational sports suffering from chronic Achilles tendon (AT) lesions in whom conservative treatment had failed. Diagnoses included 2 patients with pure peritendinitis, 4 with peritendinitis and degenerative tendinosis, and 1 with a chronic partial tear. Patients were preoperatively and postoperatively evaluated at a mean follow-up period of 16 months (range, 6 to 27 months) with a 0-100 points rating system. All patients were studied preoperatively with magnetic resonance imaging (MRI) and 6 were re-evaluated with the same procedure after surgery. All surgical interventions were performed on an ambulatory basis and 5 under local anesthesia. The surgical endoscopic technique consisted of peritenon release and debridement in cases with pure peritendinitis. In addition, 2 longitudinal tenotomies were performed in cases with degenerative tendinosis or partial tears. RESULTS According to the scoring system used, all 7 patients had improved final outcome after surgery from a mean of 39 points preoperatively to 88 points postoperatively. The patient with an AT partial tear achieved the lowest score. The only complications were a minor hematoma and edema that resolved spontaneously. Postoperative MRI in patients with tendinosis failed to show evidence of degenerative areas. CONCLUSIONS Endoscopic surgery may be a valid alternative to treat Achilles tendinopathies unresponsive to conservative treatment because of potential lower morbidity.
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Abstract
PURPOSE The purpose of this study was to perform a magnetic resonance imaging (MRI) follow-up study of bone bruises in a group of patients with acute anterior cruciate ligament (ACL) ruptures that were reconstructed and followed-up for a minimum of 2 years. TYPE OF STUDY Cohort study. METHODS The study group included 21 patients with a mean age of 31 years whose initial MRI scans showed associated bone bruises. Patients were included if they had an acute isolated ACL tear, no documentation of an episode of repeated injury to the affected knee during the follow-up period, and no evidence of cartilaginous injury at the time of arthroscopy. All patients had preoperative MRI scans and underwent arthroscopic ACL reconstruction using a bone-patellar tendon autograft an average of 2 months after injury. The preoperative MRI scans were analyzed using a 3-level grading system based on the appearance and location of bone bruises. A second MRI of the knee was obtained from 24 to 64 months postoperatively (average 34 months). The presence of resolution of bone bruises was determined and correlation with clinical scoring established. RESULTS This study showed resolution of all type I lesions and 91% of type II lesions (10 of 11). In all type III lesions, an articular cartilage thinning and depression was observed after 2 years of follow-up. In 15 patients (71%), MRI showed that the bone bruises had resolved without apparent sequelae. In the remaining 6 patients (29%), sequelae of the osteochondral lesion were evident on MRI. CONCLUSIONS According to our clinical data, there was no correlation between scores obtained from patients with resolved lesions against those with osteochondral sequelae. Although long-term clinical implications of these findings are uncertain, a severe occult osteochondral lesion sustained at the time of ACL rupture seems to be persistent on MRI even after a successful reconstruction.
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Magnetic resonance imaging evaluation and arthroscopic resection of localized pigmented villonodular synovitis of the knee. Orthopedics 2000; 23:367-9. [PMID: 10791586 DOI: 10.3928/0147-7447-20000401-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Diagnosis of localized pigmented villonodular synovitis is clinically difficult, and plain radiographs are usually normal. This article presents five patients with localized pigmented villonodular synovitis of the knee. Symptoms suggested a meniscal lesion in three patients and a loose body in two. Magnetic resonance imaging performed prior to arthroscopic resection revealed a preoperative diagnosis of a tumor in all five patients. Magnetic resonance imaging is a valuable clinical tool for the assessment of intra-articular soft-tissue tumors of the knee that may otherwise be misdiagnosed.
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Abstract
An evaluation of long-term survival and radiographic deterioration of 118 knee osteoarticular allografts in 114 patients was performed. Radiographic analysis was done according to the Musculoskeletal Tumor Society grading system. A failure was defined as when the allograft was removed during a revision procedure or amputation. Ten patients were lost to followup during the first 2 years after surgery. Eighteen patients without allograft failures died of complications related to the tumor. Twenty-six allografts failed because of infection (13 allografts), local recurrence (eight allografts), massive resorptions (three allografts) and fractures (two allografts). Sixty-four allografts still were in place at a mean of 98 months (range, 36-360 months) after implantation. The Kaplan-Meier 5-year survival rate for the knee osteoarticular allografts was 73% and the limb preservation rate was 93%. The mean radiographic score was 83%. Sixty-four percent of the allografts showed no radiologic changes or minor articular deterioration. Fourteen percent had narrowing of the joint space of more than 2 mm, and 22% had some form of subchondral bone collapse. Five patients required joint resurfacing to preserve the original allograft. Most of the allograft failures occurred during the first 4 years, and the allograft survival rate for the current series remained unchanged after 5 years.
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