[Treatment outcome of patients with bone tumors after limb salvage surgery]

In 336 patients with various tumors of the limb bones underwent limb sparing surgery with different kind of reconstructions. The oncological results of the treatment of these patients have been analysed. Local relapse after limb sparing interventions because of extremities bone tumors developed in 4,17% of all cases. In most cases, local recurrences have been observed in patients with bone sarcomas high degree of malignancy (7,14%) and low degree of malignancy (2,82%). In 57,1% of cases, local recurrences developed in patients with osteogenic sarcoma IIB stage. The appearance of local recurrence was a bad prognostic factor for patients with bone sarcomas high grade, because it reduced 5-year survival rate almost 2 times. The overall 5-year survival of patients with bone sarcomas high grade of malignancy were (59,67 +/- 5,69)%, and 5-year relapse-free survival rate--(55,23 +/- 5,52)%. Local recurrences more often developed after the use of distraction method of surgery--in 16% of all reconstructive operations, including 12% of the cases with bone tumors of high degree of malignancy, which should be considered when choosing this method of reconstruction.

Aneurysmal bone cyst of the paediatric shoulder girdle: a case series and literature review

Limited research has analysed paediatric shoulder girdle aneurysmal bone cyst management and outcomes. This study analysed locations affected, investigations, treatments and recurrence in children treated at the London Bone Tumour Unit between 1998 and 2004 and in English and French literature between 1956 and 2004. The proximal humerus and clavicle are most frequently affected whereas scapula involvement is rare. Radiographs, computed tomography and MRI are valuable. Sole curettage of clavicle and scapula lesions has low recurrence rates. Proximal humerus lesions recur most frequently. Curettage alone or with cementation are the most appealing treatments but are associated with significant recurrence.

Osteoid osteoma of the upper extremity. A diagnostic challenge

Osteoid osteomas are benign tumors that may commonly mimic other entities in the upper extremity. The purpose of this study is to describe the clinical and imaging features of osteoid osteomas involving the upper extremity, highlight the difficulties in the diagnosis in the various areas and propose a diagnostic workup. Fourty-eight patients with histologically confirmed osteoid osteoma of the upper extremity treated at the authors' department from 1985 to 2000 were retrospectively reviewed. Data pertinent on the patients' history, lesion location, clinical and imaging characteristics as well as any unique features of individual patients were collected. There were 29 males and 19 females with a mean age of 28 years (range 20-42). The average duration of symptoms before definite diagnosis was 18 months (range 2-62). Pain was the presenting symptom in 46 of 48 patients, whereas swelling was the main complaint in 2 of the patients. Mean pre-operative visual analogue pain scale (VAS), was 8.8 ranging from 5.1 to 9.3. Eight lesions were located in the humerus, 4 in the ulna and 7 in the radius. In the carpal bones, 4 were located in the scaphoid, 4 in the capitate and 5 in the hamate. Seven lesions were located at the metacarpals and 9 lesions at the phalanges (5 proximal, no middle and 4 distal phalangeal lesions). Radiographs alone were sufficient to establish the diagnosis of osteoid osteoma in 32 cases. Bone scans identified a "hot spot" in 16 patients without previous radiographic evidence of a lesion and furthermore, computed tomography was performed in 32 patients to assist in the intraosseous localization of the lesion, and in the pre-operative planning. All patients underwent operative excision of the lesion and the diagnosis was confirmed by histology. Mean follow-up was 28 months (range 25-42). Fourty-three patients had an uneventful recovery. Mean post-operative VAS value was 1.8 ranging from 0 to 3. Osteoid osteoma of the upper extremity often mimics other etiologies and the complex anatomy of the upper extremity, as well as the tendency of patients to relate their symptoms to trauma are factors that easily lead to misdiagnosis or delay in the diagnosis. A high index of suspicion is essential and the diagnosis is based on an accurate clinical assessment and careful selection of imaging studies.

The use of the Ilizarov technique in the treatment of upper limb deformity in patients with Ollier's disease

Between 1997 and 2001 three children with Ollier's disease underwent treatment of five upper limb segments using the Ilizarov technique. Average length discrepancy was 8.4 cm in the arm and 4.5 cm in the forearm, but coexisting large angular deformities were the major problem in all the children. Full correction of the axial deviations was achieved in all children. Restoration of length was achieved in all arms, but residual forearm length discrepancy persisted. In four segments conversion of the abnormal cartilage into normal regenerate was observed on radiograms. The problems, obstacles, and complications are similar to those met in more usual lengthening procedures. The Ilizarov technique should be the treatment of choice in restoring the correct axis and length of a limb in patients with Ollier's disease.

[Primary osteosynthesis in pediatrics: possibilities and perspectives]

An analysis of results of conservative strategy of treatment of unstable diaphysial fractures of long tubular bones in schoolage children allowed to expand the indications to performance of osteosynthesis as a primary method of treatment (133 children). Extracortical osteosynthesis with planes by such criteria as efficiency, safety, profitability and quality of patient's life is thought to be preferable.

[Changes in hemodynamics during regional anesthesia and medicinal sedation in children traumatology]

Thirty-nine patients, aged 8 to 15, who were operated for damaged bones in the upper lower limbs were examined. The parameters of central hemodynamics, heart rate and arterial pressure were studied (monitor HP "Viridia m3", USA). Strike volume was determined automatically (rheography monitor NCCOM-3"Boomed Co.", USA). Cardiac output, body area, stroke index and the peripheral vascular resistance were calculated by the routine formulae. Group 1 comprised 20 children who were operated on with the halothane-oxide-oxygen narcosis. Group 2 comprised 19 patients who received regional anesthesia combined with drug sedation (midazolam). A 1% lydokain solution with adrenalin was used as a local anesthetic. The block of the brachial plexus with auxiliary approach and the "3 in 1" block were in use. The changes of hemodynamics detected in the children of group 1 revealed an insufficient analgetic and antistress efficiency of halothane. The data obtained for group 2 are indicative of insignificant hemodynamic changes observed at all examination stages and related with the impact exerted by drugs, used for sedation and regional anesthesia, on the vascular tonus of the original undetected hypovolemia. A lack of complications, a fast awakening and recovery of an adequate consciousness after combined regional anesthesia as well as comfort and a lack of need in extra analgetics that are normally used in the immediate postoperative period make it possible to refer to the discussed anesthesia variation as to the preferential one in cases of surgeries for damaged bones in children.

Management of posttraumatic segmental bone defects

Because of difficulty in managing posttraumatic segmental bone defects and the resultant poor outcomes, amputation historically was the preferred treatment. Massive cancellous bone autograft has been the principal alternative to amputation. Primary shortening or use of the adjacent fibula as a graft also has been used to attempt limb salvage. Of more recent methods of management, bone transport with distraction osteogenesis has been suggested as the leading option for defects of 2 to 10 cm, but problems include delayed union at the docking site and prolonged treatment time. Free vascularized bone transfer has been suggested as the leading option for defects of 5 to 12 cm, but hypertrophy of the graft is unreliable and late fracture, common. Bone graft substitutes continue to be developed, but they have not yet reached clinical efficacy for posttraumatic segmental bone defects. Although each of the new techniques has shown some limited success, complications remain common.

[Surgical infection in combat injuries of extremities]

A retrospective analysis was performed of treatment of 1612 patients with gunshot fractures of long bones of the extremities wounded in the Republic of Afghanistan and Chechen Republic. Under study was the infrastructure of the gunshot fractures, general and local factors responsible for the development of suppurations. A angioneurodystrophy theory of pathogenesis of gunshot osteomyelitis is proposed. The level of proinflammatory cytokines was determined in blood serum and wound discharge for the early diagnosis of purulent complications. An algorithm of the diagnostic search was developed with using modern radio- and electrophysiological methods. The standards of general and local treatment are proposed for different stages and spread of the purulent process.

Serratus anterior-rib free flap in limb bone reconstruction

The authors present their experience in surgical reconstruction of bone lesions in posttraumatic bone defects, pseudarthrosis, and osteitis by using the free serratus anterior-rib flap. The flap was used in 12 cases: 7 cases in the upper limb, and 5 cases in the lower limb. The overall immediate success rate in our series was of 91.7%. We had only one failure, due to a venous thrombosis. In all successful cases, the rib showed good integration. This procedure seems to be very useful in the reconstruction of small and medium bone defects, especially in the upper limb.

[Triphalangeal thumb]

Triphalangeal thumb is often thought to be a rare congenital abnormality; it has an incidence of 1 in 25,000 births. We reviewed 49 triphalangeal thumbs in 28 Mexico City patients at the Diaz Lombardo Hospital from 1974 to 1979, Shriners Hospital from 1979 to 1982, Instituto Nacional de Ortopedia from 1981 to 1982, and at the ABC Hospital from 1971 to 1998. A total of 21 patients (75%) had bilateral deformity. Patients were classified according to Dieter Buck-Gramcko system and Müller teratologic line. All were surgically treated and evaluated with Cheng graduation scale, finding good results in 48 patients (97%), fair results in one (3%), and no poor results.

[Characteristic of combat trauma and treatment of gunshot fractures of long bones of the limbs]

Treatment of the patients with gunshot fractures of extremity long bones is one of the main problems of field surgery. The complex study of medical records obtained from 718 servicemen with gunshot fractures of extremity long bones who participated in counter-terrorist operation in the Republic of Chechnia (1994-1996) allowed to evaluate character and severity of the injuries, content of the treatment measures conducted at the stages of medical evacuation. The peculiarities of fighting trauma were the following: the high frequency of combined (22.5%) and multiple (25.9%) injuries, the high share of multi-fragmentation and splintered (76.4%), intra-articular fractures (17.3%), the primary defects of bones (7.1%) and soft tissues (4.8%), the injuries of main vessels (12.1%) and nerves (18.5%). Owing to the short periods of evacuation to the stage of specialized medical care (up to 18.2 +/- 5.3 h), high share of preserving variant of primary surgical treatment (82.3%); high quality of medical immobilization at the expense of wide introduction of functionally stable external osteosynthesis (51.2% of the casualties) it was possible to improve the treatment results.

Postoperative upper extremity radiographs using the image intensifier: a simple adjunct to the "inverted" C-arm technique

When the C-arm is used as a table in upper extremity surgery, postoperative plain radiographs can be obtained by placing the x-ray cassette directly on the image intensifier. This has many advantages, including more rapid performance than conventional techniques, a high-quality image, and no need for a recovery room radiograph. Additionally, there is no overlying splint material to obscure image detail, and the extremity can be positioned as desired by the operating surgeon.

[Use of the elastic stable intramedullary nailing technique in non-typical pediatric fractures]

PURPOSE OF THE STUDY

The "Elastic Stable Intramedullary Nailing" (E.S.I.N.) of French authors as a method of treatment of children's diaphyseal long bone fractures is well known from nineties of the last century. After we got familiar with the technique we wanted to introduce it in other indications, especially some metaphyseal long bone fractures and injuries of metacarpals, meta-tarsals and phalangeal bones in the growing skeleton.

MATERIAL

During two last years, i.e. 1999-2000, ESIN procedure in 97 children was performed in our Regional Pediatric Trauma Centre. That was 39% of all osteosyntheses and 3.05% of all children's fractures treated during this period. Children treated by ESIN procedure were divided into three groups (see in Methods), 52 being in group one, 28 in group two and 17 in group three.

METHODS

In our series of patients managed with the use of ESIN procedure according to the type of fractured bone and physical behavior of the implants three groups were formed. In the first group called "Classic ESIN Procedure" were children with diaphyseal long bone fracture (femur, tibia, humerus and forearm bones), in the second group "Non-typical ESIN Procedure" metaphyseal long bone fractures (humerus, radius, tibia) and in the third group, "ESIN-like Procedure" patients with metacarpal and phalangeal digital fractures were included. In all children the technique was very similar to original French (Nancy) description. Supraphyseal trepanation of the bone and introduction of usually two prebent elastic nails intramedullary.

RESULTS

All 97 children healed good. In four children we saw little problems. In one patient it was necessary to change the ESIN osteosynthesis of open tibia fracture to external fixation. In the other boy we saw delayed union of forearm bones and in the third a 2 centimeter overgrowth of the affected tibia was recorded. In the last boy where non-typical ESIN procedure was performed for proximal radial fracture separation the angulation of radial head, overgrowth and subluxation occurred. However, we were surprised by simplicity, short time of the procedure and good results in two new groups of patients with metaphyseal and metacarpal resp. phalangeal fractures.

DISCUSSION

Though in metaphyseal long-bone fractures (Non-typical ESIN Procedure) and metacarpal and phalangeal digital fractures (ESIN-like Procedure) the technique does not respect original physical suggestions of three point fragment fixation it works very well. Already the French authors from Nancy mention the indication of the ESIN technique for some metaphyseal fractures (supracondylar humeral and proximal radial). We do not use the method in supracondylar fractures but found it excellent in earlier problematic proximal humeral and radial fractures and especially phalangeal digital fractures. Also we were able to establish three main indication groups for this procedure.

CONCLUSIONS

The ESIN technique can be used in three groups of children's fractures. "Classic ESIN Procedure" in diaphyseal long bone fractures, "Non-typical ESIN Procedure" in metaphyseal long bone fractures and "ESIN-like Procedure" in metacarpal and phalangeal digital fractures.

Complications of vascularized fibula graft for reconstruction of long bones

The clinical results and complications of the vascularized fibular graft for the reconstruction of various long bone defects were reviewed in 60 cases. Bony reconstruction was achieved in 57 of the 60 cases; however, various postoperative complications occurred in 54 percent of the cases. One case of arterial thrombosis of an anastomosed vessel and nine cases of venous congestion of the monitoring flap occurred in the early postoperative periods. The authors managed the nine cases of venous congestion of the flap conservatively, and all flaps survived. Partial necrosis of the flap was noted in eight of these nine cases, but additional surgical intervention was required in only four cases. Treatment included a gastrocnemius musculocutaneous flap in one case and a full-thickness skin graft in three cases. The vascularized fibula survived and bony fusion was achieved in all of these cases. The one case of arterial thrombosis resulted in graft failure due to a delay in the decision to perform a thrombectomy. Graft fracture occurred in 13 cases as the mechanical stress to the graft increased. In two cases of femoral reconstruction, graft fracture occurred during dynamization of the graft, despite the use of an Ilizarov external fixator. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibular grafting offers the patient a great deal of benefit; however, this graft has a concomitant high risk of complications. Great attention to detail must be paid to prevent postoperative complications.

Endoscopic access to the extremities: the principle of fascial clefts

Technology for endoscopic surgery has developed rapidly during the last decade. Applications of endoscopic techniques to orthopaedic surgery have been made possible by the use of balloon dissectors. Balloon dissectors create an optical cavity by separating fascial layers of a constant anatomic plane called the fascial cleft. The optical cavity can be maintained with either carbon dioxide (CO2) insufflation or manual retractors. The authors of the present study have developed a safe, reliable technique using a balloon dissector to create such optical cavities in the extremities, pelvis, and acetabulum to facilitate minimally invasive surgery in these areas. The authors' clinical work and fresh cadaver dissection confirms that the fascial cleft is a universal anatomic constant. It can be accessed quickly to facilitate endoscopic procedures, such as bone grafting for delayed unions, tissue expansion for reconstructive surgery, sural nerve harvesting for nerve cable grafting, and microvascular tissue transfer harvesting and flap prefabrication for extremity reconstruction. Twenty-five cases, each with an average follow-up of 34 months, are presented. Indications, results, and complications of balloon-assisted endoscopic surgery are described.

Upper limb salvage with microvascular bone transfer for major long-bone segmental tumor resections

A series of 14 young, active patients who underwent vascularized bone graft reconstructions of large (9-15 cm) segmental skeletal defects of the upper extremity resulting from resection of a variety of bony tumors is presented. Eight defects involved the proximal humerus and required shoulder joint reconstruction, two were mid humeral and four involved the distal radius. Surgical techniques for both distal radius reconstruction with vascularized iliac crest and vascularized fibular head and glenohumeral reconstruction using the vascularized fibula are described. Several cases are discussed in detail, including achievement of bony union, postoperative range of motion and pain, and each patient's ability to resume activities. The literature is reviewed, and other reconstructive options for large bony defects of the upper extremity after tumor resection are discussed: nonvascularized bone grafts, allograft transfer, and custom prosthetic devices. The authors think that vascularized bone grafting offers the most favorable method of upper extremity salvage with preservation of joint function, especially at the shoulder.

Lateral-dorsal neurovascular island flaps for pulp reconstruction

Finger pulp loss is often observed in daily practice. When the lateral and dorsal surfaces of the injured digit remain intact, a neurovascular island flap can be designed and raised from that part of the finger for pulp reconstruction. Two types of homodigital lateral-dorsal neurovascular island flaps were used in 17 patients (13 type I and 4 type II) for reconstruction of traumatic pulp loss on an emergent basis. The type I flap was used for the pulp defect less than 2.5 cm in length; the type II flap was designed for extensive pulp loss. The size of the pulp defect varied from 1.7 x 1.2 cm to 3.8 x 1.7 cm. All flaps survived completely without any partial loss. The mean follow-up was 17.7 months. The mean static two-point discrimination was 5.2 mm in type I flaps and 9.3 mm in type II flaps. All patients except five had full range of motion of the interphalangeal joint. These five patients (3 type I and 2 type II) had 10 to 20 deg reduction in flexion of the distal interphalangeal joints. The homodigital lateral-dorsal neurovascular island flap offers a durable, well-vascularized, sensate skin flap for one-stage pulp reconstruction in select patients. This technique is relatively simple, allows early postoperative mobilization, and has an acceptable surgical outcome.

Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr

BACKGROUND

Aneurysmal bone cyst is a benign, locally destructive lesion of bone. The rates of local recurrence after curettage have varied widely. Therefore, we performed a retrospective study of patients who had had an aneurysmal bone cyst in order to identify the rate of local recurrence and the prognostic factors related to local recurrence after use of contemporary methods of curettage with a high-speed burr.

METHODS

We reviewed the cases of forty patients who had been managed by the same surgeon for an aneurysmal bone cyst, as diagnosed on the basis of the latest pathological review, between January 1, 1976, and December 31, 1993. The patients were evaluated with regard to age, gender, the duration and type of symptoms, the presence or absence of pathological fracture, the status of the growth plate, the bone and part of the bone that were involved, the type of operative procedure, the outcome, the radiographic stage, the findings on magnetic resonance imaging and computerized tomography (when it became available) and on bone scintigraphy, and histological parameters. The median duration of follow-up was eighty-seven months (range, fifteen to 267 months). According to the criteria of Enneking, no patient had a stage-1 lesion (one with a surrounding rim of cortical bone), twenty-four had a stage-2 lesion (one with a clearly defined border but no cortical bone), and sixteen had a stage-3 lesion (one with no clearly defined border).

RESULTS

Of the forty patients, thirty-four had curettage with use of a high-speed burr. Of these thirty-four, twenty-two had filling of the defect with a cancellous autogenous graft; four, with a cancellous allograft; and three, with polymethylmethacrylate. In five patients, no material was put into the defect. The remaining six patients had resection through the margin of the lesion. Four (12 percent) of the thirty-four patients who had curettage had a local recurrence. No patient who had an excision through the margin of the lesion had a local recurrence. All local recurrences were in skeletally immature girls who were three, four, ten, and eleven years old. Univariate analysis with use of the chi-square, Fisher exact, and Wilcoxon log-rank tests showed that local recurrence was associated only with a young age (p = 0.0036) and open growth plates (p = 0.039). All local recurrences occurred within two years postoperatively, at two, seven, nine, and twenty-four months, and all were treated successfully with a second operation.

CONCLUSIONS

Rates of local control of almost 90 percent can be achieved with thorough curettage with use of a mechanical burr and without use of liquid nitrogen, phenol, or other adjuvants in patients who have an aneurysmal bone cyst of an extremity. A young age and open growth plates are associated with an increased risk of local recurrence.

Decreasing length of hospital stay in treatment of osteoid osteoma

Ninety-eight operative procedures were performed for treatment of osteoid osteoma since 1978 at the authors' institution. During these years there was a progressive decrease in the length of hospital stay, decreasing from a mean of 6.8 days between 1978 and 1980 to 2.6 days between 1994 and 1996. Factors that influenced the length of stay after a surgical procedure include patient age, lesion location, choice of procedure, and surgeon. However, the decline in length of stay with time is independent of these factors, and antedates the era of managed care. Increased reliance on more conservative surgical procedures has markedly diminished the length of hospital stay required in the care of these patients.

Biological and clinical study kinetics of biodegrading apatite-collagen implant for substituting bone tissue defects

We studied kinetics of biotransformation synthetic implant for substituting defects of the bone tissue using methods of computer tomography, scintigraphy and morphology in vivo and in vitro. We found that the character of biotransformation is dependent on the degree of loaded or unloaded bone tissue.

Vascularized bone grafts to the upper extremities

From 1979 to 1995 in our clinic, vascularized bone grafting was performed in 29 patients with large bone defects, established nonunion, congenital pseudoarthrosis, or avascular necrosis in the upper extremity. Four patients had traumatic bone defects, six had posttraumatic nonunions, two had congenital pseudoarthroses, five had amputations, nine had defects following tumor resection, and three had other lesions. Reconstructed sites were the humerus in 7 patients, the radius in 12, the ulna in 2, both radius and ulna in 1, and the metacarpal and phalangeal bones in 7. Donor bones were fibula in 19 cases, radius in 6, scapula in 2, and medial condyle of the femur in 2. Postoperative circulatory disturbances and venous thrombosis resulted in revision surgery in two patients. Thrombectomy and reanastomosis to other veins were performed, and these flaps took successfully. No patients required additional bone grafts. The mean period required to obtain radiographic bone union was 4 months (fibula, 4.5 months; scapula, 3.5 months; radius, 2.6 months; medial condyle of the femur, 4 months). Vascularized fibula graft is indicated in patients with large bone defects in the humerus, radius, and/or ulna. The scapula is easy to transfer to the proximal humerus on its pedicle. This donor is indicated in young women because operative scars can be hidden. The radius is usually harvested with skin, and its use is indicated in patients with bone loss in the hand including thumb amputations. Thin corticoperiosteal graft from the femur is indicated in patients with established nonunion of the humerus and radius without significant bony defects.

Self-tapping versus standard tapped titanium screw fixation in the upper extremity

Most screws used in fracture fixation necessitate a separate step for tapping of the screw hole. Titanium screw systems have been developed in which the screws can be inserted directly after a drill hole is made. These self-tapping screws thereby eliminate an operative step. A retrospective study was conducted that evaluated all wrist and hand procedures performed between January 1992 and December 1994 by 1 surgeon using screw fixation. The results of 39 cases treated with standard tapped titanium screws were compared with 28 cases treated with self-tapping titanium screws. Nearly identical union and complication rates were obtained in each group. Comparable results can be obtained with self-tapping screw fixation, which limits the number of instruments needed, eliminates an operative step, and thereby may diminish operative risk and shorten operative time.

The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery

The analgesic efficacy and safety of propacetamol, an injectable prodrug of acetaminophen, (paracetamol) were studied in 87 children (36 boys, 51 girls; age 6-13; mean age 9.5 years) immediately after limb surgery. Using a double-blind, randomized, parallel group design, the effects of a single IV infusion of 30 mg.kg-1 propacetamol (i.e. 15 mg.kg-1 acetaminophen) were compared with a single injection of placebo (PL). Efficacy was assessed on pain scores rated on a four-point verbal scale, a five-point visual scale (faces) and on a four-point relief verbal scale before administration (T0) and 0.25, 0.5, 1, 2, 3, 4, 5, 6 h after administration. At the end the global efficacy was rated by the physician on a five-point verbal scale. Propacetamol was statistically superior to placebo on all assessment criteria. Seven side-effects were recorded: five in the propacetamol group and two in the placebo group. 30 mg.kg-1 propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery.