Background

Previous data from our institution show that more than half of all prosthetic joint infections are due to S. aureus. A significant proportion of these bacteria may have an endogenous source. Detecting and treating asymptomatic S. aureus nasal carriers preoperatively has been shown to reduce the risk of infection.

Introduction: Prosthetic joint infections are a growing burden. Since we felt that we were far from the optimistic results recently published, we decided to find out the reality in our department. The goals were to determine:

The rate of infections in primary and revision surgery (hip and knee)

Materials and Methods: We retrospectively reviewed clinical records of all patients that underwent surgical treatment due to infected hip or knee prosthetic joint between 1st July 2001 and 31st December 2007.

Results: Since the majority of infections (67%) presented in the first two years after surgery, we determined the rate of infections taking in to consideration a minimum two years follow-up. We calculated a 1.8% (12/678) rate of infection for primary total hip and 3.3% (20/588) for primary total knee arthroplasty. There was no statistically significant difference between the two groups. Revision hip surgery had a 5.4% (15/243) infection rate and revision knee surgery revealed an even higher rate of 10.3% (4/42). The difference between primary and revision surgery was statistically significant both for hip and knee.

Considering an infection free arthroplasty as the goal, the overall success rate of treatment was under 48% (30/69). The success of treating infections with debridement and retention of components was even lower (29%). Further analysis revealed a higher success of this approach (45%) when considering more appropriate candidates (short term infections). An interesting statistically significant difference was found favoring this approach in the knee.

Two-stage revision strategy was successful in achieving revision arthroplasty in 43% (20/46) of the cases. Most patients were never considered candidates to the second stage procedure. Knee joint and resistant microorganisms were found to be predictors of bad prognosis.

There was a 90% (18/20) survival rate of revision arthroplasties after two years average follow-up. There were only 2 cases of relapsing infection both controlled without prosthetic removal.

Conclusion: Our results compare poorly with the latest published data from different centers. They led us to implement new prophylactic measures as well as review our diagnostic and treatment options.

Background: Braquial plexus injuries are a major indication for shoulder arthrodesis today. Numerous investigations have addressed the optimal position of the extremity for shoulder arthrodesis, and there are still numerous opinions on the ideal position. The present consensus appears to favor less abduction and forward flexion and more internal rotation.

Purposes: Our main goal is to determine the most favorable position for arthrodesis regarding upper limb function and prevalence of periscapular pain. Secondarily we describe the fusion and complications rate as well as patient satisfaction.

Materials and Methods: Between 1997 and 2008 the authors performed a total of 19 shoulder arthrodesis using a pelvic reconstruction plate in patients with braquial plexus injuries. Six were lost to follow-up leaving a total of 11 men and two women with a mean age of 46 years available for review. At a mean follow-up of 101 months [13–149] patients were evaluated clinically using predetermined functional parameters (hand-to-mouth, brachiothoracic grip, etc) and the visual analog pain scale. DASH score and radiological studies were also performed. Three patients that presented no active elbow flexion were excluded of the functional results analysis.

Results: The mean fusion position found was 20° abduction, 32° forward flexion and 44° internal rotation. Abduction ≥ 25° relates to better function as judged by a better hand-to-mouth and brachiothoracic grip ratio as well as a better DASH score (38.8 vs. 45.4) but is also unfortunately related to higher periscapular pain prevalence (VAS pain 3.75 vs. 1.38). Forward flexion ≤ 30° also relates to slightly higher periscapular pain prevalence (VAS pain 2.7 vs. 1.7) and a better DASH score (39.5 vs. 47.7). Exaggerated internal rotation seems to have a negative influence on the functional outcome. Although relating to a surprisingly better DASH score (39.7 vs. 44.9), none of the three patients presenting with internal rotation over 45° was able to reach the mouth with his/her hand. Fusion was obtained in 12 patients. Major complications included one pseudarthrosis, one malpositioning of the extremity that forced a revision surgery to increase internal rotation and one humeral shaft fracture treated conservatively. All but one patient (including those with no active elbow flexion) were satisfied/very satisfied with the final outcome.

Discussion: Our results suggest abduction around 25° and forward flexion of no more than 30° are needed. Higher abduction and lower forward flexion values although relating to better function do so at the expense of more periscapular pain. We agree with the present trend towards increasing internal rotation but found that it should not exceed 45°.

Aims: A previous study demonstrated that negative pressure wound therapy (NPWT) increases tissue pressure. This conflicts with the understanding that these dressings increase perfusion. This randomised case control study investigates the effects that circumferential NPWT has on perfusion in humans and how different suction pressures influence this.

Methods: Ten healthy volunteers were recruited into the study and sequentially randomised to receive suction pressures of either −400 mmHg or −125 mmHg. With both hands placed in circumferential NPWT dressings, suction was only applied to one hand. Perfusion of both hands was then analysed simultaneously using radioisotope perfusion imaging. After allowing one week for complete excretion and decay of the isotope, an identical experiment was done on the same volunteers’, this time using the contralateral hand as the test hand. A total of 20 scans were carried out. Data were analysed using the Wilcoxon and Mann-Whitney tests.

Results: In the hands that received suction pressures of −400 mmHg, there was a highly significant mean reduction in perfusion of 40% (SD 11.5%, p< 0.0005). In the hands that received suction pressures of −125 mmHg there was also a highly significant mean reduction in perfusion (mean 17%, SD 8.9%, p< 0.0005). The reduction in perfusion of the group undergoing NPWT at −400 mmHg was significantly greater than the group undergoing NPWT at −125 mmHg (p< 0.015).

Conclusion: Tissue perfusion beneath circumferential NPWT dressings is significantly reduced when suction is applied, regardless of whether suction pressures of −125 mmHg or −400 mmHg are utilised. There is a significantly greater reduction in perfusion at suction pressures of −400 mmHg, compared to −125 mmHg. This implies that circumferential NPWT should be used with extreme caution, if at all, on tissues with compromised perfusion. This finding represents a paradigm shift in our understanding of the mechanism of action of NPWT.

Chondrosarcoma is the second most frequent primary malignant tumour of bone, representing approximately 25% of all primary osseous neoplasms. Chondrosarcomas are a group of tumours with highly diverse features and behavior patterns, ranging from slow-growing non-metastasizing lesions to highly aggressive metastasizing sarcomas. As radio and quimio-resistant tumours, the surgery constitutes the unique chance of cure. Nowadays, besides the curative intention, the reconstructive surgery is also a priority in order to save the limb and optimize the function.

This case report is about a young woman, of 24 years old, with hip-related pain and a large mass in the left pelvis. The imagiologic study showed a large mass of about 8 cm of large diameter, starting at the anterior wall of the acetabulum, involving the pubic arcs and with matrix calcification. The core needle biopsy confirmed the presence of a chondrosarcoma, staged as a IIB of Enneking.

Because of its size and localization the limb salvage surgery has been a challenge. The surgery included a broad approach of the left hemipelvis, with wide excision of the tumour, reconstruction of the abdominal wall with a propylene prothesis and reconstruction of the hemipelvis with a “custom-made” prothesis with preservation of the femoral neurovascular bundle. The patient started to walk with total bearing after three months and had a normal gait and a nearly normal life during eleven months. Fifteen months after the surgery lung metastasis and local recurrence were diagnosed and she died six months after.

Conclusion: The surgery is our unique weapon in the “combat” against the chondrosarcoma. The reconstructive surgery must be a concern to give to our patients the best functional result and quality of life.

Core needle: From the other 335, 116 were benign tumours or tumour-like conditions, 86 primary malignant, 53 lesions oh Hematopoietic, lymphoid and biopsy is simple, practical and easily permits diagnosis of bone and soft tissue tumours and tumour-like conditions even when immunohistochemical studies are needed.

We present the results of 412 core needle biopsies guided with fluoroscopy, CT and echo scan with assessment of accuracy and costs

From January/96 to December/08, 56 soft tissue and 356 bone tumours and tumour-like lesions were submitted to this technique in the Oncology Unit of Hospital Santo Antònio. All biopsies were performed by the same team (one radiologist, one orthopaedic surgeon) and the histological exam by the same pathologist.

There were 77 cases in which diagnosis was inconclusive (sample not representative, crushing, necrosis, hemorrhagic features or image/histological dissociation); 36 of these were soft tissue and 41 bone lesions. histiocytic elements, 65 metastases, 8 recurrent malignancies, 5 osteomyelitis and 2 metabolic diseases.

Diagnosis was confirmed in 278 cases with the definitive surgery and only one was wrong. The other 57 cases were later controlled by imaging exams and there were no reasons to suspect a wrong diagnosis.

No complications occurred.

Costs were estimated to be less than one fifth of an open biopsy.

The high accuracy (only one case was misdiagnosis), the safety, the costs and the fact that in only 18,7% the diagnosis was not established make us consider this method effective and to be encouraged. Better selection of lesions and more attention to directions of the cores may low the number of inconclusive diagnosis.

Primary synovial chondromatosis, defined by Jaffe (1951), is a rare, benign arthropathy, of unknown aetiology, distinguished by the chondroid metaplasia of the synovial membrane of the joint, bursa or tendon sheath, which leads to the formation of loose bodies, usually intra-articular. It is characteristically monoarticular and the knee, hip and elbow are the joints most commonly affected. The shoulder is a rare localisation and the extra-articular involvement even rarer, with only few cases presented in the literature.

The diagnosis is possibilited by the clinical examination and by the confirmation of the presence of multiple intra-articular loose bodies by roentgenographic studies and magnetic resonance (MR). The treatment is always surgical. Malignant degeneration of synovial chondromatosis into chondrosarcoma is described, although rare.

We report an exceptionally rare case of synovial osteochondromatosis of the shoulder with combined intra and extra-articular involvement in a 28 years old female patient, former athlete. She presented with a five-year history of shoulder pain and slight limitation of motion. Radiographic examination and magnetic resonance imaging led us to the diagnosis of synovial chondromatosis of the shoulder. The patient underwent arthroscopic removal of the intra-articular loose bodies and partial synovectomy. The subscapularis recess was then identified through an anterior deltopectoral incision and multiple loose bodies were removed from within.

Primary synovial chondromatosis of the shoulder is rare (5% of the cases) and the involvement of the extra-articular shoulder site is even rarer. Bloom and colleagues reported ten cases involving the shoulder in a meta-analysis of 191 synovial chondromatosis cases.

The arthroscopic removal of the loose bodies combined with the partial sinovectomy has demonstrated efficacy and low recurrence rates, allowing excellent visualization of the joint, decreased morbidity and early functional return. Nevertheless, we think that this approach may become insufficient when the extra-articular involvement is verified.

Synovial cell sarcoma is one of the most common soft tissue tumours. Prognosis of this tumour is related to initial care. Survival rates have improved in the past 20 years because of treatment with primary radical surgery, along with chemotherapy and radiation.

This case report is about a woman, of 68 years old, with a left shoulder-related pain and mass with about four months. The image study showed a lobulated and irregular mass, with about 12x10x9cm, infiltrating the rotator cuff and glenohumeral joint. The core needle biopsy confirmed the presence of a synovial sarcoma, staged as a T2N0M0.

The treatment started with neo-adjuvant chemotherapy, with a poor response. Then, surgery was performed, with a wide excision of the scapula, proximal humerus and clavicle (type IV of Malawer) without reconstruction. The treatment regime ended with the radiotherapy. Eighteen months after the surgery the patient remains disease-free and a neo-joint is starting to form. At this time the DASH score was 63.8. Despite the flail shoulder function is acceptable.

Conclusion: In such an aggressive tumour, an extensive and multidisciplinary approach is imperative but always with regard to the limb function.

Osteosarcoma is the most common tumor among the primitive malignant bone tumors. When different features of these lesions are considered, we can find several varieties of this tumor, with distinct anatomo-clinical presentation, treatment and prognosis.

Until the 70s, its prognosis was very poor, the standard surgical treatment was amputation and 80% of the patients died from metastatic disease. With the development of new surgical techniques, the advent of combined chemotherapy and more accurate imaging, the outcome of these patients has improved significantly. Consequently, approximately 90% of the surgical cases are treated with limb salvage procedures.

The authors reviewed 22 cases of Osteosarcoma treated in HGSA, 20 being submitted to the T20 Rosen protocol.

Trocar biopsy was performed in 19 of the patients and 3 of the patients were submitted to incisional biopsy in order to complete diagnosis.

Regarding the anatomo-clinical pattern, Classic Osteosarcoma was present in 19 patients, 2 of the cases were Parosteal and 1 was Central low-grade Osteosarcoma.

The majority of patients underwent limb salvage surgery; only 2 had amputation surgery and 1 patient was submitted to palliative chemotherapy. Considering limb salvage procedures, several techniques were performed: arthrodesis (n=1), grafts (n=4), prosthesis (n=13) and compound prosthesis (n=1). The resection margins were wide in 19 cases, marginal in 2 cases and in 1 case intra-luminal.

Among the treated patients: 12 patients are still alive and cured, 3 have metastatic disease, 6 are deceased and 1 didn’t complete the follow-up.

The final functional score obtained was 84% for the superior limb (DASH) and 81% for the inferior limb (TESS).

Although the scarce number of cases described were not enough to make any kind of correlation, it was possible to establish the accuracy of the multidisciplinary approach involved both in the diagnosis and treatment, in agreement with the “state of art”.

Osteoid osteomas are benign, painful osteogenic tumours of small size (≤ 1,5 cm). Surgical resection of the nidus has been the elected method of treatment for decades but some complications and difficulties (poor localization, extensive tissue damage, fractures, delayed recovery) encouraged the development of less invasive techniques such as radiofrequency.

Lack of histological proof is the major concern regarding radiofrequency ablation as we make the diagnosis by the clinical findings and the image features.

We present the results of 20 patients with osteoid osteoma treated with radiofrequency from January 2004 to December 2008 (mean follow up 23 months). All patients were under general anaesthesia and de access route was chosen in the CT-suite. 11 cases were located in the proximal femur (head, neck and subtrocanteric region), 2 in the distal femur, 2 in de distal humerus, 2 in the tibia, 2 in the acetabulum, and 1 in de vertebal body of D8.

In all cases we used a Cool-tip TM RF electrode (water-cooled tip) reaching a heating temperature of 42°C to 48°C during 12 minutes. In 7 patients a cannulated drill bit was used to penetrate the thick cortical or to reach the nidus through the opposite side in order to avoid a neurovascular bundle.

Hospital discharge was allowed after 6 to 8 hours after the procedure.

No complications occurred.

All patients, except one, experienced complete relief of the pain although the 6-month follow-up CT’s do not show sclerosis of the nidus. None of them recurred till data. The patient who did not recover had not had a clear diagnosis.

We conclude that radiofrequency ablation is effective, safe, favouring rapid recovery and, of course, reduces economical and social costs.

Intramuscular hemangyomas are benign tumours (0,8% of all hemangyomas). Their aetiology is uncertain but they are possibly congenital, although some seem to be related to trauma. Symptoms (usually pain and swelling) may be present for years. Histological subtypes are cavernous, capillary and mixed. Optimal management includes precise diagnosis and wide excision to prevent local recurrence.

Authors present a case of a 79 years male with cavernous hemangyoma of the thigh with three years of evolution. The tumour eroded the femur and the patient had a mass all over the thigh with tension and pain. Diagnosis was suspected by phleboliths seen on x-ray and MRI and was confirmed by open biopsy.

Treatment was a complete excision with double approach, medial and lateral, plus prophylactic nailing of the femur.

With a four years follow – up, the patient has no sign of recurrence and has a normal function of the inferior limb and a normal gait.