Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding.

40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure.

Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery.

Complex limb-salvage surgical techniques and reconstruction with sophisticated massive endoprostheses prove to be excellent tools for effective bone tumour management.

We treated 34 bone tumours (osteosarcoma, chondrosarcoma, plasmatocytoma, Ewing’s, osseous lymphoma, histocytosis-X, MFH, mets). We excised the lesions on oncologically safe surgical margins (wide excision inclunding anatomical barriers to tumour spread) and we reconstructed the defects with 29 modular and 5 custom designed and manufactured massive endoprostheses. Intramedullary stems were all cemented and they were supplied with hydroxyapatite collars that favour callus formation and extramedullary stabilisation. We did 12 proximal femoral tumour reconstructions, 17 distal femoral and proximal tibial tumours with rotating metal or polyethylene fixed-hinge knee implants and 1 total femur. In upper limb we did 2 proximal humerous with reverse polarity shoulder endoprostheses. In 1 humeral shaft case we did subtotal excision and reconstruction with two joint-saving endoprosthesis. In 1 distal humerus tumour we used custom constrained endoprosthesis of distal humerus and elbow. If tumours did not extend too close to the cartilage we applied joint-saving techniques. Function was restored with proper implant size selection and rearrangement of muscle remnants. On follow-up (4–58 months) average TESS score was 83%. There was no local recurrence and no aseptic loosening, dislocation or implant failure. Three patients with metastatic disease DOD. One case presented with late DVT and one with late deep infection.

New surgical methods and sophisticated implants with evidence-based design contributed greatly to successful limb salvage surgery as well as in overall patient prognosis and survival who enjoy better function.

Tourniquet induced ischemia-reperfusion syndrome (IRS) may trigger systemic inflammatory response following a total knee arthroplasty. The IRS will be studied in a prospective randomized controlled study in humans undergoing total knee arthroplasty, by measuring blood inflammatory mediators and blood gases.

Materials and Methods: Forty four (n=44) patients (female/male: 35/9 male) with a mean age of 72 years, undergoing primary total knee arthroplasty for osteoarthritis, were prospectively randomized in two groups. 22 patients operated with tourniquet [tourniquet group (TG)] and 22 patients operated without a tourniquet [non-tourniquet group (NTG)]. The mean overall ischemia time was 90 minutes. Arterial and venous blood samples were collected preoperatively, and at 1, 2, 3, 6, 24, 48 hours postoperatively. The pro-inflammatory (IL-1b, IL-6) and anti-inflammatory cytokines (IL-10) as well as the adhesion molecules (ICAM, VCAM), the CRP and blood counts were measured and correlated with the blood gases.

Results: Patients in TG had higher cytokine and inflammatory mediators values, compared to the NTG group especially during the sixth postoperative hour and the first postoperative day. The most abrupt changes were evident in the patients with the highest preoperative levels of cytokines and inflammatory mediators especially when the ischemia time was more than 90 minutes. Male patients demonstrated the most significant changes.

Discussion: The use of the tourniquet triggers the systemic inflammatory response. The most remarkable changes in inflammatory mediators are evident during the sixth postoperative hour and the first posoperative day. Tourniquet may be used for Total knee Replacement but care should be taken to decrease the ischemia time to the absolutely necessary specifically in males.

Our study includes 20 patients with femoral tumors during the years 1997–2002. The primary tumors were 5 sarcomas and 3 myelomas and we had 12 metastatic bone tumors. We used 12 modular prothesis and 8 long stem revision both for primary and for metastatic bone tumors. We applied special surgical techniques for the prevention of hip dislocation, the most common complication of proximal femoral resections.

In our study we describe the various surgical techniques used, the modes of application of the endoprothesis and also the techniques of the soft tissue reconstruction, hi 17 cases we used bipolar hemiarthroplasty and in 3 cases, where acetabular metastasis was evident, we used special endoprothesis which allowed us to reconstruct the acetabulum with the use of a special plexus. The most frequently used approach was the anterolateral. In one case we used an anteromedial approach due to the femoral triangle invasion by the tumor. We put special emphasis in the techniques of the soft tissue reconstruction, like capsuloplasty, with the use of a Dacron plexus under a specific modification. This plexus was also used as an extension to cover the muscular defects created due to wide tumor resection. The follow up period ranged from 6 months up to 5 years. Out of the 20 cases we had only one dislocation. The functional results according to the Ennekin scale were: Excellent – Good: 65%, Fair: 30%, Poor: 5%.

In conclusion, the new reconstruction techniques and the appropriate application of the modular prothesis that also preserve the femoral length, provide very good joint stability with good functional results.