Foreword. Silver coatings, used in many surgical devices, have demonstrated good antimicrobial activity and low toxicity. Oncological musculoskeletal surgery have an high risk of infection, so in the last decades, silver coated mega-prostheses have been introduced and are becoming increasingly widespread. Material and methods. We performed a retrospective analysis of 158 cases of bone tumors, primary or metastatic, treated between 2002–2014 with wide margins resection and reconstruction with tumoral implants. The average age was 59 years (range 11–78 years), all patients were treated by the same surgeon, with antibiotic prophylaxis according to a standard protocol. In 58.5% of patients were implanted silver-coated prostheses, in the remaining part, standard tumor prosthesis. Patients were re-evaluated annually and were recorded complications, with particular attention to infectious diseases. Results. The mean follow-up was 39.5 months. 23.4% of patients died at a median time of 34.9 months after surgery. 18.4% develop complications that required a new surgery, in 12.6% of cases due to infectious problems. Patients treated with silver-coated implants developed early infection in 2.2% of cases against the 10.7% of the patients treated with standard tumor prosthesis. This different among the two groups was statistically significant, while the percentage of late infections, occurred from 6 months after surgery, was similar between groups. Assuming a reduction of antimicrobial silver activity in the time, it was carried out a microscopic analyses [Fig. 1] of silver-coated prostheses explanted 82 months and 27 months after surgery. It confirmed an important degradation of the coating surface with almost complete absence of silver. Silver blood level, taken in a sample of patients, at different time after surgery, always showed values well below the threshold of toxicity, and no patient has never shown any sign of local or general toxicity secondary to silver [Fig. 2]. Discussion. Our study demonstrates that tumor silver-coated implants have a rate of early infection significantly less than traditional implants, while there were no differences in the rate of late infections, as described also in the literature. This likely is related to wear of the silver coating, which occurs on average around 2 years after implantation. Conclusion. We recommend to use silver–coated prosthesis as primary implants for limb
Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb
Impaired bone healing biology secondary to soft tissue deficits and chemotherapy contribute to non-union, fracture and infection following limb
Impaired bone healing biology secondary to soft tissue deficits and chemotherapy contribute to non-union, fracture and infection following limb
Aims. Present the outcomes of those patients diagnosed with Ewing's Sarcoma of the foot within the past 10 years and treated at the Royal National Orthopaedic Hospital's Bone Tumour Unit, Stanmore. Methods. Retrospective study of the cases identified from the pathology database. Notes reviewed for presentation, treatment and follow up. TESS (Toronto Extremity Salvage Score) and MSTS (Musculoskeletal tumour score) were calculated. Results. 6 patients identified with positive diagnosis of Ewing's Sarcoma of the Foot. Male:Female ratio of 5:1. Age range 15–31 (Mode 25). 4 cases skeletal, 2 extra skeletal. All cases reviewed by supra-regional MDT and received adjuvant and neo-adjuvant chemotherapy. All except one patient underwent limb-salvage surgery. The MDT decision for the remaining patient was that amputation was the only viable surgical option but the patient and his parents requested radiotherapy without surgical treatment. Mean survival 40 months (15–107 months). All patients survive at time of submission. Mean MSTS/TESS scores 93% (80–100%) and 94.6% (85–100) respectively. Discussion. All patients reported a delay between first presentation and referral to the sarcoma unit. This experience is common across the literature for this rare pathology. Lowest scores were submitted by the two patients who had amputation of their great toe. All patients are happy with their outcome and decision to salvage their limb. All patients scored themselves as “not at all disabled” and two stated this would not have been their response if they had lost their foot. Conclusion. Amputation is psychologically difficult to accept and patients are more receptive to limb
Treatment for hip displacement in children and youth with cerebral palsy (CP) is dependent upon when the problem is detected. Hip surveillance aims to identify hip displacement early through systematic screening and, together with timely orthopaedic intervention, can eliminate the need for salvage hip procedures. Here we report the impact on surgical practice of 1) hip surveillance program advocacy and knowledge translation efforts and 2) initial population-based program implementation. A retrospective review was completed of all children with CP undergoing surgery for hip displacement at a provincial tertiary pediatric hospital in the years 2004 to 2018. Date and type of surgery, age at surgery, Gross Motor Function Classification System (GMFCS) level, and pre-operative migration percentages (MP) were collected. Surgeries were categorized as soft-tissue release, reconstructive, and salvage procedures. Results were collected for three time periods: historical (September 2004- June 2010), hip surveillance advocacy and knowledge translation (July 2010- August 2015), and post provincial hip surveillance program implementation (September 2015 – December 2018). A total of 261 surgeries on 321 hips were reviewed. The rate of salvage procedures dropped from 29% (24) of surgeries performed in the historical period to 12% (14) during the period that included targeted hip surveillance knowledge translation and development of provincial guidelines. Since implementation of the surveillance program, salvage procedures have accounted for 7% (4) of interventions performed; all of these were in patients new to the province or existing patients. During the three study periods, reconstructive surgeries accounted for 64%, 81%, and 80% of the interventions performed. The mean initial MP at time of reconstructive surgery has decreased from 66% (SD 20%) in the historical time period to 57% (SD 25%) and 57% (SD 22%) in the subsequent time periods. There were a greater number of children at GMFCS levels III and IV in the two more recent time periods suggesting surveillance may assist in identifying children at these levels of impairment. The rate of soft-tissue surgeries was low during all time periods with the number trending higher since program implementation (7%, 7%, 10%). Knowledge translation and use of standardized surveillance guidelines can have a significant impact on the prevalence of
Ten to 15% of the pelvic girdle tumors are primary malignant bone tumors, while about 80% are osseous metastases. Due to improved function, enhanced quality of life, and acceptable local recurrence rates, limb
The majority of patients who develop hip arthritis have a mechanical abnormality of the joint. The structural abnormalities range from instability (DDH) to impingement. Impingement leads to osteoarthritis by chronic damage to the acetabular labrum and adjacent cartilage. In situations of endstage secondary DJD, hip arthroplasty is the most reliable treatment choice. In young patients with viable articular cartilage, joint salvage is indicated. Treatment should be directed at resolving the structural abnormalities that create the impingement. Femoral abnormalities corrected by osteotomy or increased head-neck offset by chondro-osteoplasty creating a satisfactory head-neck offset. This can safely be done via anterior surgical dislocation. The acetabular-labral lesions can be debrided and/or repaired. Acetabular abnormalities should be corrected by “reverse” PAO in those with acetabular retroversion or anterior acetabular debridement in those with satisfactory posterior coverage and a damaged anterior rim. Often combinations of the above are indicated. This talk will also update issues related to hip impingement and joint
Introduction. Patients with severe knee instability and extensive bone loss remain a surgical challenge. In such cases, regular knee implants and constrained condylar implants may not be suitable or have been attempted and failed. Hinged knee replacements have developed an important role in the management of such complex knee cases. They also have an increasingly important role in cases such as rheumatoid arthritis and other cases of severe joint destruction. We present a review of 138 consecutive hinge knee arthroplasties of 8 different Hinge models performed in our unit between 2004 and 2010. Method. Combined prospective and retrospective study of 138 (42 primary and 96 revisions) consecutive cases of Hinge knee replacements at a mean follow up of 4.2 years. Outcomes were recorded and scored using the American knee score preoperatively, 1, 2 and 5 years. Complications, re-revisions, implant failures and survivorship were also assessed. Results. Mean preoperative American knee score of 31 improved to 87 postoperatively. Implant survivorship was greater than 81% at 4 years, with most of the failures occuring in the
Introduction. Advances in the management of open tibial fractures have reduced the incidence of long-term complications of these injuries. However, a number of patients continue to suffer from sequelae such as infection, non-union and malunion. Many orthopaedic surgeons believe a below-knee amputation with a well-fitted prosthesis is a better alternative to limb reconstruction surgery. There are few studies that evaluate the long-term functional outcomes of amputees against patients who have undergone limb salvage procedures, and their results are conflicting. The hypothesis of this study is that patients who have undergone limb salvage have as good or better outcomes than those who have had below-knee amputations. Methods. This is a retrospective case study. One group (n=12) had been treated with below-knee amputation following a variety of lower limb fractures. The other group (n=11) had developed complications following tibial fractures and undergone limb
Purpose. The incidence of hip displacement in children with cerebral palsy is approximately 30% in large population based studies. The purpose of this study was to report the long-term effect of hip surgery on the incidence of hip displacement using a newly validated Cerebral Palsy (CP) hip classification. Method. Retrospectively, a sub-group of 100 children who underwent surgery for hip displacement were identified from a large-population based cohort of children born with CP between January 1990 and December 1992. These children were followed to skeletal maturity and closure of their tri-radiate cartilage. All patients returned at maturity for clinical and radiographic examination, while caregivers completed the disease specific quality of life assessments. Patients were grouped according to motor disorder, topographical distribution and GMFCS. Radiographs were independently graded according to CP hip classification scheme to ensure reliability. Surgical Failures were defined as CP Grade > IV. Results. Ninety-seven children and 194 hips were available for final review. According to GMFCS, greater than half the children were GMFCS IV and V (67/94, 67%), 12 were II and 18 were III. Fifteen hips were dislocated or had
Purpose. The focus of current management of soft tissue sarcoma on limb preservation often necessitates that patients undergo multimodal treatment, including both surgery and external beam radiotherapy. Pathologic fracture is a serious, late complication of radiotherapy. In patients who have also undergone wide excision of soft tissue sarcoma, nonunion rates of 80–90% persist despite optimal internal fixationMany sequelae of the treatments for soft tissue sarcoma exhibit the potential to perpetuate failure of bony union. Limb
Prior to the 1970s, almost all bone sarcomas were treated by amputation. The first distal femoral resection and reconstruction was performed in 1973 by Dr Kenneth C Francis at the Memorial Sloan-Kettering Cancer Centre in New York. Since that time, limb-sparing surgery for primary sarcoma has become the mainstay of sarcoma surgery throughout the world. Initially, the use of mega-prostheses of increasing complexity, involving all the major long bones and both pelvic and shoulder girdles, was popularised. In the early 1980s, wide use of massive allograft reconstructions became widespread in both Europe and in multiple centres in the USA and UK. Since that time, increasing complexity in the design of prostheses has allowed for increasing functional reconstructions to occur, but the use of allograft has become less popular due to the development of late graft failures of patients survive past ten years. Fracture rates approaching 50% at 10 years are reported, and thus, other forms of reconstruction are being sought. Techniques of leg lengthening, and bone docking procedures to replace segmental bone loss to tumour are now employed, but the use of biological vascularised reconstructions are becoming more common as patient survivorship increases with children surviving their disease. The use of vascularised fibular graft, composite grafts and re-implantation of extra-corporeally irradiated bone segments are becoming more popular. The improvement in survivorship brought about the use of chemotherapy is producing a population of patients with at least a 65% ten year survivorship, and as many of these patients are children, limb salvage procedures have to survive for many decades. The use of growing prostheses for children have been available for some 25 years, first commencing in Stanmore, UK, with mechanical lengthening prostheses. Non-invasive electro-magnetic induction coil mechanisms are now available to produce leg lengthening, with out the need for open surgery. Whilst many of these techniques have great success, the area of soft tissue attachment to metallic prostheses has not been solved, and reattachment of muscles is of great importance, of course, for return of function. There are great problems in the shoulder joints where sacrifice of rotator cuff muscles is necessary in obtaining adequate disease clearance at the time of primary resection, and a stable shoulder construct, with good movement, has yet to emerge. Similar areas of great difficultly remain the peri-acetabular and sacro-iliac resections in the pelvis. Perhaps the real future of the art of limb salvage will be in the reconstruction of failed major joint replacements where there is great loss of bone stock, and already massive tumour prostheses are providing a salvage pathway for failed standard joint replacement. The final future for limb salvage, however, may not rest with increasing surgical complexity and innovation, but with the development of molecular biology and specific targeted treatments, according to the cytogenetics of a particular tumour. We are on the threshold of yet another quantum change in the approach to cancer management; just as chemotherapy brought a tremendous change in the 1970s, molecular biology is the frontier to make much of the current limb
CT and MRI scans are complementary preoperative imaging investigations for planning complex musculoskeletal bone tumours resection and reconstruction. Conventionally, tumour surgeons analyse two-dimensional (2-D) imaging information, mentally integrate and formulate a three-dimensional (3-D) surgical plan. Difficulties are anticipated with increase in case complexity and distorted surgical anatomy. Incorporating computer technology to aid in this surgical planning and executing the intended resection may improve precision. Although computer-assisted surgery has been widely used in cranial biopsies and tumour resection, only small case series using CT-based navigation are recently reported in the field of musculoskeletal tumor surgery. We investigated the results of CT/MRI image fusion for Computer Assisted Tumor Surgery (CATS) with the help of a navigation system. We studied 21 patients with 22 musculoskeletal tumours who underwent CATS from March 2006 to July 2009. A commercially available CT-based spine navigation system (Stryker Navigation; CT spine) was used. Of the 22 patients, 10 were males, 11 were females, and the mean age was 32 years at the time of surgery (range, 6–80 years). Five tumours were located in the pelvis, seven sacrum, eight femurs, and two tibia. The primary diagnosis was primary bone tumours in 16 (3 benign, 13 sarcoma) and metastatic carcinoma in four. The minimum follow-up was 17 months (average, 35.5 months; range, 17–52 months). Preoperative CT and MRI scan of each patient were performed. Axial CT slices of 0.0625mm or 1.25mm thickness and various sequences of MR images in Digital Imaging and Communications in Medicine (DICOM) format were obtained. CT and MR images for 22 cases were fused using the navigation software. All the reconstructed 2-D and 3-D images were used for preoperative surgical planning. The plane of tumour resection was defined and marked using multiple virtual screws sited along the margin of the planned resection. We also integrated the computer-aided design (CAD) data of custom-made prostheses in the final navigation resection planning for eight cases. All tumour resections could be carried out as planned under navigation guidance. Navigation software enabled surgeons to examine all fused image datasets (CT/MRI scans) together in two spatial and three spatial dimensions. It allowed easier understanding of the exact anatomical tumor location and relationship with surrounding structures. Intraoperatively, image guidance with the help of fusion images, provided precise visual orientation, easy identification of tumor extent, neural structures and intended resection planes in all cases. The mean time for preoperative navigation planning was 1.85 hours (1 to 3.8). The mean time for intraoperative navigation procedures was 29.6 minutes (13 to 60). The time increased with case complexity but lessened with practice. The mean registration error was 0.47mm (0.31 to 0.8). The virtual preoperative images matched well with the patients' operative anatomy. A postoperative superficial wound infection developed in one patient with sacral chordoma that resolved with antibiotic whereas a wound infection in another with sacral osteosarcoma required surgical debridement and antibiotic. After a mean follow-up of 35.5 months (17–52 months), five patients died of distant metastases. Three out of four patients with local recurrence had tumors at sacral region. Three of them were soft tissue tumour recurrence. The mean functional MSTS score in patients with limb
