Objectives. In this cross sectional study, the impact and the efficacy of a surveillance programme for sarcomas of the extremities was analysed. Methods. All patients who had treatment with curative intent for a high-grade sarcoma and were diagnosed before 2014 were included and followed for a minimum of two years. Results. Of the 909 patients who had a review appointment in 2014, 131 were under review for a high-grade sarcoma of the extremities following treatment with curative intent. Of these patients, three patients died of disease, two patients died of other causes, 12 are alive, with disease, and 114 have no evidence of disease. The surveillance programme accounts for 14% of all review appointments. Four of five patients (80%) who developed local recurrence identified the recurrence themselves. Chest radiographs are adequate in identifying metastatic disease and 11 (73%) of metastases were diagnosed during a routine follow up visit. However, the chance of cure is small and only two patients were referred for a metastatectomy. Of these only one survived for more than two years. The mean time for developing metastatic disease and local recurrence was 2.0 and 3.9 years respectively. Once identified, the mean time to death was 2.1 years for patients with metastatic disease. Conclusions. Surveillance of sarcoma patients makes up a substantial amount of the workload of a sarcoma unit. The chance of cure following identification of local recurrence or metastatic disease, however, is small. Alternative methods of surveillance that allow better evaluation of the patient’s needs are recommended. Cite this article: P. Cool, G. Cribb. The impact and efficacy of surveillance in patients with sarcoma of the extremities. Bone Joint Res 2017;6:224–230. DOI: 10.1302/2046-3758.64.BJR-2016-0253.R1

Prediction tools are instruments which are commonly used to estimate the prognosis in oncology and facilitate clinical decision-making in a more personalized manner. Their popularity is shown by the increasing numbers of prediction tools, which have been described in the medical literature. Many of these tools have been shown to be useful in the field of soft-tissue sarcoma of the extremities (eSTS). In this annotation, we aim to provide an overview of the available prediction tools for eSTS, provide an approach for clinicians to evaluate the performance and usefulness of the available tools for their own patients, and discuss their possible applications in the management of patients with an eSTS. Cite this article: Bone Joint J 2022;104-B(9):1011–1016

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating; they may result in multiple subsequent surgeries and significant patient morbidity. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in resections of irradiated soft tissue sarcoma of the extremities. A consecutive series of patients of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc, Kalamazoo MI) at the time of closure. Three fellowship trained Orthopaedic Oncologic Surgeons were asked to prospectively predict likelihood of wound complications based on fluorescence. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. An a priori power analysis demonstrated that 5 patients were necessary to achieve statistical significance. Univariate and multivariate statistical analyses were performed to identify predictors of wound complications. 14 patients were consecutively imaged. The diagnosis was undifferentiated pleomorphic sarcoma in 9 (64.3%) of patients; 11 (78.6%) tumors were high grade. There were 6 patients with wound complications classified as “aseptic” in 5 cases and secondary to hematoma in 1 case. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. In the area of wound complication, the mean % of maximal signal for wound complications was 49% during the inflow phase and 48% during the peak phase. The mean % maximal signal for peri-incisional tissue without wound complications was 77% during the inflow phase and 83% during the peak phase (p=0.003 and p<0.001). During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC=0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the area under the curve (AUC=0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity 100%. Intraoperative use of indocyanine green fluorescent angiography may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis. Future studies are necessary to validate this technology in a prospective manner and to determine if interventions can be instituted to prevent predicted wound complications

Background: Adult rhabdomyosarcoma is a relatively rare tumour. Good prognosis has been reported in children with multimodality of management. Because of its rarity, very little has been written about this tumour in adults especially on extremities. Aim- To analyse the results of multimodality treatment of rhabdomyosarcoma of extremities in adults treated over a period of ten years in a UK regional centre. Material and Methods – Between 1991 and 2002, eight patients underwent enbloc resection for rhabdomyosarcoma of extremities. There were four men and four women. Age of these patients ranged from 21 to 78years. Locations of these tumours were thigh in 5 patients, legs in 2 patients and shoulder in one. Treatment consisted of surgical resection in all patients combined with radiotherapy or chemotherapy or both. These patients were studied retrospectively for surgical and treatment details, tumour recurrence, secondary and mortality. Results are analysed in relation to histological subtype, size of the tumour (less or more than 5cm) and stage of the disease. Conclusion: Our experience shows a significant incidence of metastatic recurrence and mortality in these patients. Major determinant of disease control (local and distant) seems to be the size of the tumour at presentation. Treatment must be individualized, but complete local excision with a tumour-free margin should be the goal. Major ablative amputation surgery was not performed

Aim. Gram negative bacteria (GNB) are emerging pathogens in chronic post-traumatic osteomyelitis. However, data on multi-drug (MDR) and extensively drug resistant (XDR) GNB are sparse. Methods. A multi-centre epidemiological study was performed in 10 countries by members of the ESGIAI (ESCMID Study Group on Implant Associated Infections). Osteosynthesis-associated osteomyelitis (OAO) of the lower extremities and MDR/XDR GNB were defined according to international guidelines. Data from 2000 to 2015 on demographics, clinical features, microbiology, surgical treatment and antimicrobial therapy were retrospectively analyzed. Cure was assessed after the end of treatment as the absence of any sign relevant to OAO. Factors associated with cure were evaluated by regression analysis. Results. A total of 53 infections of OAO of the lower extremities (hip, femur, tibia) were evaluated. Patients were female (n=32, 60.4%), with a mean age (SD) 57(3) years, history of trauma (83%), comorbidities (26.4%). The most frequent GNB were: E.coli (n=15), P.aeruginosa (n=14), Klebsiella spp (n=8), Enterobacter spp (n=8) and Acinetobacter spp (n=5). P.aeruginosa predominated the XDR group than the MDR one (n=6/10 vs n=8/43, p=0.01). Antibiotics were given mostly in combinations (64%) for a median duration of 117 days (SD:31.5). Carbapenems were the most frequently used agents (54.7%), followed by colistin (18.8%) and fluoroquinolones (15%). Surgical treatment included debridement with implant retention (n=22), implant explantation (n=22), new osteosynthesis (n=3), others(n=6). Only failure of the surgical treatment for OAO was associated with lack of cure [OR 8.924 (CI95%: 3.006–26.495), p<0.001] at the end of treatment, for a 12-month follow-up period. Patients' age, gender, comorbidities, history of trauma and surgery, clinical presentation of OAO, type of antimicrobial treatment (use of fluoroquinolones, carbapenems or colistin as monotherapy or in combination) as well as type of surgical intervention (explantation vs implant retention) were not found to significantly influence the patients' outcome. Overall, cure was assessed in 31 patients (58.5%). Death occurred in 7 patients, all older than 60, with failure of surgical treatment (p=0.016). These patients presented with many comorbidities (57%) and without difference in treatment outcome between XDR and MDR infection (p=0.114). Conclusion. Osteosynthesis-associated infections of the lower extremities caused by MDR/XDR GNB are a severe complication in orthopaedic surgery. The role of surgical treatment is independently associated with outcome regardless of the type of intervention (explantation or implant retention) and the type of antimicrobial treatment

Flaps constitute an integral part of the treatment of soft tissue and skeletal infections of the extremities, focusing on the coverage and augmentation of the local biology. In a 6-year period, a total of 33 septic defects of the upper (6) and lower (27) extremities were treated with 4 free and 29 pedicled flaps, after extensive surgical debridement of the septic site. In the lower extremity, treatment included 3 free (2 latissimus dorsi and 1 serratus anterior), and 24 pedicled flaps (5 heads of gastrocnemius, 7 soleus, 1 abductor hallucis, 9 reverse fasciocutaneous, 1 combined medial head of gastrocnemius and soleus and 1 extensor longus hallucis) for 3 cases of soft tissue sepsis and 24 septic defects of the skeleton. In the upper extremity, 1 free vascularised fibular graft (combined with muscle-skin) and 5 pedicled flaps (2 homodigital, 1 heterodigital, 1 cross-finger, 1 periosteal) were used for 3 soft tissue and 3 skeletal septic defects. All but one flaps of the lower extremities were covered with split thickness skin (simultaneously or within 7 days), whereas flaps of the upper extremity included skin in all cases. Three flaps (2 reverse fasciocutaneous and one soleus) were revised (with latissimus dorsi, serratus anterior and extensor longus hallucis flaps respectively) in a mean period of 4 months due to persistent infection and 4 skin grafts were revised due to superficial infection. In a minimum follow-up period of 9 months (9–60 months) full coverage of the defect and treatment of infection was accomplished in all patients, resulting in a good functional and aesthetic outcome. Except for 2 patients, all were able to walk and use their extremity and returned to previous activities. The use of flaps in the treatment of septic skeletal or soft tissue defects leads to a functional upper or lower extremity and successfully prevents amputation

Objective. was to review the experience of the Rizzoli with megaprosthetic reconstruction of the extremities in musculoskeletal oncology. Material and methods. Between April 1983 and December 2007, 1036 modular uncemented megaprostheses of the lower limbs were implanted in 605 males and 431 females: 160 KMFTR(r), 633 HMRS(r) prostheses, 68 HMRS(r) Rotating Hinge and 175 GMRS(r). Sites: distal femur 659, proximal tibia 198, proximal femur 145, total femur 25, distal femur and proximal tibia 9. Histology showed 612 osteosarcomas, 113 chondrosarcomas, 72 Ewing's sarcoma, 31 metastatic carcinomas, 89 GCT, 36 MFH,68 other diagnoses. Between 1975 and 2006 at Rizzoli 344 reconstructions of the humerus using prosthetic devices (alone or in association with allografts) were performed: 289 MRS(r), 37 HMRS(r), 2 Osteobridge(r), 4 composite prostheses, 8 Coonrad-Morrey(r), 4 custom made prostheses. Sites of reconstruction were: proximal humerus 311, distal humerus 19, diaphysis 5, total humerus 9. Histology showed 146 osteosarcomas, 56 chondrosarcomas, 23 Ewing's sarcoma, 67 metastatic carcinomas, 14 GCT, 10 MFH, 28 other diagnoses. Patients were followed periodically in the clinic. Information were obtained from clinical charts and imaging studies with special attention to major complications requiring revision surgery. Major prostheses-related complications were analysed and functional results evaluated according to the MSTS system. Univariate analysis by Kaplan-Meier actuarial curves was used for studying implant survival to major complications. Results. Major complications causing implants failure in lower limbs were 80 infections (7.7%), 64 aseptic loosening (6.2%) and 33 breakages (3.2%). In lower limbs infection occurred in 18 KMFTR(r), 47 HMRS(r), 5 HMRS(r) Rotating Hinge, 10 GMRS(r). Breakage of the prosthetic reconstruction occurred in 16 KMFTR(r), 16 HMRS(r), 1 HMRS(r) Rotating Hinge. Aseptic loosening occurred in 15 KMFTR(r), 28 HMRS(r), 18 HMRS(r) Rotating Hinge, 3 GMRS(r). Major complications causing implants failure in upper limbs were 15 infections (4.3%), 8 aseptic loosening (2.3%) and 4 breakages (1.2%). In upper limbs infection occurred in 14 MRS(r) and 1 Coonrad-Morrey(r). Aseptic loosening in 8 cases MRS(r). Breakage in 4 cases MRS(r) prostheses. Most patients in both lower and upper extremities series showed satisfactory function (good or excellent) according to the MSTS evaluation system. Implant survival to all major complications of lower limb megaprostheses evaluated with Kaplan-Meier curve was 80% at 10 years and 60% at 20 years. Implant survival for the newer designs (GMRS(r)) available only at middle term follow up showed an implant survival to major complications at about 90% at 5 years. Implant survival to all major complications was over 80% at 10 years and 78% at 20 years. Conclusions. Megaprostheses are the most frequently used type of reconstruction after resection of the extremities, since they provide good function and a relatively low incidence of major complications. Both function and implant survival improved in the last decades with the introduction of newer designs and materials

Aims: In patients who have malignant bone tumour (MBT) of the proximal extremities, it is often possible to carry out resection which salvage the limb. Reconstruction, however, remains a problem because none of the procedures which are available adequately compensates for the functional loss after amputation. Material and Methods:Between 1985 and 2001, 45 patients (p) with MBT or aggressive BT of the proximal extremities were reviewed. All (p) have pathologic confirmation. Among them 7 were osteosarcoma, 6 chondrosarcoma, 2 fibrosarcoma, 1 Ewing’s sarcoma, 1 plasmocitoma, 4 bone metastases and 24 giant cell tumour. Radiographs, CT, MRI, scan with Tc 99 m were useful for treatment decision. We used for reconstruction non vascularised fibular autografts in 29p, a free vascularised fubular grafts in 4 p.tibia grafts in 2 p. Ticoff-Limberg procedures in 1 p.resection of the proximal radius in 1 p.endoprosthesis of the proximal humerus in 4 p.and MMA cement and Rush-Pin in 4 p. The functional results were graded according to the rating system of the MSTS. The mean duration of follow-up was 64 months (12–201 m). Results:Our results were satisfactory with regard to pain, emotional acceptance and manual dextterity.29 p.were still alive at the time of the latest follow-up.2 p.died from other disease.14 p. died from the disease. Function and lifting ability were unsatisfactory in 4 p.(8,9%). Radiographs schow:2 p.(4,4%) with delayed union,4 p.(8,9%) had colaps or fracture of the head of the fibula,2 p. had local recurence. Conclusion: different methods of reconstruction of the proximal extremities after resection of the MBT are effective in selected cases

Background: Skin grafting is one of the simplest techniques of providing skin cover following enbloc resection of soft tissue sarcomas on extremities. But many authors have questioned the tolerance of skin graft to post operative radiotherapy. Aim: To assess the integrity of skin grafts following post operative radiotherapy for soft tissue sarcomas on extremities. Material and methods: During the period between 1997 and 2003, 10 patients received postoperative external beam radiotherapy following excision of soft tissue sarcomas on extremities and skin grafting at this regional soft tissue sarcoma unit. Age of these patients ranged from 26 years to 92 years. Malignant fibrous histiocytoma was the commonly encountered tumour. Commonest site of resection and skin grafting was lower leg. These patients were retrospectively analysed for interval between skin grafting and radiotherapy, dose, type and fractions of radiation, break in radiotherapy, adjuvant chemotherapy and effect of radiation on skin graft. Results: One patient developed moist desquamation and two developed dry desquamation during the course of treatment. All acute skin reactions were healed within 3 weeks of completion of radiotherapy. No patients required further soft tissue reconstruction. Conclusion: Adjuvant external beam radiotherapy can be delivered to skin-grafted areas on extremities following enbloc excision of soft tissue sarcomas without any major complications. Our experience indicates that the radiation reaction can be minimised if the graft is allowed to heal adequately prior to the initiation of radiotherapy

Necrotising fasciitis (NF) of the extremities is a rapidly progressive, potentially life threatening soft tissue infection. Recent advances in its management, like hidrobisturi-assisted debridement (Versajet®), negative pressure wound therapy (NPWT), or Intravenous Immunoglobulin (IVIG) have not clearly influenced in mortality and morbidity rates, still high. We therefore sought to study the necrotising fasciitis of the extremities diagnosed in the last four year in our hospital. We investigate (1) the morbidity and mortality rates, (2) the microbiologic characteristics of the infection, and (4) the management focusing on the use of new treatment technologies. This is a 4-year retrospective chart review of all NF of the extremities who presented in our hospital, from 2010 through 2013. We collected data on demographics, comorbidities, diagnostic test, LRINEC score and microbiological information. We evaluated the therapeutic management of these patients, focusing in the intensive care necessities, the use of hidrobisturi and NPWT as well the treatment with IVIG. 20 patients satisfied our inclusion criteria. Lower extremity was the most common location of infection (60%). Blood cultures were available in 14 cases, 7 with a negative culture result (50%). The average LRINEC score on the day of presentation was 6 (range: 0–11). All the patients were treated operatively with 2.5 interventions on average (range: 1 to 5 operations). In the operative samples, one or more causative microorganisms were identified in 18/20 (90%) of the NF cases, with two culture negative cases. Overall, type II NF (Group A β-haemolytic streptococci) was found in 11 cases (55%) and Type I (synergistic polymicrobial) in 7 cases (35%). Versajet® was used in the first debridement in 40% (8 out 20) of the cases and in the second-look in 80% of the cases. In 5 cases (25%) a direct wound closure was selected and in 75% cases a VAC closure was the technique of choice. Thirteen patients (65%) were admitted in the intensive care unit, with a medium stay of 12 days. The overall mortality was 30 % with LRINEC score, glucose level and creatinin level being an independent risk factor of death (p < .05). Five amputations were identified in this series (25%). According our data, despite surgical advances, pharmacological new drugs and intensive care improvements, NF remains a disease with high mortality and morbidity. New technologies have been used widely in the last four years in our center without appearing to influence the final outcome of the disease

Introduction. Lesions of the upper extremities, and especially of the hands, are the most common form of occupational injury in the agricultural and industrial sectors [1]. When the grip strength and the way of its development are relevant, it would be very useful to be able to rely on an instrumental procedure, in support of the clinical examination, for both clinical and legal purposes. The possibility of differentiating between healthy subjects and patients affected by disabilities of the upper extremities, using parameters based on force-time curves for handgrip tests, was investigated with the aim to obtain objective and comprehensive outcome, useful to support the clinical evaluation. Materials and Methods. The reference group consisted of 151 subjects examined for occupational trauma of the upper limbs, all with a dominant right arm, who had suffered an occupational injury. The 74% of the injuries affected the hand. A further 648 healthy people were enrolled as the control group. Grip strength was measured with an electronic dynamometer. The signals acquired with the dynamometer were subdivided into 5 characteristic phases [2]: first reaction, explosive contraction, isometric contraction, release and relaxation. The maximum force, the ratio between the maximum force exerted by the two arms and an index related to the explosive muscle power and the ability to maintain maximum voluntary contraction were calculated. Percentage variations of each parameter, as compared to a threshold value, were taken into account and an overall value (T) was calculated, representing the sum of these variations. Result and Discussion. This acquisition system was shown to be reliable and easy to use, and the test could be administered simply and fairly rapidly. The findings in the control group were comparable to those reported in the literature [3–4]. A negative value of T invariably identified a subject with a disability. By associating assessment of T with those of the specific indexes, other subjects with a clinical disability were identified. The use of the parameters we describe makes it possible not only to assess the maximum force of the handgrip but also how it is exerted and maintained, thus providing a more reliable method of differentiating between normal function and impairment and what it is more obtaining an objective and comprehensive outcome, which sensitivity is useful to support clinical evaluation. The proposed functional tests could offer the clinician a possible diagnostic aid, providing a method that can describe the motor skill on the basis of objective parameters. In view of its good sensitivity (0.99%) and specificity (0.84%), relatively rapid execution and the low cost of the tools, it could be usefully adopted in the clinical setting

Purpose: The purpose of this study is to evaluate the results of the treatment by severe blast injuries to limbs. Materials and methods: Twenty-seven patients after blast injuries were treated. There were 13 patients with tibial fractures, 7 fractures of the femur, 4 – fractures of the humerus and 3 with fractures of the forearm bones. According to Gustilo all fractures were open grade 3B and 3C. According to MESS a median value was 4,7 points (range 3 – 7). Six had on admission vascular injuries, and 12 had peripheral nerve injuries. There was other major organ trauma in 55,5% of patients. On admission, the fractured bones are realigned and stabilized with an AO tubular external fixation frame followed by immediate thorough soft tissue debridement, vascular reconstruction. In patients with peri-articular fractures temporary trans-articular bridging was needed. After 5 to 7 days or when wound condition permits, delayed primary sutures, the application of skin grafts or free tissue flaps are performed. At this stage, the tubular fixator is exchanged for a circular frame that allows stability, sufficient for full weight bearing by minimal invasive fixation and meticulous attention to freeing the previously bridged joints. Hybrid frames allows combination of advantages of each type of external fixators. Closed reduction of fractures was performed in most patients by ligamentotaxis and use thin wires with olives. Fixation in elastic frame combined with cyclic loading provide favorable biomechanical environment for fracture healing. In patients with high-energy “floating elbow” injuries the hybrid circular devices of the humerus and forearm were connected by hinges to allow immediate elbow joint movements. The separate fixation of the forearm bones was performed to allow early pronation/supination motions. Results: In all patients the external fixation was the definitive treatment. Fracture union was achieved at median time of 240 days (range 90 – 546). Throughout the period of fracture healing the patients were fully ambulatory, living at home. In three patients with bilateral highly complex blast injuries of lower extremities, where one limb had to be amputated, the Ilizarov device for severely injured contralateral limb provided the conditions necessary for early prosthetic fitting. There was one non-union and one patient developed chronic osteomyelitis treated by serial debridement and sequestrectomies. Conclusions: Based on this experience, we suggest that the stabilization in ring frame with radical debridement and early tissue transfer provides fracture healing and good functional results in extensive compound blast injuries of the extremities even in limbs categorized as high risk

Introduction: The role of surgery for local control in the multimodal management of Ewing’s sarcoma has substantially increased during the past 20 years. However, selection bias due to location (extremities vs axial skeleton) and relatively non-homogeneous treatment received by patients in multi-institutional trials may limit objective evaluation and comparison of the relative role of surgery and radiation therapy in this setting. Purpose of this study was to review a large series of patients homogeneously treated at a single institution. Methods: 268 patients with non-metastatic Ewing’s sarcoma of the extremities treated by contemporary multimodal management were reviewed. Chemotherapy was administered according to 4 sequential protocols of adjuvant (1) and neoadjuvant (3) treatment. Local control consisted of surgery in 136 patients, surgery and radiation therapy in 70 patients, and radiation therapy in 60 patients. Two patients underwent only chemotherapy. Results: The 5-year event-free survival (EFS) and overall survival (OS) were 62 and 69 per cent respectively. The rates of 5-year EFS and local control were significantly lower in patients treated with radiation therapy compared to patients treated by surgery or surgery and radiation therapy (48 vs 66 per cent, p=0.002; 80 vs 94 per cent, p= 0,0001). In group 3 (Radiation Therapy only) there were also 6 secondary malignancies. Conclusion: Surgery was associated with better survival and local control in this series. In our opinion, surgery should always be considered in the local treatment of Ewing’s sarcoma of the extremities. Postoperative Radiation Therapy must be added in cases of inadequate surgical margins

STS are rare malignant tumours of mesenchymal origin giving a wide array of histological types and behaviour. Common sites of involvement include the extremities which are of most relevance to orthopaedic surgeons. Like almost all other malignancies, STS become more common with increasing age with median age of 65 years. All patients aged 65 and over with STS of the extremities referred to the NZ Tumour Registry at Middlemore Hospital between 1967 and 2010 were included in the study. Data collected include baseline demographics (age, sex), diagnosis, site, time of referral, definitive treatment, adjuvant therapy, surgical margins (if applicable), local recurrence, survival, and cause of death. Each patient was staged according to AJCC (1997, 5th edition) and Enneking's staging systems. Primary outcomes were measured in terms of 5-year survival alongside with cause of death. A total of 116 patients. 21 upper extremities, 95 lower extremities. Average age of 74 with a 1.2:1 female to male ratio. Stage 1 disease was uncommon, accounting for only 5 cases (4%). 3 patients died within 5 years (1 due to metastatic disease and 2 from non-sarcoma related disease). 2 patients were still alive in 2010 with 1 of them surviving >5yrs. Stage 2 disease was found in 41 patients (35%). Common histologies included malignant fibrous histiocytoma (MFH), liposarcomas, or leiomyosarcomas (LMS). 44% (n=18) had greater than 5-year survival. 20% (n=8) died within 5 years succumbing to metastatic disease. 11 were under 5-yr follow up. Stage 3 disease was found in 48 patients (41%). MFH was by far the most common diagnosis accounting for 63% of patients. 5-year survival 25% (n=12). 5-year mortality 56% (n=27) mainly from advanced disease and metastases. Rest (n=9) are still within 5-yr follow up. Distant metastases at presentation were seen in about 10% of all patients (12 cases) with the most common site of involvement being the lung. 9/13 died of metastatic disease within 5 yrs while others are still within the 5 yr follow up period. STS are most commonly observed in the elderly and prognosis depends on several factors. Management should ideally be carried in a specialised centre with early referral and combined multidisciplinary approach to optimise patient outcome

There have been a worldwide change in the susceptibility patterns of antibiotics by many community-acquired microorganisms including those associated to wound infection after open fractures. However, the current antibiotic prophylaxis practice adopted by orthopedic surgeons to prevent infectious complications following open fractures has not changed, since Gustilo and Andersen classification was published several decades ago. Few studies have addressed the current pattern of infectious organisms identified in open fracture wounds and its susceptibility to antibiotics that have been empirically used. We aim to study the incidence of community-acquired resistant organisms isolated in lower extremities open fracture and analyze if antibiotic therapy based upon identified resistant pathogens, would decrease surgical site infection (SSI) rates. In a prospective, single center cohort study, from August 2013 to March 2015 at a tertiary public university institution, 136 subjects presenting Gustilo type II or III lower extremities open fractures were randomly assigned in two arms. Both arms were submitted to surgical debridement, fracture stabilization, and empirical antibiotic therapy, but subjects on Group II had at least three samples of tissue cultures collected during debridement. Patients previously treated at an emergency department other them ours were excluded. When resistant bacteria was identified, antibiotic therapy was modified according to antibiogram tests. The primary outcome was to compare the infection rates between these two groups, after early 60-days follow up. We included 136 patients with Gustilo-II (43.4%), –III, (34.5%) open fractures, of which 86% were male, with median age of 33.7 years, and 69.1% presented no comorbidities. Group II (collection of tissue cultures) accounted 36.7% of patients, and among them bacterial growth were detected in 36% (16/50). Microorganism resistant to empirical antibiotic therapy was identified in 18% (9/50), including Staphylococcus aureus, coagulase-negative Staphylococci, Enterococcus sp, Pseudomonas aeruginosa, Klebsiella sp, Serratia sp, Escherichia coli, and Enterobacter sp. Median duration of antibiotic treatment was eleven days. During 60-days of follow up, 71 patients (52.2%) were evaluated for signs of infection using the Centers for Disease Control and Prevention criteria, of which 63.4% (45/71) and 36.6% (26/71) were on Group I and II, respectively. No significant difference in the rates of SSI was observed between the study arms (19.2% vs 22.2%, respectively, P = 0.95). We detected higher rates of bacterial resistance on Gustilo type II and III open fracture wounds, but adjusting antibiotic therapy towards these contaminants did not affected the rates of infection afterwards

When total ankle arthroplasty (TAA) is performed, although tibial osteotomy is instructed to be perpendicular to long axis of tibia, there is no established index for the talar bone corrective osteotomy. Then, we have been deciding the correction angle at the plan for adjustment of the loading axis through whole lower extremities. We studied 17 TAA cases with rheumatoid arthritis (RA). X-ray picture of hip to calcaneus view (hip joint to tip of the calcaneus) defined to show more approximated loading axis has been referred for the preoperative planning. Furthermore, the data of correction angle has been reflected to pre-designed custom-made surgical guide. If soft tissue balance was not acceptable, malleolar sliding osteotomy was added. The distance between the centre of ankle joint and the axis (preD) was measured (mm) preoperatively, and the distance between the centre of prosthesis and the axis (postD) was measured postoperatively. Next, the tilting angle between tibial and talar components (defined as the index of prosthesis edge loading) were measured with X-rays during standing. Tibio Calcaneal (TC) angle was also measured pre and postoperatively. TC angle was significantly improved from 8.3±6.0° to 3.5±3.6° postoperatively (P=0.028). PreD was 12.9±9.6mm, and that was significantly improved to 4.8±6.3mm (postD) (P=0.006). Within 17 cases, 8 cases showed 0–1mm of postD, 4 cases showed 1–5mm of postD, remaining 5 cases concomitant subtalar fusion with severe valgus and varus hindfoot deformity showed over 8mm of postD. All of the 12 cases showing within 5mm of postD indicated within 13mm of preD. The tilting angle between components was 0.17±0.37° postoperatively. Taken together, pre-designed corrective talar osteotomy based on preoperative planning using hip to calcaneus view was useful to adjust the mechanical axis for replaced ankle joint in RA cases. Furthermore, after surgery, the hip to calcaneus view was useful to evaluate post-operative mechanical axis of whole lower extremities

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous methods. We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. During the entire procedure, the tool navigator was used frequently to reconfirm the location and the depth of burring. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus. The age of the patients varied from 10 years to 27 years. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it was attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years. Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation

The authors comment on the treatment of patients suffering from spina bifida. The indications to surgical-orthopaedic approach for lower limb correction in patients with spina bifida are outlined. According to the authors’ experience, the therapeutic approach should be aimed at treating deformities of the lower extremities in order to apply orthotic devices, particularly for higher levels of medullary lesion, and to obtain standing and/or gait with support. In the natural history of spina bifida, this purpose has become more and more important, since reduced complications, longer average life, and improved clinical, therapeutic and technological knowledge have radically changed the life expectancy of these patients. The analysis of a series of 71 patients with spina bifida, treated over 20 years, has enabled the authors to evaluate the main sites of deformities. They examined the surgical procedures carried out in relation to the levels of damage and observed the resulting functional autonomy. The foot was the site which offered the most frequent opportunities for treatment at all levels. Knee deformities were treated in a few cases. In particular, difficulties arose when treating L3-L4-L5 neurosegmental levels of the hip, with the result that today bone correction of this joint is performed in association with muscle transposition (external oblique abdominis m. pro medio gluteus m.) in order to ensure a dynamic correction. The authors emphasise the need for a more cautious surgical approach, since lower limb alignment, often achieved using orthopaedic aids and splints, is more important from a functional point of view than the anatomic and radiographic correction of the deformities. From a functional point of view, apparently positive neurosegmental levels for functional recovery are damaged by the lack of early training using splints. Actually, even severe clinical conditions can acquire increased functional autonomy if splints are early introduced to aid walking. Moreover, there are increased indications for spinal surgery in patients suffering from severe paraplegia in order to improve cardio-respiratory function. A correct alignment and an adequate application of orthotic devices reduce the frequency of pelvic obliquity, which favours spine deformities

Aim. To assess the spread of foot infection and its impact on the outcomes of major amputations of lower extremities in diabetic patients. Method. In a multicentre retrospective and prospective cohort study, we included adult diabetic patients (≥ 18 years) who underwent a major amputation of a lower limb in 5 hospitals between 2000 and 2009, 2012 and 2014. A total of 51 patients were included (of which 27 (52.94%) were men and 24 (47.06%) were women) with the mean age of 65.51 years (SD=16.99). Concomitant section's osseous slice biopsy (BA) and percutaneous bone biopsy of the distal site (BD) were performed during limb amputation. A new surgical set-up and new instruments were used to try and reduce the likelihood of cross-contamination during surgery. A positive culture was defined as the identification of at least 1 species of bacteria not belonging to the skin flora or at least 2 bacteria belonging to the skin flora (CoNS (coagulase negative staphylococci), Corynebacterium spp, Propionibacterium acnes) with the same antibiotic susceptibility profiles. A doubtful culture was defined as the identification of 1 species of bacteria belonging to the skin flora. The patients were followed-up for 1 year. Stump outcomes were assessed on the delay of complete healing, equipment, need of re-intervention and antibiotics. Results. In total, 51 BA were performed during major lower limb amputations (17 above the knee and 34 below the knee) in diabetic patients. Nine (17.65%) bacterial culture results from BA specimens were positive, 7 (13.73%) doubtful and 35 (68.63%) sterile. Before amputation, 23 patients (45.1%) had not received any antibiotics, including 16 (31.37%) with an antibiotic-free interval of 15 days or more. Microorganisms identified in BA were also cultured from the distal site in 33.33% of the cases. Positive BA was associated with prolonged complete stump healing, delay of complete healing (more than 6 months), re-amputation and the need of antibiotics. Conclusions. The microorganisms identified from BA play a role in stump healing in diabetic patients. BA is useful during major limb amputation due to infectious complications and antibiotic therapy could be corrected on the basis of the BA culture results

Introduction: Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous Methods:. Methods: We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus. Results: The age of the patients varied from 10 to 27. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it is attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years. Conclusions: Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation