Traumatic acute or chronic tendon injuries are a wide clinical problem in modern society, resulting in important economic burden to the health system and poor quality of life in patients. Due to the low cellularity and vascularity of tendon tissue the repair process is slow and inefficient, resulting in mechanically, structurally, and functionally inferior tissue.

Tissue engineering and regenerative medicine are promising alternatives to the natural healing process for tendon repair, especially in the reconstruction of large damaged tissues. The aim of TRITONE project is to develop a smart, bioactive implantable 3D printed scaffold, able to reproduce the structural and functional properties of human tendon, using FDA approved materials and starting from MSC and their precursor, MPC cell mixtures from human donors.

Total cohort selected in the last 12 months was divided in group 1 (N=20) of subjects with tendon injury and group 2 (N=20) of healthy subject. Groups were profiled and age and gender matched. Inclusion criteria were age>18 years and presence of informed consent. Ongoing pregnancy, antihypertensive treatment, cardiovascular diseases, ongoing treatment with anti-aggregants, acetylsalicylic-acid or lithium and age<18 years were exclusion criteria.

Firstly, we defined clinical, biological, nutritional life style and genetic profile of the cohort. The deficiency of certain nutrients and sex hormonal differences were correlated with tendon-injured patients. It was established the optimal amount of MPC/MSC human cell (collected from different patients during femoral neck osteotomy). Finally, most suitable biomaterials for tendon regeneration and polymer tendon-like structure were identified. Hyaluronic acid, chemical surface and soft-molecular imprinting (SOFT-MI) was used to functionalize the scaffold.

These preliminary results are promising. It will be necessary to enroll many more patients to identify genetic status connected with the onset of tendinopathy. The functional and structural characterization of smart bioactive tendon in dynamic environment will represent the next project step.

The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution.

From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems

In proximal humerus reconstructions, osteoarticular massive allograft (OA) allows a biologic reattachment of tendineous structures of the host providing stability and functional recovery. Allograft-prosthesis composites (APC) are more technically demanding, but functional advantages with new prosthetic design are expected with lower fracture and failure rate with time. We compared the outcome of patients treated with OA reconstruction (group A) and patients treated with an APC (group B) after humerus resection for bone tumours.

Thirty six patients treated between 1996 and 2009 were included in the study (18 group A; 18 group B). The diagnosis was a malignant bone tumour in 28 cases, an aggressive benign bone tumour in 6 and a bone metastasis in 2. Three total humerus resections were performed (two in group A and one in group B). Three different type of prosthesis were used (conventional, reverse and resurfacing). In group A, at an average follow-up of 66 months (2-116), 16 patients were continuously disease free.

Ten patients (56%) had no complication; in 6 cases (33%) we observed a fracture of the graft and in 3 cases (17%) a pseudoarthrosis. In group B, at an average follow up of 44 months (3-164), 16 patients were continuously disease free.

Thirteen patients (72%) had no complication, in 2 cases (11%) stem loosening, in 2 cases (11%) dislocation, in 1 case pseudoarthrosis and in 1 case resorption and detachment of allograft's great tuberosity was observed. Functional outcome was evaluated using MSTS scoring system: a mean score of 24 (13-30) in group A and 23 (15-27) in group B was observed.

In our experience, proximal humerus APC showed functional results comparable to OA allograft with lower complication rate.

In conclusion, in biologic reconstruction of the proximal humerus, APC seems to provide a more reliable solution than OA allograft at long term

Aim

While the association of surgery and radiation therapy in high grade Soft Tissue Sarcoma (STS) of extremities is considered the “golden standard”, there is not international agreement regarding type, timing, overall dose of radiation, and size, site and histology of tumours to be irradiated. A similar consideration is about low grade STS. The aim of our paper is critically reconsider our experience, trough a retrospective analysis of 15 years experience. This in order to propose a perspective protocol of treatment of high and low grade STS, in order to minimize the late complication rate.

Modular endoprostheses are commonly used for reconstruction of proximal tibia defects after bone tumor resection and patellar tendon reattachment directly on the prosthesis represent an issue frequently ending in extension lag. Allograft-prosthesis composite implants theoretically provide the advantages of prosthetic implants (joint stability, mechanical resistance and long term durability) and the advantages of massive allograft reconstruction (bone stock mantainance and biologic reattachment of patellar tendon). From 1997 to 2007 19 patients (mean age: 39±16 years old) underwent proximal tibia oncologic intra-articular resection with wide margins. Primary diagnosis included giant cell tumor, osteosarcoma, chondrosarcoma and a failed osteoarticular allograft in 10, 4, 3 and 2 patients respectively. Tibial resection length was 10.4±3.4 cm in 18 knees. In one patient with chondrosarcoma the entire tibia was resected. Three patients received preoperative and postoperative chemotherapy, one only postoperative.

Reconstruction was performed with an allograft-prosthesis composite implant and direct suture of the host patellar tendon to the allograft one. Fresh frozen allograft and modular Link prosthesis were used for reconstruction. Five to six weeks of knee immobilization in extension followed the operation. A transient peroneal nerve palsy was observed in three patients. Two patients with a stiff knee underwent an open release after less than one year from index surgery. One patient had a local recurrence from osteosarcoma and underwent an above knee amputation. No patient developed distant metastasis at follow-up.

After 59±37 months none of the patients had implant revision for mechanical complications. One patient had 2-stage implant revision for deep infection. A minor allograft resorption with aseptic drain was observed in one patient who underwent surgical debridement. One other patient had a moderate allograft resorption. Knee flexion was 96±12 degrees. All the patients but two could reach complete knee extension and only two had a minor extensor lag (less than 15 degrees).

In conclusion intrarticular tibia resection and allograft-prosthesis composite replacement ensures satisfactory oncologic and functional results at a mid-term follow-up.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score and a wrist-specific functional score (PRWE).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

Knee extensor mechanism reconstruction after excision for bone or soft tissue tumors is a challenging procedure. When a resection of the patellar bone-tendon apparatus is required, an omologous graft can be used for its reconstruction to avoid knee arthrodesis and preserve a functional knee. Since 1996 we performed such a procedure in 15 cases in 14 patients. In 4 cases (Group 1) excision and reconstruction involved only the patella and the attached tendons together with the involved soft tissues. In the remaining 11 cases (Group 2) an extrarticular en-bloc knee resection was accomplished and reconstruction was obtained by a megaprosthesis to replace the distal femur and a composite allograft-prosthesis to replace proximal tibia and the extensor apparatus. One of the en-bloc knee resections was performed in a patient who had previously had an isolated extensor apparatus replacement, which was later converted to a complete knee resection and substitution after a local relapse.

A free flap (anterolateral thigh) was used in 4 patients.

Histotypes were as follows:

Group 1: pleomorphic sarcoma 2, synovial sarcoma 1, myxofibrosarcoma 1.

One patient in group 2 was lost at follow-up after a few months. In the remaining patients follow-up ranged from 7 to 132 months.

In Group 1 two local and one distant (groin lymphnodes in one of the two patients affected by local recurrence) relapses occurred, in Group 2 one local and 4 distant relapses (lung) occurred. One of these latter distant relapses affected the patient at the beginning in Group 1 and later converted to Group 2.

Besides recurrences, 4 patients in Group 2 were affected by local complications:

one deep infection;

Active extension was initially obtained in all patients and, when local complications did not occur, it was stable with time. Extension lag ranged from 0 to 30°. Maximum flexion ranged from 80 to 110°. Patients could walk without brace nor aids.

Allograft reconstruction after extensor apparatus excision, either alone or combined to a total knee resection, can be an efficacious option in the treatment of sarcomas of the knee.

The treatment of bone metastases is usually palliative and aims to achieve adequate control of pain, to prevent and resolve compression of the cord in lesions of the spine and to anticipate or stabilise pathological fractures in the appendicular skeleton. In selected cases the complete resection of an isolated bone metastasis may improve the survival of the patient. During recent decades, the life expectancy of patients affected with metastatic carcinoma has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution.

From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures seemed relatively high. However in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure.

Proximal tibia reconstruction after oncologic resection is challenging due to bone stock and extensor mechanism restoration.

From 1997 to 2007 19 patients (mean age: 39±16 years old) underwent proximal tibia oncologic intra-articular resection with wide margins. Primary diagnosis included giant cell tumor, osteosarcoma, chondrosarcoma and a failed osteoarticular allograft in 10, 4, 3 and 2 patients respectively. Tibial resection length was 10.4±3.4 cm in 18 knees. In one patient with chondrosarcoma the entire tibia was resected. Three patients received preoperative and postoperative chemotherapy, one only postoperative.

Reconstruction was performed with an allograft-prosthesis composite implant and direct suture of the host patellar tendon to the allograft one. Fresh frozen allograft and modular Link prosthesis were used for reconstruction. Five to six weeks of knee immobilization in extension followed the operation. A transient peroneal nerve palsy was observed in three patients. Two patients with a stiff knee underwent an open release after less than one year from index surgery. One patient had a local recurrence from osteosarcoma and underwent an above knee amputation. No patient developed distant metastasis at follow-up.

After 59±37 months none of the patients had implant revision for mechanical complications. One patient had 2-stage implant revision for deep infection. A minor allograft resorption with aseptic drain was observed in one patient who underwent surgical debridement. One other patient had a moderate allograft resorption. Knee flexion was 96±12 degrees. All the patients but two could reach complete knee extension and only two had a minor extensor lag (less than 15 degrees).

In conclusion intrarticular tibia resection and allograft-prosthesis composite replacement ensures satisfactory oncologic and functional results at a midterm follow-up.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score, a wrist-specific functional score (PRWE) and a comprehensive evaluation of upper arm function score (DASH).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

Sternal resection is commonly performed for primary and metastatic chest wall tumours involving the sternum or the ribs near the sternum and, in case of wide resections, it is necessary to restore the stability of the chest wall. We analyze our experience with emphasis on surgical management and survival. From 2001 to 2007, 16 patients underwent surgical resection of the sternum for malignant lesions: 10 (62.5%) primary lesions (chondorsarcoma n=8; osteosarcoma n=2) and 6 (37.5%) secondary lesions (4 local recurrence from breast cancer and 2 metastases). We performed 12 partial resections (resected area from 65 to 20 %), 2 subtotal resections (about 90% of total area) and 1 total resection. Chest wall stability was obtained by prosthetic material, rigid and non rigid, and muscolar flaps. As non rigid material we used a polytetrafluoroethylene patch (Gore-tex Dual Mesh Plus) while replacement after total sternectomy was performed using a new rigid system of mould-able titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System, Medxpert, GMbH). Prosthetic material was combined in 3 cases with a latissimus dorsi muscolar flap, in 1 case with a vertical rectus abdominis muscolar flap, in 12 with a pectoralis major flap. There was no perioperative mortality or significant morbidity. All patients were extubated within 24 hours after operation. At a mean follow-up of 44.1 months (range 82–14), 5 years actuarial survival for primary tumours was 85%, while 3 years actuarial survival after resection of secondary tumours was 39% (median 20,5 months). In case of primary lesion wide resection with tumour-free margins is necessary to minimize local recurrence and to contribute to long-term survival; reconstruction with a rigid system composed of mould-able titanium bars and rib clips allows to plan extensive demolition minimizing the risk of chest wall instability. In metastatic disease surgery can provide good palliation, although survival is poor.

Ankle arthrodesis is considered a valid reconstructive option after bone tumor resection of the distal tibia, distal fibula and of the talus. The purpose of the present study was the review of author’s experience in ankle arthrodesis for bone tumors with the employ of bone grafts.

Over the last 15 years, 17 ankle arthrodesis were performed in author’s Institution for oncological pathologies. Average age at the time of surgery was 41 years (4–75). Twelve patients had a malignant tumor (3 osteosarcoma, 2 fibrosarcomas, 1 Ewing sarcoma, 1 emangioendotelioma, 1 condrosarcoma, 1 pleomorphic sarcoma, 1 adamantinoma and 2 metastases from renal carcinoma) and 5 patients had a benign tumor (4 giant cell tumors, 1 condroblastoma). In 13 cases the tumor involved the distal tibia, in 2 cases the distal fibula and in 2 cases the talus. In 15 patients we performed a tibiotalar arthrodesis and in 2 patients (tumors of the talus) a tibiocalcaneal arthrodesis.

The bone defect after resection was reconstructed with: cortical structural autografts from controlateral tibia and autologous bone chips from iliac crest in 5 patients; cortical structural autografts from controlateral tibia + cortical structural allografts + autologous bone chips from iliac crest in 2 patients; cortical structural allografts + autologous bone chips from iliac crest in 2 patients; structural autografts in 4 patients; autogenous vascolarized fibula in 4 patient with cortical allograft in 3 cases and autograft in 1 case. Stabilization was obtained by intramedullary anterograde nailing in 8 patients, plate in 2, two or multiple screws in 7 (including two tibiocalcaneal arthrodesis).

Three patients died before this review (1, 1.5, 7 years after surgery: 1 Ewing sarcoma, 2 patients with metastases from kidney cancer). Follow-up for alive patients ranged from 14 to 146 months (average 53). Two local recurrences were observed, in a Ewing sarcoma in 1 case and in a giant cell tumor in 1 case. One patient is alive with lung metastases but no signs of local recurrence. In all patients but one the arthrodesis healed successfully. In one case a deep infection occurred (with wound dehiscence) and the arthrodesis did not heal. Complications included 1 deep infection, 1 superficial infection of the donor site (controlateral leg) and 1 fracture of the controlateral tibia (donor site of cortical autograft) treated with plaster cast. Three patients underwent a secondary surgical procedure: two partial hardware removals and one myocutaneous sural flap.

The low rate of local recurrence (1/5 in benign tumors and 1/12 in malignant tumors) and the high percentage of bone union (16 out of 17) together with the satisfactory functional outcome showed that ankle arthrodesis with bone grafts can be an oncologically safe and a meccanically successful procedure in bone tumor surgery.

Neoadjuvant therapy in soft-tissue sarcomas is still a controversial issues regarding indications, patients selection and treatment protocols. In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. Among these patients, 49 received preoperative chemotherapy (epirubicin plus ifosfamide, according to Italian Sarcoma Group protocol), associated to preoperative conventional external beam radiationtherapy in 36 cases (73.5%). The histologic types were liposarcoma (30,6%), synovial sarcoma (20,4%), fibrosarcoma (16,3%), pleomorphic sarcoma or malignant fibrous histiocitoma (12,1%), leiomyosarcoma (8,2%), other histotypes (12,1%). Tumor size was 10 cm or larger in 21 cases, 6 to 9 cm in 23 patients and 5 cm or smaller in 5 cases. Neoplasms were high-grade (Broders grade 3 or 4) in all cases but five.

After neoadjuvant treatment we performed a limb-sparing surgical excision of the tumor in 47 patients (96%), while a primary amputation of the limb was necessary in only two cases (4.1%). A vascularized miocutaneous flap was used in 8 cases, and adequate surgical margins were achieved in more than 70% of the cases.

Postoperative chemotherapy was given in 26 cases (53%), postoperative radiotherapy just in 5 (10%). We report the outcome data on these 49 cases, regarding overall survival, local or distant relapse, local and systemic complications, early and long-term limb salvage rate.

According to histologic examination of the resection specimen, average percent of necrosis after neoadjuvant treatment was 70.6% (range 30 – 99%). Wound dehiscence occurred in 6 patients but ultimately healed succesfully in all of them.

At an average follow-up of 23 months (range 3 – 82), 37 patients were continuously disease free (76%), two patients had local recurrence (one amputated), four patients were alive with metastatic disease, five patients had died with disseminated disease (at 4, 19, 28, 37 and 61 months after surgery), one patient had died of unrelated disease.

Due to the inconstant tumor response, neoadjuvant treatment in soft tissue tumors is still a controversial issue. On the basis of data presently available, we think that it can be a useful treatment in high-risk tumors (larger than 5 cm; high grade). In these cases, at a low and acceptable rate of local complications, the conjoined use of preoperative chemotherapy and radiotherapy can help to make a limb-salvage surgery possible and at the same time can maybe reduce the risk of distant metastasis.

In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. We investigated the outcome and risk factors in a homogeneous group of 112 patients, affected by high-grade soft tissue sarcomas of the limbs (not metastatic at presentation) and treated with limb-sparing surgery, brachytherapy and conventional postoperative radiation therapy. Postoperative chemotherapy was added in one fourth of the cases.

The histologic types were liposarcoma (21.4%), leiomyosarcoma (19.6%), synovial sarcoma (17.9%), pleomorphic sarcoma or malignant fibrous histiocitoma (14.3%), fibrosarcoma (9.8%), other histotypes (17%).

All the tumors were high-grade (Broders grade 3 or 4). Size of the neoplasm was 10 cm or larger in 8 cases, 6 to 9 cm in 60 patients and 5 cm or smaller in 44 cases.

A limb-sparing surgical excision was performed in all the cases; histologically adequate margins were achieved in 96 cases (85.7 %). In 28 cases a myocutaneous or fasciocutaneous flap was necessary for local reconstruction.

At an average follow-up of six years, 67 patients (59.8%) were continuously disease-free; 8 patients (7.1%) had presented metastatic disease (in one case combined with local relapse) but were alive with no evidence of disease at last follow-up; 3 patients (2.7%) were alive with metastatic disease; 28 patients (25%) had died with disseminated disease; 6 (5.4%) had died of unrelated causes.

Local recurrence occurred in 10 patients (8.9%) requiring an amputation in 2; metastatic disease occurred in 39 patients (34.8%).

Four more patients required an amputation for complications different from recurrence: one early amputation for surgery-related complications and three late amputations for radiation-related complications (two not-healing fractures, one unresolvable wound sloughing).

Wound sloughing occurred in 12 patients (5 surgery-related and 7 radiation-related).

Local control rate, disease-free survival, overall survival and limb salvage rate were examined at 5 and 10 years, aiming also to identify tumor or treatment characteristics with prognostic value for the outcome.

The use of brachytherapy is an important option for achieving a significant boost in radiation within the surgical bed. Combined treatment with limb sparing surgery plus brachytherapy and external beam radiation therapy seems to offer satisfactory results in terms of local control and limb salvage survival. The use of myocutaneous or fasciocutaneous flaps is often useful in this kind of surgery, making possible a limb-sparing procedure with adequate oncological margins. New protocols and randomized studies on chemotherapy need to be introduced to improve systemic control and overall survival.

Liposarcomas (LPS) are the most common soft tissue malignant tumor with a reported annual incidence of 2.5 per million people. The latest histopathologic classification of liposarcomas identifies three main groups: well-differentiated LPS; myxoid-round cell LPS; pleomorphic LPS. Dedifferentiated LPS is considered as a subgroup of well-differentiated LPS where there is an area of transition from a low grade to a high grade non lipogenic lesion (typically MFH or fibrosarcoma). The purpose of the present study was a retrospective review of the data of 146 consecutive patients affected by liposarcoma, with the aim to correlate the outcome of patients with treatment modalities and prognostic factors.

There were 89 males and 57 females with an average age of 54 years (range 16–92). The tumor grading following Broders criteria showed a low grade lesion in 48% of cases and a high grade lesion in 52% of cases. The histologic pattern showed a well differentiated liposarcoma in 25 patients (17%). The most frequent histologic finding was a myxoid liposarcoma in 55 cases (38%) while a round cell component of variable rate was seen in 22 cases (15%). A pleomorphic LPS was observed in 32 cases (22%). Dedifferentiated liposarcoma occurred only in 3 cases (2%). Surgery alone was performed in 31% of cases while chemotherapy (adriamycin and ifosfamide) and/or radiationtherapy were associated in 69% of cases. Brachytherapy was performed in 50 cases. Surgical margins resulted radical in 4 (2.5%) of cases, wide in 89 (61%), marginal in 45 (31%) and intralesional in 8 (5.5%) of cases.

In 10 cases (6.8%) a local recurrence occurred and in 33 cases (22.6%) a metastatic lesion was observed. Local recurrence were treated with surgical excision in 7 cases and with amputation in 3 cases. At an average follow up of 55 months, 68.5% of patients were continuosly disease free, 6.8% were disease free after local recurrence or metastasis excision or both, 4.8% were alive with disease, 14.4% were dead of the disease, 5.5% were dead of other cause. Eleven patients (7%) underwent an amputation, in 5 cases as first surgical procedure, in 3 cases after a local recurrence and in 3 cases for complications of the radiationtherapy. Local control was significantly correlated with the type of surgery at presentation and with surgical margins. Overall survival was significantly correlated with surgical margins, with grading and with the histotype of the tumor.

In the present series of soft tissue liposarcoma the combined treatment allowed limb salvage in 93% of cases (7% of amputations). Virgin lesions at presentation and free surgical margins resulted positive prognostic factors for local control. The histotype of the tumor, grading, and surgical margins resulted significative prognostic factors in survival, with round-cell and pleomorphic and high grade lesions showing the worse prognosis.

Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible.

In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields.

In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.

In the period from 1999 to 2003 bacterial contamination of explanted cadaver bones and tendons from the Regional Tuscan Tissue and Cell Bank was studied. During this period 1124 explants from 402 donors were taken, of which 311 donors whose heart was beating and from 91 whose heart was not beating.

The bone explantation procedure followed a standardized protocol.

Al the samples were explanted in the operation room by a team of two surgeons and a nurse during the first 24 hours after death. The protocol concerning the sterility of the explanting procedure was standardized and followed accurately. The bacteriological examination was performed immediately after the explantation and before the samples were treated with antibiotic solution. Three different tests were used: superficial microbiological swabs of the bone surface, one from the medullar canal and a small bone or soft tissue sample. The samples were inoculated immediately in culture medium and incubated for at least 10 days. From 1124 explanted samples 430 were contaminated: 99 with pathological bacteria such as Staphylococcus aureus, Enterococcus, Escherichia coli etc., 331 with nosocomial bacteria such as coagulase neg. Staphylococcus, Corynebacteria, etc. The samples that were contaminated with pathological bacteria were excluded from the study. The other contaminated group was re-processed and re-tested for contamination.

The factors influencing the results of contamination were anatomical location of the explants and the experience of the surgical team. In contrast, the donor type (heart beating vs. heart not beating) did not play any role.

From 1999 to 2003 the University Hospital of Careggi in Florence, Italy, used 721 explants from which 624 were retrieved from the Regional Tuscan Tissue and Cell Bank, 72 from foreign banks and 14 from another national bank. The explants from foreign banks were all re-tested according to our standards. Among those, 699 samples were sterile and 22 samples (3%) were contaminated. Seventeen (2.3%) of the 22 samples were contaminated with pathological bacteria with low morbidity and 5 (0.7%) with medium morbidity. Compared to the control group contamination of the explants retrieved from the Regional Tuscan Tissue and Cell Bank was 2.8%.

However, the contamination of samples of an explant is not necessarily correlated with a true infection of the specimen. This study shows that factors such as retrieval techniques, contamination factors in the operating room and laboratory mistakes can cause false-positive contamination results. In fact, only three of 604 patients who were operated in major orthopaedic procedures using bone and soft tissue allografts developed clinical evidence of infection (0.5%). In conclusion, the infection rate of our allografts in this study is not higher than the standard infection risk of any other major orthopaedic procedure (0.5%).

The reconstruction of large bone segments is a major goal in orthopaedic surgery. Autologous cancellous bone is recognized as the most biologically active graft material, but autologous bone harvest is associated with significant morbidity and founds its limit in the available quantity. Biomaterials or allografts do not encounter these limitations, but have no osteogenic and limited osteinductive potential. In order to enhance tissue regeneration and healing we have tried to obtain a graft with osteconductive, inductive and osteogenic properties. The day before operation 350 cc of autologous blood is donated from the patient and centrifuged to obtain a platelet-rich plasma. Bone marrow is aspirated from the posterior iliac crests with the patient under spinal anaesthesia and is processed to increase its stem cell content. The structural scaffold used is morcellized cancellous bone provided from our Bone Bank. At operation bone is mixed with bone marrow buffy coat and Platelet Rich Plasma in a sterile glass becker with addition of CaCl2 till clot formation to produce a gel-like component that is handled easily. We have utilized this technique from November 2000 till January 2004 for 68 patients: 41 of these patients required healing of large bone defects: 22 males and 19 females. Fresh bone marrow alone was used for a percutaneous injection in 11 cases; open surgery with autologous growth factors, bone marrow buffy coat and allograft was used in 30 patients. The radiological and clinical results showed early healing of the defects treated with this technique and no complications related to the procedure at an average follow up of 23 months (3–40).

Aims:Vascularized fibula has been widely used in limb salvage surgery to reconstruct large bone defects. Aim of this study is the analysis of the complications related both to the donor and the recipient site in a series of patients affected by bone tumors. Material and methods: In the period from 1988 to 2002, 114 patients ranging in age between 4 and 64 years underwent bone reconstruction by mean of a vascularized fibula graft. There were 64 men and 50 women and all them were affected by malignant neoplasm. The upper limb was involved in 25 cases and the lower extremity in 89 cases. The length of resection ranged between 7 and 28 cm, the follow up between 6 and 166 months. Results: Several complications have been noted either at the donor or at the recipient site. The most common complications affecting the donor leg, have been the retraction of flexor tendons (6), the valgus deformity of the ankle (3) the retraction of extensor hallucis longus (1) and a transient palsy of the peroneal nerve (1). The most frequent complications observed at the recipient site has been a fracture of the graft (15) followed by non union (12), infection (5 cases), failure of plate (5), skin necrosis (4), transient palsy of the peroneal nerve (3) and joint stiffness. Because of complications, a total failure of the procedure occurred in 4 cases. Conclusions: Although the vascularized fibula graft is the recommended procedure in dealing with challenging reconstruction of large diaphyseal defects, this option is not free of complications. However, in our experience, when conservative treatment of complications was not successful, further surgery was able to lead to recovery in the majority of cases.