After 25 years in orthopaedic
Aim. was to analyze infections after bone tumour surgery. Method. 1463 patients treated from 1976 to 2007 were analized: 1036 with resection and prostheses in the lower limbs, 344 with resection and prostheses in the upper limbs, 83 with surgery for sacral tumours. Infections were analyzed for time of occurrence (“postoperative” in the first 4 weeks from surgery, “early” within 6 months, and “late” after 6 months), microbic agents, treatment, outcome. Results. In lower limbs, infections occurred in 80 cases (7.7%): generally monomicrobial, caused by gram positives, postoperative in 9, early in 12, late in 59 cases. Treatment was “two stage” in 73, “one stage” in 4, primary amputation in 3. Revisions for infection were successful in 63 patients (79%), while 17 patients were amputated (21%). In upper limbs, infections occurred in 20 cases (5.8%): generally monomicrobial, caused by gram positives (88.5%), postoperative in 2 cases, early in 7, late in 11. “Two stage” treatment was attempted in all cases, but only in 3 prosthesis was re-implanted, since the cement spacer yelded similar function. No infections were observed in 28 intralesional excisions of sacral giant cell tumours. Infection occurred in 23/52 resected sacral tumours (44%) (Three patients died postoperatively were excluded from this group): postoperative in 16 cases and early in 7, caused by gram negatives in 62% and multimicrobial in 74%. Surgical debridements associated with antibiotic therapy according to coltures cured infection in all cases. Conclusion. Infection is a severe complication in orthopedic
Introduction. The use of computer navigation has a potential to allow precise tumour resection and accurate reconstruction of the resultant defect. This can be useful in difficult areas such as pelvis, diaphyseal (intercalary) resections and geometric bony resections. Methods. We have carried out resections of musculoskeletal tumours in 7 patients using an existing commercial computer navigation system (Orthomap 3D). CT & MRI scans of each patient were fused preoperatively using navigation software and the tumour margins were marked. The planes of tumour resection were defined on the 3D image generated. During surgery, trackers were attached to bone with tumour and registration performed. Instruments attached to navigation tracker were then used to identify the predetermined resection points. Of the 4 pelvic tumours, 1 had biological reconstruction with extra corporeal irradiation, 3 had endoprosthetic replacement & 1 did not need any bony reconstruction. 1 patient with proximal femur tumour needing extraarticular resection had endoprosthetic replacement. The 2 tibial diaphyseal tumours had biological reconstruction. Results. Examination of the resected specimens revealed tumour free margins. Postoperative radiographs showed resection and reconstruction as planned in all cases. In the patient with extraarticular proximal femur resection the hip joint was inadvertently exposed whilst making the acetabular osteotomy & in one patient with pelvic tumour the intra-operative registration could not be accurately performed as she was overweight and a real time matching of anatomy & virtual images was not achieved. Discussion and Conclusion. The use of computer navigation in musculoskeletal
Rates of prosthetic joint infection in megaprostheses are high. The application of silver ion coating to implants serves as a deterrent to infection and biofilm formation. A retrospective review was performed of all silver-coated MUTARS endoprosthetic reconstructions (SC-EPR) by a single Orthopaedic
Given the low prevalence of sarcoma, international cooperation is necessary to recruit sufficient numbers of patients for surgical trials. The PARITY (Prophylactic Antibiotic Regimens in Tumour Surgery) trial is the first international multicentre trial in orthopedic
Musculoskeletal tumours are relatively rare and as such, they are not well known by the population and by general practicioners. We observed that an important proportion of our patients has seen major delays at diferent stages of their referral pathway. It is well recognised that such delays can cause avoidable loss of function, local and systemic recurrence and increase in health system costs. The main objective of this study was to prospectively assess the referral paterns of our patients to pinpoint the causes of the delays. This should allow the formation of strategies to minimise delas and their impact. The secondary objective was to assess the performance of our centre in comparaison to other centre with the goal of improving quality of care. Prospective follow up data is available for 457 patient referred to our musculoskeletal
Purpose. The consequences of infection in orthopedic
Functional outcomes are commonly reported in studies of musculoskeletal
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. From January 1994 to June 2009 we have operated in our Centre 976 patients affected by STS of extremities and superficial trunk. They were 741 High grade STS (76%), and 235 Low grade STS (24%). The most represented histotype was Liposarcoma (239) followed by Leiomyosarcoma (150) and synovial sarcoma (94). Regarding tumour site, upper limb was involved in 255 cases, lower limb in 679, superficial trunk in 42; regarding tumor size, 323 where less than 5 cm, 386 where between 5 and 10 cm and 267 where more than 10 cm. Radiation therapy was utilized in 447 cases (46%): 83 patients had a low grade STS, 364 a high grade STS.Aim
Method
In orthopaedic
Most types of bone tumor surgery require intra-operative imaging or measurement to control margins and prevent unnecessary bone loss. Computer Assisted Surgery (CAS) has been used as a replacement of fluoroscopy or direct measurement tools in four specific types of oncological orthopaedic surgical approaches. There are intralesional treatments, image-based resections, image-based resections with image-based reconstructions and image-based resections with imageless tumor prostheses reconstruction. Since 2006 we have performed 130 oncological surgeries with CAS. Most cases were excochleations, 64, where CAS replaces fluoroscopy as an intra-operative imaging modality. Advantages over fluoroscopy are real time three dimensional feedback, high-res image and no use of ionizing radiation. It is especially useful in larger lesions or lesions located in the femoral head or pelvis. Currently a study is being performed on patient satisfaction, recurrence and complications. Another application where CAS has often been used is in resections and segmental resections (together 45). These can be preplanned before surgery, incorporating the margin required, and checked intra-operatively. Coloration of the tumor, critical structures is useful to avoid these. Sometimes it's possible with careful planning to spare structures that otherwise probably would not confidently have spared. With hemicortical resection (5) it's possible to use CAS to exactly copy the shape of the resected bone to an allograft. A Ct scan of one case shows an average gap between host and graft of 0.9 mm (range 0–5.4) along the 6 cm resection. Finally in 16 cases of imageless use in placement of tumor prostheses it feels greatly helpful in reconstructing the joint line, length and correct rotation. There were 8 failures in these 130 cases with the system or software. Setup time was measured in 47 cases and was on average 6:50 (range 2:26–14:27). Indication and performance of CAS in orthopedic
The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision. We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation; three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. The use of computer navigation in musculoskeletal
The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision and achieve pre-planned oncological margins with improved accuracy. We resected musculoskeletal tumours in ten patients using commercially available computer navigation software (Orthomap 3D, Stryker UK Ltd). Of the five pelvic tumours, two underwent biological reconstruction with extra corporeal irradiation, two endoprosthetic replacement (EPR) and one did not require bony reconstruction. Three tibial diaphyseal tumours had biological reconstruction. One patient with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. The use of computer navigation in musculoskeletal
Background. The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision. Materials and methods. We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Results. Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation, three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR. Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration. Discussion. The use of computer navigation in musculoskeletal
Quality outcomes from medical intervention are assumed by patients &
the community. However such quality cannot be assured in every case. There are systems which can be developed which will make the safety of patients more assured. In any system of medical care, it is presumed that the practitioners who are taking care of the patient are qualified both in their basic qualification &
also in their higher qualification. As well it is now accepted that appropriate credentialling occurs &
that this is the purview of the hospital which will check the qualifications &
currency of practice with the medical board &
the higher degree &
currency (participation in CPD) with the College concerned. They should also review the privileges which define the scope of practice. In orthopaedic
Introduction. Clear operative oncological margins are the main target in malignant bone tumour resections. Novel techniques like patient specific instruments (PSIs) are becoming more popular in orthopaedic
Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia. We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test. A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals. On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity.
To assess the performance of calcium sulphate pellets as a bone graft substitute in an Orthopaedic
Objective. was to review the experience of the Rizzoli with megaprosthetic reconstruction of the extremities in musculoskeletal
The aim of this project is to test the parameters of Patient Specific Instruments (PSIs) and measuring accuracy of surgical cuts using sawblades with different depths of PSI cutting guide slot. Clear operative oncological margins are the main target in malignant bone tumour resections. Novel techniques like patient specific instruments (PSIs) are becoming more popular in orthopaedic