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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 187 - 187
1 Sep 2012
Ruggieri P Calabrò T Valencia JD Mavrogenis A Romantini M Guerra G Mercuri M
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Aim

Bone metastases of the upper limb are a frequent complication of primary tumors. The aim of this study is to evaluate treatment and functional results of patients with prosthetic reconstruction of the proximal humerus.

Method

Between 1975 and 2007, 67 patients were treated by resection of humeral metastasis and reconstruction with prosthesis. Cemented modular prostheses of the proximal humerus were implanted in 59 cases (all MRS Bioimpianti® prostheses), uncemented prostheses in 2 (HMRS® Stryker), 4 elbow Coonrad-Morrey prostheses (in 2 cases with bone allograft), 1 elbow custom-made cemented and 1 intercalary prosthesis (Osteobridge Merete®).

Sites of primary tumors: kidney (23), lung (13), bone and unknow (7 each), liver and breast (3 each), bladder, endometrium, thyroid, soft tissues and nervous tissues (2 each), ovarium (1).

Complications were evaluated and univariate analysis with actuarial Kaplan-Meier curves of implant survival was performed. Functional results were assessed with the MSTS system.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 181 - 181
1 Sep 2012
Ruggieri P Pala E Calabrò T Romagnoli C Romantini M Casadei R Abati C Mercuri M
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Aim

Aim of this study was to review surgical treatment of femural metastases, comparing nailing versus resection and prosthetic reconstruction.

Method

Between 1975 and 2008 110 patients were surgically treated for metastatic disease of the femur. Prostheses were implanted in 57 cases (16 HMRS® Stryker, 38 MRP® Bioimpianti, 2 Osteobridge® and 1 GMRS®). In 53 patients femoral nailing was performed with different types of locked nails (32 Gamma, 14 Grosse-Kempft and 6 T2-Stryker®). Sites of primary tumor were breast (33 cases), kidney (18), lung (17), undifferentiated carcinoma (14), g.i. (8), bladder and prostate (5 each), endometrium and thyroid (3 each), skin (2), pheochromocytoma and pancreas (1 each). Indications to nails were given in patients with femoral metastasis and poor prognosis: multiple metastases, short free interval, unfavourable histotype, poor general conditions. Resection and prosthesis was preferred for patients with solitary metastasis, long free interval, favourable histotype, good general conditions or in whenever the extent of the lesion was not amenable to a durable internal fixation. Complications were analysed. Univariate analysis by Kaplan-Meier curves of implant and oncological survival was performed. Functional results were assessed with MSTS system.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 240 - 240
1 Sep 2012
Ruggieri P Angelini A Drago G Guerra G Ussia G Mavrogenis A Mercuri M
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Introduction

Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. We review our experience to characterize its prevalence, treatment, relapse and survivorship at long term follow-up.

Methods

Eighty-seven patients aged from 4 to 60 years (mean 20 years), were treated from 1985 to 2008. Lesions affected the femur (38), humerus (20), tibia (19), fibula (4), pelvis (3), foot (2) and radius (1). Eight patients had metastatic disease at diagnosis. Seventy-eight patients were treated with neoadjuvant chemotherapy with three or more drugs according to different protocols, nine had surgery as first treatment. Limb salvage surgery was performed in 71 cases, amputation in 14 and rotationplasty in one. One patient died before surgery. Prognostic factors were evaluated with Kaplan-Meier analysis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 145 - 145
1 Sep 2012
Fabbri N Kreshak JL Ruggieri P Sim FH Mercuri M
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Purpose

Durable fixation may be difficult to achieve when significant bone loss is present, as it occurs in pelvic sarcoma resection and revision surgery of tumor implants. Purpose of this study was to review clinical results of primary and revision surgery of the pelvis and lower extremity in the setting of severe bone loss following limb salvage procedures for bone sarcoma using modular porous tantalum implants.

Method

Retrospective study of 15 patients (nine females, six males) undergoing primary or revision pelvic reconstruction (five patients) or revision surgery of a tumor implant of the hip (five patients), knee (four patients), and ankle (one patient) using porous tantalum implants was undertaken. Reason for the tumor implant was resection of bone sarcoma in 13 cases and tumor-like massive bone loss in the remaining two cases. Cause for revision was aseptic failure (nine patients) or deep infection (six patients); average age at the time of surgery was 31 years (16–61 yrs). Revision was managed in a staged fashion in all the six infected cases. All patients presented severe combined segmental and cavitary bone defects. Bone loss was managed in all patients using porous tantalum implants as augmentation of residual bone stock and associated with a megaprosthesis in eight cases (five proximal femur, two distal femur, one proximal tibia). Average follow-up was 4.5 years for hip/knee implants and 2.5 yrs for pelvic reconstructions (range 1–6.8 yrs). Minimum follow-up of two years was available in 11 cases.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 183 - 183
1 Sep 2012
Ruggieri P Pala E Henderson E Funovics P Hornicek F Windhager R Temple T Letson D Mercuri M
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Introduction

The current investigation includes a retrospective review of the experience of five Institutions with distal femur megaprostheses for tumor over a twenty year period, to analyze the incidence and etiology of failure, using a new classification system based upon the failure modes.

Methods

Between 1974 and 2008, 2174 patients underwent primary limb preservation for a benign or malignant extremity tumor using a metallic megaprosthesis at five Institutions, 951 (43.7%) were distal femur replacements. Retrospective analysis of complications according to the Letson and Ruggieri Classification was performed and Kaplan-Meier curves of implant survival were defined.

Segmental megaprosthetic reconstruction failures were categorized as mechanical and non-mechanical failures.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 318 - 318
1 Sep 2012
Ruggieri P Pala E Angelini A Drago G Romantini M Romagnoli C Mavrogenis A Abati C Mercuri M
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Introduction

Dedifferentiated chondrosarcoma (D.C.) has a very poor prognosis. The efficacy of chemotherapy is still debated. Aim of this study was to evaluate the survival of patients with D.C. and to evaluate possible prognostic factors.

Methods

Between 1990 and 2006, 109 patients were treated for D.C.: 55 males and 54 females, mean age of 59.6 years. In 81 cases tumor was located in the extremities and in 28 cases in the trunk. The most frequent dedifferentiation was in osteosarcoma (53.2%) followed by spindle cell sarcoma (21%), malignant fibrous histiocytoma (13.8%), fibrosarcoma (6.4%). All patients received surgery and mostly, limb salvage with tumor resection and implantation of a megaprosthesis or allograft (65 patients). Chemotherapy was given to 43 patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XL | Pages 155 - 155
1 Sep 2012
Ruggieri P Pala E Mavrogenis AF Romantini M Manfrini M Mercuri M
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Introduction

Historically, amputation or rotationplasty were the treatment of choice in skeletally immature patients. The introduction of expandable endoprostheses in the late 1980s offered the advantages of limb-salvage and limb length equality at skeletal maturity and a promising alternative with improved cosmetic results and immediate weight bearing.

Objective

to describe the Rizzoli experience in reconstruction with three different types of expandable prostheses in growing children with malignant bone tumors of the femur, assess the outcome of limb salvage in these patients, analyze survival and complications related to these prostheses used over time.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 186 - 186
1 Sep 2012
Ruggieri P Mavrogenis A Rossi G Rimondi E Angelini A Ussia G Mercuri M
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Aim

To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery.

Material and Methods

From January 2003 to December 2009, 243 patients (148 men and 95 women; age range, 20–87 years) with painful bone metastases were treated with N-2-butyl Cyanoacrylate. Overall, 309 embolizations were performed; 56 patients had more than one embolization. Embolizations were performed in the pelvis (168 procedures), in the spine (83 procedures), in the upper limb (13 procedures), in the lower limb (38 procedures) and in the thoracic cage (21 procedures). Primary cancer included urogenital, breast, gastrointestinal, thyroid, lung, musculoskeletal, skin, nerve and unknown origin. Renal cell carcinoma was the most commonly treated tumor. In all patients, selective embolization was performed by transfemoral catheterization.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 143 - 143
1 Sep 2012
Kreshak JL Fabbri N Manfrini M Gebhardt M Mercuri M
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Purpose

Rotationplasty was first described in 1930 by Borggreve for treatment of limb shortening with knee ankylosis after tuberculosis. In 1948, Van Nes described its use for management of congenital defects of the femur and in the 1980s, Kotz and Salzer reported on patients with malignant bone tumors around the knee treated by rotationplasty as an alternative to above-knee amputation. Currently, rotationplasty is one of the options for surgical management of lower extremity bone sarcomas in skeletally immature patients but alternative limb salvage techniques, such as the use of expandable endoprosthesis, are also available. Despite rather satisfactory functional results have been uniformly associated with rotationplasty, concern still exists about the potential psychological impact of the new body imagerelated to the strange appearance of the rotated limb. Results of rotationplasty for sarcomas of the distal femur over a 20-year period were analyzed, focusing on long-term survival, function, quality of life and mental health.

Method

Retrospective study of 73 children who had a rotationplasty performed at two institutions between 1984 and 2007 for a bone sarcoma of the distal femur; 42 males and 31 females, mean age at surgery 8.7 yrs (range 3–17). Four patients were converted to transfemoral amputation due to early vascular complication; 25 eventually died of their disease (mean survival 34 months, range 4–127). The 46 remaining survivors were evaluated for updated clinical outcome, MSTS score, gait analysis, SF-36 score, quality of life interview and psychological assessment at mean follow-up of 15 yrs (range 3–23).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 492 - 492
1 Sep 2012
Ruggieri P Mavrogenis A Ussia G Angelini A Pala E Guerra G Drago G Mercuri M
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Background

There is doubt regarding resection compared to curettage for pelvic metastases. Previous studies have reported that curettage is associated with decreased survival compared with wide resection, and have justified a radical surgical approach to achieve pain palliation and tumor control.

Aim

To evaluate the role of wide en bloc resection compared to curettage/marginal resection for patients with pelvic metastases. The rationale was that wide resection does not improve survival even in patients with solitary pelvic metastases.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 494 - 494
1 Sep 2012
Ruggieri P Angelini A Mercuri M
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Introduction

Although various reports analyzed “en-bloc” excision of sacral tumors, there are still technical problems to improve protection of nerve roots, preserve surrounding structures and reduce intraoperative bleeding, maintaining the oncologic result. We present a new technique for sacral resection, with short term preliminary results, derived with modification from Osaka technique.

Methods

Seven patients were resected for their sacrococcygeal chordoma with the followed described technique. Two patients had previous surgery elsewhere. The sacrum is exposed by a posterior midline incision and complete soft-tissue dissection. Lateral osteotomies were performed through the sacral foramina using a threadwire saw and Kerrison rongeurs, to avoid sacral roots damage. After proximal osteotomy, the sacrum is laterally elevated and mobilized to allow dissection of presacral structures. Mean surgical time was 5 hours (range: 3 to 8). Mean blood loss was 3640 ml.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 196 - 196
1 Jun 2012
Ruggieri P Pala E Mercuri M
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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.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 197 - 197
1 Jun 2012
Ruggieri P Pala E Mercuri M
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Objective

of this study was to analyse results of two stage revisions in infected megaprostheses in lower limb.

Material and methods

Between April 1983 and December 2007, 1036 modular uncemented megaprostheses were implanted in 605 males and 431 females with mean age 33.5 yrs: 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.

Infection occurred in 80 cases (7.7%) at mean time of 4 yrs (min 1 month, max 19 yrs) in 18 KMFTR(r), 47 HMRS(r), 5 HMRS(r) Rotating Hinge, 10 GMRS(r). Sites: 51 distal femurs, 21 proximal tibias, 6 proximal femurs, 1 total femur and 1 extrarticular knee resection. Most frequent bacteria causing infection were: Staphilococcus Epidermidis (39 cases), Staphilococcus Aureus (17) and Pseudomonas Aeruginosa (5). Infection occurred postoperatively within 4 weeks in 9 cases, early (within 6 months) in 12 cases, late (after 6 months) in 59 cases.

Usual surgical treatment was “two stage” (removal of implant, one or more cement spacers with antibiotics, new implant), with antibiotics according with coltures. One stage treatment was used for immediate postoperative infections, only since 1998.

Functional results after treatment of infection were assessed using the MSTS system.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 19 - 19
1 Apr 2012
Ruggieri P Rossi G Mavrogenis A Ussia G Angelini A Rimondi E Mercuri M
Full Access

Aim

To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery.

Material and Methods

From January 2003 to December 2009, 243 patients (148 men and 95 women; age range, 20-87 years) with painful bone metastases were treated with N-2-butyl Cyanoacrylate. Overall, 309 embolizations were performed;

56 patients had more than one embolization. Embolizations were performed in the pelvis (168 procedures), in the spine (83 procedures), in the upper limb (13 procedures), in the lower limb (38 procedures) and in the thoracic cage (21 procedures). Primary cancer included urogenital, breast, gastrointestinal, thyroid, lung, musculoskeletal, skin, nerve and unknown origin.

Renal cell carcinoma was the most commonly treated tumour. In all patients, selective embolization was performed by transfemoral catheterization.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 63 - 63
1 Apr 2012
Ruggieri P Montalti M Pala E Calabrò T Guerra G Fabbri N Ferrari S Picci P Mercuri M
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Aim

Patients treated with limb salvage surgery for bone sarcomas of the extremities (upper and lower) may have physical disability as a result of treatment. Goal of this study was to evaluate the quality of life after treatment (chemotherapy and conservative surgery) at long term.

Method

208 patients resected for a bone sarcoma and with prosthetic reconstruction (45 in the upper and 163 in the lower limb) were evaluated. Assessment of results was done using the Karnofsky Scale (K.S.). Patients were followed in the clinic and functional results assessed according to the Musculoskeletal Tumour Society (MSTS) system. Moreover the Toronto Extremity Salvage Score questionnaire (TESS) was mailed to 144 patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 43 - 43
1 Apr 2012
Manfrini M Colangeli M Staals E Bianchi G Mercuri M
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Aim

The use of megaprostheses for knee reconstruction after distal femur resection in young bone sarcoma patients has become popular since early ′80. The authors reviewed their experience with different distal femur megaprostheses in children.

Method

Clinico-radiographic evolution in a consecutive series of 113 children, that had implanted below age 15 (range 6-14) a distal femur megaprosthesis in the period 1984-2007, was analized. A modular implant was used in 97 cases with uncemented femoral stem (three different models along the period). The implant presented fixed-hinge joint in 78 cases while rotating-hinge knee was utilized in 19 cases. In 39 cases the fixed-hinge joint had a tibial component with a polished stem to allow the residual growth of proximal tibia; in two cases a mechanically extendable prosthesis was used. A custom-made noninvasive extendable prosthesis with cemented femoral stem and smooth uncemented tibial stem was used in 15 cases since 2002. Radiological and functional results were analysed and a statistical comparison of implant outcome according different stems was obtained.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 56 - 56
1 Apr 2012
Ferrari S Serra M Longhi A Alberghini M Ruggieri P Palmerini E Staals E Mercuri M Abate M Picci P
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Prognostic stratification of patients with non-metastatic osteosarcoma may improve the clinical management and the design of clinical trials.

Data from 773 patients [median age 15 years (3-40)] treated at our Institute from 1983 to 2000 with high-dose methotrexate, cisplatin, doxorubicin and ifosfamide (neoadjuvant chemotherapy) were analyzed. After multivariate analysis including age, site, tumour volume (cut-off 200 mL), serum LDH and Alkaline Phosphatase (SAP), histology (osteoblastic and chondroblastic vs others), high LDH and SAP, osteoblastic and chondroblastic histotypes resulted independent prognostic factors of DFS.

Patients were grouped according to a score from 0 (absence) to 3 (one to 3 adverse factors). The scoring system was implemented by the addition of PgP expression and grade of chemotherapy-induced necrosis.

A score of 0, 1, 2, 3 was given to 14%, 38%, 32% and 16% of patients respectively.10-year DFS was 80% (95%CI 72-89) for score of 0, 58% (95%CI 52-64) for 1, 53% (95%CI 46-59) for 2 and 40% (95%CI 32-50) for 3 (p= 0.001). PgP expression (168 patients) identified patients with 100% probability of DFS (score of 0 and negative PgP) and patients with 18% (95%CI 52-64) DFS (score of 3 and positive PgP).

Good (GR) and poor responder (PR) patients had the same probability of DFS in case of score of 0 [GR82% (95% CI 72-91), PR79% (95% CI 65-93)] and score of 3 [GR43% (95% CI 32-55) PR36% (95% CI 21-51)]. Different probability of DFS in case of score of 1 [GR64% (95% CI 57-72) PR47% (95% CI 36-59)] and score of 2 [GR63% (95% CI 55-71) PR36% (95% CI 21-51)].

It is possible to stratify outcomes of patients with non metastatic osteosarcoma of the extremity by means of a simple score based on easily available clinical parameters. This scoring system is worth to be validated on larger series.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 67 - 67
1 Apr 2012
Ruggieri P Pala E Calabrò T Angelini A Fabbri N Mercuri M
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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.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 65 - 65
1 Apr 2012
Fabbri N Tiwari A Umer M Vanel D Alberghini M Ruggieri P Ferrari S Picci P Mercuri M
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Aim

Purpose of this study was to review a single Institution experience and results of management of extraskeletal osteosarcoma (OGS), with emphasis on the role of combined treatment consisting of surgery and adjuvant chemotherapy.

Method

Retrospective study of 48 patients observed 1966- 2007 was undertaken: 36 patients were managed at our Institution while 12 cases were consultations and not included in this study. Clinico-pathologic features and details of treatment of all 36 patients were correlated with outcome. Updated follow-up was available in all patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XIV | Pages 59 - 59
1 Apr 2012
Picci P Sieberova G Alberghini M Vanel D Hogendoorn P Mercuri M
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Aim

To report late development of sarcomas on sites of previously curetted and grafted benign tumours. Rare cases of development of sarcomas in sites of previous benign lesions are documented, and the development is generally considered secondary to progression of benign lesions, even without radiotherapy.

Methods and Results

In our files, 12 cases curetted and grafted, without radiotherapy addition developed sarcomas from 6 to 28 years from curettage (median 18). Age at first diagnosis (9 GCT, 1 benign fibrous histiocytoma, ABC and solitary bone cyst) ranged from 13 to 55 (median 30). For all cases radiographic and clinic documentation was available. Histology was available for 7 of the benign lesions and for all malignant lesions. The type of bone used to fill cavities was autoplastic in 4 cases, homoplastic in 2 cases, homoplastic and tricalciumphosphate/hydrossiapatite in 1 case, autoplastic and homoplastic in 1 cases, heteroplastic in 1 case. In 3 cases the origin was not reported. Secondary sarcomas, all high grade, were 8 OS, 3 MFH, and 1 fibrosarcoma.