Aim

Megaprosthesis have become a standard option in limb preserving surgery after bone resection in musculoskeletal tumors. Recently they have also been used in complex revision arthroplasty in cases with massive bone loss. The aim of this study was to analyze the incidence of periprosthetic joint infection (PJI) both in primary oncology cases and aseptic revision cases and analyze which are the significant risk factors for PJI with a special interest on the use of prophylactic antibiotic loaded calcium sulfate beads

Primary tuberculous bursitis was a relatively frequent manifestation of the disease before the antituberculosis drug era. Nowadays, it is considered a rare condition; it accounts for 1–2% of all musculoskeletal tuberculosis. The diagnosis and treatment of tuberculous bursitis may be delayed because the paucity of symptoms, its indolent clinical course and a low clinical suspicion. A 50-year-old patient with tuberculous trochanteric bursitis is reported.

A 50-year-old woman was referred to our department to investigate a persistent pain in her left hip with 6 months duration. She was afebrile. The examination revealed a diffuse swelling from the buttock through the thigh, notable over the trochanter, but no sign of acute inflammation such as heat and redness. Her past medical and family histories revealed no previous tuberculosis.

Plain films of the left hip showed a partial destruction of the margin of the greater trochanter, lytic foci in the underlying bone and a small focus of calcification in the adjacent soft tissues. A computed tomogram showed a soft tissue mass and demonstrated the relationship with the trochanter. We performed a needle biopsy which revealed granulomatous tissue. The patient underwent complete excision of the bursa and curettage of the surface of the trochanter. The postoperative course was uneventful. Mycobacterium tuberculosis was isolated and definitive diagnosis of tuberculous bursitis was made. There was no evidence of concomitant tuberculosis at other musculoskeletal sites. The patient completed a treatment with rifampicin and etambutol for 6 months.

There has been a complete resolution of the symptoms after 3 months and no recurrence after 4 years of follow-up. On plain radiograph the remodeling of the bone structure is clearly visible.

Tuberculosis in the region of the greater trochanter is extremely rare. This rarity leads orthopedic surgeons to neglect this potential diagnosis, resulting in a delay in treatment. The pathogenesis of tuberculosis of the greater trochanteric area has not been well defined. The incidence of concomitant tuberculosis at other musculoskeletal sites, as well as the lung, is approximately 50%. Both hematogenous infection and propagation from other locations are reasonable explanations. Surgical intervention is mandatory for cure and the use of several antituberculosis agents is a standard approach.

The Universal Clamp (U-Clamp) is based in a sub-laminar ribbon and one titanium clamp. The ribbon is passed under the lamina and the clamp is fixed to the rod. The correction is obtained in a very similar way to the old Luque system.

This system allows a gradual force of traction on the lamina (translation) like the Luque’s type system without some of its inconvenience (pullout, the irritation that the tip of wires could cause in the soft tissue, not compatible with the MRI). But also added some advantages, such us a higher capability of traction force, and we can perform the MRI after surgery. And in some severe cases, that in the past we had to do in the same patient, an anterior and a posterior approach, now we can achieve the same amount of correction using only posterior approach with the U-Clamps.

Our department acquired, throughout more than two decades, a wide experience in the surgical correction of the most severe deformities of the spine, using the sub-laminar steel wiring (Luque’s technique). Although we got satisfactory results, the system had some problems that we already mentioned.

The new systems using pedicle screws with or without hooks (considered by most spine surgeons as the “gold standard”) have also some limitations comparing with the Luque system, as Vora, Lenke and al. showed (“Spine” Jan. 2008). It causes frequently hypokyphosis.

We tried a hybrid system to correct the spine deformities in the adolescent and children, some with severe curves.

Since January 2007, 42 patients were operated using proximal hooks and distal screws and the “U-Clamp” in the apex. In our series the mean age was 15 years old, the youngest was 8 and the oldest 19. Most of them were girls (33). The most common aetiology was AIS (24), three were Cerebral Palsy and the rest had different aetiologies. The instrumentation we used was Incompass^® (23) or CD Legacy^® (14). The mean deformity angle before surgery was 78.81° (measured by Cobb method), with the maximum deformity 117° and minimum 53°. After correction the mean angle of deformity was 38.56 (maximum 77 e minimum 18). The preoperative flexibility (PF) (%) was 21.56. The postoperative correction (POC) (%) was 52.42. And the Cincinnati correction index (CCI) (%) was 3.7.

Comparing our patients with the Vora, Lenke and al. (Spine Jan. 2008), our patients had a more severe deformity and where more stiff with the CCI=3.7 (Vora and Lenke, CCI < 1.95)

This new system allows much greater correcting force over the lamina with less wire pullout. Also it doesn’t have the inconvenience of the steel wire if we need to study the patient after surgery with a MRI. The Kyphosis is preserved with this system contrary to the all screw construct.

This system has its place in the spine instrumentation, namely, in situations where the deformity is severe and the osteoporosis is important.

Chondrosarcoma is the second most frequent primary malignant tumour of bone, representing approximately 25% of all primary osseous neoplasms. Chondrosarcomas are a group of tumours with highly diverse features and behavior patterns, ranging from slow-growing non-metastasizing lesions to highly aggressive metastasizing sarcomas. As radio and quimio-resistant tumours, the surgery constitutes the unique chance of cure. Nowadays, besides the curative intention, the reconstructive surgery is also a priority in order to save the limb and optimize the function.

This case report is about a young woman, of 24 years old, with hip-related pain and a large mass in the left pelvis. The imagiologic study showed a large mass of about 8 cm of large diameter, starting at the anterior wall of the acetabulum, involving the pubic arcs and with matrix calcification. The core needle biopsy confirmed the presence of a chondrosarcoma, staged as a IIB of Enneking.

Because of its size and localization the limb salvage surgery has been a challenge. The surgery included a broad approach of the left hemipelvis, with wide excision of the tumour, reconstruction of the abdominal wall with a propylene prothesis and reconstruction of the hemipelvis with a “custom-made” prothesis with preservation of the femoral neurovascular bundle. The patient started to walk with total bearing after three months and had a normal gait and a nearly normal life during eleven months. Fifteen months after the surgery lung metastasis and local recurrence were diagnosed and she died six months after.

Conclusion: The surgery is our unique weapon in the “combat” against the chondrosarcoma. The reconstructive surgery must be a concern to give to our patients the best functional result and quality of life.

Condromixoid sarcoma is a rare tumor (about 2,3% of soft tissue sarcomas in one of the series published) occurring mainly in muscular part of extremities. The reconstruction after block resection of tumor lesions of dorsal column invading the thorax almost always represents a great challenge to the surgical team. The case presented reports an infrequent location of this rare tumor what highlights it in an oncologic point of view. From the surgical point of view the surgical steps of wide tumor resection are described and of the reconstruction of the dorsal column and the involved thoracicregion (adjacent to vital structures) what resulted in an asymptomatic correction.

The authors present a case of a 47 years old patient operated to a volumous dorsal condromixoid sarcoma, practically asymptomatic, with invasion and compression of the neurological space and thoracic cavity. After biopsy, a wide resection of the tumor was made, using a double surgical approach (anterior and posterior), with resection of posterior part of vertebras D6–D9 and part of the 7th, 8th and 9th costal arches. The reconstruction consisted in correction of thoracic wall with prosthesis and stabilization of column with pedicular instrumentation from D5 to D11. The post-operatory recover had no complications and in clinically the patient is asymptomatic.

Only the elevated level of suspicion conducted the realization of biopsy in an apparent innocent lesion. The Condromixoid sarcoma occurs rarely in the nervous axis, what created some difficulties in the histological diagnosis. The dimensions of the tumor mass and its localization were object of great discussion and of detailed surgical planning. After a massive surgical resection, the clinical result after 2 years of follow-up is excellent (patient asymptomatic). The almost inevitable oncological decision of surgery in a malignant tumor with medullar cord compression was the only effective way of treatment.

Core needle: From the other 335, 116 were benign tumours or tumour-like conditions, 86 primary malignant, 53 lesions oh Hematopoietic, lymphoid and biopsy is simple, practical and easily permits diagnosis of bone and soft tissue tumours and tumour-like conditions even when immunohistochemical studies are needed.

We present the results of 412 core needle biopsies guided with fluoroscopy, CT and echo scan with assessment of accuracy and costs

From January/96 to December/08, 56 soft tissue and 356 bone tumours and tumour-like lesions were submitted to this technique in the Oncology Unit of Hospital Santo Antònio. All biopsies were performed by the same team (one radiologist, one orthopaedic surgeon) and the histological exam by the same pathologist.

There were 77 cases in which diagnosis was inconclusive (sample not representative, crushing, necrosis, hemorrhagic features or image/histological dissociation); 36 of these were soft tissue and 41 bone lesions. histiocytic elements, 65 metastases, 8 recurrent malignancies, 5 osteomyelitis and 2 metabolic diseases.

Diagnosis was confirmed in 278 cases with the definitive surgery and only one was wrong. The other 57 cases were later controlled by imaging exams and there were no reasons to suspect a wrong diagnosis.

No complications occurred.

Costs were estimated to be less than one fifth of an open biopsy.

The high accuracy (only one case was misdiagnosis), the safety, the costs and the fact that in only 18,7% the diagnosis was not established make us consider this method effective and to be encouraged. Better selection of lesions and more attention to directions of the cores may low the number of inconclusive diagnosis.

Primary synovial chondromatosis, defined by Jaffe (1951), is a rare, benign arthropathy, of unknown aetiology, distinguished by the chondroid metaplasia of the synovial membrane of the joint, bursa or tendon sheath, which leads to the formation of loose bodies, usually intra-articular. It is characteristically monoarticular and the knee, hip and elbow are the joints most commonly affected. The shoulder is a rare localisation and the extra-articular involvement even rarer, with only few cases presented in the literature.

The diagnosis is possibilited by the clinical examination and by the confirmation of the presence of multiple intra-articular loose bodies by roentgenographic studies and magnetic resonance (MR). The treatment is always surgical. Malignant degeneration of synovial chondromatosis into chondrosarcoma is described, although rare.

We report an exceptionally rare case of synovial osteochondromatosis of the shoulder with combined intra and extra-articular involvement in a 28 years old female patient, former athlete. She presented with a five-year history of shoulder pain and slight limitation of motion. Radiographic examination and magnetic resonance imaging led us to the diagnosis of synovial chondromatosis of the shoulder. The patient underwent arthroscopic removal of the intra-articular loose bodies and partial synovectomy. The subscapularis recess was then identified through an anterior deltopectoral incision and multiple loose bodies were removed from within.

Primary synovial chondromatosis of the shoulder is rare (5% of the cases) and the involvement of the extra-articular shoulder site is even rarer. Bloom and colleagues reported ten cases involving the shoulder in a meta-analysis of 191 synovial chondromatosis cases.

The arthroscopic removal of the loose bodies combined with the partial sinovectomy has demonstrated efficacy and low recurrence rates, allowing excellent visualization of the joint, decreased morbidity and early functional return. Nevertheless, we think that this approach may become insufficient when the extra-articular involvement is verified.

Synovial cell sarcoma is one of the most common soft tissue tumours. Prognosis of this tumour is related to initial care. Survival rates have improved in the past 20 years because of treatment with primary radical surgery, along with chemotherapy and radiation.

This case report is about a woman, of 68 years old, with a left shoulder-related pain and mass with about four months. The image study showed a lobulated and irregular mass, with about 12x10x9cm, infiltrating the rotator cuff and glenohumeral joint. The core needle biopsy confirmed the presence of a synovial sarcoma, staged as a T2N0M0.

The treatment started with neo-adjuvant chemotherapy, with a poor response. Then, surgery was performed, with a wide excision of the scapula, proximal humerus and clavicle (type IV of Malawer) without reconstruction. The treatment regime ended with the radiotherapy. Eighteen months after the surgery the patient remains disease-free and a neo-joint is starting to form. At this time the DASH score was 63.8. Despite the flail shoulder function is acceptable.

Conclusion: In such an aggressive tumour, an extensive and multidisciplinary approach is imperative but always with regard to the limb function.

Osteosarcoma is the most common tumor among the primitive malignant bone tumors. When different features of these lesions are considered, we can find several varieties of this tumor, with distinct anatomo-clinical presentation, treatment and prognosis.

Until the 70s, its prognosis was very poor, the standard surgical treatment was amputation and 80% of the patients died from metastatic disease. With the development of new surgical techniques, the advent of combined chemotherapy and more accurate imaging, the outcome of these patients has improved significantly. Consequently, approximately 90% of the surgical cases are treated with limb salvage procedures.

The authors reviewed 22 cases of Osteosarcoma treated in HGSA, 20 being submitted to the T20 Rosen protocol.

Trocar biopsy was performed in 19 of the patients and 3 of the patients were submitted to incisional biopsy in order to complete diagnosis.

Regarding the anatomo-clinical pattern, Classic Osteosarcoma was present in 19 patients, 2 of the cases were Parosteal and 1 was Central low-grade Osteosarcoma.

The majority of patients underwent limb salvage surgery; only 2 had amputation surgery and 1 patient was submitted to palliative chemotherapy. Considering limb salvage procedures, several techniques were performed: arthrodesis (n=1), grafts (n=4), prosthesis (n=13) and compound prosthesis (n=1). The resection margins were wide in 19 cases, marginal in 2 cases and in 1 case intra-luminal.

Among the treated patients: 12 patients are still alive and cured, 3 have metastatic disease, 6 are deceased and 1 didn’t complete the follow-up.

The final functional score obtained was 84% for the superior limb (DASH) and 81% for the inferior limb (TESS).

Although the scarce number of cases described were not enough to make any kind of correlation, it was possible to establish the accuracy of the multidisciplinary approach involved both in the diagnosis and treatment, in agreement with the “state of art”.

Osteoid osteomas are benign, painful osteogenic tumours of small size (≤ 1,5 cm). Surgical resection of the nidus has been the elected method of treatment for decades but some complications and difficulties (poor localization, extensive tissue damage, fractures, delayed recovery) encouraged the development of less invasive techniques such as radiofrequency.

Lack of histological proof is the major concern regarding radiofrequency ablation as we make the diagnosis by the clinical findings and the image features.

We present the results of 20 patients with osteoid osteoma treated with radiofrequency from January 2004 to December 2008 (mean follow up 23 months). All patients were under general anaesthesia and de access route was chosen in the CT-suite. 11 cases were located in the proximal femur (head, neck and subtrocanteric region), 2 in the distal femur, 2 in de distal humerus, 2 in the tibia, 2 in the acetabulum, and 1 in de vertebal body of D8.

In all cases we used a Cool-tip TM RF electrode (water-cooled tip) reaching a heating temperature of 42°C to 48°C during 12 minutes. In 7 patients a cannulated drill bit was used to penetrate the thick cortical or to reach the nidus through the opposite side in order to avoid a neurovascular bundle.

Hospital discharge was allowed after 6 to 8 hours after the procedure.

No complications occurred.

All patients, except one, experienced complete relief of the pain although the 6-month follow-up CT’s do not show sclerosis of the nidus. None of them recurred till data. The patient who did not recover had not had a clear diagnosis.

We conclude that radiofrequency ablation is effective, safe, favouring rapid recovery and, of course, reduces economical and social costs.

Intramuscular hemangyomas are benign tumours (0,8% of all hemangyomas). Their aetiology is uncertain but they are possibly congenital, although some seem to be related to trauma. Symptoms (usually pain and swelling) may be present for years. Histological subtypes are cavernous, capillary and mixed. Optimal management includes precise diagnosis and wide excision to prevent local recurrence.

Authors present a case of a 79 years male with cavernous hemangyoma of the thigh with three years of evolution. The tumour eroded the femur and the patient had a mass all over the thigh with tension and pain. Diagnosis was suspected by phleboliths seen on x-ray and MRI and was confirmed by open biopsy.

Treatment was a complete excision with double approach, medial and lateral, plus prophylactic nailing of the femur.

With a four years follow – up, the patient has no sign of recurrence and has a normal function of the inferior limb and a normal gait.