Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding.

40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure.

Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery.

Our aim was to assess the value of external fixation in pathological fractures in selected patients.

During 2003–2008 we treated 35 patients with multiple myeloma or disseminated cancer, visceral metastases and pathological fractures with external fixation under sedation and local anaesthetic, because they were not fit for general anaesthesia. We used external fixation on 1 hip fracture, 1 fracture of the second metatarsal, 2 wrist fractures, 4 radial, 5 intertrochanteric, 1 subtro-chanteric, 12 fractures of the humerus, 1 ulna fracture, 4 femoral fractures, 3 tibial fractures and 1 femoral osteolysis. Operating times were 15–35 min, all patients were comfortable, cooperated well and they did not experience any pain during the procedure. In all cases XRT was applied either pre- or post-operatively.

On follow up (2–48 months) 4 of the patients were deceased. Fracture stabilization was adequate and X-rays confirmed porosis in 4 fractures; however, two lesions expanded further, despite proper adjuvant bio-pharmaceutical therapy. 5 patients impoved so we could operate them later to treat the fractures definitively. All individuals experienced pain relief, they were adequately mobilized and most function was restored, while there was no major problem with pin tract infections.

We suggest external fixation as a palliative treatment in patients with pathological fractures and multiple metastases, who don’t qualify for major surgery because of their critical illness. The later puts under local offer an excelent chance to fix fractures quikly, manage the pain and restore function without the risks of general anaesthesia

Complex limb-salvage surgical techniques and reconstruction with sophisticated massive endoprostheses prove to be excellent tools for effective bone tumour management.

We treated 34 bone tumours (osteosarcoma, chondrosarcoma, plasmatocytoma, Ewing’s, osseous lymphoma, histocytosis-X, MFH, mets). We excised the lesions on oncologically safe surgical margins (wide excision inclunding anatomical barriers to tumour spread) and we reconstructed the defects with 29 modular and 5 custom designed and manufactured massive endoprostheses. Intramedullary stems were all cemented and they were supplied with hydroxyapatite collars that favour callus formation and extramedullary stabilisation. We did 12 proximal femoral tumour reconstructions, 17 distal femoral and proximal tibial tumours with rotating metal or polyethylene fixed-hinge knee implants and 1 total femur. In upper limb we did 2 proximal humerous with reverse polarity shoulder endoprostheses. In 1 humeral shaft case we did subtotal excision and reconstruction with two joint-saving endoprosthesis. In 1 distal humerus tumour we used custom constrained endoprosthesis of distal humerus and elbow. If tumours did not extend too close to the cartilage we applied joint-saving techniques. Function was restored with proper implant size selection and rearrangement of muscle remnants. On follow-up (4–58 months) average TESS score was 83%. There was no local recurrence and no aseptic loosening, dislocation or implant failure. Three patients with metastatic disease DOD. One case presented with late DVT and one with late deep infection.

New surgical methods and sophisticated implants with evidence-based design contributed greatly to successful limb salvage surgery as well as in overall patient prognosis and survival who enjoy better function.

We evaluated the use of unreamed expanding nails in prophylactic stabilization of impending fractures in patients with multiple bone mets.

During 2004–2008 we treated 25 impending fractures due to metastasis (11 male, 14 female patients) with so-called expanding intramedullary nails. All they had multiple bone mets and signs of impending fracture due to extensive osteolysis. We stabilized 6 impending humeral fractures, 15 femoral and 1 tibial with antegrade nailing and 3 pertrochanteric with cephalomedullary nailing. Fluoroscopy was used to check the nail entry-point. No medullary reaming was performed. The nails were not interlocked at the mid-shaft but fixed rather firmly within the medullary cavity after introducing normal saline under pressure that expands its walls. The operation time ranged from 12min (humerus) to 25min (pertrochanteric). No blood transfusion was necessary. On follow-up (8–41 mos) all patients were reviewed. In all cases the risk of impending fracture was remarkably decreased. The patients with humeral fractures regained function quickly. The patiens with lower limb fractures were mobilized immediately post-op and were allowed to walk with TWB.

Surgery of impending fractures of long bones in patients with multiple bone mets is palliative. It aims in safer patient’s mobilization, fracture risk reduction, pain control and function restoration in order to render the patient capable to continue the treatment for the main disease. The expanding nailing is indicated in selected cases as it can be inroduced quickly and effectively with minimal blood loss and morbidity.

Aim: In the present study we examine the role of bone scan with 99mTc-MIBI, following a positive 99mTc-MDP scan, in the work up to differentiate between malignant and benign bone lesions.

Material and methods: Fifty-nine patients, with a positive 99mTc-MDP bone scan had further investigation of the affected area with the oncophilic radiopharmaceutical 99mTc-MIBI (15 mCi). The agent was administered IV and images were obtained (planar/SPECT) 20 min and 3 hours later. All patients had biopsy and CT/MRI imaging.

The 99m Tc-MIBI images were estimated by 3 independent observers and every abnormal uptake, ranging from faint to intense, was considered positive.

Results: 32 patients had benign bone lesions according to histology pathology; 28 of them (87.5%) had a negative 99mTc-MIBI scan (trauma, benign bone tumors). Four patients with benign bone lesions had positive 99mTc-MIBI (chronic osteomyelitis,osteochondroma, osteochondroblastoma, chondroblastoma). 27 patients had malignant bone tumors proven by biopsy; 25 of them (92.6%) had possitive 99mTc-MIBI scans (sarcomas and metastases) and 2 negative (chondrosarcoma, MFH).

Conclusions: The 99mTc-MIBI scan in patients with positive 99mTc-MDP scan and a high index of suspicion for malignancy (either primary or metastatic) was found to have a high negative pedictive value (NPV=0.875) in excluding the presence of malignancy and a high positive pedictive value (PPV=0.926) in identifying patients with malignancy. The 99mTc-MIBI was positive in all patients with metastatic disease (PPV=1.00). We suggest the use of 99mTc-MIBI as a useful method in decision-making in cases with bone pathology.

Introduction: We studied the role of intraoperative radiotherapy (IORT) in preventing local recurrence, in cases of malignant soft-tissue tumors and desmoids.

Methods: Ten patients (age 5814yrs) with recurrent soft-tissue tumors, grade IIA/IIB, 3 – 7cm long, involving thigh, calf, forearm and thenar were widely excised and irradiated into the operating room by a specially designed electron linear accelerator. The field was irradiated with electons (10 – 15Gy, 3 – 7MeV) with a circular-cut applicator (Φ40 – Φ80).

Results: Common local post-irradiation complications such as neuropathy, vascular damage, fibrosis, wound problems or bone necrosis, were not noticed. At follow-up (24 – 38months) four patients (40%) remain disease free. Six (60%) had recurrence shortly after operation, two developed lung metastases.

Discussion and Conclusion: IORT permits the application of high dose radiation during surgery. Manual displacement of healthy tissues situated between the radiation beam and the target reduces its toxicity. Direct vision assures maximum precision in the administration of radiation. It eliminates any remaining tumor, intensifies radiotherapy‘s antitumoral effect as it permits the administration of high doses of radiation otherwise not approachable. External irradiation is applied after wound closure. IORT reduces the lapse time between surgical exploration and irradiation during which residual satellite cellular clones can grow. We did wide resection and IORT in aggressive, recurrent tumors, as an alternative to amputation. Considering the advantages of IORT, we conclude that modification of the dose and irradiated area may further improve the results and reduce unpleasant therapies.

Aims: We evaluated the results of molecular diagnostics to see if they can help in conþrming an accurate diagnosis quickly in cases of Ewingñs sarcomas. Methods: We did biopsies and genetic studies in 19 patients (8 females, 11 males Ð 35±19 years old) with a bone tumor with clinical and imaging signs of Ewingñs sarcoma. Cytogenetic examination aimed at tracing characteristic products of the hybrid genes of the tumor. We did molecular analysis with RT-PCR. Results: In ten patients biopsy conþrmed the diagnosis of Ewingñs sarcoma. The genetic tests of 12 patients came to a clear conclusion. In 7 cases (4 Ewingñs sarcomas histologicaly) we had no answer. In seven cases we found products of hybrid genes Ews/Fli and Ews/Erg. These are the result of fusion of genes from chromosomes 22q12, 11q24 and 21q22 and the characteristic chromosomal translocation of Ewingñs sarcoma between exon 7 and exon 6 of the Fli fusion gene was conþrmed. Five cases had no characteristic numerical or structural chromosomal abnormalities. Histologic and cytogenetic diagnoses of Ewingñs sarcoma concur in þve cases. One case of Ewingñs sarcoma was not conþrmed with genetic diagnostics. Two cases with gene mutations characteris tic of Ewingñs sarcoma had an histologic diagnosis of an osteosarcoma. Conclusions: Malignant cells commonly exhibit speciþc chromosomal deletions, which may lead to tumor formation. Our cases show the strong relation between Ewingñs sarcoma and certain chimerical genetic transcriptions. Identical cytogenetical translocations in a few cases of other tumors and their absence in some Ewingñs sarcomas is confusing and indicates their common origin from a primitive tumor.