Aims

The aim of this study was to report the results of three forms of reconstruction for patients with a ditsl tibial bone tumour: an intercalary resection and reconstruction, an osteoarticular reconstruction, and arthrodesis of the ankle.

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used.

From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation.

29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test.

Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients.

Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction.

The use of antibiotic-spacer, it is essential to treat infections in orthopedics. They play a dual role, to fight the infection directly on the outbreak and keep the length or the articulation of the limbs thus facilitating the second operation. To date it is not known, the superiority of use of 3 antibiotics compared to two. Authors try to compare industrial preformed spacers with two antibiotics with custom made spacers with three antibiotics to assess (a) the control of infection, (b) complications, (c) quality of life, (d) pain and (e) patient satisfaction.

137 patients treated at the Institute Codivilla-Putti from January 2010 to December 2012 were considered: 68 patients treated with antibiotic preformed spacer (clindamycin + gentamicin) or (Erythromycin + Colistin), 69 patients treated with antibiotic spacer added with 3 antibiotics (clindamycin + gentamicin + vancomycin) or (Erythromycin Vancomycin + Colistin).

Demographic data were collected:

type and site of infection (classified by Cerny-Mader)

Primary outcome of infection control or relapse after at least 12 months of follow-up were assessed. Complications were recorded. Each patient completed a test on the quality of life and a satisfaction scale self-referenced.

After a mean follow-up of 33.82 months (SD 14:50), at the end of the treatment, at last follow up 15/133 were infected. 4 died from other causes not correlated with infection, whit a 11.3% rate of reinfection.

Up to our knowledge, there is only one study using the procedure in two steps comparing the use of spacers loaded with 2 or 3 antibiotics. Our results show that a revision protocol in two steps with 3 antibiotic loaded spacers have a high success rate in the treatment of chronic osteomyelitis. We can observe that patients treated with custom-made cements are 4 percentage points lower than those treated with preformed cements, but there are no statistically significant differences in the rate of recurrence of infection. Our results suggest that a two stages procedure with three antibiotic loaded spacers should be considered in selected patients to avoid rescue procedures, such as amputation and arthrodesis. We think is important to do more randomized trials, controlled, prospective study with a larger group to detect statistically significant differences.

Introduction: It is noted that infections make up the most feared complications of prostheses’ surgery in orthopaedic implants after resection of primary or secondary cancer of limb bones. The causes must be attributed to the entity of the skeletal resection and of surrounding soft tissues sacrifice, to the duration of surgery and to the pre-operative cycle of chemotherapy or radiotherapy. Infections of prostheses in oncology are caused mainly by bacteria present either in isolated strains or in poly-microbic associations, and most recently fungus infections have begun to be found, in immunodepressed patients. Candidemia makes up an important cause of systemic infections in immuno-compromised oncological patients, who received high doses of chemotherapy; moreover candidemia represents a high risk of hospital sepsis. It is noted that the behaviour of the Candida is interpreted through the production of a biofilm and then the inhibition of the production of the biofilm itself is translated into a potential antifungal effect. From the analysis of the literature a protective role carried out by the silver coating of the tumoural prostheses towards the bacterial infections is deduced. It is noted, in fact, the antimicrobiotic effect of medical devices coated in silver; in particular in studies conducted in animals favourable results were demonstrated on bacterial adherence of titanium devices coated with silver. The aim of the study was to evaluate in vitro the inhibition of the production of biofilm by different strains of Candida in the presence of titanium and titanium coated with silver.

Materials and Methods: Six strains of Candida were analyzed: 2 strains of C. albicans, 2 of C. tropicalis and 2 of C. parapsilosis. The fungal strains were stratified on discs of pure titanium, a material in which implants of tumoural prostheses are made, and furthermore on discs of titanium coated in silver, and the ability of the fungus to produce protective biofilm on different substratum was evaluated. All of the studies were conducted 3 times. The adherence to the biofilm was measured by semi-quantitative, colormetric and spettrophotometric methods according to standardized protocols.

Results: The spettrophotometric analysis demonstrated a statistically significant reduction of the production of biofilm by fungus strains that came in contact with titanium coated in silver compared to pure titanium in all of the strains that were examined, attested by the fact that the silver creates a micro-environment unfavourable for fungus growth.

Conclusion: The analysis of the results demonstrated that the Silver coating of the oncological prosthesis made an unfavourable micro-environment not only for bacteria, as has already been widely established, but also for fungus. For this reason we maintain that this coating constitutes a valid opportunity in oncological resections for those patients who, being treated with chemotherapy, radiotherapy and to long hospitalitations present an elevated risk of fungal infection in oncological resections. From the studies we conducted it appeared how fundamental the use of silver in tumoural prosthesis is in order to prevent contamination by fungal strains and how this use must be taken more and more into consideration to improve life expectancy of a particular and sensitive category of patients, especially oncological.

Aims: Reconstruction of bone continuity after wide resections for malignant tumours has always been a big problem in orthopaedic surgery. During the growing age the problem of reconstruction is harder because of the arrest of growing referring to the scheletal segment involved.

Authors present their experience with different surgical methods.

The choice of surgery depends on the age of the growing child and on the site of the neoplasm.

Methods: The personal series of the authors refer to nine osteogenic sarcomas (five of the distal femur, and four of the proximal tibia) and four Ewing’s sarcomas of the femoral diaphysis. The age of the patients was between nine and sixteen years.

Females were eight and males were five. After ten years only ten patients were disease free (seven osteogenic sarcomas and three Ewing’s sarcomas).

Results and conclusion: In four cases of osteogenic sarcoma the patients were under ten years of age and the surgical choice of Authors was dependent to the exention of the surgical resection including the growing cartilage and the normal growing of the controlateral scheletal segment. For this reason authors employed a conservative method using the association of the Ilizarov external fixator with a final arthrodesis employing a long intramedullary nail.

In five cases of o.s. the age of the patients was over fourteen years, the remaining growing period was limited and for this reason a mechanical growing prosthesis was employed.

In the four cases of diaphyseal Ewing’s sarcoma the reconstruction was performed in two cases employing an autologous graft taken from the iliac crest and in two cases a microvascularized fibular graft.

Functional results of the affected limb, in the surviving patients, depend on the sacrifice of the joint (arthro-dhesis) or in the use of a modular prosthesis that, in AA. experience have a follow-up of 12 years; in diaphyseal reconstruction an anatomical result was obtained either with the mcrovascularized fibular graft or with the autologous graft from the iliac crest, the only difference between these two methods depending on the time of bone healing.

It is well known that wide resection and reconstruction with modular or composite prostheses is the treatment of choice in high chondrosarcoma of metasepiphyseal bone. Nevertheless there is a debate concerning the treatment of low grade chondrosarcoma, a locally aggressive tumour, similar also histologically to benign lesion. Two different therapeutic options are reported in these lesions: wide resection and intralesion curettage. Between 1995 and 2003 the Authors analysed a series of 37 cases of low grade chondrosarcoma of long bone treated with curettage and local adjuvant, like liquid nitrogen and acrylic cement, if necessary associated with synthesis. The least follow-up was two years. The authors observed 3 local recurrences within the first 12 months from the surgical treatment; and, in every case, an increased grade of malignity was observed at histology. The Authors confirmed that the aggressive intralesional treatment with the use of the local adjuvant like liquid nitrogen and cement, is a valid therapeutic possibility in these lesions, but they confirm that it’s necessary an accurate preoperative diagnosis with also open biopsy for an efficacy treatment.

The Pamidronate inhibits osteoclastic bone resorption and have been successfully used as an intravenous infusion in the treatment of fibrous dysplasia (FD) of the bone.

We describe the preliminary results of this approach in a 14 years old male patient with a monostotic fibrous dysplasia of the femur. A biopsy was performed before given the biphosphonate. He received 2 cycles of 180 mg intravenous infusion of pamidronate every months (60 mg/day for 3 days): Clinical symptoms, serum levels of calcium and electrolytes were valued during each treatment.

X-rays and BMD of total skeleton studies were performed at baseline and every 3 months. We observed a significant clinical improvement of the pain associated with the radiographic evidence of the thickening of bone cortex surrounding the lesion. Therefore, pamidronate seems to be a valid therapeutic option for patients with FD of the bone.

Introduction: SCC is a rare but well-known complication of chronic osteomyelitis since 1835, with an incidence from 0.5 to 2.3%. Amputation has generally been the treatment of choice; in selected Patients, Limb-salvage procedures have been employed 28 cases are presented here.

Materials and Methods: From 1975 to 2000, 4089 Patients with ostemyelitis were admitted to our service. SCC was present or arising in 28 cases: they were all middle aged males, except one woman. Mean age was 56.6 yrs, range 40–72. Clinical data were pointed out, and in all of them single or multiple biopsy was performed.

Results: All the cases were affected by SCC in the lower limb: tibia was the main site 20, followed by hip (2), foot (2), femur (4). Bone infection was born over 40 yrs. before (range 21–57). Patients were painfree up to 51 years. From worsening symptoms to admission, time was about 9 months (1–24). 19/28 cases came with wide leg ulcers, the rest with one discharging sinus or more (up to 8). In 6 cases pathological fracture was observed. Microbiological yields were not significant.

13 cases were transferred to Bone Tumors Centers: 10 of them were lost at F.U. Among those who underwent amputation: in two of them, local recurrence was observed, and one deceased after two years. Another Patient deceased for non-related heart problems.

Conclusions: In chronic osteomyelitis relapses are frequent, malignancy rare. If clinical changes in lower limb are observed, (pain, increased discharge, fethor, enlarging ulcer), SCC must be suspected. Early diagnosis is vital: biopsy should be wide, deep, multifocal, including the marrow space. Amputation is the treatment of choice. Metastases occur in 18 months; prognosis after 3 yrs from surgery is good.

Aetiology is still unknown: there is no evidence for an initiating factor. About favouring conditions ( inflammation, lower limb,) data are not clear enough.

In limb preserving surgery, our experience suggests one-stage procedures, avoiding to re-create chronic inflammation near the site of cancer.

Aims: PMMA is currently used as grouting agent of arthroprostheses and for filling of bone cavities after bone curettage. It is moreover used as a carrier of antibiotics in the local treatment of bone infections and it has been proposed as a carrier of antiblastic drugs in the local treatment of bone metastases. The aim of this study is to analyse the biological properties and compressive strenght of PMMA-Methotrexate mixture to be used for the local treatment of bone metastases.

Methods: Cylinders of PMMA containing Methotrexate in different concentrations were manufactured according to ASTM F-451. Cylinders of PMMA were used as control. The porosity of the cylinders was characterised by SEM. Drug elution rate in saline solution was measured by HPLC. The biological activity of Methotrexate was analysed on human breast cancer cells using MTT test at different time (from 5 minutes to 30 days). Compressive tests was performed in conformity to ASTM F-451 on PMMA- Methotrexate samples and control as-made and after 30 days of aging in saline

Results: SEM analysis showed the presence of granules of Methotrexate on the surface of as-made cylinders that can be readily released from PMMA cylinders. The release occurred in large amount within 24 hours after immersion. We observed a relative release rate is more sustained in samples containing the drug in lower concentration. Also the biological activity was time dependent: cell death decreased progressively from 60% at 24 hours to 10% at 30 days.

Compressive tests showed no statistical differences between PMMA cylinders containing Methotrexate and controls before and after aging in saline.

Conclusions: The results show that PMMA-Metho-trexate may be considered an interesting option in the treatment of bone metastases because cement allows mechanical resistance after bone curettage or resection and Methotrexate improves locally anticancer activity.

In primary malignant bone tumours, the “en – block” excision with the sacrifice of soft tissues causes a functional deficit of the interested limb. There are many possibilities for reconstruction after a wide resection of the proximal humerus. The Authors report their experience using megaprostheses, focusing to soft tissue reconstruction, in order to obtain a good and fast functional recovery of the involved limb. 13 megaprostheses of the proximal humerus were employed. All patients were affected of primary malignant bone tumors with different histology. The tumor was staged according to Enneking’s system. 8 cases were classified as IIB and the remaining as IIA. All the tumors were treated with an intrarticular resection. Soft tissues reconstruction was performed, in 8 cases, using a mesh (Trevira tube), dressed all along the prosthesis, with a high resistance to traction. Radio and/or chemotherapy were employed referring to the histology.

At a medium follow – up of two years, for the surviving patients, we have obtained excellent functional results in 1 case, good in seven cases, fair in three cases and poor in two cases. The size of the resection is a main factor in order to obtain a good functional recovery of the joint motion. A wide excision (below deltoid insertion) with the sacrifice of large muscular masses and of the osteoarticular structures can represent a functional amputation causing the loss of muscles that are important to have an acceptable joint movement.

In our experience we retain that the use of modular prostheses in reconstructive orthopaedic surgery is advantageous because of its versatility and of its quick implantation, despite of other reconstructive systems. Moreover the use of a device, as that described, for an easy anchorage of the myotendinous structures, allows a quick functional recovery offering the patients considerable advantages for their social life.

Aim: This study evaluated the complication rate and surgical outcome following medial femoral neck fractures, in elderly patients over 75 y, treated by biarticu-lar endoprosthesis. Methods: We followed prospectively 100 patients over 75 years old consecutively operated in our department of clinical orthopaedics at Catholic University of Rome for subcapital femoral fractures graded as Garden 3 or 4. In the study were also included patients affected by senile dementia and Parkinson disease. Patients were operated on by several surgeon of different experience in the þeld, we evaluated the time needed for the intervention, blood loss, survival rate at 1 months. Outcome was evaluated on the basis of walking recovery rate and pain. Bed ridden patients were evaluated only for residual pain after surgery. Results: Mean time interval between trauma and surgery has been 3,96 days. The intervention lasted 45 minutes in average (range 35 Ð 70 minutes). Blood loss has been limited. Return to walking with assistance has been achieved in fourth postoperative day. Pain disappeared in almost every patient. Dislocation of prosthesis was observed in 2 patients. Survival rate at one month was 89%.,Conclusions: Biarticular endoprosthesis in our experience demonstrated to be an effective mean for treatment in the elderly patients and above all in the neurological patients.

Objective: Starting from results of studies made in the last ten years about the presence of myofibroblasts as the main cells involved into fibro-contractile disease, we investigated if this cells were also involved into pathogenesis of club foot deformities.

Methods: Specimens removed surgically from five patients affected by congenital club foot were investigated. Each specimen was cut in three parts: the first, was fixed for optical microscopy in formalin; the second was fixed for trasmission electron microscopy (TEM) in glutaraldehyde and postfixed in osmium tetroxide; the third was immediately placed in cold (4°C) tissue culture medium. We have stained the first part of each specimen with: haematoxylineosin, Pasini, Masson, Congo red, Van Gieson, Martius scarlet blue and immunostaining for a-smooth muscle actin (a-SM actin). The third part of each specimen, dissected into 2mm. cubes, was place in standard medium and cultured at 37°C. On the cultured cells, we have valued metalloproteinases and a-SM actin expressions. Moreover, a part of culture cells, when reached confluence, were detached with trypsin-EDTA and centrifuged for 10 min. at 2000 rpm. to obtain a pellet, subsequently fixed for TEM.

Results: Optical and electron microscopy have showed, only in one of our cases, the presence of myofibroblast’s clusters in the Henry’s nodule and in the medial and lateral fibrous nodules, that are characteristic nodule of congenital club foot.

Conclusions: Starting from the results of our studies, we would like to study in detail the role of myofibroblast in the pathogenesis of club foot.