Orthopedic Surgical Treatment and Perioperative Complications in Multiple Myeloma Bone Disease: Analysis of a Series (2009-2018).

BACKGROUND: More than 90% of patients with multiple myeloma (MM) develop lytic bone lesions that can be surgically treated for symptomatic relief and functional improvement. METHODS: This was a retrospective observational analytic study conducted between 2009 and 2018, including 58 patients with MM bone disease who underwent 77 orthopedic surgical procedures and were co-managed by internal medicine. Analysis of data related to MM bone disease, different modalities of surgical treatment, perioperative complications, and survival was performed. RESULTS: Median age was 72 years (66.5-77 years) and 56.9% of patients were males; 54.43% of injuries were located in the spine, 27.85% in the pelvis or lower limbs, 15.19% in the upper limbs, and 75.32% of patients had pathologic fractures. In 29.31% of the cases, the bone lesion was the debut of MM. Surgical procedures performed were mainly kyphoplasty (48.05%) and intramedullary nailing (29.87%). The overall complication rate following surgery was 74.03%. Only 20.78% of cases had a surgical complication. Among medical complications, we registered 28.57% transfusion requirements, 25.97% acute renal failures, 24.68% developed an infection, and 10.39% developed hypercalcemia. Patients were followed-up for a mean of 6.13 years and 37.93% suffered a new fracture. The median overall survival time for patients after surgery was 32.9 months (11.6-49). The estimated overall survival at 1, 3, and 5 years after surgery was 81.17%, 57%, and 34.11%, respectively. CONCLUSIONS: The orthopedic surgical treatment of MM bone disease aims to improve symptomatology and patient quality of life; however, these patients have a high risk of perioperative complications and considerable early mortality, making multidisciplinary management with medical specialties essential.

A clinical review of 11 cases of large-sized well-differentiated liposarcomas.

Well-differentiated liposarcomas of the extremities are one of the most frequent types of malignant soft tissue tumors in adults. These tumors are typically locally aggressive and show a tendency to recurrence after surgical excision even though they do not metastasize and very rarely dedifferentiate. Its clinical presentation is generally a progressively growing mass causing aesthetic, functional, or compressive symptoms depending on the tumor's size and localization. Several authors recommend a wide excision with free margins in order to minimize the risk of recurrence, while others report good results and a low rate of recurrence with more conservative or even marginal excision thereby avoiding complications due to surgical site morbidity. We present a retrospective study of 11 patients with a large-sized well-differentiated liposarcoma of the lower limb with a mean follow-up of 3.2 years. The mean size was 22 × 19 × 17 cm, and a marginal resection was made, respecting the affected neurovascular structures, in all cases. Only one recurrence was found and the functional results were 81.6% according to the MSTS functional scale 1 year after surgery. We believe that the marginal excision is a good alternative when the tumor is located near vascular or nerve structures, and as to our experience, it is not associated with elevated recurrences.

Management of infectious discitis. Outcome in one hundred and eight patients in a university hospital.

PURPOSE: The optimal management of pyogenic discitis is not agreed on. We conducted a retrospective, cross-sectional, observational study in which all patients with discitis who attended Hospital San Carlos Madrid from January 1999 to January 2009 were included. METHODS: We identified 108 consecutive adult patients with infectious discitis. There were 49 men and 59 women with an average age of 67,5 (+/- 16,89) years in the study group. Mean follow-up interval was 6,06 (12,5-2) years. 78 patients had spontaneous discitis and 30 patients had postoperative discitis. Inclusion criteria for the review were illness compatible with vertebral infection and / or evidence of spinal involvement on magnetic resonance imaging (MRI). RESULTS: In 56 percutaneous discal biopsy (52% patients) were positive in 28 cases. A single disc was infected in 100 patients. The segments involved were the cervical spine in four, the thoracic spine in 38 and the lumbar spine in 66. One or more comorbid diseases were present in 73 (68%) of 108 patients. Diabetes mellitus was the most common disease. Comorbid disease was rapidly fatal in four patients, ultimately fatal in seven patients, and nonfatal or not present in 97 patients (90 %). CONCLUSION: Early diagnosis is a major challenge. Heightened awareness and the prompt use of MRI are necessary to avoid diagnostic delay. Prolonged antimicrobial therapy and the judicious application of timely surgical intervention are essential for an optimal outcome.

Synovial Sarcoma of the Foot as an Atypical Cause of Persistent Metatarsalgia: A Report of 3 Cases.

CASE: Three cases of atypical metatarsalgia are presented, all diagnosed with foot synovial sarcomas (SSs) at different stages of evolution, after a year of medical consultations. One case was treated with marginal excision without requiring bone excision; the second patient required amputation of the first ray; and the third patient, with advanced disease, required amputation through Chopart's joint. CONCLUSION: Metatarsalgia is a recurrent reason for consultation in orthopaedics. Even so, patients with persistent symptoms should be studied further in depth. Computed tomography or magnetic resonance imaging can detect tumor pathology, such as SS, of insidious development.

Hidradenocarcinoma over a Surgically Excised Hidradenoma of the Foot. A Case Report of a Very Rare Presentation of a Rare Tumor.

Introduction: Hidradenocarcinomas are very rare and aggressive soft-tissue tumors, originated from sweat gland cells, which are located most frequently in head and neck, being their appearance at the extremities rare. This kind of tumor usually appears de novo and very few cases have been reported until now of appearance over benign lesions such as hidradenomas. Malignancy progression rate of hidradenomas is unknown, and this benign lesion has clinical and histopathological characteristics in common with hidradenocarcinomas that could lead to misdiagnosis. Hidradenocarcinomas have a very poor survival rate; therefore, an early diagnosis is essential for a better prognosis, and that is the reason why hidradenomas should be widely excised from the beginning, instead of performing marginal resections of this lesions that could lead to an aggressive recurrence. Case Presentation: Here is a case report of a 27-year-old woman diagnosed with a hidradenocarcinoma over a previously excised hidradenoma in the right foot. The diagnosis was made after right pelvic and inguinal lymphadenopathies appeared few months after a new small asymptomatic lump appeared at the same place in the sole of the right foot were the excised hidradenoma five years before was located. Lymph node biopsy was performed, with histopathological diagnosis of hidradenocarcinoma metastasis. Surgical local wide excision of the lump at the foot and lymphadenectomies was performed. Histopathological analysis of the samples confirmed the diagnosis of hidradenocarcinoma. The patient later received adjuvant radiotherapy and after one year there are no signs of disease recurrence. Conclusion: Many questions remain uncertain about the management and treatment of hidradenocarcinomas due to the rarity of this type of tumor. Although targeted molecular therapies have shown promising results, more studies in this field are necessary. An early diagnosis and differentiation from its benign counterparts that allow local control of the disease before spreading is essential to improve survival rates.

Paraneoplastic vasculitis associated to pelvic chondrosarcoma: a case report.

Vasculopathic syndromes have been associated with hematological and solid organ malignancies. The pathogenesis of these syndromes remains largely unknown and there are no biologic markers identified. Whether it is or is not a paraneoplastic syndrome is under discussion, the close temporal relationship of cancer and vasculitis suggests that these vasculitides are a paraneoplastic condition. We report a case of a 45-year-old female patient with pelvic chondrosarcoma who underwent surgical treatment and started to present visual loss, systemic inflammatory response syndrome (SRIS), cardiac insufficiency, hepatosplenomegaly, cholestasis as well as pulmonary bleeding suggesting a sarcoma-associated vasculitis. All antibodies were negative as in secondary vasculitis. After corticoideal therapy the vasculitis resolved and at 3-year follow-up the patient had not showed any further medical complications or recurrences of the vasculitis. The parallel evolution of the vasculitis and the solid tumor combined with the resolution of the vasculitis after corticotherapy enhances the likelihood of a paraneoplastic vasculitis associated with a chondrosarcoma according to literature review.

Diagnosis of infection in hip and knee revision surgery: intraoperative frozen section analysis.

UNLABELLED: In this study we validated intraoperatively the analysis of polymorphonuclear leucocyte frozen sections for diagnosis of infection in hip and knee revisions. Between 1996 and 2002 we examined sections and cultured periprosthetic tissues in prosthetic revision in 170 cases, including 146 cases (83 hips and 63 knees). We assessed sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), Youden index, positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We compared intraoperative findings and paraffin-embedded samples. The results in the knee group were SE=66.7%, SP=89.7% [95% confidence interval (CI)], PPV=81% (95% CI), NPV=81.4% (95% CI), Youden index=0.56, PLR=6.5 (95% CI) and NLR=0.4 (95% CI). In the paraffin-embedded samples the results were SE=91%, SP=87% (95% CI), PPV=81% (95% CI), NPV=94% (95% CI), PLR=7 (95% CI) and NLR=8.7 (95% CI). We found a significant difference. The results in the hip group were SE=50%, SP=100% (95% CI), PPV=100% (95% CI), NPV=94.9% (95% CI), Youden index=0.5 and PLR=0.5 (95% CI). In hip and knee prosthetic revision surgery the presence of polymorphonuclear cells correlates with infection, but their absence does not exclude it. It is a quick and inexpensive test that should be included in the diagnostic protocol in revision surgery. LEVEL OF EVIDENCE: diagnostic Study (investigating a diagnostic test), level I. See instructions to authors for a complete description of levels of evidence.