Carbon vs. Titanium Nails in the Treatment of Impending and Pathological Fractures: A Literature Review.

Background: Long bones are commonly affected by musculoskeletal tumors, but they also represent one of the most frequent locations for metastases. The treatment is based on pain management and the prevention or stabilization of pathological fractures by intramedullary nailing. While titanium nails are probably the most used, carbon-fiber-reinforced (CFR) nails have emerged as a new option for oncological patients. The aim of this review is to compare titanium and CFR nails according to current findings. Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed: a total of 1004 articles were identified and 10 were included. Results: Traditionally, titanium implants are highly valued for their optimal biomechanical properties and ease of insertion, facilitated by their radiopacity. However, the use of titanium poses challenges in radiotherapy due to interference with radiation dosage and the creation of ferromagnetic artifacts. Conversely, CFR implants have emerged as a recommended option for intramedullary fixation, due to their biomechanical and structural properties and their benefits during radiotherapy and follow-up monitoring X-ray. Conclusions: CFR nailing represents a promising advancement in the surgical management of oncological patients with long bone metastases. However, further studies are needed to increase surgeons' confidence in their use.

Electrochemotherapy in the Treatment of Bone Metastases: A Systematic Review.

BACKGROUND AND AIM: Cancers are one of the most frequent causes of death and disability in humans. Skeletal involvement has a major impact on the quality of life and prognosis of cancer patients. Electrochemotherapy is a palliative and minimally invasive oncologic treatment that was first used to treat subcutaneous nodules for malignant tumors. The aim of our review is to evaluate the results of electrochemotherapy in the treatment of bone metastases. METHODS: A systematic review of the literature indexed in the PubMed MEDLINE and Cochrane Library databases using the search key words "electrochemotherapy" AND ("metastasis" OR "metastases") was performed. The Preferred Reporting Items for Systematic Reviews and MetaAnalyses was followed. Inclusion criteria were proven involvement of the appendicular skeleton in metastatic carcinoma or melanoma, through at least one percutaneous electrochemotherapy session on the metastatic bone lesion. The exclusion criterion was no skeletal metastatic involvement. RESULTS: Eight articles were finally included. We reached a population of 246 patients. The mean age and follow up were 60.1 years old and 11.4 months, respectively. The most represented primary tumor was breast cancer (18.9%). A total of 250 bone lesions were treated with electrochemotherapy. According to RECIST criteria, in our population we observed 55.5% stable diseases. The mean pre-electrochemotherapy VAS value was 6.9, which lowered to 2.7 after treatment. Adverse events occurred in 3.4% of patients. CONCLUSIONS: Electrochemotherapy as a minimally invasive and tissue-sparing treatment should be considered for patients with no other alternative to obtain tumor control and improvement in quality of life.

Functional Outcomes and Shoulder Instability in Reconstruction of Proximal Humerus Metastases.

(1) Background: Some of the goals of orthopedic surgical oncology are saving limbs and function. The humerus is the third most frequent site in primary tumors and one of the most involved sites for metastases. Prosthetic replacement with modular megaprosthesis is one of the treatment choices, but there are several types of complications, such as problems with function and pain. The aim of our study is to assess functional outcomes and shoulder instability in the reconstruction of proximal humerus metastases. (2) Methods: This is a retrospective observational study. Twenty-eight patients, with proximal humerus metastases, admitted to the department of Orthopaedics and Traumatology of our University Hospital between 2014 and 2022 were recruited. Each patient underwent resection and prosthetic replacement surgery with modular megaprosthesis. Clinical evaluation was assessed through MSTS score, WOSI index, and DASH score. (3) Results: Twenty patients were included in the study. Fairly good results, especially regarding pain, function, and emotional acceptance, were obtained in all three tests: DASH, MSTS, and WOSI. Patients who reported shoulder instability actually have worse outcomes than those who report having stable shoulders. In addition, patients with a resection >10 cm have worse outcomes than those who had a resection of 10 cm. No significant differences were found between the deltopectoral approach group and the lateral approach group. (4) Conclusions: Reconstructive surgery with megaprosthesis of the proximal humerus in patients with metastases can be considered a treatment option, especially in patients with pathological fractures or injuries with a high risk of fracture and good life expectancy. This study shows how this type of surgery affects instability, but in terms of functionality, pain, and patient satisfaction, it gives satisfactory results.

Prevention of postoperative anemia in hip hemiarthroplasty for femoral neck fractures: comparison between local haemostatic agents.

Background: Tranexamic acid and fibrin sealant have been shown to be effective in reducing the need for transfusion after hip fracture surgery. Objective: The aim of this study was to evaluate the efficacy of local haemostatic agents to reduce the need of postoperative transfusion in elederly patients after hip hemiarthroplasty. Methods: All patients admitted to our institution with a diagnosis of proximal femur fracture from September 2018 to March 2021 were involved. Inclusion criteria were: diagnosis of femoral neck fracture, classified as AO 31B2-3, surgical treatment with hip hemiarthroplasty, hemoglobinemia on admission > 8 gr/dL. Patients were divided in four groups. Results: EVICEL was used on 25 patients, TRANEX was used on 52 patients, standard hemostatic care was used on 73 patients, while post-surgical drain was used on 21 patients. 3 patients were transfused in the EVICEL group while 26 patients were transfused in the control group (p 0,0404), there was also statistical significant difference in the need of perioperative transfusion between EVICEL group and drain group with 10 patients transfused (p 0,0102). Statistical significant differences was found about haemoglobin variation in the first post-operative day between TRANEX group and control group (p 0,000155) and between TRANEX group and drain group (p 0,013) and also between TRANEX group and control group in the third post-operative day (p 0,0004). Conclusion: This study demonstrates that the use of both fibrin sealant or TXA can reduce total blood loss and the need of transfusions in geriatric population with intracapsular femur fracture.

Cemented vs uncemented megaprostheses in proximal femur metastases: a multicentric comparative study.

BACKGROUND: Hip megaprostheses are a long known reconstructive method in the treatment of proximal femur metastases. The use of cemented or uncemented stems is still matter of debate. The aim of this study to compare cemented and uncemented megaprostheses on functional outcomes and complications, in order to establish the role of cementation. METHODS: We retrospectively analysed 51 metastatic patients with proximal femur metastases treated with endoprosthetic reconstruction by megaprostheses, 25 with cementless stems and 26 with cemented ones with different megaprosthetic implants. The primary endpoint was MSTS score, and the secondary endpoint was to state the incidence of surgical and clinical complications in the two groups. An un-paired T test was used to compare anthropometric, anamnestic data, and MSTS. Chi-square test was performed for evaluation of complication in the two group. Multiple linear regression was used to match the functional outcomes and complications' incidence in the population study. Logistic regression was performed to analyse the odds ratio of different parameters and their role in the incidence of complications. RESULTS: The mean follow-up was 50.1 months (+ 12.5). In thirty case right side was involved. No statistical differences were noticed between Group A and B regard the age, gender, active fracture/impending fracture. Comparing the MSTS results within the two groups at last follow-up, the score cemented group was higher than cementless one (17.9 + 7.8 vs 24.2 + 5.3; statistical significance p = 0.001). Regarding surgical complications a logistic regression was performed to analyse the odds ratio of age, cementation and length of resection; cementation confirm and odds ratio of 11 times in the incidence of surgical complications. CONCLUSIONS: Cementation seems to be more liable to complications onset, while improves functional score in metastatic patients compared to uncemented megaprostheses. More studies have to be conducted in order to create a protocol and establish criteria to use cemented or uncemented stems in a frail population like metastatic patients.

Periprosthetic knee fractures in an elderly population: open reduction and internal fixation vs distal femur megaprostheses.

The incidence of periprosthetic fractures of distal femur (PPDFFx) after primary total knee arthroplasties is described around 0.3% and 2.5% and it is increasing as the number of patients with total knee arthroplasty continues to arise. surgical options treatments for PPDFFx include fixation in the form of eather Open reduction and internal fixation (ORIF), or retrograde intramedullary nailing (RIMN), or conventional (non locked) plating, or locked plating such as the Less Invasive Stabilization System (LISS), or dynamic condylar screws. In recent years, however, the use of megaprostheses has been increasing. Patients with periprosthetic fractures of distal femur after primary total knee arthroplasties treated with ORIF or with the use of Distal femur replacement (DFR) were retrospectively analyzed in this to evaluate differences in intra-operative blood loss, need of blood trasfusion, weight bearing, range of motion, rate of complications, rate of revision surgery and functional outcome according Oxford Knee Score between two groups. Treatment of Periprosthetic distal femur fracture remains controversial. While ORIF seems to guarantee less percentage of complications and reoperation rate, those treated with megaprosthesis seem to gain better range of motion in a very short post-operative time. In the future it will be necessary to investigate with greater numbers possible advantages and disadvantages of the various treatments in periprosthetic distal femur fractures.

Cemented versus cementless megaprosthesis in proximal femur metastatic disease: A systematic review.

The proximal femur is the long bone most commonly affected by metastatic disease. There are many treatment options, such as hip megaprostheses. A topic still widely debated in literature is the use of cemented or uncemented megaprostheses in this kind of patients. The purpose of this review is to examine both these surgical options to understand which of them should be preferred in metastatic patients. Twelve articles were finally included in the review. Eight authors used cemented mega - prostheses, two cementless megaprostheses and two authors used both techniques. Better functional outcomes and lower infection rates were found in cementless mega - prostheses. More studies have to be performed to choose the better technique and improve patients' quality of life.

Elastofibroma dorsi: What's new?

Elastofibroma dorsi is a rare slowgrowing soft tissues tumor. The lesion usually grows near the shoulder but could also involve other location. Pathogenesis of elastofibroma dorsi is still unknown and in the literature, there are mostly described case report or case series. The aim of our study is to summarize the recent innovation in the histology and immunoistochemical finding about elastofibroma and update the radiological algorithm of diagnosis.