Surgical Management and Denosumab for Aneurysmal Bone Cysts of the Spine in an Australian Tertiary Paediatric Centre.

Aneurysmal bone cysts (ABC) are rare osteolytic, benign but often locally aggressive tumours of the long bones or vertebrae. For spinal ABC, surgical management, embolisation or sclerotherapy alone often carry high morbidity and/or high recurrence rates. Interruption of receptor activator of nuclear factor-kappa B ligand (RANKL) signalling holds promise as an effective therapeutic strategy for these tumours. We aimed to review the approach to surgical management and evaluate the efficacy and safety of denosumab for ABC of the spine in children. Retrospective review of 7 patients treated with denosumab using a standardised protocol for ABC of the spine in a tertiary paediatric centre. Surgical intervention was only conducted if there was spinal instability or significant neurological impairment. Denosumab 70 mg/m2 was given 4-weekly for at least 6 months, followed by 2 doses of zoledronate 0.025 mg/kg, aiming to prevent rebound hypercalcaemia. All patients achieved stability of the spine and resolution of neurological impairment, if present. Six patients achieved metabolic remission and have ceased denosumab without recurrence to date; the other showed clinical and radiological improvement without complete metabolic remission. Three patients developed symptomatic hypercalcaemia 5-7 months after cessation of denosumab, requiring additional bisphosphonate treatment. We present our algorithm for the surgical and medical management of paediatric spinal ABC. Denosumab produced a radiological and metabolic response in all patients, with complete remission in most. Follow-up time was not long enough to evaluate the endurance of response after cessation in some patients. Incidence of rebound hypercalcaemia in this paediatric cohort was high, prompting a change to our protocol.

The use of the E-PASS scoring system in determining complication development in patients with isolated acetabular fractures.

BACKGROUND: The decision to treat acetabular fractures is occasionally deferred or foregone in patients perceived to be unfit for surgery. The previously validated estimation of physiologic ability and surgical stress (E-PASS) score has been shown to predict outcome in a variety of fractures, and consists of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS). PURPOSE: To correlate E-PASS and its components with postoperative complication to quantify risk for individual surgical and patient factors in acetabular fracture management. METHODS: A retrospective review of patient records was performed for all patients with acetabular fractures surgically treated between January 2013 and June 2018 in a level 1 Trauma Centre. Patients with multiple injuries and/or malignancies were excluded. E-PASS scores were determined with standard demographic data and subscores were correlated with complication development. RESULTS: Of the included 106 patients (mean age 61 years, range 17-93), complications were reported in 37 (34.9%) patients and 3 (2.8%) died. Hospital postoperative morbidity and mortality rates increased significantly with the PRS and CRS. The SSS did not correlate significantly with frequency of complications. Age was found to be the only significant independent risk factor (p value = 0.031, OR = 1.03 per year of age). CONCLUSION: Latent patient factors have a clear influence on adverse outcomes in contrast to controllable factors such as surgical stress indicating an important role for perioperative care in reducing postoperative complications. Integrated orthogeriatric care with assessment of comorbidities, prevention or early recognition, and treatment of perioperative complications is essential.