Plastia de rotación en escolar por osteosarcoma: Protetización y actualización / Rotationplasty in a schoolboy for osteosarcoma: Prosthesis fitting and update

Introducción La cirugía ablativa era la opción clásica para el tratamiento del osteosarcoma.Tras la aparición de la quimioterapia adyuvante aumenta la supervivencia de estos pacientes, y con ello los niños afectos en edad escolar con alto potencial de crecimiento. Se proponen cirugías reconstructivas con mayor preservación del miembro y mejor función que las amputaciones convencionales. Presentación del caso Describimos un caso de osteosarcoma en un niño de 9 años con antecedente de retinoblastoma. El tumor involucraba toda la longitud del fémur izquierdo. También presentaba una metástasis pulmonar. Ante la respuesta incompleta a la quimioterapia neoadyuvante, se optó por resección ósea abarcando la lesión, rotacionoplastia y protetización del miembro inferior izquierdo y toracoscopia para tratar la lesión pulmonar. Se inició proceso con una ortoprótesis bypass las 6 primeras semanas, hasta comprobar cicatrización, consolidación ósea y ausencia de complicaciones, y una ortoprótesis definitiva los siguientes 4 meses. Al cabo de un año el paciente realizaba marcha independiente con el uso de la ortoprótesis, natación con aleta adaptada al muñón y reiniciaba actividad en bicicleta. En la última revisión clínica, con 13 años, se encuentra libre de enfermedad y sigue controles periódicos en nuestra consulta para adaptaciones oportunas de ortoprótesis acorde a su crecimiento. Discusión Este caso destaca las diversas opciones reconstructivas y las dificultades encontradas en el manejo de estos procesos malignos tan agresivos. La cirugía de rotacionoplastia es una opción terapéutica viable en pacientes jóvenes con osteosarcoma, que permite al niño volver a participar en las actividades de la vida diaria y recreativa premórbidas (AU)

Introduction The classical treatment of osteosarcoma used to be ablative surgery. After the appearance of adjuvant chemotherapy, survival in these patients increased, and with it, the number of affected school age children with high growth potential. Hence, reconstructive surgeries are currently proposed instead of conventional bone resections due to greater limb preservation and better functional status than those achieved with conventional amputations. Case presentation We describe a case of osteosarcoma in a 9-year-old boy with a history of retinoblastoma. The tumour involved the entire length of the left femur. He also had a lung metastasis. Given the incomplete response to neoadjuvant chemotherapy, we chose bone resection, rotation and fitting of the left lower limb and thoracoscopy to treat the lung injury. A bypass ortoprosthesis was placed for the first 6 weeks, until there was healing, bone consolidation and absence of complications, followed by a definitive orthoprosthesis for the next 4 months. At one year, the patient was able to walk independently with the use of the ortoprosthesis, swimming with a fin adapted to the stump and was had restarted cycling. At the last clinical review, at the age of 13 years, he is disease free and continues to have periodic follow-up visits in our office for adaptations to the prosthesis according to his growth. Discussion This case highlights the various reconstructive options available and the difficulties encountered in the management of these aggressive malignant processes. Rotationplasty is a viable therapeutic option in young patients with osteosarcoma, which allows the child to participate again in premorbid daily and recreational activities (AU)

Condrosarcoma de la pelvis en paciente joven / Pelvic chondrosarcoma in young patient

Introducción. Los sarcomas de la pelvis ósea constituyen un subgrupo muy pequeño dentro de la nosología tumoral ósea. El Condrosarcoma, frecuente a partir de la cuarta década de la vida, es la segunda neoplasia ósea más frecuente de los tumores óseos primarios malignos y su localización pélvica constituye un verdadero reto para los cirujanos actuantes. Objetivo. Reportar un caso de Condrosarcoma pélvico en edad temprana y revisar la literatura acerca del tema. Caso clínico. Paciente femenina de 19 años con antecedentes de salud que acude a consulta por dificultad al caminar y aumento de volumen en cadera derecha y dolor asociado. Luego de estudios radiológicos correspondientes, se interviene quirúrgicamente con diagnóstico presuntivo de Condrosarcoma que se corrobora a posteriori por histopatología. Conclusiones. El Condrosarcoma pélvico es una lesión de difícil abordaje quirúrgico. Su pronóstico depende de la posibilidad de exéresis amplia y del grado histológico del tumor. Para su tratamiento curativo se requiere habitualmente de intervenciones extensas, en su mayoría, mutilantes. Su escasa respuesta a la radioterapia y la quimioterapia hacen de la cirugía el arma fundamental para su resolución. (AU)

Introduction. Sarcomas of the bony pelvis constitute a very small subgroup within bone tumor nosology. Chondrosarcoma, common from the fourth decade of life, is the second most frequent bone neoplasm of malignant primary bone tumors and its pelvic locationconstitutes a real challenge for acting surgeons. Objective. To report a case of pelvic hondrosarcoma at an early age and to review the literature on the subject. Clinical case. 19-year-old female patient with a medical history who came to the clinic due to difficulty walking and increased volume in the right hip and associated pain. After corresponding radiological studies, he underwent surgery with a presumptive diagnosis of hondrosarcoma that is corroborated by histopathology. Conclusions. Pelvic chondrosarcoma is a lesion with a difficult surgical approach. Its prognosis depends on the possibility of extensive excision and the histological grade of the tumor. Its curative treatment usually requires extensive interventions, mostly mutilating. Its poor response to radiotherapy and chemotherapy make surgery the fundamental weapon for its resolution. (AU)

Post-operative fracture risk assessment following tumor curettage in the distal femur: a hybrid in vitro and in silico biomechanical approach.

The distal femur is the predominant site for benign bone tumours and a common site for fracture following tumour removal or cementation. However, the lack of conclusive assessment criterion for post-operative fracture risk and appropriate devices for cement augmentation are serious concerns. Hence, a validated biomechanical tool was developed to assess bone strength, depending on the size and location of artificially created tumorous defects in the distal femora. The mechanics of the bone-cement interface was investigated to determine the main causes of reconstruction failure. Based on quantitative-CT images, non-linear and heterogeneous finite element (FE) models of human cadaveric distal femora with simulated tumourous defects were created and validated using in vitro mechanical tests from 14 cadaveric samples. Statistical analyses demonstrated a strong linear relationship (R2 = 0.95, slope = 1.12) with no significant difference between bone strengths predicted by in silico analyses and in vitro tests (P = 0.174). FE analyses showed little reduction in bone strength until the defect was 35% or more of epiphyseal volume, and reduction in bone strength was less pronounced for laterally located defects than medial side defects. Moreover, the proximal end of the cortical window and the most interior wall of the bone-cement interface were the most vulnerable sites for reconstruction failure.

What Are the Challenges and Complications of Sterilizing Autografts with Liquid Nitrogen for Malignant Bone Tumors? A Preliminary Report.

BACKGROUND: Reconstruction of defects after resection of malignant bone tumors with liquid nitrogen-sterilized recycled autografts is an alternative to bone allografts and endoprostheses in resource-constrained environments. Most studies reporting favorable outcomes with liquid nitrogen-sterilized autografts for bone reconstruction are geographically restricted to a few countries, and the technical challenges of routinely using liquid nitrogen intraoperatively, especially when using the pedicle freezing technique, has not been documented. QUESTIONS/PURPOSES: (1) What are the technical challenges of liquid nitrogen sterilization of bone tumors for inexperienced surgeons? (2) What are the complications associated with the procedure? METHODS: Between May 2017 and October 2019, 88 patients underwent limb salvage procedures for malignant bone tumors of the extremities at our institution. An endoprosthesis was used for reconstruction of the defect following resection in 45% (40 of 88) of these patients, mostly in adults (median age 21 years; range 9 to 68). In the remaining 55% (48 of 88) of patients undergoing biological reconstruction, liquid nitrogen-sterilized autograft was used in 90% (43 of 48), extracorporeal irradiation-sterilized autograft was used in 4% (2 of 48) and allograft was used in 6% (3 of 48). Of the 43 patients receiving liquid nitrogen-sterilized autograft, 5% (2 of 43) were excluded due to loss to follow-up and the remaining 95% (41 of 43) were included for the analysis. Liquid nitrogen-sterilized autograft was the preferred method of reconstruction at our institution during the study period, unless the patient had an indication for prosthesis reconstruction; extracorporeal irradiation-sterilized autograft was used due to resource constraints with liquid nitrogen and allograft was used when patients insisted.All surgical procedures were performed by the same team of trained orthopaedic oncology surgeons. The medical records of the included 41 patients were retrieved using an institutional database search in this retrospective study, and all were used to ascertain technical challenges associated with the operations as well as early (within 3 weeks of the index procedure) and late complications (those occurring 3 weeks or more after surgery). The technical challenges were defined as follows: the quantity of liquid nitrogen to be used; arranging, storing and handling of liquid nitrogen in the operating room, type and size of the container to be used for sterilization, the positioning of the container during pedicle freezing, level of fibular osteotomy for pedicle freezing of tibia, soft tissue protection, limb rotation during pedicle freezing, managing tourniquet time, and any other intraoperative factors with the use of liquid nitrogen for sterilizing the autograft. As our experience with the technique gradually grew, the answers to the above-mentioned factors were determined. Considering the removal of autograft as the endpoint of interest, survival of the autograft was determined by Kaplan-Meier analysis.The median (range) patient age was 14 years (2 to 49), and 54% (22 of 41) were males. Osteosarcoma was the most common diagnosis (68%, [28 of 41]) followed by Ewing's sarcoma (20%, [8 of 41]). On presentation, 27% of patients (11 of 41) had radiological evidence of pulmonary metastasis. Tumors were seen frequently around the knee (39% [16 of 41] proximal tibia and 22% [9 of 41] distal femur). Before resection 85% (35 of 41) underwent neoadjuvant chemotherapy. Sixty-six percent (27 of 41) underwent pedicle-freezing and the remaining 34% (14 of 41) underwent free-freezing of the tumor segment of the bone. The median (range) duration of surgery was 280 minutes (210 to 510). The patients were followed up for a median (range) duration of 21 months (5 to 30); two patients were lost to follow-up. RESULTS: With gradual experience using liquid nitrogen-sterilization over time at our institution, we determined that the following factors helped us in performing liquid nitrogen-sterilization more efficiently. For every operation 15 L to 20 L of unsterilized liquid nitrogen was arranged, 1 or 2 days before the procedure, and stored in industrial-grade cryocylinders in the operating complex. During the procedure, the operating surgeons wore additional plastic aprons under the surgical gowns, surgical goggles, and rubber boots. The staff managing the liquid nitrogen in the operating room wore thermal protective gloves. For most of the pedicle freezing procedures, we used a cylindrical stainless-steel container that was 30 cm in height and 15 cm in diameter, with a narrow opening. The container was kept on a separate moveable cart that was placed next to the operating table at a slightly lower level, and it was wrapped in multiple cotton rolls, plastic sheets, surgical sheets, and a crepe bandage. For pedicle freezing of the tibia, we performed the fibular osteotomy at least 5 cm away from the planned surgical margin, roughly around the axis of rotation of the limb. The soft tissue at the base of the delivered bone segment was dissected for at least 5 cm beyond the planned surgical margin of bone, and was protected with multiple layers of cotton rolls, plastic drapes, a single roll of Esmarch and crepe bandage. The tumor segment was externally rotated during pedicle freezing for all anatomic sites (proximal tibia, distal tibia, proximal humerus, and proximal femur). The tourniquet was inflated just before pedicle freezing to prevent tumor dissemination and not before the initial incision in all pedicle freezing procedures.Thirty-nine percent of patients (16 of 41) experienced complications associated with the procedures, and 15% (6 of 41) underwent revision surgery. Early complications (occurring within 3 weeks of the index procedure) were skin necrosis in four of 16 patients, intraoperative fracture in one of 16, superficial infection in one of 16, and neurapraxia in one of 16 patients. Late complications (occurring 3 weeks or more after surgery) were resorption of the recycled bone in four of 16 patients, nonunion of the osteotomy site in two of 12, delayed union of the osteotomy site in one of 16, collapse of the recycled bone in one of 16, and local recurrence in 1 of 16 patients. Kaplan-Meier survivorship free from removal of autograft at 2 years after surgery was 92% (95% confidence interval 89 to 96). CONCLUSION: Liquid nitrogen-sterilization is an alternative technique that requires some training and experience for the surgeon to become proficient in treating primary malignant bone tumors. Because it is widely available, it may be an option worth exploring in resource-constrained environments, where allografts and endoprostheses cannot be procured. The methods we developed to address the technical challenges will require more study and experience, but we believe these observations will aid others who may wish to use and evaluate liquid nitrogen sterilization of extremity bone sarcomas. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Osteoblastoma in the Distal Humerus of a Cat.

A 7-year-old neutered male domestic shorthair cat was presented with chronic lameness in the right forelimb. A cystic bony lesion was identified in the distal right humerus and amputation was performed. The epiphyseal trabecular bones of the capitulum and trochlea was replaced by a tan to pink, expansile mass that was surrounded by a thin rim of cortical bone. Microscopically, the tumour was composed of a bland, osteoid producing spindle cell population within a well-vascularized fibrous stroma. Radiographical and histological features were consistent with osteoblastoma. Osteoblastoma and the related osteoid osteoma are uncommon, benign osteoblastic tumours that are reported rarely in animals. These tumours should be considered as differential diagnoses for slow growing, cystic bony lesions in cats.

Aloinjerto osteoarticular para reconstrucción de defecto óseo tras resección tumoral en húmero proximal: complicaciones y alternativas. Serie de casos y revisión de la literatura / Osteoarticular allografts for reconstruction of bone defects after proximal humerus tumour resection. Complications and options for reconstruction. Case series and review of the literature

Objetivo: Exponer nuestra experiencia en la reconstrucción de defecto óseo masivo de húmero proximal tras resección tumoral mediante aloinjerto estructural, analizar las complicaciones asociadas a la técnica, comparándolas con otras series publicadas, y revisar otras alternativas para la reconstrucción. Materiales y métodos: Presentamos una serie de cinco casos tratados mediante el mismo protocolo quirúrgico y por el mismo cirujano con diagnóstico de tumor maligno en húmero proximal o medio mediante reconstrucción con aloinjerto osteoarticular masivo. Analizamos las indicaciones y exponemos las complicaciones que aparecieron. Resultados: Se realizó la reconstrucción con aloinjerto osteoarticular a pacientes con diagnóstico de osteosarcoma (2 casos), sarcoma de Ewing, tumor de células gigantes y lesión metastásica de un cáncer de mama (1 caso). Se obtuvo, con un seguimiento medio de 3,8 años, una consolidación completa en todos los casos, en un tiempo medio de 12,6 meses. Dos pacientes tuvieron complicaciones en relación a fractura del aloinjerto o reabsorción de las tuberosidades. No hubo ningún caso de infección periimplante. Solo en un caso hubo recurrencia local de la enfermedad.Se realizó además una revisión bibliográfica sobre las complicaciones e indicaciones de las distintas técnicas de reconstrucción del húmero proximal. Conclusiones: Aunque con una tasa de complicaciones importante, la reconstrucción con aloinjerto osteoarticular es una opción válida especialmente en paciente activo, joven o pediátrico

Objetives: Massive structural allografts are a suitable option for the reconstruction of extensive tissue loss due to tumour resection. In this paper we report our experience and review indications and complications of this technique. Methods: This paper reports a five-case series of patients who were treated with the same surgical technique with malignant tumour located in proximal humerus. The reconstruction was made using osteoarticular allografts. The paper analyses the indications for the technique and reports the complications encountered. Results: The reconstructions with the massive allografts were performed in patients with diagnosis of osteosarcoma (2 cases), Ewing sarcoma, Giant cells tumour and breast metastase (1 case). After an average follow-up of 3.8 years, a complete bone fusión was achieved in all cases, in 12.6 months on average. Two patients had complications in relation to fracture. Infection did not occur in any of the cases. Only one case had a local recurrence of the tumour. In addition, literature about complications and indications for the different techniques for reconstruction of proximal humerus was reviewed. Conclusions: Reconstruction of the proximal humerus with osteoarticular allografts is a valid option especially in the functionally active patient, young or pediatric, in spite of a significant complication rate

Occult phosphaturic mesenchymal tumour of femur cortex causing oncogenic osteomalacia - diagnostic challenges and clinical outcomes.

BACKGROUND: Tumor induced osteomalacia (TIO) are extremely rare paraneoplastic syndrome with less than 300 reported cases. This report highlights the pitfalls and challenges in diagnosing and localizing TIO in patients with refractory and resistant osteomalacia. PATIENT AND METHODS: 41- year gentleman with 4-year history of musculoskeletal weakness and pathologic fractures presented in wheelchair bound incapacitated state of 1-year duration. Investigations were significant for severe hypophosphatemia, severe phosphaturia, normal serum calcium, reduced 1,25-dihydroxy vitamin-D, elevated ALP, elevated intact parathyroid hormone (iPTH), and pseudo-fractures involving pelvis and bilateral femur. Whole body MRI and 99mTc methylene diphosphonate bone-scan were also normal. Whole body FDG-PET scan involving all 4 limbs revealed a small FDG avid lesion at lateral border of lower end of left femur (SUV max 3.9), which was well characterized on 3-dimensional CT reconstruction. Plasma C-terminal fibroblast growth factor (FGF)-23 was 698 RU/ mL (normal < 150 RU/ml). Wide surgical excision of the tumor was done. Histopathology confirmed mesenchymal tumor of mixed connective tissue variant. Serum phosphorous normalized post-surgery day-1. High dose oral calcium and vitamin-D was continued. FGF-23 normalized post surgery (73RU/ml). Physical strength improved significantly and now he is able to walk independently. CONCLUSION: TIO is frequently confused with normocalcemic hyperparathyroidism and vitamin-D resistant rickets/osteomalacia, which increases patient morbidity. Imaging for tumor localization should involve whole body from head to tip of digits, cause these tumors are notoriously small and frequently involve digits of hands and legs. Complete surgical removal of the localized tumor is key to good clinical outcomes.

Clinical long-term outcome, technical success, and cost analysis of radiofrequency ablation for the treatment of osteoblastomas and spinal osteoid osteomas in comparison to open surgical resection.

OBJECTIVE: To assess the clinical success and costs of computed tomography (CT)-guided radiofrequency ablation (RFA) of osteoblastoma (OB) and spinal osteoid osteoma (OO). MATERIALS AND METHODS: Nineteen patients with OB and eight patients with spinal OO were treated with CT-guided RFA. The OBs were localized in the extremities (n = 10), the vertebral column (n = 2), and (juxta-)articular (n = 7). Dedicated procedural techniques included three-dimensional CT-guided access planning in all cases, overlapping RFA needle positions (median, two positions; range, 1-6 RF-electrode positions) within the OB nidus (multiple ablation technique, n = 15), and thermal protection in case of adjacent neural structure in four spinal OO. The data of eight operated OB and ten operated spinal OO patients were used for comparison. Long-term success was assessed by clinical examination and using a questionnaire sent to all operated and RFA-treated patients including visual analogue scales (VAS) regarding the effect of RFA on severity of pain and limitations of daily activities (0-10, with 0 = no pain/limitation up to 10 = maximum or most imaginable pain/limitation). RESULTS: All patients had a clear and persistent pain reduction until the end of follow-up. The mean VAS score for all spinal OO patients and all OB patients treated either with RFA or with surgical excision significantly decreased for severity of pain at night, severity of pain during the day, and both for limitations of daily and of sports activities. CONCLUSIONS: RFA is an efficient method for treating OB and spinal OO and should be regarded as the first-line therapy after interdisciplinary individual case discussion.

Osteocondroma gigante de falange en paciente pediátrico / Giant phalanx ostheochondroma in pediatric patient

El osteocondroma es uno de los tumores óseos más frecuentes, representando el 40 % de los tumores de hueso. En la mano supone el 20 % de los tumores óseos, a pesar de que sólo el 1 % de los osteocondromas se ubica a este nivel. Existen dos teorías respecto a su origen: una que indica que se debe a un defecto del crecimiento fisario y otra que defiende su naturaleza tumoral. Algunos autores recomiendan no tratarlo; sin embargo, se debe extirpar cuando produce sintomatología. Presentamos un caso clínico de osteocondroma gigante en la segunda falange del segundo dedo de la mano derecha de una paciente de 2 años de edad, con deformidad severa y alteraciones funcionales. Realizamos escisión mediante escoplo y curetaje medular con cucharilla y reconstrucción con material osteoconductor, con resultado satisfactorio (AU)

The osteochondroma is one of the most common bone tumours, raising a 40 % of them. It reaches a 20 % of bone hand tumours, although only 1 % of osteochondromas appear at the hand. There are two theories that try to explain its origin; one explaining that it consists on a physis growing defect, and other one defending a tumoral nature. Some authors recommend not treating them; however, when appear sintomatology should be removed. We present a clinical case of a giant ostechondroma at the second phalanx of the second finger of the right hand in a 2 years old patient, with deformity and functional alteration. We made tumoral excision by chisel and medullar curettage with satisfactory result (AU)

Tratamiento quirúrgico de los tumores malignos y localmente agresivos del tercio proximal del peroné. Resultados oncológicos y evaluación funcional / Surgical treatment of locally aggressive and malignant tumors of the proximal third of the fibula. Oncology results and functional evaluation

Introducción. Los tumores óseos malignos o benignos localmente agresivos del tercio proximal del peroné son infrecuentes y generalmente su tratamiento es quirúrgico. Cuando se requiere una resección en bloque, la estabilidad de la rodilla puede comprometerse por afectación del complejo posterolateral. Material y métodos. Se analizaron 28 pacientes operados de manera consecutiva por un tumor óseo en el tercio proximal de peroné entre los años 1980 y 2006 (osteosarcoma: 9, TCG: 9, sarcoma de Ewing: 8 y condrosarcoma: 2). El 61% eran varones y la edad media fue de 21 años (rango: 8-60). El seguimiento promedio fue de 86 meses. El complejo posterolateral fue reinsertado a nivel de la metáfisis tibial. Los pacientes fueron evaluados funcionalmente con la escala Musculoskeletal Tumor Society (MSTS). Resultados. La supervivencia global fue del 89%, con un índice de recidiva local del 11% y un porcentaje de amputaciones secundarias del 6% a los 7 años de seguimiento promedio. El resultado promedio del MSTS fue del 93%. Cinco pacientes sufrieron secuelas neurológicas, 3 de tipo permanente. Ningún paciente sufrió inestabilidad subjetiva ni insuficiencia vascular. Conclusiones. La resección en bloque del peroné proximal en el tratamiento de los tumores óseos agresivos o malignos depara un buen control local de la enfermedad y una supervivencia a los 7 años, en los casos malignos, del 89%. La reinserción del complejo posterolateral a nivel tibial supone una buena estabilidad de la rodilla, sin secuelas funcionales a largo plazo (AU)

Introduction. Proximal fibula malignant and locally aggressive benign bone tumors are uncommon and usually treat by surgery. Bloc resection of the knee can compromise knee stability due to of the resection of the posterolateral ligament complex. Material and methods. We analyzed 28 consecutive patients treated for a proximal fibula bone tumor between 1980 and 2006 (osteosarcoma: 9, giant cell tumor: 9, Ewing sarcoma: 8 and chondrosarcoma: 2). Sixty-one percent were male and the median age was 21 years (range: 8-60). The mean follow-up was 86 months. The posterolateral complex was reinserted at tibial metaphyseal level. Patients were evaluated functionally using the Musculoskeletal Tumor Society scale (MSTS). Results. Overall survival rate was 89%, local recurrence rate was 11%, and secondary amputation rate was 6% at 7 years of median follow-up. The average MSTS score was 93%. Five patients had neurological complications. No patient experienced subjective instability or vascular insufficiency. Conclusions. Bloc resection of the proximal fibula for the treatment of aggressive or malignant primary bone tumors allowed us to obtain local tumor control, and overall survival rate for sarcomas of 89% at 7 years. The posterolateral ligament complex tibial reinsertion provided functional knee stability without major functional consequences in the medium term (AU)

Predicting blood loss and transfusion requirement in patients undergoing surgery for musculoskeletal tumors.

BACKGROUND: Few studies have systematically identified factors associated with blood loss in musculoskeletal tumor surgery. We aimed to identify risk factors for requiring large-volume transfusion in musculoskeletal tumor surgery and created an interactive model to predict red blood cell transfusion requirements based on patient characteristics. These data will facilitate planning in hospital blood banks and aid identification of specific groups for future interventions targeted at reducing blood utilization. Only one similar study has been published and there are minimal data surrounding interventions designed to minimize blood loss in musculoskeletal tumor surgery. STUDY DESIGN AND METHODS: We retrospectively analyzed a database containing 1322 consecutive surgeries, performed at a quaternary referral center in Melbourne, Australia. Using logistic regression analysis and a negative truncated binomial logistic regression model, we developed prediction models for transfusion requirement. RESULTS: The following factors were associated with large-volume transfusion: malignant tumors, bone tumors, sacral and pelvic tumors, high American Society of Anesthesiologists (ASA) score, and tumor size of more than 5 cm. High ASA score was also strongly associated with 30-day mortality. CONCLUSIONS: Preoperative planning in high-risk patients is critical to ensure adequate blood product supply, minimize wastage, and optimize the patient's general health before surgery. These patients would be ideal targets for future randomized studies aimed at reducing blood utilization.

Tratamiento mediante aloinjertos óseos estructurales en resecciones por tumores óseos de huesos largos. Revisión de 37 casos / Treatment using structural bone allografts in long bone tumour resections. A review of 37 cases

Los aloinjertos óseos estructurales han supuesto una alternativa al tratamiento de los tumores óseos de miembros, con posibilidad de cirugía de conservación del mismo. Presentamos un estudio retrospectivo observacional del manejo de los aloinjertos óseos estructurales en tumores óseos de huesos largos en nuestro hospital, durante los años 1993 a 2010, en el que obtenemos una muestra de 37 pacientes subsidiarios de esta técnica quirúrgica. Mediante la obtención de datos clínicos de la muestra aplicamos las escalas de funcionalidad de Mankin y EVACOM HUVA con resultados excelentes, muy buenos o buenos del 84%, y con los datos radiológicos aplicamos la escala de osteointegración ISOLS con un 95,6% de resultados excelentes a los 24 meses. Estos resultados nos muestran que los aloinjertos óseos estructurales constituyen una técnica válida y reproducible en pacientes con tumores óseos destructivos de huesos largos (AU)

Structural bone allografts have become an alternative in the treatment of limb bone tumours with a chance of limb-saving surgery. We present an observational retrospective study on the use of structural bone allografts in bone tumours of the long bones in our hospital between January 1993 and January 2010, with a sample of 37 patients subjected to this surgical technique. After obtaining clinical information from our sample we applied the Mankin and EVACOM HUVA functional scales with excellent, very good and good results in 84%, and with the radiological information we applied the ISOLS osseointegration scale, with 95.6% of excellent results after 24 months. These results demonstrate that structural bone allografts are a valid and reproducible technique in patients with destructive long bone tumours (AU)

Calidad de vida y funcionalidad en pacientes pediátricos intervenidos de tumores óseos en miembros inferiores: cirugía reconstructiva versus amputación / Quality of life and functionality in pediatric patients operated on for lower limb bone tumors: limb salvage surgery versus amputation

Objetivo. Analizar las diferencias en cuanto a funcionalidad y calidad de vida relacionadas con la salud en pacientes intervenidos de un tumor óseo maligno en edad infantil según el tipo de cirugía practicada. Material y método. Estudio descriptivo transversal de pacientes mayores de 14 años tratados por osteosarcoma o sarcoma de Ewing en miembro inferior y que recibieron tratamiento quirúrgico en edad infantil tras una evolución mínima de 2 años. Se realizó una evaluación de funcionalidad y calidad de vida utilizando las escalas de Enneking y Medical Outcomes Study Short-Form 36. Comparamos los resultados funcionales según la técnica quirúrgica. Resultados. Nuestra muestra quedó formada por 17 pacientes (8 hombres y 9 mujeres) con una edad media actual de 22 años. El tumor más frecuente fue el osteosarcoma, y la localización, el tercio distal del fémur y proximal de la tibia. En relación a la técnica quirúrgica, en 8 pacientes se colocó endoprótesis, 4 se trataron mediante injerto y/u osteosíntesis y 5 fueron amputados en cirugía inicial. Cinco pacientes tuvieron que ser amputados en un segundo momento debido a complicaciones. La puntuación expresada en mediana y percentiles obtenidos en la escala de Enneking sobre la totalidad de la muestra fue del 83,33% (66,66-88,33%). En pacientes no amputados fue del 83,33% (73,33-86,66%), frente al 90% (80-93,33%) en pacientes amputados inicialmente. En los que se realizó amputación posterior tras complicación, la puntuación fue de 56,66% (51,66-73,33%). Conclusiones. En nuestra muestra no encontramos diferencias significativas en cuanto a funcionalidad y calidad de vida de los pacientes tratados mediante cirugía reconstructiva en comparación con amputación inicial, aunque sí peores resultados en los pacientes que sufren una amputación tardía debido a una complicación tras cirugía de salvamento inicial (AU)

Objective. To analyze the differences in functionality and quality of life related with outcome of a malignant bone tumor intervention in childhood age according to type of surgery performed. Material and methods. A descriptive, cross-sectional study of patients over 14 years treated for osteosarcoma or Ewing's sarcoma in lower limb during childhood after a minimum of two years evolution. Functionality and quality of life were evaluated with the Enneking and Medical Outcomes Study Short-Form 36 scales. The functional results were compared according to surgical technique. Results. Our sample consisted of 8 men and 9 women, with a current average age of 22 years. The most common type of tumor was osteosarcoma and most common location was distal third of the femur and proximal tibia. In relation to the surgical technique, stent was placed in 8 patients, 4 were treated by graft and/or osteosynthesis and 5 patients underwent amputation as initial surgery. Five more patients had to under amputation at a second time due to complications. The score, expressed as median and percentiles obtained in the scale of Enneking on the entire sample, was 83.33% (66.66%-88.33%). In non-amputees, it was 83.33% (73.33%-86.66%), compared with 90% (80%-93.33%) in patients who were initially amputees. In those in whom the amputation was performed later after a complication, the median Enneking score was 56.66% (51.66%-73.33%). Conclusions. In our sample, we did not find significant differences in terms of functionality and quality of life of patients treated by reconstructive surgery compared with initial amputation although there were worse results in those patients who underwent a later amputation due to a complication after the initial life-saving surgery (AU)

[Clinical and radiological evaluation of malignant metaplasia of benign primary bone tumors on the material of University Orthopaedic Department of Szczecin between 2002-2007]. / Ocena kliniczna i radiologiczna metaplazji zlosliwej pierwotnych lagodnych nowotworów kosci oraz zmian pseudonowotworowych w materiale Kliniki Ortopedii PAM w Szczecinie w latach 2002-2007.

The study presents clinical and diagnostic problems in patients with malignant bone metaplasia. Material is composed of 13 patients treated surgically between april 2002 and august 2007. In three cases tumors were localised in tibia, in 5 patients around distal femur, in 2 in pelvis, in 2 in humerus and in 1 in lumbar spine. None of the patients has had recurrence by february 2006 r, 12 patients have been free of the disease so far. However, one individual diagnosed with giant cell tumor metaplasia to osteosarcoma did not accept proposed therapy. The authors have particularly emphasized thorough clinical and radiological evaluation and the need of team work before surgical procedure.

Multidisciplinary management of primary tumors of the vertebral column.

OPINION STATEMENT: Primary spinal neoplasms are rare tumors that can lead to significant morbidity secondary to local bone destruction and invasion into adjacent neurological and vascular structures. These tumors represent a clinical challenge to even the most experienced physicians and require a multidisciplinary approach to ensure optimal patient outcomes. This review will discuss the most common primary bone tumors and focus on recent surgical, medical, and radiation treatment advances.

Indications for ablative surgery in extremity musculoskeletal tumours.

BACKGROUND: Surgical options for treatment of extremity musculoskeletal tumours include excision [limb sparing] surgery or amputation [limb ablation]. Ablative surgery is for advanced extremity musculoskeletal tumours when limb salvage surgery is not feasible. OBJECTIVE: To determine the indications for ablative surgery in extremity musculoskeletal tumours in our centre. METHOD: This is a 6 year prospective study of patients presenting with extremity musculoskeletal tumours at National Orthopaedic Hospital Lagos. Data such as age, gender, presenting complaints, anatomic location of the tumour, clinical stage, type of ablative surgery and adjuvant treatment offered, histologic type of tumour, and treatment outcome were documented. RESULTS: Nineteen patients had ablative surgery as a mode of treatment. 11 were male while 8 were female with a M:F of 1.3:1. The age range was 3 - 69 years. Seven patients [6 males and 1 female] refused ablative surgery and voluntarily discontinued treatment. Most tumours were located in the lower limb and all patients that had ablative treatment presented with stage 3 or 4 disease. Osteogenic sarcoma was the most common diagnosis, accounting for 4 cases [21.1%]. Six patients [31.6%] with non-malignant tumours had ablative surgery due to either late presentation or inaccurate preoperative diagnosis. Trans-femoral amputation was the most common level of amputation and this was done in 9 patients [47.4%]. Adjuvant chemotherapy was prescribed for all patients. The recurrence and survival rates could not be determined for each tumour as the patients were lost to follow-up soon after surgery with average post operative follow up of 5.5 months. CONCLUSION: Late presentation with locally advanced disease remains the dominant indication for ablative surgery in extremity musculoskeletal tumours.

Tumores del esqueleto: 20 años de experiencia (1984-2003) / Tumors of the skeleton: 20 years of experience (1984-2003)

Se presenta la experiencia del Servicio de Partes Blandas y Tumores Oseos del Hospital Oncológico Padre Machado, de Caracas, en el manejo de los tumores del esqueleto, por un período de 20 años (1984-2003). la evaluación de la experiencia fue retrospectiva, con un análisis objetivo estadístico lineal, presentándose el espectro de la patología atendida, y la diversidad de alternativas terapéuticas quirúrgicas utilizadas. Se reporta una incidencia preferencial de esta patología en los miembros inferiores (58,58 por ciento), particularmente alrededor de la rodilla (fémur distal y tibia proximal). El grupo de tumores más frecuentemente observado fue el de formadores de tejido óseo (20,95 por ciento, seguido de los formadores de tejido cartilaginoso (14,79 por ciento), tumor de células gigantes (9,93 por ciento), y las lesiones pseudotumorales (5,85 por ciento). Entre los tumores formadores de tejido óseo llama la atención la alta incidencia de las variedades malignas (90,52 por ciento); miemtras que en los formadores de tejido cartilaginoso, las variedades benignas fueron las más frecuentes (69,80 por ciento). Entre los tipos de cirugía realizadas, una proporción importante tuvo finalidad diagnóstica (58,41 por ciento), aunque en muchas de ellas la intención fue simultánea o adicionalmente terapéutica (escisión, drenaje, relleno, etc.). Entre las cirugías con finalidad terapéutica, hay una amplia diversidad de opciones, destacándose, la posibilidad de la práctica de una cirugía preservadora, siempre que se respeten los principios oncológicos quirúrgicos. se resalta la importancia del manejo de esta patología en centros espeializados.

The experience of the Service of Solft Tissue and Bone Tumors, of the Oncology Hospital Padre Machado, Caracas, in the management of the tumors affecting the skeleton, for a period of 20 years (1984-2003), is presented. The evaluation of this experience was a retrospective revision, with an objective statistics lineal analysis, showing the spectrum of the pathology, and the therapeutic surgical alternatives utilized. The report shows a higher incidence of this pathology affecting the lower limbs (58,58 per cent), particular..around the knee joint (distal femur and proximal tibia). The most frequent type of tumor was the bone forming tumors group (20.95 per cent), followed by the cartilaginous tissue forming tumors group (14.79 per cent, giant cell tumors (9.93 per cent), and pseudotumoral lesions (5.85 per cent). Among the bone forming tumor group, called our attention the prevalence of the malignant variety (90.52 per cent); whereas in the cartilaginous tissue forming type, the bening options were seen more frequently (69.80 per cent). Looking at the performed surgeries, an important proportion had a diagnostic goal (58.41 per cent), although many of them allowed a therapeutic solution at the same time (resection, drainage, folling defects, etc). Among the surgical options with a therapeutic goal, we performed a very large variety of them, proposing limb presenvation when the surgical oncology principles could be respected. The importance of treating this pathology in specialized centers is underlined.