Short Term Complications and Functional Results of Sarcoma Limb Salvage Surgeries.

BACKGROUND: Limb salvaging surgeries are current surgical treatment of extremity bone sarcomas. Resected bone replacement consists of two main methods; tumor prosthesis versus structural allograft. Biological reconstruction with an allograft is an economic cheap method in young sarcoma patients, however, the surgeons are more convinced with tumor prosthesis replacement. METHODS: We evaluated the short-term complications and functional results of 40 patients with aggressive extremity tumors in a retrospective cohort study. The mean age of cases was 25 and we followed them for 24 months. 17 patients underwent tumor prosthesis replacement after wide resection of limb sarcomas. 16 cases had structural allograft reconstruction and 7 patients treated with amputation. We matched confounders including age, sex, blood cell count and chemotherapy treatment in the study groups. RESULTS: We found 15 major complications (45.5%) in limb salvage surgeries composing infection, allograft nonunion, allograft fracture, prosthesis fracture, prosthesis loosening and device failure that needed another surgery to be resolved. We had 10 major complications in allograft group (62%) and 5 in tumor prosthesis group (29.4%). Although the rate of complications was higher in allograft group, it didn't statistically indicate strong correlation (Fisher's exact: 0.084). Mean Musculo-Skeletal tumor rating Scale (MSTS) score was 25.8(73.7%) and 22.3(63.7%) in allograft group and prosthesis cases respectively. MSTS score had a normal distribution in the different groups with no significant difference between them. CONCLUSION: Although complications were higher in the allograft group, allograft could be offered to bone sarcoma patients, whom are predicted to have short life expectancy.

Bacille Calmette-Guérin Osteomyelitis.

BACKGROUND: Tuberculosis is an essential problem for healthcare systems especially in developing countries. All newborns are given Bacillus Calmette-Guérin (BCG) vaccine in Iran which is prepared from live bovine tuberculosis bacillus, and is given to protect against tuberculosis. Osteomyelitis secondary to BCG vaccination is rare and usually involves epiphysis of long tubular bones. METHODS: 4 patients, 3 males and a female entered this study and were between 11 to 24 months old. The involved bones were first metatarsi, talus, humerus and tibia bone. The main radiologic finding was lytic lesion with cortical destruction and periosteal reaction. RESULTS: 3 patients underwent core needle biopsy and the one with the proximal tibia involvement, underwent open surgery. Pathology report suggested granulomatous osteomyelitis and typical caseous necrosis compatible with tuberculosis. Surgical treatment for these patients was curettage and debridement of the bone lesion and involved tissues around. The patients got standard anti TB pharmacotherapy, were completely cured and no short term complication was seen in a one year follow up. CONCLUSION: BCG osteomyelitis and cold abscess, should be kept in mind when assessing a child presenting chronic symptoms like pain, limping or local swelling of extremities. The long interval time between BCG vaccination and outbreak of the culture-negative abscess is a major point which emphasizes on pathologic evaluation. Image guided tissue biopsy and PCR studies confirm diagnosis. Early use of a surgical curettage and debridement along with chemotherapy soon afterwards, enabled these children to enjoy a satisfactory clinical outcome.

Hip Arthroplasty and its Revision in a Child: Case Report and Literature Review.

Juvenile idiopathic arthritis is the leading cause of hip replacement in young children. However, arthroplasty in this population is challenging with several concerns about quality of the growing bone, young age for revision surgery, and difficulties in potential several revisions. In this study we introduce a case of a 12-year old who is one of the youngest patients to undergo revision hip arthroplasty. The index operation was done as a hybrid replacement, cemented for stem and press fit for acetabular component. Two years later revision was done with severe femoral deficiency. This second procedure was challenging but with short-term promising results. So we reviewed the literature for arthroplasty in this young population regarding recent findings and trends. According to the literature survival of the prosthesis is longer with a cemented acetabular component and press fit stem; however, there are evidences that show poor outcome of joint replacement after the first revision in juvenile idiopathic arthritis patients.

Anterior ankle arthrodesis with molded plate: technique and outcomes.

BACKGROUND: There is still controversy regarding the best technique for ankle arthrodesis to acheive stable rigid fixation along with reconstructing a functional plantigrade foot. Moreover, existing techniques have complictions related to stability, soft tissue covering, fusion rate, and exposure. METHODS: With the anterior approach exactly on the tibialis anterior sheath, the joint was exposed and previous hardware, if any, was removed and with the safe direct approach, the ankle, hindfoot, and indirectly the subtalar joints were accessed. Then fresh cancellous bone was obtained and complete denudation was preformed. Lastly, a narrow 4.5 millimeter plate was carefully placed on what was determined to be the best final position.In this prospective study, 12 patients with severe ankle pain and arthritis enrolled from February 2010 to January 2012. Eight of them had posttraumatic arthritis and deformity with hardware, two had rheumatoid arthritis, one had poliomyelitis with severe deformity of the foot and knee, and another had chronic ulcerative synovitis of the ankle joint. The patients were assessed clinically and radiographically for an average of two years (range: 13 months to 4 years) for functional recovery, range of motion, stability of the ankle, and imaging evidence of union. RESULTS: Ankle deformities and pain in all 12 cases were corrected. With a short healing time and rapid recovery period, after six weeks all of the patients could walk independently. Also, scores of the Manchester-Oxford Foot Questionnaire (MOXFQ) improved significantly from 69 preoperatively to 33 postoperatively). CONCLUSIONS: Anterior ankle arthrodesis with molded plating can be an easy and safe way to manage deformities and it has excellent fusion rate and sufficient rigid fixation.

Bilateral intraosseous tumor of the calcaneus with imaging-pathologic discordance a case report and literatures review.

A case of bilateral intraosseous tumor of the calcaneus with different MRI imaging is presented. On the left, radiological findings suggest intraosseous lipoma, but on the right-sided lesion, imaging studies were not convincing. The microscopic report showed foreign body granulomatous reaction, a rare clinical pathological discordant.

Multicentric myxoid liposarcoma; a case report and literature review.

Liposarcoma is a common malignant soft tissue tumor, accounting for 10% to 16% of all sarcomas. Multicentric myxoid liposarcoma is an uncommon condition. Differentiation between several primary tumors and metastasis of a single liposarcoma represents the main difficulty in diagnosis. A 47-years old woman presented with right thigh myxoid liposarcoma and underwent wide margin tumor resection. Other investigations like CXR, abdominal and pelvic CT-scans were negative. After 18 months another myxoid liposarma was found in her ipsi-lateral breast without any evidence of other organs metastasis. Second lesion location, time between two presentation and cytogenetic differences are accepted criteria to site a sarcoma in multicentric category, but in myxoid liposarcoma these can be explained by the special features inherent to this tumor.

Is (99m)Tc-MIBI scintigraphy a predictor of response to pre-operative neoadjuvant chemotherapy in Osteosarcoma?

OBJECTIVES: Multidrug resistance (MDR), which may be due to the over expression of P-glycoprotein (Pgp) and/or MRP, is a major problem in neoadjuvant chemotherapy of osteosarcoma. The aim of this study was to investigate the role of Tc-99m MIBI scan for predicting the response to pre-operative chemotherapy. METHODS: Twenty-five patients (12 males and 13 females, aged between 8 and 52y) with osteosarcoma were studied. Before the chemotherapy, planar (99m)Tc-MIBI anterior and posterior images were obtained 10-min [tumor-to-background ratio: (T1/B1)10min] and 3-hr after tracer injection. After completion of chemotherapy, again (99m)Tc-MIBI scan was performed at 10-min after tracer injection. In addition to calculation of decay corrected tumor to background (T/B) ratios, using the 10-min and 3-hr images of the pre-chemotherapy scintigraphy, percent wash-out rate (WR%) of (99m)Tc-MIBI was calculated. Using the 10-min images of the pre- and post-chemotherapy scans, the percent reduction in uptake at the tumor site after treatment (Red%) was also calculated. Then after surgical resection, tumor response was assessed by percentage of necrosis. RESULTS: All patients showed significant (99m)Tc-MIBI uptake in early images. Only 9 patients showed good response to chemotherapy (necrosis≥90%) while 16 patients were considered as non-responder (necrosis<90%). There was no statistical significant difference between non-responders and responders in (T1/B1)10min.There was a significant negative correlation between WR% and percentage of necrosis (P=0.001). On the other hand, there was a significant correlation between Red% and percentage of necrosis (P<0.001).There was also statistical significant difference in WR% and Red% between non-responders and responders (both P< 0.001). CONCLUSION: Washout rate of (99m)Tc-MIBI in pre-chemotherapy scintigraphy as well as Red% using pre- and post-chemotherapy MIBI scintigraphy are useful methods for predicting response to neoadjuvant chemotherapy.