Surgical Site Infection in Patients Managed with an Endoprosthesis for the Treatment of Cancer: Evaluation of Patient, Disease, and Index Surgical Factors.

BACKGROUND: Surgical site infection (SSI) after segmental endoprosthetic reconstruction in patients treated for oncologic conditions remains both a devastating and a common complication. The goal of the present study was to identify variables associated with the success or failure of treatment of early SSI following the treatment of a primary bone tumor with use of a segmental endoprosthesis. METHODS: The present study used the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) data set to identify patients who had been diagnosed with an SSI after undergoing endoprosthetic reconstruction of a lower extremity primary bone tumor. The primary outcome of interest in the present study was a dichotomous variable: the success or failure of infection treatment. We defined failure as the inability to eradicate the infection, which we considered as an outcome of amputation or limb retention with chronic antibiotic suppression (>90 days or ongoing therapy at the conclusion of the study). Multivariable models were created with covariates of interest for each of the following: surgery characteristics, cancer treatment-related characteristics, and tumor characteristics. Multivariable testing included variables selected on the basis of known associations with infection or results of the univariable tests. RESULTS: Of the 96 patients who were diagnosed with an SSI, 27 (28%) had successful eradication of the infection and 69 had treatment failure. Baseline and index procedure variables showing significant association with SSI treatment outcome were moderate/large amounts of fascial excision ≥1 cm2) (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.001), use of local muscle/skin graft (OR,11.88 [95% CI, 1.83 to 245.83]; p = 0.031), and use of a deep Hemovac (OR, 0.24 [95% CI, 0.05 to 0.85]; p = 0.041). In the final multivariable model, excision of fascia during primary tumor resection was the only variable with a significant association with treatment outcome (OR, 10.21 [95% CI, 2.65 to 46.21]; p = 0.018). CONCLUSIONS: The results of this secondary analysis of the PARITY trial data provide further insight into the patient-, disease-, and treatment-specific associations with SSI treatment outcomes, which may help to inform decision-making and management of SSI in patients who have undergone segmental bone reconstruction of the femur or tibia for oncologic indications. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application.

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

North Atlantic climate far more predictable than models imply.

Quantifying signals and uncertainties in climate models is essential for the detection, attribution, prediction and projection of climate change1-3. Although inter-model agreement is high for large-scale temperature signals, dynamical changes in atmospheric circulation are very uncertain4. This leads to low confidence in regional projections, especially for precipitation, over the coming decades5,6. The chaotic nature of the climate system7-9 may also mean that signal uncertainties are largely irreducible. However, climate projections are difficult to verify until further observations become available. Here we assess retrospective climate model predictions of the past six decades and show that decadal variations in North Atlantic winter climate are highly predictable, despite a lack of agreement between individual model simulations and the poor predictive ability of raw model outputs. Crucially, current models underestimate the predictable signal (the predictable fraction of the total variability) of the North Atlantic Oscillation (the leading mode of variability in North Atlantic atmospheric circulation) by an order of magnitude. Consequently, compared to perfect models, 100 times as many ensemble members are needed in current models to extract this signal, and its effects on the climate are underestimated relative to other factors. To address these limitations, we implement a two-stage post-processing technique. We first adjust the variance of the ensemble-mean North Atlantic Oscillation forecast to match the observed variance of the predictable signal. We then select and use only the ensemble members with a North Atlantic Oscillation sufficiently close to the variance-adjusted ensemble-mean forecast North Atlantic Oscillation. This approach greatly improves decadal predictions of winter climate for Europe and eastern North America. Predictions of Atlantic multidecadal variability are also improved, suggesting that the North Atlantic Oscillation is not driven solely by Atlantic multidecadal variability. Our results highlight the need to understand why the signal-to-noise ratio is too small in current climate models10, and the extent to which correcting this model error would reduce uncertainties in regional climate change projections on timescales beyond a decade.

COVID-19 strategy in organizing and planning orthopedic surgery in a major orthopedic referral center in an area of Italy severely affected by the pandemic: experience of the Department of Orthopedics, University of Padova.

BACKGROUND: According to the required reorganization of all hospital activities, the recent COVID-19 pandemic had dramatic consequences on the orthopedic world. We think that informing the orthopedic community about the strategy that we adopted both in our hospital and in our Department of Orthopedics could be useful, particularly for those who are facing the pandemic later than Italy. METHODS: Changes were done in our hospital by medical direction to reallocate resources to COVID-19 patients. In the Orthopedic Department, a decrease in the number of beds and surgical activity was stabilized. Since March 13, it has been avoided to perform elective surgery, and since March 16, non-urgent outpatient consultations were abolished. This activity reduction was associated with careful evaluation of staff and patients: extensive periodical swab testing of all healthcare staff and swab testing of all surgical patients were applied. RESULTS: These restrictions determined an overall reduction of all our surgical activities of 30% compared to 2019. We also had a reduction in outpatient clinic activities and admissions to the orthopedic emergency unit. Extensive swab testing has proven successful: of more than 160 people tested in our building, only three COVID-19 positives were found, and of over more than 200 surgical procedures, only two positive patients were found. CONCLUSIONS: Extensive swab test of all people (even if asymptomatic) and proactive tracing and quarantining of potential COVID-19 positive patients may diminish the virus spread.

Infection in orthopaedic oncology: crucial problem in modern reconstructive techniques.

OBJECTIVE: Infection after orthopaedic oncology surgery is a relatively frequent complication. Infection rate ranges in the literature between 3.7% and 19.9%, increasing up to 47% after pelvic resection and reconstruction. It represents a challenging topic when occurring in oncologic patients because of the delay of systemic and local treatments, influencing prognosis. Infection is a major concern in terms of both prevention and treatment. The aim of our review was to analyze data reported in the literature about strategies and new materials for infection prevention in musculoskeletal oncology surgery. MATERIALS AND METHODS: We reviewed the literature focusing on the use of new materials that can reduce the risk of infection, avoiding biofilm formation on the implant surface. RESULTS AND DISCUSSION: New materials are available to try to reduce the risk of infection. Iodine-coating, DAC-coating or silver-coating, are the more promising technologies available at today. Initial results with DAC-coating in non-oncological patients are interesting; however, studies about its efficacy in preventing infection in orthopaedic oncology are not present in literature. On the other side, iodine-coating implants or silver-coating prostheses demonstrated efficacy against early infections, associated with lower risk of implant removal and amputation as final surgery. CONCLUSIONS: Post-operative infections in orthopaedic oncology surgery are still frequent, and their diagnosis and treatment are demanding. According to the literature, silver-coated prostheses should be considered as the best option in case of revision surgery due to infection. However, there is no evidence that these new materials are effective to decrease the risk of infection drastically. Further studies with numerous series and long-term follow up are required.

Quantification of hyaluronan in human fasciae: variations with function and anatomical site.

Recently, alterations in fascial gliding-like movement have been invoked as critical in the etiology of myofascial pain. Various methods have been attempted for the relief of this major and debilitating clinical problem. Paramount have been attempts to restore correct gliding between fascial layers and the movement over bone, joint, and muscular structures. One of the key elements that underlies such fascial movement is hyaluronan. However, until now, the precise content of hyaluronan within fasciae has been unknown. This study quantifies for the first time the hyaluronan content of human fascial samples obtained from a variety of anatomic sites. Here, we demonstrate that the average amount varies according to anatomic site, and according to the different kinds of sliding properties of the particular fascia. For example, the fascia lata has 35 µg of hyaluronan per gram of tissue, similar to that of the rectus sheath (29 µg g-1 ). However, the types of fascia adherent to muscle contain far less hyaluronan: 6 µg g-1 in the fascia overlying the trapezius and deltoid muscles. In the fascia that surrounds joints, the hyaluronan increases to 90 µg g-1 , such as in the retinacula of the ankle, where greater degrees of movement occur. Surprisingly, no significant differences were detected at any site as a function of age or sex (P-value > 0.05, t-test) with the sole exception of the plantar fascia. This work can provide a better understanding of the role of hyaluronan in fascia. It will facilitate a better comprehension of the modulation of the hyaluronan-rich layer that occurs in relation to the various conditions that affect fascia, and the diverse factors that underlie the attendant pathologies.

Freiberg's infraction: A modified closing wedge osteotomy for an undiagnosed case.

INTRODUCTION: Freiberg's infraction is an osteonecrosis affecting the metatarsal head whose pathogenesis is not fully understood, although stress overloading by multiple microtraumas remains the most widely accepted cause. Operative treatment, by different techniques, is necessary when conservative treatment fails. PRESENTATION OF CASE: A 31-year old woman presented with left foot severe pain, especially at the level of the metatarsophalangeal joint (MTPJ) of the second ray, underestimated upon initial evaluation. She had a history of repetitive microtraumas, a long second metatarsal bone and altered forefoot kinematics. Clinical and radiographic findings were compatible with Freiberg's infraction. A dorsal closing-wedge osteotomy with single screw stabilization was performed. At last follow-up, the patient was completely asymptomatic with a normal MTPJ range of motion. DISCUSSION: Our patient had a history of repetitive microtraumas combined with a long second metatarsal bone and altered forefoot kinematics. Initially, because of the low frequency of the disease and lack of knowledge about it, even among general orthopaedic surgeons, the infraction was not diagnosed. However, the radiological characteristics of the lesion, combined with intra-operative observation and histological exams associated with the medical history and clinical exam of the patient, revealed a disease compatible with Freiberg's syndrome. A closing-wedge osteotomy, performed by using a straight burr, appeared to be the most correct treatment. CONCLUSION: This case shows how Freiberg's infraction can pass unrecognized or underestimated and how dorsal closing-wedge osteotomy can be an efficient surgical treatment.

Prevalence of Traumatic Findings on Routine MRI in a Large Cohort of Professional Fighters.

BACKGROUND AND PURPOSE: Previous studies investigating MR imaging abnormalities among fighters have had small sample sizes. This investigation assessed a large number of fighters using the same conventional sequences on the same scanner. MATERIALS AND METHODS: Conventional 3T MR imaging was used to assess 499 fighters (boxers, mixed martial artists, and martial artists) and 62 controls for nonspecific WM changes, cerebral microhemorrhage, cavum septum pellucidum, and cavum vergae. The lengths of the cavum septum pellucidum and cavum vergae and the ratio of cavum septum pellucidum to the septum pellucidum lengths were assessed. RESULTS: The prevalence of nonspecific WM changes was similar between groups. Fighters had a prevalence of cerebral microhemorrhage (4.2% versus 0% for controls, P = .152). Fighters had a higher prevalence of cavum septum pellucidum versus controls (53.1% versus 17.7%, P < .001) and cavum vergae versus controls (14.4% versus 0%, P < .001). The lengths of the cavum septum pellucidum plus the cavum vergae (P < .001), cavum septum pellucidum (P = .025), and cavum septum pellucidum to the septum pellucidum length ratio (P = .009) were higher in fighters than in controls. The number of fights slightly correlated with cavum septum pellucidum plus cavum vergae length (R = 0.306, P < .001) and cavum septum pellucidum length (R = 0.278, P < .001). When fighters were subdivided into boxers, mixed martial artists, and martial artists, results were similar to those in the whole-group analysis. CONCLUSIONS: This study assessed MR imaging findings in a large cohort demonstrating a significantly increased prevalence of cavum septum pellucidum among fighters. Although cerebral microhemorrhages were higher in fighters than in controls, this finding was not statistically significant, possibly partially due to underpowering of the study.

The stability of the hip after the use of a proximal femoral endoprosthesis for oncological indications: analysis of variables relating to the patient and the surgical technique.

AIMS: Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability. PATIENTS AND METHODS: In a retrospective cohort study, we identified 527 adult patients who were treated with a PFA for tumours. Our data included demographics, the pathological diagnosis, the amount of resection of the abductor muscles, the techniques of reconstruction and the characteristics of the implant. We used regression analysis to compare patients with and without post-operative instability. RESULTS: A total of 20 patients out of 527 (4%) had instability which presented at a mean of 35 days (3 to 131) post-operatively. Capsular repair was not associated with a reduced rate of instability. Bivariate analysis showed that a posterolateral surgical approach (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.02 to 0.86) and the type of implant (p = 0.046) had a significant association with reduced instability; age > 60 years predicted instability (OR 3.17, 95% CI 1.00 to 9.98). Multivariate analysis showed age > 60 years (OR 5.09, 95% CI 1.23 to 21.07), female gender (OR 1.73, 95% CI 1.04 to 2.89), a malignant primary bone tumour (OR 2.04, 95% CI 1.06 to 3.95), and benign condition (OR 5.56, 95% CI 1.35 to 22.90), but not metastatic disease or soft-tissue tumours, predicted instability, while a posterolateral approach (OR 0.09, 95% CI 0.01 to 0.53) was protective against instability. No instability occurred when a synthetic graft was used in 70 patients. CONCLUSION: Stability of the hip after PFA is influenced by variables associated with the patient, the pathology, the surgical technique and the implant. We did not find an association between capsular repair and improved stability. Extension of the tumour often dictates surgical technique; however, our results indicate that PFA using a posterolateral approach with a hemiarthroplasty and synthetic augment for soft-tissue repair confers the lowest risk of instability. Patients who are elderly, female, or with a primary benign or malignant bone tumour should be counselled about an increased risk of instability. Cite this article: Bone Joint J 2017;99-B:531-7.

Leiomyosarcoma of the hand.

Soft-tissue sarcomas of the hand are rare and the devastating effect of an undiagnosed sarcoma warrants clinical vigilance. We present the case of an unsuspected leiomyosarcoma localised in the hand in order to underline (i) the rarity of the disease in this site, (ii) the role of adequate surgical treatment in the first step, (iii) the relationship with adjuvant treatments, lymph node metastasis and the poor prognosis of this tumour.

Degree of Collaterals and Not Time Is the Determining Factor of Core Infarct Volume within 6 Hours of Stroke Onset.

BACKGROUND AND PURPOSE: Growth of the core infarct during the first hours of ischemia onset is not well-understood. We hypothesized that factors other than time from onset of ischemia contribute to core infarct volume as measured by MR imaging. MATERIALS AND METHODS: Prospectively collected clinical and imaging data of consecutive patients with stroke presenting between March 2008 and April 2013 with anterior circulation large-vessel occlusion and MR imaging performed within 6 hours from the time of onset were reviewed. The association of time from onset, clinical, and radiographic features with DWI volume was assessed by using χ(2) and Mann-Whitney U tests. RESULTS: Of 91 patients, 21 (23%) underwent MR imaging within 0-3 hours from onset, and 70 (76%), within 3-6 hours. Median MR imaging infarct volume was similar in both timeframes, (24.7 versus 29.4 mL, P = .906), and there was no difference in the proportion of patients with large infarct volumes (≥70 mL, 23.8% versus 22.8%, P = .928). Using receiver operating characteristic analysis, we detected no association between the time from onset and MR imaging infarct volume (area under the curve = 0.509). In multivariate analysis, CTA collaterals (>50% of the territory) (adjusted OR, 0.192; 95% CI, 0.04-0.9; P = .046), CTA ASPECTS (adjusted OR, 0.464; 95% CI, 0.3-0.8; P = .003), and a history of hyperlipidemia (adjusted OR, 11.0; 95% CI, 1.4-88.0; P = .023) (but not time from stroke onset to imaging) were independent predictors of MR imaging infarct volume. CONCLUSIONS: Collateral status but not time from stroke onset to imaging was a predictor of the size of core infarct in patients with anterior circulation large-vessel occlusion presenting within 6 hours from onset.

Classification of failure of limb salvage after reconstructive surgery for bone tumours : a modified system Including biological and expandable reconstructions.

Previous classification systems of failure of limb salvage focused primarily on endoprosthetic failures and lacked sufficient depth for the effective study of the causes of failure. In order to address these inadequacies, the International Society of Limb Salvage (ISOLS) formed a committee to recommend revisions of the previous systems. The purpose of this study was to report on their recommendations. The modifications were prepared using an earlier, evidence-based model with subclassification based on the existing medical literature. Subclassification for all five primary types of failure of limb salvage following endoprosthetic reconstruction were formulated and a complementary system was derived for the failure of biological reconstruction. An additional classification of failure in paediatric patients was also described. Limb salvage surgery presents a complex array of potential mechanisms of failure, and a complete and precise classification of types of failure is required. Earlier classification systems lacked specificity, and the evidence-based system outlined here is designed to correct these weaknesses and to provide a means of reporting failures of limb salvage in order to allow the interpretation of outcome following reconstructive surgery.

Gaspare Tagliacozzi, pioneer of plastic surgery and the spread of his technique throughout Europe in "De Curtorum Chirurgia per Insitionem".

Gaspare Tagliacozzi's innovative surgical technique, which consisted of reconstructing parts of the face by grafting, was masterfully described in the work that made him famous, "De Curtorum Chirurgia per Insitionem." It was published by Gaspare Bindoni the Younger in 1597 in Venice, who was granted the exclusive right to print it by the Senate. However, in the same year in Venice Roberto Meietti published an unauthorized edition; nevertheless, this edition was soon discovered. The great demand for the text even abroad was soon testified by a 3rd edition published in Frankfurt in 1598, similar to the Bindoni edition but in another format and with a different title. This has caused confusion among bibliographers and Authors. Two centuries later, in 1831 in Berlin, a 4th edition was printed, thus suggesting renewed interest in rhinoplasty procedures, which surgeons Van Graefe and Dieffenbach promoted in Germany. However, few people know that the integral text of Tagliacozzi's De Curtorum was also published by Jacques Manget in his "Bibliotheca Chirurgica," printed in Venice in 1721. The name of the illustrator of the three fourteenth-century editions, whose illustrations in the text are compared, is not known. Instead the name of the artist, Tiburzio Passerotti, who painted Tagliacozzi's portrait holding his De Curtorum open at the ninth woodcut shortly before it was printed, is well known. The impact of Tagliacozzi's technique on modern surgery is supported by experience of the last century as well as recent years, mostly in musculoskeletal oncology reconstruction.

Survival of current production tumor endoprostheses: complications, functional results, and a comparative statistical analysis.

BACKGROUND AND OBJECTIVES: Retrospectively analyze outcomes of current-generation Global Modular Replacement System (GMRS) modular tumor endoprosthesis for the lower limb in primary and secondary implantation procedures. METHODS: Two hundred ninety five prostheses were implanted, 197 were primary implants, 98 were for revision surgery; revision procedures included 84 failed tumor reconstructions and 14 failed non-tumor reconstructions. Anatomic sites included: distal femur 199; proximal tibia 60; proximal femur 32;total femur 4. Endoprosthesis failures were classified as soft-tissue failures (Type 1), aseptic loosening (Type 2), structural fracture (Type 3), infection (Type 4), and tumor recurrence (Type 5). MSTS functional scores were measured. RESULTS: The overall failure rate was 28.8% and failure occurred at a median of 1.7 years (range, 1 month to 7 years). At a mean oncologic follow up of 4.2 years (range, 2-8 years), 195 patients are continuously NED, 43 NED after treatment of relapse, 10 AWD, 33 DWD. There was a significant difference in implant survival of all modes of failure between primary and revision implants (P = 0.03). No prosthetic fracture occurred. The average functional score was 81.6% (24.5). CONCLUSIONS: Mid-term results with GMRS are promising, with good functional results and low incidence of complications for primary implants. LEVEL OF EVIDENCE: Therapeutic study, level IV-1 (case series).

Cemented versus cementless endoprostheses for lower limb salvage surgery.

PURPOSE: To determine the survival and failures of cemented vs cementless endoprostheses. METHODS: We retrospectively studied 232 patients treated with lower limb salvage surgery and reconstruction using cementless and cemented endoprostheses from 2002 to 2007. We compared survival and failures of the endoprostheses regarding age, gender, body mass index (BMI), diagnosis, site of reconstruction, radiation therapy, chemotherapy, and stem fixation. RESULTS: The mean patient follow-up was 28 months (median 24; range 12-84). The overall survival of cemented and cementless endoprostheses at 60 months was 64 and 78%, respectively (p=0.0078). Survival at 60 months of cemented and cementless endoprostheses to infection was 68 and 82%, respectively (p=0.0248). Survival of cemented and cementless endoprostheses to aseptic loosening at 60 months was 94 and 96%, respectively (p=0.1493). The only significant univariate and multivariate predictor of survival was the cementless type of stem fixation. CONCLUSION: Cementless endoprostheses have higher overall survival and survival to infection compared to cemented endoprostheses. Survival to aseptic loosening is not different. Stem fixation is the only significant variable for survival.

Predictors of decline in verbal fluency after frontal lobe epilepsy surgery.

Few studies have focused on language changes following frontal lobe epilepsy (FLE) surgery. The aim of the current study is to quantify the role of resection location and size in verbal fluency decline after FLE surgery and to examine its predictors. A retrospective chart review identified 36 adult patients who underwent FLE surgery. Verbal fluency was assessed using the Controlled Oral Word Association Test (COWAT). Nine (25%) of the patients had significant decline. Binary logistic regression incorporating side of resection and preoperative COWAT score significantly predicted decline and accounted for 25% of the variance. A trend was also noted for decliners to have higher postoperative seizure recurrence (p=0.067). There was no effect of size of resection. Patients undergoing FLE surgery are at risk of verbal fluency decline, especially if they have a high presurgical verbal fluency score, undergo a frontal lobe resection in the language dominant hemisphere, and have poor seizure outcome.

Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts.

BACKGROUND: Clear cell sarcoma of tendons and aponeuroses is a rare, high grade malignant soft tissue tumor resembling melanoma and soft tissue sarcomas. Clinical and Imaging Presentation: The median age at presentation is 27 years and the most common location are the foot and the ankle. MR imaging typically shows a benign looking, well defined, homogenous mass; on T1-weighted MR images, it is usually homogeneous and isointense or slight hyperintense to muscle, whereas on T2-weighted MR images, it is usually more heterogeneous with variable signal intensity. Pathology: Microscopically, the clear cell appearance is due to the accumulation of glycogen. The cells show no or minimal pleomorphism, and paucity of mitotic figures that is in concordance with the slow-growing behavior of the tumor. Scattered multinucleated giant cells are commonly present; areas of necrosis and melanin pigment may be identified. The reciprocal translocation t(12;22)(q13;q12) is observed in more than 90% of clear cell sarcoma cases. In addition, polysomy of chromosome 8 has been observed as a secondary abnormality in many cases of clear cell sarcoma. The differential diagnosis of clear cell sarcoma should include melanoma, epithelioid malignant peripheral nerve sheath tumor, melanotic schwannoma, paraganglioma-like dermal melanocytic tumor, perivascular epithelioid cell neoplasms (PEComas), cellular blue naevus, synovial sarcoma (monophasic type), alveolar soft part sarcoma, paraganglioma, epithelioid sarcoma and carcinomas. Treatment and Prognosis: The treatment of choice for clear cell sarcoma is wide surgical resection. If complete excision is achieved, adjuvant treatments are not unnecessary. Chemotherapy is predominantly employed in patients with metastatic disease. The 5 to 20 year survival of the patients with clear cell sarcoma range from 67% to 10%. The rates of local recurrence ranges up to 84%, late metastases up to 63%, and metastases at presentation up to 30%.

Palliative embolisation for advanced bone sarcomas.

PURPOSE: Managing patients with advanced bone sarcomas - namely, recurrent, unresectable and metastatic - is mostly aimed at palliation. The role of embolisation for pain relief for these patients has not been previously reported. We therefore performed this study to emphasise the palliative role of embolisation for pain relief of advanced bone sarcoma patients. MATERIALS AND METHODS: We retrospectively studied 43 patients with advanced bone sarcomas treated with palliative embolisation with N-2-butyl-cyanoacrylate from 2004 to 2011. All patients had primary treatments including chemotherapy, radiation therapy, radiofrequency thermal ablation, and/or surgery for their advanced sarcomas and were referred for embolisation as end-stage treatment for continuous severe local pain. The effect of embolisation was evaluated with a pain score scale and analgesic use. Mean follow-up was 7 (range, 1-19) months); all patients were dead at the last follow-up. RESULTS: In all patients, angiography showed increased pathological vascularisation of the sarcomas; three to six feeding vessels were embolised in each procedure. Almost complete pain relief and >50% reduction in analgesic use was experienced by 36 patients with highly hypervascular sarcomas and sarcomas in the pelvis and shoulder girdle. Moderate pain relief and 50% reduction in analgesic use was experienced by seven patients with spinal and sacral lesions. Within the available follow-up, no patient had recurrent pain with the same intensity as before embolisation. All patients experienced ischaemic pain at the site of embolisation that resolved completely with analgesics. Six patients with advanced pelvic bone sarcomas experienced paraesthesias at the distribution of the sciatic nerve that resolved completely with methylprednisolone. CONCLUSIONS: Embolisation is a safe and effective local palliative treatment for patients with advanced sarcomas, providing optimum pain relief with the least discomfort and the possibility of minor complications only.

Imaging tumors of the patella.

BACKGROUND: Patellar tumors are rare; only a few series have been described in the literature and radiographic diagnosis can be challenging. We reviewed all patellar tumors at one institution and reviewed the literature. MATERIALS AND METHODS: In an evaluation of the database at one institution from 1916 to 2009, 23,000 bone tumors were found. Of these, 41 involved the patella. All had imaging studies and microscopic diagnostic confirmation. All medical records, imaging studies, and pathology were reviewed. RESULTS: There were 15 females and 26 males, ranging from 8 to 68 years old (average 30). There were 30 benign tumors; eight giant cell tumors, eight chondroblastomas, seven osteoid osteomas, two aneurysmal bone cysts, two ganglions, one each of chondroma, exostosis, and hemangioma. There were 11 malignant tumors: five hemangioendotheliomas, three metastases, one lymphoma, one plasmacytoma, and one angiosarcoma. CONCLUSION: Patellar tumors are rare and usually benign. As the patella is an apophysis, the most frequent lesions are giant cell tumor in the adult and chondroblastoma in children. Osteoid osteomas were frequent in our series and easily diagnosed. Metastases are the most frequent malignant diagnoses in the literature; in our series malignant vascular tumors were more common. These lesions are often easily analyzed on radiographs. CT and MR define better the cortex, soft tissue extension, and fluid levels. This study presents the imaging patterns of the more common patellar tumors in order to help the radiologist when confronted with a lesion in this location.