Surgical treatment of acetabular metastasis.

Breast cancer is the most common malignancy in women. Bone represents the first site of metastasis in more than 50% of patients who relapse systematically. The pelvis in the most common localization after spine in bone metastasis due to breast cancer. The peri-acetabular localization is a greater concern rather than another part of the pelvis. Bone destruction in this anatomical localization lead to pain and mechanical instability, resulting in a great reduction of autonomy and deterioration of patient's quality of life. In the current report, the Authors review the literature about the surgical treatment, the indications and complications of each surgical technique underling the importance of tailoring each surgical procedure on life span and quality of life in order to minimize peri-operative complications and maximize functional results for the patients.

PATHOLOGIC AND IMPENDING FRACTURES: BIOLOGICAL AND CLINICAL ASPECTS.

Bone metastases from carcinomas are epidemiologically rising because of the increased survival rate of oncologic patients, related to several factors such as improvement of primary and secondary screening, advancement of medical research and technology and the better understanding of mechanisms underlying bone metastases origination from primary tumor. Skeletal Related Events (SREs) can seriously affect quality of life in patients with metastatic disease. These events include the necessity of radiotherapy or bone surgery, malignant hypercalcemia, pathologic fractures and spinal cord compression. Among the SREs, pathologic fractures are the most disabling events and represent an emergency in these delicate patients. A pathologic fracture is defined as a fracture that occurs at the level of a pre-existing bone lesion (that is often a tumor), spontaneously or as the result of low-energy trauma (1). The pre-existence of the metastatic lesion in the bone, its evaluation and the assessment of progression can make these complications predictable and preventable. Pathologic fractures imply several severe consequences, including patient immobilization (in the case of fractures involving the lower limbs), loss of autonomy, anaemia, need of blood transfusion, discontinuation of medical therapies or radiotherapy and protracted hospitalization. Secondary effects of prolonged immobilization and loss of autonomy further lengthen this list of complications in patients who are already significantly limited in their activities. In the present paper, the authors present a review on the main aspects involved in bone metastastic disease: biology, quality of life, economic impact and survival.

Surgical treatment of impending and pathological fractures of tibia.

Advances in adjuvant and neoadjuvant therapies have improved the prognosis of cancer patients leading to an increasing incidence of bone metastases and consequent long bone fractures. In the present study the authors consider the indications and the different surgical options of treatment of tibial pathological lesions. 13 patients (14 lesions, 6 pathological fractures), treated according to histotype and lesion localisation, were retrospectively evaluated. Using generic outcome instruments such as the Eastern Cooperative Oncology Group (ECOG) and Quality of life questionnaire of European Organization for Research and Treatment of Cancer (QLQ-C30) pain, mobility and use of analgesics were evaluated before and after surgery. In all patients, mechanical stabilisation of the osteolytic lesion was achieved. There were no pathological fractures, and no implant mechanical failure. All patients reported pain relief, with a relevant reduction in the amount of analgesics used. Surgical treatment of tibial metastases has to be decided taking into consideration the histotype, localisation of the metastases and life expectancy. The treatment has to be all-encompassing in a solitary lesion in patients with a good prognosis but less invasive in plurimetastatic patients with poor prognosis. Acquisition of good mechanical stability is crucial for a successful outcome.

Soft tissue metastases in lung cancer: a review of the literature.

BACKGROUND: In lung cancer patients, metastases to soft tissues (STs), including skeletal muscle, subcutaneous tissue and skin, are rarely reported. Besides, lung cancer, primary carcinomas of the kidney and colon are the most commonly associated with ST metastases. AIM: To determine the prevalence, clinical-pathological features and treatment options of ST metastases originating from lung carcinoma. MATERIALS AND METHODS: A literature search was performed using the following terms: lung cancer, ST metastasis, skeletal muscle metastasis, cutaneous metastasis, subcutaneous metastasis. RESULTS: Autopsy series have detected STs metastases in 0.75-9% of patients who died from metastatic lung carcinoma. Pain and the presence of a palpable mass are the most frequent clinical features. The biopsy is recommended after MRI for diagnosis. Due to the rarity of ST metastases, the differential diagnosis must be posed especially with primary ST sarcomas. The type of treatment depends on the patient's clinical status and prognosis, and includes observation, radiotherapy, chemotherapy and surgery. CONCLUSIONS: In lung cancer patients, ST metastases are rare, but not exceptional. Their presence should be suspected in the presence of a palpable mass either painful or asymptomatic. Radiological and histological examinations are required for the definite diagnosis. The choice of treatment should be based on considerations related to the stage of the primary tumor and the patient's global health status.

Skeletal modifications in mucopolysaccharidoses: an overview.

The mucopolysaccharidoses (MPS) are a group of rare diseases characterized by deficiencies in different enzymes required for degradation of complex carbohydrates. The enzymatic deficiencies lead to lysosomal accumulation of dermatan sulphate, heparan sulphate, and keratan sulphate in different tissue resulting in multi-system complications. Six different principal types are described. Most MPS types, with the exception of MPS III, are associated with widespread skeletal abnormalities and joint disease. Authors analyzed clinical pathological and radiographical features of mucopolysaccharidoses focusing on pelvic and spine pathologies that generally limit activity and normal life so they have to be treated at the beginning of their manifestations in order to avoid major complication and improve quality of life.

Orthopaedic and dental abnormalities in osteogenesis imperfecta: a review of the literature.

Osteogenesis imperfecta is one of the most commonly recognized inheritable disorders of the connective tissue leading to bone fragility. Usually it is associated to a genetic mutation inducing a reduction in collagen quality and entity production. It involves either modification in dentin formation or multiple bone fractures. The authors reviewed the clinical aspects of these disorders, focusing on oral and orthopaedic concerns, especially related to the histological features of the fracture callus, with respect to new trends in pharmacological and surgical treatments of bone fractures. Surgical treatment varies, according to the age of the patient. In children, surgical orthopaedic procedures include multiple osteotomies and the use of telescopic rods. Medical therapy has always to be associated to surgery and is designed to reduce the incidence of fractures, to increase growth velocity and to ally pain in order to improve mobility and independence. Bisphosphonates (BP) are considered potent inhibitors of bone resorption decreasing the osteoclast population and its activity and bone turn over.

Local adjuvants in surgical management of bone metastases.

Curettage is one of the most common method for surgical treatment of bone metastasis. Local adjuvant improve most commonly used for improving the effect of curettage in local cancer surgery may exerted their effects either chemically either physically; in Orthopedic Oncology the most common are phenol, liquid nitrogen, laser, and cement. This article reviewed the main characteristics of the most common chemical and physical agents used in bone oncology, emphasizing the toxic effects of some of them, especially phenol and liquid nitrogen.

Angiogenesis in hand chondroma: an immunohistochemical study.

Hand chondroma is a particular cartilagineous tumour, being clinically benign, but morphologically malignant. This study investigates the expression of VEGF together with other growth factors and proliferation markers such as TGFß2, Ki-67, TNF, FGF1, P53 in 8 cases of hand chondroma treated with courettage, in order to define the ethiopathogenesis of this tumour and the clinical significance of the resulting immunohistochemical profile, with particular respect to angiogenesis. VEGF was expressed in all cases; 5 cases were positive for TFGß2 and 3 for PDGF. None of the other factors was expressed. On the basis of histologic results a specific model of tumour progression based on the indicators of angiogenesis could be related to hand tumours, in which VEGF expression should be the first stadium of the tumour aggressiveness, and the following PDGF, TGF 2 expression should be accompanied with a morphological outline worsening. Nevertheless the non constant expression of these indicators and the absent expression of proliferated indicators can explain the scant tendency to the relapse in presence of accurate curettage. It is important to remember that the cellular polymorphism typical of the cartilaginous tumours does not allow the application of an only oncogenesis model.

Zirconia toughened alumina (ZTA) powders: ultrastructural and histological analysis.

Ceramic materials, as Alumina and Zirconia, has made an improvement in the choice of new biomaterials for the load bearing application in dental and orthopaedic implants. These materials has shown mechanical resistance to high stress related to weight bearing and low debris in time. For this reason they are indicated on young patients implant, with high demanding activities and long life expectance. In literature however the risk of chronic inflammation due to chronic wear debris release and the possibility of carcinogenesis, is still to be definitively investigated. Another point to investigate is the acute reaction of the tissue in case of acute release of powders of these materials. The aim of this study was to investigate the possible local and systemic acute effects of ceramic precursors in form of powders of different size when released into articular joint. Powders of ZTA were implanted in the knee joint of twenty-four New Zealand white adult rabbits, that were sacrificed at 1,3,6, and 12 months. Radiographic, histological and immunoistochemestry analysis were conducted on periprosthetic tissue and peripheral organs, to verifying local host response and systemic toxic effects.

Histological and ultrastructural reaction to different materials for orthopaedic application.

Prosthetic joints loosening in absence of infection is the most common reason for revision surgery and is known as aseptic loosening. A significant role in the pathogenesis of implant failure undoubtedly played by the generation of wear debris, mainly from the load bearing joint surfaces, and the cellular reaction through the formation of tissue membrane around implants. This article analyzes histologic, immunohistochemical ad ultrastructural aspects of periprosthetic tissue membrane collected at time of surgical revision, paying attention on cell host response to different materials: metals, polyethylene and ceramics. Dimension of particles seems to be crucial in the activation of different cell population to wear debris.

An original method for the evaluation of in vivo controlled release of the ceramic materials.

In recent years, the use of ceramic materials in orthopaedics and dentistry is becoming increasingly popular. However, it is important to know their biological and mechanical properties to optimize their use. The aim of this study is to describe a specific method to assess in vivo the effects of chronic release of ceramic materials implanted, in relation also to the type of material, pellets or powders. This was achieved by implanting ceramic powders and pellets, formed by low cohesion grains, in the patellar tendon of 48 New Zealand adult rabbits (24 with powders and 24 with pellets). The motion of the joint allowed easily and progressively the release of grains, detached from surface of the pellets and released to the joint space. Animals were sacrificed at different intervals (1, 3, 6, 12 months). Retrieved knee joints underwent X-Ray, histological and ultrastructural analysis.

Infection following bone tumor resection and reconstruction with tumoral prostheses: a literature review.

Bone resection is the choice treatment of malignant bone tumors. Tumor prosthesis is one of the most common solutions of reconstruction following resection of bone tumor located to the metaphysis of long bones. Periprosthetic infections are a frequent complication of limb-salvage surgery which is largely due to prolonged and repeated surgeries, as well as to the immunocompromised condition of these patients due to neoplastic treatment. Furthermore, the large exposure of tissues during this type of surgery and the dissection across vascular distributions also contributes to the high risk of infection. The authors reviewed the literature discussing the incidence of infections of tumor prosthesis implanted following resection of bone tumors, taking into account the different sites of implantation. In the English literature, the highest risk of infection which led to limb amputation was observed after proximal tibia resection and this difference was considered to be due to the poor condition of soft tissue and also after pelvic resection due to huge dead space after sarcoma resection not filled by implant. Independent of the location, the management of infected prosthesis is similar. That is, after one or more attempts at debridement and antibiotic therapy, it consists of implant removal and insertion of a new implant in a one- or two-stage procedure, with a decreased risk of failure with the two-stage procedure.

Spontaneous gait recovery after sciatic nerve transection impairs the non-invasive evaluation of artificial nerve guides in rats.

PURPOSE: The study of the in-vivo regeneration of a nerve, made by purely histological methods, requires a high number of animals: this poses serious problems of technique, ethics and funding. A cheaper analysis, performed on the same animal along the duration of a study, is seeked with favour and Authors wanted to evaluate gait recovery after sciatic nerve transection as a non-invasive method to evaluate the performance of an artificial nerve-guide in rats. METHODS: Male Wistar rats (n=16) were divided into three groups: in group A (n=5) the experimental gap produced was bridged by a custom-made guide; in group B (n=7) animals were "sham-operated"; in group C (n=4) a PMMA cap sealed the proximal nerve stump. RESULTS: In group A a regenerated nerve was retrieved after 8 weeks, in all animals. In group B it was possible to retrieve mostly bulbous neuromatous stumps. In group C all the animals presented a voluminous neuroma. Signs of auto-mutilation had the following distribution: 1/5 in group A; 4/7 in group B; 3/4 in group C. A clear difference in gait recovery exists only between group C (no recovery) and the two other groups (early recovery in both). CONCLUSIONS: The present study highlights that in the male Wistar rat sciatic model a spontaneous recovery in gait pattern occurs very early (within the first or second week); with this animal model, a recovery in gait is likely to ensue irrespective of the kind of device eventually tested since it may happen even without a device.