Transiliac Cerclage in Unstable Pelvic Ring Fractures.

BACKGROUND: To evaluate the outcomes of transiliac cerclage with Dall-Miles cable in the internal fixation of the posterior complex in unstable pelvic ring fractures between January 1995 and December 2014. MATERIAL AND METHODS: A study of 42 men injured at work with an average age of 35.2 years (range, 23 to 61) was conducted. The mechanisms of injury were traffic accidents in 25 cases (59.5%), crushing accidents in 12 cases (28.6%), and fall from height in 5 cases (11.9%). Thirty-six cases were polytraumatized patients (85.7%). The patients were evaluated using Majeeds functional score and Mattas radiological criteria. RESULTS: The average follow-up time was 135.8 45.6 months. The clinical outcomes were excellent in 17 cases (40.5%), good in 19 cases (45.2%), fair in 5 cases (11.9%), and poor in 1 case (2.4%). The radiological outcomes were satisfactory in 32 cases (76.2%) and unsatisfactory in 10 cases (23.8%). All fractures were healed. The sequelae were 3 cases (7.2%) of lower limb dysmetria and 3 cases (7.2%) of chronic neuropathic pain. CONCLUSION: The internal fixation of the sacroiliac complex by Dall-Miles cable cerclage reinforced with small fragment plates should be considered as an alternative method for minimally invasive osteosynthesis in selected cases of unstable pelvic ring fractures.

Comparison between different prognostic models to be used for metastatic bone disease on appendicular skeleton in a Chilean population.

PURPOSE: Several preoperation prognosis models used on the treatment of metastatic bone disease on appendicular skeleton have been devised. The purpose of this study was to compare the performance of different survival prognostic models on patients with metastatic bone disease in long bones in a Chilean population. METHODS: This is a multicentric retrospective study. We retrospectively reviewed the medical records of 136 patients who were confirmed with metastatic bone disease of the appendicular skeleton and who were treated surgically from 2016 to 2019. The minimum follow-up time was 12 months. All patients were assessed using four appendicular metastatic bone disease scoring systems. A preoperative predicted survival time for all 136 patients was retrospectively calculated making use of the revised Katagiri, PathFx, Optimodel and IOR score model. RESULTS: The PathFx model demonstrated an accuracy at predicting 3 (area under the curve [AUC] = 0.61) and 6-month (AUC = 0.65) survival time after surgical management. IOR score model demonstrated an accuracy at predicting 12-month survival time (AUC = 0.64). The survival rate reached the 44% in a year. The median survival time to death or last follow-up time was 14.9 months (SD ± 15). CONCLUSION: PathFx score model demonstrated the highest accuracy at predicting a survival time of 3 and 6 months. IOR score model was the most accurate measure at predicting a survival time of 12-months. To our knowledge, this is the first study reporting a comparative analysis of metastatic bone disease with predicting models in a country located in Latin America. PathFx's and IOR score models are the ones to be used in the Chilean population as the predictive models in metastatic bone disease of the appendicular skeleton.

Estudio morfométrico del radio proximal en una población chilena / Morphometric study of the proximal radius in a Chilean population

RESUMEN: El objetivo de esta investigación fue determinar la morfometría del extremo proximal del radio, mediante mediciones efectuadas en la cabeza, cuello y tuberosidad del radio, en una población chilena y compararlas según sexo. Se efectuó un estudio transversal analizando exámenes de Tomografía Computarizada (TC) de codo, realizados entre enero de 2014 y diciembre de 2018. Se incluyó 32 TC, correspondientes a 16 hombres y 16 mujeres. Se transfirió las imágenes formateadas al software RadiAnt, para efectuar las mediciones en el radio proximal. El análisis estadístico de los resultados se realizó mediante el software SPSS 22. El diámetro de la cabeza del radio en hombres osciló entre 22,8±1,3 y 25,0±1,7 mm; en mujeres osciló entre 19,4±1,4 y 20,7±1,4 mm. El diámetro del cuello del radio proximal en hombres osciló entre 14,0±0,8 y 15,6±0,7 mm; en mujeres osciló entre 11,7±0,8 y 13,3±1,3 mm. El diámetro del cuello del radio distal en hombres osciló entre 14,4±1,0 y 16,0±1,2 mm; en mujeres osciló entre 12,5±1,0 y 13,8±1,5 mm. El diámetro de la tuberosidad radial en hombres osciló entre 15,1±1,5 y 17,7±1,8 mm; en mujeres osciló entre 13,2±1,1 y 15,5±1,8 mm. El promedio de altura de la cabeza del radio fue de 11,2±1,2 mm en hombres y de 9,5+0,8 mm en mujeres. El análisis comparativo entre sexos mostró diferencias estadísticamente significativas en todas las mediciones precedentes. El promedio de altura del cuello del radio fue de 11,2±1,2 mm en hombres y 10,1±1,6 mm en mujeres, sin diferencia significativa (p= 0,15). Los valores promedios de la morfometría del radio proximal de la población chilena difieren de los descritos para la población europea y presentan algunas similitudes con la población china. Nuestros resultados pueden ser de utilidad para el diseño de implantes y prótesis para el extremo proximal del radio y para una correcta planificación quirúrgica en ortopedia y traumatología.

SUMMARY: The aim of this research was to determine the morphometry of the proximal radius in a Chilean population, by means of measurements made in head of radius, neck of radius and radial tuberosity, and to compare them according to sex. A cross-sectional study was conducted analyzing Computed Tomography scans (CT) of elbows, performed between January 2014 and December 2018. Thirty-two CT corresponding to 16 men and 16 women were included. The formatted images were transferred to the RadiAnt software in order to perform measurements in the proximal radius. The statistical analysis of the results was performed using the SPSS 22 software. The diameter of the head of radius in men ranged between 22.8±1.3 and 25.0±1.7 mm; in women it ranged between 19.4±1.4 and 20.7±1.4 mm. The diameter of the proximal neck of radius in men ranged between 14.0±0.8 and 15.6±0.7 mm; in women, it ranged between 11.7±0.8 and 13.3±1.3 mm. The diameter of the distal neck of radius in men ranged between 14.4±1.0 and 16.0±1.2 mm; in women, it ranged between 12.5±1.0 and 13.8±1.5 mm. The diameter of radial tuberosty in men ranged between 15.1±1.5 and 17.7±1.8 mm; in women, it ranged between 13.2±1.1 and 15.5±1.8 mm. The mean height of the head of radius was 11.2±1.2 mm in men and 9.5±0.8 mm in women. Statistically significant sex differences were revealed in all the preceding measurements. The mean height of the neck of radius was 11.2±1.2 mm in men and 10.1±1.6 mm in women, with no significant difference (p= 0.15). The average values of morphometry of the proximal radius of the Chilean population differ from those describing the European population, and show some similarities with the Chinese population. Our results may be useful to design of implants and prostheses for the proximal radius, and to correct surgical planning in orthopedics and traumatology.

C-reactive protein and tumour diagnosis predict survival in patients treated surgically for long bone metastases.

PURPOSE: Surgical options for long bone metastases include intramedullary nail fixation or prosthetic reconstruction. Patients with a short life expectancy may benefit from less invasive surgery such as intramedullary nail fixation, while patients with a long life expectancy could be treated with more invasive surgery such as prosthetic reconstruction. The purpose of our study was to analyze the survival of patients treated surgically for long bone metastases, determining the prognostic factors affecting survival and analyzing the surgical complications and reoperation rates. Based on our results, we developed a prognostic score that helps to choose the best treatment for these patients. In addition, we compared the performance of our prognostic score with other previous prognostic models. METHOD: We investigated prospectively potential clinical and laboratory prognostic factors in 159 patients with metastatic bone disease who underwent surgery with intramedullary nail fixation or prosthetic reconstruction. Clinical data were collected, recording the following data: age and sex of patients, primary tumour and time of diagnosis, number (single or multiple) and presentation (synchronous or metachronous) of bone metastases, presence of visceral metastases. The following laboratory data were analyzed: hemoglobin, leukocyte counts, lymphocyte counts, platelets count, alkaline phosphatase, and C-reactive protein. RESULTS: Our study showed that pathological C-reactive protein and primary tumour diagnosis were significant negative independent prognostic factors at 12-month survival. Based on our results, we created a score using C-reactive protein and primary tumour diagnosis, creating three different prognostic groups: (A) good prognosis primary tumour and physiological CRP with probability of survival at 12 months of 88.9 [80.1-98.5]; (B) bad prognosis primary tumour and physiological CRP or good prognosis primary tumour and pathological CRP with a probability of survival at 12 months of 56.7 [45.4-70.7]; (C) bad prognosis primary tumour and pathological CRP with a probability of survival at 12 months of 12.5 [5.0-28.3]. Using ROC multiple analysis, our score (AUC = 0.816) was the most accurate in predicting a 12-month survival compared to previous prognostic models. DISCUSSION: Patients treated surgically for long bone metastases with a life expectancy over 12 months should be treated with more durable reconstruction, while patients with a life expectancy less than 12 months should be treated with less invasive surgery. The diagnosis of primary cancer and C-reactive protein are two very simple data which every orthopaedic surgeon in any community hospital can easily rely on for any decision-making in the surgical treatment of a complex patient as with a patient with skeletal metastases. CONCLUSION: Our prognostic score based on only two simple variables (C-reactive protein and primary tumour diagnosis) was able to predict the 12-month survival of patients treated surgically for long bone metastases and could be helpful in choosing the best treatment for these patients.

Does the Addition of a Vascularized Fibula Improve the Results of a Massive Bone Allograft Alone for Intercalary Femur Reconstruction of Malignant Bone Tumors in Children?

BACKGROUND: Massive bone allograft with or without a vascularized fibula is a potentially useful approach for femoral intercalary reconstruction after resection of bone sarcomas in children. However, inadequate data exist regarding whether it is preferable to use a massive bone allograft alone or a massive bone allograft combined with a vascularized free fibula for intercalary reconstructions of the femur after intercalary femur resections in children. Because the addition of a vascularized fibula adds to the time and complexity of the procedure, understanding more about whether it reduces complications and improves the function of patients who undergo these resections and reconstructions would be valuable for patients and treating physicians. QUESTIONS/PURPOSES: In an analysis of children with bone sarcomas of the femur who underwent an intercalary resection and reconstruction with massive bone allograft with or without a vascularized free fibula, we asked: (1) What was the difference in the surgical time of these two different surgical techniques? (2) What are the complications and number of reoperations associated with each procedure? (3) What were the Musculoskeletal Tumor Society scores after these reconstructions? (4) What was the survival rate of these two different reconstructions? METHODS: Between 1994 and 2016, we treated 285 patients younger than 16 years with a diagnosis of osteosarcoma or Ewing sarcoma of the femur. In all, 179 underwent resection and reconstruction of the distal femur and 36 patients underwent resection and reconstruction of the proximal femur. Additionally, in 70 patients with diaphyseal tumors, we performed total femur reconstruction in four patients, amputation in five, and a rotationplasty in one. The remaining 60 patients with diaphyseal tumors underwent intercalary resection and reconstruction with massive bone allograft with or without vascularized free fibula. The decision to use a massive bone allograft with or without a vascularized free fibula was probably influenced by tumor size, with the indication to use the vascularized free fibula in longer reconstructions. Twenty-seven patients underwent a femur reconstruction with massive bone allograft and vascularized free fibula, and 33 patients received massive bone allograft alone. In the group with massive bone allograft and vascularized fibula, two patients were excluded because they did not have the minimum data for the analysis. In the group with massive bone allograft alone, 12 patients were excluded: one patient was lost to follow-up before 2 years, five patients died before 2 years of follow-up, and six patients did not have the minimum data for the analysis. We analyzed the remaining 46 children with sarcoma of the femur treated with intercalary resection and biological reconstruction. Twenty-five patients underwent femur reconstruction with a massive bone allograft and vascularized free fibula, and 21 patients had reconstruction with a massive bone allograft alone. In the group of children treated with massive bone allograft and vascularized free fibula, there were 17 boys and eight girls, with a mean ± SD age of 11 ± 3 years. The diagnosis was osteosarcoma in 14 patients and Ewing sarcoma in 11. The mean length of resection was 18 ± 5 cm. The mean follow-up was 117 ± 61 months. In the group of children treated with massive bone allograft alone, there were 13 boys and eight girls, with a mean ± SD age of 12 ± 2 years. The diagnosis was osteosarcoma in 17 patients and Ewing sarcoma in four. The mean length of resection was 15 ± 4 cm. The mean follow-up was 130 ± 56 months. Some patients finished clinical and radiological checks as the follow-up exceeded 10 years. In the group with massive bone allograft and vascularized free fibula, four patients had a follow-up of 10, 12, 13, and 18 years, respectively, while in the group with massive bone allograft alone, five patients had a follow-up of 10 years, one patient had a follow-up of 11 years, and another had 13 years of follow-up. In general, there were no important differences between the groups in terms of age (mean difference 0.88 [95% CI -0.6 to 2.3]; p = 0.26), gender (p = 0.66), diagnosis (p = 0.11), and follow up (mean difference 12.9 [95% CI-22.7 to 48.62]; p = 0.46). There was a difference between groups regarding the length of the resection, which was greater in patients treated with a massive bone allograft and vascularized free fibula (18 ± 5 cm) than in those treated with a massive bone allograft alone (15 ± 4 cm) (mean difference -3.09 [95% CI -5.7 to -0.4]; p = 0.02). Complications related to the procedure like infection, neurovascular compromise, and graft-related complication, such as fracture and nonunion of massive bone allograft or vascularized free fibula and implant breakage, were analyzed by chart review of these patients by an orthopaedic surgeon with experience in musculoskeletal oncology. Survival of the reconstructions that had no graft or implant replacement was the endpoint. The Kaplan-Meier test was performed for a survival analysis of the reconstruction. A p value less than 0.05 was considered significant. RESULTS: The surgery was longer in patients treated with a massive bone allograft and vascularized free fibula than in patients treated with a massive bone allograft alone (10 ± 0.09 and 4 ± 0.77 hours, respectively; mean difference -6.8 [95% CI -7.1 to -6.4]; p = 0.001). Twelve of 25 patients treated with massive bone allograft and vascularized free fibula had one or more complication: allograft fracture (seven), nonunion (four), and infection (four). Twelve of 21 patients treated with massive bone allograft alone had the following complications: allograft fracture (five), nonunion (six), and infection (one). The mean functional results were 26 ± 4 in patients with a massive bone allograft and vascularized free fibula and 27 ± 2 in patients with a massive bone allograft alone (mean difference 0.75 [95% CI -10.6 to 2.57]; p = 0.39). With the numbers we had, we could not detect a difference in survival of the reconstruction between patients with a massive bone allograft and free vascularized fibula and those with a massive bone allograft alone (84% [95% CI 75% to 93%] and 87% [95% CI 80% to 94%], respectively; p = 0.89). CONCLUSION: We found no difference in the survival of reconstructions between patients treated with a massive bone allograft and vascularized free fibula and patients who underwent reconstruction with a massive bone allograft alone. Based on this experience, our belief is that we should reconstruct these femoral intercalary defects with an allograft alone and use a vascularized fibula to salvage the allograft only if a fracture or nonunion occurs. This approach would have resulted in about half of the patients we treated not undergoing the more invasive, difficult, and risky vascularized procedure.Level of Evidence Level III, therapeutic study.

Differential diagnosis and treatment of enchondromas and atypical cartilaginous tumours of the pelvis: analysis of 21 patients.

INTRODUCTION: Studies focusing on enchondroma and atypical cartilaginous tumour (ACT) of the pelvis are lacking. The purpose of this study was to verify possible clinical and radiological findings with regard to distinguishing enchondromas from ACT of the pelvis. In addition, this study analysed functional and oncological outcomes in patients with enchondromas or ACT of the pelvis treated with curettage or resection. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 21 patients with confirmed enchondroma or ACT of the pelvis treated by curettage or resection from 1985 to 2018. The minimum follow-up was 18 months. The relationship between clinical and radiological factors and tumour type or local recurrence was assessed using Fisher exact test and Mann-Whitney U test. RESULTS: Endosteal scalloping (p = 0.039), tumour size (0.005) and age (0.006) were shown to statistically favour ACT over enchondroma; by contrast, enchondroma and ACT patients had no difference in pain frequency (p = 0.5528). All patients with enchondroma had no local recurrence; in contrast, local recurrence occurred in one patient with ACT, initially treated with resection. The patient with local recurrence had a disease progression with a higher histological grade than the original tumour. Patients treated with curettage had better functional outcomes than patients treated with resection (p = 0.001). DISCUSSION: Endosteal scalloping, tumour size and age could be helpful in the differential diagnosis between enchondroma and ACT of the pelvis. In addition, our study showed that ACT of the pelvis can be safely treated with curettage due to a low risk of local recurrence and better functional results compared with resection. In case of recurrence, we suggest to treat these patients with resection for the risk of disease progression.