Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial).

BACKGROUND: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. METHODS: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. DISCUSSION: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

Allograft Alone vs. Allograft with Intramedullary Vascularized Fibular Graft for Lower Extremity Bone Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Limb salvage surgery has become a first-line treatment in the setting of lower extremity cancer. Despite a multitude of techniques, the most effective modality for osseous reconstruction has not been described. We aim to examine outcomes of allograft reconstruction alone compared to an allograft combined with a vascularized fibula graft (VFG) (Capanna Technique) through a meta-analysis of the literature. METHODS: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining articles utilizing an allograft with or without an intramedullary VFG for the reconstruction of lower extremity osseous defects following oncological resection. A meta-analysis examined outcomes, including nonunion, infection, fractures, explantation, and functional limb status, that were evaluated dependent upon reconstructive modality. RESULTS: Twenty-five articles were deemed appropriate for inclusion. The allograft with VFG group had considerably lower rates of nonunion (13%) in comparison to the allograft alone group (21.4%) (p < .001). Rates of infection (7.9% vs. 9%, respectively) and fracture (19.6% vs. 19.1%) were not statistically different. The allograft with VFG group also had significantly lower rates of explantation (6.57%) compared to the allograft alone cohort (18.11%) (p < .001). Functional outcomes were similar across groups as measured by Musculoskeletal Tumor Society scores (88.22% vs. 87.77%). CONCLUSIONS: Allograft reconstruction with a supplementary inlay VFG decreases the risk of nonunion and explantation compared to allograft alone reconstruction in the setting of oncological resection of the osseous lower extremity. This technique warrants increased consideration in the operative planning of lower limb reconstruction following tumor extirpation.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note / 中华创伤杂志(英文版)

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

[Long bone fractures in cattle: A retrospective study of treatment and outcome in 194 cases]. / Frakturen der langen Röhrenknochen beim Rind: Eine retrospektive ­Auswertung der Therapie und des Verlaufs bei 194 Tieren.

INTRODUCTION: The present retrospective study investigated the localization, cause, treatment and healing of long bone fractures in cattle. Over a period of ten years, medical records of 194 cattle of all ages with a long bone fracture, presented at the Clinic for Ruminants with Ambulatory and Herd Health Services at LMU Munich, were evaluated. The majority of patients (n = 131, 67.5%) were younger than two weeks of age. Of these, 118 calves sustained the fracture on the day of birth (60.8%). An obstetrical assistance was found in 57.4% (n = 58) of birth-related cases as a fracture cause. The femur was most frequently affected in calves aged up to two weeks (n = 35; 26.7%). The second most frequent fractures occurred in the metacarpus (n = 31; 22.9%) in this age group, followed by metatarsus (n = 28; 21.4%) and tibia (n = 27; 20.6%). Fractures of the antebrachium (n = 9; 6.9%) and the humerus were rare (n = 1; 0.8%). A total of 194 patients were diagnosed with 50 femur fractures (25.8%), 53 metacarpal fractures (27.3%), 43 metatarsal fractures (22.2%), 30 tibial fractures (15.5%), 11 antebrachial fractures (5.7%) and 7 humeral fractures (3.6%). Of the 194 animals, 78 (40.2%) had to be euthanized, 42 of them (53.8%) without treatment. In 150 patients, treatment was initiated, of which 110 patients (73.3%) were dismissed healthy from the clinic. Among the conservative treatment methods were stall rest, casts, casts combined with a U-shaped metal rail (walking casts) and the Thomas splint. Surgical therapy (internal fixation with plates or screws, transfixation pin casts) was used to treat 65 animals (33.5%). While 86.9% (74 out of 85) of the conservatively treated animals left the clinic alive, it were only 58.1% (36 out of 65) animals after surgical treatment. In the newborn calves, colostrum supply had a significant effect on the success of the treatment. If the gamma-glutamyl transferase concentration was below 200 IU/L in the calves aged under 4 days, the healing rate was significantly different from the cure rate of sufficiently immunized patients (26.9% (7 out of 26) vs. 65.3% (47 out of 72), P = 0.001).

INTRODUCTION: La présente étude rétrospective a examiné la localisation, la cause, le traitement et la guérison des fractures des os longs chez les bovins. Sur une période de dix ans, les dossiers médicaux de 194 bovins de tous âges souffrant d'une fracture d'un os long et présentés à la Clinique pour les ruminants avec services ambulatoires et services de santé du troupeau à la Ludwig-Maximilians-Universität de Munich, ont été évalués. La majorité des patients (n = 131, 67,5%) étaient âgés de moins de deux semaines. Parmi ceux-ci, 118 veaux ont subi la fracture le jour de leur naissance (60,8%). Une assistance obstétricale par traction a été trouvée dans 57,4% (n = 58) des cas liés à la naissance en tant que cause de fracture. Le fémur était le plus souvent touché chez les veaux âgés de moins de deux semaines (n = 35; 26,7%).). La deuxième fracture la plus fréquente survenait au niveau du métacarpe (n = 31; 22,9%)), suivi du métatarse (n = 28; 21,4%) et du tibia (n = 27; 20,6%).). Les fractures de l'antebrachium (n = 9; 6,9%) et de l'humérus étaient rares (n = 1; 0,8%). Au total, sur les 194 patients ont a diagnostiqué 50 fractures du fémur (25,8%), 53 fractures du métacarpe (27,3%), 43 fractures du métatarse (22,2%), 30 fractures du tibia (15,5%), 11 fractures antébrachiales (5,7%) et 7 fractures de l'humérus (3,6%). Sur les 194 animaux, 78 (40,2%) ont dû être euthanasiés, dont 42 (53,8%) sans traitement. Deux animaux (1.0%) ont été abattus. Sur les 150 patients traités, 36 (24.0%) ont été euthanasiés et 4 ont péri. 110 patients (73,3%) ont été renvoyés en bonne santé de la clinique. Parmi les méthodes de traitement conservatif figurent le repos en stalle, les plâtres en résine, les plâtres en résine combinés à une attelle en métal en forme de U comme attelle de marche et l'attelle de Thomas. Un traitement chirurgical (fixation interne à l'aide de plaques et/ou de vis de traction, broches de transfixion avec pont en matière synthétique) a été utilisé pour traiter 65 animaux (33,5%). Alors que 86,9% (74 sur 85) des animaux traités de manière conservatrice ont quitté la clinique en vie, ce ne sont que 58,1% (36 sur 65) des animaux après traitement chirurgical. Chez les veaux nouveau-nés, l'apport de colostrum a eu un effet significatif sur le succès du traitement. Si la concentration de gamma-glutamyl transférase était inférieure à 200 UI / L chez les veaux âgés de moins de 4 jours, le taux de guérison était significativement différent du taux de guérison de patients suffisamment immunisés (26,9% (7 sur 26) contre 65,3% (47 sur 72), p = 0,001).

Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission, and Reoperation in the Operative Lower Extremity Orthopaedic Trauma Patient.

INTRODUCTION: Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient. METHODS: Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders. RESULTS: Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66-8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin. CONCLUSION: Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Retrospective evaluation of perioperative and short term clinical outcomes in appendicular long bone skeleton fractures repaired via the string of pearls (SOP) locking plate system.

BACKGROUND: Internal plate fixation and, more recently, locking plate fixation are commonly used in the repair of fractures in small animal surgery. This retrospective study reviewed the use of the String of Pearls locking plate system in the fixation/repair of appendicular long bone skeleton fractures in 31 small animal veterinary patients (33 fractures). RESULTS: Major complications necessitating revision surgery occurred in 7/33 (21%), with implant failure as the inciting cause in all cases. Variables corresponding to an unsuccessful outcome were evaluated, and a correlation was found with plates placed in a bridging manner (placed without rigid anatomic reconstruction, p = 0.02) and length of follow-up (p = 0.01). CONCLUSIONS: The SOP plating system can be used in the repair of appendicular longbone skeletal fractures, however, the authors propose that adjunct fixation, such as intramedullary pin, double plating, or external coaptation would likely improve results and should be considered imperative in cases in which anatomic reconstruction is either not desirable or achievable.

Abaloparatide versus teriparatide: a head to head comparison of effects on fracture healing in mouse models.

Background and purpose - Teriparatide accelerates fracture healing in animals and probably in man. Abaloparatide is a new drug with similar although not identical effects on the teriparatide receptor. Given at 4 times the teriparatide dose in a human osteoporosis trial, abaloparatide increased bone density more than teriparatide, and both reduced fracture risk. We investigated in mice whether abaloparatide stimulates fracture healing, and if it does so with the suggested dose effect relation (4:1). Patients and methods - In a validated mouse model for metaphyseal healing (burr hole with screw pull-out), 96 mice were randomly allocated to 11 groups: control (saline), teriparatide or abaloparatide, where teriparatide and abaloparatide were given at 5 different doses each. In a femoral shaft osteotomy model, 24 mice were randomly allocated to 3 groups: control (saline), teriparatide (15 µg/kg) or abaloparatide (60 µg/kg). Each treatment was given daily via subcutaneous injections. Results were evaluated by mechanical testing and microCT. Results - In the metaphyseal model, a dose-dependent increase in screw pull-out force could be seen. In a linear regression analysis (r = 0.78) each increase in ln(dose) by 1 (regardless of drug type) was associated with an increase in pull-out force by 1.50 N (SE 0.18) (p < 0.001). Changing drug from teriparatide to abaloparatide increased the force by 1.41 N (SE 0.60; p = 0.02). In the diaphyseal model, the callus density was 23% (SD 10), 38% (SD 10), and 47% (SD 2) for control, for teriparatide and abaloparatide respectively. Both drugs were significantly different from controls (p = 0.001 and p = 0.008), but not from each other. Interpretation - Both drugs improve fracture healing, but in these mouse models, the potency per µg of abaloparatide seems only 2.5 times that of teriparatide, rather than the 4:1 relation chosen in the clinical abaloparatide-teriparatide comparison trial.

Improved Surface-Based Registration of CT and Intraoperative 3D Ultrasound of Bones.

The intraoperative registration of preoperative CT volumes is a key process of most computer-assisted orthopedic surgery (CAOS) systems. In this work, is reported a new method for automatic registration of long bones, based on the segmentation of the bone cortical in intraoperative 3D ultrasound images. A bone classifier was developed based on features, obtained from the principal component analysis of the Hessian matrix, of every voxel in an intraoperative ultrasound volume. 3D freehand ultrasound was used for the acquisition of the intraoperative ultrasound volumes. Corresponding bone surface segmentations in ultrasound and preoperative CT imaging were used for the intraoperative registration. Validation on a phantom of the tibia produced encouraging results, with a maximum mean segmentation error of 0.34⁡mm (SD=0.26⁡mm) and a registration accuracy error of 0.64⁡mm (SD=0.49⁡mm).

Implant and limb survival after resection of primary bone tumors of the lower extremities and reconstruction with mega-prostheses fifty patients followed for a mean of forteen years.

PURPOSE: Previous studies reported variable outcome and failure rates after mega-prosthetic reconstructions in the lower extremities. The purpose of this study was to make a long-term single-center evaluation of patients treated with limb-sparing surgery and reconstruction with mega-prostheses in the lower extremities. METHODS: We identified 50 patients (osteosarcoma (n = 30), chondrosarcoma (n = 9), osteoclastoma (n = 6), Ewing sarcoma (n = 4), angiosarcoma (n = 1)), who underwent limb-sparing reconstruction of the lower extremities (proximal femur (n = 9), distal femur (n = 29), proximal tibia (n = 9), and the entire femur (n = 3)) between 1985 and 2005. Surviving patients not lost to follow-up were evaluated using the MSTS score. Causes of failure were classified according to the Henderson classification. Kaplan-Meier survival analysis was used for evaluation of patient, prosthesis, and limb survival. RESULTS: Twenty-eight patients were alive at follow-up. Fifty-four percent had revision surgery (n = 27). The ten year patient survival was 60% (95%CI 46-74%); the ten year implant survival was 24% (95%CI 9-41%), and the ten year limb survival rate was 83% (95%CI 65-96%). Type 1 failure occurred in 9%, type 2 in 16%, type 3 in 28%, type 4 in 18%, and type 5 in 3%. Mean MSTS score was 21 (range, 6-30), representing a median score of 71%. CONCLUSIONS: Our long-term results with mega-prostheses justify the use of limb-salvage surgery and prosthetic reconstruction. Our results are fully comparable with other findings, with regard to limb and prosthesis survival, but also with regard to functional outcome.

Motorcyclists and pillion passengers with open lower-limb fractures: a study using TARN data 2007-2014.

Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007-2009 and 2010-2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.

Prophylactic negative pressure wound therapy after lower extremity fracture surgery: a pilot study.

PURPOSE: Infectious complications following lower extremity fracture surgery are a major concern and account for a substantial socio-economic burden to society. The aim of this pilot study was to investigate the feasibility of a new portable single-use negative pressure wound therapy device in patients undergoing major foot ankle surgery. METHODS: Patients undergoing major foot ankle fracture surgery at a single level 1 trauma centre were eligible for this prospective case series. Patient characteristics were collected, as were fracture and surgical characteristics. Primary outcome was surgical site infection within 30 days as classified by the criteria from the Centers for Disease Control and Prevention. Patients in the prospective cohort were case-matched with a historical cohort from the same institution. RESULTS: Sixty patients were included. In seven patients, the NPWT failed and treatment was ceased. Mean age was 44 years and 85% was ASA 1; 43% of the patients were actively smoking. Indications for surgery were midfoot, calcaneal, talar, and ankle fractures. In 53 patients, four (7.5%) surgical site infections occurred, two superficial (3.3%) and two (3.3%) deep infections. For 47 patients, a match was available. The incidence of surgical site infection did not statistically significantly differ between the prospective cohort and retrospective matched cohort (4.3 versus 14.9%, p = 0.29, respectively). This was also the case when looking at superficial and deep surgical site infections separately (0 versus 8.5%, p = 0.08, and 4.3 versus 6.4%, respectively). CONCLUSION: We have observed surgical site infections in 7.5% of the patients with the use of prophylactic negative pressure wound therapy. The incidence of surgical site infections was not statistically significantly lower compared to a matched historical cohort.

[Treatment principles in bone reconstruction and limb lengthening of the lower extremity].

Limb length discrepancies, axis deviations and bone loss on a congenital, traumatic or infectious basis are treated with restoration of axis and bone elongation. The intention is to improve gait and function, to relieve pain caused by imbalance in the musculoskeletal system and to prevent degenerative joint disease. Modern motorized intramedullary nails spare the patients for external fixators, and thus complications are being reduced. X-ray, CT-based planning and a thorough clinical examination is essential for a good result. Complications are frequent, and treatment can be lengthy. Modern techniques have made treatment more gentle and allow a normal daily life during treatment and rehabilitation.

Tratamiento quirúrgico de las dismetrías y deformidades angulares de miembros inferiores mediante epifisiodesis con tornillos transfisarios (técnica de Metaizeau) / Surgical treatment of lower limb length discrepancy and angular deformity by epiphysiodesis with transphyseal screw (Metaizeau technique) / Tratamento cirúrgico das dismetrias e deformidades angulares de membros inferiores mediante epifisiodese com parafusos transfisários (técnica de Metaizeau)

Evaluamos los niños con dismetrías y deformidades angulares operados mediante la Técnica de Metaizeau en el período 2010-2014, mediante un estudio retrospectivo de 11 pacientes, analizados en 2 Grupos. Grupo 1 (Dismetrías), formado por 5 pacientes, de los cuales 3 fueron operados solamente mediante esta técnica, mientras que 2 requirieron adicionalmente procedimientos de alargamiento femoral, valoramos dismetría inicial, dismetría por predicción para el último control y para el final de la madurez, y dismetría final. Grupo 2 (Deformidades Angulares), formado por 6 pacientes, de los cuales 1 presentaba genu varo, 4 genu valgo y 1 valgo de tobillo, valoramos el ángulo femorotibial anatómico, ángulo femoral distal lateral anatómico, ángulo tibial proximal medial, y ángulo tibioastragalino. En ambos Grupos se valoraron las complicaciones. El seguimiento promedio fue de 2 años y 5 meses. En el Grupo 1 obtuvimos dismetría promedio inicial 7,64 cm., dismetría promedio por predicción para el último control 8,54 cm., dismetría promedio final 7,62 cm., corrección promedio lograda 0,91 cm. En el Grupo 2 el promedio de corrección del ángulo femorotibial anatómico 16,85˚, promedio de corrección del ángulo femoral distal lateral anatómico 16,85˚, promedio de corrección del ángulo tibial proximal medial 7,62˚. No detectamos complicaciones en ningún paciente. En 8 (72,72%) pacientes la Técnica fue efectiva, mientras que en 3 (27,27%) los resultados fueron malos por errores técnicos o error en la predicción. La Técnica de Metaizeau, respetando los detalles quirúrgicos y realizando una adecuada predicción, es una buena opción para el tratamiento de dismetrías y deformidades angulares.

We evaluated children with lower limb length discrepancy and angular deformity operated by the Metaizeau technique in the 2010-2014 period through a retrospective study of 11 patients analyzed in 2 groups. Group 1 (Lower limb length discrepancy), consisted of 5 patients, among whom 3 were operated only by Metaizeau technique, whereas the other 2 additionally required procedures for femoral elongation. We evaluated initial discrepancy, predicted discrepancy for ultimate control and at maturity, and final discrepancy. Group 2 (Angular deformity), consisted of 6 patients, among whom 1 had genu varum, 4 genu valgum and, 1 ankle valgus. We evaluated anatomic femorotibial angle, anatomic lateral distal femoral angle, medial proximal tibial angle, and tibio talar angle. In both groups the complications were assessed. The average follow-up was 2 years and 5 months. In Group 1 we obtained the following values: average initial discrepancy, 7.64 cm; average discrepancy predicted for ultimate control, 8.54 cm; average final discrepancy, 7.62 cm and average correction achieved, 0.91 cm. In Group 2 the values were: average correction anatomic femorotibial angle, 16.85˚; average correction anatomic lateral distal femoral angle, 16.85˚ and average correction medial proximal tibial angle, 7.62˚. We found no complications in any patient. In 8 patients (72.72%) the technique was effective, while in 3 (27.27%) the results were poor due to technical errors or prediction errors . Metaizeau Technique, respecting the surgical details and making an accurate prediction is an effective, simple and uncomplicated procedure.

Avaliamos as crianças com dismetrias e deformidades angulares operadas pela técnica de Metaizeau no período de 2010 até 2014, mediante um estudo retrospectivo de 11 pacientes analisados em dois grupos. Grupo 1 (Dismetrias), constituído por cinco pacientes, dos quais 3 foram operados apenas por esta técnica, enquanto que os outros dois precisaram de procedimentos adicionais de alongamento femoral. Avaliamos a dismetria inicial, a dismetria por predição para o último controle e para o final da maturação, e a dismetria final. Grupo 2 (deformidades angulares), constituído por 6 pacientes, entre os quais um apresentava genu varo, 4 genu valgo e um, valgo do tornozelo. Avaliamos o ângulo femorotibial anatômico, o ângulo femoral distal anatômico o ângulo femoral distal lateral anatômico, o ângulo tibial proximal medial, e o ângulo tibioastragalino. Em ambos os grupos foram avaliadas as complicações. O seguimento médio foi de 2 anos e 5 meses. No Grupo 1, obtivemos dismetría inicial média de 7,64 cm, dismetria média por previsão para o último controle de 8,54 cm, dismetría final média de 7,62 cm e correcção média atingida de 0,91 cm. No Grupo 2, a correção de ângulo tibiofemoral anatómica média 16,85˚, correção média do ângulo femoral distal lateral anatómico 16,85˚, e correção média de ângulo tibial proximal medial de 7,62˚. Não detectamos complicações em nenhum paciente. A técnica foi efetiva em 8 (72,72%) pacientes, mas em 3 (27,27%) os resultados foram insatisfatórios por erros técnicos ou na predicção. A técnica de Metaizeau, desde que sejam respeitados os detalhes cirúrgicos e seja feita uma predicção adequada, é uma boa escolha para o tratamento de dismetrías e deformidades angulares.

A Comparison of Vascularized Free Fibular Flaps and Nonvascularized Fibular Grafts for Reconstruction of Long Bone Defects after Tumor Resection.

Background The use of the fibula autograft has been a reliable method in the reconstruction of long bone defects after tumor resection. The objective of this study was to report the outcomes fibular grafting in terms of graft union, functional score, complications, and oncologic outcome. Methods A retrospective review of patients with fibular grafting after tumor resection was done from January 1, 1993 to December 31, 2013. The primary outcome was graft union and the revised musculoskeletal tumor society scoring system (MSTS score). The secondary outcomes were oncologic outcomes, complications, and the factors associated with graft union. Results A total of 52 patients with a mean follow-up of 42 months (SD, 33; range, 12-132 months) were included. The overall union for all fibular grafts was 37 of 52. The use of vascularized free fibula flaps had a higher union rate compared with nonvascularized fibula grafts. The use of a vascularized free fibular flap was four times likely to unite (95% CI 1.1-12.8, p = 0.039) compared with nonvascularized fibular grafts. The mean MSTS score in 36 patients was 82.5 (SD, 12.9) at 35 months from surgery (SD, 30). A total of 39 complications were present in 29 patients. On final follow-up, 45 of 52 patients were alive, six patients had died of disease and one died of other causes. Conclusion A higher union rate was achieved using vascularized free fibular flaps compared with nonvascularized fibular grafts for long bone reconstruction after tumor resection. There was no difference in terms of MSTS score between the two types of grafts.

Surgically treated patients with axial and peripheral Ewing's sarcoma family of tumours: A population based study in Finland during 1990-2009.

BACKGROUND: The surgical treatment of Ewing's sarcoma family tumours (ESFTs) is challenging especially with axial tumours. The aim of the study was to analyse surgical treatment and outcome in a nationwide, population-based material consisting of surgically treated axial and peripheral ESFTs of bone and soft tissue. METHODS: The data were collected from the Finnish National Cancer Registry and the medical records of patients diagnosed during 1990-2009. Fifty-seven patients with surgically treated ESFTs were included, 22 with an axial and 35 with a peripheral primary tumours. The surgical treatment, its complications, survival and prognostic factors were analysed. RESULTS: Fifty-four patients underwent surgery with a curative intent and three underwent de-bulking operations. Bone reconstruction was performed in six patients with an axial and 15 with a peripheral tumour. Positive resection margins were associated with a worse five-year local relapse-free survival (33% vs. 84% for those with resection margins free of tumour cells, p = 0.003). The five-year sarcoma-specific survival was affected only by an axial location of the primary (61% vs. 89% for those with a peripheral tumour, p = 0.031). The late complications were mainly associated with bone reconstruction and more frequent among patients with a peripheral compared to an axial tumour (p = 0.031). CONCLUSIONS: In the treatment of ESFTs, achieving adequate resection margins is crucial to avoid local relapses. Surgical complications are common particularly with bone reconstruction.

Infected Prostheses after Lower-Extremity Bone Tumor Resection: Clinical Outcomes of 100 Patients.

BACKGROUND: Infection of megaprostheses after bone tumor resection is a major concern; management is challenging. This study evaluated the survivability from such infections, the microbial isolates, treatment tactics, and outcome of megaprosthesis reconstructions. MATERIALS AND METHODS: We studied 1,161 patients retrospectively who underwent megaprosthesis reconstruction for limb salvage after a sarcoma from 1983 to 2010. The mean followup was 9 y (range 3-20 y). We evaluated the overall survival of the megaprosthesis reconstructions in patients with infection and the survival with respect to the type of megaprosthesis, site of reconstruction, cemented or cementless fixation, type of tumor, adjuvant treatments, microbial isolate(s), treatment tactics, and outcome. RESULTS: The incidence of infection was 8.6%. The most common microbial isolate was Staphylococcus epidermidis (47%). Overall survival with definitive management of infection was 88% at 10 y and 84% at 20 y. Survival was higher for cementless reconstructions and not different with respect to the type of megaprosthesis, site of reconstruction, or adjuvant therapy. Infections resolved completely with one- or two-stage surgery in 75% of patients. The rate of amputation because of infection was 21%. CONCLUSIONS: Megaprosthesis reconstructions may be infected in 8.6% of cases. Infections more commonly occur late, caused usually by S. epidermidis. The survival rate is higher with cementless megaprosthesis reconstructions and no different with respect to the type of tumor or megaprosthesis or the adjuvant treatments. One-stage revision is effective for acute post-operative infections; however, two-stage revision surgery is necessary for early and late infections. The rate of amputation because of occurrence or persistence of megaprosthesis infection is 21%.

Orthopedic inpatients' ability to accurately reproduce partial weight bearing orders.

Partial weight bearing is often prescribed for patients with orthopedic injuries. Patients' ability to accurately reproduce partial weight bearing orders is variable, and its impact on clinical outcomes is unknown. This observational study measured patients' ability to reproduce partial weight bearing orders, factors influencing this, patients' and physiotherapists' ability to gauge partial weight bearing accuracy, and the effect of partial weight bearing accuracy on long-term clinical outcomes. Fifty-one orthopedic inpatients prescribed partial weight bearing were included. All received standard medical/nursing/physiotherapy care. Physiotherapists instructed patients in partial weight bearing using the hand-under-foot, bathroom scales, and/or verbal methods of instruction. Weight bearing was measured on up to 3 occasions during hospitalization using a force-sensitive insole. Factors that had the potential to influence partial weight bearing accuracy were recorded. Patients and their physiotherapists rated their perception of partial weight bearing accuracy. Three-month clinical follow-up data were retrieved from medical records. The majority of patients (72% or more) exceeded their target load, with mean peak weight bearing as high as 19.3 kg over target load (285% of target load). Weight bearing significantly increased over the 3 measurement occasions (P<.001) and was significantly associated with greater body weight (P=.04). Patients and physiotherapists were unable to accurately gauge partial weight bearing accuracy. The incidence of clinically important complications at 3 months was 9% and not significantly associated with partial weight bearing accuracy during hospitalization (P≥.45). Patients are unable to accurately reproduce partial weight bearing orders when trained with the hand-under-foot, bathroom scales, or verbal methods of instruction.

[Basic principles of surgical treatment of bone metastases]. / Grundlagen der operativen Behandlung von Knochenmetastasen.

Due to an increased life expectancy and improved oncological treatment, the necessity for surgical treatment of bone metastases has increased as well. Ideally, therapy should concentrate on the improvement of the patient's quality of life while preferably being interdisciplinary. The type and extent of surgical therapy depend on the prognosis, tumor entity, localization of the tumor as well as on the patient's general condition. The main aims of surgical treatment is to reduce pain and preserve or restore function and mobility. After the contribution on spinal metastases in the last volume, this article focusses on metastases of the extremities and the pelvis. Pathologic fractures with an unclear oncological situation should be examined thoroughly before any surgical treatment is performed. In case of doubt, a biopsy should be performed. Depending on the individual prognosis, possible options for extremity surgery are (compound) osteosynthesis and implantation of a tumor endoprosthesis. The latter should be preferred for patients with a favorable prognosis and long life expectancy. To avoid revision surgery, the selected implant should outlast the patient's remaining life expectancy.

Principles of rotationplasty.

Rotationplasty is a reconstructive, limb-sparing option for management of lower extremity bone deficiency. This technique involves an intercalary resection, followed by 180° rotation of the distal limb to allow the ankle to function as a knee joint when it is fitted with a modified below-knee prosthesis. Gait analysis and functional outcome studies have reported favorable results with rotationplasty compared with those of above-knee amputation. Moreover, patient satisfaction with rotationplasty is higher than with other limb salvage procedures. The primary drawback of this procedure is patient acceptance of the limb's appearance.