Extended distal femur resection: Megaprosthesis with telescopic bone allograft augmentation versus total femur prosthesis.

BACKGROUND AND OBJECTIVE: Oncological distal femur resections can leave a proximal femur too short to host a stem. Reconstructive techniques are then challenging. The purpose of the study is to compare implant survival, complication rate and MSTS of two different options. METHODS: We retrospectively divided 33 patients with primary bone tumours of distal femur in Group 1 (16 patients reconstructed with knee megaprosthesis with proximal bone augmentation, APC) and Group 2 (17 patients reconstructed with total femur prosthesis, TFP). Less than 12 cm of remaining proximal femur were planned for all resections. RESULTS: MSTS score at 2 years is 25 ± 5 for Group 1 and 19 ± 7 for Group 2 (confidence interval [C.I.] 95%, p = 0.02). At 5 years it is 27 ± 2 for Group 1 and 22 ± 6 for Group 2 (C.I. 95%, p = 0.047). Failure and complication rates are lower for Group 1, but no statistical significance was reached. In APC reconstruction, union at the host-allograft junction was achieved in 16 out of 16 patients using the telescopic bone augmentation technique. CONCLUSIONS: APC provides higher functional results compared to TFP after extended distal femur resection. In APC reconstruction, telescopic augmentation is excellent for achieving union at the host-allograft junction.

Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem.

PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Histological examination of a retrieved custom-made 3D-printed titanium vertebra : Do the fine details obtained by additive manufacturing really promote osteointegration?

PURPOSE: In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma. METHODS: Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure. RESULTS: The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization. CONCLUSION: The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.

Denosumab Re-Challenge and Long-Term Efficacy for Aneurysmal Bone Cyst of the Spine: Enhanced Treatment Algorithm.

Background/Objective: Surgical treatment of aneurysmal bone cysts (ABCs) can be challenging, especially in the spine. Non-surgical treatments such as with denosumab have shown promising results in different osteolytic pathologies. This retrospective observational study aimed to evaluate the long-term clinical and radiologic response of patients with ABCs of the mobile spine treated with denosumab and propose an updated treatment algorithm. Methods: Six patients with relapsed and symptomatic ABCs of the mobile spine were treated with denosumab (120 mg subcutaneously on days 1, 8, 15, 29, and every 4 weeks thereafter) between 2012 and 2023. Disease assessments were conducted using CT and MRI at 3, 6, 9, and 12 months post-treatment. Clinical data, including pain levels, symptoms, and adverse events, were documented from patients' charts. Results: Patients underwent an initial phase of treatment with denosumab, receiving a mean of 22 administrations (range 13-42) over a median follow-up period of 41 months (range 15-98 months). Clinical improvement was observed in all patients after 4 weeks of treatment, and all patients demonstrated a radiological response after 12-24 weeks on denosumab. Three patients were progression-free after discontinuing denosumab following 13, 15, and 42 administrations, respectively. At the last follow-up, after 38, 43, and 98 months, these patients remained stable without relapse of the disease. Three patients had a relapse of disease after denosumab; two of them underwent denosumab re-challenge, while one patient received one mesenchymal stem cells (MSCs) injection. All patients showed clinical and radiological improvement and were resulted to be disease-free at the last follow-up. Conclusions: This study demonstrates the long-term efficacy and safety of denosumab in treating ABCs of the mobile spine, as well as the potential of re-challenge in managing recurrence. A treatment algorithm is proposed, positioning denosumab as a viable therapeutic option after other local treatments. Careful patient selection, monitoring, and further research are necessary to optimize denosumab use for ABCs.

Prolonged operative time significantly impacts on the incidence of complications in spinal surgery.

BACKGROUND: In spinal surgery adverse events (AE) and surgical complications (SC) significantly affect patient's outcome and quality of life. The duration of surgery has been investigated in different surgical field as risk factor for complications. The aim of this study is to analyze the correlation between operative time and adverse events in spinal surgery. METHODS: We retrospectively analyzed data collected prospectively in a cohort of 336 patients surgically treated for spinal diseases of oncological and degenerative origin in a single center, between January 2017 to January 2018. Demographics and clinical data were collected. Adverse events were classified using Spinal Adverse Events Severity System version 2 (SAVES-V2) capture system. Focusing on degenerative patients, bivariate analysis and univariate logistic regression were used to determine the association between operative time and complications. RESULTS: A total of 105/336 patients experienced an AE related to surgery, respectively 38% in the oncological group and 28% in the degenerative group. The average age at surgery was 60.3 years (SD 17.1) and the mean operative time was 164.8 ± 138 min. A total of 206 adverse events (30 intraoperative, 135 early postoperative and 41 late postoperative AEs) were recorded. Early post-operative complications accounted for the most recorded AEs (55.5% in the oncological group and 73.2% in the degenerative group). Univariate logistic regression analyses confirmed that operative time correlated with increased risk of intra-operative (p-value = 0.0008), early post-operative (p-value < 0.001) and late post-operative (p-value < 0.001) adverse events. CONCLUSIONS: This study highlights the strong correlation between the occurrence of adverse events in spinal surgery and prolonged operative time and suggests that efforts should be made to minimize the duration of surgical procedures while prioritizing patient's safety, without compromising the technical achievement of the procedure.

Intentional Enneking-inappropriate surgery and high-energy particle therapy for unresectable osteogenic sarcoma of the spine: a retrospective study.

OBJECTIVE: The aim of this study was to compare the outcome of intralesional gross-total resection (GTR) followed by high-energy particle therapy with en bloc and intralesional resections. METHODS: A retrospective study of patients diagnosed with primary osteogenic sarcoma (OGS) of the spine between 2009 and 2020 was conducted. Demographic information, including age, affected site, tumor volume, and Weinstein-Boriani-Biagini stage, was collected. Additionally, information on metastases at diagnosis, length of stay, operating time, complications, planned surgical treatment, and radiotherapy was also collected. Outcome measures, including local recurrence (LR) and disease-specific survival (DSS), were compared using Kaplan-Meier curves. RESULTS: In total, 20 patients with a median age of 38 (IQR 23-60) years were included. The median follow-up was 15.7 (IQR 6.3-36.9) months. Eight patients underwent en bloc resection with a 38% (3 patients) LR rate and a median DSS of 26.4 months. Four patients received adjuvant high-energy particle therapy after planned GTR. Their median follow-up was 36 months; none of these patients experienced LR. Both the 1-year and 3-year DSSs were 100%. Another 8 patients underwent intralesional resection. Six of the 8 patients (75%) died of their disease, with a median survival of 7.3 (IQR 4.7-14) months. CONCLUSIONS: GTR combined with adjuvant high-energy particle therapy appears to be a safe and effective alternative approach for patients with OGS of the spine when en bloc resection is not feasible. The results demonstrated a 3-year DSS of 100% and no major surgical complications.

Minimally invasive treatment of pedicle stress fracture in a young athlete: A case report.

INTRODUCTION: Pedicle stress fractures are an uncommon type of non-union often associated with contralateral neural arch interruption in young, active patients. Patients present with long-lasting low back pain, and the diagnosis is usually delayed. Treatment is generally conservative. Few cases treated surgically are described in the literature, with a high degree of treatment heterogeneity and no consensus on optimal treatment. PRESENTATION OF CASE: A 24-year-old male, following a sports-related trauma, developed persistent lower back pain. Imaging revealed a right L3 pedicle stress fracture with left lamina and pars interarticularis interruption. A minimally invasive percutaneous approach targeting the pedicle fracture was chosen. The procedure aimed to alleviate pain and promote non-union healing, without addressing the contralateral defect. The patient quickly recovered, achieving significant pain relief, and starting a tailored physical therapy program. At the 4-month follow-up, the pedicle fracture healed with callus formation. The patient returned to sports practice. DISCUSSION: Pedicle stress fractures may result from biomechanical force redistribution. Diagnosis is challenging, necessitating advanced imaging, including bone scintigraphy, MRI, and CT scans. Conservative management with rest, restriction with a brace, and focused rehabilitation usually achieves good results. When conservative management fails, surgery should be considered. Surgical options include direct repair, bone grafting, and screw fixation of the pedicle and contralateral pars defect. CONCLUSION: Minimally invasive surgery can achieve good clinical and functional results while avoiding blood loss and soft tissue trauma. Treating only the stress fracture is sufficient to promote bone healing, in contrast to more complex procedures.

Carbon Fiber-Reinforced PolyEtherEtherKetone (CFR-PEEK) Instrumentation in Degenerative Disease of Lumbar Spine: A Pilot Study.

CFR-PEEK is gaining popularity in spinal oncological applications due to its reduction of imaging artifacts and radiation scattering compared with titanium, which allows for better oncological follow-up and efficacy of radiotherapy. We evaluated the use of these materials for the treatment of lumbar degenerative diseases (DDs) and considered the biomechanical potential of the carbon fiber in relation to its modulus of elasticity being similar to that of bone. Twenty-eight patients with DDs were treated using CRF-PEEK instrumentation. The clinical and radiographic outcomes were collected at a 12-month FU. Spinal fusion was evaluated in the CT scans using Brantigan scores, while the clinical outcomes were evaluated using VAS, SF-12, and EQ-5D scores. Out of the patients evaluated at the 12-month FU, 89% showed complete or almost certain fusion (Brantigan score D and E) and presented a significant improvement in all clinical parameters; the patients also presented VAS scores ranging from 6.81 ± 2.01 to 0.85 ± 1.32, EQ-5D scores ranging from 53.4 ± 19.3 to 85.0 ± 13.7, SF-12 physical component scores (PCSs) ranging from 29.35 ± 7.04 to 51.36 ± 9.75, and SF-12 mental component scores (MCSs) ranging from 39.89 ± 11.70 to 53.24 ± 9.24. No mechanical complications related to the implant were detected, and the patients reported a better tolerance of the instrumentation compared with titanium. No other series of patients affected by DD that was stabilized using carbon fiber implants have been reported in the literature. The results of this pilot study indicate the efficacy and safety of these implants and support their use also for spinal degenerative diseases.

Individual Trajectories of Bone Mineral Density Reveal Persistent Bone Loss in Bone Sarcoma Patients: A Retrospective Study.

Multiagent chemotherapy offers an undoubted therapeutic benefit to cancer patients, but is also associated with chronic complications in survivors. Osteoporosis affects the quality of life of oncologic patients, especially at the paediatric age. However, very few studies have described the extent of loss of bone mineral density (BMD) in bone sarcoma patients. We analysed a retrospective series of children and adolescents with primary malignant bone tumours (52 osteosarcoma and 31 Ewing sarcoma) and retrieved their BMD at diagnosis and follow-up as Hounsfield units (HU). We studied their individual BMD trajectories before and after chemotherapy up to 5 years, using routine chest CT scan and attenuation thresholds on T12 vertebrae ROI. At one year, bone sarcoma patients showed significant bone loss compared to diagnosis: 17.6% and 17.1% less for OS and EW, respectively. Furthermore, a bone loss of more than 49.2 HU at one-year follow-up was predictive of the persistence of a reduced bone mass over the following 4 years, especially in patients with EW. At 4 years, only 26% and 12.5% of OS and EW, respectively, had recovered or improved their BMD with respect to the onset, suggesting a risk of developing morbidities related to a low BMD in those subjects.

Custom-Made 3D-Printed Implants for Anterior Column Reconstruction in the Upper Cervical Spine after Intralesional Extracapsular Excision-Report of 2 Cases and Literature Review.

The use of three-dimensional (3D)-printed custom-made implants is spreading in the orthopedics field for the reconstruction of bone losses or for joint replacement, thanks to their unparalleled versatility. In particular, this novel technology opens new perspectives to formulate custom-made fixation strategies for the upper cervical region, sacrum and pelvis, where reconstruction is challenging. We report and analyze the literature concerning upper cervical reconstruction with 3D-printed personalized implants after tumor surgery, and discuss two cases of patients where this technology was used to reconstruct the anterior column after extracapsular debulking of C2 recurrent chordoma at our institution.