RESUMO
PURPOSE: There has been a renewed interest in the repair of the torn anterior cruciate ligament (ACL). Purpose of this study was to evaluate the functional outcome of arthroscopic ACL repair with additional suture augmentation (SA), hypothesizing that isolated ACL ruptures would yield superior patient-reported outcome measures (PROMs) compared to those with concomitant meniscal and/or ligamentous injuries. METHODS: This is a retrospective analysis of 93 consecutive patients (67 female, median age 42 years) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 for an acute traumatic ACL tear confirmed by magnetic resonance imaging (MRI). Patients with pre- or intraoperative mid-substance or distal ACL tears and/or poor tissue quality of the ACL remnant were not considered for ACL repair but were scheduled for an ACL reconstruction with a tendon autograft. In patients who underwent ACL repair with SA, the SA construct was proximally stabilized with a flip-button and distally with a suture anchor. Surgery was preferably performed on the day of injury and all surgeries were performed by the same surgeon. Postoperative rehabilitation included partial weight-bearing (20 kg) for 6 weeks and immobilization in a brace limited at 90-degrees of knee flexion for 4 weeks. Patient-reported outcome measures (PROMs) were determined using International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Score (LS), Tegner Activity Score (TS) and Forgotten Joint Score (FJS). Knee-laxity was assessed using the KT-1000 arthrometer (Med Metrics Corp. Inc., San Diego, USA). RESULTS: Nine patients underwent revision surgery for a traumatic re-tear (four patients) and chronic instability (five patients) and were excluded from further functional analysis. Functional results of 77 patients (54 female) with a median age of 44 years (IQR 33-51) on the day of surgery were available for follow-up after a median time of 35 months (IQR 33-44). Concomitant injuries were observed in 66 Patients (86%), meniscal injuries in 43 patients (55%) and ligamentous injuries in 50 patients (65%). Median interval from injury to surgery was 1 day (IQR 0-1) with 81% (62/77) of patients being treated within 24 h of injury. The median IKDC was 92 (IQR 86-99), the median LS was 95 (IQR 86-100), the median pre-traumatic TS was 7 (IQR 6-7), the median post-traumatic TS was 6 (IQR 5-7) with a non-significant median difference (TSDiff) of 0 (IQR 0-1). The median FJS was 95 (IQR 78-98). KT-1000 measurements were available in 34 of 77 patients with a median postoperative laxity compared to the uninjured side of 1 mm (IQR 0-2). Interval from injury to surgery, patients' age, body mass index (BMI), knee laxity and concomitant ligamentous or meniscal injuries had no statistically significant impact on postoperative PROMs (n.s.). CONCLUSION: Following arthroscopic ACL repair with SA good-to-excellent functional results were observed. However, a failure rate of 10% cannot be neglected and warrants further attention. Concomitant injuries to the meniscus and/or collateral ligaments do not seem to be associated with inferior PROMs. LEVEL OF EVIDENCE: Level IV.
Assuntos
Lesões do Ligamento Cruzado Anterior , Ligamento Cruzado Anterior , Humanos , Feminino , Adulto , Recém-Nascido , Ligamento Cruzado Anterior/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Articulação do Joelho/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Suturas , SeguimentosRESUMO
INTRODUCTION: Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. MATERIALS AND METHODS: We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22-51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan-Meier survival curves and comparative non-parametric testing. RESULTS: 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64-89%) after 1 year and 38% (95% CI 18-57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher's exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. CONCLUSION: The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.
Assuntos
Artrite Infecciosa , Artroplastia do Joelho , Infecções Relacionadas à Prótese , Humanos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Estudos Retrospectivos , Infecções Relacionadas à Prótese/cirurgia , Infecções Relacionadas à Prótese/complicações , Resultado do Tratamento , Articulação do Joelho/cirurgia , Artrite Infecciosa/cirurgiaRESUMO
PURPOSE: The purpose of the study was to determine the long-term survivorship, functional outcomes of a single-design condylar constrained (CCK) TKA in primary and revision cases as well as to assess specific risk factors for failure. It was hypothesized that primary CCK TKA had a better survival than revision knees. METHODS: One hundred and forty three patients who underwent revision TKA (n = 119) or complex primary TKA (n = 24) using a single-design condylar constrained knee system (Genesis CCK, Smith & Nephew) performed at a single institution between 1999 and 2008 were retrospectively included. The median follow-up amounted to 11.8 years (IQR 10.3-14.4). Implant survivorship was analyzed using Kaplan-Meier survival estimates and multivariate Cox regression analysis to identify risk factors for failure. Function was determined using the Oxford Knee Score (OKS). RESULTS: The implant survival was 86.4% after five, 85.5% after ten and 79.8% at 15 years. A reduced implant survivorship was found in males (HR 5.16, p = 0.001), smokers (HR 6.53, p = 0.004) and in obese patients (HR 2.26, p = 0.095). Patients who underwent primary TKA had a higher revision-free implant survivorship compared to revision TKA at 15 years (100% vs. 76%, p = 0.036). The main cause for re-revision was infection in 10% of all revision TKA performed with the CCK design included, while no case was revised for instability. The median OKS was 39 (IQR 35-44) in 102 patients available for long-term functional outcome. CONCLUSION: CCK implants are associated with excellent long-term survival when used in primary TKA; however, survival was worse when used during revision TKA. Males, smokers, obese patients and are at higher risk for revision. While instability and aseptic loosening were rare, infection remains a major concern. LEVEL OF EVIDENCE: Level IV, retrospective observational study.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Seguimentos , Humanos , Articulação do Joelho , Masculino , Obesidade , Desenho de Prótese , Falha de Prótese , Reoperação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: With the novel coronavirus-induced disease (COVID-19), there is the fear of nosocomial infections and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmissions to healthcare workers (HCW). We report the case of a 64-year-old male patient who underwent explantation of a shoulder prosthesis due to a periprosthetic infection. He was tested SARS-CoV-2 positive 7 days after admission to the orthopaedic department following strict infection control measures, routinely including screening all patients for multi-drug-resistant organism (MDRO) colonization upon admission. Aim of our study is to report on the spreading potential of SARS-CoV-2 in a healthcare setting if standard contact precautions and infection control measures have been established. METHODS: All HCW with exposure to the patient from day of admission until confirmed diagnosis of COVID-19 were identified and underwent oropharyngeal swab testing for SARS-CoV-2 by real-time RT-PCR. RESULTS: Sixty-six HCW were identified: nine orthopaedic surgeons, four anaesthesiologists, 25 orthopaedic nurses, five nurse anesthetists, eight scrub nurses, five nursing students, two medical assistants and seven service employees. Fourteen HCW (21%) showed clinical symptoms compatible with a SARS-CoV-2 infection: cough (n = 4), sore throat (n = 3), nasal congestion (n = 3), dyspnea (n = 2), fever (n = 1), headache and myalgia (n = 1). SARS-CoV-2 was not detected in any of the 66 HCW. CONCLUSION: Hygienic measures and contact precautions, aimed at preventing the spread of MRDO, may have helped to prevent a SARS-CoV-2 transmission to HCW-despite high-risk exposure during intubation, surgical treatment and general care. LEVEL OF EVIDENCE: IV, case series.
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COVID-19 , Pessoal de Saúde , Controle de Infecções , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Exposição Ocupacional , COVID-19/diagnóstico , COVID-19/prevenção & controle , COVID-19/transmissão , Teste de Ácido Nucleico para COVID-19/métodos , Busca de Comunicante/métodos , Remoção de Dispositivo/métodos , Pessoal de Saúde/classificação , Pessoal de Saúde/estatística & dados numéricos , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/análise , Exposição Ocupacional/prevenção & controle , Procedimentos Ortopédicos/métodos , Infecções Relacionadas à Prótese/cirurgia , Gestão de Riscos , SARS-CoV-2 , Ombro/cirurgiaRESUMO
The correction of angular deformities of the lower limb is a key task in paediatric orthopaedic surgery. The growth potential of the physis can be employed for the correction of these malalignments in childhood and adolescence. Hemiepiphysiodesis (HED) is a surgical technique used for growth modulation by permanent or temporary asymmetrical arrest of the growth plate. In permanent HED, exact timing of the procedure is mandatory to achieve optimal correction. Temporary HED through tension band devices such as two-hole-plates or flexible staples has been established as the treatment of choice for growth guidance with excellent results. Implant-associated complications have been significantly reduced through implant modifications. Several experimental procedures have the potential to achieve growth modulation even without the requirement of surgical intervention.
Assuntos
Geno Valgo , Adolescente , Placas Ósseas , Criança , Lâmina de Crescimento/cirurgia , Humanos , Extremidade Inferior , SuturasRESUMO
PURPOSE: This study first analyzes implant survival of this single design modular rotating hinge knee and identifies potential risk factors for failure and evaluates joint function using the postoperative WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, active flexion and extension deficit. METHODS: 131 prostheses implanted for failure of prior total knee arthroplasty (n = 120) or complex primary procedures (n = 11) using a single modular implant (MUTARS-modular universal tumor and revision system GenuX, Implantcast, Buxtehude, Germany) between 2006 and 2014 including 73 patients treated for periprosthetic joint infection with a two-stage revision protocol were retrospectively identified. Implant survival was assessed using the Kaplan-Meier method; potential risk factors were identified using the log-rank test, as well as non-parametric analysis. Postoperative function was assessed using the WOMAC and measurement of range of motion. RESULTS: After a median follow-up of 62 months, 37 implants required implant revision (28%). Five-year survival was 69.7% [95% CI (confidence interval) 60.9-78.5] with periprosthetic (re-) infection being the main cause for failure (15%), followed by aseptic loosening (9%). In cases of periprosthetic infection, infection-free survival was 83% at 5 years (95% CI 74-92) with twelve patients suffering reinfection (16%).While body mass index (p = 0.75), age (p = 0.16) or indication for rotating hinge knee arthroplasty (p = 0.25) had no influence on survival, Charlson comorbidity score (CCI) (p = 0.07) and number of previous revision surgeries (p = 0.05) correlated with implant failure. There was trend (p = 0.1) for improved survival in fully cemented implants. Mean postoperative WOMAC was 127(range 55-191), 11 patients (15%) had limited knee extension. CONCLUSIONS: Rotating hinge total knee arthroplasty using a single modular implant shows acceptable survival rates and function compared to previous studies with (re-)infection being the most relevant mode of failure. Patients with a high CCI and multiple previous surgeries are at increased risk for failure. LEVEL OF EVIDENCE: Retrospective cohort study, III.
Assuntos
Artroplastia do Joelho/métodos , Análise de Falha de Equipamento , Prótese do Joelho , Desenho de Prótese , Idoso , Artrite Infecciosa/etiologia , Artroplastia do Joelho/efeitos adversos , Feminino , Alemanha , Humanos , Estimativa de Kaplan-Meier , Prótese do Joelho/efeitos adversos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/cirurgia , Infecções Relacionadas à Prótese/etiologia , Amplitude de Movimento Articular , Reoperação , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Intraoperative cultures are important in the diagnosis and targeted treatment of periprosthetic joint infection (PJI). Positive cultures at reimplantation during a two-stage exchange are discussed as a risk factor for reinfection. The aim of this study is the investigation of the incidence and risk factors for positive cultures during reimplantation. METHODS: We retrospectively identified 204 patients (111 knees, 93 hips) who were treated between 2012 and 2016 for PJI using a two-stage exchange protocol at a median follow-up of 42 months. PJI was diagnosed using the criteria of the musculoskeletal infection society (MSIS) of 2011. All cultural findings from first and second stage surgery were recorded. The primary endpoint was revision for infection. Risk factors for positive cultures and reinfection were analyzed. RESULTS: During reimplantation 25% (51/204) of patients had at least one positive culture, in 19.1% (39/204) only a single culture. Patients with culture-negative infections had a higher risk for positive cultures at reimplantation (HR 2.946 (95% CI 1.247-6.961), P = .014) and patients with infected total hip arthroplasty (THA) (HR 3.547 (95% CI 1.7-7.4), P = .001). Patients with positive cultures during reimplantation had a higher risk for reinfection (HR 2.27 (95% CI 1.181-4.363), P = .014) as well as patients with a single positive culture (HR 2.421 (95% CI 1.139-5.143), P = .021). CONCLUSION: As positive cultures are common and increase reinfection risk irrespective of their numbers, longer antibiotic therapy following reimplantation can be an option. Single positive cultures in reimplantation surgery should not be considered contamination.
Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Infecções Relacionadas à Prótese , Antibacterianos/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Humanos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/cirurgia , Reinfecção , Reoperação , Reimplante/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients. QUESTIONS/PURPOSES: (1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision? METHODS: Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models. RESULTS: A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009). CONCLUSIONS: Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Neoplasias Ósseas/cirurgia , Osteossarcoma/cirurgia , Osteotomia/efeitos adversos , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Próteses e Implantes/efeitos adversos , Medição de Risco/métodos , Adulto , Idoso , Neoplasias Ósseas/diagnóstico , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Osteossarcoma/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Desenho de Prótese , Falha de Prótese , Reoperação , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Limb lengthening and deformity correction with motorized intramedullary lengthening nails is a more comfortable and equally safe procedure than the use of external fixators. While this treatment is a well-established method in adults, intramedullary nailing for skeletally immature patients remains a challenge and is the focus of current clinical investigations. OBJECTIVE: Elucidation of the indications for the application of femoral and tibial lengthening nails in skeletally immature patients, presentation of essential characteristics and limitations of the treatment. MATERIAL AND METHODS: Treatment of skeletally immature patients up to 16 years old who had a lengthening nail inserted was retrospectively clinically and radiologically evaluated (2016-2018). RESULTS: A total of 60 procedures were performed on 54 patients. Mean age at the time of surgery was 13.6 years and the mean follow-up time was 10 months. Different nailing approaches were used: antegrade femoral (nâ¯= 42), retrograde femoral (nâ¯= 10) and antegrade tibial (nâ¯= 8). The average amount of lengthening was 45â¯mm. In 58 of the 60 cases (96.7%) the desired amount of lengthening was achieved, while 2 patients experienced complications that required interruption of the treatment. None of the patients developed growth disorders associated with the nailing approach. CONCLUSION: Different approaches for intramedullary lengthening nails can be used in children and adolescents to correct leg length discrepancy with or without concomitant deformities. The treatment is limited by the size of the available nails, the residual growth and extent of the deformity. Larger trials will be needed to further validate the application of lengthening nails in skeletally immature patients.
Assuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas , Adolescente , Adulto , Criança , Fêmur , Humanos , Desigualdade de Membros Inferiores , Unhas , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Tumors localized in the proximal tibial meta-diaphysis often lead to osteoarticular resections. MATERIALS AND METHODS: In this study, we retrospectively reviewed four patients who underwent intercalary tumor resection and reconstruction using an ultra-short stem in the proximal tibial epiphysis, a procedure that to our knowledge has not been reported in literature so far. RESULTS: At the time of operation, the mean patient age was 26.2 years. Three patients were male and one was female. Patients were diagnosed with osteosarcoma in two cases, Ewing's sarcoma and malignant fibrous histiocytoma of bone in one case each. In all cases, wide tumor resections were achieved (osteotomy 3-3.5 cm below the tibia plateau joint surface, mean resection length of tibial bone 18 cm) at a mean time of operation of 198.8 min. Two superficial wound-healing disorders occurred, leading to one surgical revision in each case. One local tumor recurrence occurred 12 months after operation in a patient who discontinued his adjuvant chemotherapy. This patient died of disease, 31 months after operation. Three patients are alive with no evidence of disease at a mean follow-up of 56 months. Walking is not impaired and light sports activities have been reported in all cases. The mean MSTS score is 28/30. CONCLUSIONS: Therefore, we report this reconstruction technique to be considered for special indications where the functional outcome can be improved by preservation of the knee joint in tumors of the proximal meta-diaphyseal tibial region.
Assuntos
Neoplasias Ósseas/cirurgia , Histiocitoma Fibroso Maligno/cirurgia , Osteossarcoma/cirurgia , Osteotomia/métodos , Desenho de Prótese , Sarcoma de Ewing/cirurgia , Tíbia/cirurgia , Adolescente , Criança , Diáfises/cirurgia , Epífises/cirurgia , Feminino , Seguimentos , Humanos , Articulação do Joelho , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Procedimentos Ortopédicos/métodos , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Partial articular supraspinatus tendon avulsions (PASTA) lesions remain challenging with regard to diagnosis and treatment. DIAGNOSTICS: For the diagnosis of PASTA lesions, arthroscopic evaluation of the supraspinatus tendon is key. Preoperative imaging alone is usually not sufficient to make the treatment decision. OPERATIVE TECHNIQUE: For non-significant partial tears of less than 50 % of the tendon thickness a simple debridement is indicated. Two basic repair techniques, a transtendon repair technique and a repair after tear completion, can be distinguished. In PASTA lesions, a repair is generally preferred to debridement. RESULTS: Results in the literature do not favor one repair technique over the other. Prospective randomized trials comparing debridement with repair are lacking in the literature. From a technical standpoint tear completion and repair seem to be a bit more reproducible.
Assuntos
Artroscopia/métodos , Desbridamento/métodos , Lesões do Manguito Rotador/diagnóstico , Lesões do Manguito Rotador/cirurgia , Manguito Rotador/cirurgia , Técnicas de Sutura , Terapia Combinada/métodos , Medicina Baseada em Evidências , Humanos , Procedimentos de Cirurgia Plástica , Resultado do TratamentoRESUMO
BACKGROUND: We sought to examine whether mitotic count (MC) and the amount of viable tumour (VT) following neoadjuvant systemic chemotherapy (SC) for primary, localised, high-grade soft tissue sarcoma (STS) correlate with prognosis. METHODS: Retrospective analysis of 57 patients who underwent SC involving a combination of an anthracycline and an alkylating agent, followed by surgical resection between 2001 and 2011. RESULTS: The amount of VT after chemotherapy was significantly associated with disease-specific survival (DSS) and event-free survival (EFS). Patients with <10% VT had a DSS of 94% at 5 years, compared with 61% for patients with ⩾10% VT (P=0.033); EFS was 75%, compared with 48% (P=0.030). Patients with an MC of ⩾20/10 high power fields (HPF) after chemotherapy had a significantly lower DSS (33% vs 84% at 5 years, P<0.001) and EFS (40% vs 63% at 5 years, P=0.019) than patients with an MC of <20/10 HPF. CONCLUSIONS: The MC and the amount of VT after neoadjuvant therapy for primary, localised, high-grade STS appear to correlate with prognosis. If these results are validated prospectively, then they could provide a rational for the design of neoadjuvant treatment modification/escalation studies, analogue to the EURAMOS-1 trial for bone sarcomas.
Assuntos
Antineoplásicos/uso terapêutico , Índice Mitótico , Sarcoma/mortalidade , Sarcoma/patologia , Neoplasias de Tecidos Moles/mortalidade , Neoplasias de Tecidos Moles/patologia , Adolescente , Adulto , Idoso , Antraciclinas/administração & dosagem , Antineoplásicos Alquilantes/administração & dosagem , Sobrevivência Celular/efeitos dos fármacos , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Gradação de Tumores , Neoplasia Residual , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Sarcoma/terapia , Neoplasias de Tecidos Moles/terapia , Adulto JovemRESUMO
BACKGROUND: Four international study groups undertook a large study in resectable osteosarcoma, which included two randomised controlled trials, to determine the effect on survival of changing post-operative chemotherapy based on histological response. PATIENTS AND METHODS: Patients with resectable osteosarcoma aged ≤40 years were treated with the MAP regimen, comprising pre-operatively of two 5-week cycles of cisplatin 120 mg/m(2), doxorubicin 75 mg/m(2), methotrexate 12 g/m(2) × 2 (MAP) and post-operatively two further cycles of MAP and two cycles of just MA. Patients were randomised after surgery. Those with ≥10% viable tumour in the resected specimen received MAP or MAP with ifosfamide and etoposide. Those with <10% viable tumour were allocated to MAP or MAP followed by pegylated interferon. Longitudinal evaluation of quality of life was undertaken. RESULTS: Recruitment was completed to the largest osteosarcoma study to date in 75 months. Commencing March 2005, 2260 patients were registered from 326 centres across 17 countries. About 1334 of 2260 registered patients (59%) were randomised. Pre-operative chemotherapy was completed according to protocol in 94%. Grade 3-4 neutropenia affected 83% of cycles and 59% were complicated by infection. There were three (0.13%) deaths related to pre-operative chemotherapy. At definitive surgery, 50% of patients had at least 90% necrosis in the resected specimen. CONCLUSIONS: New models of collaboration are required to successfully conduct trials to improve outcomes of patients with rare cancers; EURAMOS-1 demonstrates achievability. Considerable regulatory, financial and operational challenges must be overcome to develop similar studies in the future. The trial is registered as NCT00134030 and ISRCTN 67613327.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Ósseas/tratamento farmacológico , Osteossarcoma/tratamento farmacológico , Adolescente , Neoplasias Ósseas/cirurgia , Criança , Cisplatino/administração & dosagem , Cisplatino/efeitos adversos , Terapia Combinada , Doxorrubicina/administração & dosagem , Doxorrubicina/efeitos adversos , Etoposídeo/administração & dosagem , Etoposídeo/efeitos adversos , Feminino , Humanos , Ifosfamida/administração & dosagem , Ifosfamida/efeitos adversos , Interferon-alfa/administração & dosagem , Interferon-alfa/efeitos adversos , Masculino , Metotrexato/administração & dosagem , Metotrexato/efeitos adversos , Terapia Neoadjuvante , Osteossarcoma/cirurgia , Polietilenoglicóis/administração & dosagem , Polietilenoglicóis/efeitos adversos , Qualidade de Vida , Projetos de Pesquisa , Adulto JovemRESUMO
Curative therapies for Ewing sarcoma have been developed within cooperative groups. Consecutive clinical trials have systematically assessed the impact and timing of local therapy and the activity of cytotoxic drugs and their combinations. They have led to an increase of long-term disease-free survival to around 70% in patients with localized disease. Translational research in ES remains an area in which interdisciplinary and international cooperation is essential for future progress. This article reviews current state-of-the art therapy, with a focus on trials performed in Europe, and summarizes novel strategies to further advance both the cure rates and quality of survival.
Assuntos
Neoplasias Ósseas/terapia , Comportamento Cooperativo , Comunicação Interdisciplinar , Sarcoma de Ewing/terapia , Neoplasias de Tecidos Moles/terapia , Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Ósseas/mortalidade , Criança , Ensaios Clínicos como Assunto , Terapia Combinada , Progressão da Doença , Humanos , Terapia Neoadjuvante , Osteotomia , Radioterapia Adjuvante , Sarcoma de Ewing/mortalidade , Neoplasias de Tecidos Moles/mortalidade , Taxa de SobrevidaRESUMO
The aim was to evaluate the effects of additional exercises during inpatient stays on bone mass in pediatric bone tumor patients. 21 patients were non-randomly allocated either to the exercise group (n = 10) or the control group (n = 11). DXA of the lumbar spine, the non-affected femur and both calcanei was performed after completion of neoadjuvant chemotherapy (baseline), as well as 6 and 12 months after baseline. Bone mineral content (BMC), bone mineral density (BMD) and height-corrected lumbar spine Z-scores were determined. Group changes after 6 and 12 months were compared by covariance analyses. Additionally, daily physical activities (PA) were assessed by means of accelerometry. After adjusting for initial age, height and weight, mean reductions in lumbar spine and femoral BMC were lower in the exercise group (not significant). Effect sizes during the observational period for lumbar spine and femur BMC were generally small (partial η² = 0.03). The exercise group demonstrated substantially higher PA levels in terms of gait cycles per day, per hour and moderate PA (activities above 40 gait cycles per minute). Additional exercises for bone tumor patients are feasible during hospitalization. Though the intervention did not influence BMC, it appeared beneficial regarding PA promotion with respect to volume and intensity.
Assuntos
Densidade Óssea , Neoplasias Ósseas/fisiopatologia , Neoplasias Ósseas/terapia , Ossos da Extremidade Inferior/fisiologia , Terapia por Exercício , Adolescente , Calcâneo/fisiologia , Criança , Terapia Combinada , Feminino , Fêmur/fisiologia , Humanos , Pacientes Internados , Vértebras Lombares/fisiologia , Masculino , Estudos ProspectivosRESUMO
Primary bone neoplasms can be classified into benign, locally/aggressive and rarely metastasizing and malignant tumors. Patients with benign tumors usually undergo surgical treatment in cases of local symptoms, mainly consisting of pain or functional deficits due to compression of important anatomical structures, such as nerves or blood vessels. Locally/aggressive and rarely metastasizing tumors exhibit an infiltrative growth pattern, so that surgical treatment is necessary to prevent further destruction of bone leading to local instability. Finally, the surgical treatment of malignant tumors is, with few exceptions, considered to be a prerequisite for long-term survival, either alone or in combination with systemic chemotherapy. Whereas the main objective of surgery in the treatment of benign tumors is relief of local symptoms with a minimum amount of damage to healthy tissue and minimizing the risk of local recurrence while ensuring bone stability in locally aggressive and rarely metastasizing tumors, the primary goal in the operative treatment of bone sarcomas is the resection of the tumor with clear surgical margins followed by defect reconstruction and the preservation of function. This review examines the current developments in the surgical treatment of primary bone neoplasms with respect to the management of the tumors and novel reconstructive options.
Assuntos
Neoplasias Ósseas/cirurgia , Procedimentos Ortopédicos/métodos , Neoplasias Ósseas/classificação , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/patologia , Osso e Ossos/patologia , Osso e Ossos/cirurgia , Humanos , Invasividade Neoplásica , Prognóstico , Sarcoma/patologia , Sarcoma/cirurgia , Análise de SobrevidaRESUMO
BACKGROUND: Due to its growing popularity golf has now come into the focus of orthopedic sports medicine. With a wide range of age groups and playing levels, orthopedic surgeons will encounter a wide range of musculoskeletal problems which are usually the result of overuse rather than trauma. ANATOMY: The shoulder joint plays an important role in the golf swing whereby not only the muscles around the glenohumeral joint but also the scapula stabilizing muscles are extremely important for an effective golf swing. INJURY PATTERNS: Golf is strictly not considered to be an overhead sport; however, the extreme peak positions of the golf swing involve placing the shoulder joint in maximum abduction and adduction positions which can provoke impingement, lesions of the pulley system or even a special form of posterior shoulder instability. PERSPECTIVES: Even after complex shoulder operations, such as rotator cuff repair or shoulder arthroplasty, a return to the golf course at nearly the same level of play can be expected.
Assuntos
Traumatismos em Atletas/diagnóstico , Golfe/lesões , Lesões do Ombro , Adolescente , Adulto , Fatores Etários , Traumatismos em Atletas/fisiopatologia , Traumatismos em Atletas/cirurgia , Transtornos Traumáticos Cumulativos/diagnóstico , Transtornos Traumáticos Cumulativos/fisiopatologia , Transtornos Traumáticos Cumulativos/cirurgia , Eletromiografia , Humanos , Atividades de Lazer , Pessoa de Meia-Idade , Músculo Esquelético/lesões , Músculo Esquelético/fisiopatologia , Músculo Esquelético/cirurgia , Traumatismos Ocupacionais/diagnóstico , Traumatismos Ocupacionais/fisiopatologia , Traumatismos Ocupacionais/cirurgia , Amplitude de Movimento Articular/fisiologia , Fatores de Risco , Manguito Rotador/fisiopatologia , Manguito Rotador/cirurgia , Lesões do Manguito Rotador , Ombro/fisiopatologia , Adulto JovemRESUMO
BACKGROUND: The majority of benign bone tumors are cartilage tumors. Most common are enchondroma and osteochondroma. Often they represent incidental findings in radiological diagnostics. Thus, the incidence of cartilage tumors is unknown, as most of them are never diagnosed due to the absence of any symptoms. OBJECTIVES: This article describes the diagnostic and therapeutic approach of benign cartilage tumors, focusing on incidental findings. METHODS: The current knowledge and our own experience in the diagnostics and treatment of benign condroid tumors are presented. RESULTS: As enchondroma represent most often the classic incidental finding without any symptoms or clinical findings, osteochondroma are often diagnosed in young patients by clinical examination showing a painless swelling that can increase in size according to skeletal growth. Most of these asymptomatic enchondroma and osteochondroma are so called "leave me alone lesions" and do not need any treatment, while other benign tumors (e.g., atypical cartilage tumors, chondroblastoma, chondromyxoidfibroma or osteochondroma with a cartilage cap of over 2 cm) need surgical treatment. These active or local aggressive tumors must be differentiated from the "leave me alone lesions". Additionally, patients with syndromes like Ollier disease (enchondromatosis), Maffucci syndrome or hereditary multiple exostosis must be examined and checked carefully as malignant degradation is possible. CONCLUSION: As most cartilage tumors are benign and remain benign, inappropriate diagnostics or operative treatment just to provide security is obsolete. Plain X-ray is often enough for follow-up and other modalities only become necessary when symptoms occur.
Assuntos
Neoplasias Ósseas/diagnóstico , Neoplasias Ósseas/cirurgia , Condroma/diagnóstico , Condroma/cirurgia , Osteocondroma/diagnóstico , Osteocondroma/cirurgia , Osteotomia/métodos , Humanos , Achados IncidentaisRESUMO
BACKGROUND: Primary bone sarcomas typically arise in the long bones and the pelvis of children and adolescence but may also occur in adults. Meta/diaphysial tumour involvement resulting in the necessity of a joint replacement is more common than diaphysial tumour sites. AIM: In the treatment of these tumours, both endoprosthetic replacement and biological reconstruction techniques are used. Each technique has method-specific advantages and disadvantages. RESULTS: To choose the appropriate surgical method, a multitude of influencing parameters need to be considered. The age at treatment (soft tissue situation/estimated growth/biological potential of the bone), therapeutic concept (palliative vs. curative), the tumour site (upper/lower extremity), tumour expansion (diaphysis/metaphysis) and oncological treatment concept (chemotherapy/radiotherapy) are key factors significantly influencing the surgical technique in terms of functional outcome and longevity of the reconstruction. CONCLUSION: Surgical treatment of bone sarcoma requires broad-based experience of the oncological surgeon. Knowledge of the different surgical technics and reconstruction methods is decisive to offer the individual patient the best oncological and functional outcome.
Assuntos
Bioprótese , Neoplasias Ósseas/cirurgia , Prótese Articular , Osteossarcoma/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adulto , Neoplasias Ósseas/diagnóstico por imagem , Terapia Combinada , Medicina Baseada em Evidências , Humanos , Osteossarcoma/diagnóstico por imagem , Radiografia , Procedimentos de Cirurgia Plástica/instrumentaçãoRESUMO
BACKGROUND: Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES: The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS: The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS: Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS: Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.