Topical Application of Vancomycin Powder to Prevent Infections after Massive Bone Resection and the implantation of Megaprostheses in Orthopaedic Oncology Surgery

Introduction

Periprosthetic joint infection (PJI) represents a serious burden in orthopaedic oncology. Through the years, several local expedients have been proposed to minimise the risk of periprosthetic infection. In this study, we report our outcomes using topical vancomycin powder (VP) with the aim to prevent PJIs.

Materials and methods

Fifty oncological cases treated with massive bone resection and the implant of a megaprosthesis were included in our study. Among them, 22 [(GGroup A) received one gram of vancomycin powder on the surface of the implant and another gram on the surface of the muscular fascia]. The remaining 28 did not receive such a treatment (Group B). The rest of surgical procedures and the follow-up were the same for the two groups. Patients underwent periodical outpatient visits, radiographs and blood exams' evaluations. Diagnosis of PJIs and adverse reactions to topical vancomycin were recorded.

Results

None of the cases treated with topical vancomycin developed infections, whereas 6 of the 28 cases (21.4%) who did not receive the powder suffered from PJIs. These outcomes suggest that cases treated with VP had a significantly lower risk of post-operative PJI (p=0.028). None of our cases developed acute kidney failures or any other complication directly or indirectly attributable to the local administration of VP.

Conclusions

The topical use of vancomycin powder on megaprosthetic surfaces and the overlying fascias, alongside with a correct endovenous antibiotic prophylaxis, can represent a promising approach in order to minimise the risk of periprosthetic infections in orthopaedic oncology surgery.

Reconstruction after Pelvic Bone Massive Resection: Evolution and Actuality of 3D-Printing Technology

PURPOSE OF THE STUDY

Pelvic reconstructions after massive bone resections are among the most challenging practices in orthopedic surgery. Whether the bone gap results after a trauma, a tumor resection, or it is due to a prosthetic revision, it is mandatory to reconstruct pelvic bone continuity and rebuild the functional thread that connects spine and hip joint. Several different approaches have been described in literature through the decades to achieve those goals.

MATERIAL AND METHODS

To this date, 3D-printed implants represent one of the most promising surgical technologies in orthopedic oncology and complex reconstructive surgery. We present our experience with 3D-printed custom-made pelvic prostheses to fulfi ll bone gaps resulting from massive bone loss due to tumor resections. We retrospectively evaluated 17 cases treated with pelvic bone reconstruction using 3D-printed prostheses. Cases were evaluated in terms of both oncological and functional outcomes.

RESULTS

At the last follow-up, local complications were found in 6 cases (36%): in 4 (23.5%) of them the cause was a local recurrence of the disease, whereas only 2 (12.5%) had non-oncologic issues. The mean MSTS score in our population increased from 8.2 before surgery to 22.3 at the latest clinical control after surgery.

DISCUSSION

3D-printing technology, used to produce cutting jigs and prosthetic implants, can lead to good clinical and functional outcomes. These encouraging results are comparable with the ones obtained with other more frequently used reconstructive approaches and support custom-made implants as a promising reconstructive approach.

CONCLUSIONS

Our data confi rm 3D-printing and custom-made implants as promising technologies that could shape the next future of orthopedic oncology and reconstructive surgery.

KEY WORDS

custom made prosthesis, pelvic reconstruction, orthopedic oncology, cutting jigs, 3D-printing.

Use of Statins and Hip Fracture Risk: a Case-Control Study

PURPOSE OF THE STUDY To evaluate a possible association between hip fracture and statin use. MATERIAL AND METHODS In this case-control study we compared the use of statins between two groups of 210 patients: the first group (case group) included patients hospitalized for hip fractures while the second group (control group) included patients who did not suffer femur bone injuries. The two groups were matched for age, sex, year of hospitalization and possible confounding factors. Inside the group of cases, we also evaluated the differences in terms of fracture type, presence of previous fragility fracture and mortality between statin users and non-users. RESULTS The use of statins was most common among patients without previous fractures (OR=0.54; 95% CI=0.33-0.89; p=0.0138), especially in older patients (OR=0.40; 95% CI=0.22-0.76). We did not find any significant difference in statin intake between men and women in the control group. In the case group, those who did not use statins were more likely to undergo a medial hip fracture (28.5% vs 16.1%). Patients from case group also presented a greater mortality (27.9% vs 19.35%) and an higher percentage of previous hip fractures (20.11% vs 9.7%). However, they didn't presented a significant higher rate of fragility fractures in other sites. DISCUSSION AND CONCLUSIONS Our study suggests a reduced hip fracture risk, especially in cases aged 80 or more, a different fracture pattern (lower percentage of medial fractures) and a reduced mortality at 9 months in patients treated with HMG-CoA reductase inhibitors, confirming the previous evidences reported in literature. Key words: statin, hip fractures, fracture risk, osteoporosis.

Hemivertebrectomy of L5 in Grade 2 Chondrosarcoma: Is a Single Posterior Approach with No Nerve Root Sacrifice Possible? A Case Report

En-bloc resection of spine tumors is difficult to achieve compared to extremities tumors for anatomical reason. Several surgical techniques have been described, such as combined multiple surgical approaches or an enlarged single posterior approach. These demanding strategies correlate with high rate of intraoperative/postoperative complications. The current case is about a patient treated with a single posterior-lateral surgical approach to perform hemivertebrectomy of L5 for a single grade 2 chondrosarcoma metastasis (WBB 2-5/b-c). Usually, L5 hemivertebrectomy requires a combined surgical approach to preserve L5 root. The final solution was to perform a T-shape skin incision: a longitudinal branch centered on the vertebral spine and a transverse branch on the iliac crest. This approach allowed osteotomy of the ipsilateral iliac crest, achieving sufficient view to preserve L5 root and vessels anteriorly; the same osteotomy was used to create a bone autograft to reconstruct the residual part of L5. Finally, cryotherapy was used in order to increase the adequacy of surgical margins. A L3-S1 arthrodesis is assembled to achieve stability of the system. Surgical time was 5 hours, no nerve roots have been sacrificed nor any other intraoperative complications occurred. This surgical technique had never been described before in literature.