Is acute compression and distraction superior to segmental bone transport techniques in chronic tibial osteomyelitis ? Comparison of Distraction Osteogenesis Techniques

Treatment of tibial osteomyelitis with infected, necrotic, unstable bone segments (Cierny-Mader Type IV local osteomyelitis) includes débridement and segmental resection, which results in long bone defects. Reconstruction may be with distraction osteogenesis. Segmental bone transport and acute compression and distraction techniques are two main distraction osteogenesis techniques used in the treatment of Type IV local tibial osteomyelitis. In this retrospective, four-center study we compared these two techniques during a 15-year period. 29 patients treated using segmental bone transport technique and 45 patients were treated using acute compression and distraction technique. The mean age (p= 0,34) and the mean bone loss with preoperative shortening (P=0,08) and the mean number of previous operation (p=0,06) were not different in these two groups. . At latest followup, functional and radiographic results were evaluated There was no difference between two technique on the Paley's scoring system ( p=0,33) and in the total number of complication(p=0,16). Mean external fixator index was lower in the second group ( p=0.02 ). Both techniques can be used safely; however, the acute compression distraction technique may provide greater patient satisfaction because of shorter external fixator index, although future studies will be needed to determine whether this is.

Bilateral humeral lengthening in achondroplasia with unilateral external fixators

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104).

The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies.

Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Cite this article: Bone Joint J 2015;97-B:1577–81.

Combined technique for the correction of lower-limb deformities resulting from metabolic bone disease

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture.

Fixator-assisted nailing and consecutive lengthening over an intramedullary nail for the correction of tibial deformity

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

Complications of limb salvage surgery in childhood tumors and recommended solutions

Bone and soft tissue malignancies are associated with serious diagnostic and therapeutic problems in every level of pubertal growth in children. Current treatment modality preferred in bone and soft tissue tumors is wide resection of tumor followed by the reconstruction of consequent defect by various methods. Chemotherapy and radiotherapy are applied for systemic effects to the patient pre- and post-operatively and for local effects that facilitate the surgical procedure. Mostly, it is very difficult to control problems following wide resection and reconstruction. In this study, our aim is to discuss the problems encountered in different resection and reconstruction approaches in childhood bone and soft tissue tumors, and the recommended solutions addressed to these problems. From 1990 to 2003, a total of 68 patients (38 female, 30 male) with a mean age of 13.1 (1.5-18) were included in the study. 85.3% of patients were diagnosed as osteosarcoma and the rest was Ewing's sarcoma. Seventy-five percent of patients had stage IIB disease. The lesions of 34 patients were detected to be in distal femur, 26 in proximal tibia and fibula, 4 in foot and ankle joint, and the remaining 4 in pelvis. As reconstructive surgery, 40 patients had modular prosthesis, vascularized fibular graft was performed in 13 patients, and 10 patients underwent arthrodesis with vascularized fibular graft. 20.6% of patients had shortened limb, infection was detected in 4 patients, laxity in 5, and restricted motion in 4 as complication of prosthesis. With sacrificed physis, 13 patients had a mean value of 4.6 cm limb shortness. Limb salvage surgery has been considered as the gold standard treatment in orthopedic oncological surgery. More understanding of the biology of sarcoma, introduction of new effective chemotherapeutic agents, development of new techniques concerning the surgical resection, advances in diagnostic methods, and improvements in reconstructive surgery all make a major contribution to limb salvage surgery. Since some problems are still encountered, we offer a therapeutic algorithm for complications in the management of childhood tumors that we have encountered so far.

Childhood osteosarcoma: Evaluation of 94 cases. A single institution study

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Background: Osteosarcoma is the most frequent bone tumor in children and adolescents. The aim of this study is to evaluate the demographic characteristics, therapy, and long term outcome of children with osteosarcoma in a single institution. Methods: Between January 1990 and December 2006, 94 children (53 male, 41 female) with a median age of 13 (5–16) years and a histopathologic diagnosis of osteosarcoma were treated with an institutional chemotherapy regimen comprising of 6 courses (3 pre-, 3 postoperatively) of epirubicin (90 mg/m2), cisplatin(100 mg/m2), and ifosfamide(2 g/m2 × 3 days) every 3 weeks. Results: The median follow-up time was 36 (2–219) months. 68 patients were alive at the time of analysis. 26 patients died; 20 of disease, 5 of toxicity, and 1 of second malignancy (acute myeloid leukemia). 90% of the patients had a limb salvage. 5 and 10 year OS for all patients were 64.7 % ( [95 % CI] 74.8–52.94 %) and 62.2 % (95 % CI 74.6–49.9 %), respectively. 5 and 10 year EFS for all patients was 51.8 % (95% CI 40.2–63.4 %). 5 and 10 year OS for nonmetastatic patients were 78.3 % (95% CI 66.9–89.7 %) and 75.1 %(95% CI 62.6–87.6), vs. 13.5 % 5 year OS for metastatic patients(95% CI 0–30.8 %) (p< 0.001). 5 and 10 year EFS for nonmetastatic patients was superior to those with metastatic disease [62.4 % (95% CI 49.9–79.9 %) vs. 6.9 % (95% CI 0–19.9 %)) (p<0.001). A total of 33 patients experienced relapse and/or progression at a median of 9 months (range 0–40 months). 10 year OS for 18 patients (11 metastatic at diagnosis) who progressed during preoperative chemotherapy was 13 % vs. 75 % for those who didnot have progressive disease (p< 0.001). The rate of histologically good response to preoperative chemotherapy was 64.5 %. Histologic response (<90 percent necrosis vs ≥90 percent) significantly correlated with 5 year EFS (31 % vs 67.6 %, p=0.023) but not with OS (57.7 % vs 76.5 %, p=0.13). Conclusions: The presence of metastases at diagnosis was the most significant characteristic influencing outcome. Our results demonstrate that the combination of epirubicin, cisplatin, and ifosfamide is an active and reasonably well-tolerated regimen for childhood osteosarcoma.

No significant financial relationships to disclose.

An alternative method for the treatment of nonunion of the tibia with bone loss

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient.

We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.

A correction of windswept deformity by fixator assisted nailing

We report two cases with windswept deformities of the lower extremities. All deformities were corrected by fixator-assisted intramedullary nailing. At the latest follow-up, the patients had normal alignment, without symptoms and no loss of correction.

Treatment of humeral shaft non-unions by the Ilizarov method

Thirty-five humeral shaft non-unions treated by the Ilizarov external fixator were studied after an average of 39 months. Bone union was achieved in all but one. The mean time to union was 5.5 months (range: 3-10 months). Major pin tract problems leading to removal of the Schanz screws occurred in three patients. A radial nerve palsy developed in three patients, two recovered spontaneously and one was treated with a triple tendon transfer.

Surgical treatment of distal intraarticular humeral fractures in adults

We reviewed 17 patients with distal intraarticular humeral type C fractures, treated by open reduction and internal fixation, followed by an early rehabilitation programme. The results, as judged by the criteria of Jupiter, were excellent in ten, good in five and fair in two. Non-union of the olecranon osteotomy occurred in one patient.

Anterior instrumentation for adolescent idiopathic scoliosis

Thirty-two patients with adolescent idiopathic scoliosis underwent anterior fusion with rigid single rod (third generation instrumentation) and titanium mesh cages. The mean follow-up was 31 (24-45) months and the mean age was 14.9 years. There were 8 patients with King type I, 10 with type II, 6 with type III, 4 with type IV and 4 with lumbar curves. Titanium mesh cages were used in all the lumbar procedures and at the cranial and caudal ends of the instrumented area in thoracic cases. All the patients were immobilized in an orthosis for 3-6 months postoperatively. Mean preoperative primary coronal Cobb angle of 56 degrees was improved to 8.6 degrees. Average correction rate was 84%. Sagittal balance was restored with a mean thoracic kyphosis of 28 degrees and a mean lumbar lordosis of 38 degrees. Spontaneous secondary curve decompensation did not occur and postoperative thoracolumbar junctional kyphosis was not seen. One case had to be revised due to proximal screw pull out and loss of correction.

Transoral resection and reconstruction for primary osteogenic sarcoma of the second cervical vertebra

STUDY DESIGN

A case of primary osteogenic sarcoma at the second cervical vertebra is reported.

OBJECTIVES

To document an osteogenic sarcoma of the second cervical vertebra and its treatment, and to review the literature.

SUMMARY OF BACKGROUND DATA

Primary osteosarcoma of the cervical spine is encountered infrequently, and its location in the upper cervical spine is extremely rare. Two cases of osteosarcoma in the second cervical vertebra have been reported previously in the literature.

METHODS

A 15-year-old boy with a mass lesion in the axis was treated surgically by anterior transoral resection, fusion, and reconstruction of the defect with a Harms cage. The resection was completed by posterior excision of the remaining vertebral elements, and by occipitocervical instrumentation and fusion between the occiput and the fourth cervical vertebra. The therapy was completed by adjuvant chemotherapy and radiotherapy.

RESULTS

At this writing, 40 months after the initial diagnosis, the patient was in a good state of health with his underlying disease.

CONCLUSIONS

The axis is a very rare location for the occurrence of primary osteosarcoma. Osteosarcoma may histologically mimic chondroblastoma. The axis can be surgically exposed, resected, and instrumented transorally. The stabilization must be augmented by posterior occipitocervical fusion.

Rice bodies of synovial origin in the knee joint

Rice bodies are free corpuscles of synovial origin with a cartilage-like appearance that may reach hundreds in number in the intra-articular space. Rheumatologic or infectious pathologies that may produce synovial hypertrophy play a major role in the etiology. Already recognized by rheumatologists, this entity is rarely reported in orthopaedic literature. Numerous particles in the size and form of rice bodies were noted in the knee joint of an 11-year-old patient who underwent arthroscopic drainage and partial synovectomy. Histopathologic examination showed that some of the rice bodies consisted only of fibrin and some of them included a collagenous nucleus surrounded by a fibrin layer. No evidence of recurrence was observed by orthopaedic and rheumatologic evaluations within 2.5 years after the arthroscopic procedure.

Synovial chondromatosis of the subcoracoid bursa

Synovial chondromatosis, is the chondroid metaplasia of the synovial membrane. Large joints such as the knee and hip are most commonly involved. Extraarticular involvement is rarely described. Synovial chondromatosis may be associated with impingement syndrome of the shoulder. We report a case of synovial chondromatosis of the subcoracoid bursa, which resulted in impingement symptoms.