Antimikrobielle Silberbeschichtung von Tumorprothesen

Oncologic patients are especially vulnerable due to their illness and accompanying (neo)adjuvant therapy. The early and late infection of tumor mega-endoprostheses with biofilm producing bacteria is an essential problem which can lead to secondary amputation. Prophylaxis against infection is an effective strategy for decreasing morbidity. For centuries, the anti-infective properties of silver on infected wounds has been known. Nowadays, there is a revival in silver application due to its broad spectrum of activity against bacteria and even fungi with low local and systemic toxicity. Newer applications use metallic silver and not silver salts. Surrounding conditions should be prepared in a way that does not reduce the silver ion effect (hematoma, seroma, iodine containing antiseptic lavages, etc.). In future, hospitalization and antibiotic use are likely to be reduced by the use of silver coating. Long-term results are not yet available.     

Silver-coated megaprostheses in the proximal femur in patients with sarcoma

European Journal of Orthopaedic Surgery & Traumatology - Proximal femur replacements in patients with sarcoma are associated with high rates of infection. This study is the largest one...     

The effect of rotationplasty on the ankle joint: long-term results

In patients with rotationplasty the biomechanical conditions in the ankle joint are altered dramatically. By displacement and reduction of the weight-bearing area of the joint, the stress affecting its cartilage is increased. The use of an exoprothesis results in skin and soft tissue irritation. Due to these biomechanical changes, a prearthrotic deformity or skin problems could be expected. The current study examines changes in 21 patients treated with rotationplasty (mean follow-up 13.5 years) because of a malignant bone tumour or a femoral segmental defect. Local tenderness, skin and soft tissue changes, problems with exoprostheses, and pain was assessed by clinical examination and documented. Osseous changes were evaluated by plain X-ray. A MRI-scan was also obtained in five patients. Hardened skin and blisters were located at the main loading areas of the rotated foot. These changes could be reduced by optimizing the exoprosthetic fit. Radiographically, a slight asymptomatic attenuation of the articular space was observed in four patients and a slight coexistent subchondral sclerosis with small osteophytes in one patient. No degenerative changes were observed on X-ray and no cartilaginous changes were observed on MRI. The results suggest that the foot is able to adapt to the load changes after this procedure and that rotationplasty does not cause an inevitable arthrosis in the ankle joint.     

Treatment of primary malignant bone tumours of the distal tibia

We treated 15 patients with primary malignant bone tumours of the distal tibia of which 14 were treated by limb salvage surgery. Reconstructions were done by allografts with or without microvascular fibula transfer, by bone transport, by fibula transfer alone or by endoprosthetic replacement. The most successful methods were bone transport and endoprosthetic replacement. However, serious complications with deep infections leading to secondary amputation occurred in four patients and in all reconstruction groups. After a mean follow up of 7 years, no local recurrence occurred, and all patients were alive and free of disease. After radical resection, bone transport in defects less than 15 cm is a viable option. In larger defects in children, allograft with vascularised fibula is an acceptable alternative, but amputation still has a role in this group. In adults, endoprosthetic replacement with proper soft tissue coverage is a viable option in cases with large bony defects.

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Résumé Nous avons traité 15 malades avec une tumeur maligne primitive du tibia distal avec pour 14 dentre eux une chirurgie conservatrice du membre. Les reconstructions ont été faites par allogreffe avec ou sans transfert de péroné vascularisé, transport osseux, transfert du péroné seul ou par remplacement prothétique. Les meilleures méthodes étaient le transport osseux et le remplacement prothétique. Des complications sérieuses avec infection profonde menant à une amputation secondaire, se sont cependant produites chez quatre malades et dans tous les groupes de reconstruction. Après un suivi moyen de 7 ans, aucune récidive locale nest survenue et tous les malades sont vivants et libres de maladie. Après une résection radicale, le transport osseux dans les défauts de moins de 15 centimètres est une option valable. Dans plus grands défauts chez les enfants, lallogreffe avec péroné vascularisé est une alternative acceptable, mais lamputation a encore un rôle dans ce groupe. Chez les adultes le remplacement prothétique avec couverture cutanée adéquate est un choix valable dans les grands défauts osseux.

     

Fibromyxoma of bone: a case report and review of the literature

In this study, a case of fibromyxoma of the proximal femur in a 59-year old woman is reported. The classification of this rare bone tumour is still a matter of debate and some investigators have suggested that these lesions represent a degenerative form of fibrous dysplasia. Some authors make a further distinction between fibromyxoma and myxoma of bone. In a review of 23 cases of fibromyxoma and five cases of myxoma, no differences in clinical, radiographic and biologic behaviour between fibromyxoma and myxoma were found. Apart from the age at diagnosis, the most important difference between fibromyxoma and myxoma was the degree of myxoid matrix. Therefore, we suggest that extragnathic myxoma is a regressive variant of extragnathic fibromyxoma and should be termed as the same entity. In contrast to monostotic fibrous dysplasia fibromyxoma / myxoma often causes pain and presents as a Lodwick IC lesion with a soft tissue mass. Therefore, fibromyxoma / myxoma should be distinguished from fibrous dysplasia because of its different clinical and radiographic features.     

Silver-coated megaendoprostheses in a rabbit model--an analysis of the infection rate and toxicological side effects

Deep infection of megaprostheses remains a serious complication in orthopedic tumor surgery. Despite the use of systemic and local antibiotic prophylaxis the reported infection rate is between 5% and 35%. Silver-coated medical devices proved their effectiveness in reducing infections. The objective of this study was to examine in vivo the antimicrobial efficacy and possible side-effects of a silver-coated megaprosthesis. In a first study, 30 rabbits (15 titanium versus 15 silver-coated Mutars-endoprostheses) were infected with Staphylococcus aureus. In a second study, toxicological side effects were analyzed in 10 rabbits with a silver-coated megaprosthesis. The silver group showed significantly (p<0.05) lower infection rates (7% versus 47%) in comparison with the titanium group. Measurements of the C-reactive-protein, neutrophilic leukocytes, rectal temperature and body weight showed significant (p<0.05) lower signs of inflammation in the silver group. The analysis of the silver concentration in blood (median 1.883ppb) and in organs (0.798-86.002ppb) showed elevated silver concentrations without pathologic changes in laboratory parameters and without histological changes of organs. In conclusion, the new silver-coated Mutars-megaprosthesis resulted in reduced infection rates without toxicological side effects, suggesting that this prosthesis might be a promising device in tumor surgery exhibiting antimicrobial activity.     

Primary multifocal osseous Hodgkin disease: a case report and review of the literature

Purpose Hodgkin disease (HD) typically involves the lymphatic system at one or more sites. Rarely, Hodgkin disease presents as an osseous lesion without involvement of lymph nodes. Therefore, the histologic diagnosis of osseous HD can be problematic. We present a rare case of multifocal osseous HD and a review the literature with special emphasis on treatment and prognosis.Methods Osteomyelitis and lymphoma are the main differential diagnoses and can only be excluded histologically by the presence of Sternberg Reed cells or by immunohistochemical examinations. This case reports a 21-year old man with a Hodgkin lymphoma located at the proximal femur and the proximal tibia.Results Staging studies revealed no other tumor manifestations. Regarding the Ann Arbor classification, the presented case should be a stage IV disease. The patient is without evidence of disease 4 years after curettage, local radiation therapy, and systemic chemotherapy despite the poor prognosis considering the Ann Arbor classification.Conclusion Reviewing the few reported cases, osseous HD must be distinguished from systemic HD with diffuse bone marrow involvement and from osseous metastases in advanced stage of disease because it seems to have a better prognosis.     

Percutaneous CT-guided radio-frequency ablation of osteoid osteoma of the foot and ankle

Introduction

Percutaneous radiofrequency ablation (RFA) has been considered, in recent years, the standard treatment for osteoid osteoma (OO) of the appendicular skeleton. The variable clinical presentations in the foot and ankle pose problems in diagnosis, localization and thus treatment. The aim of this study was to assess the efficacy of RFA for patients with osteoid osteoma of the foot and ankle.

Materials and methods

A total of 29 patients (22 males, 7 females; mean age 16.7?years; range 8?C44?years) with OO of the foot and ankle (distal tibia, n?=?17; distal fibula, n?=?6; talus, n?=?3; calcaneus, n?=?3) were enrolled in the study. A CT-guided RFA was performed, using a cool-tip electrode without the cooling system, heating the lesion up to 90?°C for 4?C5?min. Clinical success, assessed at a minimum follow-up of 1?year, was defined as complete or partial pain relief after RFA. Pain and clinical outcomes were scored pre-operatively and at the follow-up with a visual analogue scale (VAS) and with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Complications and local recurrences were also recorded.

Results

Clinical success was achieved in 26 patients (89.6?%). After RFA, mean VAS and AOFAS score significantly improved from 8?±?1 to 2?±?1 (p?<?0.05) and from 60.7?±?12.7 to 89.6?±?7.1 (p?<?0.05), respectively. Two patients experienced partial relief of pain and underwent a second successful ablation. Local recurrences were found in three patients, always associated with pain. These underwent conventional excision through open surgery. No early or late complications were detected after RFA.

Conclusion

CT-guided RFA of foot and ankle osteoid osteoma is a safe and effective procedure, showing similar results for the rest of the appendicular skeleton.     

Risk of recurrence and survival after relapse in patients with Ewing sarcoma

Background

The prognosis in patients with relapsed Ewing sarcoma is unfavorable. Our investigation identifies factors predicting for the outcome following relapse.

Procedure

We analyzed type of relapse, time to relapse and overall survival after relapse (OSr) in 714 patients with first recurrence. All patients had been treated within the Cooperative Ewing Sarcoma Studies (CESS) 81 or 86, or the European Intergroup CESS (EICESS 92). OSr time was calculated from diagnosis of first relapse to last follow‐up or death.

Results

Median follow‐up time from diagnosis of primary disease was 2.2 years (mean = 4.0; range: 0.2–24.9). Relapse sites were local in 15%, combined local and systemic in 12%, and systemic in 73%. Among patients with a localized primary tumor, 20% relapsed locally, while 12% showed combined and 68% systemic relapse. When the primary disease was disseminated, 82% developed systemic, 13% combined, and 5% local relapse. Five‐year OSr was 0.13 (SE = 0.01). Outcome following local relapse, with a 5‐year survival rate of 0.24 (P < 0.001), was superior to outcome after systemic or combined recurrence. Five‐year OSr was 0.07 (SE = 0.01) in patients who relapsed 0–2 years after the diagnosis of primary disease, as compared to a 5‐year OSr of 0.29 (SE = 0.03) when relapse occurred later.

Conclusions

5‐year OSr in Ewing sarcoma is poor (<0.2). Prognostically favorable factors are: late onset (>2 years) and strictly localized relapse. Pediatr Blood Cancer 2011; 57: 549–553. © 2011 Wiley‐Liss, Inc.