Filippo Frenos

Surgical treatment of pathologic fractures of humerus

This study evaluates different operative treatment options for patients with metastatic fractures of the humerus focusing on surgical procedures, complications, function, and survival rate. From January 2003 to January 2008, 87 pathological fractures of the humerus in 85 cancer patients were surgically treated in our institutions. Histotypes were breast (n=21), lung (n=14), prostate (n=5), bladder (n=4), kidney (n=13), thyroid (n=7), larynx (n=1), lymphoma (n=5), myeloma (n=8), colon-rectum (n=1), melanoma (n=1), testicle (n=1), hepatocellular carcinoma (n=1) and unknown tumours (n=3). Lesions of the proximal epiphysis were treated with resection and endoprosthetic replacement (n=30). The remaining 57 fractures were stabilized with antegrade unreamed intra-medullary locked nailing without (9 cases) or with resection and use of cement (48 cases). The function of the upper limb was assessed using the Musculo-Skeletal Tumor Society (MSTS) rating scale and survival rate was retrospectively analysed. The mean survival time of patients after surgery was 8.3 months. Complications of endoprosthetic replacement recorded included disease relapse (n=3), soft tissue infection (n=2) and palsy of musculocutaneous nerve (n=1) whereas, for intra-medullary locked nailing there were three cases of soft tissue infection and one case of radial nerve palsy. The mean MSTS score at follow-up was 73% for endoprosthesis and 79.2% for locked intra-medullary nailing. Endoprosthetic replacement of the proximal humerus provides a good function of the upper limb, a low risk of local relapse with a low complication rate at follow-up. Unreamed nailing provides immediate stability and pain relief, minimum morbidity and early return of function.

Modular Endoprostheses for Nonneoplastic Conditions: Midterm Complications and Survival

The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1–167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (p = 0.921), nor to the reconstruction site (p = 0.402). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (p = 0.851). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease.

Soft tissue myxofibrosarcoma: A clinico-pathological analysis of a series of 75 patients with emphasis on the epithelioid variant.

The clinical course of soft tissue myxofibrosarcoma is characterized by a high incidence of recurrences and there is no agreement on how to identify patients at major risk. An epithelioid histological variant has been described, with a possible worse prognosis. We reviewed our series to identify prognostic factors and assess clinical significance of the epithelioid variant.

Modular megaprosthesis reconstruction for oncological and non-oncological resection of the elbow joint.

BACKGROUND Reconstruction of large bone defects around the elbow joint is surgically demanding due to sparse soft tissue coverage, complex biomechanics and the close proximity to neurovascular structures. Modular megaprostheses are established reconstruction tools for the elbow, but only small case series have been reported in the literature. METHODS Thirty-six patients who underwent reconstruction of the elbow joint with a modular megaprosthesis were reviewed retrospectively. In 31 patients (86.1%), elbow replacement was performed after resection of a bone tumour, whereas five non-oncological patients (13.9%) underwent surgery because of a previous failed elbow reconstruction. Functional outcome, rate of complications and oncological results were considered as primary endpoints. RESULTS The mean follow-up was 25 months. The average achieved Mayo Elbow Performance Score (MEPS) was 77.08 (range 40-95) and the average Musculoskeletal Tumor Society (MSTS) score was 22.9 (range 8-30). Six complications (16.7%) were observed: two radial palsies, one temporary radial nerve dysfunction, one ulnar palsy, one disassembling of the articular prosthesis component and one deep infection necessitating the only implant removal. The overall 5-year survival rate of the patients was poor (25.1%) because of rapid systemic progression of the oncological disease in patients with metastatic lesion. However, the 5-year survival rate of the implant was very satisfactory (93%). CONCLUSIONS Modular megaprosthesis is a reliable and effective reconstruction tool in large bone defects around the elbow joint. The complication rates are lower than seen in osteoarticular allografts and allograft-prosthesis composites while the functional outcome is equal. In palliative situations with metastatic disease involving the elbow, modular megaprosthesis enables rapid recovery and pain relief and preserves elbow function.

Surgery for Soft Tissue Sarcomas

Soft-tissue sarcomas are rare tumours of extreme heterogeneity. The degree of malignancy, the dimensions, the spontaneous necrosis and vascular invasion are important prognostic factors. Surgery, curative in more than 90 % of cases, is the main therapy. Obtaining adequate surgical margins (wide or radical) is essential. An important surgical aggressiveness however requires more complex reconstructions (free flaps, motor units transplants, nerves and tendons grafts etc.). Resection margins are must be adequate or if not, the use of radiotherapy will improve local control. The effect of radiotherapy does not differ significantly whether it is used pre- or post-operatively. The first, however, most frequently leads to local complications. Interstitial brachytherapy and intra-operative radiotherapy have special advantages. Currently, with surgery combined with radiation therapy, the risk of local recurrence is less than 10 %. Loco-regional treatment (infusion of hyperthermia with TNF, neo-adjuvant chemotherapy, etc.) are reserved for non-operable patients and may produce a reduction in the neoplastic mass which allows conservative surgery in 85 % of cases.

Is Arthrodesis a Reliable Salvage Option following Two-Stage Revision for Suspected Infection in Proximal Tibial Replacements? A Multi-Institutional Study

The aim of this multicentric retrospective study was to verify whether knee arthrodesis (KA) is a viable reconstructive option after two-stage revision for infection of proximal tibia (PT) endoprosthetic reconstruction (EPR). Sixty patients who underwent a two-stage revision were included. Definitive EPR or a KA with a modular system was performed following consideration of soft tissue and extensor mechanism conditions. Patients were evaluated with Musculoskeletal Tumor Society Score and Oxford Knee Score. Implant survival was assessed on the basis of recurrence of infection. Five patients did not receive any reconstruction after the first stage. In 14 cases, a KA was performed, and in 41, an EPR was implanted. At 5 years follow-up, reinfection rate in the KA group was lower (10 vs. 17.5% in KA and EPR groups, respectively). In reinfected patients, the KA group had a reduced rate of amputation when compared with those with EPR (50 vs. 88%). Functional evaluation did not show any significant differences between the two groups. A successful KA using a modular implant can eradicate infection and allow preservation of the limb with good function and good pain relief in after two-stage revision for an infected PT EPR.

Myxoid Liposarcoma: Prognostic Factors and Metastatic Pattern in a Series of 148 Patients Treated at a Single Institution

Objectives The authors reported a retrospective study on myxoid liposarcomas (MLs), evaluating factors that may influence overall survival (OS), local recurrence-free survival (LRFS), metastasis-free survival (MFS), and analyzing the metastatic pattern. Methods 148 MLs were analyzed. The sites of metastases were investigated. Results Margins (p = 0.002), grading (p = 0,0479), and metastasis (p < 0,0001) were significant risk factors affecting overall survival (OS). Type of presentation (p = 0.0243), grading (p = 0,0055), margin (p = 0.0001), and local recurrence (0.0437) were risk factors on metastasis-free survival (MFS). Authors did not observe statistically significant risk factors for local recurrence-free survival (LRFS) and reported 55% extrapulmonary metastases and 45% pulmonary metastases. Conclusion Margins, grading, presentation, local recurrence, and metastasis were prognostic factors. Extrapulmonary metastases were more frequent in myxoid liposarcoma.

Vascularized fibular autografts in upper limb oncological reconstructions

Introduction The objective of the present study was to review our series of vascularized fibular graft (VFG) reconstructions in intercalary and articular bone defects of the upper limb after oncological resection. Materials and methods The total number of patients was divided in 4 groups concerning reconstruction type: 13 intercalary (11 VFG, 2 VFG + allograft); 12 growth plate transplantation (8 proximal humerus, 4 distal radius); 6 wrist arthrodesis; 2 proximal humerus reconstruction with allograft + VFG. We observed 15 complications at recipient site requiring surgical revision in 8 cases with implant removal in 3 cases. A fibular fracture occurred in 11 cases, healed after conservative treatment in 7 cases and after new osteosynthesis in 2, while in 2 cases the graft was removed and replaced with a prosthetic implant. Deep infection occurred in 1 case requiring graft removal. At donor site, in growth plate transplantation 60% of patients presented a peroneal nerve deficit, spontaneously resolved in all but 1 case. One patient developed a valgus ankle deformity. Results At a mean follow-up of 73.5 months (1–165), 29 patients were continuously disease free, 3 patients were alive after metastasectomy and 2 patients were died of the disease. Functional results according with MSTS on 28 evaluable patients were excellent in 20 cases, good in 6 and fair in 2 cases. Conclusions VFG showed to be a valid reconstructive option after bone tumor resections of the upper limb. In intercalary resections, a stable and long lasting reconstruction was achieved with only one failure due to deep infection. Wrist arthrodesis showed 100% success rate at long term with satisfactory functional results. Growth plate transplantation in children allowed excellent function but was technically demanding, presenting the risk of donor site complications. The association of proximal humerus osteoarticular allograft and vascularized fibula was unsuccessful resulting in a failure for fracture in both patients. C02—MUSCULOSKELETAL TUMORS AND METABOLIC DISEASES 2