Luiz Eduardo Moreira Teixeira

Complicações precoces no tratamento ortopédico das metástases ósseas

OBJETIVO: Avaliar as complicacoes precoces do tratamento ortopedico de lesoes osseas metastaticas e os fatores associados a essas complicacoes. METODOS: Foram avaliados retrospectivamente 64 pacientes submetidos a tratamento cirurgico de metastases osseas, analisando as complicacoes ocorridas no peroperatorio e pos-operatorio precoce e associando-as com a origem do tumor, o tipo de procedimento realizado, a necessidade de reposicao de sangue no peroperatorio, necessidade de novos procedimentos cirurgicos e a mortalidade em decorrencia das complicacoes. RESULTADOS: Complicacoes precoces do tratamento foram observadas em 17 (26,6%); seis (35,2%) evoluiram para obito em decorrencia dessa complicacao. De acordo com o tipo, em 15 (23,8%) casos foram complicacoes cirurgicas, em quatro (6,3%), clinicas e tres (4,7%) pacientes apresentaram tanto complicacoes clinicas quanto cirurgicas. Nao houve diferenca significativa na frequencia das complicacoes ou mortalidade quando avaliados o tipo de reconstrucao ou o local acometido. Os tumores de origem renal necessitaram de maior reposicao sanguinea e tiveram maior frequencia de complicacoes (p = 0,0001). CONCLUSAO: As complicacoes ocorreram em 26,6%. As complicacoes nao estao associadas ao tipo de tratamento realizado, nem ao local acometido. Os tumores de origem renal apresentaram risco aumentado de hemorragia.

Reprodutibilidade da classificação da AO/ASIF para fraturas dos ossos longos na criança

OBJECTIVE: To evaluate the interobserver and intraobserver reproducibility of the classification proposed by the AO/ASIF group for long bone fractures in children. METHODS: One hundred roentgenograms of long bone fractures in children were evaluated and classified according to the alphanumeric AO/ASIF classification by six observers. The strength of theintraobserver(performed with a 90-day interval) and interobserveragreementwere evaluated using the Kappa coefficient. RESULTS: The intraobserver Kappa index was 0.69 (good agreement). The interobserver index was 0.64 (good agreement) in the first evaluation and 0.61 (goodagreement) in the second analysisperformed 90 days after the initial classification. CONCLUSION: The classification proposed by the AO/ASIF group for long bone fractures demonstrated good inter- and intraobserver agreement. This classification is useful for describing fractures of long bones in children.

Recidiva local nos sarcomas de tecidos moles: fatores prognósticos

OBJECTIVE To determinate the prognostic factors associated with the local relapse in patients treated for soft tissue sarcoma in extremities. METHODS Retrospectively, 30 patients were evaluated after being treated with surgical resection of soft tissue sarcoma located in extremities, with a outcome of 36,5 +/- 12,2 months. The prognostic factors evaluated were: age, sex, location, depth, location in the anatomic compartments, size, tumor previous manipulation, surgical margins, grade of histological malignance, presence of histological necrosis or histological vascular invasion. These factors were correlated with the local relapse of the tumor with a univariated and multivariated analysis with significance when p = 0,05. RESULTS Local relapse presented significant correlation in univariated and multivariated analysis with extra-compartimental location (p = 0,001) and with high grade histological malignance (p = 0,001). There was no significant association with age (p = 1,000), sex (p = 1,000), body location (p = 0,544), depth (p = 0,288), size (p = 0,694), surgical margins (p = 0,384), previous manipulation (p = 0,461), necrosis (p = 0,461) or with the presence of vascular invasion (p = 1,000). CONCLUSION Local relapse presents correlation with extra-compartimental location and with high grade malignancy tumors.

EXTRA-ABDOMINAL DESMOID TUMOR: LOCAL RECURRENCE AND TREATMENT OPTIONS

ABSTRACT Objective: To evaluate the rate of local recurrence of extra-abdominal desmoid tumor and compare the outcomes of surgical treatment and conservative treatment. Methods: Twenty one patients (14 women and seven men), mean age 33.0±8.7 years old, with a diagnosis of desmoid tumor were evaluated. The mean follow-up period was 58.5±29.0 months. Fourteen cases involved the lower limbs, four cases involved the upper limbs, and three cases involved the trunk. The average tumor size was 12.7±7.5 cm. Of the 21 patients, 14 did not undergo previous treatment and seven patients relapsed before the initial evaluation. Surgical treatment was performed in 16 patients and conservative treatment was performed in five patients. Results: Recurrence occurred in seven patients (33%) and six of them relapsed within the first 18 months. No significant difference was observed between conservative and surgical treatment. However, a significant difference was observed among patients undergoing wide resection and who experienced improved local control. Conclusion: The recurrence rate of desmoid tumor was 33.3%. There was no difference in recurrence between conservative and surgical treatment. In surgical treatment, wide margins showed better results for recurrence control. Level of Evidence III. Retrospective Observational Study.

Prognostic Factors in Soft Tissue Sarcoma

Soft tissue sarcoma (STS) represents a heterogeneous group of mesenchymal malignant tumors with variable natural history. This term was first introduced to describe a circumscribed neoplasm consisting of malignant fat cell occurring principally in the trunk (Abernethy, 1817). Nowadays, more than 30 types of STS have been described, and many of these present innumerable subtypes. Despite this wide range of entities, they represent less than 1% of all types of cancer, but still one of the most therapeutically challenging group of tumor (Choong & Rudiger, 2008). Surgery is the keystone of treatment, associated or not to adjuvant method, and the two aims are avoid metastatic spread and local relapse. Despite advances in local control of the sarcomas, the metastatic disease, which is the cause of death for most patients, presents little recent advances. In fact, 10% of patients have metastasis at the diagnosis and 25% with localized disease will develop distant spread (Delaney et al, 1991). The systemic disease occurs primarily by hematogenic spread, and the lungs are the most common distant organs involved by the distant metastasis. Some subtypes demonstrated predilection for lymphatic route of dissemination such as synovial sarcoma and epithelioid sarcoma while the alveolar sarcoma targets the brain involvement. In contrast to bone sarcomas, soft tissue malignancies do not respond well to chemotherapies schemes. This may be explained by the diversities of subgroups or by different factors that affect the prognosis. Therefore, the difficult in treating soft tissue sarcomas is determinate which patients will need the adjuvant chemotherapy or radiation therapy. The indication of these methods is guided by factors that predict the risk of metastatic disease or local recurrence. These factors are called prognostic factors and the purpose of this chapter is to define the different prognostic factors of soft tissue sarcoma. As a heterogeneous group, the behavior and natural evolution of this tumor are variable, but, in general aspects the metastatic spreading is observed in about one third of the patients, local relapse is seen in 10% to 30% and the global 5-year survival is 60%. Different factors are reported in the literature such as tumor grade, size, location, vascular invasion, histological necrosis and presence of cytogenetic markers. However, the importance of each factor is unclear. In this chapter we will discuss each prognostic factor including: age, sex, location, size, subtype, histological aspects, grade, surgical manipulation, recurrence, imunohistochemical pattern, genetic and gene markers.

Influence of biomaterials on scintigraphic diagnosis of periprosthetic infections. Ceftizoxime-99m technetium model

PURPOSE To compare the influence of two metallic implants in the diagnosis of periprosthetic infection using 99m technetium-labeled ceftizoxime. METHODS Twenty rats were randomly divided into four groups, which received sterile and contaminated titanium and stainless steel implants. After 3 weeks, scintilographic images were obtained using a gamma chamber. Radioactivity counts were obtained for the region of interest (ROI) on the operated and non-operated paws. RESULTS Groups A, B, and C showed homogenous distribution of the radiopharmaceutical. Hyper uptake was observed in the operated paw from group D. The ROI target count was higher in the two groups with stainless steel implants. Among the control groups, the count was higher in the stainless steel group. Furthermore, among the contaminated groups, the uptake was higher in the stainless steel group, with a significant difference. The target: non-target ratio was significantly lower in the control and contaminated groups with both titanium and stainless steel, but the comparison between control groups and contaminated groups was only significant in the former. The cpm/g observed after a decay of 48h showed statistically significant differences between groups. CONCLUSION Different biomaterials used in implants have an influence on the results of scintigraphy with 99mTc-CFT.

Total knee replacement in patients with diffuse villonodular synovitis

This paper reports a case of diffuse pigmented villonodular synovitis (DPVNS), associated with advanced gonarthrosis, submitted to total knee replacement. The patient had progressive pain and swelling. She had two previous surgeries, firstly arthroscopic synovectomy and subsequently open synovectomy associated with radiotherapy, with recurrence of the disease. Magnetic resonance imaging revealed diffuse synovitis, advanced arthrosis, and bone cysts. The patient was submitted to a total knee replacement and synovectomy. There was a good postoperative clinical course, with improvement of pain, function, and joint edema on examination. The patient will be followed regarding the possibility of disease recurrence and implant survival.

Piriformis pyomyositis in a patient with Kikuchi–Fujimoto disease: a case report and literature review

Primary pyomyositis is a deep bacterial infection of the skeletal muscle. If left undiagnosed and untreated, the infection spreads, leading to sepsis, septic shock, and even death. The authors report a 23-year-old female presenting with piriformis pyomyositis during a treatment for Kikuchi–Fujimoto disease. Pyomyositis is a rare but potentially severe infection, which can lead to septic shock. The present case shows the need for a high degree of clinical suspicion for patients with compromised immune systems to begin treatment at an early stage. The literature demonstrates that outcomes of the treatment of piriformis pyomyositis are good.

Amputation risk after the revascularization procedures in sarcoma resections

Objective The objective of this study is to evaluate the efficacy of vascular reconstructive surgery after resection of bone and soft tissue tumors in extremities and the risk of progression to amputation. Methods This is a retrospective, observational data collection from medical records of patients who underwent resection of bone and soft tissue tumors in the period of 2002–2015. Thirteen patients met the inclusion criteria, which evaluated the correlations between certain factors (gender, tumor type, location, reconstruction, revascularization and patency, infection) with amputation in the postoperative period. Results In this study, of the 13 patients undergoing reconstruction, five (38.46%) evolved to amputation. All patients who progressed to amputation had the following in common: presence of bone sarcoma (p = 0.005), having undergone reconstruction with an orthopedic prosthesis (p = 0.005), lack of vascular patency in the revascularization site in the postoperative period (p = 0.032), and surgical site infection (p = 0.001). None of the patients with soft tissue sarcoma underwent amputation, and the only patient with bone sarcoma who did not undergo amputation had no infection and maintained vascular patency of the graft. Conclusion The occurrence of infection appears to be one of the main risk factors for failure of revascularization, especially in cases of bone sarcoma in which vascular reconstruction is performed with placement of a non-conventional joint prosthesis.

Biomechanical study of the effect of platelet rich plasma on the treatment of medial collateral ligament lesion in rabbits

PURPOSE To evaluate the use of platelet-rich plasma in the early stages of healing of traumatic injury of the medial collateral ligament in the knee of rabbits. METHODS Thirty rabbits were subjected to surgical lesion of the medial collateral ligament. Of these, 16 were treated with platelet-rich plasma and 14 with saline (control). After 3 and 6 weeks of treatment, 50% of the animals from each group were sacrificed, and biomechanical tests were performed on the injured ligament to compare the tensile strength between the two groups. RESULTS Platelet-rich plasma significantly increased the tensile strength of the ligament in the groups treated after3 and 6 weeks. In the group treated with platelet-rich plasma vs. saline, the tensile strength values were 3192.5 ± 189.7 g/f vs. 2851.1 ± 193.1 g/f at3 weeks (p = 0.005) and 5915.6 ± 832.0 g/f vs. 4187.6 ± 512.9 g/f at 6 weeks (p = 0.0001). CONCLUSION The use of platelet-rich plasma at the injury site accelerated ligament healing in an animal model, demonstrated by an increase in the tensile strength of the medial collateral ligament.