Pierre-Francois Leyvraz

Isolated limb perfusion with tumor necrosis factor and melphalan for non-resectable soft tissue sarcomas: long-term results on efficacy and limb salvage in a selected group of patients.

Isolated limb perfusion with TNF‐alpha and melphalan (TM‐ILP) is a limb salvage therapy for non‐resectable soft tissue sarcomas (STS) of the extremities. It is indicated for patients for whom amputation or debilitating surgery is the only alternative. It can be used either as an exclusive therapy (in palliation) or as a neo‐adjuvant treatment, followed by marginal resection of tumor remnants with minimal functional impairment.

Leg textiloma. A case report.

Objective: To report and highlight the potential diagnostic pitfalls and consequences of leg textiloma. Case Report and Intervention: A soft tissue pseudotumor of the left leg diagnosed in a 58-year-old man is described. The lesion was caused by a retained surgical gauze after surgery for varicose veins. The surgical gauze had remained in the subcutaneous tissue for 3 years and led to the formation of a 3-cm, well-circumscribed, pseudotumoral foreign body granuloma which appeared like a soft tissue tumor. A surgical intervention was performed and the mass was excised. During the procedure an old surgical gauze was found. The histologic examination revealed that a large foreign body granuloma (pseudotumor) had developed in contact with foreign material birefracting under polarized light (gauze). No sign of malignancy was noted. Conclusion: Although no fatal complications have been described in the musculoskeletal localization, the diagnosis is difficult and costly. According to clinical presentation, a differential diagnosis should be made between a tumoral lesion, such as a sarcoma, or a pseudotumoral lesion, such as a gossypiboma. Focal myositis or infections should also be suspected.

Closed and Open Grade I and II Tibial Shaft Fractures Treated by Reamed Intramedullary Nailing

Objective: To evaluate the results of closed and open grade I and II tibial shaft fractures treated by reamed nail and unreamed nailing. Subjects and Methods: Between 1997 and 2000, 119 patients with tibial shaft fractures were treated with reamed tibial nails. Postoperatively 96 patients (70 closed and 26 grade I and II open fractures) were followed clinically and radiologically for up to 18 months. The nail was inserted either by patellar tendon splitting or by nonsplitting technique. The nail was inserted after overreaming by 1.5 mm. Postoperatively, patients with isolated tibial fracture were mobilized by permitting partial weight bearing on the injured leg for 6 weeks. Patients with associated ankle fractures were allowed to walk with a Sarmiento cast. Results: Postoperatively, 6 (6.3%) patients developed a compartment syndrome after surgery. In 48 (50%) cases, dynamization of the nail was carried out after a mean period of 12 weeks for delayed union. Overall, a 90.6% union was obtained at a mean of 24 weeks without difference between closed or open fractures. Two (2.1%) patients with an open grade II fracture developed a deep infection requiring treatment. A 9.4% rate of malunion was observed. Eight (8.3%) patients developed screw failure without clinical consequences. At the last follow-up, 52% of patients with patellar tendon splitting had anterior knee pain, compared to those (14%) who did not have tendon splitting. Conclusion: Reamed intramedullary nail is a suitable implant in treating closed as well as grade I and II open tibial shaft fractures.

Prognostic factors in adult soft tissue sarcoma treated with surgery combined with radiotherapy: a retrospective single-center study on 164 patients

The aim of the present study is to assess the disease profile, outcome and prognostic factors in patients treated with surgery combined with radiotherapy (RT), with or without chemotherapy (CXT), for soft-tissue sarcoma (STS) in a multidisciplinary setting. One hundred and sixty-four patients with STS treated between 1980 and 2010 at the Centre Hospitalier Universitaire Vaudois were enrolled in this retrospective study. Seventy-six percent of patients underwent postoperative RT with (24%), or without (52%) CXT, 15% preoperative RT with (5%), or without (10%) CXT, surgery alone (7%), or RT alone (2%) with or without CXT. The median follow-up was 60 months (range 6-292). Local failure was observed in 18%, and distant failure in 21% of the patients. Overall survival (OS), diseasefree survival (DFS), local control (LC) and distant metastases-free survival (DMFS) were 88%, 68%, 83%, and 79% at 5 years, and 80%, 56%, 76%, and 69% at 10 years, respectively. In univariate analyses, favorable prognostic factors for OS, DFS, and DMFS were tumor size 6 cm or less, World Health Organization (WHO)/Zubrod score 0, and stage 2 or less. Age and superficial tumors were favorable only for OS and DMFS respectively. STS involving the extremities had a better outcome regarding DFS and LC. Histological grade 2 or less was favorable for DFS, DMFS, and LC. Radical surgery was associated with better LC and DMFS. RT dose more than 60 Gy was favorable for OS, DFS, and LC. In multivariate analyses, independent factors were age for OS; tumor size for OS, DFS and DMFS; WHO/Zubrod score for OS, DFS and LC; hemoglobin level for DFS; site for DFS and LC; tumor depth for DMFS; histological grade for DFS and LC; surgical procedure for LC and DMFS; and RT dose for OS. This study confirms that in a multidisciplinary setting, STS have a fairly good prognosis. A number of prognostic and predictive factors, including the role of surgery combined with RT, were identified. Regarding RT, a dose of more than 60 Gy was associated with a better outcome, at the price of a higher toxicity. We could not demonstrate a superiority of preoperative RT over postoperative RT.

Spontaneous Reduction of a Traumatic L2-L3 Subluxation without Fracture in a 14-Year-Old Boy

Objective: To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively. Clinical Presentation and Intervention: A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly. Conclusion: To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent.