Po-Kuei Wu

Effectiveness of plate augmentation for femoral shaft nonunion after nailing.

Background: Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger‐sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods: Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17–77 years). The mean period of nonunion after surgery was 20.0 months (range, 7–63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results: All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back‐out, axial or rotational malalignment, or deep infections. Conclusion: Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.

The Prognosis of Patients with Primary Osteosarcoma Who Have Undergone Unplanned Therapy

OBJECTIVE For diagnosing osteosarcoma correctly, a combination of clinical, radiological and histological examinations is required. Erroneous treatment may cause local contamination and systemic seeding in patients. The purpose of this study was to compare outcomes of planned and unplanned treatment for osteosarcoma. METHODS A retrospective review of patients with high-grade osteosarcoma who received appropriate surgical treatment and chemotherapy (n = 134) and those who were misdiagnosed and received unplanned surgery (n = 16) between July 1995 and February 2005. RESULTS Patients who received unplanned treatment were older (mean age: 29.7 vs. 19.7 years; P = 0.003) and had a smaller mean tumor volume (119 vs. 280 ml; P = 0.015). The 5-year survival rate was not statistically different between the groups. Patients who had unplanned treatment had a higher local recurrence rate (43.8 vs. 17.9%; P = 0.024) and a shorter mean time for recurrence (11.9 vs. 20.8 months; P = 0.036). Furthermore, in patients who underwent unplanned treatment, lung metastases occurred earlier (6.1 vs. 16.2 months P = 0.021) and the final limb salvage rate was less (68.7 vs. 87.3%; P < 0.001). CONCLUSIONS Unplanned treatment for high-grade osteosarcoma can result in failure of local control and earlier systemic metastases.

Osteomyelitis of the femur mimicking bone tumors: a review of 10 cases

BackgroundThe clinical symptoms and radiographic appearance of osteomyelitis can mimic those of bone tumors.MethodsWe reviewed 10 patients with osteomyelitis of the femur who were initially diagnosed as having bone tumors and were subsequently transferred to our institution.ResultsNocturnal pain of moderate intensity occurred in seven patients, and all 10 patients had elevated C-reactive protein levels. The radiographic findings included the following: a permeative, moth-eaten osteolytic lesion in six patients, an osteolytic lesion with sclerotic borders in three patients, and cortical destruction with pathological fracture in one patient. Magnetic resonance imaging was performed for eight patients, and only one had a positive penumbra sign. All patients underwent a surgical biopsy to confirm the final diagnosis for histological analysis and cultures. Klebsiella pneumoniae was detected in six patients and Staphylococcus aureus, the most common organism in osteomyelitis, was detected in three. Recurrence of infection occurred in five patients following debridement surgery; of these three had a Klebsiella pneumoniae infection. All patients received antibiotic treatment for an average of 20.4 weeks (range, 4 to 44) and surgical treatment an average of 1.8 times (range, 1 to 4). At the final follow-up, all patients were fully recovered with no signs of infection.ConclusionsWhen used in combination, clinical examinations, laboratory data, and radiographic findings can reliably distinguishing osteomyelitis from bone tumors.

Improvement in High-Grade Osteosarcoma Survival: Results from 202 Patients Treated at a Single Institution in Taiwan.

AbstractThe aim of this study was to compare survival before and after 2004 and define the prognostic factors for high-grade osteosarcomas beyond those of typical young patients with localized extremity disease.Few studies have reported the long-term treatment outcomes of high-grade osteosarcoma in Taiwan.A total of 202 patients with primary high-grade osteosarcoma who received primary chemotherapy at Taipei Veterans General Hospital between January 1995 and December 2011 were retrospectively evaluated and compared by period (1995–2003 vs 2004–2011). Patients of all ages and tumor sites and those following or not following controlled protocols were included in analysis of demographic, tumor-related, and treatment-related variables and survival.Overall survival and progression-free survival at 5 years were, respectively, 67.7% and 48% for all patients (n = 202), 77.3% and 57.1% for patients without metastasis (n = 157), and 33.9% and 14.8% for patients with metastasis (n = 45). The survival rates of patients treated after 2004 were significantly higher (by 13%–16%) compared with those of patients treated before 2004, with an accompanying 30% increase in histological good response rate (P = .002). Factors significantly contributing to inferior survival in univariate and multivariate analyses were diagnosis before 2004, metastasis at diagnosis, and being a noncandidate for a controlled treatment protocol.By comparison with the regimens used at our institution before 2004, the current results support the effectiveness of the post-2004 regimens, which consisted of substantially reduced cycles of high-dose methotrexate and a higher dosage of ifosfamide per cycle, cisplatin, and doxorubicin, for treating high-grade osteosarcoma in Asian patients.

Bone–Prosthesis Composite with Rotating Hinged-Knee Prosthesis in Limb Salvage Surgery for High-Grade Sarcoma Around the Knee

Bone prosthesis composite (BPC) had been widely-used in reconstruction after wide excision of malignant tumors around the knee. However, implant selection for BPC remains a dilemma. Forty-one patients with high-grade malignant bone tumors around the knee who underwent excision and reconstruction with BPC and rotating hinged knee (RHK) prosthesis were included. The mean follow-up time was 54 months (range, 31-78 months). The average Musculoskeletal Tumor Society Rating score was 93.4% (range, 73-100%). The mean range of motion was 125°. Complications included 2 local recurrences, 2 nonunions, and 1 peri-prosthetic fracture. The reconstruction with BPC using the RHK prosthesis provided consistently good functional results with a low complication rate. The RHK prosthesis is a promising choice for BPC reconstruction.

Intralesional curettage of central low-grade chondrosarcoma: A midterm follow-up study

Background The aim of this study was to review the experience of surgical treatment of low‐grade chondrosarcoma and to assess the long‐term oncological and functional outcomes between intralesional curettage and wide excision. Methods We included 11 patients with central low‐grade chondrosarcoma lesions treated with intralesional curettage or wide excision from 1998 to 2013. Seven patients were treated with intralesional curettage and local adjuvant treatment (Group A), and four patients were treated with wide excision and reconstructive surgery (Group B). The mean age of patients was 43.8 ± 17.6 years (range, 20–71 years), and the mean duration of follow‐up was 84.4 ± 47.6 months (range, 48–194 months). Results Group A had a significantly lower complication rate than Group B; three complications were documented in Group B (0% vs. 75%, p = 0.024). The operative time (177.1 hours vs. 366.3 hours, p = 0.010) and the hospital stay (6.6 days vs. 12.5 days, p = 0.010) were significantly shorter in Group A. There was one local recurrence in Group A without statistical significance. Also, there were no differences between intralesional curettage and wide excision with respect to the blood loss. No metastasis disease occurred in either group during the follow‐up period. The Musculoskeletal Tumor Society (MSTS) scores in Groups A and B were 99.0 ± 2.5 and 94.2 ± 4.2, respectively, with statistically significant difference (p = 0.048). Conclusion Extended intralesional curettage has the benefits of good MSTS score, shorter operative time, shorter hospital stay, and lower complication rate without increasing local recurrence in central low‐grade chondrosarcoma. For central low‐grade chondrosarcoma, we suggest extended curettage to decrease soft tissue damage and surgical risk.

Manipulation therapy prior to diagnosis induced primary osteosarcoma metastasis--from clinical to basic research.

Osteosarcoma (OS) patients who suffer manipulation therapy (MT) prior to diagnosis resulted in poor prognosis with increasing metastasis or recurrence rate. The aim of the study is to establish an in vivo model to identify the effects of MT on OS. The enrolled 235 OS patients were followed up in this study. In vivo nude mice model with tibia injection of GFP-labeled human OS cells were randomly allocated into MT(+) that with repeated massage on tumor site twice a week and no treatment as MT(−) group. The five-year survival, metastasis and recurrence rates were recorded in clinical subjects. X-ray plainfilm, micro-PET/CT scan, histopathology, serum metalloproteinase 2 (MMP2), metalloproteinase 9 (MMP9) level and human kinase domain insert receptor (KDR) pattern were assayed in mice model. The results showed that patient with MT decreased 5-year survival and higher recurrence or metastasis rate. Compatible with clinical findings, the decreased body weight (30.5±0.65 g) and an increased tumor volume (8.3±1.18 mm3) in MT(+) mice were observed. The increasing signal intensity over lymph node region of hind limb by micro-PET/CT and the tumor cells were detected in lung and bilateral lymph nodes only in MT(+) group. MMP2 (214±9.8 ng/ml) and MMP9 (25.5±1.81 ng/ml) were higher in MT(+) group than in MT(−) group (165±7.8 ng/ml and 16.9±1.40 ng/ml, individually) as well as KDR expression. Taking clinical observations and in vivo evidence together, MT treatment leads to poor prognosis of primary osteosarcoma; physicians should pay more attention on patients who seek MT before diagnosis.

Etiologies and outcome of osteonecrosis of the femoral head: Etiology and outcome study in a Taiwan population

Background Osteonecrosis of the femoral head (ONFH) is an important indication for total hip arthroplasty in Taiwan. We demonstrated the etiologies of ONFH and outcomes based on stratification of patients according to different etiologies. Methods We reviewed medical records and images from January 2000 to May 2010 in our database with the diagnosis of “osteonecrosis of the femoral head.” We categorized all patients into different etiologies, including corticosteroid, alcohol, and idiopathic. All patients received subsequent follow up for ipsilateral precollapse ONFH and contralateral disease‐free femoral head status after initial diagnosis. Results Of the 1153 patients who had undergone 1674 hip surgeries including core decompression and total hip replacement, alcohol use was the most prevalent etiology in our population (45.2%). Patients with corticosteroid‐ and alcohol‐associated ONFH were younger and more likely to have bilateral disease. Patients with alcohol‐ or steroid‐associated ONFH were found to have a higher rate of contralateral disease and faster progression of precollapse ONFH than patients who had or had not undergone core decompression. Conclusion Alcohol use had the greatest impact on ONFH in our population. Nonidiopathic ONFH patients had the worst outcome. Understanding the nature of progression of ONFH and incidence of contralateral disease may provide great prognostic value to detect and perform early intervention.

Pathological fractures in predicting clinical outcomes for patients with osteosarcoma

BackgroundStudies reported contradictory results for the prognostic significance of a pathological fracture in osteosarcoma patients. The aim of this study is to report the outcomes for a cohort of patients with osteosarcoma who presented with and without pathological fractures and to identify the prognostic importance of pathological fracture in predicting outcomes and influences on survival.MethodsData of patients with osteosarcoma were retrospectively reviewed. Between March 1992 and June 2014, a total of 268 patients with osteosarcoma were included in this analysis, of whom 34 (12.7%) with fractures at diagnosis or sustained after chemotherapy and 234 (87.3%) without fracture. All patients were treated with approaches that integrated chemotherapy and surgical resections to maximal extent of all sites whenever feasible. The association between potential prognostic factors and survival for these patients were analyzed and compared.ResultsNo significant difference was observed in overall survival, progression free survival, and disease free survival between osteosarcoma patients with pathological fractures and without fracture. The patients without fracture had a 5-year survival of 50% and 10-year survival of 21%, in contrast to 37% (5-year) and 22% (10-year) in patients with fractures. Lung metastasis was the significant predictor for the presence of fractures. Advanced stage (III) of tumor, lung metastasis, poor response to chemotherapy, and local recurrence were associated increased risk for death in all osteosarcoma patients.ConclusionPathological fracture is not a predictor of worse survival in this study. Further studies with matched cases are needed to confirm our observations.

Does Implant Selection Impact Postoperative Complications Following Hip Arthroplasty for Failed Intertrochanteric Fractures? A Retrospective Comparative Study

The purpose of this study is to compare postoperative complications among different acetabular and femoral components of hip arthroplasty for failed intertrochanteric fractures. A total of 79 patients were included and followed-up for an average of 75.6 months (range, 24-244). Fifty-five patients underwent total hip arthroplasty, and 24 had bipolar hemiarthroplasty. Cementless metaphyseal locking, cementless diaphyseal locking, and cemented standard stems were used in 41, 29, and 9 patients, respectively. Dislocation and wear rate were not different between the total hip arthroplasty and bipolar hemiarthroplasty groups. Stem subsidence or loosening was more frequently found in the cementless, metaphyseal locking stem groups. In conclusion, cemented standard stem and cementless diaphyseal locking stem might be better implant choices. With regard to dislocation rate, our results were insufficient to conclude a better implant choice of total hip arthroplasty or bipolar hemiarthroplasty than the other.