Biological reconstruction for children with osteosarcoma around the knee

<p><b>INTRODUCTION</b>Limb salvage in children with primary malignant bone tumours around the knee is challenging, with considerations such as shortening, bone and joint remodeling and high functional demands of active children. The ultimate aim for reconstruction is restoring a stable, painless and mobile joint. With improved survival rates from chemotherapy, reconstructive techniques should ideally last the child's lifespan. We adopted a biological approach by preserving the patients' native joint, with bony defects bridged by fibula grafts supplemented by autoclaved bone grafts infused with bone marrow. We conducted this retrospective review to determine if we were able to meet our objectives of reconstruction.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of children with osteogenic sarcoma involving the distal femur or proximal tibia treated at our institution was done. Patients aged 13 years and below at the time of surgery who had undergone a limb salvage procedure that preserved the knee joint were included.</p><p><b>RESULTS</b>Nine patients were identified, 3 males and 6 females. The average age was 10.0 years (range, 7 to 13 years) at the time of surgery. Seven had tumours involving the distal femur while 2 had tumours involving the proximal tibia. There were no cases of local recurrence. Four of the 9 patients died from metastatic disease, the 5 surviving patients have no evidence of disease, and the average follow-up for survivors was 13.2 years. The average active range of motion for the knee joint was 96° (range, 50° to 130°). The average Musculoskeletal Tumour Society (MSTS) score was 26.3 (range, 23 to 30).</p><p><b>CONCLUSION</b>We have observed this technique of limb salvage offers satisfactory limb function with long-term follow-up.</p>

Effect of negative-pressure wound therapy on open fractures of the lower limb

<p><b>INTRODUCTION</b>Early debridement and coverage has long been regarded as the standard of care for open fractures of the lower limb, as infection is a serious complication. However, the best time for wound closure remains controversial. Negative-pressure wound therapy (NPWT) is thought to result in reduced flap infection and failure. To determine the effect of NPWT, we reviewed patients with open fractures of the lower limb and compared the rates of infection and flap failure in two time-based cohorts.</p><p><b>METHODS</b>Two cohorts of patients (periods 2003-2004 and 2008-2009) with Gustilo type IIIB open tibial fractures were recruited and their outcomes were compared. In the 2003-2004 cohort, wounds were dressed with occlusive dressing. In the 2008-2009 cohort, all patients underwent NPWT. Data was retrospectively analysed with regard to infection, failure, age, type of flap, comorbidities and defect size. The incidences of infection and flap failure were further analysed for any statistical difference between the different treatment protocols.</p><p><b>RESULTS</b>In the 2003-2004 cohort, 33% of patients developed infection and 11% had flap failure. However, in the 2008-2009 cohort, 10% of patients developed infection and 6% had flap failure. The difference in the incidence of infection was statistically significant between the two cohorts (p = 0.029).</p><p><b>CONCLUSION</b>Patients in the 2008-2009 cohort had better outcomes, and we are of the opinion that performing NPWT may have contributed to this result.</p>

SARS in Singapore--predictors of disease severity

<p><b>INTRODUCTION</b>Severe acute respiratory syndrome (SARS) affected 8096 individuals in 29 countries, with 774 deaths. In Singapore, there were 238 cases of SARS with 33 deaths. A retrospective analysis was performed to identify predictors of poor outcome in patients with SARS locally.</p><p><b>MATERIALS AND METHODS</b>Clinical, laboratory and outcome data of 234 patients admitted to Tan Tock Seng Hospital and Singapore General Hospital were collected and analysed. Only data collected at the time of admission were used in the analysis for predictors of poor outcome. Adverse events were defined as admission to the intensive care unit or death.</p><p><b>RESULTS</b>Clinical (temperature, FiO2) and laboratory [leukocyte, lymphocyte, neutrophil, platelet, lactate dehydrogenase (LDH), albumin] trends in groups with and without an adversarial event were presented. Fifty patients experienced an adverse event. On univariate analysis, male gender, advanced age, presence of comorbidities, neutrophilia, lymphopaenia, hyponatraemia, hypoalbuminaemia, transaminitis and elevated LDH or C-reactive protein were found to be significant predictors. On multivariate analysis, predictors of poor outcome were increased age [odds ratio (OR) 1.73 for every 10-year increase; 95% CI, 1.35 to 2.21], neutrophilia (OR 1.06 for every 1 x 10(9)/L increase; 95% CI, 1.02 to 1.11) and high LDH (OR 1.17 for every 100 U/L increase; 95% CI, 1.02 to 1.34). None of the 12 paediatric patients had an adverse event.</p><p><b>CONCLUSION</b>Advanced age, neutrophilia and high LDH predict poor outcomes in patients with SARS.</p>