The results of surgical management of bone metastasis involving the periacetabular area: Siriraj experience.

BACKGROUND: Periacetabular metastasis is a common site of bone metastasis and can cause major disability to the patients. Non-operative treatment including medication or radiation therapy is the first treatment modality. The operative treatment is indicated in patients with failed non-operative treatment or pathologic fracture. OBJECTIVE: To assess the functional results, quality of life, and complications after reconstruction of the periacetabular metastasis. MATERIAL AND METHOD: Fourteen patients underwent 16 intralesional excisions of tumor and cemented total hip arthroplasty reconstruction from 2002 to 2006. The primary tumors were breast carcinoma in five patients, thyroid carcinoma in three, kidney carcinoma in two, and one each of cervix carcinoma, urinary bladder carcinoma, lung carcinoma, and multiple myeloma. Type of periacetabular metastases by Harrington 's classification, age of patients, blood loss, unit of blood transfusion, and postoperative complication were reviewed. Pre- and Postoperative pain by the visual analogue scale was evaluated. RESULTS: The mean age of patients was 56years with a mean follow up time of 389 days (range 30-1,275 days). The mean time from diagnosis of primary tumor to periacetabular metastatic surgery was 32.5 months (range 0-84 months). By Harrington 's classification, seven patients were classified in class I, four patients were class II, and three patients were class III. The visual analogue scale was improved from more than 8/10 preoperatively to 2/10 postoperatively. All patients could ambulate and walk independently and two patients could walk without gait support. Four patients died of disease progression and 10 patients are still alive. Two patients had complications from postoperative hip dislocation and acetabular loosening which successfully treated by closed reduction and revision of the prosthesis respectively. CONCLUSION: With promising results, low rate of complication and improvement of quality of life could be achieved after total hip arthroplasty reconstruction in the appropriately selected patient with a periacetabular metastasis. Additional surgery may be required in the patient with longer survival or progression of the disease.

Endoprosthetic reconstruction for malignant bone and soft-tissue tumors.

BACKGROUND: Nowadays, the results of the management of malignant bone and soft-tissue tumors have been dramatically improved because of the advance in imaging, chemotherapy, radiation therapy, and surgical techniques. Patients can have longer survival times with limb-salvage surgery. Several techniques of reconstruction have been advocated and gained more popularity following malignant tumor resection by using allograft, tumor prostheses, composite allograft prosthesis, or arthrodesis. OBJECTIVE: To report the preliminary results of 32 endoprosthetic reconstructions following malignant bone and soft-tissue tumor resection. The oncologic results, functional outcomes, and complications from the surgery were assessed in the present study. MATERIAL AND METHOD: Since September 1988, the authors have performed 188 limb-salvage surgical operations for the treatment of musculoskeletal tumors at Siriraj Hospital. From March 1994 to July 2006, 32 endoprosthetic reconstructions were performed on 30 patients following malignant bone or soft-tissue tumor removal. There were 16 males and 14 females with a mean age of 28 years (range 10-73). The diagnosis was conventional osteosarcoma in 16 patients, parosteal osteosarcoma in two patients, chondrosarcoma in two patients, leiomyosarcoma in two patients, failed allograft in two patients and one patient each of periosteal osteosarcoma, Ewing's sarcoma, Gorham's disease, synovial sarcoma, malignant fibrous histiocytoma, metastatic renal cell carcinoma, and prosthetic loosening. Wide excision was performed with a mean length of 18.5 cm (range 10-41). Five proximal femurs, 17 distal femurs, 1 total femur 3 proximal tibias, 1 intercalary tibia, 4 proximal humerus and 1 distal humerus were used for reconstruction. Modular replacement systems (MRS, Stryker/Howmedica/Osteonics) were the most common prostheses used in the present series. RESULTS: The mean follow-up time was 26 months (range 6-128.7). Sixteen patients are continuously free of the disease, two are alive with the disease, two had no evidence of the disease, nine died of the disease, and one patient died from complication of hypertension. The mean Musculoskeletal Tumor Society functional analysis for upper extremity reconstruction was 93% (range 86.7-100) and for lower extremity was 89% (range 63.3-100). Two patients (6.7%) were determined to be a failure. Revision due to aseptic loosening was performed in one patient (3.3%) and one hip disarticulation was done related to local recurrence (3.3%). One patient with sciatic nerve palsy and two seromas was found and successfully treated in the present study. CONCLUSION: Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb-salvage for patients with malignant bone and soft-tissue tumors. Most patients in the present report had good to excellent functions following surgery and few complications occurred in the present report.

Neuropathic arthropathy of the elbow: a report of two cases.

BACKGROUND: Neuropathic arthropathy (charcot joint) of the elbow is a rare condition. It is among the least frequently reported charcot pathology of the joint. The clinical symptoms are characterized by a painless and unstable joint. Infection in the neuropathic joint is rare. Only a limited number of cases have been reported in the literature. The authors present two cases of neuropathic arthropathy of the elbow. One of them was diagnosed as Septic neuropathic arthropathy. MATERIAL AND METHOD: Two patients with neuropathic arthropathy of the elbow (an infected and a noninfected case) were treated at our department. Both patients were over 60 years old. The underlying conditions associated with the arthropathy included combined median and ulnar neuropathy in the infected case and idiopathic in the non-infected case. Both of the patients had a history of specific trauma at the affected elbows. The radiographs of the elbows revealed dislocation, fracture fragmentation and some bony sclerosis. The management in the non-infected case aimed to maintain the function of the elbow with a short period of immobilization and physical therapy. For the infected case, the patient was treated successfully with systemic antibiotic, surgical debridement and a period of immobilization with an external fixator RESULTS: The patients were followed-up for approximately 9 months for the non-infected and 2 years for the infected case. Both of them had painless and functional range of motion of the elbows in the most recent follow-up examination. For the infected case, the surgical incision healed well and there was no recurrent discharge from that affected elbow. CONCLUSION: In the first case, with neuropathic arthropathy of the elbow, the investigations were made to find the underlying disease. The second case with septic neuropathic joint, systemic antibiotic, surgical debridement and appropriate immobilization were needed. With gross instability and marked distortion of the joint, the elbow of both patients functioned remarkably well.

A knee model for arthrocentesis simulation.

OBJECTIVES: To produce a knee model for medical students and residents to practice knee aspiration and intra-articular injection. MATERIAL AND METHOD: The model was made of plastic, rubber and silicone that included the lower third of the femur, the upper third of the tibia and the patella. They were fixed on 2 plastic boxes in the anatomical position and the boxes were connected together with 2 small hinge joints. A rubber bag was made in the pattern of synovial space of the knee. Quadriceps, anterior muscles of the leg and patellar tendon were also presented. The model was covered with silicon sheet, representing the skin. Water was used to fill up the synovial bag to simulate joint aspiration via supero-lateral approach with the knee in extension. The model was appraised by 30 medical students, 26 orthopedic residents and 10 orthopedic staff in terms of size, anatomy, physical examination, feeling during aspiration, need of the model in education and commercial use. RESULTS: Most of the medical students, residents and staff (80-90%) were satisfied with the model and rated it as good to very good teaching media. However, the model should come out in different sizes and the synovial bag should be modified to improve the ballotment test. Mass production of the model should be done. CONCLUSION: The knee model is an acceptable teaching model for arthrocentesis simulation with affordable cost.