Computer-assisted surgery (CAS) in orthopedic oncology. Which were the indications, problems and results in our first consecutive 203 patients?

AIMS: to review a group of patients with primary bone tumors treated with intraoperative navigation and analyze: (1) The technical problems; (2) Indications for Computer Assisted Surgery (CAS); (3) Oncological results; (4) Non oncological complications. MATERIALS AND METHODS: All patients from a single institution who had preoperative virtual planned for an oncological primary bone resection assisted with navigation between May 2010 and July 2017 were enrolled in the study (203 patients). The use of computer-assisted surgery (CAS) was classified according to the oncologic procedure performed: (1) intralesional resections, (2) en-block resections, and (3) en-block resections + navigated allograft reconstructions. RESULTS: Four patients (4/203, 2%) of the series presented technical problems which came from 2 software and 2 hardware crashes. Eight (4%) procedures were intralesional resections and no local recurrences or complications were reported in this group. Ninety-eight surgeries (49%) were pure en block resection. The pelvis and sacrum were the main location in this group (57%). All bone margins were defined negative but 2 patients presented a positive resection in the soft tissues. Infection was the most prevalent complication (16/23). Ninety-three procedures were done for en block resections + allograft reconstruction (all extremities tumor). All margins were free of tumor and non oncological rate for this group was 28%. CONCLUSION: The main indications for CAS were malignant bone tumors resection. The technical failures precluded navigation use in 2%. CAS for pure en-block resections were mainly indicated in pelvic and sacrum tumors while en-block resection + allograft reconstruction assisted with navigation were only indicated in extremities tumors. LEVEL OF EVIDENCE: IV.

[La Scientific activity in a highly complex center: What, who, where and how much is published?] / La actividad científica en un centro de alta complejidad: Qué, quién, dónde y cuánto se publica?

Introduction: We proposed to analyze the scientific production of our institution, through the publications indexed in the PUBMED and analyze: a) Total number of publications and progression over time; b) Type of publications; c) Unit participation; d) Relation between % publications / % medical unit staff; e) Impact factor. Methods: A retrospective research was performed in PUBMED database between 1/1/2013 and 12/31/2018 and all the papers that respond to the affiliation name of "Hospital Italiano" (spanish) o "Italian Hospital" (english) were reviewed. The following information was collected from each publication: authors, journal, impact factor, unit involved and language of publication. Results: A total of 1421 publications were included for the analysis. There was a progressive increase of 417% between 2013 and 2018. 802 (56%) were done only by our institution and 619 (44%) corresponded to multicenter studies. Internal medicine (341 - 23.99%) was the unit with more publications and Medical Informatics the unit with the best relation between % of publications and % professional staff (5.39). 82% (1167) of the papers were in English and the medina value of the impact factor was 2,61 (range: 0,01-29,78). Conclusion: The scientific production, measurable by the number of publications indexed in PUBMED has shown a progressive and sustained increase in time from 2013 to the present. We consider it important to stimulate and encourage professionals to continue with scientific production without neglecting quality standards of care activity.

Introducción: El objetivo del trabajo fue revisar la actividad científica de nuestra institución, a través de las publicaciones indexadas en PUBMED y analizar: a) Número total de publicaciones; b) Tipo de publicaciones; c) Servicios participantes; d) Relación % publicaciones / % plantel medico hospitalario; e) Factor de impacto de las revistas. Metodología: Se realizó una búsqueda retrospectiva en la base de datos PUBMED entre 2013 y 2018 inclusive y todos los artículos que tenían en su afiliación "Hospital Italiano" (español) o "Italian Hospital" (ingles)" fueron revisados. De cada publicación se recopilo: autores, revista, factor de impacto, servicio involucrado, instituciones intervinientes e idioma de publicación. Resultados: Un total de 1421 publicaciones fueron incluidas para el análisis y se evidencio un aumento progresivo del 417% entre 2013 y 2018. 802 (56%) correspondían a trabajos propios de nuestra institución y 619 (44%) a trabajos multicéntricos. El servicio de Clínica Médica (341 - 23.99%) fue el que presento más publicaciones e Informática Médica el de mejor relación entre % de publicaciones y % plantel profesional (5.39). El 82% (1167) de las publicaciones fueron realizadas en el idioma ingles y el valor medio del factor de impacto fue 2,61 (rango: 0,01-29,78). Conclusión: La producción científica, medible por el número de publicaciones indexadas en PUBMED ha mostrado un aumento progresivo y sostenido en el tiempo desde 2013 a la fecha. Consideramos importante estimular y fomentar a los profesionales para continuar con la actividad científica sin descuidar los estándares de calidad de la actividad asistencial.

Face to Face Appointment vs. Telemedicine in First Time Appointment Orthopedic Oncology Patients: A Cost Analysis.

Medicine has evolved considerably in recent decades in part thanks to information and communication technologies in health (ICTs). However, face-to-face consultations continue to be the predominant model, since alternatives such as telemedicine are still the subject of debate. On the other hand, in some very specific specialties, centralization is relevant, mainly due to the low frequency and prevalence of diseases, as well as the need to have highly specialized professionals, causing problems in terms of accessibility and costs for the health system. In this study we have analyzed the first consultations to an orthopedics oncology service at a tertiary institution and performed an analysis of economic costs was carried out between 2 possible scenarios: face-to-face consultations versus telemedicine. Analyzing the 2 scenarios, there would be a cost-benefit in the use of telemedicine leading to a decrease in healthcare cost between 12.2% and 72%.

Denosumab-treated giant cell tumor of bone. Its histologic spectrum and potential diagnostic pitfalls.

Giant cell tumor (GCT) of bone is a locally aggressive, rarely metastasizing primary bone neoplasm that occurs most frequently in the epiphysis of long bones of young adults. It is composed of round, oval, or elongated mononuclear cells admixed with osteoclast-like giant cells that express receptor activator of nuclear factor κB (RANK). The mononuclear stromal cells express RANK ligand, a mediator of osteoclast activation. Denosumab, a monoclonal antibody that reduces tumor associated bone lysis by inhibiting the action of RANK ligand, has been used to treat selected cases of GCT. We reviewed the clinical records and histologic slides of 9 patients with GCT who had received denosumab therapy and were subsequently surgically treated. There were 5 men and 4 women aged 20 to 66 years (mean, 36 years). Duration of treatment varied from 2.5 to 13months (mean, 5.9 months). In all cases, different degrees of ossification, fibrosis, depletion of giant cells, and proliferation of mononuclear cells were seen. With this combination of changes, denosumab-treated GCT may mimic other lesions such as fibrous dysplasia, juvenile ossifying fibroma, nonossifying fibroma, and osteoblastoma. Less frequent but more relevant is the presence of cellular atypia or patterns of ossification that resemble an undifferentiated pleomorphic sarcoma, a conventional osteosarcoma, or a low-grade central osteosarcoma. The presence of clinical and radiologic response to denosumab, along with the lack of high mitotic activity, atypical mitotic figures, extensive necrosis, or a permeative pattern of growth, represents clues to achieve a correct diagnosis.

Validación posoperatoria en la selección asistida por computadora de aloinjertos de fémur distal / Postoperative assessment in computer assisted selection of femur osteoarticular allograft

El objetivo de nuestro trabajo fue comparar dos grupos de pacientes tratados con trasplantes osteoarticulares del fémur distal en términos de evaluar: 1) el volumen del fémur distal del receptor y del trasplante, 2) la superficie articular de contacto del fémur distal del receptor y del trasplante, 3) el ángulo del valgo anatómico femoral del fémur distal del receptor y del trasplante. Materiales y métodos: se realizó una búsqueda retrospectiva entre 2002 y 2012 analizando a pacientes tratados con un trasplante osteoarticular de fémur distal. Se incluyó un total de 32 pacientes. Estos fueron divididos en dos grupos de acuerdo con el método de selección del trasplante: Grupo 1, conformado por 16 pacientes con trasplantes seleccionados mediante tomografía 2D y Grupo 2, 16 pacientes con trasplantes seleccionados a través de un método 3D. La evaluación fue realizada por un observador independiente y ciego para los dos grupos. Resultados: las diferencias en las pruebas de estimación de volumen y superficie articulares entre el donante y el receptor no fueron estadísticamente significativas (p>0,05). Sin embargo, la diferencia entre los ángulos de valgo del fémur receptor y el fémur donante, seleccionados por el método 2D fue significativa (p<0,05), mientras que la diferencia de estos ángulos en el método 3D no lo fue (p>0,05). Conclusión: el método de selección de un aloinjerto, mediante la utilización de un banco de huesos virtual 3D para la reconstrucción con un trasplante osteoarticular de femur distal, permite obtener una mejor alineación del miembro comparado con aquellos seleccionados solo con un método bidimensional. (AU)

The aim of our study was to compare two groups of patients treated with distal femur osteoarticular allograft in terms of: 1) the volume of the distal femur of the allograft and patient, 2) the articular surface contact, 3) the anatomical femoral valgus angle. Material and methods: a retrospective review was performed between 2002 and 2012 and all patients with an osteo-articular allograft of the distal femur were analysed. A total of 32 patients were included in the study. Patients were divided into two groups according to the selection method of the allograft: Group 1, 16 patients with allograft selected by 2D (CT) and Group 2, 16 patients selected through a 3D method. The evaluation was done by an independent and blind observer. Results: the differences in terms of volume estimation and joint surface contact between the donor allograft and patient distal femur were not statistically significant (p>0.05). However, the difference between the valgus angle showed significant differences between donor and patient femurs selected by the 2D method (p<0.05) but no difference in the group of patients selected by 3D method (p>0.05). Conclusion: the 3D method for allograft selection of the distal femur showed better results in limb alignment compared to 2D selection method. (AU)

Accuracy of Chest Wall Tumor Resection Guided by Navigation: Experimental Model.

Difficulty in identification wall chest tumors lead to unnecessary wide resections. Optical navigation and preoperative virtual planning are assets for surgeries that require exactness and accuracy. These tools enable physicians to study real anatomy before surgery and to follow an established pathway during procedure ensuring effectiveness. The aim of this paper is to demonstrate that Preoperative Virtual Planning is a useful tool in chest tumor interventions to define oncological margins successfully. Moreover, it is possible to use a virtual specimen in order to quantify accuracy. Optical navigation has been used in surgical procedures such as neurosurgery, orthopaedics and ENT over the last ten years. This principle is used in order to orientate the surgeon in three dimensional spaces during the surgery. Surgeons are guided intraoperatively with navigation and are able to obtain a correspondence between images acquired and processed before the surgery and the real anatomy.

Transfer accuracy and precision scoring in planar bone cutting validated with ex vivo data.

The use of interactive surgical scenarios for virtual preoperative planning of osteotomies has increased in the last 5 years. As it has been reported by several authors, this technology has been used in tumor resection osteotomies, knee osteotomies, and spine surgery with good results. A digital three-dimensional preoperative plan makes possible to quantitatively evaluate the transfer process from the virtual plan to the anatomy of the patient. We introduce an exact definition of accuracy and precision of this transfer process for planar bone cutting. We present a method to compute these properties from ex vivo data. We also propose a clinical score to assess the goodness of a cut. A computer simulation is used to characterize the definitions and the data generated by the measurement method. The definitions and method are evaluated in 17 ex vivo planar cuts of tumor resection osteotomies. The results show that the proposed method and definitions are highly correlated with a previous definition of accuracy based in ISO 1101. The score is also evaluated by showing that it distinguishes among different transfer techniques based in its distribution location and shape. The introduced definitions produce acceptable results in cases where the ISO-based definition produce counter intuitive results.

Sarcomas de partes blandas en pacientes pediátricos: análisis de una serie de casos del subtipo no rabdomiosarcoma / Pediatric soft tissue sarcomas: analysis of non rhabdomyosarcoma group

Se evaluó una serie de 29 pacientes con diagnóstico de sarcomas de partes blandas variante no rabdomiosarcomas tratados quirúrgicamente entre2000 y 2010, y se analizó la supervivencia global y los factores que influyen en el pronóstico. La edad media fue de 11,6 años (rango de 3 meses-17 años); 16 pacientes eran de sexo masculino y el tiempo promedio de seguimiento fue de 56 meses (de 8 a 132 meses). Se documentaron 8 variedades histológicas diferentes de tumores malignos, y el sarcoma sinovial resultó ser el más frecuente (14 pacientes). La cirugía de conservación de miembro fue posible en 28 pacientes y se asoció tratamiento adyuvante en 26. La supervivencia global de la serie estudiada fue de 72% a los 5 años y, en 9 pacientes, se diagnosticó una recurrencia local. La presencia de metástasis (p < 0,0001) y la recurrencia local (p < 0,007) resultaron ser factores de pronóstico negativo para la supervivencia global.

We evaluated 29 patients with non rhabdomyosarcoma soft tissue sarcomas treated with surgery between 2000 and 2010; we analyzed overall survival and which factors affect the prognosis. The mean age was 11.6 years (range 3 months-17 years); 16 patients were males and the median follow-up was 56 months (8 to 132 months). Eight different histological malignant tumors were identified, being synovial sarcoma the most prevalent one (14 patients). Twenty-eight patients were treated with limb salvage surgery and in 26 cases, adjuvant therapy was used. Five years overall survival was 72%. Nine of the 29 patients presented a local recurrence. The presence of metastases (p <0.0001) and local recurrence (p <0.007) were negative prognostic factors for overall survival.

Sarcomas de partes blandas en pacientes pediátricos: análisis de una serie de casos del subtipo no rabdomiosarcoma / Pediatric soft tissue sarcomas: analysis of non rhabdomyosarcoma group

Se evaluó una serie de 29 pacientes con diagnóstico de sarcomas de partes blandas variante no rabdomiosarcomas tratados quirúrgicamente entre2000 y 2010, y se analizó la supervivencia global y los factores que influyen en el pronóstico. La edad media fue de 11,6 años (rango de 3 meses-17 años); 16 pacientes eran de sexo masculino y el tiempo promedio de seguimiento fue de 56 meses (de 8 a 132 meses). Se documentaron 8 variedades histológicas diferentes de tumores malignos, y el sarcoma sinovial resultó ser el más frecuente (14 pacientes). La cirugía de conservación de miembro fue posible en 28 pacientes y se asoció tratamiento adyuvante en 26. La supervivencia global de la serie estudiada fue de 72% a los 5 años y, en 9 pacientes, se diagnosticó una recurrencia local. La presencia de metástasis (p < 0,0001) y la recurrencia local (p < 0,007) resultaron ser factores de pronóstico negativo para la supervivencia global.(AU)

We evaluated 29 patients with non rhabdomyosarcoma soft tissue sarcomas treated with surgery between 2000 and 2010; we analyzed overall survival and which factors affect the prognosis. The mean age was 11.6 years (range 3 months-17 years); 16 patients were males and the median follow-up was 56 months (8 to 132 months). Eight different histological malignant tumors were identified, being synovial sarcoma the most prevalent one (14 patients). Twenty-eight patients were treated with limb salvage surgery and in 26 cases, adjuvant therapy was used. Five years overall survival was 72%. Nine of the 29 patients presented a local recurrence. The presence of metastases (p <0.0001) and local recurrence (p <0.007) were negative prognostic factors for overall survival.(AU)

[Pediatric soft tissue sarcomas: analysis of non rhabdomyosarcoma group]. / Sarcomas de partes blandas en pacientes pediátricos: análisis de una serie de casos del subtipo no rabdomiosarcoma.

We evaluated 29 patients with non rhabdomyosarcoma soft tissue sarcomas treated with surgery between 2000 and 2010; we analyzed overall survival and which factors affect the prognosis. The mean age was 11.6 years (range 3 months-17 years); 16 patients were males and the median follow-up was 56 months (8 to 132 months). Eight different histological malignant tumors were identified, being synovial sarcoma the most prevalent one (14 patients). Twenty-eight patients were treated with limb salvage surgery and in 26 cases, adjuvant therapy was used. Five years overall survival was 72%. Nine of the 29 patients presented a local recurrence. The presence of metastases (p <0.0001) and local recurrence (p <0.007) were negative prognostic factors for overall survival.

Sarcomas de partes blandas en pacientes pediátricos: análisis de una serie de casos del subtipo no rabdomiosarcoma. / [Pediatric soft tissue sarcomas: analysis of non rhabdomyosarcoma group].

We evaluated 29 patients with non rhabdomyosarcoma soft tissue sarcomas treated with surgery between 2000 and 2010; we analyzed overall survival and which factors affect the prognosis. The mean age was 11.6 years (range 3 months-17 years); 16 patients were males and the median follow-up was 56 months (8 to 132 months). Eight different histological malignant tumors were identified, being synovial sarcoma the most prevalent one (14 patients). Twenty-eight patients were treated with limb salvage surgery and in 26 cases, adjuvant therapy was used. Five years overall survival was 72

. Nine of the 29 patients presented a local recurrence. The presence of metastases (p <0.0001) and local recurrence (p <0.007) were negative prognostic factors for overall survival.

Ligamento poplíteo-peroneo de la rodilla: estudio anatomoquirúrgico del complejo posterolateral

En los últimos años ha adquirido gran importancia la presencia de una inserción del tendón poplíteo al peroné en la estabilidad posterolateral, el ligamento poplíteo-peroneo. Se ha realizado disección de 20 rodillas cadavéricas formolizadas y se han analizado las estructuras posterolaterales, hallando en forma constante al ligamento lateral externo, al tendón poplíteo y al ligamento poplíteo-peroneo. Se realizaron en 3 rodillas cortes selectivos de estas estructuras y control radiográfico con bostezo externo y cajón posterior. Sólo se observó aumento del bostezo externo ante la sección del ligamento lateral externo, que se incrementaba con la sección de las otras estructuras. Sin embargo, se halló un aumento del cajón posterior en los primeros grados de flexión al seccionar cualquiera de las 3 estructuras, por lo que puede existir inestabilidad posterolateral en ausencia de varo. Las disecciones anatómicas y la evaluación radiográfica indican que el ligamento poplíteo-peroneo participa de la estabilidad posterolateral