Occipito-cervical fusion in post-traumatic instability of the upper cervical spine and cranio-cervical junction.

INTRODUCTION: Surgical management of upper cervical spine (UCS) unstable injuries may be challenging as the number of cases requiring this surgery collected in every single center is small. This retrospective study was conducted to analyze the radiographic and clinical results in 12 patients undergoing a posterior occipito-cervical fusion by a polyaxial screws-rod-plate system. METHODS: There were eight male and four female patients with a mean age of 73.7 years (range 32-89 years). Six patients presented neurologic deficits at admission. Six patients had sustained major trauma. The remaining six patients had suffered a minor trauma. RESULTS: Two patients died postoperatively in Intensive Care Unit. All surviving patients achieved solid fusion at 6 months. No surviving patient had neurological deterioration postoperatively. There were no instrumentation failures or revision required. Two patients suffered from superficial occipital wound infection. CONCLUSIONS: Although the indication to occipito-cervical fusion decreased since the new C1-C2 posterior fixation techniques were described, it remains a valid and reliable option in UCS post-traumatic instability to be applied even in emergency especially in the elderly.

Complications in minimally invasive percutaneous fixation of thoracic and lumbar spine fractures.

Minimally invasive stabilization of thoracic and lumbar fractures without neurologic involvement is becoming a more frequent alternative to open fusion and conservative treatment. The authors analyzed the complication rate and limits of this technique in a consecutive series of 99 patients (127 thoracolumbar vertebral fractures) who underwent this technique between May 2005 and November 2009. Eighty-three patients had only spine injuries, whereas 16 had polytrauma injuries (mean Injury Severity Score, 25.2). In these 16 patients, percutaneous fixation was performed as a damage control procedure. The most frequent construct was monosegmental: 1 level above and 1 level below the fractured vertebra. In the remaining 21 patients, multilevel construction was performed for multiple injuries. Complications were analyzed according to the period of onset (intra- and postoperative) and the severity (major and minor). Twelve (12%) complications were recorded: 4 (4%) were intraoperative, 6 (6%) were early postoperative, and 2 (2%) were late postoperative; 4 (4%) were minor and 8 (8%) were major. Mean follow-up was 52 months (range; 36-90 months). All patients except 1 were considered healed after 6-month follow-up. The failed patient had an initial kyphosis greater than 20°, and a posterior open reduction and fusion would have been more appropriate. Minimally invasive stabilization of selected spine injuries is a safe technique with a low complication rate. The main goal of this approach is a fast recovery time, so any complication leading to an extended length of stay should be considered severe. An adequate learning curve is important to minimize complications.

Minimal invasive percutaneous fixation of thoracic and lumbar spine fractures.

We studied 122 patients with 163 fractures of the thoracic and lumbar spine undergoing the surgical treatment by percutaneous transpedicular fixation and stabilization with minimally invasive technique. Patient followup ranged from 6 to 72 months (mean 38 months), and the patients were assessed by clinical and radiographic evaluation. The results show that percutaneous transpedicular fixation and stabilization with minimally invasive technique is an adequate and satisfactory procedure to be used in specific type of the thoracolumbar and lumbar spine fractures.

Intralesional methylprednisolone for painful solitary eosinophilic granuloma of the appendicular skeleton in children.

BACKGROUND: Previous case reports and small series have reported on the treatment of eosinophilic granuloma of bone. We present our long experience in a large group of children and teenagers with symptomatic eosinophilic granuloma of the appendicular skeleton to evaluate clinical and imaging outcome after methylprednisolone injection. METHODS: Sixty-six patients with symptomatic solitary eosinophilic granuloma of the appendicular skeleton treated by incisional or percutaneous biopsy and methylprednisolone injection were retrospectively studied. There were 38 boys and 28 girls (mean age, 7.2 y). The mean follow-up was 10.7 years (median, 11.2 y; range, 3 to 15 y). All patients presented with symptomatic lesions including pain or tenderness and fever and had 1 intralesional injection of methylprednisolone acetate after biopsy: 52 patients had incisional biopsy and 14 patients had percutaneous computed tomography-guided biopsy. RESULTS: Complete resolution of symptoms was observed in 58 patients (92%) at 48 to 72 hours (50 patients) and in 7 days (8 patients) after the procedure. Complete imaging reconstitution of bone was observed in 60 patients (95.2%) at 1 to 2 years after the procedure. No patient had recurrence. Multifocal disease was diagnosed in 7 patients (11%) at 3 months to 6 years. Complications occurred in 2 patients: one patient with a clavicular lesion had a pathologic fracture after open direct methylprednisolone injection and the second patient developed trochanteric bursitis after computed tomography-guided methylprednisolone injection. CONCLUSIONS: Biopsy and direct intralesional methylprednisolone injection is safe for symptomatic eosinophilic granulomas of the appendicular skeleton in children with effective clinical and imaging resolution of the lesions.

Desarthrodesis and prosthetic reconstruction of the knee after resection of bone tumors.

BACKGROUND AND OBJECTIVES: The aim of the present study was to review the long-term results in patients who had undergone modular prosthetic reconstruction of the knee, following a failed arthrodesis performed after the resection of bone tumors. METHODS: We reviewed 16 desarthrodeses and prosthetic reconstructions of the knee following a failed artificial arthrodesis after bone tumor resection. Desarthrodeses and subsequent knee megaprosthesis were performed after breakage of the arthrodesis implant in 11 cases and following presumed eradication of infection in five cases. RESULTS: The mean follow-up was 15.9 years. The mean post-operative range of knee flexion was 70°, but only four patients had active extension of the knee. Functional results, according to the MSTS system, were satisfactory in 11 patients. Complications included deep infections in five patients, aseptic loosening in three patients, breakage of the joint hinge in one patient, and patellar tendon avulsion in one patient. Despite a high rate of complications, all but two patients were satisfied. CONCLUSION: Our findings indicate that conversion of oncological knee arthrodesis to total knee arthroplasty should be taken into consideration only after giving the patient extensive information about the high risk of serious complications.

Local recurrence, survival and function after total femur resection and megaprosthetic reconstruction for bone sarcomas.

BACKGROUND: The choices of treatment for patients with extensive tumors of the femur include total femur megaprosthesis or large allograft-prosthetic composites. Previous reports suggest variable survival ranging from 60-70% at 1 to 2 years. However, these studies described earlier prostheses and techniques. QUESTIONS/PURPOSES: To confirm previous reports we determined (1) risk of local recurrence; (2) overall survivorship; and (3) function in patients with total femur reconstructions for tumors. METHODS: We retrospectively reviewed 23 patients with total femur megaprostheses implanted between 1987 and 2006 after resection of bone tumors. Two patients lost at followup were excluded; the remaining 21 included 15 males and six females with a mean age of 21 years. The mean followup was 48 months (range, 1 month 17 years). Function was assessed according to the MSTS System II. RESULTS: No patient developed a local recurrence during followup. At last followup, six patients were continuously disease-free at a mean of 148 months, one patient had no evidence of disease after treatment of a recurrence, one patient was alive with disease, and 13 patients died of their disease at a mean time of 17 months. In 15 patients evaluated with the MSTS score, the mean score was 66%; four patients had over 75%, eight from 51% to 75%, three from 26% to 50%. Four patients (19%) had complications requiring further surgery in absence of trauma. A fifth patient had a posttraumatic periprosthetic fracture. CONCLUSIONS: A total femur prosthesis allows a limb-preserving procedure in tumors with extensive femoral involvement or in the presence of a skip lesion along the femur. The prognosis of these tumors is poor, but this reconstruction provides function with a relatively low rate of major complications.

Unusual radiographic appearance of adamantinoma.

Adamantinoma is a rare tumor with an indolent course that occurs most commonly in the tibia. It is locally aggressive, and local recurrences are described after resection. Pain is the most common symptom. Since the lesion is typically slow growing, the pain can be present for many years before the patient seeks medical attention. Microscopically, adamantinoma consists of islands of epithelial cells in a fibrous stroma. Nuclear atypia is minimal, and mitotic figures are rare. The most common radiographic appearance is that of multiple sharply demarcated radiolucent lesions surrounded by areas of dense, sclerotic bone. This tumor most often affects the tibial diaphysis and produces lytic lesions that can cause fractures. A 31-year-old man presented with a rapidly growing lytic lesion of the distal tibia. On histological examination, many areas of epithelial cells in a fibrous stroma were identified. Diagnosis of adamantinoma was performed. The lesion was treated with en bloc resection and reconstruction with distal tibia allograft and ankle arthrodesis with retrograde nail. At 2-year follow-up, there were no clinical or radiological signs of recurrence of disease.