Bulky malignant peripheral nerve sheath tumour of the left thigh in a pregnant woman presenting with a pathological fracture of the proximal femur.

Malignant peripheral nerve sheath tumour (MPNST) is an aggressive soft tissue sarcoma with a poor prognosis, affecting most commonly the extremities. The lungs constitute the most frequent location for distant metastases. Half of all MPNSTs arise in patients with neurofibromatosis type 1, while approximately 10% are radiation induced and the rest are sporadic.The authors present a pregnant woman in her 40s with a sporadic MPNST of the lower limb and with lung metastases at diagnosis. Treatment consisted of interilioabdominal amputation, followed by adjuvant chemotherapy. Partial response and disease stabilisation were achieved with chemotherapy.Surgical resection with negative margins is the only potentially curative therapy, while radiation therapy and chemotherapy might be useful in the neoadjuvant or adjuvant setting, but their advantage in survival is not demonstrated. In the reported case, chemotherapy permitted the achievement of partial response and stabilisation of the disease.

Greater tuberosity fractures of the humerus: complications and long-term outcomes after surgical treatment.

BACKGROUND: Isolated greater tuberosity (GT) fractures typically occur in younger patients following high-energy trauma compared to humeral neck fractures. Surgical treatment is indicated when superior displacement is > 5 mm. This study aimed to assess the complications and long-term outcomes of surgically-treated GT fractures. METHODS: A retrospective review of 39 patients who underwent surgery from 2010 to 2014 was conducted. The cohort comprised 54.6% females, with an average age of 56.74 years and a median follow-up of 6.71 years. Only 25 patients returned for reevaluation, with functional outcomes assessed using Constant-Murley score. RESULTS: Women were older than men (63.00 ± 12.15 vs. 48.65 ± 16.93, p = 0.006). 18/39 patients (46.1%) sustained avulsion-type, 1 patient out of 39 (2.6%) depression-type, and 20/39 patients (51.3%) split-type fractures. The mean Constant-Murley score was 84.08 ± 18.36, with higher scores observed in men (p = 0.021). Avulsion-type fractures were related to higher postoperative scores compared to split fractures (p = 0.069). Post-surgical complications occurred in 20.5% of patients, with no differences noted between sexes, fracture types, or procedures. CONCLUSION: This study enhances understanding of the long-term outcomes of surgically-treated GT fractures, aiding in treatment selection. Interfragmentary screws may be preferable in younger male patients, but are associated with the higher risk of reintervention, particularly in fragile bone. Prospective multicentric studies are warranted to further elucidate long-term results and treatment strategies.

Malignant “triton” tumor of the lower extremity with a history of fracture / Tumor «tritón» maligno de la extremidad inferior con antecedentes de fractura

Introduction Malignant triton tumor (MTT) is a rare and aggressive subtype of malignant peripheral nerve sheath tumor consisting of a neurogenic tumor with rhabdomyoblastic differentiation. Only 170 cases have been reported to date, two-thirds occurring in young patients with neurofibromatosis type 1 and the remaining third presenting as a sporadic tumor. Case presentation We present the case of a 49-year-old man with a sporadic grade 2 MTT of the lower limb which had had a previous tibial fracture. The patient underwent an above-knee amputation. Five months post-operatively metastases were present in the liver and vertebral column causing compression of the spinal cord, so decompressive radiotherapy and palliative chemotherapy were initiated. Conclusion Due to the precocious spread of the disease, we would suggest that adjuvant chemotherapy be considered for the eradication of micrometastases. To our knowledge, this is only the second reported case of an MTT arising in a site with a history of previous severe trauma. (AU)

Introducción El tumor tritón maligno (MTT) es un subtipo raro y agresivo de tumor maligno de la vaina del nervio periférico que consiste en un tumor neurogénico con diferenciación rabdomioblástica. Hasta la fecha solo se han descrito 170 casos, dos tercios de ellos en pacientes jóvenes con neurofibromatosis tipo 1 y el tercio restante como tumor esporádico. Presentación del caso Presentamos el caso de un varón de 49 años con un MTT esporádico de grado 2 de la extremidad inferior que había tenido una fractura tibial previa. El paciente fue sometido a una amputación por encima de la rodilla. A los 5 meses del postoperatorio presentaba metástasis en el hígado y en la columna vertebral que causaban compresión de la médula espinal, por lo que se inició radioterapia descompresiva y quimioterapia paliativa. Conclusión Debido a la diseminación precoz de la enfermedad, sugerimos que se considere la quimioterapia adyuvante para la erradicación de las micrometástasis. Hasta donde sabemos, este es solo el segundo caso descrito de un MTT surgido en un lugar con antecedentes de traumatismo grave previo. (AU)

Malignant “triton” tumor of the lower extremity with a history of fracture / Tumor «tritón» maligno de la extremidad inferior con antecedentes de fractura

Introduction Malignant triton tumor (MTT) is a rare and aggressive subtype of malignant peripheral nerve sheath tumor consisting of a neurogenic tumor with rhabdomyoblastic differentiation. Only 170 cases have been reported to date, two-thirds occurring in young patients with neurofibromatosis type 1 and the remaining third presenting as a sporadic tumor. Case presentation We present the case of a 49-year-old man with a sporadic grade 2 MTT of the lower limb which had had a previous tibial fracture. The patient underwent an above-knee amputation. Five months post-operatively metastases were present in the liver and vertebral column causing compression of the spinal cord, so decompressive radiotherapy and palliative chemotherapy were initiated. Conclusion Due to the precocious spread of the disease, we would suggest that adjuvant chemotherapy be considered for the eradication of micrometastases. To our knowledge, this is only the second reported case of an MTT arising in a site with a history of previous severe trauma. (AU)

Introducción El tumor tritón maligno (MTT) es un subtipo raro y agresivo de tumor maligno de la vaina del nervio periférico que consiste en un tumor neurogénico con diferenciación rabdomioblástica. Hasta la fecha solo se han descrito 170 casos, dos tercios de ellos en pacientes jóvenes con neurofibromatosis tipo 1 y el tercio restante como tumor esporádico. Presentación del caso Presentamos el caso de un varón de 49 años con un MTT esporádico de grado 2 de la extremidad inferior que había tenido una fractura tibial previa. El paciente fue sometido a una amputación por encima de la rodilla. A los 5 meses del postoperatorio presentaba metástasis en el hígado y en la columna vertebral que causaban compresión de la médula espinal, por lo que se inició radioterapia descompresiva y quimioterapia paliativa. Conclusión Debido a la diseminación precoz de la enfermedad, sugerimos que se considere la quimioterapia adyuvante para la erradicación de las micrometástasis. Hasta donde sabemos, este es solo el segundo caso descrito de un MTT surgido en un lugar con antecedentes de traumatismo grave previo. (AU)

Malignant "triton" tumor of the lower extremity with a history of fracture.

INTRODUCTION: Malignant triton tumor (MTT) is a rare and aggressive subtype of malignant peripheral nerve sheath tumor consisting of a neurogenic tumor with rhabdomyoblastic differentiation. Only 170 cases have been reported to date, two-thirds occurring in young patients with neurofibromatosis type 1 and the remaining third presenting as a sporadic tumor. CASE PRESENTATION: We present the case of a 49-year-old man with a sporadic grade 2 MTT of the lower limb which had had a previous tibial fracture. The patient underwent an above-knee amputation. Five months post-operatively metastases were present in the liver and vertebral column causing compression of the spinal cord, so decompressive radiotherapy and palliative chemotherapy were initiated. CONCLUSION: Due to the precocious spread of the disease, we would suggest that adjuvant chemotherapy be considered for the eradication of micrometastases. To our knowledge, this is only the second reported case of an MTT arising in a site with a history of previous severe trauma.

Effective VTE prophylaxis with enoxaparin after elective THR or TKR: a retrospective observational study.

Background: Orthopedic patients are at the highest risk for venous thromboembolism (VTE). Nowadays, with VTE prophylaxis as a routine in patients undergoing total hip replacement (THR) and total knee replacement (TKR), fatal pulmonary embolism (PE) is rare and the rates of symptomatic VTE within 3 months dropped to 1.3%-10%, compared with the rates of 50%-70% before VTE prophylaxis implementation. In this study, we aim to evaluate the VTE prophylaxis and incidence in patients who underwent THR and TKR in Centro Hospitalar Universitário de Santo António (CHUdSA). Methods: We included 483 patients who underwent elective THR or TKR in CHUdSA from March 2019 to February 2020 and who were under enoxaparin as a VTE prophylaxis drug. All data related to prescribed enoxaparin were collected from the nationwide common electronic drug prescription system (PEM). Results: Of the 483 eligible patients, 192 (39.75%) underwent elective THR and 291 (60.25%) underwent TKR. Enoxaparin was prescribed for 31.86 ± 5.98 and 30.28 ± 5.97 days, on average, for the THR and TKR groups, respectively (P = .005). Patients completed, on average, 29.38 ± 8.12 days and 28.20 ± 7.32 days of VTE prophylaxis with enoxaparin in the THR and TKR groups, respectively (P = .098). The incidence of VTE was approximately 3.13% and 0.69% in the THR and TKR groups, respectively (P = .064). Conclusion: In CHUdSA, we usually prescribe enoxaparin 40 mg once daily for up to 35 days for VTE prophylaxis after THR or TKR. High therapeutic compliance rates resulted in very few events.

Is preoperative fat infiltration in lumbar spine muscles associated with worse clinical outcomes after lumbar interbody fusion?

PURPOSE: Lumbar musculature has a fundamental role in spine stability and spinal balance. Muscle atrophy and fat infiltration play an important role in pain pathophysiology. Accordingly, the preoperative condition of lumbar muscles may influence clinical outcomes after surgical treatment. In this context, the aim of this study was to evaluate the association between preoperative lumbar paravertebral muscle fat infiltration and clinical outcomes after lumbar interbody fusion. METHODS: A retrospective study of patients with lumbar pathology submitted to lumbar transforaminal (TLIF) or posterior interbody fusion (PLIF) was performed, with a minimum of two years of follow-up. Preoperative lumbar magnetic resonance imaging (MRI) images were classified for fat infiltration in lumbar multifidus muscle and correlated with clinical outcomes. RESULTS: Seventy-five patients were included: 24 submitted to PLIF and 51 to TLIF. Most patients underwent surgery for spondylolisthesis (67%). Higher degrees of fat infiltration were associated with more advanced age (54.8 vs. 49.1 years old, p = 0.04) and more leg pain after surgery (p = 0.04). No statistically significant differences in other clinical outcomes such as Oswestry Disability Index, visual analogue scale for back and leg pain, self-reported back pain relief, return to work and overall satisfaction were found between different groups of fat infiltration. The improvement in leg pain was associated with improvement in self-reported lumbar pain (p < 0.001). CONCLUSION: Age and preoperative degree of fat infiltration may be important to predict improvement in leg pain after lumbar interbody fusion. The absence of solid literature on this topic and universal assessment methodologies reinforce the need for further studies.

Risk factors for cage subsidence and clinical outcomes after transforaminal and posterior lumbar interbody fusion.

BACKGROUND: Cage subsidence is a very common complication after lumbar interbody fusion. It may compromise vertebral interbody fusion through progressive spinal deformity and consequently cause compression of neural elements. Clinical relevance remains, however, unclear, with few studies on this subject and even less information regarding its correlation with clinical findings. The aim of this study was to identify risk factors for cage subsidence and clinical evaluation after transforaminal (TLIF) and posterior (PLIF) lumbar interbody fusion. METHODS: A retrospective study in patients submitted to TLIF and PLIF between 2008 and 2017 was conducted. RESULTS: A total of 165 patients were included (123 TLIF and 42 PLIF). Univariate analysis showed an increased risk of cage subsidence in spondylolisthesis comparing with degenerative disk disease (p = 0.007). A higher preoperative lumbar lordosis angle (p = 0.014) and cage placement in L2-L3 (p = 0.012) were associated with higher risk of subsidence. The posterior cage positioning on vertebral endplate was associated with a higher risk of subsidence (p = 0.028) and significant subsidence (p = 0.005), defined as cage migration > 50% of cage height. PLIF presented a higher risk when comparing with TLIF (p = 0.024). Hounsfield unit (HU) values < 135 (OR6; 95% CI [1.95-34]) and posterior positioning (OR7; 95% CI [1.7-27.3]) were independent risk factors for cage subsidence and significant subsidence, respectively, in multivariate analysis. There was a tendency for significant subsidence in degrees ≥ 2 of Meyerding spondylolisthesis (OR4; 95% CI [0.85-21.5]). Significant cage subsidence was not associated with worse clinical results. Other analyzed factors, such as age (p = 0.008), low bone mineral density (BMD) (p = 0.029) and type of surgery (TLIF) (p = 0.004), were associated with worse results. CONCLUSION: The present study shows that lower BMD and posterior cage positioning are relevant risk factors for lumbar cage subsidence. Low BMD is also a predictor of poor clinical results, so it must be properly evaluated and considered, through HU values measurement in CT scan, a feasible and reliable tool in perioperative planning.

Effects of nepicastat upon dopamine-ß-hydroxylase activity and dopamine and norepinephrine levels in the rat left ventricle, kidney, and adrenal gland.

Background and Objective: Evaluate the activity of dopamine-ß-hydroxylase (DßH) as well as the effect of the DßH inhibitor nepicastat upon enzyme activity and levels of dopamine (DA) and norepinephrine (NE) in the rat left ventricle, kidney, and adrenal glands.Methods: DßH assay consisted of the enzymatic hydroxylation of tyramine into octopamine, and DA and NE tissues levels were quantified by HPLC-ED.Results: Nepicastat (30 mg/kg, p.o.) reduced DßH activity by 93% and 80% in the adrenals at 4 h and 8 h postdrug administration, accompanied by significant reductions in NE and epinephrine tissue levels and an increase in DA levels and of DA/NE tissue ratios, with similar findings for NE, DA and of DA/NE tissue ratios in left ventricle and kidney. DßH activity in the left ventricle and kidney showed a high degree of variability, which does not allow corroboration of the effects of nepicastat upon catecholamine tissue levels.Conclusion: The assay of DßH activity in heart and kidney lacks the necessary robustness, but DßH activity in the adrenals appears to be an appropriate marker. However, the effect size upon DA/NE tissue ratios (an indirect measure of DßH activity) as induced by nepicastat was very similar in sympathetically innervated tissues, left ventricle and kidney, and the adrenal medulla.