Browsing by Author "Casanova, J"
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- Abordagem terapêutica em sarcomasPublication . Casanova, J
- Are Complications Associated With the Repiphysis(®) Expandable Distal Femoral Prosthesis Acceptable for Its Continued Use?Publication . Staals, EL; Colangeli, M; Ali, N; Casanova, J; Donati, DM; Manfrini, MBACKGROUND: Reconstruction of the distal femur after resection for malignant bone tumors in skeletally immature children is challenging. The use of megaprostheses has become increasingly popular in this patient group since the introduction of custom-made, expandable devices that do not require surgery for lengthening, such as the Repiphysis(®) Limb Salvage System. Early reports on the device were positive but more recently, a high complication rate and associated bone loss have been reported. QUESTIONS/PURPOSES: We asked: (1) what are the clinical outcomes using the Musculoskeletal Tumor Society (MSTS) scoring system after 5-year minimum followup in patients treated with this prosthesis at one center; (2) what are the problems and complications associated with the lengthening procedures of this implant; and (3) what are the specific concerns associated with revision of this implant? METHODS: At our institute, between 2002 and 2007, the Repiphysis(®) expandable prosthesis was implanted in 15 children (mean age, 8 years; range, 6-11 years) after distal femoral resection for malignant bone tumors. During this time, the general indication for use of this implant was resection of the distal femur for localized malignant bone tumors in pediatric patients. Alternative techniques used for this indication were modular prosthetic reconstruction, massive (osteoarticular or intercalary) allograft reconstruction, or rotationplasty. Age and tumor extension were the main factors to decide on the surgical indication. Of the 15 patients who had this prosthesis implanted during reconstruction surgery, five died with the implant in situ or underwent amputation before 5 years followup and the remaining 10 were evaluated at a minimum of 5 years (mean, 104 months; range, 78-140 months). No patients were lost to followup. These 10 patients were long-term survivors and underwent the lengthening program. They were included in our study analysis. The first seven lengthening procedures were attempted in an outpatient setting; however, owing to pain and burning sensations experienced by the patients, the procedures failed to achieve the desired lengthening. Therefore, other procedures were performed with the patients under general anesthesia. We reviewed clinical data at index surgery for all 15 patients. We further analyzed the lengthening procedures, implant survival, radiographic and functional results, for the 10 long-term survivors. Functional results were assessed according to the MSTS scoring system. Complications were classified according to the International Society of Limb Salvage (ISOLS) classification system. RESULTS: Nine of the 10 survivors underwent revision of the implant for mechanical failure. They had a mean MSTS score of 64% (range, 47%-87%) before revision surgery. At final followup the 10 long-term surviving patients had an average MSTS score of 81% (range, 53%-97%). In total, we obtained an average lengthening of 39 mm per patient (range, 17-67 mm). Exact expansion of the implant was unpredictable and difficult to control. Nine of 10 of the long-term surviving patients underwent revision surgery of the prosthesis-eight for implant breakage and one for stem loosening. At revision surgery, six patients had another type of expandable prosthesis implanted and three had an adult-type megaprosthesis implanted. In five cases, segmental bone grafts were used during revision surgery to compensate for loss of bone stock. CONCLUSIONS: We could not comfortably expand the Repiphysis(®) prosthesis in an outpatient setting because of pain experienced by the patients during the lengthening procedures. Furthermore, use of the prosthesis was associated with frequent failures related to implant breakage and stem loosening. Revisions of these procedures were complex and difficult. We no longer use this prosthesis and caution others against the use of this particular prosthesis design. LEVEL OF EVIDENCE: Level IV, therapeutic study.
- Doença Tumoral Acetabular E Reconstrução Com Prótese De Pedestal LUMiC® - Análise De 2 Casos ClínicosPublication . Freitas, J; Moura, DL; Casanova, JAs resseções peri-acetabulares e reconstrução subsequente estão entre os procedimentos mais desafiantes na Ortopedia Oncológica. Os autores apresentam 2 casos em que foram aplicadas endopróteses modulares tripolares de reconstrução peri-acetabular com pedestal do ilíaco e os seus resultados clínico-funcionais. Apresenta-se uma mulher de 70 anos com metastização óssea única ao nível do acetábulo esquerdo, com origem primária num tumor papilar do urotélio vesical de alto grau. Entretanto sofreu queda da própria altura, da qual resultou fratura-luxação central patológica da anca esquerda, com lesão lítica acetabular na zona de carga. Foi então submetida a cirurgia de resseção tumoral, com resseção total da zona II (peri-acetábulo) e resseção parcial da zona III (púbis) de Enneking. Aplicou-se uma prótese LUMiC® com pedestal no ilíaco, componente acetabular com rebordo anti-luxante e cúpula de dupla mobilidade. A nível femoral, foi aplicada uma haste de Wagner, com utilização de manga de Trevira para reinserções musculares. Apresenta-se uma jovem do sexo feminino de 26 anos referenciada ao nosso centro por cordoma coccígeo recidivado, com envolvimento de várias estruturas, entre as quais pilar posterior do acetábulo, vértebras sagradas, músculos pélvicos incluindo os glúteos e parede retal. Através de abordagem multi-disciplinar foi submetida a resseção tumoral, com necessidade de osteotomia superior a nível da 2ª vértebra sagrada e de resseção do canal anal e ânus, com realização da respetiva colostomia. Depois da remoção tumoral, foi realizada osteotomia da zona II do acetábulo e reconstrução com prótese de pedestal no ilíaco com componente acetabular com rebordo anti-luxante e cúpula de dupla mobilidade, com haste cimentada a nível femoral. Para encerramento posterior, foi realizada passagem transabdominal de retalho músculo-cutâneo do reto anterior do abdómen. O pós-operatório imediato de ambas as pacientes consistiu inicialmente em repouso no leito em decúbito dorsal, com almofada entre as pernas e tornozelos imobilizados, sendo apenas permitidas semi-lateralizações. Após 4 semanas, a primeira paciente iniciou levante com ortótese anti-abdutora da anca e às 16 semanas fazia marcha autónoma com apoio de canadianas. Na segunda paciente foi constatada uma dismetria de 3,5cm, pelo que foi necessária osteotomia femoral homolateral de encurtamento para correção. Teve episódios de deiscências de suturas e ao fim de 8 semanas foi realizada a osteotomia. Às 10 semanas iniciou levante e deambulação com andarilho/canadianas, sem queixas dolorosas relevantes. A resseção e reconstrução acetabular são das cirurgias mais desafiantes a nível da Ortopedia Oncológica. A anatomia complexa, dimensão tumoral e proximidade a estruturas neuro-vascular major leva a que muitas vezes seja difícil de conseguir margens de resseção adequadas. Em segundo lugar, a reconstrução de um membro funcional e indolor é cirurgicamente exigente devido à extensão da resseção e à biomecânica complexa a restaurar. Por outro lado, as reconstruções deste calibre estão associadas a risco elevado de infeção, chegando a 40% em alguns relatos. Os autores apresentam 2 casos clínicos em que a reconstrução peri-acetabular com recurso a endoprótese com pedestal no ilíaco permitiu excelentes resultados clínico-funcionais, apesar de extensa resseção (zonas II e III). Como complicações apenas se verificou dismetria acentuada do membro. Esta complicação foi verificada intra-operatoriamente, no entanto, preferiu-se garantir estabilidade da prótese a nível do ilíaco e posteriormente corrigir a dismetria. As reconstruções acetabulares são cirurgias complexas de elevado risco. O aparecimento de próteses de reconstrução acetabular para grandes defeitos ósseos pós-resseções tumorais, tais como as próteses modulares tripolares com pedestal no ilíaco, e a sua correta aplicação e indicação, permitem obter resultados promissores no tratamento e recuperação funcional capaz destes pacientes.
- Extraskeletal osteosarcoma: A European Musculoskeletal Oncology Society study on 266 patientsPublication . Longhi, A; Bielack, SS; Grimer, R; Whelan, J; Windhager, R; Leithner, A; Gronchi, A; Biau, D; Jutte, P; Krieg, AH; Klenke, FM; Grignani, G; Donati, DM; Capanna, R; Casanova, J; Gerrand, C; Bisogno, G; Hecker-Nolting, S; De Lisa, M; D'Ambrosio, L; Willegger, M; Scoccianti, G; Ferrari, SPURPOSE: Prognosis of extraskeletal osteosarcoma (ESOS) is reported to be poorer than that of skeletal osteosarcoma. This multicenter retrospective study aimed to evaluate factors influencing ESOS prognosis. PATIENTS AND METHODS: Members of the European Musculoskeletal Oncology Society (EMSOS) submitted institutional data on patients with ESOS. RESULTS: Data from 274 patients treated from 1981 to 2014 were collected from 16 EMSOS centres; 266 patients were eligible. Fifty (18.7%) had metastases at diagnosis. Of 216 patients with localised disease, 211 (98%) underwent surgery (R0 = 70.6%, R1 = 27%). Five-year overall survival (OS) for all 266 patients was 47% (95% CI 40-54%). Five-year OS for metastatic patients was 27% (95% CI 13-41%). In the analysis restricted to the 211 localised patients who achieved complete remission after surgery 5-year OS was 51.4% (95% CI 44-59%) and 5-year disease-free survival (DFS) was 43% (95% CI 35-51%). One hundred twenty-one patients (57.3%) received adjuvant or neoadjuvant chemotherapy and 80 patients (37.9%) received radiotherapy. A favourable trend was seen for osteosarcoma-type chemotherapy versus soft tissue sarcoma-type (doxorubicin ± ifosfamide) regimens. For the 211 patients in complete remission after surgery, patient age, tumour size, margins and chemotherapy were positive prognostic factors for DFS and OS by univariate analysis. At multivariate analysis, patient age (≤40 years versus >40 years) (P = 0.05), tumour size (P = 0.0001) and receipt of chemotherapy (P = 0.006) were statistically significant prognostic factors for survival. CONCLUSION: Patient age and tumour size are factors influencing ESOS prognosis. Higher survival was observed in patients who received perioperative chemotherapy with a trend in favour of multiagent osteosarcoma-type regimen which included doxorubicin, ifosfamide and cisplatin.
- HorrendoplastiasPublication . Freitas, J; Casanova, J; Moura, DL; Ferreira, R; Judas, F; Fonseca, FA infeção e reações alérgicas associadas a grandes perdas de tecido ósseo em artroplastias protéticas da anca e joelho ou a infeção em reconstruções ósseas com aloenxertos estruturais de grandes dimensões pós resseções ósseas por patologia tumoral, correspondem a grandes desafios cirúrgicos de salvamento de membros. São casos clínicos submetidos a múltiplas cirurgias, anos de evolução, fistulas profusamente produtivas, tratamentos antibióticos múltiplos, pessoas socialmente e profissionalmente destruídas. Muitos destes casos são propostos para cirurgia mutiladora com amputações de membros ou extração de material protético sem reconstrução estrutural, condenando o doente a incapacidades funcionais marcantes. Apresentam-se 9 casos clínicos de doentes, 8 com artroplastias primárias, de revisão ou tumorais, de anca e joelho, complicadas com infeção (6 doentes) e/ou reação alérgica a metais/iodo (2 doentes) e 1 doente com aloenxerto estrutural do fémur de grandes dimensões infetado, a maioria com perda de osso e proposta de amputação, nomeadamente desarticulação pela anca. Na maioria dos casos tratava-se de infeção por St. aureus meticilino resistente, havendo 1 doente com flora polimicrobiana hospitalar resistente, submetidos a múltiplas cirurgias e oriundos de vários hospitais do país. Os doentes foram operados entre Novembro de 2013 e Abril de 2016 tendo o mais novo 23 anos e o mais velho 76 anos. O tratamento cirúrgico foi composto por 2 tempos operatórios. Primeiro tempo (7 a 9h): extração de material protético; excisão de osso infetado e sem viabilidade; excisão em bloco de tecidos moles desvitalizados/necrosados e com exsudato em toda a periferia do material protético e tecido ósseo infetado, numa espessura com o mínimo de 4 mm; lavagem pulsátil do leito cirúrgico sangrante desbridado com betadine/H2O2 e soro fisiológico; reconstrução articular temporária com espaçador de grandes dimensões em metilmetacrilato com gentamicina. Todos os doentes foram submetidos a terapia antibiótica tripla endovenosa durante 8 a 9 semanas, com controlo analítico rigoroso, tendo alguns deles deambulado com apoio de ortóteses. 2º tempo cirúrgico (4 a 7h) após valores de PCR normais, fez-se conversão dos espaçadores utilizando material protético de revisão e do foro tumoral revestido a prata (potencial bactericida), 8 dos casos com próteses tumorais da anca (5 com reconstrução de ½ fémur proximal e 3 com fémures totais protéticos). Os doentes tiveram alta autónomos e com apoio de canadianas após +- 3 semanas com triterapia antibiótica e.v. e PCR normal ou “borderline”, com passagem a antibióticoterapia dupla oral em ambulatório, no mínimo durante 3 meses até normalização de PCR em 3 avaliações analíticas espaçadas em 15 dias. O doente mais antigo tem +- 29 meses com PCR normal (avaliações analíticas frequentes) e clinicamente todos se apresentam com PCR normais e sem sinais de infeção e/ou fistulas ativas. Funcionalmente, estão autónomos, os mais novos deambulam sem apoio de canadianas enquanto os mais velhos, por vezes, necessitam do apoio de 1 ou 2 canadianas, mas todos negam dores. Todas estas situações clinicas devem ser tratadas de forma agressiva, do ponto de vista de antibióticoterapia alargada e com conjugação de complexas técnicas cirúrgicas do âmbito de revisão protética e do foro tumoral, para se poder obter os melhores resultados possíveis no salvamento de membros, livres de infeção e com capacidade funcional. Os doentes estão satisfeitos com o tratamento, apesar de extremamente exigente do ponto de vista físico e psíquico, por manterem os membros inferiores, referindo que se tivessem de voltar atrás passariam por tudo de novo. Não se pode dizer que estejam curados mas aqui apresenta-se uma metodologia médica e cirúrgica, como uma forma de ir mais além, na esperança da cura de situações clinico-cirúrgicas que muitos cirurgiões designam de horrendoplastias.
- Limb salvage surgery in extreme situations of prosthetic complicationsPublication . Freitas, J; Moura, DL; Fonseca, R; Ferreira, R; Casanova, J; Judas, F; Fonseca, FThe treatment of periprosthetic hip and knee infection associated with loss of bone substance, as well as the treatment of the infection of large structural allografts used in tumoral reconstructive surgery, are a major challenge to the orthopaedic surgeon. Indeed, these are chronic conditions which are submitted to multiple surgeries and prolonged antibiotic therapy in socially and professionally vulnerable patients. Many of these cases receive proposals for limb amputation/disarticulation or extraction of the prosthesis without structural reconstruction aggravating, even more, their suffering and functional disability. The aim of this study is to show the results of a treatment of complex hip and knee periprosthetic infections and of a structural allograft, in the context of limb salvage surgery. 9 patients were treated, minimum age of 22 years and maximum of 76 years with multiple surgeries and from different national hospitals. Six of these patients had periprosthetic infection of the hip and knee (primary, revision and tumoral prostheses) and two of the patients showed an apparent allergic reaction to metal/iodine. The remaining case, an infection of a large femoral structural allograft, used in tumoral surgery. The main cause of the infection was the St. aureus multiresistant. One of the patients showed multimicrobial multiresistant flora. Treatment consisted in 2 different operative stages. First stage (7 to 9h): Extraction of the prosthesis or allograft; debridement and extensive excision of the periprothetic infected and devitalized bone and soft tissue, a minimum thickness of 4 mm; pulsatile lavage of the bleeding “surgical bed” with betadine / H2O2 and saline; implantation of large methyl methacrylate with gentamicin spacer. Triple intravenous antibiotic therapy was made for 8 to 9 weeks, with rigorous analytical control, and some of the patients were able to walk with the support of axillary support crutches. The second surgical stage (5 to 7h) takes place after normal levels of PCR: spacer excision with prosthetic joint reconstruction in 8 cases and in one case a silver coated knee arthrodesis prosthetic implant (bactericidal effect). So, 3 silver coated total femoral prostheses and 5 silver coated total hip prostheses, with the reconstruction of the proximal half of the femur, were applied. The interventions took place between July 2014 and April 2016. Patients were discharged after being able to walk with the help pf crutches and kept taking oral antibiotics until the normalization of PCR in 3 consecutive analytical assessments spaced by 15 days. After a clinical/ analytical evaluation, all patients showed a normal PCR, without pain and without signs of infection and/or active fistulas. Currently 5 patients walk without external support. The oldest case has 28 months of follow-up and all have a minimum follow-up of 7 months, average of 17,5 months. All patients expressed great satisfaction with the outcome of the surgical procedures for the preservation of their lower limbs. Chronic relapsing, multidrug-resistant, periprosthetic infection should be treated aggressively in a combination of surgical techniques of prosthetic revision and tumoral surgery, first through an extended debridement of devitalized tissue and the extraction of the prosthesis with the appropriate antibiotic therapy; second, with the reconstruction of the bone loss with silver coated modular prostheses, which are indicated in order to prevent the mutilating surgery and provide the restoration, as much as possible, of the functional capacity. The results obtained have been very satisfactory, although the follow-up time is insufficient to draw definitive conclusions about the infectious relapse. Such limb salvage surgery is indicated for the treatment of complex clinical situations as an alternative to the disarticulation / limb amputation, i.e. supports the hope of curing clinical and surgical situations that many surgeons designate by horrendoplasties.
- Linfoma primário da coluna vertebral: caso clínicoPublication . Vaio, T; Rial, M; Oliveira, J; Santos, A; Filipe, C; Almeida, S; Teixeira, A; Casanova, J; Santos, R; Reis, C; Porto, A
- Low-impact humeral fracture revealer of chondrosarcoma: a case of exuberant tissue destructionPublication . Coutinho, M; Laranjo, A; Casanova, J
- Mesenchymal chondrosarcoma: prognostic factors and outcome in 113 patients. A European Musculoskeletal Oncology Society studyPublication . Frezza, AM; Cesari, M; Baumhoer, D; Biau, D; Bielack, S; Campanacci, DA; Casanova, J; Esler, C; Ferrari, S; Funovics, PT; Gerrand, C; Grimer, R; Gronchi, A; Haffner, N; Hecker-Nolting, S; Höller, S; Jeys, L; Jutte, P; Leithner, A; San-Julian, M; Thorkildsen, J; Vincenzi, B; Windhager, R; Whelan, JBACKGROUND: Mesenchymal chondrosarcoma (MCS) is a distinct, very rare sarcoma with little evidence supporting treatment recommendations. PATIENTS AND METHODS: Specialist centres collaborated to report prognostic factors and outcome for 113 patients. RESULTS: Median age was 30 years (range: 11-80), male/female ratio 1.1. Primary sites were extremities (40%), trunk (47%) and head and neck (13%), 41 arising primarily in soft tissue. Seventeen patients had metastases at diagnosis. Mean follow-up was 14.9 years (range: 1-34), median overall survival (OS) 17 years (95% confidence interval (CI): 10.3-28.6). Ninety-five of 96 patients with localised disease underwent surgery, 54 additionally received combination chemotherapy. Sixty-five of 95 patients are alive and 45 progression-free (5 local recurrence, 34 distant metastases, 11 combined). Median progression-free survival (PFS) and OS were 7 (95% CI: 3.03-10.96) and 20 (95% CI: 12.63-27.36) years respectively. Chemotherapy administration in patients with localised disease was associated with reduced risk of recurrence (P=0.046; hazard ratio (HR)=0.482 95% CI: 0.213-0.996) and death (P=0.004; HR=0.445 95% CI: 0.256-0.774). Clear resection margins predicted less frequent local recurrence (2% versus 27%; P=0.002). Primary site and origin did not influence survival. The absence of metastases at diagnosis was associated with a significantly better outcome (P<0.0001). Data on radiotherapy indications, dose and fractionation were insufficiently complete, to allow comment of its impact on outcomes. Median OS for patients with metastases at presentation was 3 years (95% CI: 0-4.25). CONCLUSIONS: Prognosis in MCS varies considerably. Metastatic disease at diagnosis has the strongest impact on survival. Complete resection and adjuvant chemotherapy should be considered as standard of care for localised disease.
- Pigmented Villonodular Synovitis: a diagnostic challenge. Review of 28 casesPublication . Coutinho, M; Laranjo, A; Casanova, JOBJECTIVE: Pigmented Villonodular Synovitis (PVNS) is a benign and uncommon clinical entity, characterized by excessive proliferation of synovial membrane of joints, tendon sheaths and bursas. The objective of this study was to evaluate demographic and clinical parameters, diagnostic and treatment procedures and the outcome of 28 patients with PVNS. MATERIAL AND METHODS: Retrospective study of the histologically proven cases of PVNS, diagnosed between January 1998 and April 2010 in the Orthopaedics Department of Coimbra University Hospital. Clinical data were reviewed for each patient and the following parameters were evaluated: gender, age at diagnosis, initial clinical symptoms and site of onset, symptom duration, main imaging findings (x-ray and magnetic resonance imaging of the involved structure), histological features of the lesion, treatment, follow-up duration, evidence of recurrence and time between surgery and recurrence. RESULTS: A total of 28 patients with histologically proven PVNS were included. The majority of patients were female (53.6%) and the mean age at the time of diagnosis was 39.2 ± 19.1 years (mean ± SD). The time between onset of symptoms and diagnosis was un- known in one patient and, in the other 27 patients, mean delay in diagnosis was 24.4 ± 20.5 months (mean ± SD). The knee was the most frequently affected site (75% of the cases). Pain and progressive local swelling sensation were the most frequent symptoms at onset (in 82.1% and 71.4% of the cases, respectively). Joint x-ray identified abnormalities in only 17.8% of the patients. Magnetic resonance imaging (MRI) of the affected structure identified the presence of synovial membrane proliferation in all cases and extra-articular extension of the lesion and bone erosions in 39.1% and 34.8%, respectively. Diagnosis was histologically proven in all cases (27 with synovial joint origin and 1 with tenosynovial origin). Subtotal synovectomy, total synovectomy, local excision of the lesion, synovectomy associated with arthroplasty and synovectomy associated with arthrodesis were performed in 53.6%, 21.4%, 10.7%, 7.1% and 3.6% of the cases, respectively. Local recurrence occurred in 25% of the patients, with a mean time of recurrence of 60.8 months after surgery. CONCLUSION: In PVNS patients, the non-specific symptoms often contribute to a delay in establishing a diagnosis. As in the majority of the reported studies, in this study the knee was also the most commonly affected articular site. Although the x-ray of the affected joint revealed abnormalities in just a few number of patients,MRI identified the presence of synovial membrane proliferation in all cases, proving its value in the diagnostic approach to this entity. However, only the histological study of the lesion allows establishing a definitive diagnosis.