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AimsOur purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R).MethodsWe present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score.ResultsA total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up.ConclusionThis study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV Cite this article: Bone Joint Open 2020;2(1):3–8.

Chondrosarcoma is the second most frequent primary malignant bone tumor. It is typically described in adults between 40 and 70 years of age, being the majority of the series published in this age group. The objective of this study was to report a series of young adults (16-40 years old) with a diagnosis of chondrosarcoma of bone in order to describe the particularities of this tumor in this population. From a total of 37 patients between 16 and 40 years old, surgically treated for chondrosarcoma in our institution, 18 had low-grade tumors (G1/atypical cartilaginous tumor), 16 had an intermediate-grade (G2), and a minority had high-grade tumors (2 with a G3 and 1 with a dedifferentiated chondrosarcoma). The overall survival rate was 97% (95% CI 82%-99%) at 2 years of follow-up and 90.5% (95% CI 73-96) at 5 years of follow-up. The local recurrence free rate was 92% (95% CI % 77%-97.5%) at 1 year of follow-up and 89% at 2 and 5 years of follow-up (95% CI 73%-96%). Histological grade was the most relevant prognostic factor. The concordance of the histological grade between the preoperative diagnosis of the biopsy and the surgical resection material was 81% (30/37).El condrosarcoma ocupa el segundo lugar en frecuencia, entre los tumores malignos primarios óseos, en pacientes adultos. Típicamente afecta a adultos de entre 40 y 70 años, siendo la mayoría de las series publicadas de este grupo etario. El objetivo de este estudio fue comunicar una serie de pacientes adultos jóvenes (16 a 40 años) con diagnóstico de condrosarcoma óseo, que buscó describir las particularidades en la forma de presentación en esta población. De un total de 37 pacientes de 16 a 40 años operados por condrosarcoma en nuestro centro, entre los años 2008 y 2019, 18 presentaron tumores de bajo grado (G1/tumor cartilaginoso atípico), 16 de grado intermedio (G2), quedando una minoría con tumores de alto grado (2 con condrosarcoma G3 y 1 con un condrosarcoma desdiferenciado). La tasa de supervivencia global fue del 97% (IC 95% 82%-99%) a 2 años y 90.5% (IC 95% 73%-96%) a 5 años y la tasa libre de recurrencia local fue de 92% (IC 95% 77%-97.5%) a los 12 meses y de 89% a los 2 y 5 años (IC 95% 73%-96%). El grado histológico fue el factor pronóstico más relevante. La concordancia del grado histológico entre el diagnóstico preoperatorio de la biopsia y el material de resección quirúrgica fue del 81% (30/37).

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.

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.

Ewing sarcoma of the bone is a rare, highly aggressive tumor that typically affects children and young adults. In Argentina, the lack of Ewing's sarcoma registries reflects in the absence of information regarding prevalence, treatment protocols and patient's outcome. The purpose of this study was to analyze, in a group of patients diagnosed with Ewing sarcoma of the bone, treated with chemotherapy and limb-conserving surgery, their overall survival rate, local recurrence rate, and oncological risk factors. A retrospective research was conducted between 1990 and 2017. Eighty-eight patients with Ewing sarcoma of the bone matched the inclusion criteria. Median age was 14.5 years and median follow-up was 8.8 years. Overall survival rate was 79.5%, 69% and 64% at 2, 5 and 10 years respectively. Negative prognostic factors, associated with less survival rate after univariate analysis, were: bad response to chemotherapy (tumoral necrosis 0-89%), age > 16 years-old, central tumor localization and local recurrence. Gender and tumor size were not significant prognostic factors. After multivariate analysis, response to chemotherapy remained statistical significant. Local recurrence-free survival rate at 2 and 5 years was 87%. Tumor response to chemotherapy (0-89%) was the only significant factor for local recurrence. We consider that limb-salvage surgery, with neoadjuvant and adjuvant chemotherapy, are the mainstays of treatment for Ewing's sarcoma, with an overall survival rate, at 5 years, of 69%. In this population, response to chemotherapy is the most relevant prognostic factor, being associated with both local recurrence and overall survival.

Giant cell tumor of bone is an intermediate, locally aggressive and rarely metastasizing, primary bone neoplasia. In recent years denosumab emerged as a treatment alternative for this pathology. The objective of this work was to analyze its indications as well as the clinical outcomes, side effects and local recurrence rates in patients diagnosed with giant cell tumor of bone, who received denosumab as neoadjuvant treatment. Between 2010 and 2018, 80 patients with giant cell tumor were analyzed, of whom 14 received denosumab as a neoadjuvant treatment. The minimum follow-up was 12 months. In 8 patients it was a primary tumor, while 6 showed tumor recurrence. In all cases, clinical improvement was evident. Thirteen patients presented radiographic changes, and 11 showed complete histological response. A local recurrence was evidenced in 6 of 14 patients, and at least one adverse effect related to denosumab (including tumor malignancy) was identified in 7. Despite being a useful tool for treating giant cell tumor, the use of denosumab is associated with a higher rate of local recurrences and is not free of adverse effects.El tumor de células gigantes óseo es una neoplasia de agresividad local intermedia, que raramente metastatiza. En los últimos años el denosumab, anticuerpo monoclonal humano, surgió como una alternativa de tratamiento para esta enfermedad, al bloquear el comportamiento lítico tumoral. El objetivo de este trabajo fue determinar sus indicaciones y efectos adversos, analizando también los resultados oncológicos, y las tasas de recurrencia local en pacientes con diagnóstico de tumor de células gigantes óseo que recibieron denosumab como tratamiento neoadyuvante. Entre 2010 y 2018 se analizaron 80 pacientes con tumor de células gigantes, de los cuales 14 recibieron denosumab como tratamiento neoadyuvante. El seguimiento mínimo fue 12 meses. En 8 pacientes se trató de un tumor primario, mientras que 6 fueron pacientes con recidiva tumoral. En todos los casos se evidenció una mejoría clínica. Trece presentaron cambios radiográficos, y 11 respuesta histológica completa. En 6 de 14 pacientes se evidenció una recurrencia local y en 7 se identificó al menos un efecto adverso relacionado con el denosumab (incluyendo una malignización tumoral). A pesar de ser una herramienta útil para el tratamiento del tumor de células gigantes, el uso de denosumab está asociado a mayor tasa de recurrencias locales y no está exento de efectos adversos.

Background Few studies in the literature show results with more than 20 years of follow-up after anterior cruciate ligament reconstruction (ACLR). The main purpose of this retrospective study was to describe knee-specific quality of life, functional results and prevalence of osteoarthritis (OA) of the knee in patients with ACLR using bone–patellar tendon–bone (BPTB) autograft with ultra-long-term follow-up. Methods Prospective analyzed data included demographics, meniscus status, radiographic OA, KT-1000 arthrometer measurements and physical examinations. KOOS, Lysholm and IKDC subjective surveys were conducted. Multivariate and univariate logistic models were used to determine the effect of potential predictors of OA and symptomatic knees. Results Seventy-two knees were included at a median follow-up of 22 (IQR 21–25) years postoperatively. Radiographic scores were normal in 15%, nearly normal in 57%, abnormal in 18% and severely abnormal in 10%. Multivariate analysis showed that the predictive factor for the presence of OA in the long-term was an associated meniscal lesion; patients with meniscal lesions were 3.9 times as likely to develop OA in comparison with those without meniscal injury. The subjective scores were progressively and significantly lower as the level of OA was greater. Conclusion At a median of 22 years of follow-up, this study shows that patellar tendon autograft ACL reconstruction provides good clinical outcomes, with clinically objective knee stability and a 28% prevalence of OA. Additionally, we identified that meniscal injury at time of surgery was an independent predictor of OA. Level of evidence Level IV; case series.

Resumen Objetivo Analizar una serie de pacientes oncologicos tratados con protesis modulares y evaluar: 1) Supervivencia del implante. 2) Causas de fracaso. 3) Tasa de reintervencion. 4) Supervivencia del miembro. 5) Resultados funcionales y tiempo hasta la carga completa. Materiales y metodos Se realizo una busqueda retrospectiva en una base de datos oncologica entre marzo de 2001 y agosto de 2015 de pacientes con tumores oseos y pacientes con cirugia de revision de trasplantes oseos reconstruidos con endoprotesis. Se incluyo a 106 pacientes con seguimiento minimo de 2 anos. Se dividio la poblacion en 3 grupos: grupo 1, tumores oseos primarios; grupo 2, metastasis osea; grupo 3, revisiones de trasplantes oseos masivos. Las causas de fracasos fueron clasificadas segun Henderson et al. (2014) y la funcionalidad se evaluo segun el la escala de la Musculoskeletal Tumor Society (MSTS). Se realizo analisis demografico, estimacion de la supervivencia y se compararon las diferencias entre grupos. Resultados El seguimiento medio de los pacientes fue de 68 meses. La edad promedio fue de 43 anos. La supervivencia global del implante fue del 86% a 2 anos (IC 95%: 79-94) y del 73% a 5 anos (IC 95%: 60-80). Diecinueve pacientes (18%) presentaron fracaso protesico, con revision. La conservacion del miembro en nuestra serie fue del 96% a 5 anos(IC 95%: 91-99). Los resultados funcionales promedio segun la escala de la MSTS fueron de 24 y el tiempo medio para carga completa de 2, 3 semanas. Conclusion La cirugia de conservacion de miembro representa el tratamiento de eleccion en pacientes con tumores oseos y la reconstruccion con endoprotesis resulta una alternativa valida, con indices de fracaso similares a otras reconstrucciones.

Introduction The proximal humerus is a common site for primary bone sarcomas, of which chondrosarcoma represents 15%. There are few reports about this select group of tumours. We set out to analyse a group of patients with proximal humerus chondrosarcoma treated with surgery and to assess their long term surgical and oncological outcomes. Material and methods A retrospective review was performed and all patients with a proximal humerus chondrosarcoma treated with surgery were included in the study. Overall survival and local recurrence rates were analysed. Post-operative complications were recorded and limb salvage surgery failures classified according to the Henderson classification. Results 37 patients were included in the study. The median age was 46 years (SD: 15.6, range: 17–24), 24 (65%) were female and the mean follow-up was 8.5 years (SD: 6.4, range: 2–26). Eighteen patients were classified as grade 1 (49%), 15 as grade 2 (40%), 2 as grade 3 (5%) and 2 dedifferentiated chondrosarcomas (5%). The 10-year overall survival was 94.5% and the 10-year event-free survival was 84.5%. Five patients developed local recurrences (13%) and none of them was grade 1. The reconstruction failure rate was 27% at 5 years and 34% at 10 years. There were no complications or local recurrence in patients treated with curettage. Conclusion Proximal humerus chondrosarcoma presented high survival rates. Curettage and bone grafting is a safe procedure, with low risk of complications and local recurrence for grade 1 chondrosarcomas and should be the first indication for the proximal humerus. Reconstruction of the proximal humerus after a wide resection has a 5-year failure rate of 27% and 10-year failure rate of 34%.

Resumen Introduccion El humero proximal es una localizacion frecuente de los sarcomas oseos y el condrosarcoma representa el 15%. Existen pocos trabajos sobre este grupo seleccionado de tumores. El objetivo del estudio fue analizar a un grupo de pacientes con condrosarcoma del humero proximal tratados con cirugia y evaluar los resultados quirurgicos y oncologicos a largo plazo. Material y metodos Se realizo una busqueda retrospectiva y se incluyeron en el estudio todos los pacientes con condrosarcoma de humero proximal tratados quirurgicamente en una unica institucion. Se analizaron la supervivencia global y la tasa de recurrencia local. Las complicaciones postoperatorias fueron registradas y los fracasos de la cirugia de conservacion de miembros se clasificaron de acuerdo a la clasificacion de Henderson. Resultados Treinta y siete pacientes fueron incluidos en el estudio. La mediana de edad fue de 46 anos (DE: 15,6; rango: 17-24), 24 (65%) eran mujeres y la media de seguimiento fue de 8,5 anos (DE: 6,4; rango: 2-26). Diez y ocho fueron clasificados como grado 1 (49%), 15 como grado 2 (40%), 2 como grado 3 (5%) y 2 condrosarcomas desdiferenciados (5%). La supervivencia global a 10 anos fue del 94,5% y la supervivencia libre de eventos a 10 anos del 84,5%. Cinco pacientes desarrollaron recurrencias locales (13%) y ninguno de ellos fue grado 1 . Las tasas de fracaso en la reconstruccion fue del 27% a los 5 anos y del 34% a los 10 anos. No se registraron complicaciones ni recurrencia local en los pacientes tratados con raspado. Conclusion El condrosarcoma de humero proximal presento altas tasas de supervivencia. El raspado y relleno con injerto oseo es un procedimiento seguro, con bajo riesgo de complicaciones y recurrencia local para los condrosarcomas de grado 1 y debe ser la primera indicacion para el humero proximal. La reconstruccion del humero proximal despues de una reseccion en bloque tiene una tasa de fracaso del 27% a 5 anos y del 34% a 10 anos.

Objective To analyse a series of patients with bone tumours reconstructed with modular prostheses and to evaluate: (1) Survival of the implant. (2) Causes of failure. (3) Complication rates. (4) Limb salvage overall survival. (5) Functional results and full weight bearing. Materials and methods A retrospective study from longitudinally maintained oncology databases was undertaken. All patients with bone tumours reconstructed with endoprosthesis were analysed. A total of 106 patients matched the inclusion criteria. They were divided into groups: group 1, primary bone tumours; group 2, bone metastasis; group 3, osteoarticular allograft reconstruction revisions. The type of failures were classified according to Henderson et al. (2014) and functional results assessed by the Musculoskeletal Tumor Society (MSTS). Demographic analysis, survival and the differences between groups were recorded. Result The mean follow-up of the patients was 68 months. Mean age was 43 years. Overall implant survival was 86.4% at 2 years (95% CI: 79–94) and 73% at 5 years (95% CI: 60–80). Nineteen patients (18%) developed a prosthetic failure. The limb salvage overall survival was 96% at 5 years (95% CI: 91–99). The mean functional results according to the MSTS was 24 and mean time to full weight bearing was 2.3 weeks. Conclusions Limb conservation surgery and endosprosthetic reconstruction is a valid option for patients with bone tumours with failure rates similar to other reconstruction methods.

Background En bloc resection of benign tumors is only indicated in aggressive lesions with substantial destruction of the affected bone. Few reports have evaluated the long-term outcome of Grade 3 giant cell tumor of bone (GCTB; defined as severe bone destruction and soft tissue extension) treated with en bloc resection and reconstruction with a massive allograft. We recently reported that patients with benign tumors achieved better allograft reconstruction survivorship compared with those treated for a malignant bone tumor. In light of that finding, we wondered whether osteoarticular allografts would be a viable long-term alternative for Grade 3 GCTB, which could be important in some countries because of greater availability and lower costs compared with endoprostheses. Questions/purposes We analyzed a group of patients with Grade 3 GCTBs treated with en bloc resection and osteoarticular allograft reconstruction in terms of (1) survivorship free from allograft removal at 10 years; (2) survivorship free from reoperation for any reason at 10 years, (3) functional results as measured by the Musculoskeletal Tumor Society (MSTS) score, (4) assessment of arthrosis at the knee. Methods We retrospectively analyzed all patients with a Grade 3 GCTB treated between 1980 and 2007. Only patients treated with en bloc resection and reconstruction with massive osteoarticular allografts were included in the analysis. The indication for osteoarticular reconstruction during that time included severe bone destruction with intraarticular compromise of the tumor, intraarticular fracture because of tumor growth, the presence of inadequate remaining subchondral bone to resist normal loading (for the distal femur or proximal tibia), and the preservation of a soft-tissue component (ligaments or meniscus) for articular stability. During the period, 75 patients were treated with en bloc resection. Patients treated with intralesional curettage (n = 7), reconstruction with an endoprosthesis (n = 2), intercalary arthrodesis (n = 13), or unicondylar reconstruction (n = 14) were excluded. Of the original 75 treated with en bloc resection, 52% (39) were treated with osteoarticular allograft reconstruction, and no patient was lost to follow-up before 2 years or had substantial missing data. However, of the 39 patients, another 21% (8) have not been seen in the last 5 years, but these were included here because they reached the 10-year minimum surveillance period before being lost. Twenty-three of those 39 patients were previously reported by our group and 16 new patients (treated between 1980-1985) were included in this series (eight distal radius, six distal femur, two proximal tibias), extending the follow-up period and including more patients for analysis. The median (range) follow-up duration was 26 years (10 to 34). We assessed survivorship using a Kaplan-Meier analysis, we drew MSTS scores retrospectively from patients´ medical records, and we graded arthrosis using the Ahlback scale for the knee (which was by far the most common joint involved, n = 31, and so it was the joint we assessed for the presence of arthrosis). Results The survivorship free from allograft removal was 85% at 10 years (95% CI 74 to 96). The allograft survivorship free from reoperation for any reason at 10 years was 72% (95% CI 59 to 87). The median (range) MSTS score was 28 points (19 to 30). The grade of arthrosis in the knee at last follow-up was analyzed in 20 patients and classified in nine as Ahlback Type 4, in six as Type 3, in three as Type 2 and in two as Type 5. Conclusions Osteoarticular allograft reconstruction after a Grade 3 GCTB en bloc resection showed excellent long-term survivorship. We believe these results compare favorably with other studies on endoprosthetic reconstruction and head-to-head studies of these approaches should be performed; these would need to be multicenter trials. In the meantime, in locations where endoprostheses are unavailable or too expensive, we believe our results support the use of osteoarticular allografts. Level of evidence Level IV, therapeutic study.

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.

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.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.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).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.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.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.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).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.

BACKGROUND Massive bone allografts have been used for limb salvage in patients undergoing bone tumor resections as an alternative to endoprostheses. Although several studies on massive allograft reconstructions for bone tumors reported that most complications occur in the first 3 years after surgery, there are no long-term reports on complications to substantiate this contention. We believe such information is important so that surgeons and patients can make more informed decisions when choosing a reconstructive method after tumor resection. QUESTIONS/PURPOSES (1) What is the survival of allografts free from removal, amputation, or joint replacement in patients treated for bone tumors in the lower limb with a minimum of 10 years of followup? (2) What complications occur after 10 or more years of followup? (3) Are there factors associated with allograft survival, such as age, sex, the affected bone, reconstruction type (intercalary or osteoarticular allograft), tumor type (malignant or benign), failure type, and chemotherapy use? METHODS We retrospectively analyzed the records of 398 patients treated in one center with benign or malignant bone tumors in the femur or tibia between 1986 and 2007. During the period in question, our general indications for using allografts (354 patients) included patients with benign or low-grade sarcomas and patients with high-grade sarcomas with clinical and imaging response to neoadjuvant chemotherapy. Other approaches such as endoprostheses (44 patients) were indicated if the patient received radiotherapy, in patients with high-grade sarcomas without clinical and imaging response to neoadjuvant chemotherapy, or with neurovascular tumor involvement. We excluded from the analysis 53 patients treated with allograft-prosthetic composites, 46 with hemicondylar osteoarticular allografts, and 57 with intercalary hemicylindrical allografts. The study was thus performed in 198 patients treated with segmental massive allografts in the long bones of the lower extremity (132 femurs and 66 tibias) after resection of a primary bone tumor, including 120 patients treated with osteoarticular and 78 with segmental intercalary allografts. A total of 32 (16%) of the 198 patients died before 10 years, and graft status was known in all of those patients; these patients were included (mean followup, 192 months; range, 1-370 months). All remaining 166 patients who were not known to have died before 10 years were accounted for at least 10 years after the allograft procedure (mean, 222 months; range, 120-370 months). No patient was lost to followup. The mean age was 22 years (range, 2-55 years); 105 patients were male (53%) and 93 were female. The predominant diagnoses were osteosarcoma (n = 125, 63%), giant cell tumor of bone (n = 27, 14%), and Ewing's sarcoma (n = 19, 10%). In all, 146 patients (74%) underwent chemotherapy. Selected variables were analyzed using multivariate logistic regression analyses to identify risk factors of allograft removal, joint replacement, or amputation. We performed competitive risk analysis with allograft removal, joint replacement, or amputation as the endpoint at 5, 10, and 20 years. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system. RESULTS The risk of allograft removal, joint replacement, or amputation was 36% at 5 years (95% CI, 30-43), 40% at 10 years (95% CI, 33-47), and 44% at 20 years (95% CI, 37-51). Fractures occurred in 15% (29 patients), infection in 14% (27 patients), nonunion in 12% (23 patients) and tumor recurrence in 7% (13 patients). Thirty-two patients died of disease before 10 years; nine of these patients had a second surgery before death, eight had an amputation, and one underwent graft removal. Of the 166 patients who were still alive 10 years after the allograft procedure, 36 underwent allograft removal, six patients underwent joint replacement, and four had an amputation; however, after 10 years, six more allografts were removed (four due to fractures, one due to infection, and one due to instability), and another patient was amputated due to a second malignancy. After controlling for potentially confounding variables including death, we found that the risk of allograft removal, joint replacement, or amputation in osteoarticular tibial grafts (58% [95% CI, 43-73] at 5, 10, and 20 years) was higher than that of osteoarticular femur allografts (29% [95% CI, 18-39] at 5 years, 30% [95% CI, 19-40] at 10 years, 37% [95% CI, 25-48] at 20 years; p = 0.010) and tibia intercalary allografts (26% [95% CI, 7-45] at 5, 10 and 20 years; p = 0.020). Fractures occurred more frequently in the femur (18% [95% CI, 11-25]) than in the tibia (5% [95% CI, 0-10]; p < 0.010), and infections occurred more frequently in the tibia (24% [95% CI, 14-35]) than in the femur (4% [95% CI, 0-8]; p < 0.001). With the number of patients we had, we found no difference in the proportion of local recurrence in the tibia (12% [95% CI, 4-20]) compared with the femur (5% [95% CI, 1-9]; p < 0.053). CONCLUSIONS Infections were the most common complications associated with allograft removal in the first 2 to 3 years after reconstruction and were more frequently associated with tibial allograft removal. Fractures were more commonly associated with graft removal with longer term followup and were more frequently associated with femoral allograft removal. Although we cannot directly compare our results with other types of reconstructions, we believe that allografts still have a role in the reconstruction of patients with a benign or low-grade bone tumor. Future studies in femoral allograft with longer followup should be performed to analyze factors that may explain why some grafts fail, such as the percent of the length of the bone resected, type and number of plates and screws used and type of fixation (rods versus plates). There was a higher incidence of graft removal in patients with proximal tibia osteoarticular allografts, which has led us to use this type of reconstruction only in pediatric patients over the last 15 years. LEVEL OF EVIDENCE Level III, therapeutic study.

Los sarcomas de partes blandas en menores de 2 anos son infrecuentes. Durante 2007-2017, 445 pacientes con sarcomas de partes blandas fueron tratados en nuestra Institucion; 6 (el 0,5 %) eran menores de 2 anos. Se analizaron los resultados clinicos y oncologicos en este grupo. La edad media de diagnostico fue 15 meses. Cuatro eran varones y 2, mujeres. El seguimiento promedio fue 29 meses. El fibrosarcoma (n = 4) fue la variedad mas frecuente. Cinco fueron tratados con cirugia de conservacion del miembro; al restante se le realizo amputacion. Todos realizaron tratamiento adyuvante con quimioterapia. La supervivencia a 24 meses fue del 100 %. Dos pacientes presentaron recidiva local; ambos casos, antes de los 24 meses. El tratamiento quirurgico asociado a la quimioterapia impresiona ser la mejor opcion terapeutica. La proporcion de recurrencia local es alta para este grupo de pacientes luego de la cirugia de conservacion del miembro.

Background: The treatment of locally aggressive bone tumors is a balance between achieving local tumor control and surgical morbidity.Wide resection decreases the likelihood of local recurrence, although wide resection may result in more complications than would happen after curettage.Navigationassisted surgery may allow more precise resection, perhaps making it possible to expand the procedures indications and decrease the likelihood of recurrence; however, to our knowledge, comparative studies have not been performed. Questions/purposes The purpose of this study was to compare curettage plus phenol as a local adjuvant with navigation-guided en bloc resection in terms of (1) local recurrence; (2) nononcologic complications; and (3) function as measured by revised Musculoskeletal Tumor Society (MSTS) scores. Methods Patients with a metaphyseal and/or epiphyseal locally aggressive primary bone tumor treated by curettage and adjuvant therapy or en bloc resection assisted by navigation between 2010 and 2014were considered for this retrospective study. Patients with a histologic diagnosis of a primary aggressive benign bone tumor or low-grade chondrosarcoma were included. During this time period, we treated 45 patients with curettage of whom 43 (95%)were available for followup at a minimum of 24 months (mean, 37 months; range, 24-61 months), andwe treated 26 patientswith navigation-guided en bloc resection, of whom all (100%) were available for study. During this period, we generally performed curettage with phenol when the lesionwas in contactwith subchondral bone. We treated tumors that were at least 5 mm from the subchondral bone, such that en bloc resection was considered possible with computer-Assisted block resection. There were no differences in terms of age, gender, tumor type, or tumor location between the groups. Outcomes, including allograft healing, nonunion, tumor recurrence, fracture, hardware failure, infection, and revised MSTS score, were recorded. Bone consolidation was defined as complete periosteal and endosteal bridging visible between the allograft-host junctions in at least two different radiographic views and the absence of pain and instability in the union site. All study data were obtained from our longitudinally maintained oncology database. Results In the curettage group, two patients developed a local recurrence, and no local recurrences were recorded in patients treated with en bloc resection. All patients who underwent navigation-guided resection achieved tumorfree margins. Intraoperative navigation was performed successfully in all patients and there were no failures in registration. Postoperative complications did not differ between the groups: in patients undergoing curettage, 7%(three of 43) and in patients undergoing navigation, 4% (one of 26) had a complication. There was no difference in functional scores: mean MSTS score for patients undergoing curettage was 28 points (range, 2730 points) and for patients undergoing navigation, 29 (range, 27-30 points; p = 0.10). Conclusions In this small comparative series, navigationassisted resection techniques allowed conservative en bloc resection of locally aggressive primary bone tumors with no local recurrence. Nevertheless, with the numbers available, we saw no difference between the groups in terms of local recurrence risk, complications, or function. Until or unless studies demonstrate an advantage to navigation-guided en bloc resection, we cannot recommend wide use of this novel technique because it adds surgical time and expense. Level of Evidence Level III, therapeutic study. Fil: Farfalli, Germán Luis. Hospital Italiano; Argentina Fil: Albergo, Jose I.. Hospital Italiano; Argentina Fil: Piuzzi, Nicolas Santiago. Hospital Italiano; Argentina Fil: Ayerza, Miguel A.. Hospital Italiano; Argentina Fil: Muscolo, D. Luis. Hospital Italiano; Argentina Fil: Ritacco, Lucas. Hospital Italiano; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Aponte Tinao, Luis A.. Hospital Italiano; Argentina

Objectives The COVID-19 pandemic is unprecedented as a global crisis over the last century. How do specialist surgeons make decisions about patient care in these unprecedent times? Design Between April and May 2020, we conducted an international qualitative study. Sarcoma surgeons from diverse global settings participated in 60 min interviews exploring surgical decision making during COVID-19. Interview data were analysed using an inductive thematic analysis approach. Setting Participants represented public and private hospitals in 14 countries, in different phases of the first wave of the pandemic: Australia, Argentina, Canada, India, Italy, Japan, Nigeria, Singapore, Spain, South Africa, Switzerland, Turkey, UK and USA. Participants From 22 invited sarcoma surgeons, 18 surgeons participated. Participants had an average of 19 years experience as a sarcoma surgeon. Results 17/18 participants described a decision they had made about patient care since the start of the pandemic that was unique to them, that is, without precedence. Common to 'unique' decisions about patient care was uncertainty about what was going on and what would happen in the future (theme 1: the context of uncertainty), the impact of the pandemic on resources or threat of the pandemic to overwhelm resources (theme 2: limited resources), perceived increased risk to self (theme 3: duty of care) and least-worst decision making, in which none of the options were perceived as ideal and participants settled on the least-worst option at that point in time (theme 4: least-worst decision making). Conclusions In the context of rapidly changing standards of justice and beneficence in patient care, traditional decision-making frameworks may no longer apply. Based on the experiences of surgeons in this study, we describe a framework of least-worst decision making. This framework gives rise to actionable strategies that can support decision making in sarcoma and other specialised fields of surgery, both during the current crisis and beyond., Australian National Health and Medical Research Council Practitioner Fellowship [APP1154203], This work was supported by an Australian National Health and Medical Research Council Practitioner Fellowship held by PFMC (APP1154203). All authors were independent from funders, and all authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Computer navigation during surgery can help oncologic surgeons perform more accurate resections. However, some navigation studies suggest that this tool may result in unique intraoperative problems and increased surgical time. The degree to which these problems might diminish with experience–the learning curve–has not, to our knowledge, been evaluated for navigation-assisted tumor resections. (1) What intraoperative technical problems were observed during the first 2 years using navigation? (2) What was the mean time for navigation procedures and the time improvement during the learning curve? (3) Have there been any differences in the accuracy of the registration technique that occurred over time? (4) Did navigation achieve the goal of achieving a wide bone margin? All patients who underwent preoperative virtual planning for tumor bone resections and operated on with navigation assistance from 2010 to 2012 were prospectively collected. Two surgeons (GLF, LAA-T) performed the intraoperative navigation assistance. Both surgeons had more than 5 years of experience in orthopaedic oncology with more than 60 oncology cases per year per surgeon. This study includes from the very first patients performed with navigation. Although they did not take any formal training in orthopaedic oncology navigation, both surgeons were trained in navigation for knee prostheses. Between 2010 and 2012, we performed 124 bone tumor resections; of these, 78 (63%) cases were resected using intraoperative navigation assistance. During this period, our general indications for use of navigation included pelvic and sacral tumors and those tumors that were reconstructed with massive bone allografts to obtain precise matching of the host and allograft osteotomies. Seventy-eight patients treated with this technology were included in the study. Technical problems (crashes) and time for the navigation procedure were reported after surgery. Accuracy of the registration technique was defined and the surgical margins of the removed specimen were determined by an experienced bone pathologist after the surgical procedure as intralesional, marginal, or wide margins. To obtain these data, we performed a chart review and review of operative notes. In four patients (of 78 [5%]), the navigation was not completed as a result of technical problems; all occurred during the first 20 cases of the utilization of this technology. The mean time for navigation procedures during the operation was 31 minutes (range, 11–61 minutes), and the early navigations took more time (the regression analysis shielded R2 = 0.35 with p

Central chondrosarcoma of bone is graded on a scale of 1 to 3 according to histological criteria. Clinically, these tumors can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. Although en bloc resection has been the most widely used treatment, it has become generally accepted that in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment, but prior reports have indicated that both imaging and biopsy do not always give an accurate prediction of grade.(1) What is the concordance of image-guided needle preoperative biopsy and postoperative grading in central (intramedullary) chondrosarcomas of long bones, and how does this compare with the concordance of image-guided needle preoperative biopsy and postoperative grading in central pelvic chondrosarcomas? (2) What is the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones, and how does this compare with the concordance in central pelvic chondrosarcomas?Between 1997 and 2014, in our institution, we treated 126 patients for central chondrosarcomas located in long bones and the pelvis. Of these 126 cases, 41 were located in the pelvis and the remaining 85 cases were located in long bones. This study considers 39 (95%) and 40 (47%) of them, respectively. We included all cases in which histological information was complete regarding preoperative and postoperative tumor grading. We excluded all cases with incomplete data sets or nondiagnostic preoperative biopsies. To evaluate the needle biopsy accuracy, we compared the histological tumor grade, obtained from the preoperative biopsy, with the final histological grade obtained from the postoperative surgical specimen. The weighted and nonweighted kappa statistics were used to evaluate the agreement.Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]; odds ratio, 8, 48). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma for the determination of histological grade (0.63; 95% confidence interval [CI], 0.34-0.91 versus 0.12; -0.32 to 0.57; p0.001). When categorizing the lesions as low grade or high grade, concordance between the preoperative biopsy and the final pathological analysis was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (90% [36 of 40] versus 67% [26 of 39]; odds ratio, 4, 5). Likewise, the weighted kappa coefficients were higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (0.73; 95% CI, 0.51-0.94 versus 0.26; 0.04-0.48; p0.001).Image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The histological grade should be correlated with imaging and the clinical presentation, but under these circumstances, experienced tumor surgeons may use this information in planning surgical treatment. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution.Level III, diagnostic study.

Chondroblastoma is an uncommon, benign, but locally aggressive bone tumor that occurs in the apophyses or epiphyses of long bones, primarily in young patients. Although some are treated with large resections, aggressive curettage and bone grafting are more commonly performed to preserve the involved joint. Such intralesional resection may result in damage to the growth plate and articular cartilage, which can result in painful arthritis. Prior studies have focused primarily on oncologic outcomes rather than long-term joint status and functional outcomes.(1) What local complications can be expected after aggressive intralesional curettage of epiphyseal chondroblastoma? (2) What is the joint survival of a joint treated in this way for chondroblastoma? (3) What additional procedures are used in treating symptomatic joint osteoarthritis after treatment of the chondroblastoma? (4) What are the functional outcomes in this group of patients?A retrospective study of our prospectively collected database between 1975 and 2013 was done. We found 64 patients with a diagnosis of chondroblastoma of bone. After applying our selection criteria, 53 patients were involved in this study. We excluded seven patients with tumors initially treated with en bloc resection (five located in the extremities and two in the axial skeleton) and two patients with apophyseal tumors. One patient who underwent nonsurgical treatment and one patient lost to followup were also excluded. The mean age was 18 years (range, 11-39 years); the minimum followup was 2 years with a mean followup 77 months (range, 24-213 months). We analyzed all patients with a diagnosis of epiphyseal chondroblastoma of the limb treated with aggressive curettage and joint preservation surgery. During the period in question, our general indications for curettage were patients with active, painful tumors and those with more aggressive ones that remained intracompartmental, whereas initial wide en bloc resection was indicated in patients who had tumors with an extracompartmental extension breaching the adjacent joint cartilage and massive articular destruction. The tumor location was the distal femur in 14 patients, proximal tibia in 11, proximal humerus in 10, proximal femur in eight, the talus in seven, and elsewhere in the lower extremity in three. Local complications including joint degeneration and tumor recurrence were evaluated. Based on radiographic analysis, secondary osteoarthritis was classified by using the Kellgren-Lawrence grading system from Grade 0 to Grade IV. Patients who underwent joint replacement resulting from advanced symptomatic osteoarthritis were considered to have had joint failure for purposes of survivorship analysis, which was estimated using the Kaplan-Meier method. Functional results were evaluated with the Musculoskeletal Tumor Society functional score by the treating surgeon, who transcribed the results on the digital records every 6 months of followup.Twenty-two patients (42%) developed 26 local complications. The most common local complication was osteoarthritis in 20 patients (77% [20 of 26 complications]); tumor recurrence was observed in four patients; an intraarticular fracture and superficial infection treated with surgical débridement and antibiotics developed in one patient each. Joint survival was 90% at 5 years (95% confidence interval [CI], 76%-100%) and 74% at 10 years (95% CI, 48%-100%). Proximal femoral tumor location was associated with lower survivorship of the joint than other locations showing a 5-year survival rate of 44% (95% CI, 0%-88%; p = 0.000). Of the 20 patients with osteoarthritis, four were symptomatic enough to undergo joint replacement, all of which were for tumors in the proximal femur. The mean Musculoskeletal Tumor Society functional score was 28 of 30 points (93%).Osteoarthritis was a frequent complication of aggressive curettage of epiphyseal chondroblastoma, and tumors located in the proximal femur appeared to be at particular risk of secondary osteoarthritis and prosthetic replacement. Because chondroblastoma is a tumor that disproportionately affects younger patients, the patient and surgeon should be aware that arthroplasty at a young age is a potential outcome for treatment of proximal femoral chondroblastomas.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Editorial

Purpose To compare the results for patients treated with intercalary endoprosthetic replacement (EPR) or intercalary allograft reconstruction for diaphyseal tumours of the femur in terms of: (1) reconstruction failure rates; (2) cause of failure; (3) risk of amputation of the limb; and (4) functional result. Methods Patients with bone sarcomas of the femoral diaphysis, treated with en bloc resection and reconstructed with an intercalary EPR or allograft, were reviewed. A total of 107 patients were included in the study (36 EPR and 71 intercalary allograft reconstruction). No differences were found between the two groups in terms of follow-up, age, gender and the use of adjuvant chemotherapy. Results The probability of failure for intercalary EPR was 36% at 5 years and 22% for allograft at 5 years (p = 0.26). Mechanical failures were the most prevalent in both types of reconstruction. Aseptic loosening and implant fracture are the main cause in the EPR group. For intercalary allograft reconstructions, fracture followed by nonunion was the most common complication. Ten-year risk of amputation after failure for both reconstructions was 3%. There were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (27.4, range 16–30 vs. 27.6, range 17–30). Conclusions We have demonstrated similar failure rates for both reconstructions. In both techniques, mechanical failure was the most common complication with a low rate of limb amputation and good functional results. Fil: Albergo, J. I.. Instituto Universidad Escuela de Medicina del Hospital Italiano; Argentina Fil: Gaston, L. C.. Royal Orthopaedic Hospital; Reino Unido Fil: Farfalli, Germán Luis. Instituto Universidad Escuela de Medicina del Hospital Italiano; Argentina Fil: Laitinen, M.. Helsinki University Central Hospital; Finlandia. Royal Orthopaedic Hospital; Reino Unido Fil: Parry, M.. Royal Orthopaedic Hospital; Reino Unido Fil: Ayerza, M. A.. Instituto Universidad Escuela de Medicina del Hospital Italiano; Argentina Fil: Risk, Marcelo. Consejo Nacional de Investigaciones Cientificas y Tecnicas. Oficina de Coordinacion Administrativa Houssay. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Hospital Italiano. Instituto de Medicina Traslacional E Ingenieria Biomedica. - Instituto Universitario Hospital Italiano de Buenos Aires. Instituto de Medicina Traslacional E Ingenieria Biomedica.; Argentina Fil: Jeys, L. M.. Royal Orthopaedic Hospital; Reino Unido Fil: Aponte Tinao, L. A.. Instituto Universidad Escuela de Medicina del Hospital Italiano; Argentina

Background Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprosthesis, although they have different outcomes and risks. The use of massive bone allografts has been thought to be associated with a high risk for infection, and there is no general consensus on the management of this complication and final outcome. Because infection is such a devastating complication of limb salvage, at times leading to loss of a limb, recognizing the risk factors for infection and the results of treatment is important.

Background Preservation of limb function after resection of malignant bone tumors in skeletally immature children is challenging. Resection of bone sarcomas and reconstruction with an allograft in patients younger than 10 years old is one reconstructive alternative. However, long-term studies analyzing late complications and limb length discrepancy at skeletal maturity are scarce; this information would be important, because growth potential is altered in these patients owing to the loss of one physis during tumor resection. Questions/purposes At a minimum followup of 10 years after reconstructions in children younger than 10 years of age at the time of reconstruction, we asked what is (1) the limb length discrepancy at skeletal maturity and how was it managed; (2) the risk of amputation; (3) the risk of allograft removal; and (4) the risk of second surgery resulting from complications? Methods Between 1994 and 2006, we performed 22 bone allografts after bone sarcoma resections in children younger than 10 years of age. Of those, none were lost to followup before the minimum followup of 10 years was reached, and an additional six had died of disease (of whom three died since our last report on this group of patients), leaving 16 patients whom we studied here. Followup on these patients was at a mean of 13.5 years (range, 10-22 years). During the period in question, no other treatments (such as extendible prostheses, amputations, etc) were used. The mean age at the time of the original surgery was 7 years (range, 2-10 years), and the mean age of the 16 alive patients at last followup was 20 years (range, 15-28 years). This series included 10 boys and six girls with 14 osteosarcomas and two Ewing sarcomas. Ten reconstructions were performed with an intercalary allograft and six with an osteoarticular allograft. The growth plate was uninvolved in three patients, whereas in the remaining 13, the growth plate was included in the resection (seven intercalary and six osteoarticular allografts). Limb length discrepancy at skeletal maturity was measured with full-length standing radiographs, and data were collected by retrospective study of a longitudinally maintained institutional database. The risk of amputation, allograft removal, and secondary surgery resulting from a complication was calculated by a competing-risk analysis method. Results We observed no limb length discrepancy at skeletal maturity in the three patients with intercalary resections in whom we preserved the physes on both sides of the joint (two femurs and one tibia); however, one patient developed malalignment that was treated with corrective osteotomy of the tibia. The remaining 13 patients developed limb length discrepancy as a result of loss of one physis. Seven patients (four femurs, two tibias, and one humerus) developed shortening of ≤ 3 cm (mean, 2.4 cm; range, 1-3 cm) and no lengthening was performed. Six patients developed > 3 cm of limb discrepancy at skeletal maturity (all distal femoral reconstructions). In four patients this was treated with femoral lengthening, whereas two declined this procedure (each with 6 cm of shortening). In the four patients who had a lengthening procedure, one patient had a final discrepancy of 4 cm, whereas the other three had equal limb lengths at followup. The risk of amputation was 4% (95% confidence interval [CI], 0-15) and none occurred since our previous report. The risk of allograft removal was 15% (95% CI, 1-29) and none occurred since our previous report on this group of patients. The risk of other operations resulting from a complication was 38% (95% CI, 19-57). Eleven patients underwent a second operation resulting from a complication (three local recurrences, five fractures, one infection, one nonunion, and one tibial deformity), of which three were performed since our last report on this group of patients. Conclusions Limb length inequalities and subsequent procedures to correct them were common in this small series of very young patients as were complications resulting in operative procedures, but overall most allografts remained in place at long-term followup. In skeletally immature children, bone allograft is one alternative among several that are available (such as rotationplasty and endoprosthesis), and future studies with long followup may be able to compare the available options with one another. Level of evidence Level IV, therapeutic study.

We propose to study a group of patients with primary bone sarcoma of the pelvis treated with limb salvage surgery and analyze overall survival, local recurrence rates and functional outcomes. A retrospective review was performed, and all patients diagnosed with pelvic primary bone sarcomas between 1990 and 2012 were analyzed. Patients treated with limb salvage surgery and with a minimum of 12-month follow-up for patients alive were included. The overall survival and the local recurrence rate were calculated for the assessment of oncological results. The associations with gender, age, histological grade, type of surgery, margins chemotherapy response and use of navigation were examined. Fifty-two patients were included in the study. The mean age was 37 years (range 10–82), and mean follow-up was 44 months (range 8–189). Forty-five (86 %) tumors were histologically classified as high-grade sarcomas, four (8 %) as low-grade sarcomas and three (6 %) as dedifferentiated sarcomas. Cancer-specific overall survival was 37.5 % for 5 years and 31 % for 10 years. Local recurrence rate was 30 %. High-grade tumors and chemotherapy necrosis below 90 % were negative prognosis factor. Postoperative complication rate was 34.5 % (n:18), being deep infection the most prevalent (n:13). Reconstruction of the pelvis after an oncology resection for primary pelvic sarcomas increased the incidence of complication significantly (p

Bone tumor resections for limb salvage have become the standard treatment. Recently, intercalary tumor resection with epiphyseal sparing has been used as an alternative in patients with osteosarcoma. The procedure maintains normal joint function and obviates some complications associated with osteoarticular allografts or endoprostheses; however, long-term studies analyzing oncologic outcomes are scarce, and to our knowledge, the concern that a higher local recurrence rate may be an issue has not been addressed.We wanted to assess (1) the overall survival in patients treated with this surgical technique; (2) the percentage of local recurrence and limb survival, specifically the incidence of recurrence in the remaining epiphysis; (3) the frequency of orthopaedic complications, and, (4) the functional outcomes in patients who have undergone intercalary tumor resection.We analyzed all 35 patients with osteosarcomas about the knee (distal femur and proximal tibia) treated at our center between 1991 and 2008 who had resection preserving the epiphysis and reconstruction with intercalary allografts. Minimum followup was 5 years, unless death occurred earlier (mean, 9 years; range, 1-16 years), and no patients were lost to followup. During the study period, our indications for this approach included patients without metastases, with clinical and imaging response to neoadjuvant chemotherapy, that a residual epiphysis of at least 1 cm thickness could be available after a surgical margin width in bone of 10 mm was planned, and 16% of patients (35 of 223) meeting these indications were treated using this approach. Using a chart review, we ascertained overall survival of patients, oncologic complications such as local recurrence and tumor progression, limb survival, and orthopaedic complications including infection, fracture, and nonunion. Survival rates were estimated using the Kaplan-Meier method. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system.Overall survival rate of the patients was 86% (95% CI, 73%-99%) at 5 and 10 years. Five patients died of disease. No patient had a local recurrence in the remaining bony epiphysis, but three patients (9%; 95% CI, 0%-19%) had local recurrence in the soft tissue. The limb survival rate was 97% (95% CI, 89%-100%) at 5 and 10 years. Complications treated with additional surgical procedures were recorded for 19 patients (54%), including three local recurrences, two infections, 11 fractures, and three nonunions. In 10 of these 19 patients, the allograft was removed. Only five of the total 35 study patients (14%) lost the originally preserved epiphysis owing to complications. The mean functional score was 26 points (range, 10-30 points, with a higher score representing a better result) at final followup.Although the recurrence rate was high in this series, the small sample size means that even one or two fewer recurrences might have resulted in a much more favorable percentage. Because of this, future, larger studies will need to determine whether this is a safe approach, and perhaps should compare epiphyseal preservation with other possible approaches, including endoprosthetic reconstruction and/or osteoarticular allografts.Level IV, therapeutic study.

Resumen Introduccion Los tumores oseos malignos o benignos localmente agresivos del tercio proximal del perone son infrecuentes y generalmente su tratamiento es quirurgico. Cuando se requiere una reseccion en bloque, la estabilidad de la rodilla puede comprometerse por afectacion del complejo posterolateral. Material y metodos Se analizaron 28 pacientes operados de manera consecutiva por un tumor oseo en el tercio proximal de perone entre los anos 1980 y 2006 (osteosarcoma: 9, TCG: 9, sarcoma de Ewing: 8 y condrosarcoma: 2). El 61% eran varones y la edad media fue de 21 anos (rango: 8-60). El seguimiento promedio fue de 86 meses. El complejo posterolateral fue reinsertado a nivel de la metafisis tibial. Los pacientes fueron evaluados funcionalmente con la escala Musculoskeletal Tumor Society (MSTS). Resultados La supervivencia global fue del 89%, con un indice de recidiva local del 11% y un porcentaje de amputaciones secundarias del 6% a los 7 anos de seguimiento promedio. El resultado promedio del MSTS fue del 93%. Cinco pacientes sufrieron secuelas neurologicas, 3 de tipo permanente. Ningun paciente sufrio inestabilidad subjetiva ni insuficiencia vascular. Conclusiones La reseccion en bloque del perone proximal en el tratamiento de los tumores oseos agresivos o malignos depara un buen control local de la enfermedad y una supervivencia a los 7 anos, en los casos malignos, del 89%. La reinsercion del complejo posterolateral a nivel tibial supone una buena estabilidad de la rodilla, sin secuelas funcionales a largo plazo.

Introduction Proximal fibula malignant and locally aggressive benign bone tumors are uncommon and usually treat by surgery. Bloc resection of the knee can compromise knee stability due to the resection of the posterolateral ligament complex. Material and methods We analyzed 28 consecutive patients treated for a proximal fibula bone tumor between 1980 and 2006 (osteosarcoma: 9, giant cell tumor: 9, Ewing sarcoma: 8 and chondrosarcoma: 2). Sixty-one percent were male and the median age was 21 years (range: 8–60). The mean follow-up was 86 months. The posterolateral complex was reinserted at tibial metaphyseal level. Patients were evaluated functionally using the Musculoskeletal Tumor Society scale (MSTS). Results Overall survival rate was 89%, local recurrence rate was 11%, and secondary amputation rate was 6% at 7 years of median follow-up. The average MSTS score was 93%. Five patients had neurological complications. No patient experienced subjective instability or vascular insufficiency. Conclusions Bloc resection of the proximal fibula for the treatment of aggressive or malignant primary bone tumors allowed us to obtain local tumor control, and overall survival rate for sarcomas of 89% at 7 years. The posterolateral ligament complex tibial reinsertion provided functional knee stability without major functional consequences in the medium term.

Fresh frozen allograft reconstruction has been used for a long time in massive bone loss in orthopedic surgery. Allografts have the advantage of being biologic reconstructions, which gives them durability. Despite a greater number of complications in the short term, after 5 years these stabilize with high rates of survival after 10 years. The rate of early complications and the need for careful management in the first years has led the orthopedic surgeon to the use of other options. However, the potential durability of this reconstruction makes this one of the best options for younger patients with high life expectancy.

In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions after excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. Kaplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. The function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at five years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at five years and 54% at ten years. The limb salvage rate was 98% at five and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. The best functional score was observed in the intercalary humeral allograft.

The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers.The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results.Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system.With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p0.001; 95% CI, 5.8-16.4).Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous.Level III, therapeutic study.

Background The purpose of this study was to evaluate the survival, the complications and the functional outcome of intercalary tibial allografts reconstructions following tumor resections. Methods Intercalary tibia segmental allografts were implanted in 26 consecutive patients after segmental resections. Average follow-up was 6 years. Allograft survival was determined with the Kaplan-Meier method. Function was evaluated with the Musculoskeletal Tumor Society scoring system (MSTS). Results The rate of survival was 84% (CI 95%: 90%- 70%) at 5 years and 79% at 10 years (CI 95%: 95%-63%). Allografts were removed in 5 patients (3 due to infections and 2 due to local recurrences). Two patients showed diaphyseal nonunion and 3 had an incomplete fracture, but it was not necessary to remove the allografts. Average MSTS functional score was 29 points (range 27 to 30). Conclusions Despite the incidence of complications, this analysis showed an acceptable survival with excellent functional scores. The use of intercalary allograft clearly has a place in the reconstruction of a segmental defect created by the resection of a tumor in the diaphyseal and/or metaphyseal portion of the tibia.

Most authors believe the ACL does not spontaneously heal after a complete rupture. Although several studies have reported spontaneous healing of torn ACLs, it is difficult to determine its healing potential and whether patients will be able to return to sports activities.We therefore asked whether (1) a complete ACL rupture in patients can spontaneously heal without the use of a specific rehabilitation program or bracing and (2) patients are able to return to their athletic activity after spontaneous ACL healing.We retrospectively reviewed 14 patients with acute ACL injury established by physical examination and MRI (proximal third in eight patients and the midligament in six). Average age at injury was 31 years (range, 23-41 years). All patients were athletically active before injury. Surgery was indicated in all patients but for various reasons postponed. We obtained International Knee Documentation Committee scores, Lysholm-Gillquist scores, and MRI. The minimum followup was 25 months (mean, 30 months; range, 25-36 months).At last followup, the mean Lysholm-Gillquist score was 97. According to the International Knee Documentation Committee evaluation, 10 knees were normal and four nearly normal. All knees regained end point with a negative pivot shift test; MRI at followup showed an end-to-end continuous ACL with homogeneous signal. All patients returned to their former activity level. However, after the study period, two patients had a rerupture of the ACL (2.5 years after the first lesion).Our observations indicate an acutely injured ACL may eventually spontaneously heal without using an extension brace, allowing return to athletic activity.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Vascular reconstruction in infants constitutes a surgical challenge and is indicated frequently for acute occlusions. With the presence of a subacute vascular occlusion, including that produced by tumor resection, collateral circulation develops quickly. Thus a surgeon can consider tumor and vessel resection, without the need for vascular reconstruction.We report the 2-year postoperative outcome of a 2-month-old boy who had a groin synovial cell sarcoma with vascular involvement, treated using limb salvage surgery with resection of the femoral vessels and without performing vascular reconstruction.In adults with military wounds, ligation of the superficial femoral artery and common femoral artery reportedly result in amputation rates of 54% and 86%, respectively. Infants with a common femoral artery ligation may have a lower amputation rate because of some congenital collateral vessels, such as the sciatic artery. Further, when tumors involve major peripheral vessels, subacute or chronic vascular compression likely would facilitate development of collateral circulation. Similar chronic situations have been described in adults treated with debridement and common femoral artery ligation, after infected femoral artery pseudoaneurysms.Considering our patient's history and clinical and radiographic findings, infants with musculoskeletal sarcomas involving vascular structures can be treated selectively with tumor and vessel resection without the need for vascular reconstruction if distal limb perfusion is detected intraoperatively.

Objectives The purpose of this study was to evaluate the clinical and imaging results in a series of patients who underwent a meniscal allograft transplant (MAT). Methods A retrospective study was performed. The International Knee Documentation Committee (IKDC) score, Lysholm score, and physical examinations were reviewed to measure clinical outcomes after MAT. Osteoarthritic changes were assessed by Plain radiography according to Kellgren-Lawrence (KL) classification and meniscal extrusion by magnetic resonance imaging (MRI). Surgical technique and related procedures were analyzed. Complications were registered. The minimum follow-up was 2 years. Results Surgeries were performed in 41 patients, 36 fulfilled the inclusion criteria. Twenty-five were male and 11 women. The mean age was 35 years old (SD 8). The mean follow-up was 71 months (range 24 to 184). The mean time between meniscectomy and meniscal transplant was 12.8 years (SD 6,7). Twenty-three were lateral menisci. The following related procedures were performed: Seven ACL reconstructions, 3 ACL revisions, 19 mosaicplasties and 3 osteotomies. The mean preoperative results of IKDC and Lysholm scores were 30.3 (SD 15.5) and 43.8 (SD 16.8) respectively and postoperative results were 78.8 (SD 21.1) and 61.1 (SD 15) respectively. There were no significative radiographic changes at the end of the follow-up. Mean KL preoperative was 2 (IQR 1) and last follow up was 2 (IQR 1) p= 0.053. Preoperative KL grade 1: 33%, grade 2: 50% and grade 3: 17% and last follow up KL grade 1: 22%, grade 2 56% and grade 3 22%. The average percentage of extruded meniscus was 53% in 22 patients evaluated with MR (range 19% to 100%). Five presented arthrofibrosis that required mobilization under anesthesia and partial meniscectomy of the MAT was required in 6 patients. Two transplants failed. Conclusion Although 53% of meniscal extrusion was observed in the MR, we found no correlation with clinical outcomes. MAT achieved good clinical results without osteoarthritic changes after a mean of 6-years follow-up, with 5% of failure. MAT appears to be a safe and effective treatment, which should be considered as a suitable option in the clinical practice.

The emergence of limb salvage surgery as an option for patients with osteosarcoma is attributable to preoperative chemotherapy and advancements in musculoskeletal imaging and surgical technique. While the indications for limb salvage have greatly expanded it is unclear whether limb salvage affects overall survival.We asked whether over the past three decades limb-sparing procedures in high-grade osteosarcoma had increased, and whether this affected survival and ultimate amputation.We retrospectively reviewed 251 patients with high-grade osteosarcoma treated from 1980 to 2004 with a multidisciplinary approach, including neoadjuvant chemotherapy. We compared survival rates, limb-salvage treatment, and amputation after limb-sparing procedure during three different periods of time. Fifty-three patients were treated from 1980 to 1989, 97 from 1990 to 1999, and 101 from 2000 to 2004. Thirty-seven patients were treated with primary amputations and 214 with primary limb salvage.The 5-year survival rate in the first period was 36%, whereas in the 1990 s, it was 60% and 67% from 2000-2004. Limb salvage surgery rate in the 1980s was 53% (28 of 53), whereas in the 1990 s, it was 91% (88 of 97) and 97% from 2000-2004 (98 of 101). In the limb salvage group, 22 of the 214 patients (10%) required secondary amputation; the final limb salvage rate in the first period was 36% (19 of 53), whereas in the 1990 s, it was 81% (79 of 97) and 93% from 2000-2004 (94 of 101).Patients with osteosarcoma treated in the last two periods had higher rates of limb salvage treatment and survival, with lower secondary amputation.

Resection of large tumors of the proximal tibia may be reconstructed with endoprostheses or allografts with fixation. Endoprosthetic replacement is associated with high failure rates and complications. Proximal tibia osteoarticular allografts after tumor resection allows restoration of bone stock and reconstruction of the extensor mechanism, but the long-term failure rates and complications are not known.We therefore determined (1) the middle- and long-term survival of proximal tibia osteoarticular allografts, (2) their complications, and (3) functional (Musculoskeletal Tumor Society score) and radiographic (International Society of Limb Salvage) outcomes in patients treated with this reconstruction.We retrospectively reviewed 52 patients (58 reconstructions including six repeat reconstructions) who underwent osteoarticular proximal tibia allograft reconstructions after resection of a bone tumor. The minimum followup of the 46 surviving patients was 72 months (mean, 123 months; range, 10-250 months). Survival of the allograft was estimated using the Kaplan-Meier method. We documented outcomes using the Musculoskeletal Tumor Society functional scoring system and the International Society of Limb Salvage radiographic scoring system.Six patients died from tumor-related causes without allograft failure before the 5-year radiographic followup. At last followup, 32 of the 52 remaining allografts were still in place; 20 failed owing to infections, local recurrences, or fractures. Overall allograft survival was 65% at 5 and 10 years, with an average Musculoskeletal Tumor Society functional score of 26 points and an average radiographic result of 87%.Based on these data we believe proximal tibia osteoarticular allograft is a valuable reconstructive procedure for large defects after resection of bone tumors.Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Curettage is the most attractive procedure for surgically treating a giant cell tumor because it preserves joint function. However, since many giant cell tumors compromise subchondral bone this technique can jeopardize the articular surface with subsequent fractures or collapse. We asked whether intralesional curettage of a giant cell tumor close to the knee that combined morselized bone and cortical structural allograft would preserve joint function. We retrospectively reviewed 22 patients treated with that approach. The minimum followup was 2 years (average, 48 months; range, 24–80 months). The distal femur was involved in 12 patients and proximal tibia in 10. Complications and failures were recorded and functional results evaluated with Musculoskeletal Tumor Society score. We determined survivorship using the Kaplan-Meier technique using removal of the implant as the endpoint. The survival was 85% and the average functional score 28 points. Three of the 22 patients had a local tumor recurrence and one had a partial subchondral collapse not requiring further treatment. Among the remaining patients, none had fracture, infection, or knee instability. The combination of fragmented and cortical allograft allows reconstructing the bone defect and ligaments created after extensive curettage of a knee giant cell tumor obtaining normal joint function and a high survival rate with minimal complications in a high percentage of the patients. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Although there are numerous reports of septic pyogenic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction, there is limited information regarding the outcomes of fungal infection. We determined the outcomes of six patients with mycotic infection after regular ACL reconstruction. There were four males and two females with a mean age of 33 years. We determined the number of procedures performed, bone loss originating to control infection, and final reconstruction in these patients. An average of five arthroscopic lavage procedures had been performed at the referring centers. Fungal infection was diagnosed based on pathologic samples; five infections were the result of mucormycosis and one was Candida. After final débridement, the mean segmental bone loss was 12.8 cm. All patients were treated with intravenous antifungal coverage and cement spacers before final reconstruction. At final followup, all patients were free of clinical infection. Three had reconstruction with an allograft-prosthesis composite, two with hemicylindrical allografts, and one with an intercalary allograft arthrodesis. Despite the extremely unusual presentation of this complication, surgeons should be aware of potential and catastrophic consequences of this severe complication after ACL reconstruction.

Preservation of limb function in pediatric oncology patients is challenging with the ongoing growth of limbs contralateral to reconstructed limbs. We analyzed 22 patients younger than 10 years old who received an allograft after resection of a bone sarcoma with a minimum followup of 2 years (mean, 4 years; range, 2-14 years). The mean age was 7 years (range, 2-10 years). There were 16 boys and six girls with 17 osteosarcomas and five Ewing's sarcomas. Thirteen reconstructions were performed with an intercalary allograft and nine with an osteoarticular allograft. Physes were uninvolved in five patients and one physis in 17. We documented outcomes using the Musculoskeletal Tumor Society functional and the International Society of Limb Salvage radiographic scoring systems. At last followup, three of the 22 patients died of their tumor, one was alive but with an amputation, and 18 retained their limbs. These 18 patients had an average functional score of 27 points and a mean radiographic score of 94%. Eight complications required a second surgery; in four, the allograft was removed (one infection, one local recurrence, two fractures) and in four, the allograft was preserved (two local recurrences, one fracture, one nonunion). We consider biologic reconstruction with allografts after sarcoma resection an appropriate reconstructive procedure in young children.Level IV, therapeutic study.