drpprb@gmail.com, Autor em Oncosurgery

29Apr2024

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Eosinophilic Granuloma

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Eosinophilic Granuloma – Pseudotumor Lesion. History: In 1938, Schairer diagnosed a child’s skull lesion as eosionphilic myeloma or eosinophilic osteomyelitis1. This condition was later described as a new clinical entity by Otani and Ehrlich in 1940 under the name Solitary Granuloma of Bone2.

Eosinophilic granuloma – Pseudo-tumorous lesion

Farber and Green, in 1942, demonstrated that the lesion could occur in a localized or multiple manner in the skeleton and possibly be related to Hand-Schuller-Christian disease and Letter-Siwe disease3.

In 1944, Jaffe and Lichtenstein introduced the term eosinophilic granuloma of bone4. The relationship of this lesion with the systemic forms of the disease was confirmed by Lichtenstein in his 1953 publication, encompassing them under the name Histiocytosis X5.

Currently, this entity is called Langerhans Cell Histiocytosis, which has four distinct clinical forms: Eosinophilic Granuloma, a form restricted to the skeleton, which can be localized or multiple; Hand-Schuller-Christian, chronic and disseminated form; Letter-Siwe, acute or subacute disseminated form and Hashimoto-Pritzker, postnatal form with spontaneous resolution6.

Introduction: Solitary eosinophilic granuloma of the bone is the most common of the four forms of presentation of Langerhans Cell Histiocytosis, representing between 60% and 80% of cases7.

Among benign bone lesions, it is a rare entity, accounting for less than 1%8. It preferentially affects children and adolescents with a male predominance 2:19. Around 80% of patients are under 21 years of age and the majority of these are between five and 15 years of age6,7,9.

Some patients may begin with an isolated bone lesion and later develop multiple bone lesions. These cases can eventually evolve into systemic forms of the disease. When this occurs, it generally happens within the first six months of diagnosis and practically never after a year of evolution, which is a criterion for good prognosis, when no new lesions appear after this period of clinical follow-up10.

Hand-Schuller-Christian Syndrome is the chronic form of Langerhans cell histiocytosis, characterized by systemic involvement with multiple bone lesions, mainly in the skull, exophthalmos and diabetes insipidus, affecting children over 3 years of age10.

Letter-Siwe Syndrome affects children under three years of age, it is the acute or subacute form, also with systemic involvement. It presents with fever, otitis media, recurrent bacterial infections, anemia, hemorrhages, viceromegaly, diffuse and painful adenopathy with skin involvement similar to seborrheic eczema and generalized ostelitic lesions, with frequent progression to death10.

Hashimoto-Pritzker Syndrome is a form of Langerhans cell histiocytosis that affects the skin exclusively. It affects children in the first month of life, manifesting with eczematous eruptions that resolve spontaneously6.

Etiology: Unknown.

Genetics: No significant reports regarding this.

Definition: Eosinophilic Granuloma is a pseudotumor lesion, of unknown etiology, characterized by bone rarefaction that can be solitary or multiple. Microscopically, it presents a profile of mononuclear histiocytic cells, presenting antigens of dendritic origin, known as Langerhans cells, amidst the variable quantity of leukocytes, eosinophils, lymphocytes and giant cells.

Epidemiology: Eosinophilic Granuloma mainly affects the axial skeleton, in this order: skull, pelvis, vertebrae, ribs, mandible, clavicle and scapula.

In the appendicular skeleton the femur, proximal region and diaphysis, humerus and tibia9. Most of the time it affects the diaphysis or metadiaphyseal region, being rare in the epiphysis7.

The spine represents 10% of cases in the pediatric population, the majority in the lumbar region.

In adults, it occurs more frequently in the ribs and less frequently in the spine, respectively 25% and 3%6.

Clinical picture: The most frequent symptom of Eosinophilic Granuloma is localized, throbbing, short-lasting pain, worsening at night associated with local heat and edema. When it affects the skull, this pain can be confused with other causes of headache.

Compromise of vertebral bodies can produce painful scoliosis. Any angular deviations are small, less than 100, as the vertebral flattening is usually uniform and rarely produces neurological symptoms.

In other forms of Langerhans Cell Histiocytosis, systemic symptoms may be present such as fever, skin rush and diabetes insipidus. Hepatosplenomegaly can occur in Letter-Siwe syndrome, which is the most severe form of the disease6

Classification: Eosinophilic granuloma can manifest itself in two clinical forms: Solitary or Multiple .

Laboratory tests: Laboratory changes that can be found are an increase in ESR and CRP, and mild eosinophilia may occasionally occur in the blood count.

Imaging tests: The radiographic image is of bone rarefaction, rounded or oval, which begins in the medullary bone and progresses with erosion of the cortical bone.

In the initial phase, the edges are irregular and poorly defined.

In the late phase, slight sclerosis may occur around the lesion. In long bones, there is an evident periosteal reaction that appears as multiple thick lamellar layers, which characterizes slow-evolving benign lesions or the reaction of osteomyelitis.

This type of solid periosteal reaction differentiates Eosinophilic Granuloma from Ewing’s Sarcoma, where the periosteal reaction is thin lamellar, due to the rapid evolution of the malignant tumor.

Another radiographic difference between these two lesions is that Ewing’s tumor early presents extra-cortical tumor tissue, with a large volume, which does not occur in Eosinophilic Granuloma.

In flat bones, such as the skull or pelvis, erosion affects both cortices in an irregular and asymmetrical manner, producing the visual impression of a hole within another hole, called a double contour lesion.

In the mandible, destruction of the alveolar bone produces the radiographic impression of floating teeth.

In the spine, the disease affects the vertebral body, with flattening occurring in 15% of cases, producing the so-called flat vertebra of Calvè6. The posterior elements and intervertebral discs are preserved, even when the injury occurs in more than one vertebra.

Pathologic anatomy:

Macroscopic appearance: it has a soft, gelatinous consistency, yellowish in color, necrotic liquefaction is common.

Microscopic appearance: They appear as clusters of large histiocytic cells, with a slightly basophilic cytoplasm, globose, lobulated or indented nucleoli, in these cases similar to a bean seed, which correspond to Langerhans cells.

These clusters are interspersed with giant cells, lymphocytes, numerous eosinophils and areas of necrosis, simulating an abscess. Electron microscopy presents typical cytoplasmic granules called Birbeck bodies11,12.

Immunohistochemistry shows positivity for S-100 protein, vimentin and CD1a11,13.

Diagnosis:

Differential diagnosis: The main radiological differential diagnoses of Eosinophilic Granuloma are Osteomyelitis and Ewing Tumor.

When the lesion occurs in the skull, it must be differentiated from an epidermoid cyst or metastasis. The main histological differential diagnoses are Osteomyelitis and Lymphoma.

Staging:

Treatment: The literature presents reports that expectant treatment or biopsy alone can be indicated as an effective therapeutic strategy for isolated skeletal injuries7,14.

Eosionophilic Granuloma can resolve spontaneously, especially in children. The capacity for the affected bone to rebuild itself exists, as the majority of patients are affected before skeletal maturity, therefore with great potential for remodeling by the growth physes, which are normally not affected15,16.

In our experience, there was resolution in five cases, which regressed only with percutaneous biopsy. The same happens after vertebral collapse in spinal injuries, probably due to the leakage of the contents of the lesion, resembling the drainage of an abscess, with surgical indication in the spine being extremely rare. Cases have been reported where there was complete restitution of the height of the vertebral body15. In our series we had two cases that presented this evolution.

Although there may be spontaneous resolution, the time required is unpredictable, and there may be significant morbidity secondary to intense pain and functional limitation.

Currently, the best therapeutic approach for Eosionophilic Granuloma is to perform a percutaneous biopsy, if possible with immediate diagnosis by frozen section, followed by intralesional corticosteroid infusion (methylpredinisolone – 40mg to 120mg depending on the size of the lesion)7. The anatomopathological result must be subsequently confirmed by histology in paraffin blocks.

Eosionophilic Granuloma can take up to three months to regress, and it may be necessary to repeat the infusion6. In our experience, we had only one case, of an isolated injury to the humerus, which required complementation of the initial treatment in which we performed oral corticosteroid therapy, prednisolone 5mg/24h, for four months. In polyostotic Eosinophilic Granuloma, systemic corticosteroid therapy is used.

When an incisional biopsy is necessary, corticosteroids can be applied locally after curettage of the lesion, which facilitates the resolution of the process. This curettage must be careful, carried out by opening in the form of a narrow slit, longitudinal to the bone, trying not to add greater local fragility. Eventually, the cavity can be filled with a bone graft, but this is generally unnecessary due to the great potential for regeneration that exists.

Radiofrequency was proposed as a percutaneous treatment for Eosionophilic Granuloma, being applied in a second stage, two to four weeks after the biopsy17. The author restricts the technique to small injuries that are at least one centimeter away from the neural or visceral structures, warning of the risk of fractures in the load-bearing limbs. This approach, in addition to increasing costs and causing local morbidity, does not add any advantage to the treatment. The biopsy itself may have been curative, and the infusion of corticosteroids has greater justification, as this is indicated both in isolated cases and in multiple lesions. To date, there are no studies comparing percutaneous techniques with corticosteroid infusion in relation to the use of radiofrequency that justify their use.

Historically, radiotherapy was used in low and fractionated doses for the treatment of Langerhans Cell Histiocytosis. Currently, the indication of radiotherapy for benign lesions is controversial.

In cases of eosinophilic granuloma with more than one skeletal lesion, without visceral involvement, systemic treatment may be indicated for a period of approximately six weeks with corticosteroid therapy (2 mg/kg) and Vinblastine (6 mg/kg).

Prognosis: Solitary lesions of eosinophilic granuloma evolve well in 97% of cases, with biopsy alone or in addition to corticosteroid infusion or surgical treatment ⁶ .

See also: Eosinophilic granuloma of the radius

Bibliography:

1 SCHAIRER, E. Ueber eine eigenartige Erkrankung des kindlichen Schädels. Zentralbl Allg Patho Pathol. Anat., 71:113, 1938.

2 Otani S, Ehrlich JC; Solitary granuloma of bone simulating primary neoplasm. Am J Pathol 16:479–90. 1940

3 Green WT, Faber S; “eosinophilic or solitary granuloma” of bone. J Bone Joint Surg (Am) 24:499-526. 1942

4 Jaffe HL, Lichtenstein L; Eosinophilic granuloma of bone. Arch Pathol 37: 99-118. 1944.

5 Lichtenstein L.: Histiocytosis Pathol. 56:84, 1953

6 Schwartz HS. Orthopedic Knowledge Update: Musculoskeletal Tumors 2. American Academy of orthopedic Surgeons, Rosemont, Illinois. Chapter 12 (128-32), 2007

7 Mavrogenis AF, Abati CN, Bosco G, Ruggieri P. Intralesional Methylprednisolone for Painful Solitary Eosinophilic Granuloma of the Appendicular Skeleton in Children. J PediatrOrthop 2012;32:416–422

8 Chadha M, Agarwal A, Agarwal N, et al. Solitary eosinophilic granuloma of the radius. An unusual differential diagnosis. Acta Orthop Belg. 2007; 73:413–417.

9 Campanacci, M. Bone and Soft Tissue Tumors; Springer-Verlag Wien New York. Second Edition, (54); 857-75. 1999.

10 SCHAJOWICZ, F. Buenos Aires: Osseous Tumors; Talleres de editorial Médica Panamericana SA (9); 464-80. 1981.

11 CHRISTIAN, HA Defects in membranous bones, exosphthalmos and diabetes insipidus: in a usual syndrome of dyspituitarism: a clinical study. Med.Clin. North. Am., 3:849, 1920.

12 ARCECI, RJ; BRENNER, M.K.; PRITCHARD, J. Controversies and new approaches to the treatment of Langerhans cell histiocytosis. Hemtol. Oncol. Clinic. North. Am., 12:339, 1998

13 ALBRIGHT, F.; REIFNSTEIN, EC The parathyroid glands and metabolic disease. Baltmore, Williams & Wilkins, 1948.

14 Plasschaert F, Craig C, Bell R, et al. Eosinophilic granuloma. A different behavior in children than in adults. J Bone Joint Surg Br 2002;84:870–872.

15 Greenlee JD, Fenoy AJ, Donovan KA, et al. Eosinophilic granuloma in the pediatric spine. Pediatr Neurosurg. 2007; 43:285–292.

16 Sessa S, Sommelet D, Lascombes P, et al. Treatment of Langerhans cell histiocytosis in children. Experience at the Children’s Hospital of Nancy. J Bone Joint Surg Am. 1994; 76:1513–1525.

17 Corby RR, Stacy GS, Peabody TD, et al. Radiofrequency ablation of solitary eosinophilic granuloma of bone. Am J Roentgenol.2008;190:1492–1494.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

29Apr2024

drpprb@gmail.com Academic Articles 0 comment

Post-Operative Infection

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Post-Operative Infection. Objective: To carry out a retrospective analysis of cases submitted to orthopedic damage control in a teaching hospital orthopedic emergency room with the aim of evaluating patients with postoperative infection after being converted to internal osteosynthesis. Methods: Retrospective analysis of patients from June 2012 to June 2013 undergoing orthopedic damage control with an external fixator that were later converted to definitive osteosynthesis, with a rod or plate. Results: We found an infection rate of 13.3% in our sample and verified technical errors in the preparation of the fixator in 60.4% of opportunities.Conclusion: An infection rate was found that we consider high, as well as inadequacies in the construction of the external fixator. We emphasize that this procedure is not without risk and training for doctors who perform it must be mandatory.

Postoperative infection in patients undergoing orthopedic damage control using external fixation

a Department of Orthopedics, Santa Casa de São Paulo, São Paulo, SP, Brazil
b Orthopedics and Traumatology Service, Hospital Israelita Albert Einstein, Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil
c Institute of Orthopedics, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (USP), São Paulo, SP, Brazil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil

Introduction

Damage control in orthopedics is a surgical tactic recommended for polytraumatized patients or those with severe soft tissue injuries, as recognized in the literature.1However, this procedure is not without risks. Local and systemic complications associated with external fixation for damage control2 have been reported, and one of them is bone infection. Studies show infection rates in pin tracts ranging from 0.5 to 30%.

Bacterial contamination and infection in the path of external fixator pins are relatively common and conversion to internal osteosynthesis, whether with intramedullary nails or plates, in the presence of such a condition, can lead to serious complications, local and/or systemic.4The frequency of this association of events is not clear in the literature.

The correlation between infection in the path of external fixator pins and post-traumatic osteomyelitis after internal osteosynthesis, which constitutes chronic infection of the locomotor system, is well established.

Infection at the bone-fixator pin interface has been proven to be directly associated with the insertion technique, stability and position in the limb, during pin placement, by establishing tension or not in the soft parts. The presence of these factors contributes to infectious complications after conversion to definitive internal osteosynthesis, whether intramedullary nail or plate.

The objective of our work is to identify in patients undergoing control of musculoskeletal damage admitted to the emergency room for one year, the quality of reduction and fixation and the frequency of bone infection after definitive treatment.

Casuistry and methods

This work was duly submitted to and approved by the institution’s Ethics Committee and is registered under protocol CEP no. 624.307.

We retrospectively evaluated 120 patients who underwent external fixation to control musculoskeletal damage from June 2012 to June 2013 and were treated at the time of emergency in the emergency room of the Department of Orthopedics and Traumatology at our institution.

In this retrospective study, we included patients who underwent damage control surgery using external fixation that

after conversion to definitive osteosynthesis, they developed infection.

Patients who presented infectious complications due to local systemic changes, such as vasculopathies, diabetes mellitus or consumptive disease, and patients with psychiatric disorders that may have impaired the development or care of the fixator in any way were excluded.

All radiographs were generated in digital form and analyzed using the Impax program. The distances between Schanz holes and pins until the definitive synthesis were analyzed in the program itself. We sought to identify the presence of technical errors during drilling (characterized by multiple perforations) or subjective analysis carried out by three different groups of two evaluators. One group was made up of assistant doctors with at least five years of experience in orthopedic trauma, another with two third-year residents and another with two second-year orthopedic residents. The evaluators were named (table 1):

– Evaluator 1: assistant with more than five years of experience

– Evaluator 2: assistant with more than five years of experience

– Evaluator 3: third year resident

– Evaluator 4: third year resident

– Evaluator 5: second year resident

– Evaluator 6: second year resident

Postoperative infection was characterized by clinical examination, during hospitalization or during outpatient investigation, based on data recorded in the medical records. The following clinical criteria for infection were considered: erythema, hyperemia or fistula in the path of the pins or surgical incision (fig. 1).

During external fixation, prior drilling with a drill and manual insertion of the pins were always respected.

In no case did we have a pin in the fracture exposure zone.

In evaluating the radiographs, we observed the pre- and post-operative exams, we measured the position and distance of the Schanz pins in relation to the definitive synthesis, the presence of perforations in a greater number than the pins installed as this suggests difficulty and additional damage in installing the external fixator, presence of osteolysis in the holes for the Schanz pins and if the place where the pins were drilled caused problems for definitive internal fixation. Among these, we evidence postponed surgery due to infection in the pin path, changes in the surgical incision for definitive osteosynthesis and unplanned surgical procedures for reassembly of the fixator due to unstable assembly.

The average conversion time from external fixators to definitive osteosynthesis was evaluated by retrospective analysis of medical records.

Results

Of the 120 patients who underwent damage control, 16 (13.3%) suffered post-traumatic osteomyelitis after definitive synthesis. In these 16 patients, we were able to directly relate it to definitive internal osteosynthesis, as there were no signs of local infection after external fixation in the urgency.

The average age of these 16 patients was 43.4 years, ranging from 19 to 81. We observed a predominance of males, with 13 patients (81.2%), and the remaining three (18.8%) females.

Regarding the external fixator conversion time for definitive osteosynthesis, the shortest period was five days and the longest was 30. We had an average of 15 days for the final conversion.

Infection occurred in eight isolated leg fractures (50%), two patients with fractures of the femur and ipsilateral tibia (floating knee), two (12.5%) with ankle fractures (12.5%), two (12.5%) %) with a tibial plateau fracture, one (6.2%) with an isolated femur fracture and one (6.2%) with a humeral fracture.

Of the 16 patients with post-traumatic infection, 37.5% of the time (six patients) occurred after closed fractures and in 62.5% (10) after Gustillo grade 3 A open fractures (table 2).

In 62.5% (10 patients) the fixator was mounted transarticularly and in the remaining six (37.5%) it was monostolic with monolateral configuration, with tube-to-tube connection.

As for the etiological agent, it was adequately identified in 10 patients (62.5%) of the 16 infected, in a third of these there were multiple bacteria and there was a need for surgery to clean, debridement and curettage of the pin hole path. The polymicrobial findings found in intraoperative cultures were: Staphylococcus aureus, coagulase-negative Staphylococcus, Klebsiella sp, Acinetobacterbaumanni and Pseudomonas aeruginosa.

Regarding the objective assessment of multiple bone perforations, we observed a greater number than pins used in eight patients (50%) of the 16 patients infected after definitive osteosynthesis (fig. 2).

When we measured the distance between the position of the Schanz pin and that of the osteosynthesis, we obtained an average of 2.2 cm, with a variation of up to 6 cm. In seven cases (43.8%) of the 16 infected people, the distance measured was 0 cm, two between 1 and 2 cm, two between 3 and 4 cm, one between 4 and 5 cm, three with 5 cm and one with 6 cm (table 2). Regarding the evaluation of the quality of fixation and reduction, we were able to observe that of the 16 cases, in four (25%) the six evaluators agreed, in two the fixation was considered adequate and in the other two inadequate; in five cases (31.3%) five evaluators agreed on the quality of the evaluation, in two it was considered adequate and in three inadequate; in four cases (25%) four evaluators agreed with the evaluation, all were considered inadequate; In three cases (18.7%) there was no agreement between the evaluators, three considered the fixation and reduction to be adequate and three others to be inadequate (table 3).

In the 13 cases (81.2%) in which there was some agreement (adequate or inadequate), it was considered adequate in four (30.8%) and inadequate in nine (69.2%).

When analyzing the evaluations, we obtained 96 evaluations, which were considered adequate in 38 cases (39.6%) and inadequate in 58 cases (60.4%). When analyzing the evaluations of each evaluator, we obtained for evaluator one: five cases (31.3%) evaluated as adequate and 11 (68.7%) as inadequate; assessor two: 10 cases

When we separately evaluated orthopedists with more than five years of experience, we obtained 32 evaluations, 15 (46.9%) were considered adequate and 17 (53.1%) were considered inadequate (table 4). In this group, there was agreement in the quality of fixation and reduction in nine cases (56.3%) and non-agreement in the remaining seven (43.7%), of the nine cases with agreement in four (44.4%). ) the quality of reduction and fixation was considered adequate and in five (55.6%) inadequate.

When we evaluated third-year residents separately, we obtained 32 evaluations, 14 evaluations (43.7%) were considered adequate and 18 (56.3%) were considered inadequate (table 4). In this group, there was agreement on the quality of reduction and fixation in nine cases (56 .3%) and non-agreement in the remaining seven (43.7%), of the nine cases with agreement in four (44.4%) the reduction and fixation was considered adequate and in five (55.6%) inadequate.

When we evaluated second-year residents separately, we obtained 32 evaluations, nine (28.1%) were considered adequate and 23 (71.9%) were considered inadequate (table 4). In this group, there was agreement on the quality of reduction and fixation in 13 cases (81.3%) and non-agreement in the remaining three (18.7%), of the 13 cases with agreement in three (23.1%), reduction and fixation were considered adequate and in 10 (76.9%) inadequate.

When observing the assessments considered adequate, we can see a tendency towards similar assessments between assistants and third-year residents, but a lower assessment of cases considered suitable for second-year residents (table 5).

When we compared the cases in which the assistants agreed with the third-year residents’ assessment, we observed that there was agreement in five (31.3%) of the 16 cases, in three the reduction and fixation was considered adequate and in two inadequate. Of the remaining 11 cases, in four, despite the agreement of the assistants’ assessment, there was no agreement with the third-year residents; in one case, the reduction and fixation was considered adequate by the assistants and in three cases, inadequate.

When we compared the cases in which the assistants agreed with the assessment of the second-year residents, we observed that there was agreement in seven (77.8%) of the nine cases, in two of these the reduction and fixation was considered adequate and in five inadequate. In one case where there was agreement from the assistants (considered adequate) the second year residents considered it inadequate.

When evaluating the seven cases in which there was no agreement among assistants with more than five years of experience, we observed that in one case the residents, whether third or second year, also did not agree. In four cases, the two third-year resident evaluators also did not agree and in three cases the two third-year resident evaluators agreed and considered the reduction and fixation inadequate. Of the seven cases in which the assistants did not agree, the second-year resident evaluators considered the reduction and fixation adequate in one case and inadequate in four.

Discussion

External fixators, more versatile fixation devices that allow different types of assemblies and configurations, can be placed quickly, are applied in the treatment of fractures in urgent and emergency situations (damage control) and in a percutaneous, with less damage to soft tissues.

This procedure, both provisional and definitive, is still routine in many services and varies from 32 to 89% of the choice of a group of orthopedists in a previous study.9However, this procedure is not without risks.

In our sample, we found a frequency of 13.3% of infection after the use of an external fixator for damage control. Although compatible with literature data, which range from 0.5 to 30%,2,3 we are concerned with judging this rate very high among the possible complications.

The first issue always remembered when searching for the etiology of the infection is the environment in which the treatment takes place, in our case a teaching hospital. It seems like a weak cause-and-effect correlation, because the procedure is considered to be of little complexity and there was at least one doctor with three years of training on the surgical team.

Another factor that is involved in the complication of infection after internal osteosynthesis is infection of the Schanz pin tract. In our patients, the presence of clinical suspicion of infection was an indication to exchange the pin for installation in another location or to continue treatment with osteosynthesis using the external fixator.

Reduction and fixation were considered inadequate in 60% of evaluations, a value considered very high, and on average, assistants and third-year residents found reduction and fixation adequate in only 50% of evaluations. This shows that there is a need for better teaching in the treatment of emergency situations with external fixators.

External fixation is often neglected in our environment both in its preoperative planning, procedure and subsequent care. In any external fixation procedure, the future definitive synthesis must always be considered when assembling the fixator and placing the pins. This situation should always be discussed with the attending physician, who can make a pre-operative schedule with a view to future synthesis, whether plate or rod. In our study, in 43.8% of cases, the location of the Schanz pin was not far from the definitive osteosynthesis.

The correct technique for inserting the pin, care with the dressing and the surgical wound are essential to prevent these complications.9,10Pre-drilling, manual insertion of the pins, use of the safety corridor are factors that cannot be forgotten during the fixation. The systematization of this intra- and post-operative care is a factor that we found capable of control by the doctor to influence the infection rate of the Schanz pin path in damage control.

Routinely, the quality of fracture reduction is not so important to consider postoperative infection, since the use of the external fixator is temporary.8 However, in some situations in which the fixator remains in place for a prolonged time, this factor must be taken into account. In our series, the longest period for conversion was 30 days and the temporary reduction is important for stabilizing the condition, local care and general condition.

In our cases, we observed that all of them had a safety event respected in the analysis of the radiographs (in our case series, no neurovascular lesions were observed).

When we identified the importance of the quality of the installation and spatial assembly of external fixators, we asked doctors with different training periods to judge the quality of the assembly and look for signs of technical inadequacy in the x-rays in the files, which occurred 60% of the time in our study, value considered very high.

Regarding the frequency of bone infection post-damage control, we confirmed that of the 13% infected, 50% identified the presence of error or technical inadequacy that may have contributed to the undesirable outcome./p>

When considering external fixator assemblies, we cannot correlate the frequency of infection with a given type of assemblage. There was a prevalence of transarticular assemblies, used in metaepiphyseal fractures, ipsilateral bone fractures and extensive soft tissue injuries to avoid post-traumatic joint deformities (62.5% of cases).

Although it was not possible to correlate infection after internal osteosynthesis and the use of fixators to control damage, the presence of inadequacy in assemblies in the emergency room suggests the possibility and need for training and rules for their use and assembly.

Conclusion

Bone infection occurred in 13.3% of cases treated with control of musculoskeletal damage after internal osteosynthesis. In these cases, reduction and fixation was considered adequate in 39.6% of evaluations and inadequate in 60.4%. We emphasize that this procedure is not without risk and training for doctors who perform it must be mandatory.

Interest conflicts

The authors declare no conflicts of interest.

Interest conflicts

The authors declare no conflicts of interest.

REFERENCES

1. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullarynailing for patients with multiple injuries and with femurfractures: damage control orthopedics. J Trauma.2000;48(4):613-21.2. Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma. 2003;17(7):503-7.3. Mahan J, Seligson D, Henry SL, Hynes P, Dobbins J. Factors in pin tract infections. Orthopedics. 1991;14(3):305-8.4. Harwood PJ, Giannoudis PV, Probst C, Krettek C, Pape HC. The risk of local infectious complications after damage control procedures for femoral shaft fracture. J Orthop Trauma.2006;20(3):181-9.5. Green SA, Ripley MJ. Chronic osteomyelitis in pin tracks. JBone Joint Surg Am. 1984;66(7):1092-8.6. Clasper JC, Cannon LB, Stapley SA, Taylor VM, Watkins PE.Fluid accumulation and the rapid spread of bacteria in the pathogenesis of external fixator pin track infection. Injury.2001;32(5):377-81.7. Moroni A, Vannini F, Mosca M, Giannini S. State of the art review: techniques to avoid pin loosening and infection in external fixation. J Orthop Trauma. 2002;16(3):189-95.8. Cardozo RT, Silva LG, Bragante LA, Rocha MA. Treatment of tibial shaft fractures with an external fixator compared to a locked intramedullary nail. Rev Bras Ortop.2013;48(2):137-44.9. Balbachevsky D, Belloti JC, Martins CVE, Fernandes HJA, Faloppa F, Reis FB. How are open tibial fractures treated in Brazil? Cross-sectional study. Acta Ortop Bras.2005;13(5):229-32.10. Petinne KA, Chao EY, Kelly PJ. Analysis of the external fixatorpin-bone interface. Clin Orthop Relat Res 1993;293:18-27.

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Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

29Apr2024

drpprb@gmail.com Academic Articles 0 comment

Metastasis in the femur

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Metastasis in the femur from male breast carcinoma. The authors report a case of pathological fracture due to bone metastasis from male breast carcinoma. The patient in question had a breast lump on the right with a history of six years, undiagnosed when treated for a femur fracture eight months ago. The importance of a complete and careful physical examination is highlighted in this work. This will avoid making a late diagnosis of neoplasia and bone metastasis. The importance of thinking about breast cancer in patients with pathological fractures is highlighted, even if they are men. The case is presented because it is a rare disease in humans. General aspects of the treatment of bone metastases are mentioned.

Metastasis in the femur from male breast carcinoma

INTRODUCTION

Breast cancer is a neoplasm that most frequently originates from the excretory ducts of the gland and also from its acini. It occupies a prominent place as a cause
of death in women, but in men it is very rare. For every 100 cases of breast cancer, only one is male. It affects the adult age group, generally over 50 years old. Due to the scarcity of breast parenchyma in men, cancer infiltrates more quickly and adheres to the skin with ulceration(3,5). It behaves exactly as in invasive ductal carcinomas in women, but generally presents with minor desmoplasia. The spread is the same as in women, with
early metastases in the axillary nodes. Metastases in the lungs, brain, bones and liver are also frequent, via the hematogenous route. The femur is the most affected bone(3). The objective of this work is to report a rare case of bone metastasis from male breast carcinoma, due to its rarity and propensity for misdiagnosis.

CASE REPORT

A 69-year-old male patient was admitted to the emergency room of the Department of Orthopedics and Traumatology of Santa Casa de São Paulo, with a history of
falling to the ground four hours ago, with pain and functional impotence of the right lower limb. At admission, shortening and deformity in external rotation of the right lower limb were observed
. At the time, no other abnormalities were noted on physical examination.
On radiographic examination, in the anteroposterior projection of the pelvis and lateral aspect of the right hip (Fig. 1), a long oblique fracture without comminution or other bone injury was observed in the subtrochanteric region of the right femur. Biochemical and hematological blood analyses, chest x-rays and electrocardiogram were normal. The patient underwent anatomical reduction and osteosynthesis of the fracture with a 95º angled plate (fig. 2).

The patient evolved well in the immediate postoperative period, with no signs of infection or any other significant changes. After discharge, he began to be monitored monthly through clinical and radiographic examination. The radiographic controls apparently showed good evolution of the fracture (fig. 3, A and B), but, in the sixth postoperative month, the patient returned complaining of pain and a rapid and progressive increase in the volume of the thigh. Radiographs of the pelvis (antero-posterior) and right hip (lateral) (fig. 4, A and B) showed a lytic lesion at the level of the previously fractured area and loosening of the synthetic material.

The patient was referred to the Musculoskeletal Tumor Group for case study. On this occasion, the presence of a tumor in the right breast measuring approximately 2.5 cm in diameter, with retraction of the nipple, which had not been previously detected (fig. 5, A and B), accompanied by lymph node involvement was noted. axillary. Upon rectal exam, there was an enlarged prostate with regular edges and a soft consistency, considered normal for his age. On orthopedic examination, the patient showed increased volume in the right thigh, pain on local palpation and a limping gait with the aid of crutches. The mobility of the right hip was: flexion of 100º, extension of –15º, abduction of 30º, adduction of 15º, external rotation of 60º and internal rotation of 0º. Neurological and vascular examinations were normal.

The patient underwent a trocar biopsy of the lesion in the femur and an incisional biopsy of the mass in the breast. The results of the anatomopathological examinations were as follows: metastasis of adenocarcinoma in the femur and infiltrative ductal carcinoma of the breast. A resection of the proximal third of the right femur was performed and a non-conventional Fabroni endoprosthesis (ENCF) was placed (fig. 6). The evolution in the immediate postoperative period was satisfactory. Two weeks after surgery, the patient began chemotherapy with cyclophosphamide, fluoracil and farmorubicin with the aim of facilitating breast resection and lymph node emptying. Currently (six months post-operatively), the patient, still undergoing chemotherapy, has a limp with the aid of crutches, a normal neurological examination and the following mobility of the right hip: 90º of flexion,
–15º of extension, 30º of abduction , 20º of adduction, 60º of external rotation and 0º of internal rotation (fig. 5, A and B).

DISCUSSION

Male breast cancer, in addition to being rare, is highly aggressive, with early metastases to the axillary lymph nodes(5). According to a study carried out by Gallardo et al.(2) in 303 cases of bone metastasis due to breast cancer, it was found that only 1.33% were male patients.
No specific treatment for male breast carcinoma was found in the literature. The treatment for bone metastasis from breast cancer, when there is no imminent fracture, is essentially chemotherapy and radiotherapy. Sanoo et al.(7), using combined therapy with tamoxifen, cyclophosphamide, fluorocil, morphine and medroxyprogesterone 17-acetate, concluded that this chemotherapy was effective for bone pain in 96.33% of cases. Saez et al.(6) studied the survival of patients with breast cancer metastasis who underwent resection surgery, bone graft placement, chemotherapy and use of adjuvant antineoplastic agents. The study was carried out on 20 women between 24 and 56 years of age, of which nine had complete remission and 11 had partial remission. In our opinion, the use of bone grafts in metastatic tumors is highly debatable. The treatment of pathological fracture is varied. Some factors, such as age, stage of the primary disease, size of the metastasis and the patient’s general clinical impairment, influence the prognosis and help to choose the best treatment for the fracture(1). In patients with severe impairment of the general condition or large tumor extension, when surgical possibilities are very limited, treatment may be expectant(3). If the patient is ready to undergo surgery, the following can be performed: 1) reduction and osteosynthesis with a plate and bone cement aiming for a quick solution to the fracture, 2) resection of the lesion and placement of a non-conventional endoprosthesis, providing an early return to walking, and 3) amputation in extreme cases(1). We must remember the importance of carrying out a complete physical examination on all patients so that it does not go unnoticed, as in our case, a tumor in the breast that has been evolving for several years. A thorough physical examination, including in cases where there is no suspicion of a pathological fracture, can allow for an early diagnosis of the injury, improving the prognosis. We must also highlight the importance of including, in the differential diagnosis of bone lesions suggestive of metastasis in men, breast carcinoma as the primary tumor.

Click here to see a case of hypernephroma metastasis, treated before fracture.

REFERENCES

1. Carnelase, PG: “Malignant tumors of bone”, in Crenshaw, AH: Campbell’s operative orthopedics, St. Louis, Mosby Year Book, 1992. Chapter 10, p. 263-190.
2. Gallardo, H., Gonzales, R. & Astagno, A.: Osseous metastasis of breast cancer. Bol Acad Nal Med Nal 66: 459-471, 1988.
3. Campanacci, M.: Tumori delle ossa e delle parti molle, Bologna, Aulo Gaggi Editore, 1981. p. 456-512.
4. Pendleburg, SC, Bilous, M. & Langlands, SA: Sarcomas following radiation therapy for breast cancer: a report of three cases and a review of the literature. Int J Radiat Oncol Biol Phys 31: 405-410, 1995.
5. Robins, SL & Cotran, RS: “Mama”, in Structural and functional pathology, Rio de Janeiro, Interamericana, 1986. Chapter 27, p. 1158-1168.
6. Saez, RA, Slease, RB, Selby, GB et al: Long-term survival after autologous bone marrow transplantation for metastatic breast carcinoma. South Med J 88: 320-326, 1995.
7. Sanoo, H., Shimozuma, K., Kurebayashi, J. et al: Systemic therapeutic pain relief and quality of life of breast cancer patients with bone metastasis. Gan To Kagaku Ryoho 22 (Suppl): 10-15, 1995.

AUTHORS: PEDRO PÉRICLES RIBEIRO BAPTISTA, JOSÉ DONATO DE PROSPERO, FLORINDO VOLPE NETO, MARCOS SANMARTIN FERNANDEZ, NABIL ABISAMBRA PINILLA

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Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

29Apr2024

drpprb@gmail.com Academic Articles 0 comment

Giant Cell Tumor

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Giant cell tumor is a neoplasm of mesenchymal nature, characterized by the proliferation of multinucleated giant cells (gigantocytes) that resemble osteoclasts, in a stroma of mononucleated cells (fig. 1a). It is also known as osteoclastoma and gigantocellular tumor, and the acronyms TCG or TGC are commonly used. It was first described by Sir Astley Cooper(1) in 1818. Later, Paget (1853)(2) called it “brown or myeloid tumor”. Nelaton (1860)(3) described its clinical and histological characteristics, highlighting its local aggressiveness and giving it the name “myeloplaxis tumor”. Gross (1879)(4) insisted on its benignity and highlighted the difficulties of differential diagnosis with “the aneurysmal variant of medullary sarcoma”. With the advent of radiology, the differential diagnosis of this lesion was determined and Bloodgood (1923)(5) proposed the name “benign giant cell tumor”.

Giant cell tumor

In recent decades, much has been discussed about the nature of gigantocellular tumors. For Geschikter and Copeland (1949)(6) and Willis (1949)(7), the gigantocellular tumor would be a neoplasm of osteoclasts in the mesenchymal stroma, given the similarity between the gigantocyte and the normal osteoclast.

Jaffe et al (1940)(8) described its origin as being derived from stromal cells. Sherman (1965)(9) stated that the bone disappeared at the site of tumor growth and the gigantocytes resulted from the fusion of stromal mesenchymal cells, taking into account the similarity between optical microscopy of stromal nuclei and giant cells. The histochemistry and tissue culture studies carried out by Schajowicz (1961)(10) did not demonstrate significant differences between tumor gigantocytes and normal osteoclasts. On the other hand, studies using electron microscopy(11) confirmed that giant cells are syncytia made up of stromal cells. Thus, the undifferentiated mesenchymal cells from the bone marrow would give rise to the tumor stroma, whose cells, in turn, when differentiating, would form clusters with the characteristics of gigantocytes. The numerous giant cells that resemble osteoclasts, in a stroma of spindle cells, are the most important elements of this tumor. The histological aspect of GCT presents characteristics common to several tumor and pseudotumor lesions(12,13), requiring joint analysis with clinical and imaging characteristics to confirm the diagnosis(14,15).

The main differential diagnoses, both from a clinical, radiographic and anatomopathological point of view, are: aneurysmal bone cyst, teleangectatic osteosarcoma and chondroblastoma(16,17). TGC generally affects a single bone. When a lesion suggestive of this tumor is found in several bones, the possibility of it being a “brown tumor of hyperparathyroidism” should be checked, which presents a similar radiographic appearance, but with multiple lesions and suggestive changes in serum calcium and phosphorus(18 ). GCT occurs in the third and fourth decades of life, affecting both sexes equally(19-22). The main manifestation is intermittent local pain, accompanied or not by an increase in volume in the affected region. The length of history is variable and depends on the bone and the affected region(23-26).

Some patients seek treatment due to pain, others because of the perception of the tumor or a pathological fracture(27,28). Generally, they relate the beginning of the clinical history to some trauma(29,30). As the tumor is epiphyseal, joint involvement with limited movement is frequent, with progressive functional changes, and intra-articular effusion may occur (fig. 1c), simulating the clinical picture of meniscal processes or arthritis(31,32). TGC is most frequent in the distal epiphysis of the femur (28.2%) (figs. 1c and 1d) and proximal tibia(19,23,31,33) (fig. 1b), followed by the proximal and distal regions of the humerus of the radio. It is rare in the axial skeleton and, when it occurs, it predominates in the sacrum. When located in the ilium (fig. 2) or sacrum (figs. 3 and 4), it generally presents a large volume, intense pain, and can cause neurological manifestations(34,35). On the radiograph, an epiphyseal bone rarefaction lesion was observed, initially eccentric and respecting the limits of the cortex. With progression, cortical rupture and joint involvement may occur (Figs. 1c and 1d). Computed tomography can help assess the degree of joint involvement and cortical erosion, facilitating the choice of the best surgical reconstruction technique.

Bone mapping is characterized by an area of uniform hyperuptake in the affected epiphysis. More recently, we can also use magnetic resonance imaging to evaluate the limits of the tumor and its characteristics of a homogeneous solid lesion, which may present areas of liquid content, resulting from tumor necrosis or association with areas of aneurysmal bone cyst. The treatment of giant cell tumor is currently well established. Whenever possible, segmental resection of the lesion should be chosen, with an oncological safety margin in both the bone and soft tissues (figs. 2, 3 and 4). This surgery provides a greater opportunity for cure, with a lower risk of recurrence(36-39). However, in regions where segmental resection is not feasible, endocavitary curettage must be performed (fig. 8), carefully, complemented with adjuvant therapy; laser, CO2, 4% diluted phenol, liquid nitrogen or electrothermia (fig. 8b). Methylmethacrylate has a low adjuvant effect. When used to fill the cavity, it must be preceded by one of the adjuvant therapies mentioned(37,40).

In the past, curettage had high recurrence rates because the bone was not opened to allow effective cleaning and local adjuvants were not used. Currently, when endocavitary curettage is indicated, it is recommended to create a large bone window, providing a broad view of the lesion. At the SCMSP DOT, we complement curettage with cavity milling; For this purpose, we used the Lentodrill with a spherical dental milling cutter (fig. 8c)(33,37).

We used electrothermia(33,37,41) as a local adjuvant, using an electric scalpel for this purpose. This electrothermal technique is effective, as with the curved tip of the scalpel we can reach areas that are more difficult to access. Electrothermy, in addition to cauterization, also complements curettage, as the tumor cells, remaining in the small “cavities” of the bone wall, are destroyed and become detached, facilitating their removal. Electrothermy must precede milling, avoiding possible cell dissemination due to the rotation of the Lentodrill. In the knee region (fig. 5), we frequently recommend endocavitary curettage, followed by electrothermia and milling with Lentodrill. This is because segmental resection of this region would imply arthrodesis or replacement with an endoprosthesis or homologous osteoarticular graft.

Arthrodesis of the knee joint creates great limitations for the patient, which restricts its indication. Prosthetic replacements in young patients can result in problems in the near future and their indication must be judicious. The osteoarticular homologous graft presents numerous restrictions. Therefore, for the knee region, we initially recommend the most conservative therapy: curettage followed by local adjuvant, milling and filling with autologous bone graft. For advanced cases, with significant destruction of the bone structure, in which both joint function and local control of the disease may be compromised with the curettage technique, we recommend segmental resection and reconstruction with an endoprosthesis and, exceptionally, arthrodesamis(37 ). A brief comment remains regarding filling the treated cavity. This can be done with an autologous bone graft, with a homologous graft or with methylmethacrylate (fig. 10). Each of these techniques has its advantages and disadvantages (fig. 11)(33,37,39,42,43).

Methylmethacrylate makes it possible to easily visualize possible recurrences, is easy to use and allows early loading; however, it is not a biological solution and fractures may occur in the region(39).

Bone grafting is a biological and definitive solution; however, it makes it difficult to visualize possible early recurrence, which can be confused with the physiological reabsorption of the graft integration process, in addition to requiring around six months, on average, for full load. The non-autologous homologous graft has a longer integration period and is not always available, but, on the other hand, it shortens surgical time. The autologous graft has the advantage of immunocompatibility and faster integration, but it prolongs surgical time. Due to the risk of malignant transformation, radiotherapy can only be considered as a treatment option for giant cell tumors located in structures that are difficult to access surgically. Therefore, especially for the knee region, the orthopedist familiar with the treatment of oncological lesions must evaluate the clinical and radiographic aspects, the degree of joint destruction, the patient’s profession, in short, all pertinent factors, in order to make the best indication. therapy(37). Complications inherent to this tumor are recurrences, sinking of the articular surface, leading to varus, valgus, antecurvatum or retrocurvatum deviations. Exceptionally, lung metastases or malignancy may occur(43-46).REFERENCES1. Cooper A., Travers B.: Surgical Essays. London, Cox and Son, 1818. 2. Paget J.: Lectures on Surgical Pathology. London, Longmans, 1853. 3. Nelaton E.: D’une Nouvelle Espece de Tumeurs à Mieloplaxes. Paris, Adrien Delahaye, 1860. 4. Gross SW: Sarcoma of the long bones: based upon a study of one hundred and sixty five cases. Am J Med Sci 78: 17-19, 1879. 5. Bloodgood JC: Benign giant cell tumor of bone: its diagnosis and conservative treatment. Am J Surg 37:105-106, 1923. 6. Geschikter DF, Copeland NM: Tumors of Bone. Philadelphia, JB Lippincott, 1949. 7. Willis GE: The pathology of osteoclastoma or giant cell tumors of bone. J Bone Joint Surg [Br] 31: 236-238, 1949. 8. Jaffe HL, Lichtenstein L., Portis R., RB: Giant cell tumor of bone. Pathological appearance, grading, supposed variants and treatment. Arch Pathol 30: 993-995, 1940. 9. Sherman M.: “Giant cell tumor of bone” in Tumors of bone and soft tissue. Chicago, Year Book Medical Publishers, 1965. 10. Schajowics F.: Giant cell tumors of bone (osteoclastoma): a pathological and histochemical study. J Bone Joint Surg [Am] 43: 1-3, 1961. 11. Hanaoka H., Friedman NB, Mack RP: Ultrastructure and histogenesis of giant cell tumor of bone. Cancer 25: 1408-1423, 1970. 12. Wilson Jr. PD: A clinical study of the biochemical behavioral defects. Clin Orthop 87: 81-109, 1972. 13. Ackerman M., Berg NO, Person BM: Fine needle aspiration biopsy in the evaluation of tumor-like lesions of bone. Acta Orthop Scand 47: 129-136, 1976. 14. Eideken J., Hodes PJ: Roentgen Diagnosis of Diseases of Bone. Baltimoremore, Williams and Wilkins, pp 6588-6593, 1967. 15. Chaix C., Trifaud A.:Evolution and treatment of giant cell tumors of bone. Rev Chir Orthop 61: 429-434, 1975. 16. Derqui JC: Diagnosis of Giganto-cellular Osteopathies in Childhood. Buenos Ayres, Macchi HMS, 1962. 17. Lichtenstein L: Current status of problems in diagnosis and treatment. J Bone Joint Surg [Am] 33: 143-152, 1951. 18. Tornberg DN, Dick HM, Johnston AD: Multicentric giant cell tumor in the long bones. A case report. J Bone Joint Surg [Am] 57: 420-422, 1975. 19. Aegerter E., Kirkpatrick JA: Orthopedic Diseases. Philadelphia, WB Saunders, 1975. 20. Dahlin DC, Cupps RE, Johnson Jr. EW: Giant cell tumor: a study of 195 cases. Cancer 25: 1061-1070, 1970. 21. Goldenberg RR, Campbell CJ, Bonfiglio M.: Giant cell tumor of bone. An analysis of 218 cases. J Bone Joint Surg [Am] 52: 619-664, 1970. 22. Larsson SE, Lorentzon R., Boquist L.: Giant cell tumor of bone. A demographic, clinical and histopathological study recorded in the Swedish Cancer Registry. J Bone Joint Surg [Am] 57: 167-173, 1975. 23. Lichtenstein L.: Bone Tumors. St. Louis, CV Mosby, 1972. 24. McGrath PJ: Giant cell tumor of bone. An analysis of fifty two cases. J Bone Joint Surg [Br] 54: 216-227, 1972. 25. Marcove RC, Weiss LD, Vaghaiwalla MR: Cryo surgery in the treatment of giant cell tumors of bone. A report of 52 consecutive cases. Cancer 41: 957-964, 1978. 26. Rodrigues JS: Giant cell tumors of bone [Thesis]. Recife, Pernambuco, Faculty of Medicine of the Federal University of Pernambuco, 1972. 27. Sissons HA: “Bone tumors” in Wright P., Symmers W. St. C.: Systemic pathology. London, Longmans, Green and Co., 1966. 28. Huvos AG: Bone Tumors Diagnosis, Treatment and Prognosis. Philadelphia, WB Saunders, vol. 17, pp 429-467, 1991. 29. Hutter RVP, Worcester Jr. JN, Francis KC: Benign and malignant giant cell tumors of bone. A clinicopathological analysis of the natural history of the disease. Cancer 15: 663-672, 1962. 30. Levine HA, Eurile F.: Giant cell tumor of patellar tendon coincident with Paget’s disease. J Bone Joint Surg [Am] 53: 335-341, 1971. 31. Jaffe HL: Tumors and tumorous conditions of the bones and joints. Philadelphia, Lea & Febiger, 1958. 32. Cameron GW: Giant cell tumor of the patella. J Bone Joint Surg [Am] 37: 184-187, 1955. 33. Baptista PPR: Treatment of giant cell tumors by curettage, electrothermal cauterization, drill regularization and autologous bone graft. Rev Bras Ortop 30: 819-827, 1995. 34. Ottolenghi CE: Massive osteo and osteoarticular bone graft. Technique and results of 62 cases. Clin Orthop 87: 156-164, 1972. 35. Kambin P.: Giant cell tumor of thoracic spine with pathological fracture paraparesis: a method of stabilization. J Bone Joint Surg [Am] 48: 774-779, 1966. 36. Parrish FF: Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg [Am] 48: 968-990, 1966. 37. Baptista PPR:Treatment of giant cell tumor of the distal end of the femur and proximal end of the tibia – Curettage, electrothermal cauterization and autologous bone graft [Thesis]. São Paulo: Faculdade de Ciências Médicas da Santa Casa de São Paulo, 1994. 38. Murphy WR, Ackerman L.: Benign and malignant giant cell tumor of bone. Cancer 9: 317-324, 1956. 39. Camargo FP: Segmental resection in bone tumors and surgical reconstitution of the skeleton [Thesis]. São Paulo: Faculty of Medicine of the University of São Paulo, 1968. 40. Forrest M.: The pathology of giant cell tumors of bone. Rev Chir Ortho 61: 359-366, 1975. 41. Barnes R.: Giant cell tumor of bone. J Bone Joint Surg [Br] 54: 213-215, 1972. 42. Campbell CJ, Akbarnia BA: Giant cell tumor of the radius treated by massive resection and tibial bone graft. J Bone Joint Surg [Am] 57: 982- 986, 1975. 43. Frangakis EK: Soft tissue spread of giant cell tumor. J Bone Joint Surg [Am] 52: 994-998, 1971. 44. Caballos RL: The mechanism of metastasis in the so-called “benign giant cell tumor of bone”. Hum Pathol 12: 762-768, 1981. 45. Schajowics F.: About the degeneration and malignant variety of giant cell tumors. Rev Orthop Traum 10: 349-355, 1941. 46. Riley LD, Hartmann W.: Soft tissue recurrence of giant cell tumor of bone after irradiation and excision. J Bone Joint Surg [Am] 49: 365-368, 1967.

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Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

29Apr2024

drpprb@gmail.com Academic Articles 0 comment

Medial access route to the hip

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Medial access route to the hip for resection of tumor lesions

Medial access route to the hip. The access routes for the medial approach to the hip described in the literature have proven to be insufficient for the treatment of tumors that simultaneously affect the anterior, medial and posterior regions. The authors describe a medial approach, through an inguinotomy, which facilitates the resection of tumors in this area. Disinsertion of the adductor muscles is an important step in this technique, which allows for broad exposure and better tissue manipulation. There were no postoperative complications resulting from the use of this route in the nine cases in which it was used. The advantages include: ease, speed, small intraoperative bleeding, safety regarding neurovascular structures and the wide exposure it provides.

The medial approach to the coxofemoral joint is frequently used to treat congenital hip dislocation and neuromuscular disorders. Outside this scope, its use is limited and the techniques found in the world literature are few when compared to other access routes to the hip, used for the anterior, lateral and posterior approaches.

Based on a case of synovial chondromatosis, which affected the anterior, medial and posterior regions of the hip (fig. 4, AL), the senior author began using a surgical approach via medial inguinotomy, with disinsertion of the adductor muscles, different from the medial routes. described in the literature, as they do not allow, in isolation, adequate exposure of the region.

The objective of this work is to describe a medial access route to the hip, through an inguinotomy, with disinsertion of the adductor muscles, which simultaneously provides broad access to the anterior, medial and posterior regions and facilitates the resection of tumors in this location.

METHOD

The patient is placed in a horizontal supine position. It begins with asepsis of the entire region, including the abdomen, back and perineum, in addition to the entire lower limb, which is prepared to allow free movement during the operation, in order to facilitate access to the anterior regions. and posteriorly through external and internal rotation movements (fig. 4D). The lower limb on the affected side is positioned in flexion, abduction and slight external rotation, a semi-gynecological position (fig. 1). The skin incision begins medial to palpation of the femoral artery pulse, goes towards the pubic tubercle, the point of insertion of the inguinal ligament into the pubis and the center of the incision, and extends posteriorly towards the ischial tuberosity (fig. 2 ). Next, dissection is carried out through the subcutaneous cellular tissue, cauterizing the small vessels (fig. 3, A and B). The fascia incision has the same direction as the skin incision. We continue with the detachment of the pectineus muscle from the iliopubic branch, the adductor longus, adductor brevis and gracilis pubis muscles and part of the adductor magnus muscle from the ischiopubic branch (fig. 3, C and D). The obturator nerve, which passes between the pectineus muscle and the adductor longus, is protected when this muscle is reflected (fig. 3D). The iliac psoas muscle is detached from the joint capsule and isolated up to the confluence of the circumflex vessels, allowing the greatest possible exposure (fig. 3, E and F). At this point, a Langembeck or Hom-man type retractor is positioned under the iliac psoas in order to retract and protect the femoral nerve and vessels. An incision is made in the medial portion of the joint capsule (fig. 3G) and the tumor resection or the procedure in question can be continued (fig. 3H). The capsule is closed with absorbable suture. An aspiration drain is placed and the adductor muscles are reinserted, anchoring it in the periosteum. The subcutaneous cellular tissue and skin are closed with simple sutures (Fig. 4G). It is not necessary to perform any type of postoperative immobilization.

DISCUSSION

The techniques of Ludloff(9), Zazepen & Gamidov(13) and Fer-gusson(3) have traditionally been used for the medial surgical approach to the hip. These access roads,

however, they do not always meet the needs of wide exposure for resection with adequate margin of tumors in this location (figs. 2, A and B; 3, A and C), as the adductor muscles, when separated, do not allow a satisfactory visual field, mainly in adults.

The Smith-Petersen approach(12) allows access to the antero-medial region of the hip when the joint is placed in flexion and maximum external rotation, but does not expose the post-tero-medial region. In the posterior routes(2,4,7), the posterior wall of the acetabulum can make it difficult to adequately expose the femoral head. In extreme cases, the surgeon’s only alternative is hip dislocation, a dangerous procedure in terms of preserving circulation to the femoral head. In children, there is still concern about the growth physis. These factors led us to search for a technique that would allow the region to be more easily exposed, aiming for less traumatic manipulation for the tissues. The lateral approach with greater trochanter osteotomy(6), although it allows anterior and posterior access, does not expose the medial region.

The medial approach to the hip that we are describing may seem risky at first impression. This may be due to thinking based on two aspects: first, the proximity of the femoral vessels and second, the infrequent use, by orthopedists, of medial access in general. The experience acquired with resections of tumors of the obturator ring using the technique of Radley et al.(11) and with the performance of hemipelvectomies(8) made it possible to visualize this access and allowed the extrapolation of the techniques used in these cases for the treatment of tumors of the obturator ring. medial region of the hip.

The advantages of inguinotomy are several. The approach does not require major detachments or osteotomies, factors that increase postoperative morbidity. The intraoperative concern with the large femoral vessels becomes minimized, as they, when removed, are protected and, with hip flexion, move forward, moving away from the region. Intraoperative bleeding is small. The direction of the incision runs parallel to the Langerhans lines, therefore providing a good scar. Postoperative skin tension is minimal in the patient’s resting position, in which the limbs are normally in adduction. The incision site is easily covered by clothing (including swimwear) and pubic hair. The cosmetic appearance is the best possible (figs. 5 and 6).

Nine patients (Table 1) with hip tumors were treated and operated using the method described. All patients had some degree of joint limitation, with improvement in all cases after surgery. No complications were found resulting from the use of this access route. Disinsertion of the adductor muscles did not result in any deficit in adduction strength or limitation of abduction (fig. 4, HL). There were no changes in sensitivity postoperatively. The adductor muscles are reinserted into the periosteum in a similar way to the reinsertion of the abdominal muscles into the iliac crest performed in graft removal procedures.

Disinsertion of the adductor muscles is a fundamental point to allow broad exposure, given that, as it is reflected distally, it allows the retractors to be placed in a stable manner, facilitating the action of assistants. These conditions are important with regard to oncological criteria for tumor resection, considering that excessive manipulation of the retractors has the potential to spread neoplastic cells, increasing the risk of recurrence.

The oncological criteria for the resection margin of tumor lesions often require the surgeon to sacrifice neurovascular structures. With regard to the approach we are describing, ligation of the circumflex vessels is occasionally necessary. This procedure, when performed in situations where there is already compromised endostal irrigation, such as in cases of epiphysiolysis and femoral neck fractures, increases the risk of necrosis of the femoral head. However, in the case of tumor resections, when it is possible to preserve the endosteal vessels, the risk is lower.

The purpose of this work is to present an access route to the coxofemoral joint, highlighting that it is easy, quick and safe. Its use is not restricted to the treatment of tumors in the medial region of the hip. Its use can extend to other indications, such as surgery for congenital hip dislocation, resection-biopsies, synovectomies and removal of foreign bodies (such as firearm projectiles). In our opinion, this is the best way to simultaneously expose the anterior, medial and posterior regions of the hip.

REFERENCES

1. Capener, N.: The approach to the hip joint (editorial). J Bone Joint Surg [Br] 32: 147, 1950.

2. Crenshaw, AH: Campbell’s Operative Orthopedics, 8th ed., Vol. 1,

3. JB Mosby Year Book, 1992.

4. Ferguson Jr., AB: Primary open reduction of congenital dislocation of the hip using a median adductor approach. J Bone Joint Surg [Am] 55:671, 1973.

5. Gibson, A.: Posterior exposure of the hip joint. J Bone Joint Surg [Br] 32: 183, 1950. Hardinge, K.: The direct lateral approach to the hip joint. J Bone Joint Surg [Br] 64: 17, 1982.

6. Harris, WH: A new lateral approach to the hip. J Bone Joint Surg [Am] 49:891, 1967.

7. Iyer, KM: A new posterior approach to the hip joint. Injury 13:76, 1981.

8. King, D. & Steelquist, J.: Transiliac amputation. J Bone Joint Surg 25:351, 1943.

9. Ludloff, K.: Zur blutigen Eihrenkung der Angeborenen Huftluxation. Z Orthop Chir 22: 272, 1908.

10. Osbourne, RP: The approach to the hip joint: a critical review and a suggested new route. Br J Surg 18:49, 1930-1931.

11. Radley, TJ, Liebig, CA & Brown, JR: Resection of the body of the pubic bone, the superior and inferior pubic rami, the inferior ischial ramus, and the ischial tuberosity: a surgical approach. J Bone Joint Surg [Am] 36:855, 1954.

12. Smith-Petersen, MN: A new supra-articular subperiosteal approach to the hip joint. Am J Orthop Surg 15:592, 1917.

13. Zazepen, S. & Gamidov, E.: Tumors of the lesser trochanter and their operative management. Am Dig Foreign Orthop Lit Fourth quarter: 191, 1972.

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Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

28Apr2024

drpprb@gmail.com Techniques 0 comment

Biopsy – Concept – Types – Indications – Planning

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For better understanding, we suggest that you first read the chapters:

https://oncocirurgia.com.br/introducao-ao-estudo-dos-tumores-osseos/

https://oncocirurgia.com.br/diagnostico-dos-tumores/

Biopsy Considerations

Biopsy – Concept – Types – Indications – Planning

1. Only after the clinical evaluation, with careful history taking and clinical examination, which will allow us to raise diagnostic hypotheses, should we request additional tests.

With the analysis of complementary exams, we should verify:

A- If our hypotheses are compatible with the tests and continue to qualify as possible diagnoses;

B- A new hypothesis has appeared, which we had not thought of, and we will have to redo our clinical reasoning.

C- If the exams are correct, well done, images centered on the lesion, with good quality or we will have to repeat them.

2. Diagnosis hypotheses must first be made through clinical examination, laboratory tests and imaging.

3. Pathology must be used as a “tool” to confirm or not confirm the suspected diagnosis.

If the anatomopathological examination reveals a diagnosis that was not on our list, we must reanalyze the case, redo our reasoning. If there is no clinical, radiological and anatomopathological correlation , something may be wrong and we will need to review it together, in a multidisciplinary team, to determine the best course of action. New biopsy?

4. To reason about the diagnosis, it is first necessary to frame the condition we are analyzing within the five chapters of pathology, figures 1 and 2.

Biopsy – concept – types – indications – planning

5. If we conclude that our patient has a neoplasm, we need to carry out the reasoning exercise already described in the Introduction to the Study of Tumors and Tumor Diagnosis chapters (Links: https://oncocirurgia.com.br/introducao-ao-estudo- dos-tumores-osseos/ and https://oncocirurgia.com.br/diagnostico-dos-tumores/ ).

After these steps, we can think of the biopsy as a “tool” for the definitive diagnosis.

Before we address the topic “biopsy”, let’s analyze some cases.

Patient A : figures 3 and 4.

Thirty days ago, they requested a biopsy of an abdominal wall lesion on a patient admitted for investigation.

The patient’s doctor found me in the radiology room, analyzing the CT scan.

Following the “how I think” about injuries I asked myself: – what structures form the abdominal wall? The. skin (squamous cell carcinoma, basal cell carcinoma, melanoma) ; B. subcutaneous (lipoma, liposarcoma) ; w. muscular fascia (desmoid fibroma) ; d. striated muscle (fibroma, fibrosarcoma, desmoid fibroma, rhabdomyosarcoma) ; It is. vessel (hemangioma, leiomyosarcoma) ; f. peritoneum and abdominal cavity (no longer my jurisdiction).

It seemed like an extensive lesion and I suggested that I look for a surgeon in the area, as I wouldn’t know how to drive if it was a malignant neoplasm. Ideally, the biopsy should be performed by the person who will operate on the patient.

He told me that the patient was jaundiced, an ultrasound and several laboratory tests had been performed, insisting that I perform a biopsy. I asked him some information and as I didn’t know how to find out, I suggested that we visit the bed. We could extract the clinical history and examine the patient.

The patient reported being asthmatic and reported that the symptom began abruptly after a coughing fit eleven days ago, in a sudden change of weather, cold and drizzling. He had severe pain in the anterior wall of the abdomen, where a “ball” appeared. The bulging and pain were decreasing and the side wall had hardened.

Leaving the room, I suggested that we not do a biopsy, that we discharge the patient, that the jaundice with elevated bilirubin was the result of a large hematoma that had infiltrated the lateral wall, due to the spontaneous rupture of the anterior rectus abdominis. This lesion was already undergoing repair and the biopsy would only show the scarring inflammatory process (with the risk of proliferative myositis).

Still not convinced, he asked me if I had ever seen a case of spontaneous rupture of the rectus abdominis muscle. I answered no, but that was what common sense said. Going down the stairs we met a general surgeon and I asked him about the matter. This clarified that it was common in patients with chronic bronchitis who were taking corticosteroids, as was the case with our patient. The clinical history made the diagnosis.

Patients B and C : Figures 5 and 6.

Pacientes B e C: Figuras 5 e 6.

Patients B : Figure 5.

At the outpatient clinic, the resident asks:

– “By which access route should we perform the biopsy?”

I see the image and ask: – How old is the patient?

– “Um… Dona Maria, how old are you?”

I reflect in silence, evaluating the learner’s lack of knowledge. The patient responds 67 years old DOCTOR!

… Sixty-seven years, multiple lesions, metastasis? Multiple myeloma? Brown tumor of hyperparathyroidism? – How long has she had symptoms?

– “Um… Dona Maria, how long have you had this problem?”

In the medical record I see symptoms of pain in the ischial tuberosity noted , measurements of Ca ⁺⁺ , P ⁺⁺ , FA, Na ⁺ , K ⁺ , protein electrophoresis, blood count, ESR, blood glucose, urea, creatinine, ultrasound, x-rays,…, …

When examining the patient, I observed that the “tumor” is anterior , in the inguinal region, and not posterior , as noted in the medical record, “ischial tuberosity”. The patient had not been examined !!! She had an inguinal-crural hernia. Pelvic x-ray images represent gas from the intestine. The “biopsy” would result in intestinal perforation. The physical examination made the diagnosis.

Patient C : Figure 6.

Passing through the emergency room, the person on duty asks:

– “Doctor, what tumor do you think this patient has? Can we schedule the biopsy?”

The resident knew nothing about the history and had only taken the frontal x-ray!!! When asked, the patient reports that the inflammatory symptoms began six months ago, with hot pain and the release of purulent secretions. When it was open, secreting, the symptoms improved. When he closed the fistula it started to swell, hurt and he had a fever.

With difficulty, as the patient often withholds information, we learned that he had been injured in the thigh two years ago, when he jumped over the guardrail of a house, which bled a lot, but did not seek treatment ( clinical history ) . We requested a lateral x-ray which confirmed that it was a foreign body. The spear tip of the grid was surrounded by solid periosteal reaction, giving the false impression of a sclerotic tumor. Appropriate imaging confirmed the diagnosis.

After these important considerations, we will study the controversial topic of biopsy.

WE NEED:

1- Define the hypotheses of possible diagnoses, for our case, firstly with the clinical history and physical examination ;

2- Carry out laboratory and imaging tests, to corroborate or not our hypotheses, our reasoning and

3- Only after these steps can we perform the biopsy, for the pathology to “ recognize the signature ” of the diagnosis, previously thought out with our anamnesis, physical, laboratory and imaging examination.

“Pathological anatomy is not a short path to diagnosis. We must always correlate it with the clinic, laboratory and imaging tests”.

Regarding biopsy, we can subdivide musculoskeletal lesions into three groups:

Cases in which CLINICAL – RADIOLOGICAL diagnosis (image) is sufficient for diagnosis and treatment, and biopsy is not indicated.
Cases that may not require this procedure due to difficulty in histological diagnosis, and due to the characteristics of clinical and radiological aggressiveness , the necessary surgical procedure should not be altered.
Cases that require pathological confirmation for chemotherapy treatment prior to surgery

We will discuss the three groups, analyzing some examples, figures below.

GROUPS 1 and 2 : Biopsy is not necessary or does not change management.

1a . OSTEOMA, figures 13 to 18.

IDENTITY: Benign, well-defined neoplastic lesion, characterized by a homogeneous, sclerotic and dense tumor, mature bone tissue. It’s bone within a bone.

These lesions are well-defined, homogeneous, without symptoms. They are diagnosed by occasional imaging findings or by presenting aesthetic changes. Occasionally, they may be symptomatic, as in a case where the nasal cavity was obstructed, making breathing difficult. The diagnosis is clinical and radiological, and does not require a biopsy. Treatment is restricted to observation and monitoring. They are rare and occasionally operated on.

See: http://osteoma and http://osteoma of the skull

1b . OSTEOID OSTEOMA, figures 19 to 26.

IDENTITY: Benign neoplastic lesion, characterized by a circumscribed tumor, up to approximately one centimeter in diameter, which presents a central osteoid niche, surrounded by a halo of sclerosis and located in the cortex of the long bones, the most compact part.

The femoral neck region is covered by a thin periosteum that does not present a periosteal reaction. This makes it difficult to locate the lesion during surgery.

Making a hole in the cortical bone, close to the lesion, guided by radioscopy, will facilitate the operation.

After this marking, we perform a tomography to measure the distance from the hole to the center of the lesion, locating it. See the complete technique at: http://osteoid osteoma resection technique

Osteoid osteoma is a lesion of the cortical bone. In the spine, it occurs in the pedicle, which is the most compact, hardest part, resembling the cortex.

It has a central niche with a halo of sclerosis around it and does not exceed one centimeter.

There is no such thing as a “giant osteoid osteoma”, larger than 1.5 cm, as in this situation there is cortical erosion, there is no delimitation by the sclerosis halo and, although it may present similar histology, we are dealing with an osteoblastoma, which is a benign lesion. , but locally aggressive. Osteoblastoma may or may not be associated with an aneurysmal bone cyst and may also require a differential diagnosis with teleangiectatic osteosarcoma. Read also: http://osteoid osteoma

1c . OSTEOCHONDROMA, figures 27 to 32.

IDENTITY: It is an exostosis in which the central cancellous bone continues with the medullary of the affected bone and the dense peripheral, cortical layer of the tumor continues with the cortical layer of the affected bone. It presents with an enlarged, sessile, or narrow, pedicled base . It can be single or multiple (hereditary osteochondromatosis).

Osteochondromas require surgical treatment when they alter aesthetics or function, displacing and compressing vascular-nervous structures, limiting movement or generating angular deformities. It is the most common benign bone lesion.

They generally grow while the patient is in the growth phase. When an osteochondroma increases in size after completion of skeletal maturity, it may mean post-traumatic bursitis or malignancy to chondrosarcoma and should be treated as such, resecting with an oncological margin.

Solitary osteochondroma has a 1% malignancy rate. Multiple osteochondromatosis can reach 10%.

The diagnosis of osteochondroma is clinical and radiological and does not require a biopsy for treatment.

Read: http://osteochondroma

1d . CONDROMA, figures 33 to 50.

IDENTITY: Benign, painless, cartilage-forming tumor with foci of calcification in the short bones of the hands and feet, diagnosed by chance or due to deformity or fracture. It can be solitary or multiple (enchondromatosis, Maffucci syndrome, Ollier disease).

In the fingers and toes, cartilaginous lesions generally behave benignly.

The eventual unwanted evolution to chondrosarcoma, resulting from curettage surgery in these locations, does not compromise the possibility of a cure, as complete resection of the finger, which is the treatment of chondrosarcoma , would continue to be possible.

CONTROVERSY : CHONDROMA OR CHONDROSSARCOMA GRADE I?

Chondroma occasionally occurs in the metaphysis of long bones (distal femur, humerus and proximal tibia) and limb roots (shoulder, pelvis) . In these cases, it can be confused with bone infarction or grade I chondrosarcoma.

In occasional findings, as the anatomopathological diagnosis between chondroma and grade I chondrosarcoma is controversial , it is preferable not to perform a biopsy and monitor clinically and radiographically whether there is progress.

Grade I chondrosarcoma is slow to evolve, which allows monitoring, enabling observation for a safe diagnosis of its activity or not.

The exams are repeated at one, three and six months, and then annually. The tumor must be treated surgically as chondrosarcoma at any time if comparison between images reveals changes in the lesion.

If the injury remains unchanged, the best course of action is to continue monitoring. Some patients ask until when? The answer is: – Always. Reevaluation should continue regardless, whether the patient undergoes surgery or not.

Treating an asymptomatic lesion, a casual finding, without changing the image with minor surgery is “ overtreatment”, which will also require follow-up or worse, if the anatomopathological examination reveals malignant histology.

Exemplifying this conduct, we will analyze the following case, followed for 14 years, figures 39 to 42.

CHONDROMA or CHONDROSSARCOMA? In these cases common sense must prevail, he warns us that the paper accepts any writing.

We must base ourselves on the clinical behavior of the lesion. Was there a change or not? If we choose to perform a biopsy, we can only add whether or not it is a “cartilaginous lesion” . We cannot change our behavior: OBSERVE OR OPERATE AS CHONDROSSARCOMA . To be safe, if we choose to operate, we must treat it surgically as chondrosarcoma, which is our only “ tool” , as they do not respond to chemotherapy or radiotherapy.

Continuing, let us analyze figures 43 to 50.

The message we want to leave is:

¨The doctor can perform the biopsy , as it is an academic procedure, which gives him more support as to whether it is a cartilaginous lesion. But you should not operate with a curettage technique , such as chondroma, as latent chondromas of long bones, casual findings, do not require surgical treatment but rather observation. The biopsy hinders this observation because we will not know whether the pain and changes in the image, which may occur after the biopsy, would be due to the aggression of the biopsy or whether it is a chondrosarcoma manifesting itself. In conclusion, if the doctor chooses to intervene, he must operate on chondrosarcoma . We also remember that surgery, performed using any technique, will not eliminate the need for observation and monitoring¨.

Read: http://chondrosarcoma or chondroma?

1 and . CHONDROBLASTOMA, figures 51 to 54.

IDENTITY: Benign epiphyseal neoplastic lesion of the growing skeleton (1st ^and 2nd ^decades ), characterized by bone rarefaction, erosion of the articular cartilage with inflation, cartilaginous cells (chondroblasts), giant cells and foci of calcification.

Adjuvant curettage and electrothermal surgery for this neoplasm, in these locations and in small-sized lesions, is nothing more than an incisional biopsy, in which the macroscopic appearance of cartilage allows complete curettage of the tumor. The presence of the pathologist in the surgery is useful to corroborate and assist the surgeon. Read: http://chondroblastoma

1f . SIMPLE BONE CYST – COS, figures 55 to 58.

IDENTITY: Pseudoneoplastic lesion, unicameral, surrounded by a membrane, well delimited, filled with serous fluid, central metaphyseal location , which does not exceed its width and occurs in children and adolescents.

Read: http://simple bone cyst

1g . JUSTAARTICULAR BONE CYST – GANGLION, figures 59 to 62.

IDENTITY: Pseudoneoplastic lesion, epiphyseal in location , unicameral, surrounded by synovial membrane, well defined and filled with serous fluid, which communicates with the adjacent joint.

These lesions do not require a biopsy for treatment.

1h . CORTICAL FIBROUS DEFECT / NON-OSSIFYING FIBROMA, figures 63 and 64.

IDENTITY: Pseudoneoplastic lesion in the cortical bone with precise limits, asymptomatic. Occasional find.

These lesions occur in the cortical bone and do not require a biopsy for treatment/monitoring.

1i . FIBROUS DYSPLASIA OF THE TIBIA / OSTEOFIBRODYSPLASIA, figures 65 to 70.

IDENTITY: Pseudoneoplastic lesion in the tibial diaphysis with bone rarefaction of intermediate density, as if the bone had been “erased” , with a ground-glass appearance. It can occur in more than one location. Its evolution is variable and can cause deformity, dedifferentiation or harmonious growth, stabilizing at skeletal maturity.

See: https://oncocirurgia.com.br/osteofibrodisplasia-tecnica-de-tibializacao-da-fibula/

1J . MYOSITIS OSSIFICANS, figures 71 and 72.

IDENTITY: Injury located close to a bone and in soft tissues, related to previous trauma, whose ossification begins in the periphery.

1k . SOFT TISSUE TUMOR – SOME , figures 73 to 78.

IDENTITY: Delimited, homogeneous lesions, with typical images, without contrast uptake or with uptake only in the periphery, can be operated on without prior biopsy, when the surgical approach would not be different, even in the case of a malignant neoplasm.

Malignant soft tissue tumors would have the same surgical resection procedure, with the narrow margins presented in the case above and would be complemented with local radiotherapy. Soft tissue sarcomas, to date, do not respond to chemotherapy nor show an improvement in the patient’s survival rate.

See: http://soft tissue sarcomas / chemotherapy

A possible biopsy could cause nerve damage and would not change the management.

Biopsy can be performed, it is academic, it complements the case studies, but surgical resection must prevail, even in the case of malignant neoplasia. Soft tissue sarcomas, to date, do not benefit from neoadjuvant treatment and ablative surgery does not alter survival.

See: http://adjuvant radiotherapy/soft tissue sarcoma

GROUPS 3 : Biopsy is necessary for treatment (surgery; with/without neoadjuvance)

We need to emphasize that the biopsy must be performed/ monitored by the surgeon who will perform the surgery. Your presence is essential for this to be carried out in accordance with the surgery planning.

Transverse incisions should not be made, nor extensive incisions where there is no musculature for subsequent coverage, such as on the leg, for example. The suture should not have points far from the incision, as this will require a larger resection of tissue and much less more than one incision, figures 79 (tables A, B, C and D) and 80.

See the complete case of figure 80 at: http://tgc-prótese intraepifisária

See the complete case in figure 82 at: http://internal pelvectomy

Below, we exemplify two cases of biopsies performed correctly, figures 83 to 86.

*See the complete case of figures 83 and 84 at: http://growth cartilage transplant

*See the complete case of figures 85 and 86 at: http://partial rotational prosthesis

PLANNING AND EXECUTION OF BIOPSIES : CONSIDERATIONS – HOW TO PERFORM

Case 1 Considerations : We will describe how we proceeded in this female patient, 40 years old, with pain in the right posterior superior iliac crest for six months, figures 87 to 116.

In the MRI analysis, we studied the involvement of the lesion, planned the surgical access and resection tactics with margin, and then chose the most appropriate and safe route for our biopsy, figures 91 and 92.

Thus, the planned resection is to be accessed through an incision following the iliac crest, dissecting externally through the fat plane and internally detaching the peritoneum. We intended to place the patient in the supine position, but while dressing the patient was anesthetized and placed in the prone position, which made the procedure difficult, in our opinion, figures 93 and 94.

The Rx operator argued that that position was the best and that we could easily obtain the material for the histological study and… made an X where he would obtain the sample! Figures 95 and 96.

I explained that we should not change the direction of the planned surgical incision, as this would make internal access to the pelvis difficult. We advise you to puncture at the lateral point of the crest, despite the difficulty in angulating the needle, due to the prone position. This procedure is described as ¨freezing biopsy¨ , figures 97 to 102.

With the confirmation of a cartilaginous tumor, likely chondrosarcoma GII, we performed partial resection of the right pelvis, as planned, without neoadjuvance, figures 103 to 116.

Video 1: Exposure of the internal surface of the pelvis and delicate osteotomy, performed with minimally invasive drills.

Case 2 Considerations : Let’s now discuss the biopsy in this eleven-year-old patient, with pain and a tumor in the left thigh for two weeks. Probable osteosarcoma, figures 115 to 118.

We very frequently see patients with biopsy scars performed in the anterolateral region of the distal metaphysis of the femur. The red arrow points to the fascia lata, which is most often interrupted by the biopsy path, carried out by professionals who will not operate on the patient, making it difficult to cover future surgery and the function of this limb that will need to be reconstructed.

The yellow arrow indicates the posterolateral path, most suitable for biopsy and reconstruction, providing the best coverage and function.

To perform the biopsy using this route, the appropriate positioning of the patient is in the prone position, figures 119 to 122.

For the treatment of tumors of the distal end of the femur, such as this lesion, with this degree of involvement and location, we recommend biopsy as described and neoadjuvant induction chemotherapy, resection with oncological margin and reconstruction with modular prosthesis and adjuvant chemotherapy.

The patient in this example is out of treatment, with excellent function, and the complete case can be seen at Link: http://osteosarcoma-length discrepancy .

The performance of musculoskeletal biopsy, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals.

“Carrying out musculoskeletal biopsies, aiming at the diagnosis and adequate treatment of neoplasms, must be very well planned and carried out by experienced professionals and with the participation of the surgeon who will be managing the case”.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

28Apr2024

drpprb@gmail.com Techniques 0 comment

Thigh Soft Tissue Sarcoma Resection Technique

Thigh Soft Tissue Sarcoma Resection Technique. Female patient, 33 years old, reports a tumor on the posterior and distal aspect of the left thigh for a year, with greater growth in the last three months, during the end of pregnancy. After consultation with another professional, in which she underwent ultrasound examinations, bone scintigraphy, magnetic resonance imaging and biopsy, Figures 1-20, she was referred to us for evaluation and treatment.

Thigh soft tissue sarcoma resection technique

It is instructive to comment that some requested tests could be waived. Bone scintigraphy for this soft tissue injury is an exam that does not add value, as well as radiography of the pelvis, since the lesion is not in this location, the best imaging test to evaluate soft tissue injury is magnetic resonance imaging. new resonance, seeking to obtain better definition of the images, without granulation and in all routine weightings, aiming to evaluate in detail the relationship of the lesion with the vascular and nevus bundles. Figures 21 to 33.

Tumor resection surgery was performed on 10/28/2014. We indicate an incision that begins at the posterior fold of the knee and goes proximally over the path of the internal saphenous muscle, to provide access to the entire path of the artery, vein and femoral nerve, figures 34 to 55.

The resected piece was sent for pathological anatomical study, figures 56 to 61.

After discussing the case again with the oncologists, adjuvant chemotherapy (after surgery) was not indicated, nor was neoadjuvant use recommended (before surgery). With the healing of the surgical wound progressing satisfactorily, we indicated the consolidation of local treatment with adjuvant radiotherapy.

Analysis of the history, clinical picture and images of a homogeneous, compact lesion, with precise limits, producing mature bone, allowed the diagnosis of osteoma, with resection of this lesion for aesthetic reasons. The surgery was performed under general anesthesia and local infiltration to reduce bleeding (figures 10 to 20).

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

28Apr2024

drpprb@gmail.com Techniques 0 comment

Technique for Revision of Infected Hip Prosthesis

Technique for Revision of Infected Hip Prosthesis. A 52-year-old patient, with bilateral osteoarthritis of the hips, due to aseptic necrosis of the femoral heads, with more severe pain and disability on the left, underwent total hip arthroplasty E, figures 1 and 2.

Technique for revision of infected hip prosthesis – Arthrosis due to femoral head necrosis – Loosening and breakage of prosthesis, infection and fracture.

He later underwent surgery on the hip on the right side. During follow-up, the left femoral component became loose and, in February 2008, the stem broke. In May, the first revision was carried out, with a new prosthesis using a long neck and short stem, figures 3 and 4.

In February 2010, the long femoral stem was loosened, followed by a new revision with a plate, mesh, homologous graft and reinforced plate. Infection with active fistula and new releases, now with the patient presenting diabetes, figures 9 to 12.

From 2010 to 2014, the patient underwent surgical cleaning and systemic antibiotic therapy, under the supervision of an infectious disease specialist, in successive hospitalizations, aiming to achieve control of the infection for a two-stage revision. In March 2014, we evaluated the patient and analyzed the case. We recommend a single-stage revision, resecting the proximal segment en bloc, with prosthesis, plate, screws, mesh, wires, grafts, sequestrations and necrotic tissue, as if it were a neoplasm, and replacing it with a non-conventional polyethylene endoprosthesis. This endoprosthesis is nothing more than a spacer, with the advantage of immediately filling the dead space and providing immediate function of the operated limb, figures 13 to 15.

Pre-operative radiographs of the revision in a surgical procedure, in April 2014, figures 19 to 128.

Revision surgery, April 8, 2014, figures 19 to 15.

After testing with the trial prosthesis and choosing the definitive modules, we proceed to cementing the endoprosthesis components, figures 42 to 53.

Around any endoprosthesis, fibrosis forms as a result of a foreign body reaction, resulting in a thick pseudo capsule, forming a case, which practically isolates this endoprosthesis from the body. The muscles and tendons, which were initially inserted into the prosthesis with ethibond threads, end up definitively adhering to this pseudo capsule. This pseudo capsule has a lining of fluid-secreting synovial epithelium, which ends up covering the endoprosthesis. This reactional fibrosis of the pseudocapsule can reach 5 mm in thickness. In revisions and even in surgeries with major muscle detachment, an increase in dead space may occur, resulting in the formation of excess synovial fluid, which increases the ¨case¨ that surrounds the prosthesis. This increase in volume, associated with weakness of the abductor muscles, can facilitate hip dislocation. On May 15, 2014, one month after surgery, the patient returned with an increase in thigh volume, no fever, no local heat, and signs of excess liquid content around the prosthesis. This liquid, when in excess, must be drained. Sometimes more than one procedure is necessary. It must be done with complete asepsis, using a large-caliber needle and emptying the contents as much as possible, figures 62 to 64.

A new drainage was performed by puncture, on 05/28/2015, after two weeks. The patient was already able to walk with a walker and had no recurrence of the infection, figures 65 to 67.

Video 1: Patient walking with a walker two months after the review.

In June 2014, he performed a hyperflexion and internal rotation movement, while sitting on a low toilet, presenting hip dislocation. A closed reduction was performed and we reoriented again regarding the movements that facilitated the dislocation, as there was significant hypotrophy of the gluteus medius, which made stabilization of the prosthesis even more difficult. A new episode of dislocation in July 2014, three months after surgery. We performed reduction maneuvers under radioscopy, without the need for sedation and obtained easy reduction and also easy displacement, confirming the inability to contain the reduced hip, due to the insufficiency of the abductor muscles and the femoral head that we used, which was small in size, figures 65 to 67 .

We had not changed the acetabulum in the previous surgery, maintaining a smaller head than the size of the previous acetabulum, which could also be contributing to the instability. We decided on re-intervention with replacement of the acetabulum for a constricted module, also employing a larger head.

The patient evolved well, without complications, and was evaluated after one year, figures 83 to 86.

Video 2: Patient walking with trendelenburg, one year after the last surgery, acetabulum blocked, to overcome gluteus medius insufficiency.

Video 3: Patient walking without support, despite trendelemburg, after one year, on 07/27/2015.

To date, April 2, 2017, the patient is doing well, walking with a slight limp due to Trendelemburg, without any complications, three years after the last surgery.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

28Apr2024

drpprb@gmail.com Techniques 0 comment

Epiphysiodesis technique and rotating partial prosthesis

Epiphysiodesis technique and rotating partial prosthesis. 11-year-old patient, presenting with knee pain and increased volume in the lower third of the right femur. X-rays from February 2014 showed a lesion producing bone tissue in the metaphysis, figures 1 and 2. The scintigraphy revealed that it was a single lesion with intense uptake in the distal metaphyseal region of the femur, figures 3 and 4.

Epiphysiodesis technique and rotating partial prosthesis, with preservation of the tibial growth physis, in osteosarcoma of the femur.

To expand the study of the lesion, a Pet-Ct examination was performed, figures 5 to 8.

Continuing the staging, magnetic resonance imaging was performed, figures 9 to 18.

A puncture biopsy was performed, via a lateral approach, by another professional.

Note that the biopsy site, figure 20, is much anterior, passing through the middle of the fascia lata, making future coverage of the surgery difficult, as the lower segment of the fascia would be sectioned both in the biopsy area, above, and at the edge below.

Before the last stage of neo-adjuvant chemotherapy, we take radiographs with a ruler of the segment to be resected, to plan the surgery and create a special prosthesis, when necessary, figures 23 and 24. In growing children, this procedure is generally necessary due to the different widths of the medullary canal, varying sizes of the femoral condyles, in addition to special devices that allow the growth potential of the epiphyseal plate to be preserved. At this stage we also perform a new MRI to image the evolution of the lesion, figures 26 to 41. It is rare, but the tumor may have increased during chemotherapy and will need to be resected with an oncological margin. However, the segment to be removed with margin can never be smaller than the size planned with the initial resonance, sized in the T1 view.

Tumor resection surgery was performed medially, removing the entire biopsy path and the lateral skin incision along with the surgical specimen. The surgical technique is explained in figures 42 to 98.

The approach must be performed without tourniqueting the limb and with careful hemostasis, aiming to minimize blood loss in immunocompromised patients.

Video 1: Free flexion and extension, without limitation.

Video 2: Placement of soft tissue hemostat.

Video 3: Patient undergoing postoperative chemotherapy and physiotherapy, good extension and good flexion of the knee.

Video 4: Patient undergoing chemotherapy and physiotherapy eleven months after surgery. Active flexion function, with load, of approximately 45 degrees.

Note that there has already been growth of the tibia. The red arrow points to the scar where the growth plate was. The white arrow points to the current position of the growth plate. The yellow bar marks how much this bone segment has grown, figure 130.

Video 5: Active extension of 180 degrees and flexion of 90 degrees, on 09/29/2015, sixteen months after surgery.

Video 6: Walking and 90-degree flexion function, active and with load, sixteen months after the operation.

Video 7: Good balance and good function for activities of daily living.

The path of the nail crossing the epiphyseal line is correct and is in accordance with the technique used. The presence of the nail may cause concern regarding the possibility of interference with the growth of the physis, as it is a little known technique, but this does not occur.

Careful passage of this 1.0 cm diameter rod, protected by a non-cemented polyethylene “shirt”, does not block the growth cartilage.

It can be seen that the proximal physis of the tibia continues its growth, without blockage, despite having received at its central point the passage of the rotating tibial component, protected by the polyethylene shirt, figure 155.

This growth is evident, especially if we compare it with figure 130, from 06/16/2015, four months earlier.

The red arrow points to the scar where the growth plate was. The white arrow points to the current position of the growth plate. The yellow bar marks how much this bone segment has grown. On this occasion we recommend epiphysiodesis to control the discrepancy.

Video 8: Function in December 2016, two years after surgery. Gait without lameness, good flexion function with load.

Five months passed between the indication of epiophysiodesis and its completion. During this period, the patient presented a significant growth spurt, increasing the discrepancy of the lower limbs, now reaching 1.5 cm. Scanogram from January 2017, figure 165.

Video 9: Balance and function, in January 2017, three years after surgery.

Video 10: Evident lower limb discrepancy.

We programmed epiphysiodesis to definitively block only the growth of the distal growth cartilage of the contralateral femur. This procedure is performed with the patient anesthetized, under radioscopy control, as described in the figures below.

The same procedure is repeated for the wire from medial to lateral, taking care to check the parallelism between them, leaving space so that they do not collide at the intersection. Next, drilling of the cortex begins with the calibrated drill for the passage of the full-thread cannulated screw

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office : Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638 Cell:+55 11 99863-5577 Email: drpprb@gmail.com

28Apr2024

drpprb@gmail.com Techniques 0 comment

Technique for Resection of Bone Metastasis of Renal Tumor in the Femur

Technique for Resection of Bone Metastasis of Renal Tumor in the Femur. A 57-year-old male patient reported the appearance of low back pain at the end of October 2014, radiating to the MIE. Due to the progression of symptoms, he underwent a spinal MRI which reported the presence of a herniated L5-S1 disc. He started physiotherapy and with the worsening of symptoms he underwent a tomography on 02/18/2015, with reports of facet arthrosis L2-L3, L3-L4 and L5-S1 discopathy with protrusion into the medullary canal and x-rays of the pelvis, figures 1 and 2 .

Radiotherapy – Technique for resection of bone metastasis from a kidney tumor in the femur – Reconstruction with polyethylene endoprosthesis

The following day, on 02/19/2015, he had an MRI, this time of the hip, where an osteolytic lesion appears in the left femoral neck and region of the lesser trochanter, measuring 3.6 cm in diameter, with a soft tissue component infiltrating tendons and muscles, figures 3 to 9.

The x-ray was repeated and a tomography was performed on 02/20/2015, figures 10 to 13.

The patient seeks care in a hospital specializing in oncology.

On 02/23/2015, after clinical evaluation and the images available, we requested a Pet-Ct examination, to complete the imaging studies and staging of the lesion. This examination showed hypermetabolic lesions: lung on the left, SUV=13.2 (probable primary process) and lesion in the left femoral neck, SUV=10.7 (probable secondary process), figures 16 to 21.

A biopsy of the lung and femur was performed, the pathological analysis of which diagnosed invasive adenocarcinoma, with an acinar pattern, infiltrating lung tissue and metastatic adenocarcinoma in bone tissue. Presence of mutation in exon 21 c2573T>G(L858R) of the EGFR gene. Absence of rearrangement in the ALK gene. On 03/05/2015, Foundation One: EGFR mutation: ERBB3 amplification: CDK4 amplification: TP53L257P, MYSTT3. No mutation in RET: ALKBRAF; Kras; ERBB2; MET, reports figures 22 to 24.

After the evaluation, treatment with extracranial stereotactic radiotherapy was instituted to control the femoral neck lesion and chemotherapy with: Pemetrexed (500 mg/m2) + Cisplatin inj (75 mg/m2) every 21 days. C1D1 02/25/2015; C2D1 03/18/2015, report figure 25 and clinical reassessment on 04/08/2015, figures 26a and 26b.

The radiotherapy treatment planning carried out was: 1- Technique: Stereotactic Extra Cranial Radiotherapy (SBRT) 2- Prescription dose: 2000 cGy in a single fraction 3- Energy: 15 MV 4- Technique: 3D 5- Maximum dose in PTV: 2362 cGy 6- Minimum dose: 1808 cGy 7- Median dose: 2195 cGy Figures 26 c to 26 j document the adjuvant treatment instituted.

The chest tomography from April, the radiographs and the hip tomography from May 2015 can be analyzed in figures 33 to 38.

In the orthopedic evaluation at this time, the patient did not present significant symptoms.

We considered the short period of radioablation and chemotherapy treatment, as well as the risk of fracture.

The medullary irrigation of the femoral neck in adults is retrograde, from the metaphysis to the epiphysis. The main irrigation of the epiphysis is through the posterior circumflex artery, which may have been the route of metastatic dissemination and may even be compromised. To make matters more difficult, the femoral neck has a very weak periosteum, with little capacity for bone regeneration, which is the cause of many failures in bone consolidation when fractures occur in this region.

Together with the patient and family, we decided to wait, trying to give more time and opportunity for bone repair. We chose to reevaluate in July, with new imaging tests, paying attention to the symptoms.

Postponing surgery is a difficult decision. The expectation and anxiety is shared and experienced by everyone.

The patient returns on July 22, 2015, complaining of pain when moving from sitting to standing, pain when rotating the hip and limping. The imaging exams, from the MRI on July 18, 2015, are analyzed in figures 39 to 59.

The surgery must be performed with caution, deepening the incision little by little , to achieve hemostasis in layers . Adequate anesthesia should not induce hypotension , as this is the only way the surgeon can properly observe the sectioned capillaries and make sure that he is performing an operation without blood loss, neither at that moment nor at a later time.

In oncological surgeries, the surgeon cannot have a “heavy” hand. The patient is already weakened by the illness, by chemotherapy, has possibly already undergone transfusions and the need for blood replacement must be avoided. Garroting should not be used except in amputation surgeries.

During anesthesia the patient cannot feel pain. It is not enough to be sedated, as if there is pain it increases the pressure, making hemostasis with electrocautery difficult.

In surgeries for bone metastases in the proximal third of the femur, we can remove the joint tendon of the gluteus medius and vastus lateralis muscles, with an electric scalpel, very close to the periosteum. This is a sufficient margin as it is a secondary lesion, except when the primitive tumor is melanoma.

Note that surgery with caution allows for adequate hemostasis. Blood loss is controlled, despite major surgery, with extensive exposure. The surgical procedure is like a courtship, the oncology surgeon cannot be rushed.

The osteotomy can be performed with an electric saw or a Gigle saw. It must be perpendicular to the diaphysis, for the correct adaptation of the prosthesis. As there is no cutting guide, it depends on the team’s skill, video 1.

Video 1: Perpendicular cut of the diaphysis, with a giglê saw.

After the osteotomy, a sample is taken from the medullary canal to study the distal margin and the acetabulum is prepared to be exposed, figures 85 and 86.