Search

Background: The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers.Questions/purposes: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results.Methods: Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system.Results: With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4).Conclusions: Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary arrest in children is an uncommon event, and often fatal. Resuscitation is often attempted, but at what point, and under what circumstances do continued attempts to re-establish circulation become futile? The uncertainty around these questions can lead to unintended distress to the family and to the resuscitation team. Objectives: To define the likely outcomes of cardiopulmonary resuscitation in children, within different patient groups, related to clinical features. Data Sources: MEDLINE, MEDLINE in-Process & Other non-Indexed Citations, EMBASE, Cochrane database of systematic reviews and Cochrane central register of trials, Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment database, along with reference lists of relevant systematic reviews and included articles. Study Eligibility Criteria: Prospective cohort studies which derive or validate a clinical prediction model of outcome following cardiopulmonary arrest. Participants and Interventions: Children or young people (aged 0 – 18 years) who had cardiopulmonary arrest and received an attempt at resuscitation, excluding resuscitation at birth. Study Appraisal and Synthesis Methods: Risk of bias assessment developed the Hayden system for non-randomised studies and QUADAS2 for decision rules. Synthesis undertaken by narrative, and random effects meta-analysis with the DerSimonian-Laird estimator. Results: More than 18,000 episodes in 16 data sets were reported. Meta-analysis was possible for survival and one neurological outcome; others were reported too inconsistently. In-hospital patients (average survival 37.2% (95% CI 23.7 to 53.0%)) have a better chance of survival following cardiopulmonary arrest than out-of-hospital arrests (5.8% (95% CI 3.9% to 8.6%)). Better neurological outcome was also seen, but data were too scarce for meta-analysis (17% to 71% ‘good’ outcomes, compared with 2.8% to 3.2%). Limitation: Lack of consistent outcome reporting and short-term neurological outcome measures limited the strength of conclusions that can be drawn from this review. Conclusions and Implications of Key Findings: There is a need to collaboratively, prospectively, collect potentially predictive data on these rare events to understand more clearly the predictors of survival and long-term neurological outcome. Systematic Review Registration Number: PROSPERO 2013:CRD42013005102 [ABSTRACT FROM AUTHOR]

Background: Children rarely require hip replacement, and therefore very little is known about the most effective procedure for children who require hip replacement after proximal femoral resection for a tumor. Methods: We reviewed the outcome of forty hip replacements in children between two and fifteen years old who had a proximal femoral replacement for malignant disease. Twenty-one children survived the illness and were followed for three to twenty-one years. Cemented acetabular components were used initially to restore hip function, but, in more recent procedures, unipolar replacements and uncemented implants were used. Results: Children who were over the age of eleven years at the time of surgery had a rate of failure (defined as revision of the acetabular component) of 25% at ten years compared with a rate of 75% in younger children. Unipolar replacements in children of all ages failed by ten years, either because of pain or subluxation that led to revision. In children over the age of eleven years, both cemented and uncemented acetabular implants performed well. Conclusions: The preferred method for restoration of hip function in children under the age of eleven years following proximal femoral resection for a tumor remains unclear. We recommend that at the initial hip surgery an attempt should be made to cause as little damage as possible to the acetabulum, but most children will inevitably need revision surgery as they get older. We hope that this study will guide others in their decision-making with regard to this relatively rare condition. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Trauma is the leading cause of death in the first four decades of life in western countries. A national prospective study was conducted in the UK to examine the process and quality of care of severely injured patients. We present a previously unpublished analysis of the severity of injury, place of treatment, quality of care and survival amongst patients with thoracic injuries. Methods: All UK hospitals with an emergency department were asked to provide prespecified clinical and process data on all patients presenting with significant injuries between 1st February and 30th April 2006. All data were stripped of patient, clinician and institutional identifiers before review by expert advisors. Results: Data adequate for analysis were obtained on 1735 of 2203 injured patients reported. An injury severity score (ISS)≥16, the threshold for severe injury, was derived from case records of 795 patients, who comprise the study denominator. Of these, 387 (49%) had a thoracic injury, usually as part of polytrauma. The mortality rate was 8% (of 13) 9% (of 23) 10% (of 175) 14% (of 136) 22% (of 37) and 100% (of 3) for the six ascending grades of severity for the thoracic component of the ISS score. One hundred and seventy-six of the 795 patients (22%) had a thoracic injury sufficient for them to be classified as severely injured regardless of any other injuries. The quality of care as assessed by expert advisors showed an apparent association with overall trauma volume of the 142 treating hospitals. For patients with thoracic injuries where the specialty of the team in charge could be identified (n =284/387) trauma and orthopaedics (T and O) cared for 36%, critical medicine 22%, general surgery 19%, neurosurgery 8% and only 5% were in the care of thoracic surgeons. One or more chest drains were inserted in 203/795 (26%) of patients, few of them by thoracic surgeons. Conclusions: Given that polytrauma patients rarely come under the care of thoracic surgeons and yet frequently have severe thoracic injuries there is a clear need for T and O surgeons and generalists to have a good grounding in thoracic procedures. [Copyright &y& Elsevier]