Publications by authors named "Rodolfo Capanna"

107 Publications

Hybrid Simulation and Planning Platform for Cryosurgery with Microsoft HoloLens.

Sensors (Basel) 2021 Jun 29;21(13). Epub 2021 Jun 29.

Information Engineering Department, University of Pisa, 56126 Pisa, Italy.

Cryosurgery is a technique of growing popularity involving tissue ablation under controlled freezing. Technological advancement of devices along with surgical technique improvements have turned cryosurgery from an experimental to an established option for treating several diseases. However, cryosurgery is still limited by inaccurate planning based primarily on 2D visualization of the patient's preoperative images. Several works have been aimed at modelling cryoablation through heat transfer simulations; however, most software applications do not meet some key requirements for clinical routine use, such as high computational speed and user-friendliness. This work aims to develop an intuitive platform for anatomical understanding and pre-operative planning by integrating the information content of radiological images and cryoprobe specifications either in a 3D virtual environment (desktop application) or in a hybrid simulator, which exploits the potential of the 3D printing and augmented reality functionalities of Microsoft HoloLens. The proposed platform was preliminarily validated for the retrospective planning/simulation of two surgical cases. Results suggest that the platform is easy and quick to learn and could be used in clinical practice to improve anatomical understanding, to make surgical planning easier than the traditional method, and to strengthen the memorization of surgical planning.
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http://dx.doi.org/10.3390/s21134450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8272062PMC
June 2021

Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision.

J Orthop 2021 May-Jun;25:244-251. Epub 2021 May 14.

Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy.

In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.
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http://dx.doi.org/10.1016/j.jor.2021.05.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165293PMC
May 2021

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis.

Arch Orthop Trauma Surg 2021 May 24. Epub 2021 May 24.

Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Largo Palagi 1, 50139, Florence, Italy.

Introduction: Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked.

Materials And Methods: We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes.

Results: Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections.

Conclusion: Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.
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http://dx.doi.org/10.1007/s00402-021-03929-6DOI Listing
May 2021

Humeral greater tuberosity osteolysis as a complication of intraosseous calcification migration: natural history depicted by imaging.

Acta Biomed 2021 04 30;92(S1):e2021052. Epub 2021 Apr 30.

Department of Interventional and Diagnostic Radiology Azienda Ospedaliero-Universitaria Pisana.

Migration of calcification within the bone leading to greater tuberosity osteolysis is a peculiar complication of the calcifying tendinitis of the rotator cuff. The case of a 38-year-old woman complaining of right shoulder pain, which had been going on for one year, is hereby described. The evolution of the infraspinatus tendon calcifying tendinitis leading to osteolysis of the greater tuberosity of the humerus is depicted by imaging and, particularly, by the MR and CT features changing over time. In this paper we focus on the importance of both MR and CT exams in the diagnostic process of the different phases of the disease. The correlation between clinical symptoms and imaging features is also helpful for imaging interpretation: the most painful phase corresponds to the migration of the calcification, whereas pain tends to decrease when the osteolysis develops. Awareness of the existence of this condition may prevent unnecessary invasive procedures.
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http://dx.doi.org/10.23750/abm.v92iS1.8370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142746PMC
April 2021

Acral Dedifferentiated Chondrosarcoma: Report of a Case Arising in the Proximal Phalanx of the Fourth Finger.

Int J Surg Pathol 2021 Apr 13:10668969211010221. Epub 2021 Apr 13.

9310Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.

Dedifferentiated chondrosarcoma is a well-recognized entity, but its occurrence in the distal extremities is exceedingly rare. We present the case of a 49-year-old woman who experienced local recurrence of an "enchondroma" of the proximal phalanx of the fourth finger of the left hand, which had been initially treated with intralesional curettage at another hospital 4 years before, and 1 year before for a local recurrence. The imaging findings indicated an aggressive behavior, and an incisional biopsy showed a highly cellular proliferation of spindle and pleomorphic elements without evidence of matrix production intermixed with few fragments of a well-differentiated cartilaginous neoplasm with bland cellular atypia, focal nuclear hyperchromatism, and binucleation. An isocitrate dehydrogenase 2 R172S mutation was detected. The final diagnosis was dedifferentiated chondrosarcoma. Despite amputation of the fourth finger, the patient developed lung metastases and further local relapse. Recurrent cartilaginous tumors of the extremities should not be underestimated and should be followed in view of the possible acquisition of aggressive clinical behavior.
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http://dx.doi.org/10.1177/10668969211010221DOI Listing
April 2021

Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management.

Adv Orthop 2021 19;2021:5559377. Epub 2021 Mar 19.

Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy.

Proximal humerus is one of the anatomical sites that are most frequently involved by bone and soft tissue malignant tumors. Alone or in association with adjuvant treatments, surgery represents the main therapeutic option to treat and eradicate these diseases. Once the first-line option, in the last decades, amputation lost its role as treatment of choice for the large majority of cases in favor of the modern limb sparing surgery that promises to preserve anatomy and-as much as possible-upper limb functionality. Currently, the main approaches used to replace proximal humerus after a wide resection in oncologic surgery can be summarized in biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions. The purpose of this overview is to present nowadays surgical options for proximal humerus reconstruction in oncological patients, with their respective advantages and disadvantages.
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http://dx.doi.org/10.1155/2021/5559377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004366PMC
March 2021

Custom-Made 3D-Printed Implants as Novel Approach to Reconstructive Surgery after Oncologic Resection in Pediatric Patients.

J Clin Med 2021 Mar 4;10(5). Epub 2021 Mar 4.

Orthopedic Department, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy.

Recently, custom-made 3D-printed prostheses have been introduced for limb salvage surgery in adult patients, but their use has not been described in pediatric patients. A series of 11 pediatric patients (mean age 10.8 years; range 2-13) with skeletal tumors treated with custom-made implants for the reconstruction of bony defects is described. Patients were followed up every 3 months. Functional results were evaluated by the Musculoskeletal Tumor Society Score (MSTS) for upper and lower limbs. The mean follow-up was 25.7 months (range 14-44). Three patients died after a mean of 19.3 months postoperatively-two because of disease progression and the other from a previous malignancy. Three patients experienced complications related to soft tissues. One patient required device removal, debridement, and antibiotic pearls for postoperative infection. Partial osseointegration between grafts and host bone was observed within a mean of 4 months. At the final follow-up, mean MSTS score was 75%. 3D prostheses may yield biological advantages due to possible integration with the host bone and also through the use of vascularized flaps. Further research is warranted.
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http://dx.doi.org/10.3390/jcm10051056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961419PMC
March 2021

Closed Incisional Negative Pressure Wound Therapy (ciNPWT) in Oncological Orthopedic Surgery: Preliminary Report.

Surg Technol Int 2021 03 23;38. Epub 2021 Mar 23.

Orthopedic and Traumatology Department II, University of Pisa, Pisa, Italy.

This report presents the authors' experience with surgical wound-healing using a negative-pressure wound therapy (NPWT) device in a population of oncological orthopedic patients. Two groups of 26 oncological patients each underwent surgical excision. After surgery, the control group received standard dressings and the closed incisional NPWT (ciNPWT) group was treated with a ciNPWT system on the sutured wound area for 14 days. As a primary endpoint, the percentage of post-surgery wound-site complications using ciNPWT devices was compared to that with standard patch dressings. Overall, 30.7% of the control group and 7.7% of the ciNPWT group manifested wound-site complications within 2 weeks after surgery. As a secondary endpoint, final wound healing was compared between the groups: delayed wound healing was observed in 4 (15.4%) patients in the control group and in none (0%) of those in the ciNPWT group. Finally, the length of stay (LOS) was 6.3 days in the control group and 5.1 days in the ciNPWT group. These results suggest that the ciNPWT device could be beneficial in minimizing the incidence of short-term surgical-site complications and decreasing length of stay in high-risk patients, such as those undergoing oncological orthopedic surgery.
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March 2021

What's the resolutive surgery for pseudo-ainhum in Vohwinkel syndrome? A case report and review of the literature.

Orthop Rev (Pavia) 2020 Dec 1;12(4):8868. Epub 2021 Feb 1.

Department of Orthopaedic Surgery (DICHIRONS), Università degli Studi di Palermo.

Vohwinkel Syndrome, also known as Keratoderma Hereditarium Mutilans, is an extremely rare dominant autosomal keratosis. It typically presents with "starfish" keratoses on the knuckles, palmoplantar keratoderma (PPK), hearing impairment and mutilating digital constriction bands (pseudoainhum) that cause strangulation, often leading to autoamputation of the affected digit. Both medical and surgical treatment haven't shown to date consistent results, in the treatment of pseudoainhum. In this study we present the case of a woman with Vohwinkel syndrome who showed constriction bands causing ischemic changes of the 5th digit of the right hand for which she was treated with surgery. We also present a review of the literature for the management of this disease.
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http://dx.doi.org/10.4081/or.2020.8868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883105PMC
December 2020

Distrectual osteosarcopenia in limb disuse: case report and mini literature review.

Acta Biomed 2020 12 30;91(14-S):e2020005. Epub 2020 Dec 30.

2nd Orthopedic and Traumatologic Clinic, University of Pisa, Pisa, Italy .

Osteosarcopenia is a new concept of association of osteoporosis and sarcopenia. Both of these pathologies are more frequent in old people and general affects all the skeleton with increased risk of falls and fractures, loss of global function, fragility, and mortality, but also surgical failures. The coexistence of these condition derives from a close relationship, not only anatomical, between bone and muscle tissues. Sometimes these pathological conditions can involve only a skeleton segment, due to local disuse, causing a district form of sarcopenia. In this clinical case, Authors describes a case of isolated lower limb osteosarcopenia in a young non-osteoporotic patient, due to a prolonged limb disuse, complicated by surgical treatment failure for previous pathology, diagnosed by clinical, laboratory, instrumental and histopathological exams.
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http://dx.doi.org/10.23750/abm.v91i14-S.10785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944706PMC
December 2020

Analysis of a Preliminary microRNA Expression Signature in a Human Telangiectatic Osteogenic Sarcoma Cancer Cell Line.

Int J Mol Sci 2021 Jan 25;22(3). Epub 2021 Jan 25.

Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy.

Telangiectatic osteosarcoma (TOS) is an aggressive variant of osteosarcoma (OS) with distinctive radiographic, gross, microscopic features, and prognostic implications. Despite several studies on OS, we are still far from understanding the molecular mechanisms of TOS. In recent years, many studies have demonstrated not only that microRNAs (miRNAs) are involved in OS tumorigenesis, development, and metastasis, but also that the presence in high-grade types of OS of cancer stem cells (CSCs) plays an important role in tumor progression. Despite these findings, nothing has been described previously about the expression of miRNAs and the presence of CSCs in human TOS. Therefore, we have isolated/characterized a putative CSC cell line from human TOS (TOS-CSCs) and evaluated the expression levels of several miRNAs in TOS-CSCs using real-time quantitative assays. We show, for the first time, the existence of CSCs in human TOS, highlighting the in vitro establishment of this unique stabilized cell line and an identification of a preliminary expression of the miRNA profile, characteristic of TOS-CSCs. These findings represent an important step in the study of the biology of one of the most aggressive variants of OS and the role of miRNAs in TOS-CSC behavior.
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http://dx.doi.org/10.3390/ijms22031163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866083PMC
January 2021

Treatment options in femoral radiation fractures following soft tissue sarcoma: Incidence, risk factors, failures and flowchart of treatment.

Injury 2021 Jun 24;52(6):1597-1605. Epub 2020 Dec 24.

Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.

Introduction: The femur is the most frequent involved site by post-attinic fractures. The appropriate treatment of pathological fractures after radiotherapy is still controversial as they are associated with a high risk of delayed consolidation and non-union. Authors review a single Center series of pathological fractures after radiation therapy in patients affected by soft tissue sarcomas analyzing incidence, risk factors, failure rate and proposing a flow chart of treatment of postattinic fractures of the femur.

Methods: Authors selected 570 patients treated by limb salvage surgery associated to radiation therapy from 1992 to 2018. A pathological fracture during follow up was observed in 28 cases (5%). The mean time between the onset of the fracture after the prior surgery + radiotherapy was 70 months (range 3-182). The mean follow-up from the fracture was 86 months (range 9-222).

Results: The fracture treatment was performed with an intramedullary nail in 15 cases. Eight femoral fractures healed uneventfully (57%) and 6 required further surgical procedures. A total of eight patients underwent prosthetic replacement, 3 as a primary treatment and 5 as a salvage procedure after failure of internal fixation. Five patients developed a deep infection (62.5%).We observed 10 non-union (53%) in 19 patients treated with osteosynthesis. Overall amputation rate of the entire series was 18%. Authors propose a flowchart of treatment for femoral fractures.

Conclusion: Intramedullary nailing is the treatment of choice in postradiation diaphyseal fractures of long bones, prosthetic replacement in meta-epiphyseal fracture site. Free vascularized grafts remain a valid salvage solution after failure of internal fixation.
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http://dx.doi.org/10.1016/j.injury.2020.12.010DOI Listing
June 2021

Arthroscopic labral repair with all-suture anchors: a magnetic resonance imaging retrospective study with a 2.5-year follow-up.

Med Glas (Zenica) 2021 02;18(1):192-195

Section of Orthopaedics and Traumatology, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.

Aim To evaluate radiological and clinical outcomes of a case series of patients affected by glenohumeral instability (Bankart lesion) or superior labrum tear from anterior to posterior (SLAP) lesions treated by arthroscopic repair using all-suture anchors. Methods Patients were operated by a single surgeon at a single Institution. Exclusion criteria were chondral lesions of the glenoid, rotator cuff lesions, previous surgery at the index shoulder, or a bony Bankart lesion. Position and numbers of anchors used depended on the dimension and type of lesion. The DASH (Disability of the Arm, Shoulder and Hand) and Constant scores were used for subjective and clinical evaluation at follow-ups (FUs); also, at 1-year FU, MRI scan was obtained to evaluate bone reaction to the implanted devices. Results Fifty-four patients were included. A mean of 2.7 devices per patient (145 in total) were implanted. Mean FU was 30 (range 12 - 48) months. No patient reported recurrent instability, nor hardware-related complications were registered. MRI analyses showed that 119 (82%) implants did not alter surrounding bone (grade 0), 26 (18%) implants were surrounded by bone oedema (grade 1), while no bone tunnel enlargement nor a bone cyst (grade 2 or 3, respectively) were registered. Conclusion This study confirmed the efficacy and safety of a specific all-suture anchor system in the arthroscopic repair of the glenoid labrum for glenohumeral instability or a SLAP lesion. In the short- and mid-term period, these devices were associated with good clinical and radiological outcomes without clinical failures or reaction at bone-device interface.
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http://dx.doi.org/10.17392/1320-21DOI Listing
February 2021

Medial pivot vs posterior stabilized total knee arthroplasty designs: a gait analysis study.

Med Glas (Zenica) 2021 02;18(1):252-259

Section of Orthopedics and Traumatology, Department of Medicine Surgery and Neurosciences, University of Siena, Siena, Italy.

Aim To compare a medial pivot (MP) total knee arthroplasty (TKA) with posterior stabilized (PS) TKA designs from a subjective, clinical and biomechanical point of view, in a single-centre, single-surgeon, case-control non-randomized trial. Methods Sixteen patients were randomly picked up from case series into each group. Subjective outcome was assessed using the Forgotten Joint Score Questionnaire (FJSQ). Clinical evaluation included range of motion (ROM). All patients underwent gait analysis by a treadmill with force-measuring plaques and videorecording device; data were recorded for 30 seconds and included cadence, step length, stance time and walking speed. A blinded qualitative analysis of the pattern of gait was defined as biphasic or non-biphasic. Descriptive statistics for the continuous study variables and statistical significance were calculated for all parameters with independent-samples t-test and χ2 test to analyse difference in pattern of gait between groups. Results Mean FJSQ in the MP group was 91.87 (CI 95%: 88.12- 95.46) and 75.31 (CI 95%: 67.97-81.56) in the PS group (p=0.029). Mean post-operative ROM was 117° (CI 95%: 113°-122°) in the MP group and 112° (CI 95%: 108°-117°) in the PS group (p=0.14). No statistical difference was found between groups regarding all gait analysis parameters which have been recorded. Conclusion MP TKA design showed better subjective results using the FJSQ, but it did not improve significantly clinical and functional outcomes compared to PS TKA design, at a short-term follow-up.
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http://dx.doi.org/10.17392/1312-21DOI Listing
February 2021

A hollow, custom-made prosthesis combined with a vascularized flap and bone graft for skeletal reconstruction after bone tumour resection.

Surg Oncol 2021 Mar 29;36:56-60. Epub 2020 Nov 29.

Department of Plastic Surgery and Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy. Electronic address:

Purpose: While limb-sparing surgery is now possible for more than 80% of patients with bone tumours, wide resection is often required, necessitating bone reconstruction. This paper aims to present a surgical technique that combines the advantages of a hollow, titanium, custom-made prosthesis and the biological aspects of microsurgical flaps and bone graft.

Patients And Methods: From June 2016 to September 2017 at our institution, six consecutive patients with skeletal tumours underwent one-stage reconstructive surgery with concomitant implantation of a 3D-printed prosthesis.

Results: At an average follow-up of 30 months (range: 18-45), no early complications were observed, and no implant removals were needed. One patient experienced a delayed haematogenous deep infection, which healed after surgical debridement. Three patients died of their underlying disease 18, 22, and 23 months after surgery, respectively. All flaps and custom reconstructions were successful, with primary osseointegration at a mean of four months (range: 2-7). Patients' average Musculoskeletal Tumour Society score was 23.2 (range: 18-28).

Conclusion: A hollow, custom-made, titanium prosthesis filled with bone graft, used in conjunction with a microsurgical flap, may offer good osseointegration in different anatomic locations among a patient population with a high risk of infection, pseudarthrosis, and long-term mechanical complications. The surgical technique's advantages are preliminarily demonstrated. Further studies with longer follow-up periods and larger sample sizes are required to confirm our findings.
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http://dx.doi.org/10.1016/j.suronc.2020.11.014DOI Listing
March 2021

Bone metastases.

Nat Rev Dis Primers 2020 10 15;6(1):83. Epub 2020 Oct 15.

Hospital de Santa Maria and Instituto de Medicina Molecular, Faculdade de Medicina, Centro Hospitalar de Lisboa Norte, Lisbon, Portugal.

Bone is the most frequent site for metastasis for many cancers, notably for tumours originating in the breast and the prostate. Tumour cells can escape from the primary tumour site and colonize the bone microenvironment. Within the bone, these disseminated tumour cells, as well as those arising in the context of multiple myeloma, may assume a state of dormancy, remaining quiescent for years before resuming proliferation and causing overt metastasis, which causes bone destruction via activation of osteoclast-mediated osteolysis. This structural damage can lead to considerable morbidity, including pain, fractures and impaired quality of life. Although treatment of bone metastases and myeloma bone disease is rarely curative, disease control is often possible for many years through the use of systemic anticancer treatments on a background of multidisciplinary supportive care. This care should include bone-targeted agents to inhibit tumour-associated osteolysis and prevent skeletal morbidity as well as use of appropriate local treatments such as radiation therapy, orthopaedic surgery and specialist palliative care to minimize the impact of metastatic bone disease on physical functioning. In this Primer, we provide an overview of the clinical features, the pathophysiology and the specific treatment approaches to prevent and treat bone metastases from solid tumours as well as myeloma bone disease.
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http://dx.doi.org/10.1038/s41572-020-00216-3DOI Listing
October 2020

Isolated osteoblastoma of the cuboid bone: A case report and review of the literature.

Foot (Edinb) 2020 Dec 21;45:101691. Epub 2020 May 21.

Department of Orthopaedic Surgery, University of Palermo, Palermo, Italy. Electronic address:

Osteoblastoma is a relatively rare, benign, bone-forming tumor, commonly observed in the second and third decades of life. Spine and the long tubular bones are the most common sites of involvement. Osteoblastoma is infrequently seen in other sites, including the bones of hand and foot. A rare case of a 35-year-old man that presented an osteoblastoma of the cuboid bone is reported. The patient was treated with surgical resection and grafting. After the intervention, the patient recovered with no clinical and radiological evidence of recurrence after one year of follow-up. Several cases of osteoblastoma-like variant of osteosarcoma of the cuboid have been previously reported, but, to our knowledge, this is the first case of conventional and isolated osteoblastoma involving the cuboid bone reported in the literature.
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http://dx.doi.org/10.1016/j.foot.2020.101691DOI Listing
December 2020

Bone Marrow Concentrate in the Treatment of Aneurysmal Bone Cysts: A Case Series Study.

Stem Cells Int 2020 21;2020:8898145. Epub 2020 Aug 21.

Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2, Pisa 56124, Italy.

Introduction: A recent attractive option regarding mesenchymal stem cells (MSC) application is the treatment of bone cystic lesions and in particular aneurysmal bone cysts (ABC), in order to stimulate intrinsic healing. We performed a retrospective evaluation of the results obtained at our institution.

Methods: The study group consisted of 46 cases with an average follow-up of 33 months. Forty-two patients underwent percutaneous treatment as the first approach; four patients had curettage as first treatment. In all cases, autologous bone marrow concentrate (BMC) was associated too. The healing status was followed up through a plain radiograph 45 days and 2 months after the procedure. At the final follow-up, thirty-six patients healed with a Neer type II aspect, nine healed with a type I aspect, and one patient was not classified having total hip arthroplasty. Bone marrow concentrate is easy to obtain and to manipulate and can be immediately available in a clinical setting. We can assert that the use of BMC must be encouraged being harmless and having an unquestionable high osteogenic and healing potential in bone defects.
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http://dx.doi.org/10.1155/2020/8898145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456472PMC
August 2020

Re-excision after unplanned excision of soft tissue sarcomas: Long-term results.

Surg Oncol 2020 Sep 27;34:212-217. Epub 2020 Apr 27.

Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy‬. Electronic address:

Background: Unplanned excisions of soft tissue sarcomas are still not infrequent events with patients presenting to referral Centers after having received an inadequate surgical treatment. In literature, both the wait-and-see policy and the "aggressive" management with a re-excision have been advocated. The purposes of this study were to analyze the incidence of detectable residual tumor in surgical specimens following a re-excision and to verify the long-term results of patients treated with a re-excision after previous unplanned excision.

Methods: We retrospectively evaluated 131 patients affected by localized soft tissue sarcoma (95 high grade; 36 low grade) of the limbs or the superficial trunk treated at our Institution, from 2000 to 2013, with a re-excision after a previous unplanned inadequate excision. Site, size, depth, histotype, grade, adjuvant therapies, time from unplanned surgery to re-excision were recorded and evaluated in association with clinical results. We specifically evaluated the disease-specific survival, local recurrence free survival, distant metastases free survival and the event free survival.

Results: Mean follow-up for living patients was 10.9 years (median 11.2 years), with a follow-up ranging from 14 to 227 months. 34% of patients underwent a re-excision within the first 2 months after unplanned surgery, while 66% of patients at more than 2 months. Residual detectable tumor cells were found on histological examination in 54% of re-excisions. A wide margin was obtained in 123 cases, a persisting positive margin in 8 patients. Disease-specific survival was 93.5%, 91.6% and 89.6% at 5, 10 and 15 years for whole series and 90.9%, 88.2% and 85.7% for high grade tumors. Event-free survival in patients affected by high grade tumors rated 75.0% at 5 years, 72.4% at 10 years and 72.4% at 15 years. Local recurrence free survival in high grade tumors was 87.6%, 86.2% and 86.2% at 5, 10 and 15 years. The grade of the tumor (high grade) and the initial dimension of the tumor (≥5 cm) were associated with worst survival. High grade tumor impacted negatively also on local recurrence free survival and event free survival. Instead, the initial size of the tumor significantly affected the event free survival but not the local recurrence free survival. No significant differences of outcome were found analyzing tumor depth, time interval to re-excision, presence of residual tumor or margins.

Conclusion: Based on our results and literature findings, we believe that surgeons should offer a re-excision procedure in those patients presenting with an inadequate excision of a high grade soft-tissue tumor, in particular with tumors larger than 5 cm before excision. Indeed, if an adequate second treatment is performed with surgery ± radiotherapy, the long-term results of patients receiving a re-excision after unplanned excision of a high grade soft tissue sarcoma seem to be comparable to the results generally reported for wide primary excisions. More debatable is whether to perform a re-excision or not in patients with low-grade tumors. Perhaps, in this latter group a wait and see policy can eventually be offered as well as in high grade tumors when a re-excision procedure could involve major surgery or significantly affect postoperative function.
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http://dx.doi.org/10.1016/j.suronc.2020.04.026DOI Listing
September 2020

Image-guided Cryotherapy for Musculoskeletal Tumors.

Curr Med Imaging 2021 ;17(2):166-178

Department of Musculo-Skeletal Oncology, IRCCS - Istituto Ortopedico Rizzoli, Bologna, Italy.

Background: This article represents a review of the use of image-guided cryotherapy in the treatment of musculoskeletal tumor lesions. Cryotherapy is able to induce a lethal effect on cancer cells through direct and indirect mechanisms. In this manuscript, we combined our experience with that of other authors who have published on this topic in order to provide indications on when to use cryotherapy in musculoskeletal oncology.

Discussion: Image-Guided percutaneous cryotherapy is a therapeutic method now widely accepted in the treatment of patients with musculoskeletal tumors. It can be used both for palliative treatments of metastatic bone lesions and for the curative treatment of benign bone tumors, such as osteoid osteoma or osteoblastoma. In the treatment of bone metastases, cryotherapy plays a major role in alleviating or resolving disease-related pain, but it has also been demonstrated that it can have a role in local disease control. In recent years, the use of cryotherapy has also expanded for the treatment of both benign and malignant soft tissue tumors.

Conclusion: Percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. Cryotherapy can be considered the first option in benign tumor lesions, such as osteoid osteoma, and a valid alternative to radiofrequency ablation. In the treatment of painful bone metastases, it must be considered secondarily to other standard treatments (radiotherapy, bisphosphonate therapy, and chemotherapy) when they are no longer effective in controlling the disease or when they cannot be repeated (for example, radiotherapy).
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http://dx.doi.org/10.2174/1573405616666200825162712DOI Listing
January 2021

Diffuse bone and soft tissue angiomatosis with GNAQ mutation.

Pathol Int 2020 Jul 20;70(7):452-457. Epub 2020 Apr 20.

Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.

We describe a unique case of skeletal and extraskeletal angiomatosis complicated by Kasabach-Merritt syndrome. The patient was a 3-year-old boy, who presented with involvement of both femurs and left tibia, as well as with soft tissue lesions of the left thigh. At birth, multiple hemangiomas of the soft tissues of the frontal and parietal scalp had been identified, together with a space-occupying lesion of the lung. Histologically, the skeletal and soft tissue lesions consisted of a proliferation of thin-walled, dilated blood vessels, with an endothelial lining devoid of atypia and exhibiting immunoreactivity for CD31 and CD34, while podoplanin and GLUT1 were negative. Whole exome sequencing performed on samples from the lesion of the femur, the tibia and the skin of the thigh, showed a GNAQ (c.286A>T:p.T96S) variant in all specimens, that was confirmed with digital droplet PCR. This case expands the clinical and pathologic spectrum of vascular proliferations showing similar molecular biology, characterized by GNAQ, GNA11 or GNA14 mutations.
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http://dx.doi.org/10.1111/pin.12933DOI Listing
July 2020

Clinical features, prognostic factors and outcome in a series of 29 extra-skeletal Ewing Sarcoma. Adequate margins and surgery-radiotherapy association improve overall survival.

J Orthop 2020 Sep-Oct;21:236-239. Epub 2020 Mar 25.

Divisione di Ortopedia Oncologica e Ricostruttiva Azienda Ospedaliero Universitaria Careggi Firenze, Italy.

Objective: Authors review a series of 29 extra-skeletal Ewing Sarcoma (EES).

Methods: They analyzed characteristics, prognostic factors and outcome of EES.

Results: Authors report 60% Overall Survival (OS) and 56% of Event Free Survival (EFS) at 5 years. Better 5 years EFS was found in patients with localized disease (68.8%) compared to metastatic EES (33.3%) (p = 0.042). Radiotherapy + surgery offered the best local treatment (p=0.017). Volume (p = 0.032), Surgical margins (p = 0.01), metastatic disease (p = 0.0013) were a significant prognostic factor for OS at 5-yrs.

Conclusion: Adequate margins and surgery+radiotherapy improve Overall Survival.
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http://dx.doi.org/10.1016/j.jor.2020.03.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132112PMC
March 2020

One-Step Reconstruction with Custom-made 3D-printed Scapular Prosthesis After Partial or Total Scapulectomy.

Surg Technol Int 2020 May;36:341-346

Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy.

En bloc scapulectomy with covering muscles was historically considered the only procedure available for surgical treatment of bone and soft tissue tumors of the scapula. When possible, reconstruction with scapular allograft is the gold standard, and gives satisfactory functional, cosmetic, and oncological outcomes. While good results have recently been reported with 3D-printed prostheses for reconstruction of bone loss, there is little information available in the medical literature regarding scapula reconstruction with a 3D-printed prosthesis. Between 2016 and 2018, we performed four scapular resections (two total and two involving the superior 1/3) followed by reconstruction with a 3D-printed prosthesis made of a porous titanium alloy (Ti-6Al-4V, diameter between 100 and 400 mm), using computer-aided design (CAD) and patient-specific implants (PSI) with previously acquired CT-MR fusion images. At 2 years follow-up, the patients with partial scapulectomy had an MSTS score of 76%, no local or systemic recurrence, good clinical results and no pain. At 1 year 6 months follow-up, the patients with total scapulectomy had an MSTS score of 46%, no local or systemic recurrence, fair clinical results and no pain. Thus, custom-made 3D-printed prostheses appear to be valuable in orthopedic surgery. However, a larger cohort and longer-term analysis are needed to evaluate the scapular 3D-printed prosthesis as a reliable reconstruction technique.
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May 2020

Contribution of Raman Spectroscopy to Diagnosis and Grading of Chondrogenic Tumors.

Sci Rep 2020 02 7;10(1):2155. Epub 2020 Feb 7.

Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.

In the last decade, Raman Spectroscopy has demonstrated to be a label-free and non-destructive optical spectroscopy able to improve diagnostic accuracy in cancer diagnosis. This is because Raman spectroscopic measurements can reveal a deep molecular understanding of the biochemical changes in cancer tissues in comparison with non-cancer tissues. In this pilot study, we apply Raman spectroscopy imaging to the diagnosis and grading of chondrogenic tumors, including enchondroma and chondrosarcomas of increasing histologic grades. The investigation included the analysis of areas of 50×50 μm to approximately 200×200 μm, respectively. Multivariate statistical analysis, based on unsupervised (Principal Analysis Components) and supervised (Linear Discriminant Analysis) methods, differentiated between the various tumor samples, between cells and extracellular matrix, and between collagen and non-collagenous components. The results dealt out basic biochemical information on tumor progression giving the possibility to grade with certainty the malignant cartilaginous tumors under investigation. The basic processes revealed by Raman Spectroscopy are the progressive degrading of collagen type-II components, the formation of calcifications and the cell proliferation in tissues ranging from enchondroma to chondrosarcomas. This study highlights that Raman spectroscopy is particularly effective when cartilaginous tumors need to be subjected to histopathological analysis.
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http://dx.doi.org/10.1038/s41598-020-58848-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005702PMC
February 2020

Total femur prosthesis in oncological and not oncological series. Survival and failures.

J Orthop 2020 Jan-Feb;17:215-220. Epub 2019 Nov 12.

Divisione di Ortopedia Oncologica e Ricostruttiva, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy.

Total femur prosthesis (TFP) can be used in both oncological and prosthetic revision surgery. A retrospective analysis of 32 patients receiving a TFP at a single Center between 2002 and 2018 was performed. The average follow-up was 60 months. Revision implant free survival (RIFS) of the implants was 87% at 5 and 10 years and 72% at 15 years. Overall implant survival (OIS) of the prosthesis was 90% at 5, 10 and 15 years. Complications observed: two soft tissue failures, two infection failure and one tumor progression failure.
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http://dx.doi.org/10.1016/j.jor.2019.11.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928329PMC
November 2019

Carbon/PEEK nails: a case-control study of 22 cases.

Eur J Orthop Surg Traumatol 2020 May 21;30(4):643-651. Epub 2019 Dec 21.

Department of Orthopaedic and Trauma Surgery, University of Pisa, Via Paradisa, 2., 56124, Pisa, Italy.

Background: Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies.

Purposes: The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site.

Patients And Methods: In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site.

Results: The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups.

Conclusions: Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC.

Level Of Evidence: III Case-control therapeutic study.
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http://dx.doi.org/10.1007/s00590-019-02602-4DOI Listing
May 2020

Hereditary Multiple Exostoses: Current Insights.

Orthop Res Rev 2019 13;11:199-211. Epub 2019 Dec 13.

Department of Translational Research on New Surgical and Medical Technologies, University of Pisa, Pisa, Italy.

Hereditary multiple exostoses (HME), also called hereditary multiple osteochondromas, is a rare genetic disorder characterized by multiple osteochondromas that grow near the growth plates of bones such as the ribs, pelvis, vertebrae and especially long bones. The disease presents with various clinical manifestations including chronic pain syndromes, restricted range of motion, limb deformity, short stature, scoliosis and neurovascular alteration. Malignant transformation of exostosis is rarely seen. The disease has no medical treatment and surgery is only recommended in symptomatic exostoses or in cases where a malignant transformation is suspected. HME is mainly caused by mutations and functional loss of the EXT1 and EXT2 genes which encode glycosyltransferases, an enzyme family involved in heparan sulfate (HS) synthesis. However, the peculiar molecular mechanism that leads to the structural changes of the cartilage and to osteochondroma formation is still being studied. Basic science studies have recently shown new insights about altering the molecular and cellular mechanism caused by HS deficiency. Pediatricians, geneticists and orthopedic surgeons play an important role in the study and treatment of this severe pathology. Despite the recent significant advances, we still need novel insights to better specify the role of HS in signal transduction. The purpose of this review was to analyze the most relevant aspects of HME from the literature review, give readers an important tool to understand its clinical features and metabolic-pathogenetic mechanism, and to identify an effective treatment method. We focused on the aspects of the disease related to clinical management and surgical treatment in order to give up-to-date information that could be useful for following best clinical practice.
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http://dx.doi.org/10.2147/ORR.S183979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916679PMC
December 2019

Aneurysmal Bone Cyst: A Review of Management.

Surg Technol Int 2019 11;35:325-335

Department of Orthopaedic Oncology and Reconstructive Surgery Azienda Ospedaliero Universitaria Careggi, Firenze, Italy.

Aneurysmal bone cyst is a rare lesion that is most often found in young adults and children. It can have an unpredictable behavior, with a high recurrence rate after treatment. Treatment is based on personal and institutional experience and preferences. Standard treatment consists of curettage (manual + motorized high-speed burr) plus local adjuvants and bone grafting to fill the void. In anatomical locations that are difficult to reach surgically, percutaneous procedures (injection of sclerosant agents, radiofrequency thermal ablation (RFTA)) or selective arterial embolization (SAE) are used. Medical management with bisphosphonates (BPs) or denosumab has also been advocated. Minimally invasive surgical procedures such as "curopsy" and percutaneous demineralized bone matrix (DBM) and/or autologous bone marrow concentrate (BMC) grafting have also been proposed. SAE is used as a pre-operative procedure to reduce intra-operative bleeding in the case of large lesions and as primary treatment for spinal lesions. The purpose of this review is to present currently available options for the management of aneurysmal bone cyst.
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November 2019

An exceptional case of malignant glomus tumor and a review of the literature.

Acta Orthop Traumatol Turc 2019 Jul 31;53(4):313-317. Epub 2019 May 31.

Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy.

Malignant glomus tumors (MGTs) are exceptional but pose diagnostic and therapeutic challenges. Wide resection is the recommended treatment method, however, no data are available concerning adjuvant therapies. We present an exceptional case of extradigital deep-seated MGT of the forearm, with an exceptional bone infiltration. Despite being treated with wide resection, the patient had an optimal functional outcome, no functional loss, no motor or sensitive deficits and has returned to his full daily activity.
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http://dx.doi.org/10.1016/j.aott.2019.04.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739266PMC
July 2019

Leiomyosarcoma: Clinicopathological study and retrospective analysis of prognostic factors in a series of 100 patients.

J Orthop 2019 Jul-Aug;16(4):303-307. Epub 2019 Mar 25.

Divisione di Ortopedia Oncologica e Ricostruttiva Azienda Ospedaliero Universitaria Careggi Firenze, Italy.

The Authors reported a retrospective study of 100 Leiomyosarcoma (LMS), evaluating factors that may influence Overall Survival (OS), Local Recurrence Free Survival (LRFS), Metastasis Free Survival (MFS). Tumor Size (P = 0,0009), Local Recurrence (P = 0,0487), Distant relapse (P < 0,0001), Type of Presentation (P = 0,0213) were significant risk factors affecting overall survival (OS). Tumor Size (P = 0.024), age at diagnosis (P = 0,0086), type of presentation (P < 0,0001) and Local Recurrence (P = 0.0152) affected metastasis free survival (MFS). Type of presentation (P = 0,001) was an independent prognostic factor of local recurrence-free survival (LRFS).
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http://dx.doi.org/10.1016/j.jor.2019.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441716PMC
March 2019
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