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Total sacrectomy via posterior approach for malignant sacral tumors

Wei SUN ; Quanchi CHEN ; Xiaojun MA ; Yingqi HUA ; Zhengdong CAI

Chinese Journal of Orthopaedics.2014;34(11):1097-1102. doi:10.3760/cma.j.issn.0253-2352.2014.11.003

Objective To investigate the surgical indication,approach,resection methods and complications of total sacrectomy via posterior approach for primary malignant sacral tumors involving high level (S1,S2).Methods 5 cases of primary malignant sacral tumors treated by total sacrectomy via posterior approach and iliolumbar reconstruction from March 2010 to March 2011 were analyzed retrospectively.There were 3 males and 2 females.The mean age was 41,ranging from 32 to 55.The imageology examination showed osteolytic destruction,among which there were 4 cases of obvious soft tissue mass,1 case of obvious sacral foramina expansion with bone damage.MRI showed 1 case of the tumors in S1-S5,1 case of the tumors in S1 、S2,1 case of the tumors in S1-S3.The smallest tumor was 9.2 cm×7.6 cm×4.1 cm,while the largest was 22.0 cm× 19.0 cm× 16.0 cm.Preoperative TTNB were done on the 5 patients.Pathological diagnosis:2 cases of chordoma,1 case of malignant neurilemmoma,1 case of chondrosarcoma and 1 case of malignant hemangioendothelioma.5 patients had sacrococcygeal pain or lumbocrural pain before the surgery.Visual analogue scale (VAS):2 cases of 2,2 cases of 6 and 1 case of 8.Ilium stability reconstructions were all performed on 5 patients with spine pedicle screw-rod system.Results The mean operation time was 6.5 hours (range,4.5-11 hours),with the mean intraoperative blood loss of 3 700 ml (range,2 000-7 200 ml).There was no perioperative death.The mean follow-up time was 17 months (range,9-23 months).There were 2 cases of wound complications 2 weeks after surgery and healed by second intention with washing and drainage after debridement.There was no deep infection.1 case of rectal injury,which was performed with colostomy during the operation,and stoma returned 12 weeks after surgery.4 cases of sciatic nerve symptom of lower limbs and plantar flexion dyskinesia after bilateral S1 nerve roots resection.The patients walked with ankle brace fixed after the surgery.There was 1 case of implant breakage and no obvious spine down.5 patients had functional disability in sphincter after surgery.1 case of hemangioendothelioma recurred locally 9 months later.Local radiotherapy was performed since there was no reoperation indication.The patient is currently on the 13th month follow-up and survives with tumors.Compared with combined approach,the selection of posterior approach alone has relatively strict surgery indications.Conclusion Total sacrectomy via posterior approach is an effective way to treat the primary high-level malignant sacral tumors.The good surgical resection boundary is important to achieve the good oncology prognosis.The occurrence rate of postoperative complication is high,which has great influence on patients' postoperative neurological function.

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Surgical technique and clinical efficacy of giant cell tumor of axis

Guojing CHEN ; Zheng GUO ; Zhen WANG ; Xiangdong LI ; Jing LI ; Hongbin FAN

Chinese Journal of Orthopaedics.2014;34(11):1103-1109. doi:10.3760/cma.j.issn.0253-2352.2014.11.004

Objective To evaluate the prognostic effects of treatment of giant cell tumor of axis by tumor resection associated with biological reconstruction and internal fixation.Methods From 2009 to 2013,5 patients that had giant cell tumor of axis underwent combined anterior and posterior surgery program.The posterior use pedicle screw system to stabilize the cervical spine,then the anterior use stemocleidomastoid inner edge of the mandibular angle approach to reveal the axis.When the cortex of vertebrae was relatively complete,.When the cortical bone was destroyed,vertebra was resected and the ilium was taken to reconstruct the defect.Adjuvant radiotherapy and diphosphate treatment was used postoperatively.Regular follow-up for X-ray,3D CT and MRI examination were done to observe the tumor recurrence,healing of biological reconstruction and function of cervical vertebra.Results The follow-up time was 12-60 months.No recurrence of the tumor was observed in all patients.The 3 patients accepted beta-TCP implanting after curettage was observed with fuzzy internal structure 3 months after surgery,and the grafted bone fusion can be found 12 months after surgery.The 2 ilium grafted patients can be found with bone fusion with the adjacent vertebrae 6 months after surgery.The bend and stretch function of cervical vertebrae of the 5 patients returned to normal after 3months.The biological healing of bone graft,cervical stability and activity were satisfied.The local pain and neurological symptoms were relieved.Conclusion Anterior and posterior surgery program in combination with biological reconstruction and adjuvant radiotherapy provide an excellent option for treatment of giant cell tumor of axis.The dens could be retained to keep the function of occipital cervical when the odontoid bone cortex is not destructed.

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Comparison of anteromedial portal technique and accessory anteromedial portal technique for femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction

Yuanhuan QIU ; Yun ZHOU ; Hao LYU ; Juehua JING

Chinese Journal of Orthopaedics.2015;35(1):48-54. doi:10.3760/cma.j.issn.0253-2352.2015.01.008

Objective To compare the primary clinical results of the anteromedial portal (AMP) and accessory anteromedial portal (AAMP) techniques for femoral tunnel drilling in single-bundle anterior cruciate ligament (ACL) reconstruction.Methods Data of isolated ACL rupture patients who had undergone single-bundle ACL reconstruction with autologous semitendinosus and gracilis tendons from March of 2012 to February of 2014 were retrospectively analyzed.The femoral tunnels were drilled with AMP techniques in 14 patients (group AMP) and with AAMP techniques in 23 patients (group AAMP).All the patients were followed up for 6 to 29 months.At the latest follow-up the Lysholm,Tegner and international knee documentation committee (IKDC) scores were used to estimate knee joint function,while the Lachman test and Pivot-shift test were used to estimate knee joint instability.Results The average follow-up time was 16.07±7.31 months in group AMP and 13.35±5.92 months in group AAMP.In group AMP,the Lysholm,Tegner and IKDC average scores were 89.86±7.90,8.64±1.65 and 89.31±8.16,respectively.While they were 92.17±6.72,8.91±1.16 and 90.89±7.80 in group AAMP,respectively.In group AMP the Lachman test was negative in 11 patients and positive in 3 patients.In group AAMP the Lachman test was negative in 20 patients and positive in 3 patients.The Pivotshift test was negative in 9 patients,positive in 5 patients and negative in 20 patients,positive in 3 patients in group AMP and AAMP,respectively.There were no significant differences in Lysholm,Tegner,IKDC scores,the negative rates of Lachman and Pivot-shift tests between two groups.Conclusion Single-bundle ACL reconstructions using AMP and AAMP techniques for femoral tunnel drilling have similar excellent primary clinical results.

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Preliminary results of treatment of complex hip dysplasia with combined periacetabular and intertrochanteric osteotomies

Yimin CUI ; Xiaodong CHEN ; Junfeng ZHU ; Chao SHEN ; Guiquan CAI

Chinese Journal of Orthopaedics.2015;35(3):212-217. doi:10.3760/cma.j.issn.0253-2352.2015.03.002

Objective To detect the preliminary results of combined periacetabular and intertrochanteric osteotomies for complex hip dysplasia.Methods From January 2006 to August 2011,23 patients (25 hips) with complex hip dysplasia were treated with combined periacetabular and intertrochanteric osteotomies (ITO).Valgus ITO was performed on 2 hips and varus ITO on others.The averagc age of patients at the time of index procedure was 20.5± 3.9 years (range:15 to 26).The hip pain period before surgery varied from 5 to 24 months (mean 11±4.7 months).The Shenton's line was broken in every hip and the mean preoperative lateral central edge angle (LCEA) was 5.6°±4.6°.The average preoperative fenoral neck-shaft (CCD) angles were 158°±3.2° and 110° in 23 valgus hips and both of two varus hips respectively.The preoperative Harris hip score was 76.7±3.7.According to T(o)nnis osteoarthritis grades,there were 7 hips at grade 0,12 hips at grade Ⅰ and 6 hips at grade Ⅱ.Results The mean followup period was 40±18 months (range:12 to 78).The CCD angle (130°±2.1°),LCEA (28.6°±2.9°) and Harris hip score (90.8±3.3)were all improved postoperatively,whereas no progression was found in preoperative T(o)nnis grades.The postoperative Harris hip scores were excellent in 17 hips and good in 8 hips.The T(o)nnis osteoarthritis grades were grade 0 in 6 hips,grade Ⅰ in 11 hips and grade Ⅱ in 8 hips.There wcre six cases with lateral femoral cutaneous nerve injury,three cases with limp and two cases with broken Shenton's line.Neither femoral head necrosis nor bone nonunion was found in this study.Conclusion Satisfactory preliminary results could be obtained through combined periacetabular and intertrochanteric osteotomies among patients with complex hip dysplasia.The risk of femoral head necrosis and bone nonunion was low.

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Outcome of surgical treatment for pelvic chondrosarcoma of 165 cases

Wei GUO ; Tao JI ; Yi YANG ; Xiaodong TANG

Chinese Journal of Orthopaedics.2014;34(11):1079-1087. doi:10.3760/cma.j.issn.0253-2352.2014.11.001

Objective To review the long-term oncologic and functional outcomes of surgical treatment for pelvic chondrosarcoma at a single institution to further delineate surgical strategy of resection and function reconstruction.Methods All of 165 patients with pelvic chondrosarcoma that had been surgically treated between July 2000 and Dec 2013 were reviewed retrospectively.There were 102 male and 63 female patients who had a mean age of 43.5 (range,13 to 75) years.The resection type included Type T 16,type Ⅱ 18,type Ⅲ 11,type Ⅰ+Ⅱ 19,type Ⅱ+Ⅲ 63,type Ⅰ+Ⅳ 15,type Ⅰ+Ⅱ+Ⅲ 10 and type Ⅰ+Ⅱ+Ⅳ 13 cases.The pathology diagnosis was grade Ⅰ in 15,grade Ⅱ in 88,grade Ⅲ in 20,dedifferentiated in 28,mesenchymal in 12 and clear cell chondrosarcoma in 2 patients.Nine cases were secondary lesion following multiple exostoses.114 patients received no previous treatment while others were referred due to recurrent tumor.En bloc resection was achieved in 142 patients and intralesional resection in 23 cases.Twelve patients had a hemipelvectomy to achieve local tumor control,whereas 153 patients underwent a limb-salvage procedure.Spinal screw-rod system was used to reconstruct anterior pelvic ring after ilium resection.Modular hemipelvic endoprosthesis was utilized to reconstruct periacetabular defect after tumor resection while no reconstruction was performed after ischium and pubis resection.Results The median duration of follow-up was 54.1 (range,l0 to 159) months.147 (89.1％) patients were alive at the final follow-up,seven of which were alive with tumor.The estimated 5-year survival was 81.5％.Thirty-three patients (20％) had local recurrence,and twenty (12.1％) had lung metastasis.Recurrent case,sacroiliac joint involvement and intralesional resction were three risk factors for postoperative recurrence.Patients who received type Ⅱ+Ⅲ resection and reconstruction had a mean functional score of 23 according to MSTS 93.The mean MSTS 93 for patients with type Ⅰ+Ⅱ and type Ⅰ+Ⅱ+Ⅳ resection and reconstruction was 18.The wound complication rate was 15.8％.Two aseptic loosening and 2 pubic connection plate breakage were observed in hemipelvic endoprosthesis reconstruction.Conclusion Tumor grade correlates with overall or disease-free survival.For low-grade chondrosarcoma,adequate surgical margin can provide long-term local control while for high-grade cases,distant metastasis is the main case of treatment failure.Adequate surgical margin can be achieved in cases with acetabulum involved.However,aggressive surgical resection of pelvic chondrosarcoma still remains as a challenge for orthopaedic oncologists when the tumor invades the iliosacral joint,which necessitates careful preoperative plan and skilled surgical techniques.

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Surgical outcome for occipitocervical intradural extramedullary tumors

Hua JIANG ; Zengming XIAO ; Xinli ZHAN ; Shide LI ; Qianfen CHEN ; Maolin HE

Chinese Journal of Orthopaedics.2014;34(11):1119-1126. doi:10.3760/cma.j.issn.0253-2352.2014.11.006

Objective To investigate the surgical strategy and outcome for occipitocervical extramedullary tumors.Methods 15 patients with occipitocervical extramedullary tumors from January 2007 to July 2010 were reviewed retrospectively.There were 7 males and 8 females with an mean age of 44.6 years (range,21-72 years).All cases were intradural tumors,including 7 cases in dorsolateral,5 cases in lateral side,and 3 cases in ventralis of spinal cord.Functional and neurological statuses were assessed using the Frankel grade and Japanese Orthopaedic Association (JOA) scale.According to Frankel grade system,there were 4 patients with Grade C,8 with Grade D,and 3 with Grade E.The mean preoperative JOA score was 10.5±3.6.Based on the tumor site,there were 5 cases in medulla oblongata-C1 and 10 cases in C1,2.Frankel grade and JOA score were used to evaluate neurological status and general health.The improvement of symptoms and characteristics of surgical strategies were analyzed.Results All cases were followed up for 2-4 years (mean 2.8 years).Complete resection of tumor and good fusion of bone graft were found in radiography postoperatively.The pathological diagnoses included 10 cases of schwannoma,3 cases of meningioma and 2 cases of neurofibroma.There was statistical difference between the preoperative and the final follow-up functional and neurological statuses including Frankel grade and JOA score.At the latest follow-up,2 cases improved from Frankel grade C to D,2from C to E,6 from D to E,but none in 2 cases with grade D.The mean JOA score at final follow-up was 15.6±1.6,and the average improvement rate was 80.7％± 17.4％.The mean preoperative C0-2 angle was 27.0°±4.1 °,and C2-7 angle was 16.8°± 12.7°.C0-2 angle was 27.6°±8.8°,and C2-7 angle was 10.2°±6.8° at the latest follow-up.However,these differences did not reach statistical significance.Conclusion Surgical treatment can effectively maintain or improve neurological function and improve quality of life.Extramedullary tumors can be resected completely by posterior approach,and spinal stabilization can be obtained satisfactorily through selecting appropriate surgical strategies.For medulla oblongata-C1 level,occipitocervical fusion is usually chosen after extirpation of tumor.For C 1,2 level,C1,2 fusion after tumor resection is useful in preventing atlantoaxial instability.

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Survival analysis of 121 patients with spinal metastases accepted spinal surgery

Xiuxin HAN ; Guowen WANG ; Chao ZHANG ; Jian DUO ; Zhichao LIAO

Chinese Journal of Orthopaedics.2014;34(11):1127-1133. doi:10.3760/cma.j.issn.0253-2352.2014.11.007

Objective To investigate the safety and efficacy of surgery in 121 patients with spinal metastases.Methotds A retrospective analysis of clinical data from April 2009 to March 2013 was performed in 121 patients with spinal metastases.From 37 to 65 years,69 males and 42 females with mean age of 55.6 years.Primary tumor origin:Lung 35(28.9％),Breast 26(21.4％),Renal 17 (14.0％),Prostate 20 (16.5％),Thyroid 14 (11.6％),Liver 2 (1.7％),Colon 1 (0.8％),other 6 (5.0％).All patients received surgery.Follow-up and survival time were analyzed.In preoperation and postoperative 3 month,pain levels were assessed by visual analogue scale (VAS),neurologic deficit was evaluated by Frankel Grade and functional impairment was classified by Karnofsky Score.The quality of the life was assessed by EORTC QLQ-C30 questionnaire.Survival analysis was evaluated by Kaplan-meier.Results The period of follow-up ranged from 5 to 35 months with the average of 15.9 months.The mean survival was 14.5 months.1-year survival was 53.5％.2-year survival was 36.5％.In patients with lung cancer,the mean survival was 8.5months.1-year survival was 14.3％.2-year survival was 11.4％.In patients with breast cancer,the mean survival was 31 months.1-year survival was 57.7％.2-year survival was 46.2％.In preoperation and postoperative 3 month,the VAS showed statistical significance (t=21.6,P＜0.01) ;Post-operatively,80.3％ of all patients had functionally useful Frankel Grade D or E compared with 43.5％ pre-operatively.KPS score (80-100) percentage was 75.6％ postoperatively compared with 33.4％ preoperatively.In 1month postoperatively,35 of 75 patients who were sphincteric dysfunction preoperatively were improved.The EORTC QLQ-C30score was 83.39±7.23 in preoperation and 51.34±14.27 in postoperaion.The quality of life was impoved significantly (t=12.6,P＜0.01).Conclusion Surgical treatment was effective in improving quality of life by providing better pain control,enabling patients to regain or maintain mobility,and offering improved sphincter control.In all patients,the number of patents with spinal metastases from breast and lung cancer is higher.Compared with spinal metastases from breast cancer,the proportion of lung cancer origin received surgery is higher.

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Evaluation of clinical effects on biological reconstruction for large femoral diaphyseal defect after primary bone sarcoma en-bloc resection

Taiqiang YAN ; Wei GUO ; Rongli YANG ; Sen DONG ; Yi YANG ; Tao JI

Chinese Journal of Orthopaedics.2014;34(11):1134-1144. doi:10.3760/cma.j.issn.0253-2352.2014.11.008

Objective To evaluate the clinical and functional outcome of biological reconstruction by using pasteurized autograft and massive allograft after en-bloc resection of primary femoral diaphyseal sarcomas.Methods Retrospectively reviewed 19 consecutive patients with primary femoral diaphyseal sarcomas between Feb.2005 and Dec.2013.There were 11 males and 8 females with the mean age of 18 (2-38) years old.Thirteen patients were diagnosed as osteogenic sarcoma (OS),while five Ewing' s sarcoma (EWS) and one malignant fibrous histocytoma (MFH).All patients were treated with wide local excision,and 9patients were reconstructed by intercalary femur segmental allograft and 10 by pasteurized autograft.The median length of the resected bone was 16.9 (9-24) cm.15 segmental grafts were fixed by using plates including 10 intramedullary free vascularised fibular graft constructs,the other 4 segmental grafts were fixed by intramedullary nails.The average operation time for pasteurized autograft construct was 5.1 hours,while the time for intercalary allograft construct was 4.22 hours.Of 38 host-donor junctions,there are 28 diaphyseal junctions and 10 metaphyseal junctions.Results The average operation time for pausterized autograft construct tended to be longer than intercalary allograft (5.1h Vs 4.22h),although the difference did not reach the significance.Bone union occurred at a median of 10.3 months and 7.25 months at diaphyseal and metaphyseal junction for pasteurized autograft-host construct; 13.8 months at the diapyhseal junction and 11.5 months at the metaphyseal junction for allograft-host construct.Bone healing time of diaphyseal junction and metaphyseal junction between these two constructs were significant difference.Eight of 19patients (42.1％) developed complications:5 bone unnunion/fracture (including 1 subsequently developed local recurrence),1deep infection and 2 local recurrence (including 1 soft tissue recurrence).The mean overall follow-up was 33.5 months (3-107),five patients died of lung metastases,the cumulative patient survival was 76.5％ at 2 years and 61.2％ at 5 years determined by Kaplan-Meier method.All living patients except the MFH patients who received amputation,had a mean MSTS score of 83.7％ (70％-95％).Conclusion Although the reconstructive procedure with pasteurized autograft is more complicated and needs longer operation time than allograft reconstruction,the bone healing time with autograft is significant shorter than allograft.Our observations suggest the pausterized autograft shell with intramedullary free fibular graft is strongly recommeded.

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Preliminary study of sternal tumor resection and reconstruction with titanium mesh

Yan ZHANG ; Jiazhen LI ; Yingjie HAO ; Xinchang LU ; Hailong SHI ; Yuan LIU ; Pengfei ZHANG

Chinese Journal of Orthopaedics.2014;34(11):1145-1150. doi:10.3760/cma.j.issn.0253-2352.2014.11.009

Objective To explore the clinical efficacy and complications of the surgical treatment of sternal tumor resection and titanium mesh reconstruction.Methods From 2008 January to 2012 June,there were 8 cases of sternal tumor patients in our hospital,including 5 male and 3 female,with an average age of 50.4 (37-66) years old.The histological morphology included 2 cases of chondrosarcoma,1 case of osteosarcoma,2 cases of malignant fibrous histiocytoma,eosinophilic granuloma in 1 case,and 2 cases of sternal metastasis of breast cancer.Tumor invasion sites included the sternal manubrium in 3 cases,the body in 2 cases,and both in 3 cases.All patients had undergone preoperative puncture or incision biopsy.8 cases of sternal tumor patients were treated with sternal tumor resection and reconstruction of the thorax using titanium mesh.The clinical effect and complications were retrospectively analyzed.Results All patients were followed up for 9 months to 4 years.The operations went well in all cases,with no intraoperative crisis or operative death.Deep wound hematoma occurred in 1 patient 1 week postoperatively,who healed 2 weeks after drainage and debridement.There was no abnormal breathing,subcutaneous emphysema,pneumothorax,infection or other complications in other cases.1 case of malignant fibrous histiocytoma died of lung metastasis at 9 months follow-up,and 1 died of liver metastasis at 14 months,while other patients got no tumor recurrence,with good thoracic shape,free breathing,no titanium mesh loosening,dyspnea,chest tightness,pain,or abnormal respiratory discomfort during follow-up period.The chest radiograph showed no chest deformity,no loosening or fracture of the fixation device.Conclusion Sternal tumor resection and reconstruction with titanium mesh has the advantages of good shaping effect,fewer complications,and simple operation,showing that titanium mesh is an ideal material for the reconstruction of sternum.

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Imaging diagnosis of bone tumor and tumor-like lesion in the talus

Tao PAN ; Linsen WANG ; Yongcheng HU ; Shuli WANG ; Yeda WAN

Chinese Journal of Orthopaedics.2014;34(11):1151-1160. doi:10.3760/cma.j.issn.0253-2352.2014.11.010

Objective To research the variety and the imaging features of bone tumor and tumor-like lesions in the talus.Methods The imaging features of 33 cases of tumor and tumor-like lesions in the talus were reviewed retrospectively.All cases were confirmed by operation and pathology,All of 33 cases were performed X-ray examination,23 cases were examined by CT,and 11 cases were taken by MR.Results In 33 cases,24 cases were males,9 cases were females; including 7 cases of chondroblastoma(21.2％),7 cases of giant cell tumor(21.2％)(1 case of recurrence),6 cases of osteochondroma(18.2％),2 cases of osteoid osteoma(6.1％),7 cases of adjacent joint bone cyst(21.2％,2 cases of fibrous dysplasia of bone(6.1％),1 case of bone cyst(3％),1 case of malignant fibrous histiocytoma(MFH) of bone(3％).6 cases showed pathological fractures.The X-ray and CT imaging features of chondroblastoma,giant cell tumor,adjacent joint bone cyst,fibrous dysplasia of bone,bone cyst demonstrated cystic bony destruction.The common location of chondroblastoma were the posterior of talus(57％),expanding growth slightly,margin were mild osteosclerosis.The margin were osteosclerosis irregularly and osteal ridges showed in giant cell tumor.MRI features were different on pathologic basis,isointense and hypointense signal on T1WI and hyperintense signal on T2WI usually.The osteochondroma showed osseous protuberance connecting the talus,some cases showed calcification in the cap.The imaging of MFH in the talus X-ray and CT showed ill-defined osteolytic bony destruction,soft tissue-mass,no periosteal reactions and bone formation.MRI showed isointense and hypointense signal on T1WI and isointense and hyperintense signal on T2WI.The extent of tumour invasion clearly displayed.Conclusion Tumor and tumor-like lesion in the talus were rare.But there are great varieties.The benign tumor was more common than malignant tumor.Chondroblastoma,giant cell tumor,osteochondroma,osteoid osteoma and adjacent joint bone cyst were relatively common and had some imaging features.Malignant tumor rarely happened in the talus,but it is possible.

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