Limb salvage in proximal humerus malignant tumors: the place of free vascularized fibular graft

Limb-salvage surgery has become a safe and well-established alternative to amputations for malignant tumors of the proximal humerus. The authors describe six cases with favorable restoration of the upper limb following tumor resection type IB Malawer and proximal humeral reconstruction by vascularized fibula graft (VFG) as a primary or secondary procedure. A scapulofibular arthrodesis was elected in all cases. A special custom-made plate was used in four cases. One patient required a latissimus dorsi musculocutaneous flap for better coverage. Serial x-rays assessed the bone union. Neither flap necrosis nor sepsis phenomena were noted. Stress fracture was the only complication. This was encountered in two cases. Every patient was reviewed and assessed by the Enneking score. The average score was 21.8. The average follow-up was 5-years. A good quality of life was preserved due to reliable mobility of the elbow and the hand.     

Pedicle screw system reconstruction in shoulder resection type IV-total scapulectomy: A case report and short term follow up

IntroductionShoulder resection remains a challenging procedure after scapulectomy for tumour resection. The results have various functional outcome, wound coverage, and cosmetic aspect. In this case report, we reported the outcome of pedicle screw application after scapulectomy procedure within 1 month follow up after surgical tumour excision.Case presentationA 74-year-old female presented with a painful lump on the left shoulder since nine months before admission. We performed physical examination, radiological evaluation using x-ray and MRI. We performed limb salvage surgery with shoulder girdle resection of tumour procedure using Malawer technique type IVB and applied pedicle and screw in proximal end clavicula and proximal end of humerus. We performed histopathological examination to ensure the tumour. We evaluated the patient one month after surgery using DASH score.DiscussionMRI examination revealed that there was a solid mass with malignant characteristic destructing left scapular bone with the acromioclavicular and glenohumeral joint involvement. We used pedicle and screw to reconstruct the patient with efficient cost spending consideration. Clinical valuation showed there was no pain left and hand-free movement except the limitation of shoulder abduction. DASH score evaluation pre operative and post operative showed improvement from 70.8 to 45.0.ConclusionLimb salvage procedure using pedicle screw system may be one of treatment of choice for treating tumour of the shoulder affecting glenohumeral joint with excellent result of evaluation both clinical and functional outcome.     

Concomitant subclavian and carotid artery disease: the need for a combined surgical correction.

To determine the importance of carotid artery disease in patients undergoing revascularization of the proximal subclavian artery for a subclavian steal syndrome, an 18-year experience of 55 patients was reviewed. Concomitant carotid artery disease (> 50% stenosis) was present in 35 patients (Group I: 63.6%). Twenty patients (Group II: 36.4%) had no evidence of hemodynamically significant carotid disease. Twenty-five patients in Group I (Group IA: 71.4%) were treated by endarterectomy (CEA) for all their carotid lesions while one or both carotid lesions were left untreated in 10 patients (Group IB: 28.6%). The actuarial 5-year freedom rate from neurological events was 87.2% in Group IA, 34.9% in Group IB (p < 0.001) and 100% in Group II (Group IB vs. II, p < 0.001; Group IA vs. Group II, p = ns). All untreated carotid lesions had a deleterious effect on the early and late functional results after surgical reconstruction of the subclavian artery. We conclude that the combined correction of subclavian and carotid lesions should be recommended in every case.     

肩胛带区骨肿瘤的保肢治疗

目的探讨肩胛带区骨肿瘤的保肢手术方法及相关的临床效果。方法35例肩胛带骨肿瘤患者,男24例,女11例,平均年龄34岁(12～74岁)。肿瘤部位:肱骨上段21例,肩胛骨12例,锁骨2例;肿瘤类型:骨肉瘤10例,软骨肉瘤7例,恶性纤维组织细胞瘤3例,尤文肉瘤3例,纤维肉瘤1例,骨髓瘤1例,骨巨细胞瘤7例,转移瘤3例。按照Malawer等提出的手术分类方法进行分类。保肢手术方法:肿瘤假体置换8例,瘤段骨灭活回植4例,异体骨关节移植3例,自体腓骨移植2例,髓针骨水泥假体置换1例,Tikhoff-Linberg手术3例,瘤段肢体切除、上肢短缩再植2例,全肩胛骨或关节盂切除、肱骨头悬吊4例,部分肩胛骨切除6例,锁骨瘤段切除2例,其中16例作了化疗。结果本组患者平均随访71个月(6～186个月),局部复发4例,远处转移6例,死亡9例,无瘤存活22例。按MSTS上肢功能评分标准,35例患者上肢功能评分平均为77%(40%～100%),上肢功能与手术切除范围密切相关。并发症:切口感染裂开4例,移植骨骨折2例,暂时性桡神经麻痹2例,肩关节半脱位3例。结论肩胛带区骨肿瘤的治疗应根据患者情况、肿瘤类型及侵袭范围等因素决定切除范围并选择应用肿瘤假体置换、自体或异体骨关节移植、瘤段骨骨灭活回植及Tikhoff-Linberg手术等重建方法,可以达到控制肿瘤、稳定无痛的肩关节重建和保留良好的肘部与手部功能的目的。     

Impact of elastic staining on the staging of peripheral lung cancers

Accurate staging of lung cancer has a profound impact on patient management. For stage I nonsmall cell lung carcinomas (NSCLCs), the absence (stage IA) or presence (stage IB) of visceral pleural invasion represents a critical therapeutic branch point: patients with stage IB NSCLC benefit from adjuvant chemotherapy, whereas patients with stage IA NSCLC do not. Elastic staining has been advocated as a simple method for visualizing pleural invasion. The purpose of this study was to determine whether routine elastic staining of the resected peripheral NSCLCs alters tumor staging in a meaningful way. The study cases consisted of 100 consecutive peripheral NSCLCs resections that were pathologically staged as IA based on routine histologic assessment. Each case was stained with the Movats pentachrome elastic stain to aid identification of visceral pleural invasion. To assess current standards of surgical pathology practice, members of the American Association of Directors of Anatomic and Surgical Pathology were asked whether they never, sometimes, or always order elastic stains for peripheral NSCLCs that abut the pleura. Elastic staining resulted in a change of tumor stage from IA to IB in 19 (19%) cases. Of the 49 pathologists that responded to the survey, 25 (51%) never, 14 (29%) sometimes, and 10 (20%) always order an elastic stain for NSCLCs abutting the pleura. Elastic staining is currently not standard surgical pathology practice for the evaluation of peripheral NSCLCs, but it should be. Invasion of the pleura is an elusive finding that is best appreciated with an elastic stain. Our experience suggests that routine elastic tissue staining should be performed as a standard method of assessing pleural involvement for pleural-based nonsmall cell lung carcinomas.     

Allograft reconstructions of the shoulder after bone tumor resections

Large skeletal defects resulting from tumor resections about the shoulder create reconstructive challenges for the orthopedic surgeon. Bone allografts offer several advantages compared with other reconstructive techniques, and functional outcomes are generally satisfactory. They may be used either as osteoarticular grafts, intercalated segments to create an arthrodesis, or in combination with standard proximal humerus metallic implants. Patient expectations and specific oncologic factors must be considered when selecting the optimal method of reconstruction.     

Functional outcomes and complications of reconstruction of the proximal humerus after intra‐articular tumor resection

Objective: To evaluate functional outcomes and complications of reconstruction of the proximal humerus after intra‐articular tumor resection. Methods: Twenty‐five patients who underwent Malawer I type resection and reconstruction of the proximal humerus for treatment of malignant or invasive benign tumors from August 1999 to August 2005 were evaluated. A variety of reconstructive procedures, including modular tumor prosthesis, osteoarticular allograft, and allograft‐prosthetic composite (APC), were performed after resection of tumor. Oncological and radiographic parameters were evaluated. The modified Musculoskeletal Tumor Society (MSTS) evaluation system was used to assess limb functional outcome. Results: The study group consisted of 10 male and 15 female patients, among which there were 20 malignant and 5 benign tumors. Restoration of shoulder function was achieved with a prosthesis in 6 patients, osteoarticular allograft in 12, and allograft‐prosthesis composite in 7. At a mean of 48 months follow‐up, 2 patients had died of disease. Two patients had local recurrence and 2 had metastatic disease. On the basis of the modified MSTS functional evaluation, the mean scores were 22.50 in the modular prosthesis group, 24.58 in the osteoarticular allograft group, and 27.00 in APC group, respectively. Joint instability and subluxation were serious complications affecting shoulder function in 10 patients. Conclusion: Reconstruction of the proximal humerus is an option that provides good relief of pain and preserves manual dexterity. Functional outcomes are better for APC and allograft than for modular prosthesis, due to retention of the rotation cuff. Complications in the APC group were less than in the allograft one.     

Cholangiographic spectrum of intraductal papillary mucinous neoplasm of the bile ducts

OBJECTIVE: To propose a cholangiographic classification for intraductal growth type intrahepatic cholangiocarcinoma (IG-ICC) and its precursor, collectively termed intraductal papillary mucinous neoplasm of the bile ducts (IPMN-B). SUMMARY BACKGROUND DATA: For the extensive clinicopathologic variations of IPMN-B, a detailed characterization of cholangiography for IPMN-B is beneficial for determining the optimal therapeutic strategy. METHODS: A total of 124 patients with cholangiography-available and pathologically proven IPMN-B were retrospectively studied. Numbers of IPMN-B type 1, type 2, type 3, and type 4 were 33, 17, 15, and 59, respectively. A cholangiographic classification was proposed based on the presence of hepatolithiasis, mucobilia, neoplasia localization, and concomitant malignancies. The demographics, histologic grading, management, and survival were also analyzed. RESULTS: All 33 IPMN-B type 1 and 12 of 17 IPMN-B type 2 displayed cholangiographic pattern IA demonstrating hepatolithiasis-related biliary stricture. The remaining 5 IPMN-B type 2 displayed cholangiographic pattern IB or IC, which demonstrated mucobilia without discernible neoplasia. Seven of 15 IPMN-B type 3 and 52 of the 59 IPMN-B type 4 displayed cholangiographic pattern IIA or IIB, which demonstrated overt intraductal neoplasia. Seven IPMN-B type 3 or 4 displayed cholangiographic pattern IIIA or IIIB, which demonstrated IPMN-B and concomitant malignancies. For those presenting with cholangiographic pattern IA, IC, IIA, IIB, and IIIA, straightforward hepatectomies for the diseased lobes were performed. For those with pattern IB, surgical resections were performed only when there was emergence of mucin-producing neoplasia. For those with IIIB, the concomitant malignancies were considered inoperable. No disease-related death occurred in IPMN-B type 1and 2. The mean survival rates of IPMN-B type 3 and type 4 were 55.5 +/- 17.1 months and 36.9 +/- 6.3 months, respectively. CONCLUSION: The presented cholangiographic classification facilitates the management for IPMN-B. Significant survival discrepancy at the various stages warrants a more aggressive surgical strategy.     

The reversed Delta shoulder prosthesis in reconstruction of the proximal humerus after tumour resection

The authors present two series of six and seven patients respectively, with a tumour of the proximal humerus, who were treated at two different institutions with a Delta type inverted shoulder prosthesis (DePuy International Ltd) after a Malawer type Ia or Ib resection. The rationale of using an inverted shoulder prosthesis is the aim to improve the functional outcome in rotator cuff deficient shoulders. This type of prosthesis medializes and lowers the centre of rotation, lengthens the lever arm of the deltoid muscle and improves its function. At one institution the resected part of the humerus was re-implanted after extracorporeal irradiation. It was fixed intramedullarly by cementation of the humeral prosthetic component to facilitate restoration of humeral height. This graft allowed reinsertion of muscles (deltoid, pectoralis, biceps) thus improving power generation postoperatively. The largest glenosphere, size 42, was routinely used to reconstruct the glenoid; this theoretically improves the functional outcome (increased external rotation) and stability. At the other institution no graft augmentation was used except in one patient. The height of the humeral prosthetic component was assessed after resection of the tumour by measurement of the resected part. The prosthetic stem was fitted in the remaining part of the humeral diaphysis, in three cases by cementation and in three cases by press-fit (hydroxyapatite coating). Muscle balance was appreciated intra-operatively. Stability of the prosthesis was directly related to the level of resection. Both techniques resulted in a minimum active abduction of 60 degrees, reaching 90 degrees or more in most patients. When compared to other results in the literature, this is a major functional improvement. The mean adjusted postoperative Constant score was 72.5% (range: 30-90%), and the mean MSTS score was 75.8% (range 36.7-96.7%).     

Hinge total knee replacement revisited

Objective

To determine if aseptic loosening is a major problem in hinge total knee replacement.

Design

A cohort study.

Setting

A university-affiliated institute, specializing in elective orthopedic surgery.

Patients

Fifty-eight patients, mainly those requiring revision, in whom the conditions were such that it was felt only a totally constrained implant was appropriate. In 7 patients the implant was press-fitted; in the remainder it was cemented. Five patients required fusion or revision, and 8 died less than 2 years after implantation, leaving 45 for review. Follow-up was 2 to 13 years.

Intervention

Total knee replacement with a Guepar II prosthesis.

Main outcome measures

Radiolucency determined by the Cameron system and clinical scoring using the Hospital for Special Surgery system.

Results

Of the cemented components, 91% of femoral stems were type IA (no lucency), 9% were type IB (partial lucency), with no type II or III lucency. Tibial lucency was 87% type IA and 13% type IB, with no type II or III lucency. Of the noncemented components, 58% of femoral components were type IA and 42% type IB. Tibial lucency was 71% type IA and 29% type IB. Lucency was mainly present in zones 1 and 2 adjacent to the knee. Clinical rating was 18% excellent, 20% good, 20% fair and 42% poor. Postoperative complications included infection (13%), aseptic loosening (7%), quadriceps lag (16%) and extensor mechanism problems (16%).

Conclusions

Aseptic loosening is an uncommon problem in hinge total knee replacement. The complication rate in cases of sufficient severity as to require a hinge replacement remains high. Current indications for a hinge prosthesis are anteroposterior instability with a very large flexion gap, complete absence of the collateral ligaments and complete absence of a functioning extensor mechanism.     

Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors

From 1981 to 2001, 91 shoulder resections were performed to treat shoulder girdle tumors (64 primary and 27 metastatic) in 90 patients (53 male and 37 female patients). The mean age was 34 years in patients with a primary tumor and 61 years in those with metastases. There were 7 partial scapulectomies, 13 total scapulectomies, 56 proximal humeral resections, 5 diaphyseal resections, 5 total shoulder girdle resections (Tikhoff-Linberg procedure), and 5 other procedures performed. Prosthesis implantation was carried out in 41 cases, autologous fibular transposition was done in 19, and massive homologous bone grafting was done in 4. Of the patients, 37 were clinically reviewed with a mean follow-up of 4.7 years (range, 1-20 years) by use of the recommendations of the Musculoskeletal Tumor Society for pain, function, position of hand, lifting ability, manual dexterity, and satisfaction. Nine patients were reviewed via a questionnaire and telephone interview. Twenty-six had died, and eighteen were lost to follow-up. The best results were achieved after partial scapulectomy and after humeral resection reconstructed with fibular transposition, when the function of the rotator cuff was preserved. After total scapulectomy and after humeral resection with the implantation of a tumor endoprosthesis, the function of the shoulder remained moderate because the rotator cuff was damaged. The overall satisfaction was generally good after all types of shoulder resections as a result of pain relief, preserved hand function, and improvement of psychological status. Patients can compensate extremely well by using the preserved joints and the contralateral upper limb; therefore, patient satisfaction does not rely on shoulder function alone.     

Polymerase chain reaction-based identification of Propionibacterium acnes types isolated from the male urinary tract: evaluation of adolescents, normal adults and men with prostatic pathology

OBJECTIVE: To assess whether colonization of the male urinary tract with Propionibacterium acnes, in particular types IB and II (which are associated with inflammation in radical prostatectomy specimens and might be involved in the development of prostate cancer), is associated with prostate disease, and thus to develop a urine test to detect men at risk of prostate disease. PATIENTS, SUBJECTS AND METHODS: We developed the first polymerase chain reaction (PCR)-based technique for identifying P. acnes types IA, IB and II, and used this in combination with selective culture medium to compare the prevalence of these subtypes in the urinary tract of adolescent males, healthy adult men and patients with confirmed prostate pathology. RESULTS: P. acnes types IB and II were no more prevalent in the urinary tract of patients with prostate pathology than in normal control men. However, the prevalence of types IB and II appeared to be higher in adult men (at 11 of 15 and six of 15, respectively) than in adolescents (two of six and one of six), suggesting an age-related increase. Comparison of urinary tract and facial skin P. acnes from three subjects showed that type IA was more often predominant on facial skin, whereas types IB or II were more often predominant in the urinary tract. CONCLUSIONS: A urine test might not be useful for detecting men with prostatic P. acnes infection and thus at greater risk of associated prostate disease. However, this work validated our technique for detecting and identifying the three P. acnes subtypes, and identified some interesting trends worth further investigation.     

Preoperative TNM evaluation of peripheral clinical stage I small cell lung cancer treated by initial lobectomy with adjuvant chemotherapy

Surgery with chemotherapy has been the accepted procedure for treating pathological stage I small cell lung cancer. However, there is a question of whether all clinical stage I patients should undergo surgery or not because of discrepancies between clinical and pathological staging. We conducted a retrospective analysis of TNM evaluation and postoperative survival on 10 clinical stage IA (T1N0M0) and 6 stage IB (T2N0M0) patients who had undergone initial lobectomy followed by chemotherapy. Clinical stage IB showed a high incidence of hilar or mediastinal lymph node involvement than stage IA (P=0.04). The accuracy of the T-factor did not differ between both stages. The pathological mean dimension of primary tumors with lymph node metastasis (33.4 mm) was significantly larger than that without metastasis (22.1 mm) (P=0.04). The difference in survival between clinical stage IA (7 of 10) and stage IB (2 of 6) was large but not significant (P=0.07). Four patients in each clinical stage died of cancer relapses. When indicating surgery for clinical stage I small cell lung cancer, it should be taken into account that primary tumors of more than 30 mm in diameter may suggest the possibility of stages more advanced than pathological stage II because of a high incidence of lymph node metastasis.     

人工全肩胛骨置换术治疗肩胛骨肿瘤的疗效研究

目的总结人工全肩胛骨置换术治疗肩胛骨肿瘤患者的疗效。方法回顾分析2010年1月—2017年12月采用全肩胛骨切除联合人工全肩胛骨置换术治疗的17例肩胛骨肿瘤患者临床资料。男9例,女8例;年龄13~64岁,平均34.4岁。软骨肉瘤7例、骨肉瘤3例、尤文肉瘤2例、高级别肉瘤1例、多形性未分化肉瘤1例、纤维肉瘤1例、浆细胞瘤1例、骨巨细胞瘤1例。Enneking外科分期:3期1例,ⅠB期8例,ⅡB期8例。Malawer分型:ⅢB型11例,ⅣB型5例,ⅥB型1例。肿瘤体积11.0 cm×7.5 cm×6.0 cm^18.5 cm×18.0 cm×12.5 cm。病程0.5~8.0个月,平均3.2个月。术后应用1993年美国骨与软组织肿瘤协会上肢功能评分系统(MSTS评分)、肩关节活动度评估肩关节功能,影像学复查肿瘤复发及转移情况。结果术后1例切口愈合不佳,其余患者切口均Ⅰ期愈合。患者均获随访,随访时间20~72个月,平均45.4个月。其中2例因肿瘤转移导致多器官功能衰竭死亡,3例发生肺部转移、荷瘤生存;所有患者均未出现局部复发。总生存率为88.2%(15/17),无瘤生存率为70.6%(12/17)。术后因外伤导致肋骨骨折1例,假体无菌性松动1例,三角肌萎缩变薄1例,其余患者无相关并发症发生。末次随访时,MSTS评分为(26.1±1.4)分,肩关节前屈、后伸、外展活动度分别为(70.0±7.5)、(31.2±11.3)、(54.4±12.5)°。结论肩胛骨肿瘤患者行全肩胛骨切除后,应用人工全肩胛骨置换术可获得较好肩关节外观及功能。     

创伤性三角纤维软骨复合体损伤的腕关节镜诊断及治疗

目的 评价腕关节镜对创伤性腕关节三角纤维软骨复合体(TFCC)损伤进行诊断及治疗的效果.方法 选有急慢性外伤史的16例腕关节三角纤维软骨复合体可疑损伤患者,年龄19～39岁,平均27.6岁.对经体格检查、关节造影或MRI检查有异常,疑为TFCC损伤者施行关节镜检查.按照Palmer分型:I A型6例,I B型9例,I D型1例.I A型、I D型在关节镜下行TFCC修整术,IB型行边缘部撕裂缝合修复术.结果 术后平均随访19个月.按Green-O'Brien功能评定法评定:优13例,良2例,可1例.结论 腕关节镜手术治疗TFCC是一种微创、有效、安全的治疗方式.     

A new surgical classification system for shoulder-girdle resections. Analysis of 38 patients

A new, six-stage surgical classification system is described for shoulder-girdle resections for patients being treated by limb-sparing procedures for bone and soft-tissue tumors. The classification is based upon current concepts of oncological surgery, the structures removed, the type of resection performed, and the relationship of the resection to the glenohumeral joint, and it indicates the increasing surgical magnitude of the procedure. Data from 38 patients with an average follow-up period of 4.6 years (range, two to 8.4 years) were analyzed. Thirty-two tumors were in bone and six in soft tissue. Eighty-seven percent (33 of the 38 tumors) were malignant. Twenty-four lesions were located in the proximal humerus and 14 in the scapula. The system permitted classification of all shoulder girdle resections done in this study's institutions. The classification is proposed as a means of establishing a uniform terminology in the comparison of such data.     

异氟醚麻醉对老龄大鼠海马突触体蛋白质组的影响

目的 评价异氟醚麻醉对老龄大鼠海马突触体蛋白质组的影响.方法 雌性SD大鼠27只,22月龄,体重480～550 g,采用随机数字表法,将其随机分为2组:对照组(C组,n=6)和异氟醚麻醉组(Ⅰ组,n=21).C组吸入含80％氧气的空氧混合气体2h,Ⅰ组吸入3％异氟醚麻醉诱导后,经口明视气管插管,吸入2％异氟醚+80％氧气维持麻醉2h.麻醉结束后24h时,进行Y型迷宫实验测试大鼠认知功能,记录训练次数.以训练次数＞ 75次为判断认知功能低下的标准,将Ⅰ组大鼠分为2组:认知功能低下组(IA组)和认知功能未低下组(IB组).Y型迷宫实验结束后,处死大鼠,取双侧海马组织,提取突触体,进行双向凝胶电泳和质谱分析.结果 Ⅰ组有6只大鼠发生认知功能低下,有13只大鼠未发生认知功能低下.与C组和IB组比较,IA组训练次数增多(P＜0.05);C组和IB组间比较训练次数差异无统计学意义(P＞0.05).IB组和IA组差异表达的蛋白质有21个,其中11个蛋白质表达上调,10个蛋白质表达下调.C组和IA组差异表达的蛋白质有19个,其中12个蛋白质表达上调,7个蛋白质表达下调.经质谱分析鉴定出31个蛋白质.结论 异氟醚麻醉导致老龄大鼠认知功能低下可能与突触部位能量代谢相关蛋白、突触部位的细胞骨架结构及调节蛋白的改变有关.     

Temporal expression patterns of BMP receptors and collagen II (B) during periosteal chondrogenesis.

Articular cartilage has a limited ability to repair itself. Periosteal grafts have chondrogenic potential and are used clinically to repair defects in articular cartilage. An organ culture model system for in vitro rabbit periosteal chondrogenesis has been established to study the molecular events of periosteal chondrogenesis in vitro. In this model, bone morphogenetic protein-2 (BMP2) mRNA expression was found to be upregulated in the first 12 h. BMPs usually transduce their signals through a receptor complex that includes type II and either type IA or type IB BMP receptors. Receptors IA and IB play distinct roles during limb development. We have examined the temporal expression patterns for the mRNAs of these receptors using our experimental model. The mRNA expression patterns of these three BMP receptors differed from one another in periosteal explants during chondrogenesis. When these explants were cultured under chondrogenic conditions (agarose suspension with TGF-beta1 added to the media for the first 2 days), the expression of BMPRII mRNA and that of BMPRIA mRNA varied only slightly and persisted over a long time. In contrast, the expression of BMPRIB mRNAwas upregulated within 12 h, peaked at day 5, and fell to a level that was barely detected beyond day 21. Moreover, the expression of BMPRIB mRNA preceded that of collagen type IIB mRNAs, a marker for matrix-depositing chondrocytes. These data support a role for coordinate expression of BMP2 and its receptors early during periosteal chondrogenesis.     

Is adjuvant chemotherapy necessary for the peripherally located stage I adenocarcinoma of the lung?

OBJECTIVE: This study was done for the purpose of picking out the cases of poor prognosis from the peripherally located stage I adenocarcinoma of the lung. METHODS: Between January 1989 and December 2004, 235 patients with peripherally located stage I adenocarcinoma of the lung were resected curatively in our hospital. Relation between the 5-year survival rate and lymphatic and/or blood vessel invasion (from now on ductal invasion) was examined in these cases. RESULTS: The 5-year survival rate was 99% in ly0v0 cases, 86% in ly0v1 cases, 85% in ly1v0 cases, 72% in ly1v1 cases, and 80% in ly2, 3 and/or v2, 3 (lyv 2-3) cases, respectively. Obviously the outcome of the cases without ductal invasion was good. The ratio of the cases without ductal invasion was 61% in stage IA, and 31% in stage IB. The 5-year survival rate was 99% in the cases without ductal invasion in stage IA, 100% in the cases without ductal invasion in stage IB, 90% in the cases with ductal invasion in stage IA, and 65% in the cases with ductal invasion in stage IB, respectively. And the 5-year survival rate without recurrence was 94% in the cases without ductal invasion in stage IA, 76% in the cases without ductal invasion in stage IB, 76% in the cases with ductal invasion in stage IA, and 54% in the cases with ductal invasion in stage IB, respectively. CONCLUSIONS: Ductal invasion is significant prognostic factor in stage I adenocarcinoma of the lung. Adjuvant chemotherapy is unnecessary for the case without ductal invasion in stage IA. But we think that adjuvant chemotherapy is necessary for the case with ductal invasion in stage IA and for the case in stage IB, because there is much recurrence.     

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.