Failure rates and functional results for intercalary femur reconstructions after tumour resection

MUSCULOSKELETAL SURGERY - To compare the results for patients treated with intercalary endoprosthetic replacement (EPR) or intercalary allograft reconstruction for diaphyseal tumours of the femur...     

Intercalary tibial allografts following tumor resection: the role of fibular centralization

Options to reconstruct intercalary tibial defects include allografts, vascularized bone transfers, autogenous cortical grafts, endoprostheses, and Ilizarov bone transport. Five patients underwent intercalary bulk allograft reconstruction following en bloc resection of tibial sarcomas. Two patients underwent immediate fibular centralization and iliac crest bone grafting in addition to the allograft. Two patients who underwent fibular centralization during primary reconstruction united uneventfully. The remaining three patients developed nonunion, of which one was successfully salvaged by fibular centralization. A combined allograft transplant and fibular centralization with iliac crest bone grafting is an effective procedure to reconstruct the tibial diaphysis, as well as a salvage procedure for allograft nonunion.     

The use of massive allograft with intramedullary fibular graft for intercalary reconstruction after resection of tibial malignancy

Reconstruction after intercalary excision of tibia malignancy is challenging. The combined use of a vascularized fibular flap and allograft can provide a reliable reconstructive option. Eight patients underwent reconstruction with an allograft and vascularized fibula following tibia malignancy resection. Patients were examined clinically and radiographically. The average age of patients was 16.5 years. The mean follow-up time was 38.4 months. Contralateral free fibula flap was used in three patients and ipsilateral pedicle fibula in five. The average length of defect was 11.8 cm and of fibula flap was 15.9 cm. Primary union was achieved in seven patients. The average time for bone union was 5.8 months at fibula-tibia junction and 14.1 months at allograft-tibia junction. Five patients had 10 complications. The Musculoskeletal Tumor Society average score was 90.8% at final follow-up. Intramedullary fibular flap in combination with massive allografts provide an excellent option for reconstruction of large bony defects after tibial malignancy extirpation. Ipsilateral pedicle fibula transportation had the advantages of short operation time and avoidance of donor site complications compared with the contralateral free fibula transfer.     

Bone allografts after segmental resection of tumours

Summary Massive cryo-preserved bone allografts were implanted in 17 patients after segmental resection, 10 for malignant and 7 for benign bone tumours. A segmental graft alone was used in 6 cases, a bone graft with an arthrodesis in 8, and a combination of graft and prosthesis in 1. The tumours were resected widely; the average length of graft was 6.4 cm in benign tumours and 11 cm in malignant tumours. Chemotherapy was given for one year after operation. There were 2 local recurrences, one severe infection, sloughing of the wound in 2, graft absorption in 3 and breakage of metal in 2. Follow up was from 14 months to 12 years. Bone healing was assessed by radiography in 13 cases. All grafted bone in patients receiving chemotherapy failed to heal primarily, as did 3 of the grafts for benign tumours. Secondary rigid fixation and an additional autogenous graft resulted in healing of the bone junction within a year.

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Résumé Des allogreffes osseuses massives cryoconservées ont été mises en place chez 17 malades après résection segmentaire, 10 pour des tumeurs malignes et 7 pour des lésions bénignes. On a eu recours à une greffe segmentaire simple six fois, à une greffe avec arthrodèse huit fois et à l'association d'une greffe et d'une prothèse une fois. Les tumeurs ont été reséquées largement; la longueur moyenne des greffons était de 6,4 cm dans les tumeurs bénignes et de 11 cm dans les tumeurs malignes. La chimiothérapie a été poursuivie pendant un an après l'opération. On a observé deux récidives locales, une infection grave, deux nécroses cutanées, trois résorptions du greffon et deux ruptures du matériel métallique. Le recul est compris entre 14 mois et 12 ans. La guérison osseuse a été confirmée radiologiquement dans 13 cas. Aucune greffe osseuse n'a consolidé d'emblée chez les sujets soumis à une chimiothérapie, de même que dans trois tumeurs bénignes. L'emploi d'une fixation rigide et d'une autogreffe complémentaire a permis d'obtenir la consolidation de la jonction osseuse dans un délai d'un an.

     

Paediatric diaphyseal malignant tumors: options for reconstruction after intercalary resection

From January 2002 to June 2008, 525 malignant pediatric skeletal tumors were operated. Forty-two (8%) tumors were diaphyseal in origin. The age of the patients ranged from two to 16 years. Femur was the most common site.After resection, various methods of reconstruction were adopted based on tumor site and availability of reconstruction options. Thirty-seven patients were available for follow-up. Follow-up duration ranged from 4 months to 86 months (mean 38.3 months). Eight patients succumbed to the disease. There were three local recurrences. The Musculoskeletal Tumor Society Score ranged from 18 to 30 (mean 27). Joint-preserving intercalary resections are an oncologically safe option with gratifying functional results.     

骶骨肿瘤切除后重建的临床进展

骶骨肿瘤相对少见,辅助治疗效果不确切.全骶骨肿瘤切除是治疗的主要手段,但全骶骨肿瘤切除常常导致骨盆环不稳,因此,术后如何重建腰骶稳定性是手术治疗骶骨肿瘤成功的关键所在.目前文献已报道多种重建方式,包括三角框架重建装置,髂骨棒和髂骨螺钉,改良Galveston,假体置换等.作者就骶骨肿瘤切除术后重建方式及术后评价进行综述.     

The use of allografts to reconstruct intercalary defects of long bones

The problems involved in the use of freeze-dried and fresh frozen allografts in the reconstruction of large bony defects were caused by the treatment of a variety of conditions. Twenty-four patients served as a basis for the review with an average of 34.7 months of follow-up study. Fifteen of these patients had, in addition, massive supplemental autografts. Rigid internal fixation consisting of either an intramedullary fluted rod or some combination of AO plate fixation was used in most cases, except in one instance in which no internal fixation was used. There was no difference in the time to incorporation of the freeze-dried and fresh frozen allografts into the host bone bed. No appreciable differences were noted in the group that had massive supplemental autografts, except that there was improvement in the quality of the union. The average time to radiographic union was 14 months. The complication rate in this series of patients was 54%. Most of the complications were minor and resolved with little residual. The overall results produced nine excellent, eight good, three fair, and four poor results. Considering the magnitude of the procedures involved, allografts appeared to have a distinctive place in the surgeon's armamentarium for reconstruction of large bony defects.     

带血管腓骨复合异体骨修复长骨肿瘤切除后骨缺损

目的 探讨带血管腓骨复合异体骨重建长骨恶性肿瘤切除后骨缺损的临床结果.方法 2006年4月至2009年10月对19例四肢长骨恶性骨肿瘤患者行保肢手术,男11例,女8例;年龄11～37岁,平均(18.5±7.6)岁.肱骨5例、股骨7例、胫骨7例.肿瘤切除后骨缺损长度(13.2±4.3)cm,采用带血管自体腓骨复合大段异体...     

Rotational stability of a modified step-cut for use in intercalary allografts

BACKGROUND: Intercalary allografts are used for the reconstruction of major skeletal defects. Step-cuts help to provide rotational stability when intramedullary fixation is used. A modified step-cut is proposed to reduce rotation at the interface. This study compares the rotational stability of conventional and modified step-cuts. METHODS: In Phase I, seven pairs of human cadaveric femora were divided into a conventional step-cut group (left femora) and a modified step-cut group (right femora). All femora were cut transversely at the mid-diaphysis. In the conventional group, a 1-cm step-cut was created in the exact midsagittal plane in both the proximal and distal segments. In the modified group, a 1-cm step-cut was created in the parasagittal plane, leaving 2 mm of additional bone on both the proximal and the distal fragment. Phase II was identical except that in the modified step-cut group only 1 mm of additional bone was left. Smooth femoral nails were then placed after standard reaming. Specimens were tested by fixing the proximal segment and applying +/-2 N-m (17.7 in-lb) of torque to the distal segments with ten oscillation cycles. Maximum rotation was measured. The data were analyzed with the paired Student t test. RESULTS: The average rotation in Phase I was 23.3 degrees for the conventional step-cut group and 3.0 degrees for the 2-mm modified step-cut group; the difference was significant (p < 0.001). Four femora sustained an incomplete fracture during nail insertion. The average rotation in Phase II was 20.6 degrees for the conventional step-cut group and 0.5 degrees for the 1-mm modified step-cut group without any fractures; the difference was significant (p < 0.001). CONCLUSIONS: Step-cut modification that leaves more bone in the sagittal plane provides rigid fixation and significantly more stability than the conventional step-cut technique.     

Clinical and functional outcome after alcohol neurolysis of the tibial nerve for ankle-foot spasticity

PURPOSE: To report one's experience of using 50-100% alcohol for neurolysis of the tibial nerve in chronic ankle-foot spasticity. METHODS: The records of patients who received alcohol neurolysis of the tibial nerve were retrospectively reviewed. Repetitive monopolar nerve stimulation was used to localize the tibial nerve. Outcome measures included muscle tone as measured by the Modified Ashworth Score (MAS), passive ankle range of motion (PROM), effect on clonus, plantar flexor motor strength, visual gait analysis and use of orthoses. RESULTS: A total of 21 tibial nerves were neurolysed in 18 patients (mean age 38.9 +/- 15.8 years, 12 males, six females). Mean duration post-event was 14.8 +/- 3.9 months. The mean pre-neurolysis MAS was 2.50 +/- 0.77 and this improved to 0.97 +/- 0.88 (p < 0.001) and 0.93 +/- 0.85 (p < 0.001) at 1 and 6 months post-procedure, respectively. Average duration of effect was 10.5 +/- 8.9 months. Eleven out of 12 patients (91.7%) with sustained ankle clonus had complete abolishment lasting 6 months. Mean gain in PROM was 24.6 +/- 16.1 degrees and 32.6 +/- 19.0 degrees at 1 and 3 months post-neurolysis, respectively (p < 0.001, < 0.02). No decrease in motor strength was seen post-neurolysis. All 13 ambulant patients had visible improvements in gait. Complications were transient and included dysesthetic pain (4), sensory loss (1) and distal limb oedema (1). CONCLUSION: Alcohol neurolysis (50-100%) of the tibial nerves is an effective and safe method of managing ankle-foot spasticity.     

Reconstruction after intercalary resection of malignant bone tumours: comparison between segmental allograft and extracorporeally-irradiated autograft

We reviewed 29 patients who had undergone intercalary resection for malignant tumours. Of these, 14 had received segmental allograft reconstruction and 15 extracorporeally-irradiated autograft. At a mean follow-up of 71 months (24 to 132), 20 were free from disease, five had died and four were alive with pulmonary metastases. Two patients, one with an allograft and one with an irradiated autograft, had a local recurrence. Reconstruction with extracorporeally-irradiated autograft has a significantly lower rate of nonunion (7% vs 43%, p = 0.031) but an insignificantly higher rate of fracture (20% vs 14%, p = 0.535) than that with segmental allograft. Using the Enneking functional evaluation system, the mean postoperative score for the patients without local recurrence was 87% (80% to 96%) and was similar in both groups. Extracorporeally-irradiated autograft could be an acceptable alternative for reconstruction after intercalary resection, especially in countries where it is difficult to obtain allografts.     

Massive intercalary bone allografts in the treatment of primary and secondary bone tumors

From 1981 to 1993, 21 patients received intercalary bone allografts for reconstruction of the extremity after en bloc tumor resection (15 malignant and 6 benign tumors). The allografts were collected from multiorgan donors and cryopreserved at –70°C. The mean follow-up was 4.4 (range 1–13) years. The fate of the grafts was followed by conventional radiography, bone scintigraphy, and functional assessment. The overall survival rate of the 7 patients with high-grade malignancies was 86%. Solid union of the graft-host sites in less that 15 months occurred in 85%. An increased isotope uptake of the graft indicates that incorporation at the osteotomies as well as remodelling is still continuing at 9 years after operation. The overall complication rate was 43%; 3 patients had two or more complications. Complications were related to the allograft in 6 (infection or fatigue fracture in 1 and delayed healing in 4 cases) and to the osteosynthesis in 3 patients. The definitive results after treatment of complications show that satisfactory results have been obtained in all but 2 patients: 62% had excellent, 19% good, and 10% fair results. Intercalary allografts therefore provide a valuable solution for large skeletal defects after resection of bone tumors.     

Clinical outcomes and quality of life after low anterior resection for rectal cancer.

OBJECTIVE: To evaluate clinical outcomes and quality of life in terms of anal, urinary, and sexual function, after low anterior resection for rectal cancer. DESIGN: Retrospective study. SETTING: University hospital, Switzerland. SUBJECTS: 43 patients with low rectal cancers. INTERVENTIONS: 27 were not given adjuvant radiotherapy and 16 had preoperative adjuvant radiotherapy 1.6 Gy twice daily for 13 days. MAIN OUTCOME MEASURES: Anal, urinary, and sexual function postoperatively. RESULTS: 23 patients reported normal defaecation (53%), 9 had incontinence of flatus (21%), 5 had occasional minor soiling (12%), 2 had frequent major soiling (5%), 4 had a total faecal incontinence (9%), and 3 had urinary incontinence (7%). Sexual dysfunction was reported by 9 of the 13 sexually active men and 2 of the 11 sexually active women. CONCLUSION: Despite their reported faecal, urinary and sexual dysfunction most patients were satisfied with their quality of life. Counselling at the time of operation is highly recommended as a means of contributing to personal satisfaction.     

Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate

OBJECTIVES

To assess the peri‐ and postoperative outcome of patients treated with open radical retropubic prostatectomy (RRP) for prostate cancer and who had previously undergone transurethral resection of the prostate (TURP).

PATIENTS AND METHODS

Prospectively collected data from a consecutive series of 1760 patients who had RRP between July 2003 and June 2007 at our institution were used to retrospectively match 62 cases (with previous TURP) with the same number of controls (without previous TURP). Matching variables were patient age, body mass index, prostate volume, preoperative total prostate‐specific antigen (PSA) level, Gleason score, pathological stage, and intraoperative nerve‐sparing procedure. Complete 1‐year follow‐up data were available for all patients. All collected data on surgery and perioperative complications were analysed. Functional outcome data at the 1‐year follow‐up were evaluated by applying an institutional questionnaire. Sexual function was assessed using the abbreviated International Index of Erectile Function‐5 questionnaire, and urinary control was evaluated by defining complete urinary control as no pad usage.

RESULTS

The rate of complete urinary control rate in cases and controls was similar (81% vs 82%). When nerves were spared, 60% (15/25) of patients in either group were capable of sexual intercourse. The overall positive surgical margin rate was insignificantly higher in cases (19% vs 13, P > 0.05). After 1 year of follow‐up the biochemical recurrence rate (PSA >0.04 ng/mL) did not differ significantly in patients who had RRP after TURP vs RRP alone (six of 62, 10%, vs five of 62, 8%; P = 0.77).

CONCLUSIONS

RRP for prostate cancer in patients who have had previous TURP does not result in a higher perioperative complication rate, or a worse functional outcome.     

异体骨关节移植修复肢体大段骨缺损的术后并发症

目的 分析肢体恶性肿瘤患者接受异体骨关节移植修复重建大段骨缺损的术后并发症并探讨其处理方法。方法 因肢体恶性骨肿瘤行瘤段切除,采用不同内固定方式进行异体骨－关节移植术并有完整随访资料的患者１０６例,随访时间１０～１１２个月,平均３２．３个月。术后最终结果按Ｍａｎｋｉｎ’ｓ标准评价。结果 与深低温冷冻异体骨相比,酒精浸泡异体骨移植更易发生感染、骨不连等并发症;异体骨段移植或复合人工关节移植优于半关节