Co-exposure to cadmium and microplastics promotes liver fibrosis through the hemichannels -ATP-P2X7 pathway.

Microplastics (MPs) and cadmium (Cd) are important environmental pollutants, that damage the liver. However, the effect and mechanism of combined Cd and MPs exposure on liver fibrosis are still largely unknown. In this study investigated, Cd + MPs exposure increased superoxide anion production and promoted extracellular ATP release compared with exposure to Cd or MPs individually. Cd + MPs increased inflammatory cell infiltration, activated the P2X7-NLRP3 signaling pathway, and promoted inflammatory factor release. Cd + MPs aggravated Cd- or MPs-induced liver fibrosis and induced liver inflammation. In AML12/HSC-T6 cell in vitro poisoning model, exposure of AML12 cells to Cd + MPs increased the opening of connexin hemichannels and promoted extracellular ATP release. Treatment of HSC-T6 cells with the supernatant of AML12 cells exposed to Cd + MPs significantly promoted HSC-T6 cell activation. Treatment of HSC-T6 cells with different concentrations of ATP produced similar results. TAT-Gap19TFA, an inhibitor of connexin hemichannels, significantly inhibited the ATP release and activation of Cd + MPs-treated HSC-T6 cells. Finally, the expression of the ATP receptor P2X7 was silenced in HSC-T6 cells, which significantly inhibited their activation. In conclusion, exposure to Cd + MPs promoted liver fibrosis through the ATP-P2X7 pathway and synergistically affected liver inflammation and fibrosis.

VPS41-mediated incomplete autophagy aggravates cadmium-induced apoptosis in mouse hepatocytes.

Exposure to cadmium (Cd), an environmental heavy metal contaminant, is a serious threat to global health that increases the burden of liver diseases. Autophagy and apoptosis are important in Cd-induced liver injury. However, the regulatory mechanisms involved in the progression of Cd-induced liver damage are poorly understood. Herein, we investigated the role of vacuolar protein sorting 41 (VPS41) in Cd-induced autophagy and apoptosis in hepatocytes. We used targeted VPS41 regulation to elucidate the mechanism of Cd-induced hepatotoxicity. Our data showed that Cd triggered incomplete autophagy by downregulating VPS41, aggravating Cd-induced hepatocyte apoptosis. Mechanistically, Cd-induced VPS41 downregulation interfered with the mTORC1-TFEB/TFE3 axis, leading to an imbalance in autophagy initiation and termination and abnormal activation of autophagy. Moreover, Cd-induced downregulation of VPS41 inhibited autophagosome-lysosome fusion, leading to blocked autophagic flux. This triggers incomplete autophagy, which causes excessive P62 accumulation, accelerating Caspase-9 (CASP9) cleavage. Incomplete autophagy blocks clearance of cleaved CASP9 (CL-CASP9) via the autophagic pathway, promoting apoptosis. Notably, VPS41 overexpression alleviated Cd-induced incomplete autophagy and apoptosis, independent of the homotypic fusion and protein sorting complex. This study provides a new mechanistic understanding of the relationship between autophagy and apoptosis, suggesting that VPS41 is a new therapeutic target for Cd-induced liver damage.

Polystyrene Microplastics Induce Oxidative Stress in Mouse Hepatocytes in Relation to Their Size.

Microplastics have become a new type of environmental pollutant that can accumulate in various tissues and organs of the body and cause chronic damage. In this study, two different size polystyrene microplastics (PS-MPs, 5 µm and 0.5 µm) exposure models were established in mice to investigate the effects of PS-MPs with different particle sizes on oxidative stress in the liver. The results showed that PS-MPs exposure caused a decrease in body weight and liver-to-body weight. The hematoxylin and eosin staining and transmission electron microscopy results showed that exposure to PS-MPs led to the disorganized cellular structure of liver tissue, nuclear crinkling, and mitochondrial vacuolation. The extent of damage in the 5 µm PS-MP exposure group was more extensive when compared with the other group. The evaluation of oxidative-stress-related indicators showed that PS-MPs exposure exacerbated oxidative stress in hepatocytes, especially in the 5 µm PS-MPs group. The expression of oxidative-stress-related proteins sirtuin 3(SIRT3) and superoxide dismutase (SOD2) was significantly reduced, and the reduction was more pronounced in the 5 µm PS-MPs group. In conclusion, PS-MPs exposure led to oxidative stress in mouse hepatocytes and caused more severe damage in the 5 µm PS-MPs group when compared with the 0.5 µm PS-MPs group.

Polystyrene exacerbates cadmium-induced mitochondrial damage to lung by blocking autophagy in mice.

Cadmium (Cd) is an environmental heavy metal, and its accumulation is harmful to animal and human health. The cytotoxicity of Cd includes oxidative stress, apoptosis, and mitochondrial histopathological changes. Furthermore, polystyrene (PS) is a kind of microplastic piece derived from biotic and abiotic weathering courses, and has toxicity in various aspects. However, the potential mechanism of action of Cd co-treated with PS is still poorly unclear. The objective of this study was to investigate the effects of PS on Cd-induced histopathological injury of mitochondria in the lung of mice. In this study, the results have showed that Cd could induce the activity of oxidative enzymes of the lung cells in mice, increasing the content of partial microelement and the phosphorylation of inflammatory factor NF-κB p65. Cd further destroys the integrity of mitochondria by increasing the expression of apoptotic protein and blocking the autophagy. In addition, PS solely group aggravated the lung damage in mice, especially mitochondrial toxicity, and played a synergistic effect with Cd in lung injury. However, how PS can augment mitochondrial damage and synergism with Cd in lung of mice requiring further exploration. Therefore, PS was able to exacerbate Cd-induced mitochondrial damage to the lung in mice by blocking autophagy, and was associated with the apoptosis.

Indocyanine green fluorescence imaging may detect tumour residuals during surgery for bone and soft-tissue tumours.

The aim of this study was to determine the rate of indocyanine green (ICG) staining of bone and soft-tissue tumours, as well as the stability and accuracy of ICG fluorescence imaging in detecting tumour residuals during surgery for bone and soft-tissue tumours. ICG fluorescence imaging was performed during surgery in 34 patients with bone and soft-tissue tumours. ICG was administered intravenously at a dose of 2 mg/kg over a period of 60 minutes on the day prior to surgery. The tumour stain rate and signal-to-background ratio of each tumour were post hoc analyzed. After tumour resection, the tumour bed was scanned to locate sites with fluorescence residuals, which were subsequently inspected and biopsied. The overall tumour stain rate was 88% (30/34 patients), and specific stain rates included 90% for osteosarcomas and 92% for giant cell tumours. For malignant tumours, the overall stain rate was 94%, while it was 82% for benign tumours. The ICG tumour stain was not influenced by different pathologies, such as malignant versus benign pathology, the reception (or lack thereof) of neoadjuvant chemotherapies, the length of time between drug administration and surgery, the number of doses of denosumab for patients with giant cell tumours, or the tumour response to neoadjuvant chemotherapy. The overall accuracy rate of successfully predicting tumour residuals using fluorescence was 49% (23/47 pieces of tissue). The accuracy rate after en bloc resection was significantly lower than that after piecemeal resection (16% vs 71%; p < 0.001). A high percentage of bone and soft-tissue tumours can be stained by ICG and the tumour staining with ICG was stable. This approach can be used in both benign and malignant tumours, regardless of whether neoadjuvant chemotherapy is adopted. The technique is also useful to detect tumour residuals in the wound, especially in patients undergoing piecemeal resection.

Outcomes of Semiknee Replacement in Skeletally Immature Bone Sarcoma Patients.

INTRODUCTION: A semiknee mega endoprosthesis (SKMEP) was used to replace the resected distal femur or proximal tibia in skeletally immature bone sarcoma patients. This study investigated the surgical technique, endoprosthesis survival rate, functional outcome, complications, and approaches to resolve limb-length discrepancy (LLD) following this procedure. PATIENTS AND METHODS: In total, 15 girls and 16 boys with a mean age of 9.1 years (range, 4-12) and 8.9 years (range, 5-13), respectively, were included in this study. The mean length of the resected distal femur (15 cases) and proximal tibia (16) was 145.0 and 122.8 mm, respectively. Altogether, 19 custom-made SKMEPs and 12 modular units were used to reconstruct the bone and joint defects. RESULTS: The average follow-up was 82.8 months (range, 4-225 months). Five patients died of disease. Seven SKMEPs were revised to total knee endoprosthesis after a mean of 40.3 months. Nineteen patients retained the original SKMEP, and the mean LLD was 4.3 cm (range, 0-10 cm). One case each of Henderson type 1B, type 2A, type 2B, and type 5B failures was observed. Knee subluxation occurred in two cases. Although a slight laxity of the knee was identified on physical examination, the average Musculoskeletal Tumor Society 93(MSTS93) functional score was 84.5% (range, 57-97%). The estimated implant survival was 70.5% at 5 years. CONCLUSION: This was the largest retrospective study reporting the application of SKMEP in bone sarcoma patients. For selected skeletally immature bone sarcoma patients, SKMEP is an option with satisfactory functional outcomes and survival rates. However, heightening pads or shoes to compensate the LLD were indispensable before subsequent LLD was adjusted by further operation(s).

Microplastics Exacerbate Cadmium-Induced Kidney Injury by Enhancing Oxidative Stress, Autophagy, Apoptosis, and Fibrosis.

Cadmium (Cd) is a potential pathogenic factor in the urinary system that is associated with various kidney diseases. Microplastics (MPs), comprising of plastic particles less than 5 mm in diameter, are a major carrier of contaminants. We applied 10 mg/L particle 5 µm MPs and 50 mg/L CdCl2 in water for three months in vivo assay to assess the damaging effects of MPs and Cd exposure on the kidney. In vivo tests showed that MPs exacerbated Cd-induced kidney injury. In addition, the involvement of oxidative stress, autophagy, apoptosis, and fibrosis in the damaging effects of MPs and Cd on mouse kidneys were investigated. The results showed that MPs aggravated Cd-induced kidney injury by enhancing oxidative stress, autophagy, apoptosis, and fibrosis. These findings provide new insights into the toxic effects of MPs on the mouse kidney.

Elbow hemiarthroplasty with a 3D-printed megaprosthesis for defects of the distal humerus or proximal ulna after tumour resection : a preliminary report.

AIMS: The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection. METHODS: From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. RESULTS: Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. CONCLUSION: The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747-757.

Ultra-Short Course of Neo-Adjuvant Denosumab for Nerve-Sparing Surgery for Giant Cell Tumor of Bone in Sacrum.

STUDY DEIGN: This was a retrospective study about sacral giant cell tumor of bone (GCTB). OBJECTIVE: This study aimed to investigate whether ultra-short course of neo-adjuvant denosumab treatment for sacral GCTB could (1) induce radiological and histological response? (2) Facilitate nerve-sparing surgery? (3) Achieve satisfactory oncological and functional outcomes? SUMMARY OF BACKGROUND DATA: Previous reports on long course of neo-adjuvant denosumab treatment for GCTB showed significant tumor response and a relatively high recurrent rate after curettage. METHODS: Sixty-six patients with sacral GCTB treated with neoadjuvant denosumab and nerve-sparing surgery were categorized into ultra-short course group (≤3 doses and operation within D21 since 1st dose, 41 patients) or conventional group (>3 doses or operation after D21 since 1st dose, 25 patients). The radiological and histological response, operative data, oncological and functional outcomes were compared. RESULTS: The ultra-short course group demonstrated fewer doses of neo-adjuvant denosumab (mean: 2.1 vs. 4.8, P  < 0.001) and shorter time to surgery (12.2 days vs. 72.3 days, P < 0.001). Similar patterns of radiological and histological response were observed in the two groups with less fibrosis and ossification in the ultra-short course group. The operative duration (199.9 min vs. 187.8 min, P = 0.364) and estimated blood loss (1552.4 mL vs. 1474.0 mL, P = 0.740) were comparable. Most (94.8%) of the patients received adjuvant denosumab. After a mean follow-up of 29.4 months, three cases (8.8%) and five cases (20.8%) showed local recurrence in each group (P = 0.255). The estimated recurrence-free survival (56.2 vs. 51.2 months, P = 0.210) and the functional status [Motor-Urination-Defecation scores: 25.9 vs. 25.7, P = 0.762] did not differ between the two groups. CONCLUSION: Ultra-short course of neo-adjuvant denosumab for sacral GCTB could elicit radiological and histological responses as conventional course did. The less degree of fibrosis and ossification might facilitate nerve-sparing surgery and help to achieve satisfactory local control and functional status.Level of Evidence: 4.

Surgical treatment of benign osteolytic lesions in the femoral head and neck: a systematic review.

BACKGROUND AND OBJECTIVES: Treatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures. METHODS: A comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020. RESULTS: A total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage. CONCLUSION: The majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

Improving the Versatility of the Latissimus Dorsi Myocutaneous Flap Using the Perforator Propeller Flap Concept.

BACKGROUND: The latissimus dorsi myocutaneous flap is widely used in reconstructive surgery; however, primary donor-site closure remains challenging when a wide flap is harvested. METHODS: A large latissimus dorsi myocutaneous flap was elevated and transferred to repair defects. Perforators adjacent to the donor site of the myocutaneous flap were explored using an ultrasound Doppler probe or a technique of extensive exploration along the margins of the donor site wound. A single or multiple perforator propeller flaps based on these perforators were used to close the donor site defect. RESULTS: From June 2012 to April 2018, this method was used to restore posttraumatic and oncologic defects of the chest wall in 14 cases, upper extremity in 6 cases, and lower extremity in 1 case. The size and width of the latissimus dorsi myocutaneous flaps ranged from 16 × 11 cm to 33 × 17 cm (mean area, 335.6 cm) and 9 cm to 20 cm (mean width, 14 cm), respectively. The donor site defect was closed primarily by using a single flap in 11 cases, dual flap in 9, and triple flap in one. Donor site breakdown was not observed in any of the cases. CONCLUSIONS: The perforator propeller flap could be used to reconstruct a latissimus dorsi myocutaneous flap donor site defect, ensuring not only the harvesting of a wide flap but also achieving primary donor site closure, thus greatly improving the versatility and capability of the latissimus dorsi myocutaneous flap in the reconstruction of large-sized defects.

Assessment of patient experiences following total sacrectomy for primary malignant sacral tumors: A qualitative study.

BACKGROUND AND OBJECTIVES: Few reports have investigated patient experiences following total en bloc sacrectomy. The aims of this study were to obtain a deeper understanding of patients' personal experiences, needs, and satisfaction with the treatment to reveal areas in which perioperative and long-term patient care can be improved. METHODS: A qualitative design was applied to examine patient experiences and supportive care needs. Patients treated between 2007 and 2017 were identified from our institutional database. RESULTS: A total of 28 survivors were interviewed (13 females, age 13-75 years). Eight themes were identified: the effect of surgery on patients' (a) daily lives, (b) social activities, (c) work or school activities, (d) and family lives; (e) acceptance of ostomy surgery; (f) need for guidance regarding long-term rehabilitation; (g) satisfaction with the medical services provided in the hospital; and (h) satisfaction with the treatment outcomes. CONCLUSION: Total en bloc sacrectomy can yield satisfactory oncological outcomes; however, the procedure is a life-changing event for patients and their families. Physicians must provide long-term support and guidance after surgery to enable patients to fully understand and cope with the changes in their lives.

Pelvic reconstruction following resection of tumour involving the whole ilium and acetabulum.

BACKGROUND: Functional reconstruction following resection of pelvic tumours with the ileum and the acetabulum involvement is challenging and demanding. The aim of this study was to evaluate the results of these patients receiving pelvic reconstruction with a femoral head autograft plus a hemipelvic prosthesis. METHODS: Eighteen patients receiving pelvic reconstruction with a femoral head autograft plus a hemipelvic prosthesis following resection of pelvic tumours involving the whole ileum and the acetabulum were included in this study from April 2006 to June 2014. Oncological status, functional results, and complications of these selected patients were analysed. RESULTS: The follow-up was 15-125 months (median 43). The functional MSTS-93 scores of the 18 patients available for the functional analysis were 37-87% (mean 60.7%). Complications occurred in seven patients (31.8%); dislocation in two (9%); and deep infection in three patients (13.6%) and two patients healed well following thorough debridement and antibiotic treatment. Five patients had local recurrence (22.7%). Lung metastases occurred in eight patients; seven died of disease and one lived after the metastasectomy. The 5-year overall Kaplan-Meier survival and disease-free survival rates were 61.7% and 50%, respectively. CONCLUSIONS: The procedure of femoral head autograft plus hemipelvic prosthesis was an effective method to reconstruct the defect following the whole ileum and the acetabulum resection; the functional outcomes were satisfactory, and it had an acceptable complication rate.

Functional results of wrist arthrodesis versus arthroplasty with proximal fibula following giant cell tumour excision of the distal radius.

Twenty-one patients underwent excision of a Campanacci grade III giant cell tumour of the distal radius and had reconstruction using a proximal fibula autograft. We compared the functional results of wrist arthrodesis versus arthroplasty. All 21 patients healed in an average of 8 months, and all have remained disease free. The Musculoskeletal Tumor Society 93, the Disabilities of the Arm, Shoulder, and Hand scores and the grip strength of the operated wrist compared with the contralateral wrist were 93%, 7, and 71% for the arthrodesis group and 83%, 17, and 40% for the arthroplasty group. Arthrodesis of the reconstructed radiocarpal joint provided better grip strength and functional outcomes than arthroplasty. Level of evidence: III.

Factors Associated With Spinopelvic Fixation Mechanical Failure After Total Sacrectomy.

STUDY DESIGN: We retrospectively analyzed factors associated with spinopelvic mechanical failure after total sacrectomy. OBJECTIVE: To find the rate and type of mechanical fixation failure after total sacrectomy and to identify the associated risk factors. SUMMARY OF BACKGROUND DATA: Although rigid fixation has been achieved, mechanical failure is sometimes encountered in reconstruction after total sacrectomy. The incidence and factors associated with spinopelvic fixation mechanical failure after total sacrectomy are still not clear. METHODS: The study comprised 63 patients who underwent spinopelvic reconstruction after total sacrectomy. The potential risk factors for fixation mechanical failure after total sacrectomy were evaluated, which included age, sex, body mass index, type of tumor (benign or malignant), and adjuvant treatment received (e.g., chemotherapy, radiation therapy). The surgery-related factors included the classification of tumor resection (en bloc or piecemeal resection) and the type of iliosacral resection. Adoption of anterior spinal column fixation (ASCF), posterior pelvic ring fixation (PPRF), four-rod technique (FRT) of spinopelvic fixation (SPF), and structural or morselized bone grafting after total sacrectomy in patients were considered reconstruction-related factors. Cox regression models were used to analyze associations between postoperative fixation failure and risk factors for all models. RESULTS: Postoperative fixation mechanical failure occurred in 25% of patients (16/63) who underwent total sacrectomy. Univariate analysis showed that the factors associated with spinopelvic fixation mechanical failure after total sacrectomy were the non-adoption of FRT of SPF and ASCF, the adoption of Type II sacroiliac resection, and female sex, whereas multivariate analysis demonstrated similar results, except for the adoption of Type II sacroilliac resection. CONCLUSION: FRT connection of SPF and ASCF should be adopted in reconstruction after total sacrectomy, especially in female patients. LEVEL OF EVIDENCE: 3.

Reconstruction of segmental bone defect of long bones after tumor resection by devitalized tumor-bearing bone.

BACKGROUND: The reconstruction of an intercalary bone defect after a tumor resection of a long bone remains a challenge to orthopedic surgeons. Though several methods have been adopted to enhance the union of long segmental allografts or retrieved segmental autografts to the host bones, still more progresses are required to achieve a better union rate. Several methods have been adopted to devitalize tumor bone for recycling usage, and the results varied. We describe our experiences of using devitalized tumor-bearing bones for the repairing of segmental defects after tumor resection. METHODS: Twenty-seven eligible patients treated from February 2004 to May 2012 were included. The segmental tumor bone (mean length, 14 cm) was resected, and then devitalized in 20% sterile saline at 65 °C for 30 min after the tumor tissue was removed. The devitalized bone was implanted back into the defect by using nails or plates. RESULTS: Complete healing of 50 osteotomy ends was achieved at a median time of 11 months (interquartile range (IQR) 9-13 months). Major complications included bone nonunion in four bone junctions (7.4%), devitalized bone fracture in one patient (3.7%), deep infection in three patients (11.1%), and fixation failure in two patients (7.4%). The bone union rates at 1 and 2 years were 74.1 and 92.6%, respectively. The average functional score according to the Musculoskeletal Tumor Society (MSTS) 93 scoring system was 93 % (IQR 80-96.7%). CONCLUSIONS: Incubation in 20% sterile saline at 65 °C for 30 min is an effective method of devitalization of tumor-bearing bone. The retrieved bone graft may provide as a less expensive alternative for limb salvage. The structural bone and the preserved osteoinductivity of protein may improve bone union.

Preservation of the contralateral sacral nerves during hemisacrectomy for sacral malignancies.

PURPOSE: This study aimed to evaluate the oncologic and functional outcome of the cases treated with hemisacrectomy through a sagittal plane in the sacrum and simultaneous en bloc resection together with the ipsilateral sacroiliac joint without sacrificing the contralateral sacral nerves and summarize tumor resection techniques and reconstruction strategy. METHODS: En bloc resection of a sacral malignancy with ipsilateral sacroiliac joint and preservation of the contralateral sacral nerves by sagittal hemisacrectomy had been performed in 15 patients. An intra-abdominal aortic balloon was used in all these cases and a combined posterior-anterior approach was adopted. A modified Galveston technique was used to reestablish spinopelvic stability and a nonvascularized fibula autograft was used in selected cases. RESULTS: Contralateral sacral nerves were preserved in all 15 patients. Adequate margins (wide and marginal margin) were accomplished in 10 patients. Local recurrence occurred in seven (47%) patients, and four of these had an inadequate margin. There was no perioperative death. Four (27%) patients had wound problems. No mechanical breakdown occurred until the last follow-up. All the patients were able to walk without the use of a walking aid. Sphincter function was partially preserved in all these patients. At the last follow-up, seven (47%) patients survived without evidence of disease, two (13%) patients lived with disease, and six (40%) patients had died of disease. CONCLUSIONS: This procedure has an oncologic outcome that is similar to that of other high sacrectomy and a much better function outcome. Although demanding, it is indicated in selected patients.

Experience with wound complications after surgery for sacral tumors.

PURPOSE: The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence. METHODS: The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥ 12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors. RESULTS: Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥ 10 cm, and instrumentation used were risk factors for wound complications. CONCLUSIONS: The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

[Ewing's sarcoma of the pelvis: treatment results of 31 patients].

OBJECTIVE: To define oncologic and functional outcomes of multidisciplinary treatment methods combined chemotherapy, surgery and radiotherapy, patients with Ewing's sarcoma of the pelvis who were treated at our center were analyzed. METHODS: Thirty-one patients with Ewing's sarcoma of the pelvis were eligible for this analysis. Primary lung metastases occurred in ten patients who were classified as stage III according to the system of Musculoskeletal Tumor Society (MSTS). All the patients received multidisciplinary treatment methods combined chemotherapy, surgery and radiotherapy. Twenty-eight patients underwent limb-sparing surgery, three patients underwent hemipelvectomy. The complications, including radiation or surgery-related complications and mechanical failures were recorded, besides the functional results were evaluated according to the MSTS 93 criteria. Kaplan-Meier survival analysis and Cox multivariate analysis were used as statistical methods. RESULTS: The 5-year overall survival (OS) rate for all the patients was 42.3%. The 5-year OS for patients with small tumor (< 10 cm) had a significant better prognosis than patients with large tumor (≥ 10 cm, 58.2% vs. 26.0%, χ(2) = 4.382, P < 0.05). The 5-year OS for patients with surgical stage IIb was significantly better than for those with surgical stage III (50.2% vs. 30.3%, χ(2) = 4.521, P < 0.05). The 5-year OS for patients with wide or radical surgery had a better prognosis than patients with marginal, intralesional surgery or no surgery (60.0% vs. 29.4%, χ(2) = 4.851, P < 0.05). In multivariate analysis, surgical stage III (RR = 2.480, 95%CI: 0.857 - 7.173) and resection margin (RR = 2.576, 95%CI: 0.474 - 14.011) were independent prognostic factors. The mean MSTS 93 score for all the patients was 63.3%. The complication rate in patients treated with surgery was 29.0% (9/31). CONCLUSIONS: Patients with Ewing'sarcoma of the pelvis can benefit from multidisciplinary treatment in terms of improved survival, acceptable functional results and reasonable complications. Surgical staging and resection margin are independent prognostic factors.

Intralesional excision versus wide resection for giant cell tumor involving the acetabulum: which is better?

BACKGROUND: Because of the anatomic complexity of the pelvis, there is no standard surgical treatment for giant cell tumors (GCTs) of the pelvic bones, especially in the periacetabular region. Treatment options include intralesional curettage with or without adjunctive techniques and wide resection. The best surgical treatment of a pelvic GCT remains controversial. QUESTIONS/PURPOSES: We compared wide resection and intralesional excision in terms of (1) local control, (2) function, and (3) complications. METHODS: We retrospectively identified 27 patients with periacetabular benign GCTs who underwent surgery from July 1999 to July 2009. Intralesional surgery was performed in 13 patients and wide resection in 14 patients. We determined surgical complications, local disease control, and Musculoskeletal Tumor Society (MSTS) 93 functional score. The minimum followup was 18 months (mean, 50 months; range, 18-121 months). RESULTS: Four of 13 patients who had intralesional surgery and none of 14 who had wide resection had local recurrence. The mean functional score was 24 for the 13 patients who underwent intralesional surgery and 22 for the 14 patients who had wide resection. One minor and one major complication occurred among patients who underwent intralesional surgery and one minor and six major complications occurred among patients who underwent wide resection. CONCLUSIONS: Even with a higher complication rate with wide resection and prosthetic reconstruction, we believe the lower local recurrence rate makes wide resection a reasonable option for patients with extensive and/or aggressive GCTs involving the acetabulum. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.