Transthoracic exposure for anterior spinal surgery.

The anterior approach to the vertebral column is used to treat fractures, spinal deformities, and destructive lesions secondary to tumor or infection. The thoracic surgeon, working with orthopedic surgeons and neurosurgeons, is uniquely qualified to provide surgical exposure expediently and assist in postoperative care. Forty-five patients with spinal deformities secondary to trauma (18 patients), congenital anomalies (16 patients), neoplastic disease (7 patients), and inflammation (4 patients) were treated by a transthoracic (37 patients) or thoracoabdominal (10 patients) anterior approach to the vertebral column. Two patients had subsequent operations. Free and vascularized rib grafts were used for stabilization and fusion with good results and few complications (8 patients). These results indicate that interspecialty cooperation results in expedient surgical exposure and good postoperative care.

Resection and reconstruction for primary neoplasms involving the innominate bone.

Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.

Developmental defects of the distal femoral metaphysis.

The posteromedial aspect of the distal end of the femur in the area of insertion of the adductor magnus is the site of occurrence of a developmental defect that may have the roentgenographic characteristics of a malignant bone tumor. As it is asymptomatic, this common defect is almost always an incidental finding, but it has been confused with osteosarcoma. The lesion is thought to be due to trauma or the avulsion of small bits of bone at the site of insertion of the adductor magnus muscle. Histologically the lesion has been mistaken for osteosarcoma because of the immature reactive bone and fibrous tissue presnet. It is usually possible to identify these defects roentgenographically and avoid biopsy.

Surgical management of isthmic spondylolisthesis.

In order to determine the factors that produce a successful outcome in the surgical management of spondylolisthesis, 44 consecutive patients who underwent surgical treatment were reviewed. Preoperative evaluation was directed towards determining the presence or absence of nerve root compression. The patients without nerve root compression typically underwent fusion alone, while those with evidence of nerve root compression had decompression and fusion. After an average 36-month follow-up, results were good in 78%, fair in 18%, and poor in 4%. There were five complications, all of which were successfully managed. Two patients required reoperation for pseudoarthrosis. An eventual 100% fusion rate was achieved. Results in the patients with Grade III or Grade IV olisthesis were nearly equivalent to the less severe cases. Nine patients received allograft, with a fusion rate equal to the 32 receiving autogenous bone. This study suggests that in patients who have isthmic spondylolisthesis with mechanical lumbar symptoms only, or in patients with low-back pain with radicular extremity pain caused by nerve root irritation, fusion alone is indicated. In patients with documented radiculopathy resulting from nerve root compression, decompression in addition to fusion is indicated.

Resection arthrodesis of the knee for sarcoma: preliminary results.

The surgical removal of malignant bone tumors of the knee requires the generous removal of large segments of femur and tibia with large cuffs of surrounding musculature. This type of resection does not leave the necessary muscles and soft tissue for a functioning knee joint, either through the use of a large custom-made total knee replacement or a large cadaver homograft. Arthrodesis of the knee with an intramedullary rod and segmental bone grafting is a method to reconstruct the large defects remaining after this type of resective surgery. The technique may also have good application in the salvage of failed total knee replacements. Fifteen patients have undergone resection of sarcomas in the bones of the knee area followed by reconstruction with an intramedullary rod and grafting of the gap left by the resected sarcoma. Tumor has been controlled locally in all but one case, which involved prior contamination before our treatment of the patient. Twenty-six of the 28 segmental grafts, which averaged 21.6 cm, have gone to primary bone union. There have been two infections, two fractures-one of the graft and one of the donor site-and two patients with excessive shortening of the grafted segment. The limiting factor in the length of the resection possible is the narrow diameter at the isthmus of the femur and length of the fibular graft available. Updated techniques have decreased the incidence of surgical complications. It appears from this study and experimental studies that large autografts will heal in the face of preoperative and postoperative Adriamycin chemotherapy. It is our conclusion that resection arthrodesis of the knee is a functional reconstructive method for patients requiring extensive resection of sarcoma of the mid to distal femur and proximal tibia.

Skip metastases in osteosarcoma: recent experience.

Osteosarcoma associated with a skip metastasis (SM) is a rare occurrence. The impact of modern chemotherapy on this entity has not been previously reported. This paper presents three cases treated by primary amputation and postoperative chemotherapy. All patients developed typical pulmonary and subsequent bony metastases. The average disease-free interval was 6.7 months. None appeared to benefit either from intensive chemotherapy or thoracotomy. The disease disseminated extensively in all three patients without radiologic or clinical response to the varied chemotherapeutic or additional surgical procedures. We conclude that a SM is a grave prognostic sign despite modern adjuvant modalities and suggest that a different therapeutic strategy is required.

Treatment of benign lesions of the femoral head and neck.

Benign lesions of the proximal femur usually weaken the supporting framework in the femoral neck. Of seven patients aged 11 through 26 years with the diagnosis of fibrous dysplasia (four), aneurysmal bone cyst (two), and simple bone cyst (one), six were treated with curretage and an autogenous fibula strut graft in conjunction with a sliding hip screw. One patient was treated with only the curretage and strut graft. The functional results were excellent (five), good (one), and fair (one), with no local recurrence. In treating fibrous dysplasia, dysplastic bone should be supplemented with grafts of cortical bone. This construct provides increased strength and prevents deformity and fracture, but it does not eradicate the disease. Internal fixation promotes union of the cortical graft to the host cancellous bone. The sliding screw stabilizes the bone and eliminates the need for plaster casts.

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.

A large parosteal osteosarcoma with transformation to high-grade osteosarcoma: a case report.

This case of a large (31 cm) parosteal osteosarcoma had x-ray documentation 4 1/2 years before treatment. When the tumor began enlarging rapidly, treatment was sought. The tumor histologically showed typical parosteal osteosarcoma as well as malignant cartilage, osteoid, and undifferentiated sarcoma. The case shows one course a parosteal osteosarcoma can take over a 7-year untreated period. The significance of high-grade sarcoma and intramedullary involvement is discussed. When unequivocal high-grade osteosarcoma is present, it should be treated with radical resection and adjuvant multi-drug chemotherapy.

Pancreatic metastases in bone sarcomas: CT demonstration.

Two patients with bone sarcomas were found to have pancreatic masses on routine follow-up CT. Although pancreatic metastasis most often occurs in a setting of widely disseminated disease, it may occur as an isolated finding, most often asymptomatic. It may also be responsible for clinical pancreatitis. Both of these presentations have significant implications for further management.

Preoperative regional chemotherapy and rapid-fraction irradiation for sarcomas of the soft tissue and bone.

Conventional treatment for high grade and large sarcomas uses a radical surgical approach, including amputation, in many patients. We evaluated a limb-sparing treatment approach using preoperative regional Adriamycin chemotherapy and rapid-fraction radiation therapy. Thirty patients with soft tissue or skeletal sarcoma were treated in a prospective, nonrandomized clinical trial to evaluate local disease control and limb salvage in these patients who would otherwise require amputation or face a high risk of local recurrence with surgical excision. Almost all patients had large tumors with grade III histologic findings. All patients had a three day intra-arterial regional chemotherapy infusion with Adriamycin (100 milligrams total dose), followed within ten days by rapid-fraction irradiation (3,000 rads over a two week period) prior to surgical excision of the tumor. The size and location of the sarcoma permitted only a marginal resection in one-half of the patients, while the remainder could be excised in a three dimensional en bloc manner. Almost all patients received post-operative systemic Adriamycin chemotherapy (450 milligrams per square meter given intravenously over a six month period). Two of six patients with significant wound complications later required amputation. Only one patient (3 per cent) has had a local recurrence of sarcoma develop after a mean follow-up of 22 months (range nine to 42 months), and 90 per cent of the patients have a useful extremity. The three year survival rate was 68 per cent for soft tissue sarcomas, compared with an expected survival rate of 38 per cent for published historical control studies. The patient with osteogenic sarcoma has a projected 83 per cent survival rate at 18 months after treatment. This multimodality approach is an effective treatment for local disease control in patients with high risk sarcoma. It permits limb salvage in most patients without compromising the survival rates.

Metal-induced sarcoma. A case report and literature review.

The overall biocompatibility characteristics of metallic implants are important considerations in orthopedic surgery. A review of the literature shows very few reports of neoplasms in association with metallic implants. This case report demonstrates osteogenic sarcoma at the site of a Smith-Petersen nail that had been implanted for nine years in a 65-year-old woman for fixation of a femoral neck fracture. Gross examination revealed debris at the tumor site, with a concentration of 14 ppm of nickel within the tumor tissue. Experimental investigations support the possibility of neoplastic induction by heavy metals, particularly cobalt, cadmium, and nickel. Circumstantial evidence shows osteogenic sarcoma that developed at the site of this device, possibly in response to metal or factors at the site of metal.

Periosteal osteosarcoma.

An analysis of 6 patients with periosteal osteosarcoma treated by the authors along with a review of 55 patients reported in the literature demonstrates that periosteal osteosarcoma is distinctly different from conventional osteosarcoma or periosteal chondrosarcoma. Periosteal osteosarcoma is a less aggressive tumor than conventional osteosarcoma. It is a relatively well-differentiated chondroblastic osteosarcoma occurring on the surface of the long bones of the extremities. Three patients demonstrated frank medullary invasion of tumor, two grossly and one microsurgically. Patients treated with marginal resection had a 70% local recurrence rate. Patients receiving wide resection or primary amputation have survived longer with less recurrence of disease. Overall, 10 of 61 patients are dead with metastatic disease with a mean reported follow-up of 6 years and 7 months. Adjunctive therapy has been of no demonstrable aid in terms of prolonging survival. Medullary extension of this tumor should not be used to exclude this diagnosis. The authors believe that the treatment of choice is wide resection without adjunctive chemotherapy.