Guoxian Pei

Irregular osteotomy in limb salvage for juxta-articular osteosarcoma under computer-assisted navigation

Joint‐preserving limb salvage surgery has been expected to have good functional outcomes. However, it is still a unsolved problem to perform a joint preserving resection for patients with juxta‐articular osteosarcoma invading epiphyseal line. We determined whether irregular osteotomy under image‐guided navigation make joint‐saving resection possible for juxta‐articular osteosarcoma while adhering oncological principles.

Limb salvage surgery for calcaneal malignancy

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy increasingly possible. However, reconstructions of the calcaneal remain a major surgical challenge because of the rarity and specific anatomy of this condition.

Pelvic reconstruction with a combined hemipelvic prostheses after resection of primary malignant tumor

BACKGROUND Hemipelvic resections for primary malignant bone tumor require reconstruction to restore weight bearing along anatomic axes. However, reconstruction of the pelvic arch remains a major surgical challenge because of the high rate of associated complications. We designed a combined hemipelvic prosthetic system to reconstruct the pelvis and purpose of this investigation was to assess the oncology and functional outcome and complication rate following this procedures. METHODS we retrospectively reviewed 18 patients who had primary malignant pelvic tumor resections and reconstructions with the combined hemipelvic prosthesis using pedicle screw-rod constructs augmented with antibiotic cement in combination with a special designed acetabular reinforcement shell and hip prosthesis between 2001 and 2007. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society score. RESULTS Five (27.8%) patients had type II periacetabular pelvic resection and 5 (27.8%) had types I and II (periacetabular and ilium) pelvic resections. Six (33.3%) patients had types II and III (periacetabular and pubis) pelvic resections, 1 (5.6%) had types I and II and III resections and 1 (5.6%) had a types I and II and IV (periacetabular and ilium and sacrum) resections. Patient survival status, function, and complications were evaluated at a mean following up of 41 months (range, 7-73 months). Ten patients (55.6%) had no evidence of disease, five patients (27.7%) had died from their disease, and three patients (16.7%) were alive with disease. The overall survival rate was 72.2% at 5 years. Local recurrence occurred in four patients (22.2%). Six of 17 patients (35.3%) showed lung metastatic progression. The average MSTS 93 score was 65.5% and 71.7% at three months after surgery and at the last followup. Six (33.3%) patients had surgery-related complications including dislocation in 2, wound dehiscence in 2, deep-vein thrombosis in 1, screw loosening in 1 and sciatic nerve palsy in 1. There was no infection occurred in this series. CONCLUSIONS Pelvic reconstruction using combined hemipelvic prosthetic system after a limb-salvage resection is an acceptable method because of its lower complication and satisfactory functional outcome and its feasibility of reconstruction for any type of periacetabular tumor resection without elaborate preoperative customize. LEVEL OF EVIDENCE Level IV, therapeutic study.

Surgical treatment of clavicular malignancies

HYPOTHESIS Primary and metastatic malignancies of the clavicle are very rare, and little literature is available regarding the long-term functional and oncologic outcome after surgical treatment. To what advantage or disadvantages clavicle reconstruction following claviculectomy will lead is not clear. The hypothesis is that there is no advantage of allograft reconstruction over no reconstruction in terms of the functional outcome and complications. MATERIALS AND METHODS From 1999 to 2009, 11 patients with clavicular malignancy underwent total or subtotal claviculectomy with or without allograft reconstruction. Oncologic and functional results were assessed. RESULTS The average age at time of operation was 31.9 years. The mean follow-up time was 42.4 months. Six patients had allograft reconstruction after tumor resection, and 5 had claviculectomy alone. No local recurrence occurred. The oncologic result was continuous disease-free in 5 patients, no evidence of disease in 1, alive with disease in 2, and died of disease in 3. Patients with and without allograft reconstruction had average Musculoskeletal Tumor Society score of 92.2% vs 96.2% and Constant-Murley scores of 84.8 vs 88.8. Patients with allograft reconstruction had more complications than patients without reconstruction. DISCUSSION Considering complications, allograft reconstruction does not guarantee a satisfied patient. Total or subtotal excisions of the clavicle without reconstruction for malignancies are rarely associated with a clinically significant loss of function. Furthermore, the average time of full use of upper limb was slower in patients with reconstruction compared with those without reconstruction. CONCLUSIONS Clavicular malignancies had poor prognosis, although claviculectomy could provide good local tumor control. Allograft reconstruction after claviculectomy was not justified for malignancies in terms of its functional outcomes as well as complications.

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.

Precise resection and biological reconstruction under navigation guidance for young patients with juxta-articular bone sarcoma in lower extremity: preliminary report.

Background: It is a challenge to perform a joint-preserving resection for young patients with juxta-articular bone sarcomas. We determined whether osteotomy under image-guided navigation make joint-saving resection possible for juxta-articular lesions while adhering oncological principles. Methods: Between June 2008 and July 2010, joint-preserving limb salvage surgeries were performed on 9 patients with juxta-articular bone sarcomas under navigation guidance. Computed tomography/magnetic resonance imaging fusion images were used for real-time navigation. Eight lesions located around the knee and 1 in hip. Six tumors extend to and 3 beyond the epiphyseal line. Planned osteotomy under image-guided navigation was employed for achieving clear surgical margin while maximizing host tissue preservation. All tumors were en bloc removed and intercalary defect were reconstructed by combination of allograft with vascularized fibula graft. All specimens were examined for resection margin. Patients were followed up for an average of 25.2 months for evaluating of functional and oncology outcomes. Results: Entire joint were preserved in 6 patients and part of joint were saved in another 3 patients. The mean registration error for navigation was 0.40 mm (range, 0.31 to 0.62 mm). Clear surgical margin was obtained in all specimens. The average closest distance between the osteotomy line and tumor edge was 9.6 mm (range, 6 to 14 mm). Entire joint cartilage was preserved in 6 patients and portion of joint were saved in 3 patients (2 in proximal tibia, 1 in distal femur). No patient experienced local recurrence. Two patients developed lung metastasis. One died of disease and the other underwent metastasectomy and had no evidence of disease at the most recent follow-up. All reconstruction was in situ with the Musculoskeletal Tumor Society average score of 26.7 at final follow-up. Conclusions: With careful patient selection, image navigation–assisted surgery made it possible to resect the bone exactly as planned in length and orientation in the magnetic resonance imaging image, yielding a clear margin and preserving the entire or part of the articular cartilage in joint-sparing limb salvage procedures for treating skeletally immature patients with juxta-articular bone sarcomas. Level of Evidence: Level IV—therapeutic study.

Composite biological reconstruction following total calcanectomy of primary calcaneal tumors

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy or aggressive benign tumor increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition.

Precise resection and biological reconstruction for patients with bone sarcomas in the proximal humerus.

BACKGROUND It is a challenge to perform a joint-preserving resection for patients with bone sarcomas in the proximal humerus. We determined whether osteotomy under navigation guidance made joint-saving resection possible for juxtaarticular humeral sarcomas while adhering to oncological principles. METHOD Between January 2008 and July 2010, joint-preserving surgeries were performed on six patients with proximal humeral sarcomas under navigation guidance. Five tumors extended to, and one extended beyond, the epiphyseal line. Planned osteotomy under image-guided navigation was employed to achieve a clear surgical margin while preserving the humeral head and rotator cuff. All tumors were removed en bloc and intercalary defects were reconstructed by a combination of allograft and vascularized fibula graft. All specimens were examined for resection margin. Patients were followed up for an average of 19.1 months. RESULTS The entire glenohumeral joint was preserved in five patients and part of the humeral head was saved in one patient. Clear surgical margin was obtained in all specimens. The minimum closest distance between the osteotomy line and tumor edge was 7 mm. No patient experienced local recurrence. One patient developed lung metastasis and was alive with disease. The mean Musculoskeletal Tumor Society (MSTS) 93 score was 92.1%. All reconstruction was in situ at final follow-up. CONCLUSION With careful patient selection, image navigation-assisted surgery made it possible to excise the bone exactly as seen in orientation in magnetic resonance imaging (MRI) image, yielding a clear margin and preserving all or part of the humeral head in limb salvage procedures for patients with juxtaarticular bone sarcomas in proximal humerus. LEVEL OF EVIDENCE Therapeutic study; Level IV.