Martin Malawer

Cryosurgery and acrylic cementation as surgical adjuncts in the treatment of aggressive (benign) bone tumors. Analysis of 25 patients below the age of 21.

This article reviews the clinical experience with cryosurgery (use of liquid nitrogen) and acrylic cementation (polymethylmethacrylate; PMMA) in the treatment of aggressive, benign bone sarcomas and the biologic basis of this technique. The results of 25 patients below the age of 21 treated by cryosurgery, with an average follow-up period of 60.8 months, are reported. Three approaches to surgical reconstruction were used: Group 1 (four patients) had cryosurgery with no reconstruction, Group 2 (13 patients) had bone graft reconstruction alone, and Group 3 (eight patients) had composite osteosynthesis with internal fixation, bone graft, and/or PMMA. The overall control rate was 96% (one recurrence). The tumor types were giant-cell tumor, chondroblastoma, aneurysmal bone cyst, and malignant giant-cell tumor. Nineteen lesions involved the lower extremity, and six lesions were located in the upper extremity. There were two secondary fractures (8%), one local flap necrosis, and one synovial fistula. There were no infections. Two epiphyseodeses were performed. The functional results were excellent (83%), good (13%), and fair (4%). The technique of composite osteosynthesis is recommended for all large tumors of the lower extremity. Cryosurgical results compare favorably with those obtained by en bloc resection and demonstrate the ability of cryosurgery to eradicate tumors while avoiding the need for extensive resections and reconstructive procedures.

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 studys institutions. The classification is proposed as a means of establishing a uniform terminology in the comparison of such data.

Postoperative infusional continuous regional analgesia. A technique for relief of postoperative pain following major extremity surgery.

A new technique using postoperative infusional continuous regional analgesia (PICRA) for postoperative pain relief was investigated in 23 surgical patients treated by amputation (12 patients) or by limb-salvage resection operations (11 patients). Bupivacaine was delivered into peripheral nerve sheaths via catheters placed therein at the time of surgery. Only patients in whom the nerves were easily accessible were treated. Catheters were placed in the axillary sheath, the lumbosacral trunk, and the femoral nerve sheaths of patients treated with shoulder girdle and pelvic procedures (resections and amputations), and within the sciatic nerve sheath of those treated with lower extremity procedures. The anesthetic agent was delivered at controllable rates. Regional analgesia was obtained in the operative site with minimal motor or sensory decrease. To assess the efficacy of this technique, the results of this study group were compared with those of a matched group of 11 patients treated with similar surgical procedures but who received epidural morphine. Eleven of the 23 patients on PICRA required no supplemental narcotic agents. The mean level of the narcotic agents required by the remaining 13 PICRA patients was approximately one third of that required by the matched group of 11 patients receiving epidural morphine. Overall, the patients on PICRA had an 80% reduction of narcotic requirements when compared to the historical controls. The technique is reliable and can be performed by the surgeon, requiring about a ten-minute increase in operating time. It has potentially wide application in orthopedics in procedures in which the major nerves are easily accessible (e.g., pelvic fractures and revision hip surgery) and for patients with intractable pain of the extremities.

Bone and Soft-tissue Sarcomas: Epidemiology, Radiology, Pathology and Fundamentals of Surgical Treatment

An understanding of the basic biology and pathology of bone and soft-tissue tumors is essential for appropriate planning of their treatment. This chapter reviews the unique biological behavior of soft-tissue and bone sarcomas. which underlies the basis for their staging, resection, and the use of appropriate adjuvant treatment modalities. A detailed description of the clinical, radiographic, and pathological characteristics for the most common sarcomas is presented.

Biopsy of Musculoskeletal Tumors

Biopsy is a key step in the diagnosis of bone and soft-tissue tumors. An inadequately performed biopsy may fail to allow proper diagnosis, have a negative impact on survival, and ultimately necessitate an amputation to accomplish adequate margins of resection. Poorly performed biopsy remains a common finding in patients with musculoskeletal tumors who are referred to orthopedic oncology centers. The principles by which an adequate and safe biopsy of musculoskeletal tumors should be planned and executed are reviewed and a surgical approach to different anatomic locations is emphasized.

Below-knee Amputation

Below-knee amputation is usually performed for extensive high-grade soft-tissue sarcomas of the lower leg, ankle or foot. Primary bone sarcomas rarely occur in these locations. Extensive infiltration of tendons and ligaments and around bones in this area may preclude a functional extremity following wide excision. The almost universally good functional outcome of below-knee amputation makes it an even more realisticoption. General considerations that were discussed for above-knee amputation also apply for below-knee amputation; design of skin flaps is determined by the anatomic extent of the individual tumor and the large majority of these patients heal uneventfully. Emphasis is on flap design and meticulous dissection, use of continuous epineural analgesia, myodesis of the major muscle groups of the distal tibia, meticulous wound closure, and application of a rigid dressing.

Review of Endoprosthetic Reconstruction in Limb-sparing Surgery

Endoprosthetic replacement of segmental skeletal defects is the preferred technique of reconstruction after resection of bone sarcomas. Today, all of the major anatomic joints with their adjacent segmental bone can be reconstructed safely and reliably with a modular endoprosthetic replacement. Prosthetic reconstruction is routinely performed for the proximal femur, distal femur, total femur, proximal tibia, proximal humerus, and scapula. Allografts are rarely used.

The Biology and Role of Cryosurgery in the Treatment of Bone Tumors

The application of liquid nitrogen as a local adjuvant to curettage in the treatment of bone tumors was first introduced three decades ago. This technique, termed cryosurgery, was shown to achieve excellent local control in a variety of benign-aggressive and malignant bone tumors. However, early reports showed that cryosurgery has been associated with a significant injury to the adjacent rim of bone and soft tissue, resulting in high rates of fractures and infections. These results reflected an initial failure to appreciate the potentially destructive effects of liquid nitrogen and establish appropriate guidelines for its use. This chapter reviews the biological effect of cryosurgery on bone, surgical technique, and current indications for its use.

Musculoskeletal surgery for cancer : principles and techniques

Surgical treatment of soft tissue sarcomas of the extremities osteogenic sarcoma staging, pathology, and radiology of musculoskeletal tumours rehabilitation of patients with extremity sarcoma phantom limb pain combined wide local excision plus high-dose radiation for sarcoma induction chemotherapy for sarcomas of the extremities posterior flap hemipelvectomy anterior flap hemipelvectomy internal hemipelvectomy the abdominoinguinal incision for the resection of pelvic tumour buttockectomy summary of alternative approaches to hemipelvectomy hip disarticulation sacrectomy above-knee amputation distal femoral resection for sarcomas of bone below-knee amputation limb-sparing surgery for malignant tumours of the proximal tibia adductor muscle group excision quadriceps muscle group excision resection of the posterior compartment of the thigh forequarter amputation radical forequarter amputation with chest wall resection above-elbow amputation scapulectomy - type III shoulder girdle resection shoulder girdle resections - the Tikhoff-Linberg procedure and its modifications summary of alternative approaches to forequarter amputation below-elbow amputation the surgical treatment of metastatic bone disease.

Pelvic Resections (Internal Hemipelvectomies)

Internal hemipelvectomies involve resection of part or all of the innominate bone with preservation of the extremity. This chapter will describe the surgical technique of resection of the ilium (Type I pelvic resection) and the pubic region (Type III pelvic resection).These resections do not violate the hip joint and minimally compromise the stability of the pelvic girdle, and therefore do not require reconstruction. Detailed preoperative evaluation and meticulous surgical dissection are crucial because of the close proximity of the pelvic girdle to major blood vessels, nerves, and internal organs in these regions. The surgical technique of Type II (periacetabular) resection is described in Chapter 28.