Richard Whitehill

Pelvic recurrence of rectal cancer. Options for curative resection.

Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to re-resection by conventional methods. A method to permit a composite resection of these using the abdominal sacral approach has been described previously. This report updates that experience with resection of pelvic recurrence of rectal cancer in 28 patients. Of these, 24 were done with curative intent, and four were done for palliation (mainly for infected or fungating tumor). All patients had extensive preoperative evaluation by clinical and radiologic tests, and most patients had a long free interval period of approximately 18 months, after their primary resection. Although 47 patients had exploratory surgery, only 29 had local disease amenable to resection and four had palliative resections. About half the patients had had an abdominoperineal resection, half had had an anterior resection, and one third had had previous efforts to resect the recurrence. All but one patient had been irradiated with 3000-11,000 cGy. All but two patients (of the 24 curative efforts) required a formal abdominosacral resection (through S1-2 in 12, S2-3 in 9, and S4-5 in 1). Over half the patients also required a bladder resection. There were three operative deaths (12%); one patient had a cardiac death immediately after operation and two were septic deaths at 35 and 60 days. The survivors generally had relief of sacral root pain and good motor function; most of those previously employed could return to work. The actuarial 5-year survival rate is 25% and median survival is 36 months. Long-term survival over 48 months was recorded in five of 21 surgical survivors (23.8%). Survival in a historic comparative group of 30 patients treated for local recurrence only (mainly by radiation) was 15 months median, and at 5 years the survival rate was 3% (p less than 0.001). In conclusion, selected patients with pelvic recurrence of rectal cancer may be retrieved by and returned to functional life with the composite abdominosacral resection.

The nonsurgical management of odontoid fractures in adults.

Twenty-five odontoid fractures that were treated nonsurgically at the University of Virginia Hospital in the last 5 years were reviewed. Motor vehicle accidents were the major cause of this injury in our series. Early recognition and firm external stabilization of Type I and Type III fractures of the odontoid resulted in union in 100% of our patients. There were 12 Type II fractures with a nonunion rate of 42%. Thus, an overall rate of union of 80% was obtained. It is suggested in the literature and by this series that early recognition, reduction, and rigid external Immobilization of Types I and III fractures of the odontoid should promote bony union. Type II fractures may also be managed successfully by closed methods, although the outcome is less certain.

Carcinoma of the breast metastatic to the skeleton.

A review of 319 patients with breast carcinoma metastatic to the skeleton revealed a large variation in age at diagnosis, interval between diagnosis of primary disease and metastasis, and survival time with metastasis. The presence of bony metastasis only is a good prognostic sign, and the presence of neurologic defects without successful correction is a poor prognostic sign. Bone lesions are radiosensitive, and fractures usually heal with radiation. It is difficult to define impending fractures, but large lytic lesions, increased body weight, increased activity, and areas of high stress are factors that can be used to determine the risk of fracture. Femoral neck fractures should be treated by endoprostheses or total hip arthroplasty and femoral shaft fractures by appropriate internal fixation. In the present series humeral fractures were successfully managed conservatively, but it is possible that with a wider data base the advantages of immediate rigid fixation by internal fixation with methylmethacrylate cement would be more obvious. Use of methylmethacrylate should be restricted to patients with short-term survival expectancies and large defects. Most spinal metastases can be treated by radiation and orthoses, but an aggressive approach is indicated for patients with neurologic deficits. Laminectomy is indicated for lesions that produce posterior compression, anterior decompression for lesions producing anterior compression, and stabilization for alignment deformities or instability.

The Evolution of Stability in Cervical Spinal Constructs Using Either Autogenous Bone Graft or Methylmethacrylate Cement: A Follow-Up Report on a Canine In Vivo Model

Thirty-six adult mongrel dogs underwent either a posterior C4–CS bone graft or methylmethacrylate–cerclage wire construction procedure to simulate the analogous human stabilization procedures. The dogs were divided into groups of six and allowed to live 1, 2, or 3 months after surgery. At the appropriate time they were killed and their C4–C5 spinal segments excised and studied radiologically, mechanically, and histologically. In addition, the C4–C5 spinal segments from 15 other mongrel dogs were excised and either left intact as normal (five) or prepared as one of the two constructs (five each) described above. They were also tested mechanically to provide immediate postoperative stability data. At some time during the first postoperative month the methylmethacrylate constructs lost mechanical stability. In addition, fibrous tissue was noted to have grown between the posterior laminal surface and the cement mass during this same time. Radiologically, loosening was obvious by the second postoperative month. The bone graft constructs were mechanically equivalent to or superior to the normal dogs by the second postoperative month. Likewise, they were well on their way to solid fusion radiologically and histologically by the same time. Impressed by the rapidity of deterioration in mechanical stability for the methylmethacrylate constructs, the authors further questioned their usefulness in cases of traumatic cervical spinal instability. The bone graft constructs continued to appear to be a reliable way to achieve ultimate spinal stability.

The use of methylmethacrylate cement as an instantaneous fusion mass in posterior cervical fusions: a canine in vivo experimental model.

The authors previously predicted the failure of posterior cervical fusions utilizing methylmethacrylate cement as an instantaneous “fusion” mass, based on research using an in vitro canine experimental model. This report describes the results of in vivo canine studies on the same subject. Three groups of dogs had application of a posterior C4-C5 20-gauge cerclage wire and autologous lilac crest bone graft; application of a posterior C4-C5 20-gauge cerclage wire and methylmethacrylate cement; or application of a C4-C5 20-gauge cerclage wire only. This group represented the control group. The dogs were allowed to live for 3 months postoperatively, at which time they were killed and their spine fusions studied radiologically, mechanically, and histologically. Five of the bone fusions united solidly radiologically. Their flexion stability was statistically superior to the others. Histologic studies confirmed solid union of the fusion mass to the underlying bone. Four of the six methylmethacrylate fusions demonstrated cerclage wire fracture and methacrylate-bone separation by the second postoperative month. At the time the dogs were killed, their flexion stability was statistically inferior to the bone fusions and tended to be inferior to the controls as well. Histologically, fibrous tissue was noted to have grown between the methacrylate “fusion” mass and the underlying bone. This work provides a mechanical explanation for the well-known success of the traditional bony fusion. It further supports our original prediction regarding the failure of methylmethacrylate “fusions”.

Reconstruction of the cervical spine following anterior vertebral body resection: a mechanical analysis of a canine experimental model.

In some quadriplegic patients whose acute spinal injury consists of a vertebral body fracture with bony retropulsion anteriorly and ligamentous damage posteriorly, It is appropriate to perform a decompression of the injured spinal cord by excision of the fractured body. Reconstruction of such a spine to achieve immediate and ultimate stability can be quite difficult. This is a report of mechanical testing using a canine in vitro experimental model to simulate different general types of reconstruction systems applicable to the spine destabilized as above. The results explain some of the previously noted failures of the traditional anterior strut grafting procedures. In addition, one of the reconstruction systems tested (anterior and posterior tension bands compressing an anterior strut graft into place) appeared to have sufficient immediate stability to eliminate the need for a halo-vest in the post-operative period. If such a reconstruction system were to prove clinically applicable, it would be quite beneficial to the quadriplegic patient in his rehabilitation.

Posterior strut fusions to enhance immediate postoperative cervical stability

In an attempt to enhance the immediate stability of posterior interspinous fusion constructs, the authors conducted the following project. Twenty-four adult mongrel dogs underwent a posterior C4–C5 fusion using iliac crest autogenous graft and internal fixation using either ulna struts (12) or metallic struts (12) fixed into position by sublaminar wires. Half of the animals were killed at either 1 week or 3 months postoperatively, and their C4–C5 motion segments were excised and studied radiologically, mechanically, and histologically. Both fusions created immediate and 3-month stability equivalent or superior to normal C4–C5 canine spinal segments. However, three dogs were rendered completely and two dogs incompletely quadriplegic by the surgery. Clinical Relevance: Because of the relatively high rate of neurologic injury associated with these procedures in normal dogs, the authors hesitate to endorse their use in all but complete quadriplegic patients.

The treatment of fracture dislocations of the thoracolumbar spine with halofemoral traction and Harrington rod instrumentation.

Although function does not return after complete spinal cord injuries, partial recovery is possible after incomplete lesions Halofemoral traction may produce early decompression of injured neural elements in the spinal canal by anatomic realignment of the spinal column. It also acts to stabilize the very unstable thoracolumbar fracture dislocation and prevent displacement as well as further neurologic trauma. The body jacket is easy to make and apply. It allows early mobilization of patients when utilized in conjunction with the posterior spinal fusion and Harrington rod fixation.

Traumatic arteriovenous fistula of the popliteal artery associated with a closed subtrochanteric fracture: report of a case.

Major vascular injuries associated with closed fractures of the femur are rare. A 35-year-old man incurred a subtrochanteric fracture associated with an arterial injury distally. The femoral fracture type most likely to be associated with a major vascular injury is one near the junction of the middle and distal thirds of the bone. The mechanism involves tethering of the artery in the adductor hiatus. The location of the arterial injury is usually at the fracture site.