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PubMed1986

Segmental amputation with re-implantation in the treatment of malignant bone tumours of the limbs.

Stage 2 B malignant skeletal tumours are currently treated by amputation or disarticulation of the limb. The present paper describes a surgical technique for complete removal of the neoplasm and surrounding soft tissues by resection of a cylinder of the limb complete with skin. The resection of bone and adjacent soft tissues is extended sufficiently proximal and distal to the neoplasm to ensure complete removal of neoplastic tissue. The authors describe two cases; an osteosarcoma of the distal third of the femur and a malignant fibrous histiocytoma of the lower radius. After removing the affected cylinder of the limb, osteosynthesis is performed by one of a variety of methods. The main vessels and nerves are dealt with according to the findings revealed by pre-operative investigations or per-operative findings. If they have to be sacrificed, end to end suture is performed, but if main nerves can safely be spared (as in Case 1) it greatly enhances the functional prognosis. The value of this operation is that it is as radical as amputation while the aesthetic and functional results are equivalent to those of a resection-arthrodesis. The operation has therefore been designated segmental amputation.

Adult↗
PubMed1988

AO/ASIF plate for mandibular reconstruction in tumor surgery: results in 20 cases.

Between May, 1983, and February, 1987, the authors performed mandibular reconstruction using an AO/ASIF plate in 20 patients. Apart from accurate modelling of the resected segment using a template, the key features of the technique include firm fixation and wrapping the plate with pectoralis major muscle. In 19 cases the plate was inserted at the same operation as the resection of a malignant neoplasm. In 10 cases the anterior mandibular osteotomy was placed on the far side of the midline, while in five the mandible was disarticulated through the temporomandibular joint. Eleven patients are alive (average survival 22 months) and nine have died (average survival 10 months). Two AO/ASIF plates have required removal because of exposure, while in three patients limited plate exposure was corrected with a minor surgical procedure. Seven patients had soft tissue complications that were managed conservatively. Nine of the patients had been irradiated previously. Five patients were fitted with dentures successfully. The authors believe that this technique provides a safe, rapid, functional and esthetically satisfactory method of mandibular reconstruction in the patient undergoing surgery for malignant disease.

Adult↗
PubMed1977

Crepitant cellulitis and myonecrosis caused by Klebsiella.

A fatal case of crepitant cellulitis with myonecrosis, the first caused by Klebsiella pneumoniae, is reported. The infection started in the left thigh but progressed rapidly despite appropriate antibiotics and surgery, which included incision and drainage and later a left-hip disarticulation. This case emphasizes that nonclostridial crepitant cellulitis is potentially severe and that the presence of myonecrosis is an indication for early radical surgery.

Cellulitis↗
PubMed1988

[Surgical treatment for malignant soft tissue tumors of the hip].

Surgical treatment for malignant soft tissue tumors has resulted in a marked improvement in the grading of lesions, utilizing the surgical staging system introduced by Enneking. We attempted to divide malignant soft tissue tumors of the hip into four compartments; the anterior compartment, medial compartment including the neovascular bundle, posterior compartment including the sciatic nerve, and intra-bony lesions with tumors. A lesion localized in the anterior compartment would be resected with a wide margin. For resection of a lesion localized in the medial compartment, vascular reconstruction must be performed with replacement using artificial vessels for the femoral vein and the saphena magna femoral artery. As for the posterior compartment, for the lesions are easily resected with or without the sciatic nerve. In the last compartment of intra-bony lesions, disarticulation or endoprosthesis replacement after wide-resection surgery must be performed. In such cases, musculocutaneous reconstruction may be needed.

Adolescent↗
PubMed1987

The sphenoidal canal.

The sphenoidal canal is described in perinatal material, and was found in 57 out of 58 disarticulated human skeletal remains collected in Egypt between 1918 and 1928. The canal showed considerable variations in extent and morphology, but ran essentially from the region of the developing rostrum of the sphenoid in an anterosuperior direction to end in the tuberculum sellae, immediately behind the optic groove. The canal represents the impression left by the remnants of the sphenoidal synchondrosis between the presphenoid and postsphenoid. The arrangement suggests that as a growth area this synchondrosis is of limited importance once the perinatal period is reached. The spatial relationship between craniopharyngeal and sphenoidal canals is described.

Egypt↗
PubMed1987

[Dangers of ischiectomy in ulcers in the paraplegic patient. Review of 236 records].

Two hundred and thirty-six paraplegics were operated on for unilateral or bilateral ischial ulceration between 1956 and 1981. A study was made of the long-term results, of the development of recurrences or bilateral involvement in unilateral lesions, of secondary complications and of their treatment and consequences. A distinction was made between procedures involving removal of the ischium and those with preservation of bone. The results, with a follow-up of one to 28 years were less satisfactory after extensive bony resection. Recurrence reached 50 per cent and a contralateral ulcer developed in up to 50 per cent. In contrast, when the ischium was preserved, these figures were respectively 20 per cent and 10 per cent. Complications such as the appearance of other pressure sores, or of perineal or urethral lesions occurred in 50 per cent of cases in which both ischia were resected but did not reach 15 per cent if the ischia were preserved. The analysis of these complications, their etiology and their outcome, with eleven deaths and two disarticulated hips implies the need to treat these ulcerations without removing the ischium. Infection and osteomyelitis can be healed without sacrifice of bone with at most one or two procedures preceding a plastic procedure. Myocutaneous flaps can be used to fill the lesions and to cover the bone with the help of proximal mobilisation of the hamstring muscles.

Adolescent↗
PubMed1986

Hip rotationplasty for malignant tumors of the proximal part of the femur.

Disarticulation of the hip and hemipelvectomy have been the only surgical alternatives available for the adequate local control of malignant tumors of the proximal part of the femur in patients who are still growing. The use of proximal or total femoral implants is restricted to patients who have reached skeletal maturity. To improve the quality of survival for patients who have not yet reached skeletal maturity and have a malignant tumor of the proximal part of the femur, I have modified the rotationplasty procedure described by Van Nes for use in such lesions. After en bloc resection of the tumor, the distal part of the femur with the knee joint and leg is rotated 180 degrees and fixed to the lateral side of the pelvis. The knee joint then functions as a hinge hip joint and the ankle joint functions as a knee joint. This procedure was performed in eight patients, three of whom were followed for more than two years. All patients walked well with a prosthesis and the functional results were excellent. At the time of writing, there had been no recurrence of a tumor or pulmonary metastasis.

Adolescent↗
PubMed1986

[Mandibular reconstruction following extensive unilateral resection in children].

Follow up 30 months after extensive bone resection of mandible with disarticulation of condyle for widespread tumor of angle in a 9 1/2 year old child showed very satisfactory functional and esthetic bone reconstruction. Favorable elements were: conservation of periosteum made possible from results of histology of fresh specimen (showing eosinophil granuloma); the immediate insertion of a temporary prosthesis in strengthened resin to maintain anatomical relations and spontaneous functions.

Child↗
PubMed1986

[Pre- and postoperative anatomo-clinical correlations apropos of 30 conservative resections of osteogenic sarcomas. Surgical inferences].

The extent of osteogenic sarcoma has been measured in 30 bones obtained after local resection and compared with pre-operative evaluation. In only one case was the articular cartilage involved and the whole joint was resected. Other cases with a metaphyseal localisation were treated by disarticulation. Articular cartilage appears to provide good protection against local extension. In contrast, the growth cartilage, which was present in 11 cases, was crossed by tumour on three occasions. In only one case of diaphyseal localisation was a resection made across the tumour which had been previously rendered necrotic by chemotherapy. In most of the diaphyseal localisations, the post-operative study revealed that the resection had been over-extensive. Tomodensitometry is not very reliable in the precise evaluation of the extent of diaphyseal involvement.

Bone Neoplasms↗
PubMed1986

[Neo-adjuvant therapy in childhood osteogenic sarcoma: a pilot study of selective postoperative chemotherapy based on response to preoperative high-dose methotrexate].

"Neo-adjuvant therapy" with preoperative high-dose methotrexate (HD-MTX) and CF rescue therapy was investigated in four children with osteogenic sarcoma. Immediately after the diagnosis of osteogenic sarcoma from biopsy, the patients were treated with three to five courses of weekly HD-MTX (300 mg/kg) with CF rescue. Three patients had en bloc tumor resection and one patient underwent disarticulation of the hip joint after the pre-operative HD-MTX. The effect of HD-MTX was evaluated on the basis of pathological changes between the specimen of the primary tumor taken at biopsy and that during surgery. Two out of four patients showed marked tumor cell reduction (greater than 50%) of the specimen upon surgery. Two patients who responded to the preoperative HD-MTX were further treated with HD-MTX on a post-operative adjuvant therapy basis for 18 months. Both of these patients survived with no evidence of disease for 35.6+ and 20.9+ months. Two patients who responded poorly to HD-MTX were treated with a multi-drug postoperative adjuvant therapy including cis-platinum, adriamycin, cyclophosphamide, actinomycin D, and bleomycin. One patient had a solitary lung metastasis at 12.2 months after amputation. Wedge resection of the metastatic tumor was performed and adjuvant therapy with cis-platimum has been given for 20 months. He has remained with no evidence of disease for more than 30 months. Another patient has been receiving multi-drug neo-adjuvant therapy without any evidence of disease for 11.9 months after surgery. These data suggest that neo-adjuvant chemotherapy based on the response to preoperative HD-MTX is more useful for increasing the cure rate of childhood osteogenic sarcoma.

Adjuvants, Immunologic↗
PubMed1987

Primary reticulosarcoma of bone (non-Hodgkin's lymphoma). A study of 12 cases.

Reticulosarcoma, nowadays usually referred to as non-Hodgkin's malignant lymphoma, is a particularly rare primary bone tumour. This study includes 12 cases observed over more than 15 years. The favourable clinical course of the tumour, and the use of complementary therapy justify a more extensive use of surgical treatment. Five cases were submitted to surgery plus complementary chemotherapy; two resections of the tibia, one of the humerus, one scapulectomy and one disarticulation of the hip. The remaining 7 cases were treated by radiation therapy. The overall prognosis of the disease is not very favourable (25% survival rate) although its slow progress gives a favourable clinical impression. Treatment may, however, influence the prognosis; much better results are obtained by radical surgery with complementary chemotherapy. In one resection of the tibial diaphysis and one radical scapulectomy there was no local recurrence or metastases at 3 and 4 years follow-up, whereas cases treated previously by less radical surgery and inadequate chemotherapy, although showing no local recurrence, did result in systemic diffusion of the disease.

Adolescent↗
PubMed1987

[Anatomy and clinical aspects of sartoriusplasty].

According to Mathes and Nahai (1982) the sartorius muscle is supplied in a segmental fashion (Type IV) from six to ten branches arising from the superficial femoral artery. They state that the use of this flap is limited because of the segmental blood supply. In contrast, dissecting 40 cadaver specimens at the Anatomy Department of Munich University a different vascular anatomy was revealed in which only two to four branches from the femoral artery supply the whole muscle. Based on this pattern of intramuscular vascular connections, the most proximal arterial branch provides the blood supply to the whole muscle. Elevated on the proximal vascular pedicle the muscle can cover defects of symphysis, fill the acetabulum following disarticulation of the septic hip joint and osteomyelitic defects of femur.

Arteries↗
PubMed1987

Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations.

Total elbow arthroplasty (TEA) was used as a salvage procedure following failed open reduction and internation fixation, failed triaxial arthroplasties, and septic and aseptic loosening of implant arthroplasty. A minimally constrained bicondylar implant with a block to disarticulation was substituted for the reconstruction of 20 revision TEAs. Custom-designed implant TEA was substituted in cases with substantial bony or soft tissue loss. Revision of the polyethylene-bearing component, coupled with the addition of a yolk-type locking mechanism, was implanted when only the bearing system of a well-fixed implant had failed. TEA can be performed successfully with satisfactory durability as a revision procedure. Revision of failed open reduction internal fixation or a failed bearing system was highly successful. Revision of previously infected elbows in a single-stage procedure was unsuccessful in two of three cases and has been abandoned in favor of a staged procedure. A revision of loose TEA was successful in only three of five cases. Further investigations are necessary to improve the function durability of TEA.

Arthroplasty↗
PubMed1987

[Procedure in extensive or complete loss of bone substance of the femur following shaft loosening].

We reviewed our present method of treatment in cases of femoral bone loss. Our clinical experience with the method is based on 800 exchange operations performed at the Endo-Klinik per year. The review showed that in cases of proximal bone deficiency, custom-made protheses are increasingly required. Cemented implants are used in septic and aseptic cases but we also have had experience with a small number of cases in which reconstructive surgery was carried out using allografts and cementless shaft components. In 1.4% of revision cases total femoral replacement is required. We have had more than 12 years experience with this type of prostheses, which is available as a modular system. So far there has been no disarticulation as a result of implant failures but in some instances failure occurred due to persistent deep infections.

Bone Cements↗
PubMed1986

[Amputations of the child's foot].

Various partial foot amputations are described in detail, ranging from incomplete or total loss of one or several toes, transverse or longitudinal metatarsal amputation, proper performance of the Lisfranc's amputation (tarsometatarsal disarticulation) to Chopart's tenomyoplastic procedure, a modification of Pirogoff's procedure and an improved form of Syme's amputation (preserving most of the cartilage for better weight-bearing). Appropriate orthopedic footwear and prostheses compensating for the amputated parts of the foot and optimizing the remaining function are also presented. In most incidences, satisfying results can be achieved, especially in children. These consist of total weight-bearing of the stump, combined with minor disability from the functional point of view and an almost invisible handicap with regard to daily activities.

Amputation, Surgical↗
PubMed1986

[Reconstruction prosthesis of the upper part of the femur. Intermediate results in 20 resections for tumor. Current trends].

Twenty total hip prostheses inserted after massive resection of the upper part of the femur for tumour have been reviewed after a 3 year mean follow-up. Fifteen cases were of primary malignant tumour. The mean resection of the femur measured 175 mm in length and was reconstructed using Cochin prostheses. From the oncological standpoint, the results were comparable with those obtained after disarticulation of the hip, but the functional results were, of course, much better. Five patients were able to resume their previous professional work; 13 were able to have a normal type of life and only 2 were severely crippled. Nineteen hips were painless. Nine patients could walk without a stick, 9 used one stick for walking outside and 2 used sticks permanently. Two cases were complicated by dislocation. Despite an extensive resection of the greater trochanter, one third of the hips were stable on standing on one leg, thanks to the design of the prostheses. No prostheses broke. Two loosenings of the acetabular cup had to be revised. No loosening of the femoral stem was found, despite the frequency of osteolysis of the diaphysis to 4-5 cms below the level of resection. The authors intend now to improve the design of the prostheses and to aid the reinsertion of the muscles, which can be improved by using homografts surrounding the femoral prostheses.

Femoral Neoplasms↗
PubMed1985

Ground reaction forces and center of pressure patterns in the gait of children with amputation: preliminary report.

Ground reaction forces and center of pressure (CP) were studied during gait in children with unilateral lower extremity amputations. Five children, three with knee disarticulations and two with above-knee amputations, walked at slow, normal, and fast speeds, while wearing a conventional SACH prosthetic foot and again, while wearing an experimental CAPP prosthetic foot. Fore-aft (F-A) and vertical force (VF) components and CP patterns were examined for a total of 90 trials. Walking speed had a significant effect on both F-A and VF amplitudes. No differences, however, were found between the force amplitudes of the SACH foot and CAPP foot. Significant asymmetries were found in the force and amplitudes of a child's natural limb versus the prosthetic limb; the retarding and propelling F-A forces in the prosthetic limb were significantly less than the corresponding forces in a child's natural limb. The CP patterns during stance phase were markedly different for a child's natural limb, prosthetic limb with the SACH foot, and prosthetic limb with the CAPP foot. With the CAPP foot, the CP remained in the forefoot region during stance. In contrast with the CAPP foot, the SACH foot had a potential for producing a flexor moment at the knee joint at the initiation of the foot-ground contact. Stability in the prosthetic knee was enhanced when the children wore a CAPP prosthetic foot.

Adolescent↗
PubMed1975

[Palliative demolitive surgery].

Nine cases of untreatable tumour in which radical surgery was employed palliatively are presented. Three hemipelvectomies for recurrent rhabdomyosarcoma were performed. In one case, death occurred postoperatively, probably as a result of pulmonary embolism. One patient survived for 8 months, while the other is still alive after three years. Of two cases in which interscapulothoracic disarticulation was performed, survivals of 9 and 5 months were observed in subjects with fibrosarcoma in a mastectomy site and recurrent sarcoma of the humerus with ling metastases. Survival to 7 months was obtained in a case of sarcoma of the maxilla, while three patients with squama cell cancer of the mouth floor, chondrosarcoma of the mandible and botryoid sarcoma of the tonsillar fossa are still living after periods of 10 months to 2 yr. Though devoid of schematic indications, palliative demolition surgery can be considered in borderline cases where the operative risk is not high. Irrespective of "quantity", the "quality" of life remaining to the patients can be made compatible with the psychophysiological limits of the human personality.

Adolescent↗