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Weidlich A, Schaser KD, Weitz J, Kirchberg J, Fritzmann J, Reeps C, Schwabe P, Melcher I, Disch A, Dragu A, Winkler D, Mehnert E, Fritzsche H. Surgical and Oncologic Outcome following Sacrectomy for Primary Malignant Bone Tumors and Locally Recurrent Rectal Cancer. Cancers (Basel) 2024; 16:2334. [PMID: 39001396 PMCID: PMC11240444 DOI: 10.3390/cancers16132334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
INTRODUCTION Bone sarcoma or direct pelvic carcinoma invasion of the sacrum represent indications for partial or total sacrectomy. The aim was to describe the oncosurgical management and complication profile and to analyze our own outcome results following sacrectomy. METHODS In a retrospective analysis, 27 patients (n = 8/10/9 sarcoma/chordoma/locally recurrent rectal cancer (LRRC)) were included. There was total sacrectomy in 9 (incl. combined L5 en bloc spondylectomy in 2), partial in 10 and hemisacrectomy in 8 patients. In 12 patients, resection was navigation-assisted. For reconstruction, an omentoplasty, VRAM-flap or spinopelvic fixation was performed in 20, 10 and 13 patients, respectively. RESULTS With a median follow-up (FU) of 15 months, the FU rate was 93%. R0-resection was seen in 81.5% (no significant difference using navigation), and 81.5% of patients suffered from one or more minor-to-moderate complications (especially wound-healing disorders/infection). The median overall survival was 70 months. Local recurrence occurred in 20%, while 44% developed metastases and five patients died of disease. CONCLUSIONS Resection of sacral tumors is challenging and associated with a high complication profile. Interdisciplinary cooperation with visceral/vascular and plastic surgery is essential. In chordoma patients, systemic tumor control is favorable compared to LRRC and sarcomas. Navigation offers gain in intraoperative orientation, even if there currently seems to be no oncological benefit. Complete surgical resection offers long-term survival to patients undergoing sacrectomy for a variety of complex diseases.
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Affiliation(s)
- Anne Weidlich
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Klaus-Dieter Schaser
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, incl. Division of Vascular and Endovascular Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Johanna Kirchberg
- Department of Visceral, Thoracic and Vascular Surgery, incl. Division of Vascular and Endovascular Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Johannes Fritzmann
- Department of Visceral, Thoracic and Vascular Surgery, incl. Division of Vascular and Endovascular Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, incl. Division of Vascular and Endovascular Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Philipp Schwabe
- Department for Trauma and Orthopedic Surgery, Center for Musculoskeletal Tumor Medicine, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | - Ingo Melcher
- Department for Trauma and Orthopedic Surgery, Center for Musculoskeletal Tumor Medicine, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | - Alexander Disch
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Adrian Dragu
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Doreen Winkler
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Elisabeth Mehnert
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
| | - Hagen Fritzsche
- University Center for Orthopedics, Trauma Surgery and Plastic Surgery, Sarcoma Center at the National Center for Tumor Diseases (NCT/UCC), University Hospital Carl Gustav Carus Dresden, 01307 Dresden, Germany
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Quirion JC, Johnson SR, Kowalski BL, Halpern JL, Schwartz HS, Holt GE, Prieto-Granada C, Singh R, Cates JMM, Rubin BP, Mesko NW, Nystrom LM, Lawrenz JM. Surgical Margins in Musculoskeletal Sarcoma. JBJS Rev 2024; 12:01874474-202403000-00003. [PMID: 38446910 DOI: 10.2106/jbjs.rvw.23.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
» Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.» There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.» Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.» Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.
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Affiliation(s)
- Julia C Quirion
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel R Johnson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brooke L Kowalski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L Halpern
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Herbert S Schwartz
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger E Holt
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos Prieto-Granada
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reena Singh
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brian P Rubin
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Nathan W Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joshua M Lawrenz
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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3
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Bruschi A, Donati DM, Di Bella C. What to choose in bone tumour resections? Patient specific instrumentation versus surgical navigation: a systematic review. J Bone Oncol 2023; 42:100503. [PMID: 37771750 PMCID: PMC10522906 DOI: 10.1016/j.jbo.2023.100503] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/01/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
Patient specific instrumentation (PSI) and intraoperative surgical navigation (SN) can significantly help in achieving wide oncological margins while sparing bone stock in bone tumour resections. This is a systematic review aimed to compare the two techniques on oncological and functional results, preoperative time for surgical planning, surgical intraoperative time, intraoperative technical complications and learning curve. The protocol was registered in PROSPERO database (CRD42023422065). 1613 papers were identified and 81 matched criteria for PRISMA inclusion and eligibility. PSI and SN showed similar results in margins (0-19% positive margins rate), bone cut accuracy (0.3-4 mm of error from the planned), local recurrence and functional reconstruction scores (MSTS 81-97%) for both long bones and pelvis, achieving better results compared to free hand resections. A planned bone margin from tumour of at least 5 mm was safe for bone resections, but soft tissue margin couldn't be planned when the tumour invaded soft tissues. Moreover, long osteotomies, homogenous bone topology and restricted working spaces reduced accuracy of both techniques, but SN can provide a second check. In urgent cases, SN is more indicated to avoid PSI planning and production time (2-4 weeks), while PSI has the advantage of less intraoperative using time (1-5 min vs 15-65 min). Finally, they deemed similar technical intraoperative complications rate and demanding learning curve. Overall, both techniques present advantages and drawbacks. They must be considered for the optimal choice based on the specific case. In the future, robotic-assisted resections and augmented reality might solve the downsides of PSI and SN becoming the main actors of bone tumour surgery.
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Affiliation(s)
- Alessandro Bruschi
- Orthopaedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC 3065, Australia
| | - Davide Maria Donati
- Orthopaedic Oncology Unit, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Claudia Di Bella
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Fitzroy, VIC 3065, Australia
- Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Fitzroy, VIC 3065, Australia
- VBJS, Victorian Bone and Joint Specialists, 7/55 Victoria Parade, Fitzroy, VIC 3065, Australia
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Williamson T, Ryan S, Buehner U, Sweeney Z, Hill D, Lozanovski B, Kastrati E, Namvar A, Beths T, Shidid D, Blanchard R, Fox K, Leary M, Choong P, Brandt M. Robot-assisted implantation of additively manufactured patient-specific orthopaedic implants: evaluation in a sheep model. Int J Comput Assist Radiol Surg 2023; 18:1783-1793. [PMID: 36859520 PMCID: PMC10497442 DOI: 10.1007/s11548-023-02848-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/31/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Bone tumours must be surgically excised in one piece with a margin of healthy tissue. The unique nature of each bone tumour case is well suited to the use of patient-specific implants, with additive manufacturing allowing production of highly complex geometries. This work represents the first assessment of the combination of surgical robotics and patient-specific additively manufactured implants. METHODS The development and evaluation of a robotic system for bone tumour excision, capable of milling complex osteotomy paths, is described. The developed system was evaluated as part of an animal trial on 24 adult male sheep, in which robotic bone excision of the distal femur was followed by placement of patient-specific implants with operative time evaluated. Assessment of implant placement accuracy was completed based on post-operative CT scans. RESULTS A mean overall implant position error of 1.05 ± 0.53 mm was achieved, in combination with a mean orientation error of 2.38 ± 0.98°. A mean procedure time (from access to implantation, excluding opening and closing) of 89.3 ± 25.25 min was observed, with recorded surgical time between 58 and 133 min, with this approximately evenly divided between robotic (43.9 ± 15.32) and implant-based (45.4 ± 18.97) tasks. CONCLUSIONS This work demonstrates the ability for robotics to achieve repeatable and precise removal of complex bone volumes of the type that would allow en bloc removal of a bone tumour. These robotically created volumes can be precisely filled with additively manufactured patient-specific implants, with minimal gap between cut surface and implant interface.
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Affiliation(s)
- Tom Williamson
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia.
| | - Stewart Ryan
- Translational Research and Animal Clinical Trial Study Group (TRACTS), Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia
| | | | - Zac Sweeney
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
- Stryker, Sydney, Australia
| | - Dave Hill
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Bill Lozanovski
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Endri Kastrati
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Arman Namvar
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Thierry Beths
- Translational Research and Animal Clinical Trial Study Group (TRACTS), Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Australia
| | - Darpan Shidid
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Romane Blanchard
- Department of Surgery, University of Melbourne, Melbourne, Australia
- Orthopaedic Department, St Vincent's Hospital, Melbourne, Australia
| | - Kate Fox
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Martin Leary
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
| | - Peter Choong
- Department of Surgery, University of Melbourne, Melbourne, Australia
- Orthopaedic Department, St Vincent's Hospital, Melbourne, Australia
| | - Milan Brandt
- RMIT Centre for Additive Manufacturing, RMIT University, Melbourne, Australia
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Deng Z, Zhang Q, Hao L, Ding Y, Niu X, Liu W. Accuracy of bony resection under computer-assisted navigation for bone sarcomas around the knee. World J Surg Oncol 2023; 21:187. [PMID: 37344874 DOI: 10.1186/s12957-023-03071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Computer-assisted navigation has made bone sarcoma resections more precise. However, further clinical studies involving accuracy analyses under navigation are still warranted. METHODS A retrospective study for analysis of computer-assisted navigation accuracy was carried out. Between September 2008 and November 2017, 39 cases of bone sarcomas around the knee joint were resected under computer-assisted navigation. The control group comprised 117 cases of bone sarcomas around the knee treated by limb salvage surgery wherein bony cutting was achieved freehand. The length difference (LD) was defined as the specimen length minus the planned resection length. The LDs were detected in both groups and compared. The margin accuracy (MA) was defined as the achieved margin minus the desired margin at the bone cutting site and was detected in the navigation group. RESULTS The LDs between the postoperative specimen length and the preoperative planned length were compared. In the navigation group, the LD was 0.5 ± 2.5 mm (range, - 5 to 5 mm), while in the freehand group, the LD was 3.4 ± 9.6 mm (range, - 20 to 29 mm), with a significant difference (P < 0.01). In the absolute value analysis, the LD absolute value was 2.0 ± 1.6 mm in the navigation group and 8.3 ± 6.0 mm in the freehand group, with a significant difference (P < 0.01). In the navigation group, the MA was 0.3 ± 1.5 mm (range, - 3 to 3 mm) and the MA absolute value was 1.1 ± 1.0 mm. CONCLUSIONS Better accuracy can be achieved when computer-assisted navigation is conducted for bone sarcoma resection around the knee. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Zhiping Deng
- Department of Orthopaedic Oncology Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Qing Zhang
- Department of Orthopaedic Oncology Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Lin Hao
- Department of Orthopaedic Oncology Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Yi Ding
- Department of Pathology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Xiaohui Niu
- Department of Orthopaedic Oncology Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Weifeng Liu
- Department of Orthopaedic Oncology Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China.
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6
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He G, Dai AZ, Mustahsan VM, Shah AT, Li L, Khan JA, Bielski MR, Komatsu DE, Kao I, Khan FA. A novel method of light projection and modular jigs to improve accuracy in bone sarcoma resection. J Orthop Res 2022; 40:2522-2536. [PMID: 35245391 DOI: 10.1002/jor.25300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023]
Abstract
We developed a novel method using a combined light-registration/light-projection system along with an off-the-shelf, instant-assembly modular jig construct that could help surgeons improve bone resection accuracy during sarcoma surgery without many of the associated drawbacks of 3D printed custom jigs or computer navigation. In the novel method, the surgeon uses a light projection system to precisely align the assembled modular jig construct on the bone. In a distal femur resection model, 36 sawbones were evenly divided into 3 groups: manual-resection (MR), conventional 3D-printed custom jig resection (3DCJ), and the novel projector/modular jig (PMJ) resection. In addition to sawbones, a single cadaver experiment was also conducted to confirm feasibility of the PMJ method in a realistic operative setting. The PMJ method improved resection accuracy when compared to MR and 3DCJ, respectively: 0.98 mm versus 7.48 mm (p < 0.001) and 3.72 mm (p < 0.001) in mean corner position error; 1.66 mm versus 9.70 mm (p < 0.001) and 4.32 mm (p = 0.060) in mean maximum deviation error; 0.79°-4.78° (p < 0.001) and 1.26° (p > 0.999) in mean depth angle error. The PMJ method reduced the mean front angle error from 1.72° to 1.07° (p = 0.507) when compared to MR but was slightly worse compared to 0.61° (p = 0.013) in 3DCJ. The PMJ method never showed an error greater than 3 mm, while the maximum error of other two control groups were almost 14 mm. Similar accuracy was found with the PMJ method on the cadaver. A novel method using a light projector with modular jigs can achieve high levels of bone resection accuracy, but without many of the associated drawbacks of 3D printed jigs or computer navigation technology.
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Affiliation(s)
- Guangyu He
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Amos Z Dai
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Vamiq M Mustahsan
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Aadit T Shah
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Liming Li
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | | | - Michael R Bielski
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - David E Komatsu
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Imin Kao
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Fazel A Khan
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
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He G, Dai AZ, Mustahsan VM, Shah AT, Li L, Khan JA, Bielski MR, Komatsu DE, Kao I, Khan FA. A novel intraoperative method to project osteotomy lines for accurate resection of primary bone sarcomas. J Orthop 2022; 32:60-67. [DOI: 10.1016/j.jor.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022] Open
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He G, Dai AZ, Mustahsan VM, Blum CL, Kao I, Khan FA. A Novel 3D Light Assisted Drawing (3D-LAD) Method to Aid Intraoperative Reproduction of Osteotomy Lines Surrounding a Bone Tumor During Wide Resection: An Experimental Study. Orthop Res Rev 2022; 14:101-109. [PMID: 35422661 PMCID: PMC9005132 DOI: 10.2147/orr.s349240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/22/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Computer navigation and customized 3D-printed jigs improve accuracy during bone tumor resection, but such technologies can be bulky, costly, and require intraoperative radiation, or long lead time to be ready in OR. Methods We developed a method utilizing a compact, inexpensive, non-X-ray based 3D surface light scanner to provide a visual aid that helps surgeons accurately draw osteotomy lines on the surface of exposed bone to reproduce a well-defined preoperative bone resection plan. We tested the accuracy of the method on 18 sawbones using a distal femur hemimetaphyseal resection model and compared it with a traditional, freehand method. Results The method significantly reduces the positional error from 2.53 (±1.13) mm to 1.04 (±0.43) mm (p<0.001), and angular error of the front angle from 2.10° (±0.83°) to 0.80° (±0.66°) (p=0.001). The method also reduces the mean maximum deviation of the bone resection, with respect to the preoperative path, from 3.75mm to 2.69mm (p=0.003). However, no increased accuracy was observed at the back side of the bone surface where this method would not be expected to provide information. Discussion In summary, we developed a novel 3D-LAD navigation technology. From the experimental study, we demonstrated that the method can improve the ability of surgeons to accurately draw the preoperative osteotomy lines and perform resection of a primary bone sarcoma, with comparison to traditional methods, using 18 sawbones.
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Affiliation(s)
- Guangyu He
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Amos Z Dai
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Vamiq M Mustahsan
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Christopher L Blum
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Imin Kao
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Fazel A Khan
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
- Correspondence: Fazel A Khan, Email
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Gutiérrez-Santamaría J, Simon D, Capitán L, Bailón C, Bellinga RJ, Tenório T, Sánchez-García A, Capitán-Cañadas F. Shaping the Lower Jaw Border with Customized Cutting Guides: Development, Validation, and Application in Facial Gender-Affirming Surgery. Facial Plast Surg Aesthet Med 2022. [PMID: 35349332 DOI: 10.1089/fpsam.2021.0418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Importance: Three-dimensional planning software is not standardized in facial gender-affirming surgery. Objective: To develop and validate surgical planning software to create cutting guides to contour the lower jaw border. Design, Setting, and Participants: A 3-year prospective case series study done in three phases: software development, validation, and surgical guide application. Ethics committee approval was obtained to enroll the patients (Clinical Research Ethics Committee, Hospital Costa del Sol, Marbella, Spain). Main Outcomes and Measures: Validation phase: degree of agreement between the planned and obtained results, modification of cephalometric parameters, and surgical times. Application phase: surgical technique description, complications, and patient-reported outcome measures. Results: The degree of agreement between the planned and obtained results was inframillimetric (0.31 ± 0.70 mm). The guides reduced the mandible to within feminine parameters (p < 0.05). Surgical times decreased by 10.96% with chin ostectomies (p < 0.05) and 23.06% with lower jaw border (angle-to-angle) surgeries (p < 0.001). In the application phase, revision surgery was required for 11 patients out of 260 (4.23%). Conclusions and Relevance: The use of cutting guides on the lower jaw border is effective, helps reach standard feminine parameters, and decreases surgical times.
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Affiliation(s)
| | - Daniel Simon
- The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Luis Capitán
- The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Carlos Bailón
- The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Raúl J Bellinga
- The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Thiago Tenório
- The Facialteam Group, HC Marbella International Hospital, Marbella, Málaga, Spain
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Sahovaler A, Daly MJ, Chan HHL, Nayak P, Tzelnick S, Arkhangorodsky M, Qiu J, Weersink R, Irish JC, Ferguson P, Wunder JS. Automatic Registration and Error Color Maps to Improve Accuracy for Navigated Bone Tumor Surgery Using Intraoperative Cone-Beam CT. JB JS Open Access 2022; 7:JBJSOA-D-21-00140. [PMID: 35540727 PMCID: PMC9071254 DOI: 10.2106/jbjs.oa.21.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Computer-assisted surgery (CAS) can improve surgical precision in orthopaedic oncology. Accurate alignment of the patient’s imaging coordinates with the anatomy, known as registration, is one of the most challenging aspects of CAS and can be associated with substantial error. Using intraoperative, on-the-table, cone-beam computed tomography (CBCT), we performed a pilot clinical study to validate a method for automatic intraoperative registration.
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Affiliation(s)
- Axel Sahovaler
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Head & Neck Surgery Unit, University College London Hospitals, London, United Kingdom
| | - Michael J Daly
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Harley H L Chan
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Prakash Nayak
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Department of Surgical Oncology, Bone and Soft Tissue Disease Management Group, Tata Memorial Centre, Mumbai, India
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sharon Tzelnick
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Michelle Arkhangorodsky
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Jimmy Qiu
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Robert Weersink
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Peter Ferguson
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jay S Wunder
- Guided Therapeutics (GTx) Program, TECHNA Institute, University Health Network, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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Ameri BJ, O'Keefe S, Lima D, Higuera-Rueda C, Manrique J. Robotic-Assisted Pelvic Reconstruction After Metastatic Renal Cell Carcinoma Resection: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00052. [PMID: 34762604 DOI: 10.2106/jbjs.cc.20.00908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
CASE A 76-year-old man presented with metastatic renal cell carcinoma (RCC) in the right acetabulum with pelvic compromise. The patient had right hip pain and difficulty with ambulation, as such he elected to undergo tumor resection with subsequent reconstruction of pelvic defect. Given the size and location of the anticipated pelvic defect, robotic-assisted hip arthroplasty was used to execute prosthetic component placement and anatomic pelvic reconstruction. CONCLUSION Advances in technology, such as robotics and 3D navigation, have application in orthopaedic oncology surgery, especially for reconstructions after pelvic resections. The goal of this case report is to describe the utility of this technology in a case of metastatic RCC.
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Affiliation(s)
- Bijan Joseph Ameri
- Broward Health Orthopaedic Department, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Shawn O'Keefe
- Broward Health Orthopaedic Department, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Diego Lima
- Orthopaedic Surgery and Rheumatology Center, Cleveland Clinic, Weston, Florida
| | | | - Jorge Manrique
- Orthopaedic Surgery and Rheumatology Center, Cleveland Clinic, Weston, Florida
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Wilkat M, Kübler N, Rana M. Advances in the Resection and Reconstruction of Midfacial Tumors Through Computer Assisted Surgery. Front Oncol 2021; 11:719528. [PMID: 34737947 PMCID: PMC8560787 DOI: 10.3389/fonc.2021.719528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/27/2021] [Indexed: 11/14/2022] Open
Abstract
Curatively intended oncologic surgery is based on a residual-free tumor excision. Since decades, the surgeon’s goal of R0-resection has led to radical resections in the anatomical region of the midface because of the three-dimensionally complex anatomy where aesthetically and functionally crucial structures are in close relation. In some cases, this implied aggressive overtreatment with loss of the eye globe. In contrast, undertreatment followed by repeated re-resections can also not be an option. Therefore, the evaluation of the true three-dimensional tumor extent and the intraoperative availability of this information seem critical for a precise, yet substance-sparing tumor removal. Computer assisted surgery (CAS) can provide the framework in this context. The present study evaluated the beneficial use of CAS in the treatment of midfacial tumors with special regard to tumor resection and reconstruction. Therefore, 60 patients diagnosed with a malignancy of the upper jaw has been treated, 31 with the use of CAS and 29 conventionally. Comparison of the two groups showed a higher rate of residual-free resections in cases of CAS application. Furthermore, we demonstrate the use of navigated specimen taking called tumor mapping. This procedure enables the transparent, yet precise documentation of three-dimensional tumor borders which paves the way to a more feasible interdisciplinary exchange leading e.g. to a much more focused radiation therapy. Moreover, we evaluated the possibilities of primary midface reconstructions seizing CAS, especially in cases of infiltrated orbital floors. These cases needed reduction of intra-orbital volume due to the tissue loss after resection which could be precisely achieved by CAS. These benefits of CAS in midface reconstruction found expression in positive changes in quality of life. The present work was able to demonstrate that the area of oncological surgery of the midface is a prime example of interface optimization based on the sensible use of computer assistance. The fact that the system makes the patient transparent for the surgeon and the procedure controllable facilitates a more precise and safer treatment oriented to a better outcome.
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Affiliation(s)
- Max Wilkat
- Department for Oral & Maxillofacial Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Norbert Kübler
- Department for Oral & Maxillofacial Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Majeed Rana
- Department for Oral & Maxillofacial Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
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Computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction for bone sarcomas: long-term outcomes. Chin Med J (Engl) 2021; 134:2597-2602. [PMID: 34748525 PMCID: PMC8577668 DOI: 10.1097/cm9.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Computed tomography (CT) and magnetic resonance imaging (MRI) data can be fused to identify the tumor boundaries. This enables surgeons to set close but tumor-free surgical margins and excise the tumor more precisely. This study aimed to report our experience in performing computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction to treat bone sarcoma in the diaphysis and metaphysis of the femur and tibia. METHODS Between September 2008 and December 2015, 24 patients with bone sarcomas underwent surgical resection and joint-sparing reconstruction under image-guided computer navigation. The cohort comprised 16 males and eight females with a median age of 19.5 years (range: 12-48 years). The tumor location was the femoral diaphysis in three patients, distal femur in 19, and proximal tibia in two. The tumors were osteosarcoma (n = 15), chondrosarcoma (n = 3), Ewing sarcoma (n = 3), and other sarcomas (n = 3). We created a pre-operative plan for each patient using navigation system software and performed navigation-aided resection before reconstructing the defect with a custom-made prosthesis with extracortical plate fixation. RESULTS Pathological examination verified that all resected specimens had appropriate surgical margins. The median distance from the tumor resection margin to the joint was 30 mm (range: 13-80 mm). The median follow-up duration was 62.5 months (range: 24-134 months). Of the 24 patients, 21 remain disease free, one is alive with disease, and two died of the disease. One patient developed local recurrence. Complications requiring additional surgical procedures occurred in six patients, including one with wound hematoma, one with delayed wound healing, one with superficial infection, one with deep infection, and two with mechanical failure of the prosthesis. The mean Musculoskeletal Tumor Society score at the final follow-up was 91% (range: 80%-100%). The 5- and 10-year implant survival rates were 91.3% and 79.9%, respectively. CONCLUSIONS Computer navigation-aided joint-preserving resection and custom-made endoprosthesis reconstruction with extracortical plate fixation is a reliable surgical treatment option for bone sarcoma in the diaphysis and metaphysis of the femur and tibia.
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Sambri A, Fujiwara T, Fiore M, Giannini C, Zucchini R, Cevolani L, Donati DM, De Paolis M. The role of imaging in computer assisted tumor surgery of the sacrum and pelvis. Curr Med Imaging 2021; 18:137-141. [PMID: 33655874 DOI: 10.2174/1573405617666210303105735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/07/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
Abstract
The use of a navigation system allows precise resection of a tumor and accurate reconstruction of the resultant defect thereby sparing important anatomical structures and preserving function. It is an "image-based" system where the imaging (computed tomography and magnetic resonance imaging) is required to supply the software with data. The fusion of the preoperative imaging provides pre-operative information about local anatomy and extent of the tumor, so that it allows an accurate preoperative planning. Accurate pre-operative imaging is mandatory in order to minimize CATS errors, thus performing accurate tumor resections.
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Affiliation(s)
| | - Tomohiro Fujiwara
- Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences. Japan
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15
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Computer Navigation and 3D Printing in the Surgical Management of Bone Sarcoma. Cells 2021; 10:cells10020195. [PMID: 33498287 PMCID: PMC7909290 DOI: 10.3390/cells10020195] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
The long-term outcomes of osteosarcoma have improved; however, patients with metastases, recurrence or axial disease continue to have a poor prognosis. Computer navigation in surgery is becoming ever more commonplace, and the proposed advantages, including precision during surgery, is particularly applicable to the field of orthopaedic oncology and challenging areas such as the axial skeleton. Within this article, we provide an overview of the field of computer navigation and computer-assisted tumour surgery (CATS), in particular its relevance to the surgical management of osteosarcoma.
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Intrapelvic melanocytic schwannoma resection with computer-assisted navigation. Radiol Case Rep 2020; 15:2385-2390. [PMID: 32994847 PMCID: PMC7516168 DOI: 10.1016/j.radcr.2020.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/21/2022] Open
Abstract
Melanocytic schwannoma is a rare nerve tumor characterized by melanin-producing neoplastic Schwann cells. Wide surgical resection is the management of choice for this tumor; however, anatomical location and proximity to nerve roots can make locating this tumor and the surgical resection challenging. Here we describe the case of 49-year-old male with a melanocytic schwannoma in the presacral area adjacent to the second sacral nerve root that was managed by wide resection aided by computer-assisted navigation due to the difficulty in identifying its location intraoperatively. The utilization of computer-assisted navigation improves accuracy and precision through the creation of a virtual continuous tridimensional map, particularly useful when oftentimes tumor margins may seem equivocal and further resection would compromise the patient's functionality. The value of computer-assisted navigation for soft tissue tumor resections in orthopedic oncology is still in its infancy, though, in certain scenarios it may advance the technique for some soft tissue resections.
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Tepper SC, Blank AT, Gitelis S, Colman MW. Pelvic ring reconstruction with segmental spinal instrumentation after complete type I pelvic resection. J Surg Oncol 2020; 122:1721-1730. [PMID: 32844400 DOI: 10.1002/jso.26194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/17/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Internal hemipelvectomy is a complex procedure used to treat malignancy that involves the pelvis. Reconstruction of the pelvis after type I or type I/IV resection remains controversial due to high complication rates and debatable functional benefit. Modern reconstruction options may provide a rapid, intuitive, and reliable way to reconstitute the pelvic ring. METHODS This is a retrospective case series of four patients who underwent a novel reconstruction method involving computer navigation and segmental spinal instrumentation applied to the pelvis after type I or type I/IV pelvic resection for malignancy between 2015 and 2020. RESULTS Time to ambulation postoperatively ranged from 1 to 7 days, and median length of hospital stay was 8.5 (7.5, 10.5) days. Complications included wound necrosis in two patients that did not require reoperation and wound infection in one patient that required irrigation and debridement. There was no radiographic evidence of hardware loosening or failure on follow-up. Three patients remain alive and two remain disease-free. At most recent follow-up, all patients were able to ambulate and perform activities of daily living. CONCLUSIONS The technique for pelvic reconstruction described allows for rapid fixation intraoperatively with few complications and satisfactory functional results in this limited series.
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Affiliation(s)
- Sarah C Tepper
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Alan T Blank
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Steven Gitelis
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Matthew W Colman
- Department of Orthopedic Surgery, Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois
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Albergo JI, Farfalli GL, Ayerza MA, Ritacco LE, Aponte-Tinao LA. Computer-assisted surgery (CAS) in orthopedic oncology. Which were the indications, problems and results in our first consecutive 203 patients? Eur J Surg Oncol 2020; 47:424-428. [PMID: 32653262 DOI: 10.1016/j.ejso.2020.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS to review a group of patients with primary bone tumors treated with intraoperative navigation and analyze: (1) The technical problems; (2) Indications for Computer Assisted Surgery (CAS); (3) Oncological results; (4) Non oncological complications. MATERIALS AND METHODS All patients from a single institution who had preoperative virtual planned for an oncological primary bone resection assisted with navigation between May 2010 and July 2017 were enrolled in the study (203 patients). The use of computer-assisted surgery (CAS) was classified according to the oncologic procedure performed: (1) intralesional resections, (2) en-block resections, and (3) en-block resections + navigated allograft reconstructions. RESULTS Four patients (4/203, 2%) of the series presented technical problems which came from 2 software and 2 hardware crashes. Eight (4%) procedures were intralesional resections and no local recurrences or complications were reported in this group. Ninety-eight surgeries (49%) were pure en block resection. The pelvis and sacrum were the main location in this group (57%). All bone margins were defined negative but 2 patients presented a positive resection in the soft tissues. Infection was the most prevalent complication (16/23). Ninety-three procedures were done for en block resections + allograft reconstruction (all extremities tumor). All margins were free of tumor and non oncological rate for this group was 28%. CONCLUSION The main indications for CAS were malignant bone tumors resection. The technical failures precluded navigation use in 2%. CAS for pure en-block resections were mainly indicated in pelvic and sacrum tumors while en-block resection + allograft reconstruction assisted with navigation were only indicated in extremities tumors. LEVEL OF EVIDENCE IV.
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Maru T, Imanishi J, Torigoe T, Saita K, Kadono Y, Yazawa Y. Navigation-assisted surgery for chondroblastoma arising in the femoral head: A case report. Int J Surg Case Rep 2020; 70:8-12. [PMID: 32334178 PMCID: PMC7183096 DOI: 10.1016/j.ijscr.2020.03.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/28/2020] [Indexed: 01/17/2023] Open
Abstract
We reported the first case to use navigation for the femoral head chondroblastoma. Visualization of tumor on navigation helps to minimize unnecessary destruction. Navigation assistance is an optimal surgical option for chondroblastoma in the femoral head.
Introduction Surgery for chondroblastoma in the femoral head is challenging due to its inaccessibility, with high risk of local recurrence and poor functional outcomes reported. We herein report the first case of chondroblastoma in the femoral head treated by navigation-assisted surgery. Presentation of case A 12-year-old girl presented with persistent left hip pain and limited hip range of motion. Imaging studies revealed a well-defined osteolytic lesion in the left femoral head accompanied by extensive intra-osseous oedematous change. The bone lesion was radiologically diagnosed as chondroblastoma. With navigation assistance, curettage was performed via the anterior approach. The tumor was fully accessible from the femoral neck. After curettage, the bony defect was filled with bone substitute. The pathological diagnosis was chondroblastoma. The post-operative course was uneventful. Thirty months postoperatively, the patient was free of pain with full hip range of motion, and MR images showed no evidence of recurrence or osteonecrosis. Discussion This case is the first to use a navigation system for the treatment of chondroblastoma in the femoral head. The navigation system can minimize damage to intact structures and increase the efficiency of curettage by visualizing access to the tumor. Conclusion Navigation assistance is an optimal surgical option for chondroblastoma in the femoral head.
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Affiliation(s)
- Takanori Maru
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Japan; Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Japan
| | - Jungo Imanishi
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Japan; Department of Orthopaedic Surgery, Saitama Medical University Hospital, Japan.
| | - Tomoaki Torigoe
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Japan
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Japan
| | - Yuho Kadono
- Department of Orthopaedic Surgery, Saitama Medical University Hospital, Japan
| | - Yasuo Yazawa
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Japan
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Fujiwara T, Sree DV, Stevenson J, Kaneuchi Y, Parry M, Tsuda Y, Le Nail L, Medellin RM, Grimer R, Jeys L. Acetabular reconstruction with an ice‐cream cone prosthesis following resection of pelvic tumors: Does computer navigation improve surgical outcome? J Surg Oncol 2020; 121:1104-1114. [DOI: 10.1002/jso.25882] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Tomohiro Fujiwara
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
- Department of Orthopaedic SurgeryOkayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama Japan
| | - Deepak V. Sree
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Jonathan Stevenson
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Yoichi Kaneuchi
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Michael Parry
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Yusuke Tsuda
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Louis‐Romée Le Nail
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Ricardo M. Medellin
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Robert Grimer
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
| | - Lee Jeys
- Department of OncologyThe Royal Orthopaedic Hospital NHS Foundation Trust Birmingham UK
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Abstract
An orthopaedic surgeon's knowledge of anatomical landmarks is crucial, but other modalities supplement this by providing guidance and feedback to a surgeon. Advances in imaging have enabled three-dimensional visualization of the surgical field and patient anatomy, whereas advances in computer technology have allowed for real-time tracking of instruments and implants. Together, these innovations have given rise to intraoperative navigation systems. The authors review these advances in intraoperative navigation across orthopaedic subspecialties, focusing on the most recent evidence on patient outcomes and complications, the associated learning curve, and the effects on operative time, radiation exposure, and cost. In spine surgery, navigated pedicle screw placement may increase accuracy and safety, especially valuable when treating complex deformities. Improved accuracy of pelvic and peri-articular tumor resection and percutaneous fixation of acetabular and femoral neck fractures has also been achieved using navigation. Early applications in arthroscopy have included surface-based registration for tunnel positioning for anterior cruciate ligament reconstruction and osteochondroplasty for femoro-acetabular impingement. Navigated arthroplasty techniques have addressed knee gap balancing and mechanical axis restoration as well as acetabular cup and glenoid baseplate positioning. Among these orthopaedic subspecialties, significant variation is found in the clinical relevance and dedication to research of navigation techniques.
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From Bench to Bedside: Robotics and Navigation in Orthopaedics-Rise of the Machines or Just Rising Costs? Clin Orthop Relat Res 2019; 477:692-694. [PMID: 30844827 PMCID: PMC6437387 DOI: 10.1097/corr.0000000000000668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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A Cadaveric Comparative Study on the Surgical Accuracy of Freehand, Computer Navigation, and Patient-Specific Instruments in Joint-Preserving Bone Tumor Resections. Sarcoma 2018; 2018:4065846. [PMID: 30538600 PMCID: PMC6260549 DOI: 10.1155/2018/4065846] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022] Open
Abstract
Orthopedic oncologic surgery requires preservation of a functioning limb at the essence of achieving safe margins. With most bone sarcomas arising from the metaphyseal region, in close proximity to joints, joint-salvage surgery can be challenging. Intraoperative guidance techniques like computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) could assist in achieving higher surgical accuracy. This study investigates the surgical accuracy of freehand, CAS- and PSI-assisted joint-preserving tumor resections and tests whether integration of CAS with PSI (CAS + PSI) can further improve accuracy. CT scans of 16 simulated tumors around the knee in four human cadavers were performed and imported into engineering software (MIMICS) for 3D planning of multiplanar joint-preserving resections. The planned resections were transferred to the navigation system and/or used for PSI design. Location accuracy (LA), entry and exit points of all 56 planes, and resection time were measured by postprocedural CT. Both CAS + PSI- and PSI-assisted techniques could reproduce planned resections with a mean LA of less than 2 mm. There was no statistical difference in LA between CAS + PSI and PSI resections (p=0.92), but both CAS + PSI and PSI showed a significantly higher LA compared to CAS (p=0.042 and p=0.034, respectively). PSI-assisted resections were faster compared to CAS + PSI (p < 0.001) and CAS (p < 0.001). Adding CAS to PSI did improve the exit points, however not significantly. In conclusion, PSI showed the best overall surgical accuracy and is fastest and easy to use. CAS could be used as an intraoperative quality control tool for PSI, and integration of CAS with PSI is possible but did not improve surgical accuracy. Both CAS and PSI seem complementary in improving surgical accuracy and are not mutually exclusive. Image-based techniques like CAS and PSI are superior over freehand resection. Surgeons should choose the technique most suitable based on the patient and tumor specifics.
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Intraoperative O-arm-navigated resection in musculoskeletal tumors. J Orthop Sci 2018; 23:1045-1050. [PMID: 30037470 DOI: 10.1016/j.jos.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although emerging evidence has suggested that computer-assisted navigation allows surgeons to plan the optimal level of resection without compromising the surgical margins, the precise accuracy of the procedures has been unclear. The aim of this study was to investigate the accuracy and safety of the musculoskeletal tumor resection using O-arm/Stealth intraoperative navigation assistance. METHODS A retrospective study of six patients with bone and soft tissue tumors who underwent surgical resection using O-arm/Stealth navigation system was performed. The histological diagnosis was osteosarcoma, metastatic bone tumor, leiomyosarcoma, undifferentiated sarcoma, and synovial sarcoma, respectively. Tumor resection was performed according to planned osteotomy planes determined on O-arm/Stealth three-dimensional intraoperative images. The resection accuracy, length of time for the procedures, surgical margins, and perioperative complications were evaluated. RESULTS The distances between the entry and exit points for the planned and actual cuts were 1.5 ± 0.3 mm and 2.3 ± 0.3 mm, respectively, and the mean discrepancy of the osteotomy angle was 2.8 ± 1.2°. The mean length of time required for navigation was 14 min. A histological examination revealed clear margins in all patients. There were no complications related to navigation, and no patients developed local recurrence during a mean follow-up of 30.6 months. CONCLUSIONS The O-arm/Stealth intraoperative CT navigation system provides safe and accurate osteotomy in musculoskeletal tumor resections. However, surgeons should keep in mind and be careful of minimal errors during osteotomy, which are around 2 mm from the planned line.
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Mediouni M, R Schlatterer D, Madry H, Cucchiarini M, Rai B. A review of translational medicine. The future paradigm: how can we connect the orthopedic dots better? Curr Med Res Opin 2018; 34:1217-1229. [PMID: 28952378 DOI: 10.1080/03007995.2017.1385450] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/21/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Patients with complex medical and surgical problems often travel great distances to prestigious university medical centers in search of solutions and in some cases for nothing more than a diagnosis of their condition. Translational medicine (TM) is an emerging method and process of facilitating medical advances efficiently from the scientist to the clinician. Most established clinicians and those in training know very little about this new discipline. The purpose of this article is to illustrate TM in varied scientific, medical and surgical fields. MATERIALS AND METHODS Anecdotal events in medicine and orthopaedics based upon a practicing orthopaedic surgeon's training and clinical experience are presented. RESULTS TM is rapidly assuming a greater presence in the medical community. The National Institute of Health (NIH) recognizes this discipline and has funded TM projects. Numerous institutions in Europe and the USA offer advanced degrees in TM. Finally there is a European Society for Translational Medicine (EUTMS), an International Society for Translational Medicine, and an Academy of Translational Medical Professionals (ATMP). DISCUSSION The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. The need for increased participation of researchers and clinicians requires further study to identify the economic and social impact of TM. CONCLUSIONS The examples of TM presented in this article support the argument for the formation of more TM networks on the local and regional levels. Financial constraints for TM can be overcome by pooling government, academic, private, and industry resources in an organized fashion with oversight by a lead TM researcher.
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Affiliation(s)
| | | | - Henning Madry
- c Saarland University Medical Center , Homburg , Germany
| | | | - Balwant Rai
- d JBR Health Education and Research Organization , Copenhagen , Denmark
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Sternheim A, Kashigar A, Daly M, Chan H, Qiu J, Weersink R, Jaffray D, Irish JC, Ferguson PC, Wunder JS. Cone-Beam Computed Tomography-Guided Navigation in Complex Osteotomies Improves Accuracy at All Competence Levels: A Study Assessing Accuracy and Reproducibility of Joint-Sparing Bone Cuts. J Bone Joint Surg Am 2018; 100:e67. [PMID: 29762285 DOI: 10.2106/jbjs.16.01304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to assess the accuracy and reproducibility of a novel cone-beam computed tomography (CBCT)-guided navigation system designed for osteotomies with joint-sparing bone cuts. METHODS Eighteen surgeons participated in this study. First, 3 expert tumor surgeons resected bone tumors in 3 Sawbones tumor models identical to actual patient scenarios. They first performed these osteotomies without navigation and then performed them using a navigation system and 3-dimensional (3D) planning tools based on CBCT imaging. The 2 sets of measurements were compared using image-based measurements from post-resection CBCT. Next, 15 residents, fellows, and orthopaedic staff surgeons were instructed on the use of the system, and their navigated resections were compared with navigated resections performed by the 3 expert tumor surgeons. RESULTS One hundred and twenty-six navigated cuts done by the orthopaedic oncologists were compared with 126 non-navigated cuts by the same surgeons. The cuts violated the tumor in 22% (6) of the 27 non-navigated resections compared with none of the 27 navigated resections. The navigated cuts were significantly more accurate in terms of entry point, pitch, and roll (p < 0.001). The variation among the 3 surgeons when they used navigation was <0.6 mm for the entry cut and, on average, 1.5° for pitch and roll. All 18 surgeons then completed a total of 144 navigated cuts. The level of experience did not result in a significant difference among groups with regard to cut accuracy. Two cuts went into the tumor. The mean distance from the planned bone cuts to the actual entry points into bone was 1.5 mm (standard deviation [SD] = 1.4 mm) for all users. The mean difference in pitch and roll between the planned and actual cuts was 3.5° (SD = 2.8°) and 3.7° (SD = 3.2°) for all users. CONCLUSIONS Even in expert hands, navigated cuts were significantly more accurate than non-navigated cuts. When the osteotomies were aided by navigation, their accuracy did not differ according to the level of professional experience. CBCT-based metrics enable intraoperative assessments of cut accuracy and reconstruction planning. CLINICAL RELEVANCE CBCT-guided navigated osteotomies can improve accuracy regardless of surgeon experience and decrease the variability among different surgeons.
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Affiliation(s)
- Amir Sternheim
- National Unit of Orthopaedic Oncology, Tel Aviv Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aidin Kashigar
- Division of Orthopaedic Surgery, Queen's University, Kingston, Ontario, Canada
| | - Michael Daly
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Harley Chan
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Jimmy Qiu
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Robert Weersink
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - David Jaffray
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Radiation Physics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Ontario Cancer Institute, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Ferguson
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jay S Wunder
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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Farfalli GL, Albergo JI, Piuzzi NS, Ayerza MA, Muscolo DL, Ritacco LE, Aponte-Tinao LA. Is Navigation-guided En Bloc Resection Advantageous Compared With Intralesional Curettage for Locally Aggressive Bone Tumors? Clin Orthop Relat Res 2018. [PMID: 29529633 PMCID: PMC6260034 DOI: 10.1007/s11999.0000000000000054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of locally aggressive bone tumors is a balance between achieving local tumor control and surgical morbidity. Wide resection decreases the likelihood of local recurrence, although wide resection may result in more complications than would happen after curettage. Navigation-assisted surgery may allow more precise resection, perhaps making it possible to expand the procedure's indications and decrease the likelihood of recurrence; however, to our knowledge, comparative studies have not been performed. QUESTIONS/PURPOSES The purpose of this study was to compare curettage plus phenol as a local adjuvant with navigation-guided en bloc resection in terms of (1) local recurrence; (2) nononcologic complications; and (3) function as measured by revised Musculoskeletal Tumor Society (MSTS) scores. METHODS Patients with a metaphyseal and/or epiphyseal locally aggressive primary bone tumor treated by curettage and adjuvant therapy or en bloc resection assisted by navigation between 2010 and 2014 were considered for this retrospective study. Patients with a histologic diagnosis of a primary aggressive benign bone tumor or low-grade chondrosarcoma were included. During this time period, we treated 45 patients with curettage of whom 43 (95%) were available for followup at a minimum of 24 months (mean, 37 months; range, 24-61 months), and we treated 26 patients with navigation-guided en bloc resection, of whom all (100%) were available for study. During this period, we generally performed curettage with phenol when the lesion was in contact with subchondral bone. We treated tumors that were at least 5 mm from the subchondral bone, such that en bloc resection was considered possible with computer-assisted block resection. There were no differences in terms of age, gender, tumor type, or tumor location between the groups. Outcomes, including allograft healing, nonunion, tumor recurrence, fracture, hardware failure, infection, and revised MSTS score, were recorded. Bone consolidation was defined as complete periosteal and endosteal bridging visible between the allograft-host junctions in at least two different radiographic views and the absence of pain and instability in the union site. All study data were obtained from our longitudinally maintained oncology database. RESULTS In the curettage group, two patients developed a local recurrence, and no local recurrences were recorded in patients treated with en bloc resection. All patients who underwent navigation-guided resection achieved tumor-free margins. Intraoperative navigation was performed successfully in all patients and there were no failures in registration. Postoperative complications did not differ between the groups: in patients undergoing curettage, 7% (three of 43) and in patients undergoing navigation, 4% (one of 26) had a complication. There was no difference in functional scores: mean MSTS score for patients undergoing curettage was 28 points (range, 27-30 points) and for patients undergoing navigation, 29 (range, 27-30 points; p = 0.10). CONCLUSIONS In this small comparative series, navigation-assisted resection techniques allowed conservative en bloc resection of locally aggressive primary bone tumors with no local recurrence. Nevertheless, with the numbers available, we saw no difference between the groups in terms of local recurrence risk, complications, or function. Until or unless studies demonstrate an advantage to navigation-guided en bloc resection, we cannot recommend wide use of this novel technique because it adds surgical time and expense. LEVEL OF EVIDENCE Level III, therapeutic study.
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Abstract
Navigation in surgery has increasingly become more commonplace. The use of this technological advancement has enabled ever more complex and detailed surgery to be performed to the benefit of surgeons and patients alike. This is particularly so when applying the use of navigation within the field of orthopedic oncology. The developments in computer processing power coupled with the improvements in scanning technologies have permitted the incorporation of navigational procedures into day-to-day practice. A comprehensive search of PubMed using the search terms "navigation", "orthopaedic" and "oncology" yielded 97 results. After filtering for English language papers, excluding spinal surgery and review articles, this resulted in 38 clinical studies and case reports. These were analyzed in detail by the authors (GM and JS) and the most relevant papers reviewed. We have sought to provide an overview of the main types of navigation systems currently available within orthopedic oncology and to assess some of the evidence behind its use.
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Affiliation(s)
- Guy Vernon Morris
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom,Address for correspondence: Dr. Guy Vernon Morris, The Oncology Unit, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham B31 2AP, West Midlands, United Kingdom. E-mail:
| | - Jonathan D Stevenson
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Scott Evans
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Michael C Parry
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom
| | - Lee Jeys
- The Oncology Department, The Royal Orthopaedic Hospital NHS Trust, Birmingham, West Midlands, United Kingdom,School of Health and Life Sciences, Aston University, Birmingham, United Kingdom
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Ritacco LE, Milano FE, Farfalli GL, Ayerza MA, Muscolo DL, Albergo JI, Aponte-Tinao LA. Virtual Planning and Allograft Preparation Guided by Navigation for Reconstructive Oncologic Surgery: A Technical Report. JBJS Essent Surg Tech 2017; 7:e30. [PMID: 30233965 DOI: 10.2106/jbjs.st.17.00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction Advanced virtual simulators can be used to accurately detect the best allograft according to size and shape. Indications & Contraindications Step 1 Acquisition of Medical Images Obtain a multislice CT scan and a magnetic resonance imaging (MRI) scan preoperatively for each patient; however, if the time between the scans and the surgery is >1 month, consider repeating the MRI because the size of the tumor may have changed during that time. Step 2 Select an Allograft Using Virtual Imaging to Optimize Size Matching Load DICOM images into a virtual simulation station (Windows 7 Service Pack 1, 64 bit, Intel Core i5/i7 or equivalent) and use mediCAS planning software (medicas3d.com) or equivalent (Materialise Mimics or Amira software [FEI]) for image segmentation and virtual simulation with STL (stereolithography) files. Step 3 Plan and Outline the Tumor Margins on the Preoperative Imaging Determine and outline the tumor margin on manually fused CT and MRI studies using the registration tool of the mediCAS planning software or equivalent (Materialise Mimics software.). Step 4 Plan and Outline the Same Osteotomies on the Allograft Determine and outline the osteotomies between host and donor using the registration tool of the mediCAS planning software or equivalent (Materialise Mimics software.). Step 5 Assess the Patient and Allograft in a Virtual Scenario Be sure to consider the disintegration of bone tissue that occurs during the osteotomy and corresponds to the thickness of the blade (approximately 1.5 mm). Step 6 Navigation Settings A tool of the mediCAS planning software allows the virtual preoperative planning (STL files) to be transferred to the surgical navigation format, DICOM files. Step 7 Patient and Allograft Intraoperative Navigation The tumor and allograft are resected using the navigated guidelines, which were previously planned with the virtual platform. Results The 3D virtual preoperative planning and surgical navigation software are tools designed to increase the accuracy of bone tumor resection and allograft reconstruction3. Pitfalls & Challenges
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Affiliation(s)
- Lucas E Ritacco
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Federico E Milano
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Germán L Farfalli
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Miguel A Ayerza
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Domingo L Muscolo
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Jose I Albergo
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Luis A Aponte-Tinao
- Institute of Orthopedics, "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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30
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Peng X, Wang F, Su J. The value of computer-assisted navigation for bone reconstruction after tumor resection. Oncol Lett 2017; 14:2771-2774. [PMID: 28928818 PMCID: PMC5588145 DOI: 10.3892/ol.2017.6523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/28/2017] [Indexed: 12/13/2022] Open
Abstract
This study was designed to evaluate the use of computer-assisted navigation with computed tomography (CT) images for bone reconstruction after resection in malignant bone tumor treatment. Forty-five patients with malignant bone tumors were recruited for this study. CT scan images in a computer-assisted navigation system were used to assist during the osteotomy, the pairing with allografts, and the monitoring of the allograft and joint lines to perform joint reconstruction. Our results show that osteotomy and allograft pairing were successful in all patients. The average duration of the osteotomy procedures was 46.8±12.3 min; and the average pairing time was 32.5±9.8 min. The anatomical registration points and the three-dimensional virtual CT images were successfully matched. The average error of registration was 0.36±0.09 mm. Also, the range of tumor resection and allograft osteotomy were successfully paired, with an average error of 0.11±0.03 mm. No complications such as unequal limbs length or joint deformities occurred after reconstruction. The average follow-up time was 11.6±3.9 months. The tumor recurrence rate was 11.1% (5/45) and the survival rate 95.6% (43/45). The average healing time for the allograft and host bone was 5.5±1.2 months and no unexpected internal fixations, fractures or joint collapses occurred. The average knee joint functionality MSTS score was 25.5±6.6 points. No significant differences were found in the length of tumor resection, rate of negative incision margin, duration of osteotomy or of pairing, registration error or allogeneic bone and defect matching error averages between those patients with tumor recurrence and those without it (p>0.05). Based on our results, the computer-assisted navigation system for bone reconstruction after malignant tumor resection allows for high precision during osteotomy, delivers a high success rate of pairing, results in great limb function and low complication rates, and is thus a highly successful and safe approach benefiting bone cancer patients.
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Affiliation(s)
- Xuejun Peng
- Department of Traumatology, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
| | - Fengping Wang
- Department of Ultrasound, Linyi People's Hospital, Linyi, Shandong 276000, P.R. China
| | - Jing Su
- Community Health Center of Yinque Mountain, Linyi, Shandong 276003, P.R. China
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31
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Gundle KR, White JK, Conrad EU, Ching RP. Accuracy and Precision of a Surgical Navigation System: Effect of Camera and Patient Tracker Position and Number of Active Markers. Open Orthop J 2017; 11:493-501. [PMID: 28694888 PMCID: PMC5481622 DOI: 10.2174/1874325001711010493] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/19/2017] [Accepted: 02/23/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction: Surgical navigation systems are increasingly used to aid resection and reconstruction of osseous malignancies. In the process of implementing image-based surgical navigation systems, there are numerous opportunities for error that may impact surgical outcome. This study aimed to examine modifiable sources of error in an idealized scenario, when using a bidirectional infrared surgical navigation system. Materials and Methods: Accuracy and precision were assessed using a computerized-numerical-controlled (CNC) machined grid with known distances between indentations while varying: 1) the distance from the grid to the navigation camera (range 150 to 247cm), 2) the distance from the grid to the patient tracker device (range 20 to 40cm), and 3) whether the minimum or maximum number of bidirectional infrared markers were actively functioning. For each scenario, distances between grid points were measured at 10-mm increments between 10 and 120mm, with twelve measurements made at each distance. The accuracy outcome was the root mean square (RMS) error between the navigation system distance and the actual grid distance. To assess precision, four indentations were recorded six times for each scenario while also varying the angle of the navigation system pointer. The outcome for precision testing was the standard deviation of the distance between each measured point to the mean three-dimensional coordinate of the six points for each cluster. Results: Univariate and multiple linear regression revealed that as the distance from the navigation camera to the grid increased, the RMS error increased (p<0.001). The RMS error also increased when not all infrared markers were actively tracking (p=0.03), and as the measured distance increased (p<0.001). In a multivariate model, these factors accounted for 58% of the overall variance in the RMS error. Standard deviations in repeated measures also increased when not all infrared markers were active (p<0.001), and as the distance between navigation camera and physical space increased (p=0.005). Location of the patient tracker did not affect accuracy (0.36) or precision (p=0.97) Conclusion: In our model laboratory test environment, the infrared bidirectional navigation system was more accurate and precise when the distance from the navigation camera to the physical (working) space was minimized and all bidirectional markers were active. These findings may require alterations in operating room setup and software changes to improve the performance of this system.
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Affiliation(s)
- Kenneth R Gundle
- Oregon Health & Science University, Department of Orthopaedics & Rehabilitation, Portland, USA.,Portland VA Medical Center, Operative Care Division, Portland, USA
| | - Jedediah K White
- University of Washington Medical Center, Department of Orthopaedics & Sports Medicine, Washington, USA
| | - Ernest U Conrad
- University of Washington Medical Center, Department of Orthopaedics & Sports Medicine, Washington, USA.,Seattle Children's Hospital, Department of Orthopaedic Surgery, Washington, USA
| | - Randal P Ching
- University of Washington Applied Biomechanics Laboratory, Washington, USA
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Jeys L, Morris G, Evans S, Stevenson J, Parry M, Gregory J. Surgical Innovation in Sarcoma Surgery. Clin Oncol (R Coll Radiol) 2017; 29:489-499. [PMID: 28502707 DOI: 10.1016/j.clon.2017.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/24/2022]
Abstract
The field of orthopaedic oncology relies on innovative techniques to resect and reconstruct a bone or soft tissue tumour. This article reviews some of the most recent and important innovations in the field, including biological and implant reconstructions, together with computer-assisted surgery. It also looks at innovations in other fields of oncology to assess the impact and change that has been required by surgeons; topics including surgical margins, preoperative radiotherapy and future advances are discussed.
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Affiliation(s)
- L Jeys
- Royal Orthopaedic Hospital, Birmingham, UK; School of Health and Life Sciences, Aston University, Birmingham, UK.
| | - G Morris
- Royal Orthopaedic Hospital, Birmingham, UK
| | - S Evans
- Royal Orthopaedic Hospital, Birmingham, UK
| | | | - M Parry
- Royal Orthopaedic Hospital, Birmingham, UK
| | - J Gregory
- Royal Orthopaedic Hospital, Birmingham, UK
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33
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What Is the Expected Learning Curve in Computer-assisted Navigation for Bone Tumor Resection? Clin Orthop Relat Res 2017; 475:668-675. [PMID: 26913513 PMCID: PMC5289161 DOI: 10.1007/s11999-016-4761-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 02/16/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Computer navigation during surgery can help oncologic surgeons perform more accurate resections. However, some navigation studies suggest that this tool may result in unique intraoperative problems and increased surgical time. The degree to which these problems might diminish with experience-the learning curve-has not, to our knowledge, been evaluated for navigation-assisted tumor resections. QUESTIONS/PURPOSES (1) What intraoperative technical problems were observed during the first 2 years using navigation? (2) What was the mean time for navigation procedures and the time improvement during the learning curve? (3) Have there been any differences in the accuracy of the registration technique that occurred over time? (4) Did navigation achieve the goal of achieving a wide bone margin? METHODS All patients who underwent preoperative virtual planning for tumor bone resections and operated on with navigation assistance from 2010 to 2012 were prospectively collected. Two surgeons (GLF, LAA-T) performed the intraoperative navigation assistance. Both surgeons had more than 5 years of experience in orthopaedic oncology with more than 60 oncology cases per year per surgeon. This study includes from the very first patients performed with navigation. Although they did not take any formal training in orthopaedic oncology navigation, both surgeons were trained in navigation for knee prostheses. Between 2010 and 2012, we performed 124 bone tumor resections; of these, 78 (63%) cases were resected using intraoperative navigation assistance. During this period, our general indications for use of navigation included pelvic and sacral tumors and those tumors that were reconstructed with massive bone allografts to obtain precise matching of the host and allograft osteotomies. Seventy-eight patients treated with this technology were included in the study. Technical problems (crashes) and time for the navigation procedure were reported after surgery. Accuracy of the registration technique was defined and the surgical margins of the removed specimen were determined by an experienced bone pathologist after the surgical procedure as intralesional, marginal, or wide margins. To obtain these data, we performed a chart review and review of operative notes. RESULTS In four patients (of 78 [5%]), the navigation was not completed as a result of technical problems; all occurred during the first 20 cases of the utilization of this technology. The mean time for navigation procedures during the operation was 31 minutes (range, 11-61 minutes), and the early navigations took more time (the regression analysis shielded R2 = 0.35 with p < 0.001). The median registration error was 0.6 mm (range, 0.3-1.1 mm). Registration did not improve over time (the regression analysis slope estimate is -0.014, with R2 = 0.026 and p = 0.15). Histological examinations of all specimens showed a wide bone tumor margin in all patients. However, soft tissue margins were wide in 58 cases and marginal in 20. CONCLUSIONS We conclude that navigation may be useful in achieving negative bony margins, but we cannot state that it is more effective than other means for achieving this goal. Technical difficulty precluded the use of navigation in 5% of cases in this series. Navigation time decreased with more experience in the procedure but with the numbers available, we did not improve the registration error over time. Given these observations and the increased time and expense of using navigation, larger studies are needed to substantiate the value of this technology for routine use. LEVEL OF EVIDENCE Level IV, therapeutic study.
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35
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Ould-Slimane M, Thong P, Perez A, Roussignol X, Dujardin FH. The role of Intraoperative 3D navigation for pelvic bone tumor resection. Orthop Traumatol Surg Res 2016; 102:807-11. [PMID: 27318805 DOI: 10.1016/j.otsr.2016.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 02/10/2016] [Accepted: 03/15/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED Interventional 3D analysis is often used for surgery of the spine. The goal of this study was to describe the technique and initial results of intraoperative 3D CT navigation (O-Arm, Medtronic, Louisville, CO, USA) for surgery of the pelvis. Six patients were included, five with primary bone tumors and one with post-traumatic non-union. All CT procedures were completed without modifying the surgical technique, except one case in which the device had to be reinstalled during surgery. The duration of surgery was not increased and lasted for a mean 224minutes (96-380). Recorded radiation was between 450-1125mGrey/cm. All procedures were performed according to the preoperative plan resulting in systematic resection with a safe surgical margin (R0). One surgical site infection occurred. Although these operations could have been performed without 3-D navigation, this technique provided continuous intraoperative control and safety. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- M Ould-Slimane
- Orthopedic surgery department, Rouen University Hospital, 1, rue de Germont, 76031 Rouen, France.
| | - P Thong
- Orthopedic surgery department, Rouen University Hospital, 1, rue de Germont, 76031 Rouen, France
| | - A Perez
- Neurosurgery department, Rouen University Hospital, 1, rue de Germont, 76031 Rouen, France
| | - X Roussignol
- Orthopedic surgery department, Rouen University Hospital, 1, rue de Germont, 76031 Rouen, France
| | - F-H Dujardin
- Orthopedic surgery department, Rouen University Hospital, 1, rue de Germont, 76031 Rouen, France
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36
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Mesko NW, Joyce DM, Ilaslan H, Joyce MJ. Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center. Clin Orthop Relat Res 2016; 474:1516-22. [PMID: 26183844 PMCID: PMC4868174 DOI: 10.1007/s11999-015-4412-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Altered anatomy in a previously irradiated surgical bed can make accurate localization of anatomic landmarks and local recurrence nearly impossible. The use of intraoperative MRI (iMRI) has been described in neurosurgical settings, but to our knowledge, no such description has been made regarding its utility for local recurrence localization in sarcoma surgery. CASE DESCRIPTION A 58-year-old female presented after previously undergoing two previous resection and reresection procedures of a myxoid liposarcoma located adjacent to her proximal femoral vasculature. After postoperative radiation therapy, she was referred to our institution where she underwent two additional reexcisions of local recurrences during a 3-year span, eventually undergoing a regional rotational muscle flap for coverage. Two years after her third reexcision procedure, she presented with two additional, nonpalpable surgical-bed local recurrences. After converting an MRI bed and scanner to allow for proximal thigh imaging in an iMRI surgical suite, the patient underwent a successful resection that achieved negative margins. To date, she remains without evidence of disease at 37 months. LITERATURE REVIEW Real-time iMRI in neurosurgical studies has shown a high rate of residual disease leading to immediate subsequent reexcision, thus lending to improved rates of negative margin resection. To our knowledge, this is the first example using iMRI technology to remove a recurrent soft tissue sarcoma that otherwise was clinically nonlocalizable. CLINICAL RELEVANCE The use of an iMRI surgical suite can aid with identification of soft tissue nodules in conditions such as an altered tumor bed from prior resection and radiotherapy, which otherwise make recurrences difficult to localize. A team approach between administration, surgeons, and engineers is required to design and pragmatically implement the use of an MRI-compatible table extension to enhance existing iMRI surgical suite technology for extremity sarcoma resection procedures.
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Affiliation(s)
- Nathan W. Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
| | - David M. Joyce
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
| | - Hakan Ilaslan
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH USA
| | - Michael J. Joyce
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
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Aponte-Tinao LA, Ritacco LE, Milano FE, Ayerza MA, Farfalli GF. Techniques in surgical navigation of extremity tumors: state of the art. Curr Rev Musculoskelet Med 2015; 8:319-23. [PMID: 26408148 DOI: 10.1007/s12178-015-9305-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Image-guided surgical navigation allows the orthopedic oncologist to perform adequate tumor resection based on fused images (CT, MRI, PET). Although surgical navigation was first performed in spine and pelvis, recent reports have described the use of this technique in bone tumors located in the extremities. In long bones, this technique has moved from localization or percutaneous resection of benign tumors to complex bone tumor resections and guided reconstructions (allograft or endoprostheses). In recent years, the reported series have increased from small numbers (5 to 16 patients) to larger ones (up to 130 patients). The purpose of this paper is to review recent reports regarding surgical navigation in the extremities, describing the results obtained with different kind of reconstructions when navigation is used and how the previously described problems were solved.
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Affiliation(s)
| | - Lucas E Ritacco
- Italian Hospital of Buenos Aires, Potosi 4247, Buenos Aires, Argentina.
| | - Federico E Milano
- Italian Hospital of Buenos Aires, Potosi 4247, Buenos Aires, Argentina.
| | - Miguel A Ayerza
- Italian Hospital of Buenos Aires, Potosi 4247, Buenos Aires, Argentina.
| | - German F Farfalli
- Italian Hospital of Buenos Aires, Potosi 4247, Buenos Aires, Argentina.
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