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Gong T, Lu M, Wang Y, Li Z, He X, Luo Y, Zhou Y, Tu C, Min L. Is 3D-printed self-stabilizing endoprosthesis reconstruction without supplemental fixation following total sacrectomy a viable approach for sacral tumours? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08292-9. [PMID: 38713447 DOI: 10.1007/s00586-024-08292-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE The spinopelvic reconstruction poses significant challenges following total sacrectomy in patients with malignant or aggressive benign bone tumours encompassing the entire sacrum. In this study, we aim to assess the functional outcomes and complications of an integrated 3D-printed sacral endoprostheses featuring a self-stabilizing design, eliminating the requirement for supplemental fixation. METHODS We retrospectively analyzed patients with sacral tumours who underwent total sacrectomy followed by reconstruction with 3D-printed self-stabilizing endoprosthesis. Clinically, we evaluated functional outcomes using the 1993 version of the musculoskeletal tumour society (MSTS-93) score. Perioperative and postoperative complications were also documented. RESULTS 10 patients met final inclusion criteria. The median age was 49 years (range, 31-64 years). The median follow-up time was 26.5 months (range, 15-47 months). Median postoperative functional MSTS-93 was 22.5 (range, 13-25). The median operation time was 399.5 min (305-576 min), and the median intraoperative blood loss was and 3200 ml (2400-7800 ml). Complications include wound dehiscence in one patient, bowel, bladder, and sexual dysfunction in four patients, cerebrospinal fluid leak in one patient, and tumour recurrence in one patient. There were no mechanical complications related to the endoprosthesis at the last follow-up. CONCLUSION The utilization of 3D-printed self-stabilizing endoprosthesis proved to be a viable approach, yielding satisfactory short-term outcomes in patients undergoing total sacral reconstruction without supplemental fixation.
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Affiliation(s)
- Taojun Gong
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Minxun Lu
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yitian Wang
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhuangzhuang Li
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xuanhong He
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yi Luo
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yong Zhou
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chongqi Tu
- Department of Orthopedics, Orthopaedic Research Institute, Sichuan Model Worker and Craftsman Talent Innovation Research Studio, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
| | - Li Min
- Department of Orthopedics, Orthopedic Research Institute, Model Worker and Craftsman Talent Innovation Workshop of Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
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Turbucz M, Pokorni AJ, Hajnal B, Koch K, Szoverfi Z, Varga PP, Lazary A, Eltes PE. The biomechanical effect of lumbopelvic distance reduction on reconstruction after total sacrectomy: a comparative finite element analysis of four techniques. Spine J 2024:S1529-9430(24)00195-5. [PMID: 38688331 DOI: 10.1016/j.spinee.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/11/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Following total sacrectomy, lumbopelvic reconstruction is essential to restore continuity between the lumbar spine and pelvis. However, to achieve long-term clinical stability, bony fusion between the lumbar spine and the pelvic ring is crucial. Reduction of the lumbopelvic distance can promote successful bony fusion. Although many lumbopelvic reconstruction techniques (LPRTs) have been previously analyzed, the biomechanical effect of lumbopelvic distance reduction (LPDR) has not been investigated yet. PURPOSE To evaluate and compare the biomechanical characteristics of four different LPRTs while considering the effect of LPDR. STUDY DESIGN/SETTING A comparative finite element (FE) study. METHODS The FE models following total sacrectomy were developed to analyze four different LPRTs, with and without LPDR. The closed-loop reconstruction (CLR), the sacral-rod reconstruction (SRR), the four-rod reconstruction (FRR), and the improved compound reconstruction (ICR) techniques were analyzed in flexion, extension, lateral bending, and axial rotation. Lumbopelvic stability was assessed through the shift-down displacement and the relative sagittal rotation of L5, while implant safety was evaluated based on the stress state at the bone-implant interface and within the rods. RESULTS Regardless of LPDR, both the shift-down displacement and relative sagittal rotation of L5 consistently ranked the LPRTs as ICR CONCLUSIONS LPDR significantly improved both lumbopelvic stability and implant safety in all reconstruction techniques after total sacrectomy. LPDR reduced the shift-down displacement of L5, the relative sagittal rotation of L5, and the stress values at the bone-implant interface. Furthermore, in the ICR and SRR techniques, LPDR decreased the peak stress values within the rods. All four investigated LPRTs demonstrated suitability for lumbopelvic reconstruction, with the ICR technique exhibiting the highest lumbopelvic stiffness. CLINICAL SIGNIFICANCE LPDR creates a biomechanically advantageous environment following total sacrectomy; therefore, it has the potential to impact the design of custom-made 3D-printed or traditional LPRTs. However, to confirm the findings of the current FE study, long-term clinical trials are recommended.
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Affiliation(s)
- Mate Turbucz
- School of PhD Studies, Semmelweis University, Üllői Str. 26, Budapest, Hungary; In Silico Biomechanics Laboratory, National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Agoston Jakab Pokorni
- School of PhD Studies, Semmelweis University, Üllői Str. 26, Budapest, Hungary; In Silico Biomechanics Laboratory, National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Benjamin Hajnal
- School of PhD Studies, Semmelweis University, Üllői Str. 26, Budapest, Hungary; In Silico Biomechanics Laboratory, National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Kristof Koch
- School of PhD Studies, Semmelweis University, Üllői Str. 26, Budapest, Hungary; National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Zsolt Szoverfi
- National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Peter Pal Varga
- National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary
| | - Aron Lazary
- National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary; Department of Spine Surgery, Department of Orthopaedics, Semmelweis University, Üllői Str. 78/b, Budapest, Hungary
| | - Peter Endre Eltes
- In Silico Biomechanics Laboratory, National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary; National Center for Spinal Disorders, Királyhágó Str. 1-3, Budapest, Hungary; Department of Spine Surgery, Department of Orthopaedics, Semmelweis University, Üllői Str. 78/b, Budapest, Hungary.
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Wellings EP, Houdek MT, Owen AR, Bakri K, Yaszemski MJ, Sim FH, Moran SL, Rose PS. Comparison of free vascularized fibular flaps and allograft fibular strut grafts to supplement spinopelvic reconstruction for sacral malignancies. Bone Joint J 2021; 103-B:1414-1420. [PMID: 34334037 DOI: 10.1302/0301-620x.103b8.bjj-2020-2302.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques. METHODS We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5). RESULTS There was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003). CONCLUSION Supplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414-1420.
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Affiliation(s)
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Bakri
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Franklin H Sim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Pennington Z, Ehresman J, McCarthy EF, Ahmed AK, Pittman PD, Lubelski D, Goodwin CR, Sciubba DM. Chordoma of the sacrum and mobile spine: a narrative review. Spine J 2021; 21:500-517. [PMID: 33589095 DOI: 10.1016/j.spinee.2020.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
Chordoma is a notochord-derived primary tumor of the skull base and vertebral column known to affect 0.08 to 0.5 per 100,000 persons worldwide. Patients commonly present with mechanical, midline pain with or without radicular features secondary to nerve root compression. Management of these lesions has classically revolved around oncologic resection, defined by en bloc resection of the lesion with negative margins as this was found to significantly improve both local control and overall survival. With advancement in radiation modalities, namely the increased availability of focused photon therapy and proton beam radiation, high-dose (>50 Gy) neoadjuvant or adjuvant radiotherapy is also becoming a standard of care. At present chemotherapy does not appear to have a role, but ongoing investigations into the ontogeny and molecular pathophysiology of chordoma promise to identify therapeutic targets that may further alter this paradigm. In this narrative review we describe the epidemiology, histopathology, diagnosis, and treatment of chordoma.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Edward F McCarthy
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Patricia D Pittman
- Department of Neuropathology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA.
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Bourghli A, Boissiere L, Obeid I. Dual iliac screws in spinopelvic fixation: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2053-2059. [PMID: 31300882 DOI: 10.1007/s00586-019-06065-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/14/2019] [Accepted: 07/08/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The classical spinopelvic fixation includes 1 iliac screw on each side. The purpose of this study is to specify the indications of the "dual iliac screw" (DIS) construct, i.e., when to put 2 iliac screws on each side, to describe its biomechanical advantages, and to define its related technical aspects. METHODS A primary search on Medline through PubMed distribution was performed, with the use of the terms "pelvic fixation" or "spinopelvic" or "lumbo-iliac" and the terms "dual iliac screw" or "double iliac screw." English papers corresponding to the inclusion criteria were analyzed regarding the specific indications of the DIS construct and its surgical technique and advantages. RESULTS Eleven papers were identified according to the research criteria and included in this review. Three main indications were identified for the DIS technique according to three types of pathologies: in adult deformities when a long construct is needed in an osteoporotic patient or when correction requires three-column osteotomy of the sacrum; in trauma when a U-shaped fracture-dislocation of the sacrum is involved; in sacral tumors when a sacrectomy is performed or when destructive metastatic lesions of the sacrum require palliative surgical treatment. Biomechanically, the DIS technique proved to have higher construct stiffness in terms of compression and torsion. CONCLUSION In specific cases, affecting different areas of spinal diseases, the DIS technique is more advantageous, when compared to the "single iliac screw" version, as it would provide a stronger and safer fixation at the base of the spinopelvic construct. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Anouar Bourghli
- Orthopedic and Spinal Surgery Department, Kingdom Hospital, P.O. Box 84400, Riyadh, 11671, Saudi Arabia.
| | - Louis Boissiere
- Orthopedic Spinal Surgery Unit 1, Bordeaux Pellegrin Hospital, Bordeaux, France
| | - Ibrahim Obeid
- Orthopedic Spinal Surgery Unit 1, Bordeaux Pellegrin Hospital, Bordeaux, France
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Tavares Junior MCM, de Souza JPV, Araujo TPF, Marcon RM, Cristante AF, de Barros Filho TEP, Letaif OB. Comparative tomographic study of the S2-alar-iliac screw versus the iliac screw. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:855-862. [PMID: 30382431 DOI: 10.1007/s00586-018-5806-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 10/24/2018] [Indexed: 11/27/2022]
Abstract
AIMS Iliac screws and S2-alar-iliac screws provide adequate mechanical stability for the fixation of lumbosacral spine pathologies, which has led to a significant increase in the use of these techniques in the routine practice of spine surgeons. However, studies on the ideal technical positioning for both techniques are limited. STUDY DESIGN This is an observational, retrospective, analytical descriptive study. OBJECTIVE To analyze, describe and compare the insertion and positioning parameters of the S2-alar-iliac and iliac screw techniques in adult patients without spinal deformities. METHODS The present study comprises a retrospective analysis of lumbosacral computed tomography images selected continuously in 2016 from 25 patients at a university hospital. Mann-Whitney-Shapiro-Wilk tests were performed. Data reliability was assessed using intraclass correlation. RESULTS The mean length of the iliac screw was greater than that of the S2-alar-iliac screw, and the S2-alar-iliac screw sat 20.5 mm deeper than the iliac screw. The mean of the greatest bone thickness for the iliac screw was 20.72 mm; that of the S2-alar-iliac screw was 23.24 mm. The mean distance from the iliac screw entry point to the skin was 32.46 mm, and the mean distance from the S2-alar-iliac screw entry point to the skin was 52.87 mm. CONCLUSION The trajectory of the S2-alar-iliac screws studied via computed tomography was greater in terms of bone thickness and deeper relative to the skin compared with the iliac screws. The S2-alar-iliac technique may have desirable clinical advantages in terms of the diameter of the screws and reduced protrusion when used in adults. These slides can be retrieved from Electronic supplementary material.
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Affiliation(s)
| | - João Paço Vaz de Souza
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Raphael Martus Marcon
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | - Alexandre Fogaça Cristante
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Olavo Biraghi Letaif
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
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Abstract
STUDY DESIGN We retrospectively analyzed factors associated with spinopelvic mechanical failure after total sacrectomy. OBJECTIVE To find the rate and type of mechanical fixation failure after total sacrectomy and to identify the associated risk factors. SUMMARY OF BACKGROUND DATA Although rigid fixation has been achieved, mechanical failure is sometimes encountered in reconstruction after total sacrectomy. The incidence and factors associated with spinopelvic fixation mechanical failure after total sacrectomy are still not clear. METHODS The study comprised 63 patients who underwent spinopelvic reconstruction after total sacrectomy. The potential risk factors for fixation mechanical failure after total sacrectomy were evaluated, which included age, sex, body mass index, type of tumor (benign or malignant), and adjuvant treatment received (e.g., chemotherapy, radiation therapy). The surgery-related factors included the classification of tumor resection (en bloc or piecemeal resection) and the type of iliosacral resection. Adoption of anterior spinal column fixation (ASCF), posterior pelvic ring fixation (PPRF), four-rod technique (FRT) of spinopelvic fixation (SPF), and structural or morselized bone grafting after total sacrectomy in patients were considered reconstruction-related factors. Cox regression models were used to analyze associations between postoperative fixation failure and risk factors for all models. RESULTS Postoperative fixation mechanical failure occurred in 25% of patients (16/63) who underwent total sacrectomy. Univariate analysis showed that the factors associated with spinopelvic fixation mechanical failure after total sacrectomy were the non-adoption of FRT of SPF and ASCF, the adoption of Type II sacroiliac resection, and female sex, whereas multivariate analysis demonstrated similar results, except for the adoption of Type II sacroilliac resection. CONCLUSION FRT connection of SPF and ASCF should be adopted in reconstruction after total sacrectomy, especially in female patients. LEVEL OF EVIDENCE 3.
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Araújo TPF, Narazaki DK, Teixeira WGJ, Busnardo F, Cristante AF, Barros Filho TEPD. SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS. ACTA ORTOPEDICA BRASILEIRA 2018; 26:260-264. [PMID: 30210257 PMCID: PMC6131279 DOI: 10.1590/1413-785220182604183451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver. Study design: Report of a case series with description of a new surgical technique. Methods: The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used. Results: In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively). Conclusion: The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.
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Alvis-Miranda HR, Farid-Escorcia H, Alcalá-Cerra G, Castellar-Leones SM, Moscote-Salazar LR. Sacroiliac screw fixation: A mini review of surgical technique. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 5:110-3. [PMID: 25336831 PMCID: PMC4201009 DOI: 10.4103/0974-8237.142303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The sacral percutaneous fixation has many advantages but can be associated with a significant exposure to X-ray radiation. Currently, sacroiliac screw fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. It is a technique that should be used by experienced surgeons. We present a practical review of important aspects of this technique.
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Varga PP, Szoverfi Z, Lazary A. Surgical resection and reconstruction after resection of tumors involving the sacropelvic region. Neurol Res 2014; 36:588-96. [PMID: 24766410 DOI: 10.1179/1743132814y.0000000370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Surgical management of tumors in the sacropelvic region is a challenging field of spine surgery because of the region's complex local anatomy and biomechanics. Recent developments in anesthesia and intensive care have allowed us to perform extended surgeries focused on the en bloc resection of sacropelvic tumors. Various techniques for the resection and for the reconstruction were published in the last decade. METHODS Sacropelvic tumor resection techniques and methods for the biomechanical and soft-tissue reconstruction are reviewed in this paper. RESULTS The literature data is based on case reports and case-series. Several different techniques were developed for the lumbopelvic stabilization after sacropelvic tumor resection according to three different reconstruction principles (spinopelvic fixation (SPF), posterior pelvic ring fixation (PRF), and anterior spinal column fixation (ACF)); however, long-term follow-up data and comparative studies of the different techniques are still missing. Soft-tissue reconstruction can be performed according to an algorithm depending on the surgical approach, but relatively high complication rates are reported with all reconstruction strategies. The clinical outcome of such surgeries should ideally be evaluated in three dimensions; surgical-, oncological-, and functional outcomes. The last and most important step of the presurgical planning procedure is a careful presentation of the surgical goals and risks to the patient, who must provide a fully informed consent before surgery can proceed. DISCUSSION Sacropelvic tumors are rare conditions. In the last decade, growing evidence was published on resection and reconstruction techniques for these tumors; however, experience at most medical centers is limited due to the low numbers of cases. The formation of international expert groups and the initiation of multicenter studies are strongly encouraged to produce a high level of evidence in this special field of spine surgery.
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Clark AJ, Tang JA, Leasure JM, Ivan ME, Kondrashov D, Buckley JM, Deviren V, Ames CP. Gait-simulating fatigue loading analysis and sagittal alignment failure of spinal pelvic reconstruction after total sacrectomy: comparison of 3 techniques. J Neurosurg Spine 2014; 20:364-70. [PMID: 24460580 DOI: 10.3171/2013.12.spine13386] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Reconstruction after total sacrectomy is a critical component of malignant sacral tumor resection, permitting early mobilization and maintenance of spinal pelvic alignment. However, implant loosening, graft migration, and instrumentation breakage remain major problems. Traditional techniques have used interiliac femoral allograft, but more modern methods have used fibular or cage struts from the ilium to the L-5 endplate or sacral body replacement with transiliac bars anchored to cages to the L-5 endplate. This study compares the biomechanical stability under gait-simulating fatigue loading of the 3 current methods. METHODS Total sacrectomy was performed and reconstruction was completed using 3 different constructs in conjunction with posterior spinal screw rod instrumentation from L-3 to pelvis: interiliac femur strut allograft (FSA); L5-iliac cage struts (CSs); and S-1 body replacement expandable cage (EC). Intact lumbar specimens (L3-sacrum) were tested for flexion-extension range of motion (FE-ROM), axial rotation ROM (AX-ROM), and lateral bending ROM (LB-ROM). Each instrumented specimen was compared with its matched intact specimen to generate an ROM ratio. Fatigue testing in compression and flexion was performed using a custom-designed long fusion gait model. RESULTS Compared with intact specimen, the FSA FE-ROM ratio was 1.22 ± 0.60, the CS FE-ROM ratio was significantly lower (0.37 ± 0.12, p < 0.001), and EC was lower still (0.29 ± 0.14, p < 0.001; values are expressed as the mean ± SD). The difference between CS and EC in FE-ROM ratio was not significant (p = 0.83). There were no differences in AX-ROM or LB-ROM ratios (p = 0.77 and 0.44, respectively). No failures were noted on fatigue testing of any EC construct (250,000 cycles). This was significantly improved compared with FSA (856 cycles, p < 0.001) and CS (794 cycles, p < 0.001). CONCLUSIONS The CS and EC appear to be significantly more stable constructs compared with FSA with FE-ROM. The 3 constructs appear to be equal with AX-ROM and LB-ROM. Most importantly, EC appears to be significantly more resistant to fatigue compared with FSA and CS. Reconstruction of the load transfer mechanism to the pelvis via the L-5 endplate appears to be important in maintenance of alignment after total sacrectomy reconstruction.
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Yu Y, Zhu R, Zeng ZL, Jia YW, Wu ZR, Ren YL, Chen B, Ding ZQ, Cheng LM. The strain at bone-implant interface determines the effect of spinopelvic reconstruction following total sacrectomy: a strain gauge analysis in various spinopelvic constructs. PLoS One 2014; 9:e85298. [PMID: 24454839 PMCID: PMC3891848 DOI: 10.1371/journal.pone.0085298] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/25/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There is still some controversy regarding the optimal biomechanical concept for spinopelvic stabilization following total sacrectomy for malignancy. Strains at specific anatomical sites at pelvis/sacrum and implants interfaces have been poorly investigated. Herein, we compared and analyzed the strains applied at key points at the bone-implant interface in four different spinopelvic constructs following total sacrectomy; consequently, we defined a balanced architecture for spinopelvic fusion in that situation. METHODS Six human cadaveric specimens, from second lumbar vertebra to proximal femur, were used to compare the partial strains at specific sites in a total sacrectomy model. Test constructs included: (1) intact pelvis (control), (2) sacral-rod reconstruction (SRR), (3) bilateral fibular flap reconstruction (BFFR), (4) four-rods reconstruction (FRR), and (5) improved compound reconstruction (ICR). Strains were measured by bonded strain gauges onto the surface of three specific sites (pubic rami, arcuate lines, and posterior spinal rods) under a 500 N axial load. RESULTS ICR caused lower strains at specific sites and, moreover, on stress distribution and symmetry, compared to the other three constructs. Strains at pubic rami and arcuate lines following BFFR were lower than those following SRR, but higher at the posterior spinal rod construct. The different modes of strain distribution reflected different patient's parameter-related conditions. FRR model showed the highest strains at all sites because of the lack of an anterior bracing frame. CONCLUSIONS The findings of this investigation suggest that both anterior bracing frame and the four-rods load dispersion provide significant load sharing. Additionally, these two constructs decrease the peak strains at bone-implant interface, thus determining the theoretical surgical technique to achieve optimal stress dispersion and balance for spinopelvic reconstruction in early postoperative period following total sacrectomy.
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Affiliation(s)
- Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Julius Wolff Institut, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Zhi-Li Zeng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong-Wei Jia
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhou-Rui Wu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi-Long Ren
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bo Chen
- School of Life Science and Technology, Tongji University, Shanghai, China
- Institute of Orthopaedics and Traumatology, Shanghai, China
| | - Zu-Quan Ding
- School of Life Science and Technology, Tongji University, Shanghai, China
| | - Li-Ming Cheng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- * E-mail:
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Zhu R, Cheng LM, Yu Y, Zander T, Chen B, Rohlmann A. Comparison of four reconstruction methods after total sacrectomy: a finite element study. Clin Biomech (Bristol, Avon) 2012; 27:771-6. [PMID: 22705158 DOI: 10.1016/j.clinbiomech.2012.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 05/15/2012] [Accepted: 05/16/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND After total sacrectomy, it is mandatory to reconstruct the continuity between the lumbar spine and the pelvis. Only few biomechanical analyses exist which compare different reconstructions. Therefore, the aim of this study was to compare the lumbo-pelvic motion and the relative risk of implant breakage for four different reconstructions after total sacrectomy. METHOD Finite element analyses were performed for four general different reconstructions after total sacrectomy: sacral-rod reconstruction, four-rod reconstruction, bilateral fibular flaps reconstruction, and improved compound reconstruction. The rotations between L5 vertebra and ilium, the L5 shift-down displacement, and the maximum von Mises stress in the implants were calculated and evaluated for flexion, extension, lateral bending and axial rotation. FINDINGS The decreasing order of the rotations between L5 vertebra and ilium as well as of the L5 shift-down displacement for the studied reconstruction methods was four-rod reconstruction>sacral-rod reconstruction>bilateral fibular flaps reconstruction>improved compound reconstruction. The decreasing order of the maximum von Mises stress in the implants was sacral-rod reconstruction>four-rod reconstruction>bilateral fibular flaps reconstruction>improved compound reconstruction. INTERPRETATION From the mechanical point of view, improved compound reconstruction is superior to the other methods studied here as it shows the highest stability and the lowest maximum von Mises stress. However, clinical aspects must also be regarded when choosing a reconstruction method for a specific patient.
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Affiliation(s)
- Rui Zhu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, 200065 Shanghai, PR China
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Clarke MJ, Dasenbrock H, Bydon A, Sciubba DM, McGirt MJ, Hsieh PC, Yassari R, Gokaslan ZL, Wolinsky JP. Posterior-Only Approach for En Bloc Sacrectomy. Neurosurgery 2012; 71:357-64; discussion 364. [DOI: 10.1227/neu.0b013e31825d01d4] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases.
OBJECTIVE:
To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome.
METHODS:
Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed.
RESULTS:
Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome.
CONCLUSION:
It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.
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Affiliation(s)
| | | | - Ali Bydon
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel M. Sciubba
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Patrick C. Hsieh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Reza Yassari
- Albert Einstein College of Medicine, Bronx, New York
| | - Ziya L. Gokaslan
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jean-Paul Wolinsky
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
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