Pelvic reconstruction after subtotal sacrectomy for sacral chondrosarcoma using cadaveric and vascularized fibula autograft: Technical note

Comparison of free vascularized fibular flaps and allograft fibular strut grafts to supplement spinopelvic reconstruction for sacral malignancies

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.

Reconstruction after Subtotal Sacrectomy for Sacral Ewing's Sarcoma Using Tibial Allograft Strut Grafting: A Case Report

We present the case of a 15-year-old girl. Two months after becoming aware of pain, she was diagnosed with a sacral tumor and referred to our department. She was diagnosed with a sacral Ewing's sarcoma; after chemotherapy, it was determined that the tumor could be resected, so surgical treatment was performed. The sacrum and ilium were partially resected at the lower end of S1, and the lumbar vertebrae and pelvis were fixed with a pedicle screw and two iliac screws on each side of L3, and the sacral resection was reconstructed with a tibial strut allograft. No tumor recurrence or metastasis has been observed 1 year postoperatively. She developed bladder and rectal dysfunction, but she remained independent in activities of daily living and her daily life was not limited. The bone fusion in the reconstructed area confirmed the lack of instrumentation looseness. Surgical treatment for sacral Ewing's sarcoma was performed to cure the patient. We believe that the tibial allograft contributed to the patient's ability to walk on her own due to its high mechanical stability. Postoperative bone healing was observed with the same material, suggesting that the tibial allograft is useful for similar procedures.

Surgical treatment of metastatic mesenchymal chondrosarcoma to the spine: A case report

INTRODUCTION

Metastatic mesenchymal chondrosarcoma of the spine is a highly unusual disease without standard curative managements yet. The objective of this case report is to present a very rare case of metastatic chondrosarcoma to the spine successfully operated by surgical treatment. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 34-year-old woman presented with a 4-month history of continuous and progressive back pain and a 1-month history of radiating pain of bilateral lower extremities. The patient, who had been diagnosed of mesenchymal chondrosarcoma of maxillary sinus for 3 years, received surgical treatment of palliative endoscopic-assisted total left maxillary resection via mini Caldwell-Luc approach, and palliative enlarged resection due to the progress of residual lesions, followed by no adjuvant therapy. Multiple lytic, expanding lesions of the spine and paraspinal region with severe epidural spinal cord compression was identified.

DIAGNOSIS

CT, MRI and bone scan of spine showed spinal cord compression secondary to the epidural component of the metastatic lesions. Post-operative pathology confirmed the diagnosis of metastatic spinal mesenchymal chondrosarcomas.

INTERVENTIONS

The patient underwent posterior spinal canal decompression, resection of T12 and L3 lesions, internal fixation of T11-L5 pedicles, and cement augmentation of T12 and L3.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 1-year follow-up visit. There were no complications associated with the spinal surgery during the follow-up period.

CONCLUSION

Metastatic spinal mesenchymal chondrosarcoma, although rare, should be part of the differential diagnosis when the patient presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression and total resection of the metastatic chondrosarcoma when the tumor has caused neurological deficits or other severe symptoms. Osteoplasty by cement augmentation is also a good choice for surgical treatment in some patients.

Total Sacrectomy for the Treatment of Advanced Pelvic Chondrosarcoma

Primary tumors of sacrum are rare. The most common malignant tumors are metastasis, and only 6% of all malignant tumors arise from the sacrum. Chondrosarcoma is the third most common primary bone malignancy following myeloma and osteosarcoma. Surgery is usually the most important therapeutic modality; the wide en bloc excision remains the treatment of choice. These technically demanding procedures require a multidisciplinary expert team (neurosurgery, surgical and orthopedic oncology, colorectal surgery, and plastic surgery) involvement. We present in this article a case of a 52-year-old man who presented less infrequent symptoms, and the diagnosis was made in a very advanced stage. The wide surgical excision of the mass was performed by two different anterior and posterior approaches in one stage. The free surgical margins were difficult to achieve because it presented a voluminous tumor with invasion of the rectum, bone, and sacral plexus, but the age, low histological grade, and extensive experience in extreme pelvic surgery of our multidisciplinary team allowed approaching the patient with debulking surgery en bloc, successfully. Total hospital stay was 20 days. The patient was discharged without any complications. At the 6-months' follow-up, the patient showed no local recurrence.

Surgical treatment of chondrosarcoma of the sacrum with cement augmentation: A case report

RATIONALE

Chondrosarcoma of the sacrum is a highly unusual disease without standard curative managements yet. The objective of this study is to report a very rare case of chondrosarcoma of the sacrum successfully operated by percutaneous vertebroplasty. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 45-year-old woman presented with a five-month history of continuous and progressive pain and numbness of left extremity. A lytic, expanding lesion of the sacrum and paraspinal region with severe epidural spinal cord compression was identified.

DIAGNOSIS

MRI of spine showed spinal cord compression secondary to the epidural componant of the giant mass, with increased marrow infiltration of the left S2 vertebral and paravertebral region, which presented as a solid tumor. Post-operative pathology confirmed the diagnosis of sacral well-differentiated chondrosarcoma (stage I B).

INTERVENTIONS

The patient underwent percutaneous vertebroplasty and cement augmentation of sacrum via a posterior approach.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, but the patient died of multiple systemic metastases at the 2-year follow-up visit. There were no complications associated with the operation during the follow-up period.

LESSONS

Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Combined efforts of specialists from orthopedics, radiology, neurosurgery, pathology, and medical oncology led to the successful diagnosis and management of this patient. Giant sacral chondrosarcoma, although rare, should be part of the differential diagnosis when the patient presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression of the sacral chondrosarcoma when the tumor has caused neurological deficits or other severe symptoms. Osteoplasty by cement augmentation is also a good choice for surgical treatment.

Patient-Specific Three-Dimensional Model for a Safe Surgical Pathway in Sacral Chondrosarcoma

Sacral tumors are amongst the most challenging procedures to treat because of the complex anatomy. This study determined whether patient-specific models change preoperative planning decisions made in preparation for en bloc resection of complex sacral mass surgical procedures. Imaging showed a big encapsulated mass at the S2-3 level involving the neural foramina and obscuring the nerve roots. High-resolution images were acquired and utilized to generate a patient-specific 3D tumor model. The visual and tactile inspection of 3D models allowed the best anatomical understanding, with faster and clearer comprehension of the surgical anatomy. The 3D sacral model was for observation of previously unapparent anatomical details; with this new technology, surgeon can observe their planned surgical intervention, explore the patient-specific anatomy and extension of the tumor, and sharpen their procedure choices. Moreover, multiple planes showed how far the angles on the plane would extend for osteotomy of the sacrum. Another result was identifying correct guides and safe venture landmarks. The study helped to establish safe osteotomy line wherever the nerve roots were retained and enabled osteotomy by preserving bilaterally the S1 and S2 nerve roots for wide excision of wide excision of primary sacral tumor to get adequate bowel and bladder functions. Finally, it helped to determine whether or not the remaining bone in the sacrum is sufficient for spinopelvic stability and needed fixation. It was decided spinopelvic fixation was not necessary for this case. Surgical intervention of sacral tumors varies depending on the tumor, its size, extension, and location. Surgery can have profound risks including unnecessary nerve root resection spinopelvic instability and suboptimal oncological resection. 3D models help to transfer complex anatomical information to clinicians and provide guidance in the preoperative planning stage, for intraoperative navigation and for surgical training purposes.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Application of vascularized fibular graft for reconstruction and stabilization of multilevel cervical tuberculosis: A case report

Multilevel cervical reconstruction and fusion after cervical tuberculosis has always been a challenge. The current implantation materials for cervical fusion, including titanium mesh, cage, and plate are limited by its inferior biological mechanical characteristics and the properties of the metallic material. This has led to the increased risk of recurrent infection after surgery. In addition, the unique nature of tuberculosis infection results in the low rate of cervical fusion and high risk of recurrence. This case report presents 1 patient who suffered from long segmental cervical tuberculosis and had reconstruction surgery using a vascularized fibula graft. The patient had successful graft incorporation 3 months postsurgery and was followed-up for 30 months. In this review, we detail the advantages of using vascularized fibular grafts and compare it with other types of grafts.

Sacral Reconstruction with a 3D-Printed Implant after Hemisacrectomy in a Patient with Sacral Osteosarcoma: 1-Year Follow-Up Result

Pelvic reconstruction after sacral resection is challenging in terms of anatomical complexity, excessive loadbearing, and wide defects. Nevertheless, the technological development of 3D-printed implants enables us to overcome these difficulties. Here, we present a case of sacral osteosarcoma surgically treated with hemisacrectomy and sacral reconstruction using a 3D-printed implant. The implant was printed as a customized titanium prosthesis from a 3D real-sized reconstruction of a patient's CT images. It consisted mostly of a porous mesh and incorporated a dense strut. After 3-months of neoadjuvant chemotherapy, the patient underwent hemisacretomy with preservation of contralateral sacral nerves. The implant was anatomically installed on the defect and fixed with a screw-rod system up to the level of L3. Postoperative pain was significantly low and the patient recovered sufficiently to walk as early as 2 weeks postoperatively. The patient showed left-side foot drop only, without loss of sphincter function. In 1-year follow-up CT, excellent bony fusion was noticed. To our knowledge, this is the first report of a case of hemisacral reconstruction using a custom-made 3D-printed implant. We believe that this technique can be applied to spinal reconstructions after a partial or complete spondylectomy in a wide variety of spinal diseases.

Sacral Osteoneogenesis after Complete Sacrectomy in a Patient with Ewing Sarcoma

Ewing sarcomas are the second most common primary malignant bone tumors in childhood and adolescence which rapidly metastasize. Due to improvement of treatment options in recent years, the survival rate has significantly increased. Nevertheless, lethality is still high, and neurologic symptoms are frequent. To the best of our knowledge, this is the first reported case of a sacral osteoneogenesis after complete sacrectomy in a patient with Ewing sarcoma.