Efficacy of Pre- and Postoperative Chemotherapy in Patients with Osteosarcoma of the Extremities

PURPOSE

We evaluated the treatment efficacy including survival and recurrence, and factors associated with recurrence in osteosarcoma patients treated with preoperative chemotherapy, surgery, and adjuvant chemotherapy.

MATERIALS AND METHODS

Forty nine patients with osteosarcoma were treated with preoperative chemotherapy with intra-arterial cisplatin and adriamycin infusion for 3 cycles, followed by surgery. According to the pathologic response, if tumor was necrotized more than 90%, the same adjuvant chemotherapy was reintroduced for 3 cycles, and if the response was not enough, then the salvage regimen was introduced. Plain chest film and chest CT scan were taken monthly and every 3 months, respectively. When tumor recurred, the metastasectomy was performed whenever possible.

RESULTS

Forty three patients were evaluable with amedian follow up of 53 months. Five-year disease-free and overallsurvival rate was 47.0% and 66.9%, respectively. The recurrence was observed in 22 patients (51.2%) with median time of 12.5 months. Baseline alkaline phosphatase (ALP) was the only significant factor for recurrence (p=0.03) and the patients with the possibility of metastasectomy recurrence showed higher post-relapse survival compared to other treatment modalities (26 momths vs 5~12 months).

CONCLUSION

These results indicates that pre- and postoperative chemotherapy with intra-arterial cisplatin and adriamycin infusion showed comparable treatment efficacy and acceptable toxicities.

Prognostic factors and long-term outcomes following a modified Thompson’s quadricepsplasty for severely stiff knees

Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

Treatment of severe equinus deformity associated with extensive scarring of the leg

Nine severe equinus deformities of the foot associated with extensive scarring of the leg and ankle were corrected using a hinged Ilizarov apparatus and free-tissue transfer. The average duration of followup was 38 months (range, 28-54 months). Free tissue transfer was done in all patients; a parascapular flap was used in seven patients, and a groin flap was used in two patients. The results were evaluated using two objective criteria and one subjective assessment: the degree of active dorsiflexion, the range of active movement of the ankle, and daily activities. For active dorsiflexion of the ankle and activities, the results were good in seven patients and fair in two patients. For range of active motion of the ankle, the results were good in six patients and fair in two patients. One patient with ankle arthrodesis was excluded. This study showed that severe equinus deformities associated with extensive scarring of the leg and ankle can be corrected effectively with heel cord lengthening, free-tissue transfer, and a hinged Ilizarov technique.

Finger reconstruction with a free neurovascular wrap-around flap from the big toe

From 1983 to 1998, 16 cases of finger reconstruction with a free neurovascular wrap-around flap from the big toe were treated. Fourteen cases were successful, and two cases failed. The authors reviewed these cases on the average of about 38 months after surgery. Pinch power was 51 percent of the unaffected normal hand, and two-point discrimination was 7.6 mm. The mean resorption of the grafted bone was 13 percent in width and 9 percent in length. There were no complications such as fracture of the grafted bone, nonunion, and pulp dislodgement. This procedure provided length, stability, and adequate sensibility for a functional pinch and grasp. Sensory return to the wrap-around flap on the thumb was often greater than for the same area on the opposite foot. The donor site of the wrap-around flap was acceptable, both aesthetically and functionally, and allowed the wearing of open-toed shoes by young women. Finger reconstruction with a wrap-around flap from the big toe yielded excellent cosmetic and functional results in cases involving amputation at the level of the metacarpophalangealjoints or distal to it. In addition, this procedure was an excellent choice for treatment in cases involving avulsion injuries of the fingers and reconstruction of soft-tissue defects after tumor excision.

A modified Thompson quadricepsplasty for the stiff knee

Between March 1987 and March 1997, we performed a modified Thompson quadricepsplasty on 20 stiff knees and followed the patients for a mean of 35 months (24 to 52). After the operation, the knee was immobilised in flexion and periodically extended. At the final follow-up, the mean active flexion was 113.5 degrees (75 to 150). The final mean gain in movement was 67.6 degrees (5 to 105). One patient had a deep infection which resolved after wound care and intravenous antibiotics. The modified Thompson quadricepsplasty with appropriate postoperative care can give good results.

A modified Thompson quadricepsplasty for the stiff knee

Between March 1987 and March 1997, we performed a modified Thompson quadricepsplasty on 20 stiff knees and followed the patients for a mean of 35 months (24 to 52). After the operation, the knee was immobilised in flexion and periodically extended. At the final follow-up, the mean active flexion was 113.5° (75 to 150). The final mean gain in movement was 67.6° (5 to 105). One patient had a deep infection which resolved after wound care and intravenous antibiotics. The modified Thompson quadricepsplasty with appropriate postoperative care can give good results.

Reconstructive surgery in primary malignant and aggressive benign bone tumor of the proximal humerus

Primary malignant bone tumors of the proximal humerus have traditionally been treated by forequarter amputation. However, with the increased interest in limb salvage operations, efforts have been made to improve reconstructive surgery and some methods have become available for tumor control and preservation of a useful distal limb. This report describes three reconstructive techniques used for reconstruction of the humerus following primary tumor excision. We followed 11 patients treated by reconstructive surgery following tumor excision for primary malignant and aggressive benign bone tumors in the proximal humerus. The average follow-up period was 35.6 months. The histologic diagnosis included osteosarcoma (9), chondrosarcoma (1) and giant cell tumor (1). The options for reconstructive surgery following tumor excision were six prosthetic arthroplasties with low heat treated autobone, four arthroplasties with Ender nail and bone cement, and one arthroplasty with custom-made tumor prosthesis. We performed a retrospective analysis regarding functional status, as well as local recurrence, distant metastasis and complication. The functional status at final follow-up averaged 16 points (53.3%) overall: 17 points (56.7%) in the six prosthetic arthroplasties with low heat treated autobone; 15 points (50.0%) in two of four arthroplasties with Ender nail and bone cement (the two others died); and 16 points (53.3%) in the one arthroplasty with custom-made tumor prosthesis. Local recurrence was not observed in any of the cases. The complications noted were one nonunion between reimplanted, low heat treated autobone and the normal distal humerus and two metal failures. Each of these techniques for reconstructive surgery resulted in a relatively good outcome, although somewhat better results were found in the case of prosthetic arthroplasty with low heat treated autobone.

Tendon transfer with a microvascular free flap for injured feet in children

We reviewed 11 patients who had been treated between January 1986 and June 1994 for severe foot injuries by tendon transfer with microvascular free flaps. Their mean age was 5.6 years (3 to 8). Five had simultaneous tendon transfer and a microvascular free flap and six had separate operations. The mean interval between the tendon transfer and the microvascular free flap was 5.8 months (2 to 15) and the mean time between the initial injury and the tendon transfer was 9.6 months (2 to 21). The anterior tibial tendon was split in five of six cases. The posterior tibial tendon was used three times and the extensor digitorum longus tendon twice. The mean follow-up was 39.7 months (24 to 126). There were nine excellent and two good results. Postoperative complications included loosening of the transferred tendon (2), plantar flexion contracture (1) mild flat foot deformity (1) and hypertrophic scars (2). We recommend tendon transfer with a microvascular free flap in children with foot injuries combined with nerve injury and extensive loss of skin, soft tissue and tendon.

Lengthening of an amputation stump by the Ilizarov technique. A case report

A woman, 29 years of age, sustained a below knee amputation following injury and was left with a stump 5.5 cm long. Good soft tissue cover was obtained with a myocutaneous flap using the gastrocnemius muscle and heel pad flap from the injured leg. The stump was then lengthened by 7 cm, to 12.5 cm, using the Ilizarov distraction technique. The patient was able to bear weight on the end of the fixator during the 8 months it was in position. The gap filled with bone and there were no complications. She recovered good function.

Venous malformations: sclerotherapy with a mixture of ethanol and lipiodol

PURPOSE

To evaluate the usefulness of a mixture of absolute ethanol and lipiodol in the management of venous malformations.

METHODS

Percutaneous sclerotherapy was performed with a mixture of absolute ethanol and lipiodol (9:1) in 17 patients with venous malformations, once in 12 patients, twice in 5. The therapeutic efficacy was evaluated by pain reduction. Conventional radiographs (n = 15) and posttreatment magnetic resonance imaging (n = 5) were obtained for the follow-up evaluation.

RESULTS

Sclerotherapy was successful in all but two patients. The therapeutic effect was excellent in two patients, good in seven, fair in five, and poor in one. Radiopacity of lipiodol was beneficial for monitoring the procedure rather than for follow-up evaluations. Areas with low signal-intensity strands were increased on T2-weighted images obtained after the sclerotherapy.

CONCLUSION

Sclerotherapy with a mixture of ethanol and lipiodol is effective in treating venous malformations.

Thumb reconstruction with a free neurovascular wrap-around flap from the big toe: long-term follow-up of thirty cases

From March 1982 to December 1992, 30 cases of thumb reconstruction with a free neurovascular wrap-around flap from the big toe were performed at Korea University Hospital. Twenty-nine of a total of 30 cases were successful and obtained excellent functional and cosmetic results. Postoperative complications included 1 case of graft failure, 6 partial skin necroses, 1 malunion, and 15 cases of resorption of iliac bone graft including 1 case of fatigue fracture of grafted bone. Even for the first metacarpal neck amputations, thumb reconstruction with a free neurovascular wrap-around flap was possible; however, limitation of motion of the reconstructed thumb and resorption of the grafted bone occurred. Thumb reconstruction with a wrap-around free flap from the big toe gives excellent cosmetic and functional results and causes minimal morbidity on the donor site.

Soft tissue hemangiomas: MR manifestations in 23 patients

In order to assess magnetic resonance (MR) findings, MR images of 23 patients with soft tissue hemangiomas were reviewed retrospectively. All but five hemangiomas were proven histologically. All hemangiomas showed high signal intensity on T2-weighted images; common MR findings were high signal intensity in some areas on T1-weighted images (70%), the configuration of multiple small lobules or tubules (57%), and signal voids (70%). We observed all three of these findings in 6 cases (26%), two of three in 11 cases (48%), only one in 5 cases (22%), and none in 1 recurrent case. Five of 11 intramuscular hemangiomas (45%) showed atrophic change of muscles. Parts of the tubular pattern enhanced in 15 out of 17 patients with a T1-weighted sequence after injection of gadopentetate dimeglumine. Dilated vessels were seen in 2 of 4 with MR angiography. No single feature is specific for hemangioma, but a combination of several MR findings may allow a correct diagnosis.

The Orthofix external fixator for fractures of long bones

The Orthofix external fixator was used to treat 112 fractures of the long bones in 101 patients, and 22 patients with infected nonunions. Our results compared favourably with those reported in other series where external fixation was used. The overall rate of uncomplicated union was 69.6% with 24.1% of patients requiring a further operation. The overall incidence of nonunion (30.4%) was due to the relatively large number of severe open fractures in the series. The apparatus was simple to apply, and safe and effective in practice. We recommend its use for the primary treatment of open and segmental fractures, and for infected nonunion.

Tendon transfers in traumatic foot

A clinical review was performed of 11 cases of traumatic foot treated by tendon transfer. Among 11 patients, there were eight males and three females, ranging from four to 36 years of age. The anterior tibial tendon was used in six cases for tendon transfer and among these, split anterior tibial tendon was used in three cases in children. The posterior tibial tenodn was used in two cases and the extensor digitorum longus tendon of the foot was in three cases. In six cases of soft tissue injury where tendon transfer was impossible, microvascular free cutaneous flap transplantation was combined with the tendon transfer. Follow-up results were obtained from 25 months to nine years. Excellent results were obtained in eight cases and satisfactory results in three cases. For the correction of function loss in traumatic foot, tendon transfere were a useful method for the recovery of active motion of the foot. For the restoration of function loss in the traumatic foot, there are several methods of treatment such as tendon transfer, arthrodesis and tenodesis, but for recovery of the active motion of the foot, tendon transer is the only useful method.

Ossifying fibroma

Our experience includes seven cases of ossifying fibroma. The condition also appears in the literature under diagnostic names such as congenital fibrous dysplasia, congenital osteitis fibrosa, congenital fibrous defect of the tibia, and osteofibrous dysplasia of the tibia and fibula. The lesions develop in childhood and are located in the diaphysis of the tibia, or fibula. Of seven patients, we performed wide excision with free vascularized fibular graft in five cases, wide resection of the distal one-third of the fibula in one case, and curettage and bone graft in one case. Two of the patients who had wide excision with free vascularized fibular graft had recurrence. One case of recurrence occurred where incomplete wide excision with free-vascularized fibular graft was performed because the lesion was too close to the distal epiphysis of the tibia. One of the patients who had curettage and bone graft also had recurrence. It was concluded that children who have an ossifying fibroma requiring surgery can safely be treated with wide excision with or without free-vascularized fibular graft.

Free groin flaps in microsurgical reconstruction of the extremity

The authors performed free groin flap transplantation in 36 patients with extensive soft-tissue injury of the extremities. In each case, the vascular anatomy of the groin flap was analyzed during the operation. The anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: a common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); an isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent), a separate origin in three cases (7.9 percent), and an origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those reported previously. The overall success rate was 72.2 percent. The success rate was better in the upper extremity (100.0 percent) than in the lower extremity (65.5 percent). Free vascularized groin flap transplantation is a suitable procedure for the one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.

Albright's syndrome with hypophosphatemic rickets and hyperthyroidism--a case report

In this abstract we report a case of Albright's syndrome associated with hypophosphatemic rickets and hyperthyroidism in a six-year-old girl. She had suffered from repeated fractures of her long bones owing to multiple locations of radiolucent areas and generalized skeletal demineralization. The biopsy in the lucent area revealed histologic appearance of fibrous dysplasia.

An experimental study of healing of the partially severed flexor tendon in chickens

There is a lack of clinical and experimental studies of the treatment of incompletely transected tendons. The controversy concerning the source of flexor tendon nutrients is of important clinical concern in healing of the injured tendon; thus, the flexor tendon blood supply has cited as a reason for using specific tendon suture techniques, and as a rationale for preserving the superficialis tendon and its vincula during tendon repair surgery. Our knowledge of the normal physiology of digital flexor tendons and the mechanism of their healing process is deficient. The aim of this study was to investigate the relative importance of the synovial fluid and the blood supply respectively for the healing of partially severed flexor tendons. We observed the sequential histological and vascular changes which occur in healing of the partial lacerations in the dorsal and plantar aspects of the tendons. We observed the vascularities of the two partially severed tendon groups after injection of microfil and india ink through the femoral artery. In the healing process there was no sequential histological difference between the dorsal and the plantar severed tendons. The vascularity patterns of the healing tendons were significantly increased and the hypervascularity of dorsal severed tendons was greater than that of plantar severed tendons. Partially severed tendons were completely healed without surgical repair with dense collagen fibers without adhesion in most cases. We concluded from this study that the blood vessels appeared to play a significant role in the healing of the severed flexor tendons. An intact synovial environment did not seem to be required for healing of the severed tendon. It is not necessary to surgically repair the partially severed tendon for prevention of rupture and adhesion.

Clinical study of Marjolin's ulcer

Marjolin's ulcer is the malignant lesion which develops in a burn scar or chronic fistula. Due to the low prevalence of this lesion, there has been disagreement regarding its clinical features, methods of treatment, and prognosis. We evaluated 19 cases of patients who had been admitted to Severance Hospital from Jan. 1970 to Dec. 1985. The results were as follows: The previous lesion was a burn scar in 52% of the cases and a fistula of chronic osteomyelitis in 32%. The mean latent period was 31.5 years. The initial symptoms were increased pain (74%), discharge with foul odor (68%) and bleeding (58%). Upon histological examination, all of the cases were squamous cell carcinoma. The rate of metastasis at the time of diagnosis was 32%. Of the 16 patients treated by surgery, local recurrence was noted in 4 cases. Three of these cases were patients who had been treated by excision and split thickness skin graft. The time interval for local recurrence ranged from 6 months to 11 months (average 8.8 months). In conclusion, the squamous cell carcinoma of marjolin's ulcer seems to have a worse prognosis than other squamous cell carcinomas and it requires aggressive treatment. The burn scar or chronic fistula that occurs in elderly patients especially requires more adequate treatment and close observation.

Treatment of bone tumors around the shoulder joint by the Tikhoff-Linberg procedure

The Tikhoff-Linberg procedure is a limb-sparing surgical option to be considered for bony and soft tissue tumors in and around the proximal humerus and shoulder girdle. The authors reported 6 cases of the Tikhoff-Linberg procedure for tumors around the shoulder joint at the Department of Orthopedic Surgery of Severance Hospital from March 1988 to May 1989. The results of the study are as follows: The 6 cases were composed of: osteogenic sarcoma 2 cases, chondrosarcoma 2 cases, chondroblastoma 1 case, and giant cell tumor 1 case. The tumors were completely removed by the Tikhoff-Linberg procedure without amputation or disarticulation of the upper extremity. The distal clavicle, upper humerus and part of all of the scapula were resected. The Tikhoff-Linberg procedure was performed for patients whose tumors did not involve the neurovascular bundle in the axilla. The function of the hand and forearm after the Tikhoff-Linberg procedure was nearly normal in all cases. The Tikhoff-Linberg procedure would be recommended as a limb-sparing operation for tumors around the shoulder joint that require wide resection without disarticulation or forequarter amputation of the upper extremities.

Deltoid sensory flap

Eight patients were treated using the deltoid sensory flap for soft-tissue injury of the extremities. The results were one-stage reconstructions of soft tissue extremity injuries. Protective sensibility was provided to the reconstructed area; there was no limitation of motion of the shoulder after the procedure; and primary closure of the donor site was feasible. The advantages of the deltoid sensory flap exceed those of other reconstructive procedures that are used in areas where sensibility is essential.

Variance of radial growth in vascularized and nonvascularized free bone grafts including epiphysis in puppies

A portion of radius including the proximal epiphysis was either transplanted or excised and replaced in puppies. In these growing animals, growth in long bone grafts vascularized by periosteal and endosteal vessels but not epiphyseal vessels, was significantly greater than in nonvascularized grafts, but was less than normal growth (63 percent to 67 percent of normal). In nonvascularized grafts, the epiphyses closed one month postoperatively, while they closed at five months in vascularized grafts and at six months in normal controls. This study confirms that approximately two-thirds of normal longitudinal bone growth can be accomplished with a bone transplant that includes a vascular pedicle supplying the endosteum and periosteum, but not the physis.