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ABSTRACT: We report here the unique case of 60-year-old man with severe ulnar nerve palsy caused by synovial chondromatosis arising from the pisotriquetral joint. At operation, the tumor entrapped the ulnar nerve proximal to the Guyon canal so that it was severely paralyzed. The ulnar neurovascular bundle could be separated safely under the microscope. To our knowledge, this type of severe neuropathy has not been reported before. Although synovial chondromatosis associated with peripheral nerve neuropathy is extremely rare, we should be aware of the existence of this type of compression neuropathy in the upper limb.
Acta Neurochirurgica 04/2013; · 1.52 Impact Factor
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ABSTRACT: The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.
Surgical Oncology 07/2012; 21(4):263-8. · 2.44 Impact Factor
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ABSTRACT: The authors report on a patient who developed a malignant fibrous histiocytoma at the site of a benign giant cell tumour, which had been treated by curettage 38 years previously. This latency period is, to their knowledge, the longest yet reported. This female patient was initially treated for a benign giant cell tumour of the proximal tibia when she was 33 years old; she underwent curettage and Kiel bone grafting. She had not received radiation therapy. Twenty eight years later, she underwent a second operation due to recurrence of a tumour. No specific histological diagnosis was possible: histology suggested a benign tumour, however compatible with a low-grade malignant potential but not associated with giant cell tumour. The patient underwent a third operation, with extensive curettage and total knee arthroplasty 38 years after the initial surgery, because of progressive knee pain. Postoperative histopathology study showed high-grade malignant fibrous histiocytoma. Finally, she underwent above-knee amputation because of uncontrollable progression of the tumour. The use of xenogenic bone graft, bone cement and associated bone necrosis potentially contributed to the development of a malignant tumour adjacent to the primary giant cell tumour.
Acta orthopaedica Belgica 04/2012; 78(2):279-84. · 0.40 Impact Factor
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Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 02/2012; 21(2):e7-11. · 1.93 Impact Factor
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ABSTRACT: Reconstruction for large bone and osteochondral defects following musculoskeletal tumor excision remains challenging. Mega-prosthesis is clearly a useful reconstructive tool. Because the survival time of tumor patients has been increasing due to better treatment options, the aim of our group is to achieve complete biological reconstruction without using any artificial materials. With this approach, durability would not be a limitation. In the present study, we reviewed the biological reconstructive procedures currently available for large bone defects after tumor excision. Devitalized bone autograft is particularly well suited in the region where allografts are not readily available. However, the complication rate, such as infection and spontaneous bone resorption, was unexpectedly high due to non-viable graft. In an attempt to reduce these complications, we have used irradiated bone autograft in combination with free vascularized viable bone graft. In an experimental study, we demonstrated a neo-vascularization effect of vascularized bone graft with devitalized bone autograft, i.e. to convert dead bone into living bone. Clinically, this technique is best indicated for reconstruction of intercalary bone defect, especially tibial shaft. Some degree of articular change occurs after irradiation and cannot be prevented, even with the combined use of vascularized bone graft. In our experience, secondary procedures such as surface replacement prosthesis are necessary to treat the osteoarthritis in such cases, even if the radiological finding is severe. The rationale for a combined vascularized and irradiated bone autograft is the cumulative advantage provided by the biological properties of the former with the mechanical endurance of the latter.
Surgical Oncology 01/2012; 21(3):223-9. · 2.44 Impact Factor
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ABSTRACT: A key component of composite tissue allografts is the vascularized limb/bone marrow because of its capacity to reconstitute the marrow cavity of the recipient. The efficacy of a new protocol that uses total body irradiation (TBI), granulocyte colony-stimulation factor (G-CSF), and FK506 to induce high level bone marrow chimerism was evaluated with particular reference to the dose requirement and toxicity of TBI.
In total, 82 whole-limb allotransplants from LacZ transgenic rats to LEW rats were performed. TBI was administered just prior to transplantation with various doses ranging from 100 to 1500 R (almost equal to 1-15 Gy). G-CSF was given for 4 d, while FK506 was used for 28 d. The level of chimerism was evaluated by semiquantitative polymerase chain reaction (PCR).
The survival of limb allografts in recipients that were pretreated with a myeloablative TBI dose of >1000 R was prolonged to more than 1 y. Recipients pretreated with <500 R showed no prolongation of limb graft survival. A majority of long-term survivors showed chronic, nonlethal graft-versus-host disease (GVHD). PCR analysis revealed a high level of intra-bone marrow chimerism in the recipient, thus demonstrating successful induction of macrochimerism.
Vascularized limb/bone marrow graft is a proven method for supplying donor cells to the bone marrow of irradiated recipients. A new protocol involving pretransplant myeloablative TBI with >1000 R followed by treatment with G-CSF and FK506 was found to induce a high level of chimerism and significantly prolong the survival of limb allografts without causing lethal GVHD.
Journal of Surgical Research 12/2011; 171(2):807-13. · 2.25 Impact Factor
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ABSTRACT: Previous studies have revealed that cell therapy using bone marrow stromal cells (BMSCs) could promote motor functional recovery in animals with spinal cord injury (SCI). We describe here the development of cell biology technique and the experimental study of regeneration in SCI. The aim of this study was to investigate the potential for neurological recovery by transplantation neurospheres (NS) derived from BMSCs into thoracic SCI. Adult Fisher rats were used: 45 were subjected to complete thoracic SCI performed by the balloon compression method. BMSCs were cultured in vitro to obtain NS. Seven days after thoracic SCI, groups of 15 rats each received transplants of BMSCs-NS (group A), BMSCs (group B), or injection of medium only (group C) into the SCI lesion. Rats from each group were evaluated and compared longitudinally for motor function recovery. The spinal cords (SC) of injured rats were harvested at day 21 or day 42 and prepared for histological analysis. Five weeks after transplantation, many neuronal or axonal sproutings were observed and replaced by host cells in the SCI lesion of group A. Also, transplanted BMSCs-NS expressed neuronal lineage markers. Transplanted rats could walk with weight bearing and showed recovered motor evoked potentials (MEPs).
Medical Molecular Morphology 09/2011; 44(3):131-8. · 1.39 Impact Factor
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ABSTRACT: Malignant sarcomas of the femur present major challenges in their management. Radical resection of sarcoma frequently requires concomitant major femoral vessel resection and reconstruction. We describe the clinical outcomes of vascular reconstruction, the long-term patency of vascular repair, and complications involved, and also discuss possible solutions to the problems associated with this procedure.
In the past 15 years, 15 patients underwent wide resection of sarcoma of the femur with curative intent, including vascular reconstruction of the femoral arteries and/or veins. Arterial reconstruction was performed in 14 patients. In 12 patients, femoropopliteal reconstruction was performed with a contralateral great saphenous vein graft. In two cases involving femoroinguinal reconstruction, expanded polytetrafluoroethylene grafts were used because of unacceptable discrepancy. Myocutaneous flaps were used for covering of soft-tissue in 12 patients.
One patient developed a local recurrence and eight died because of their tumor. Seven patients remained completely free of recurrence after a mean follow-up time of 69 months. One case showed gradual deterioration with ischemic pain in the affected lower extremity requiring amputation. The remaining 14 cases showed sufficient vascularity primarily. Complications after surgery were noted in nine cases, with the most common being leg edema in five cases, wound infection in three, and lymphatic fistula in two. The average Musculoskeletal Tumor Society score at the final assessment was 24 points (80%).
For patients with sarcoma involving major vessels in the lower limb, wide resection followed by vascular reconstruction provides long-term local control and limb salvage with acceptable function. The complication rate from extensive resection and associated vascular reconstruction is high. The great saphenous vein graft produced results that were superior to prosthetic graft. Aggressive use of musculocutaneous flap transfers may help to minimize complications and reduce postoperative severe edema.
Annals of Vascular Surgery 08/2011; 25(8):1070-7. · 1.03 Impact Factor
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ABSTRACT: Enchondromatosis can transform into chondrosarcoma, but this event is rare in the hand. We present the case of a patient with chondrosarcomas of the ring and little fingers. The chondrosarcomas had a long progression of 60 years and the patient presented with large tumors and a severely deformed appearance.
The Journal of hand surgery 02/2011; 36(2):304-7. · 1.33 Impact Factor
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ABSTRACT: Complications after the harvesting of vascularized fibula grafts are rare. Here we present our results on patients who developed claw deformity of the great and lesser toes. We discuss the etiology of claw toe deformity and the surgical correction of this condition. Seven patients developed claw toe deformity in the donor side foot after the harvesting of a vascularized fibula graft. They comprised 5 males and 2 females with an average age of 29 years (range: 6-59 years). The affected toes in 6 patients were 1 and 2, or 1, 2, and 3. All toes were affected in the remaining patient. Four patients underwent Z-lengthening of the flexor hallucis longus at the medial malleolus of the ankle, while 3 underwent cutting of the tendons. The average time between harvesting a fibula graft and development of claw toe deformity was 13 months (range: 2.5-42 months), and the average follow-up time was 30 months (range: 10-47 months). Claw deformity of affected toes was successfully corrected in all patients by release of the flexor hallucis longus. Full extension of the affected toes was achieved by the time of final follow-up. Flexion of the interphalangeal joint was preserved in all patients except one who underwent cutting of the tendon beneath the metatarsophalangeal joint. Lengthening or cutting of the flexor hallucis longus tendon at the medial malleolus successfully corrects claw toe deformity following the harvesting of vascularized fibula grafts. Even after cutting the tendon, flexion of the great toe is possible by interconnection with the flexor digitorum longus tendon.
Annals of plastic surgery 08/2010; 65(2):161-3. · 1.29 Impact Factor
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ABSTRACT: Limb allografts consist of different types of tissues with varying antigenicities. One of the key components is the bone marrow. Removal and reconstitution of this tissue may allow better control of limb allograft rejection. The authors evaluated the efficacy of a new protocol for bone marrow removal that uses pretransplant graft irradiation, granulocyte colony-stimulating factor, and temporal FK506, with particular reference to the dose requirement and toxicity of irradiation.
In total, 57 whole-limb allotransplants from LacZ transgenic rats to Lewis rats were performed. Graft irradiation with various doses ranging from 250 to 1500 R was administered just before transplantation. Granulocyte colony-stimulating factor was given for 4 days, whereas FK506 was used for 28 days. The level of intra-bone marrow chimerism of the graft was evaluated by semiquantitative polymerase chain reaction.
Rejection-free survival of grafts was increased significantly in groups that received more than 1000 R of pretransplant irradiation and granulocyte colony-stimulating factor, whereas grafts that received less than 500 R of irradiation showed no prolongation in survival. Bone marrow in the myeloablative irradiation groups was quickly reconstituted by recipient-derived cells. In the group treated with 1500 R of irradiation, the graft tissue was damaged and this led to infection of the recipient. In the 1000-R group, two of eight recipients showed rejection-free graft survival of more than 1 year without any immunosuppression.
The authors study found that removal of allogeneic bone marrow in the limb graft and rapid reconstitution with recipient marrow cells reduced the recipient's immune response. Graft rejection was delayed significantly but not completely prevented.
Plastic and reconstructive surgery 07/2010; 126(1):53-60. · 2.74 Impact Factor
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ABSTRACT: Reconstruction of the proximal humerus following limb-saving resection of malignant bone tumor is extremely challenging. We describe here a novel anatomical reconstruction technique in a young patient. A 6-year-old girl with Ewing sarcoma of the proximal humerus was treated by wide excision of the tumor followed by reconstruction with extracorporeally-irradiated osteoarticular autograft combined with an intramedullary inserted free vascularized fibula graft. Proper alignment of the shoulder joint was maintained with no osteoarthritic changes after 16 months. The resulting limb function was satisfactory. This biological reconstruction method was safe and without serious complication. It is indicated for the reconstruction of non-weight-bearing joints and is ideal for the proximal humerus.
Journal of Plastic Reconstructive & Aesthetic Surgery 03/2010; 63(12):2177-80. · 1.49 Impact Factor
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ABSTRACT: The use of myocutaneous flaps for reconstruction following sarcoma resection is an important surgical technique. In this study, we discuss the issues surrounding proper selection of myocutaneous flaps following wide resection. A total of 59 patients underwent tumor resection and immediate reconstruction. In 26 patients, the tumor location was in the trunk and reconstructed mainly with pedicled latissimus dorsi and tensor fascia lata flaps. Functional muscle transfers were used for extremity reconstruction in 25 patients. Reinnervation was observed for 23 muscles after a mean period of 5.7 months. At final follow-up, primary wound healing was satisfactory in all surviving patients without severe complications. For sarcoma within the trunk, a pedicle latissimus dorsi flap is most suitable. The tensor fascia lata flap is best indicated for lower buttock or abdominal wall sarcomas. For extremity sarcomas, functional latissimus dorsi or gracilis muscle flaps produce good outcomes for restoration of motor function as well as wound healing.
Annals of plastic surgery 03/2010; 64(3):307-10. · 1.29 Impact Factor
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ABSTRACT: A novel reconstruction of the knee extensor apparatus was attempted in a 69-year-old patient with prepatellar myxoid fibrosarcoma. The skin (35×25 cm), subcutaneous tumor, quadriceps tendon, patella, anterior capsule, and patella tendon were widely resected en-bloc. Following wide resection, the excised quadriceps tendon, patella, and patella tendon were anatomically reimplanted into the original site after being devitalized in liquid nitrogen. These complexes were covered by a free vascularized latissimus dorsi myocutaneous flap. At 18-month follow-up, the strength of active knee extension was 4+ of 5 in the muscle manual test. The active range of motion was 110° in flexion and -10° in extension. The tumor showed no evidence of disease. The patella and femur joint showed no osteoarthritis on plain radiographs. This procedure is the only way to achieve anatomical reconstruction. Reattachment of patella tendon to the tibial tuberosity was possible. The use of liquid nitrogen to devitalize is straightforward and the operation time can be shortened. To our knowledge, this type of reconstructive procedure has never been reported in the English literature.
Orthopedics 01/2010; 33(10):773. · 2.66 Impact Factor
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ABSTRACT: Pathological fractures caused by metastatic malignant disease have been the subject of increasing interest in recent years. This article describes our experience with the treatment of metastatic bone disease of the upper extremity and our attempt to clarify the indications for different surgical procedures. Of 53 patients with metastatic lesions to the upper extremity, 20 who had been surgically treated were analyzed retrospectively. These comprised 13 men and 7 women with a mean patient age of 62 years. The most common primary tumors to metastasize were lung and liver, with the humerus involved in 12 cases and the scapula and forearm in 4 cases each. Four patients with scapula and forearm involvement underwent tumor resection due to uncontrollable tumor size, while 3 were successfully treated by selective arterial embolization. Three metastases to the humeral head were reconstructed with endoprosthesis, but functional restriction was noted. Five cases with metastases to the humeral shaft were treated with tumor curettage, internal fixation using intramedullary nailing, adjuvant cryosurgery, and cementing. This achieved good results for pain relief and functional restoration with minimal complications. Two metastases to the humeral condyle were unable to be stabilized with plate and locking screws. Metastatic lesions to the scapula and forearm are commonly treated nonsurgically, but some patients with uncontrollable tumor mass require surgical resection. Endoprosthetic replacement is recommended if the lesion involves the humeral head or condyle. Most patients with the humeral shaft lesion are likely to benefit from tumor curettage, intramedullary nailing with locking screw, and cementing.
Orthopedics 01/2010; 33(11):807. · 2.66 Impact Factor
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ABSTRACT: The induction of a high-level of chimerism (macrochimerism) may be the most reliable strategy for achieving donor-specific tolerance. The purpose of this study was to evaluate the efficacy of a new protocol using total-body irradiation (TBI) and granulocyte-colony stimulation factor (G-CSF) to induce high-level chimerism following rat whole-limb allotransplantation. In this study, we investigated whether the timing of TBI influenced the period of graft survival. In total, 50 whole-limb allotransplants from LacZ transgenic rats to LEW rats were performed. TBI was performed at days 0 and 14, and G-CSF was given for 4 days after TBI. FK506 was given for 28 days after transplant. Nontreated limb allografts were rejected after 4.2 days. The survival time was prolonged to 64 days in the FK506 monotherapy group. In the group receiving TBI at day 14, limb allograft survival was significantly prolonged to 81 days. In the group receiving TBI at day 0, 26% of recipients died but in the surviving recipients the grafts survived for longer than 1 year without lethal graft-versus-host disease (GVHD). Polymerase chain reaction (PCR) analysis revealed a high level of intrabone marrow chimerism in the recipient, thus demonstrating successful induction of macrochimerism. A new protocol of pretransplant TBI followed by treatment with G-CSF and FK506 was found to induce a high level of chimerism and to significantly prolong the survival of limb allografts in recipients without lethal GVHD.
Journal of Orthopaedic Research 10/2009; 28(4):457-61. · 2.81 Impact Factor
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ABSTRACT: Two rare cases of bowler's thumb (traumatic neuropathy of the ulnar digital nerve of the thumb) were treated surgically with encouraging results. These had different types of lesion, involving nodular neuroma and epineural mass, which were distinguished by magnetic resonance imaging. The surgical outcome for active bowlers is unclear and postoperative protection from the repetitive trauma of throwing is important. Possible technical solutions include changing the size and weight of the ball, the spacing between holes, the fitting of thumb to ball, and the slope and size of thumb holes. It is important that both bowlers and clinicians are sufficiently aware of bowler's thumb to allow early diagnosis and treatment of this lesion.
Orthopedics 08/2009; 32(7):525. · 2.66 Impact Factor
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ABSTRACT: Giant cell tumor of bone is a rare and unpredictable lesion. Standard treatment ranges from surgical curettage to wide resection, with reports of varying oncological and functional results. Twenty-three consecutive cases of giant cell tumor of long bones were treated in 10 years. Fifteen men and 8 women had a mean age of 38 years (range, 17-82 years). Average follow-up was 45 months (range, 12-180 months). The most common tumor sites were the proximal tibia (10 cases), distal femur (8), and distal radius (3). All patients remained free of recurrence at the time of final follow-up. Functional outcomes as evaluated by the Musculoskeletal Tumor Society measure were successful, with an average score of 26.6 points (range, 22-30 points). To avoid local recurrence around the knee joint, we recommend radical intralesional curettage with a high-speed drill burr, adjunctive therapy with cryosurgery, and filling with polymethylmethacrylate. Primary total knee arthroplasty is acceptable for older patients. For giant cell tumor of the upper limb or for young patients, biological reconstruction should be applied.
Orthopedics 08/2009; 32(7):491. · 2.66 Impact Factor
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ABSTRACT: Calcific myonecrosis is a rare condition characterized by a calcified lesion. Because this lesion sometimes presents as a huge mass with unique radiographic characteristics, it can be confused with soft tissue sarcoma. The appropriate treatment is still controversial. We report here three cases diagnosed as calcific myonecrosis of the lower leg and discuss its clinical presentation, diagnosis and options for treatment.
Three patients presented as expanding masses in the anterior or lateral compartment muscle and occurred more than 10 years after an initial injury. Plain radiographs showed a large soft tissue mass with extensive amorphous calcifications. Computed tomograms revealed a low-density tumor with scattered calcifications. Magnetic resonance imaging showed a bright, high-signal area on T2-weighted imaging consistent with fluid. Two patients underwent excisions for histopathological evaluation and one was treated conservatively because of the absence of disability.
Two operative patients had no complication and the returned to work without evidence of deterioration of the disease. In a patient treated conservatively, the mass was not enlarged and was still painless at 2-year follow-up.
The key points for diagnosis were (1) amorphous liner calcification, (2) anterior or lateral compartment, (3) previous injury (several decades) of the tibia or femur, and (4) compartment syndrome. Although calcific myonecrosis is not commonly encountered, it must be considered in the differential diagnosis of an expanding intramuscular mass. In asymptomatic masses where the diagnosis is recognized, observation may be possible and unnecessary aggressive surgical intervention should be avoided.
Archives of Orthopaedic and Trauma Surgery 06/2009; 129(7):935-9. · 1.37 Impact Factor
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ABSTRACT: Periacetabular reconstruction following malignant bone tumor resection for limb saving is extremely challenging. We attempted a new reconstruction method in two patients by combining a free vascularized fibula graft with an extracorporeally irradiated autograft.
A 14-year-old boy with osteosarcoma and a 44-year-old man with chondrosarcoma were treated with wide excision of the tumor, followed by periacetabular reconstruction with an autogenous, extracorporeally irradiated osteoarticular graft combined with a free vascularized fibula graft.
Incorporation of the irradiated pelvic bone was achieved without any complications and the resulting limb function was good. Osteoarthritic changes were seen in one patient.
This reconstruction method was safe and reliable for primary, limb-sparing surgery. It is best indicated when the femoral head can be preserved and the mechanical strength of the affected acetabulum is maintained.
Anticancer research 06/2009; 29(5):1669-73. · 1.73 Impact Factor
