Surgical Technology International
33rd edition
Contains 45 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
376 pages
October 2018 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Performance on a Virtual Reality DHS Simulator Correlates with Performance in the Operating Theatre
Mr. Kalpesh R. Vaghela, MBBS BSc MSc MRCS, Trauma & Orthopaedic Registrar, Percivall Pott Rotation, Mr. Joshua Lee, BSc (Hons) MBChB, MSc, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Mr. Kash Akhtar, MBBS, BSc, MEd, MD, FRSA, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London
1040
Introduction: Dynamic Hip Screw (DHS) fixation of neck of femur fractures is one of the most commonly performed orthopaedic trauma operations. Changes in working practices have impacted surgical training and have resulted in fewer opportunities to perform this procedure. Virtual reality (VR) simulation has been shown to be a valid means of gaining competency, efficiently and safely, without compromising patient safety. Objective: The aim of this study is to determine whether performance on a VR DHS simulator orrelates with performance in the operating theatre.
Materials and Methods: All episodes of DHS fixation of neck of femur fractures performed at Royal London Hospital, Barts Health NHS Trust, level 1 major trauma centre between January 2014 and December 2015 were identified using the hip fracture database. The primary surgeon was identified using the electronic operative notes. The intraoperative fluoroscopic images were accessed and the tip-apex distance (TAD) was measured, as well as the probability of cut-out. The surgeon then performed DHS fixation on a VR DHS simulator and the TAD achieved in theatre was correlated with the simulated TAD.
Results: Twenty-five surgeons, including six novices (core surgical trainees), 12 intermediates (specialist registrars), and seven experts (fellows and consultants), completed the study. There was no overall statistically significant difference in TAD between those achieved in the operating theatre and on the simulator for each participant (p=0.688).
Conclusion: There is no significant difference between performance on a VR DHS simulator and the operating theatre. This suggests that the simulator is excellent for training in this component of the DHS procedure, but further work is needed to assess whether training on the simulator can improve performance in the operating theatre.
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Linear Wear Rates of a Highly Cross-Linked Polyethylene Hip Liner
Nipun Sodhi, BA, Research Fellow, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Research Fellow, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Fellow, SUNY Downstate Medical Center, Brooklyn, New York, Charles Jaggard, MS, Clinical Trial Manager, Frank Kolisek, MD, Orthopaedic Surgeon, OrthoIndy, Greenwood, Indiana
1023
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Effects of Coronal Limb Alignment and Ligament Balance on Pain and Satisfaction Following Total Knee Arthroplasty at Short-Term Follow Up
Ahmed Siddiqi, DO, MBA, Orthopedic Surgery Resident, Peter B. White, BS, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, Lisa Kaplin, DO, Orthopedic Surgery Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, James V. Bono, MD, Clinical Professor of Orthopedic Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts, Carl T. Talmo, MD, Assistant Professor of Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts
1035
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Clinical Results of Direct Anterior Approach THA with Minimal Fluoroscopic Exposure Optimization Techniques
Sergio M. Navarro, BS, Christopher Frey, BS, Baylor College of Medicine, Houston, Texas, Terri Blackwell, PA, Orthopedic Joint Reconstructive Surgery Specialist, Sarah B. Voges ANP, Orthopedic Joint Reconstructive Nurse Practitioner, H. Del Schutte Jr. MD, FAOA, Comprehensive Joint Program Medical Director, Department of Orthopedics, Charleston Institute for Advanced Orthopedics, Charleston, South Carolina
1028
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Is an Intramedullary Nail a Valid Treatment for Limb-Length Discrepancy After Bone Tumor Resection? Case Descriptions
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Guido Scoccianti, MD, Specialist in Orthopedics and Traumatology, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Davide Matera, MD, Specialist in Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and Traumatology, Pisa, Italy, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
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One of the most frequent outcomes after resection of bone tumors in children is a limb-length discrepancy. An intramedullary nail is a valid method for lengthening the limb. We report our experience with four cases of limb-length discrepancy in the lower limbs several years after the primary treatment of bone tumor resection and subsequent reconstruction. Two femoral PRECICE® nails (NuVasive, Inc., San Diego, CA) were introduced retrograde and two were introduced in an anterograde manner. All four cases healed and showed a reduction of the limb-length discrepancy, early loading, and complete bone osteogenesis. In one case, a reduction of the joint ROM recovered after release of the iliotibial band and a quadriceps release according to Judet’s arthrolysis.
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Capsular Sparing Total Hip Replacement Technique Applied with a Dual-mobility Cup to Reduce Dislocations
H. Morton Bertram III, MD, Chief Orthopaedic Surgeon, Naples Community Hospital, Naples, Florida, Megan E. Bertram, Trainee, Northern Kentucky University, Highland Heights, Kentucky, Laura Scholl, MS, Manager, Manoshi Bhowmik-Stoker, PhD, Senior Manager, Clinical Research Department, Stryker Orthopaedics, Mahwah, New Jersey, Michael T. Manley, FRSA, PHD, President, Michael T. Manley, LLC, Wyckoff, New Jersey
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Regardless of the surgical approach used, dislocation remains a complication following total hip replacement. In recent years, newer technologies, such as the use of large femoral heads, have reduced the rate of postoperative dislocation. The combination of such technology, together with a soft tissue repair technique, may reduce the dislocation rate even further.
A single surgeon performed 513 primary total hip replacements on 505 patients using a posterior approach utilizing a technique designed to spare the capsule. There were 257 males and 248 females. Age ranged from 39 to 92 years. Surgeries were performed from January 2012 to December 2015. Implants used were cementless dual-mobility cups and cementless femoral stems. In all cases, the posterior capsule was incised and retracted, but not excised. Following implant placement, the capsule was repaired using a fiber reinforced suture. The superior border of the capsular incision, just above the piriformis, was sutured to the superior capsule or gluteus minimus muscle. The intent of this repair was to completely incarcerate the femoral head. Patients were followed at two weeks, six weeks, three months, one year, three years, and five years. Follow up was one to five years post-implantation. The dislocation rate was zero. The combination of a large dual-mobility femoral head, combined with a soft tissue repair that spares the deep capsule, has the potential to significantly reduce dislocation rates when using the posterior approach to the hip.
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Acromioclavicular Joint Stabilisation Using the Internal Brace Principle
Paul A. Byrne, MEng, MSc, MBChB, Specialty Registrar, NHS South-East Scotland, Edinburgh, Scotland, Graeme P. Hopper, MBChB, MSc, MRCS, Specialty Registrar, Trauma and Orthopaedics, William T. Wilson, MBChB BSc(Med.Sci) MRCSEd, Specialty Registrar/ Honorary Clinical Lecturer, Gordon M. Mackay, MD, FRCS(Orth), FFSEM(UK) , Consultant Surgeon, Orthopaedics Department, Ross Hall Hospital, Glasgow, Scotland
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Introduction: Injury of the acromioclavicular joint (AC joint) is one of the most common conditions affecting the shoulder girdle in athletes, particularly in contact sports. It is generally agreed that surgical management provides superior outcomes in high-grade injuries (Rockwell Grades IV–VI), with nonoperative management preferred in low-grade injuries (Grades I–II). Controversy still exists regarding the optimal treatment for Grade III injuries, with various sources reporting quicker return to activity and reduced complications with nonoperative management, but superior long-term function and satisfaction in cases managed surgically. Mean predicted return to sporting action in surgical cases varies in the literature from four months to 9.5 months.
Case Description: This retrospective case report follows a 28-year-old male Scottish Premiership professional football player after he suffered a Grade III AC joint dislocation whilst playing in a European club match. He was managed operatively using a novel minimally invasive surgical technique using the principles of internal brace ligament augmentation.
Results: This player resumed full first-team action exactly three months post-surgery. After more than two years of follow up, he has experienced no complications or re-injury of the shoulder and has maintained his previous level of performance.
Conclusion: This case represents an exceptional recovery to high-level sporting performance. The novel repair method was key to this success in allowing early mobilisation of the shoulder and could offer improved results to high-level athletes suffering such injuries.
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Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience
Olivia J. Bono, BA, Clinical Research Coordinator, Chris Damsgaard, MD, Arthroplasty Fellow, Claire Robbins, PT, DPT, MS, Research Assistant, Mehran Aghazadeh, MD, Surgical Assistant, Carl T. Talmo, MD, Vice Chair for Orthopedic Research, James V. Bono, MD, Vice Chair for Orthopedics, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
1029
Background: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period.
Materials and Methods: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA.
Results: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient’s perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%.
Conclusion: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient’s perception of pain and recovery is dramatically improved with preservation of the iliotibial band.
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Ultrasound-Guided Calcium Debridement of the Shoulder Joint: A Case Series
Edward Milman, MD, Associate Professor, Todd P. Pierce, MD, PGY-2 Orthopaedic Surgery Intern , Kimona Issa, MD, PGY-5 Orthopaedic Resident, Robert R. Palacios, BS, Undergraduate Research Volunteer , Anthony Festa, MD, Associate Professor, Anthony J. Scillia, MD, Associate Professor, Vincent K. McInerney, MD, Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey
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Objective: Our purpose was to assess the outcomes of those who underwent an ultrasound-guided debridement of the deposits. Specifically, we analyzed: (1) function; (2) pain; (3) activity level; (4) patient satisfaction; and (5) complications.
Materials and Methods: A review of patients who underwent an ultrasound-guided debridement of calcific deposits about their shoulder joint between 2005 and 2015 was performed. Our final cohort consisted of 38 patients with a mean age of 53 years (range, 35 to 62 years)—11 men and 27 women—and a mean follow up of 32 months (range, 12 to 53 months). Functional outcomes, activity level, and pain level were assessed using the Disabilities of Arm, Shoulder, and Hand (DASH) scale, the University of Southern California (UCLA) activity scale, and the Visual Analog Scale (VAS). Additionally, patients were asked if they were satisfied with the outcomes of their procedure. All medical records were assessed for potential complications from this procedure.
Results: Excellent outcomes were achieved. The mean DASH score improved from 21 to 10 points (p=0.0001). Additionally, mean UCLA score increased from 2 to 7 points (p=0.0001). Furthermore, the mean reported VAS improved from 8 to 1.6 (p=0.0001). Ninety-seven percent of patients reported being satisfied. There were no reported complications in our cohort.
Conclusion: We found that this procedure can result in effective pain relief and prevent or delay the need for more invasive procedures. Future studies should evaluate the role of calcium deposit size in the outcomes of those who undergo debridement.
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Anterolateral Ligament of the Knee: What we Know About its Anatomy, Histology, Biomechanical Properties and Function
Thomas Neri, MD, PhD, Doctor of Surgery, Frederic Farizon, MD, Professor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France, EA 7424 - Inter-university Laboratory of, Human Movement Science, Université de Lyon - Université Jean Monnet, Saint Etienne, France, Sydney Orthopaedic Research Institute, Sydney, Australia, David Anthony Parker, BMedSci, MBBS, FRACS, FAOrthA, Associate Professor of Surgery, University of Sydney, Director of Research, Sydney Orthopaedic Research Institute, Sydney, Australia, Aaron Beach, PhD, Research assistant, Sydney Orthopaedic Research Institute, Sydney, Australia, Bertrand Boyer, MD, PhD, Doctor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France
1019
To better control anterolateral rotational instability (ALRI) after anterior cruciate ligament reconstruction (ACLR), many recent studies have examined the anterolateral ligament (ALL). Although some inconsistencies have been reported, anatomic studies demonstrated that the ALL runs on the lateral side of the knee from the femoral lateral epicondyle area to the proximal tibia, between Gerdy’s tubercle and the fibula head. Histologic research has characterized the ALL structure, which is more than a simple capsular thickening; it shows a dense collagen core, typical bony insertions and mechanoreceptor function. An analysis of biomechanical properties suggests that the ALL is weaker than other knee ligaments. While its contributions to tibial anterior translation control and to a high grade on the Pivot-Shift test are still unclear, there is a consensus that the ALL controls tibial internal rotation. Further research will be needed to clarify the significance of ALL injuries and to gauge the value of combined ACL and ALL reconstructions.
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Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty
Ahmed Siddiqi, DO, MBA, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Peter B. White, BS, Medical Student, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, William Murphy, MS, Medical Student, Harvard Medical School, Cambridge, Massachusetts, Dave Terry, MBA, CEO, Founder, Archway Health, Boston, Massachusetts, Stephen B. Murphy, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Carl T. Talmo, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts
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Background: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization—a group of private practices partnering with a consultant—aimed to analyze the impact of a preoperative protocol on overall cost savings. Materials and Methods: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009–2014 were compared with 408 consecutive BPCI patients from 2014–2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission. Results: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions. Conclusion: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.
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Loss of Functional Internal Rotation Following Various Combinations of Bilateral Shoulder Arthroplasty
Jacob J. Triplet, DO, PGY-2 Orthopaedic Surgery Resident, OhioHealth Doctors Hospital, Columbus, OH, Jennifer Kurowicki, MD, Orthopaedic Surgery Research Fellow, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, Derek D. Berglund, MD, Orthopaedic Surgery Research Fellow, Jonathan C. Levy, MD, Chief of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL, Samuel Rosas, MD, Orthopaedic Physician Scientist, Wake Forest School of Medicine, Winston-Salem, NC, Brandon J. Horn, DO, Orthopaedic Surgeon, Witham Orthopaedic Associates, Lebanon, IN
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Background: Limited internal rotation (IR) remains a concern for activities of daily living (ADLs) following bilateral shoulder arthroplasty (BSA). The purpose of this study was to evaluate the loss of the ability to perform functional IR tasks following BSA using various combinations of anatomic (TSA) and reverse (RSA) shoulder arthroplasty.
Methods: A retrospective review of an institutional shoulder-surgery database was conducted for patients who underwent BSA with any combination of TSA or RSA with at least a 2-year follow-up. IR range of motion (ROM) and individual American Shoulder and Elbow Surgeons (ASES) score and Simple Shoulder Test (SST) questions specific to IR were used to assess a patient’s ability to perform IR tasks with at least one of their shoulders.
Results: Seventy-three patients met the inclusion criteria (47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA). Average age at surgery was 72.1 years. Average follow-up was 51.4 months. Loss of ability to wash one’s back was observed in 30.4% TSA/TSA, 33.3% TSA/RSA, and 52.9% RSA/RSA. Loss of ability to tuck in a shirt was observed in 10.6% TSA/TSA, 11.1% TSA/RSA, and 29.4% RSA/RSA. Loss of ability to manage toileting was observed in no TSA/TSA or TSA/RSA, but in 11.8% RSA/RSA. For each of the tasks, there were no significant differences in the ability to perform the task among the groups (p>0.05). Post-operative IR ROM for TSA/TSA was superior to those for TSA/RSA and RSA/RSA (p<0.01). IR ROM efficacies for both RSA/RSA and TSA/RSA were inferior to that for TSA/TSA (p<0.05).
Conclusion: Bilateral RSA patients can perform most IR tasks, and their ability to complete these tasks does not differ significantly from those in patients with other BSA.
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Outcomes of Revision Joint Arthroplasty Due to Metal Allergy and Hypersensitivity: A Systematic Review
Julio J. Jauregui, MD, Orthopaedic Surgery Resident, Shivam J. Desai, MD, Orthopaedic Surgery Resident, Arun Hariharan, MD, Orthopaedic Surgery Resident, Farshad Adib, MD, Orthopaedic Surgeon, University of Maryland Medical Center, Baltimore, Maryland, Vaughn Hodges, MD, Resident Physician, University of California San Francisco, San Francisco, California, Jared M. Newman, MD, Orthopaedic Surgery Resident, Aditya V. Maheshwari, MD, Director, Adult Reconstruction and Musculoskeletal Oncology Divisions, SUNY Downstate Medical Center, Brooklyn, New York
1008
Background: Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could fail due to various well-known causes. Furthermore, metal allergy-related complications have recently gained attention as one of the potential causes of failure when the common reasons have been excluded. Reported symptoms from metal allergy can include chronic eczema, joint effusions, joint pain, and limited range of motion. Few studies have explored the outcomes of patients undergoing revisions due to allergic complications. The aim of our study is to quantitatively evaluate the outcomes of revision joint arthroplasty due to metal allergy and hypersensitivity.
Materials and Methods: A comprehensive literature search using MEDLINE (PubMed), Ovid, and Embase was systematically performed to evaluate all studies included in the literature until December 2015. The search terms used were “Arthroplasty,” “Allergy,” “Revision,” “Allergic Reaction,” and “Hypersensitivity,” and a total of 414 studies were identified. After a thorough review, five studies ultimately met the inclusion criteria and were included in the final review. This was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results: A total of 44 total knee arthroplasty (TKA) revisions and three total hip arthroplasty (THA) revisions due to metal allergy were reported. All of the implants used during the primary procedures were cobalt chromium blends, and bone cement was used in all but three cases (93%). Allergen testing was performed using patch testing, modified lymphocyte stimulation test (mLST), or lymphocyte transformation testing (LTT) in all cases. Of the four studies which reported results, positive sensitizations were most commonly seen with nickel (87% of cases), followed by cobalt (37%) and chromium (reported in one study, ~10%). Following revision surgery, 100% of cases experienced symptomatic relief.
Conclusions: Overall, we found that properly selected patients with allergy-related symptoms can benefit from undergoing a revision TJA with replacement to components void of the offending allergen metals. Appropriate revision surgery provided universal resolution of symptoms and improved functional outcomes.
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Accurately Predicting Total Knee Component Size without Preoperative Radiographs
Steven M. Teeny, MD, Manoshi Bhowmik-Stoker Ph.D, Orthopedics Service, Madigan Healthcare System, Tacoma, Washington, Laura Scholl, MS, Stryker, Joint Replacement Division, Mahwah, New Jersey, Anton Khlopas, MD, Michael A. Mont, MD, Cleveland Clinic, Cleveland, Ohio, Lenox Hill Hospital, New York, New York
1013
Background: Preoperative templating of total knee arthroplasty (TKA) components can help in choosing appropriate implant size prior to surgery. While long limb radiographs have been shown to be beneficial in assessing alignment, disease state, and previous pathology or trauma, their accuracy for size prediction has not been proven. In an attempt to improve templating precision, surgeons have looked to develop other predictive models for component size determination utilizing patient characteristics. The purpose of this study was to: 1) Identify which patient characteristics influence the tibial and femoral component sizes; 2) Construct models for size prediction; 3) Test the generated models at five different centers; and 4) Compare implant survivorship and patient characteristics between those who did or did not receive an implant within one size of the prediction.
Materials and Methods: Demographic data was collected on 741 patients (845 knees) as part of a multicenter clinical trial. Correlation between component size and patient demographic data were examined using Pearson coefficients, and significant variables were included into a multivariate-linear-regression model to determine “predicted size.” Operative surgeon notes and postoperative radiographs were used to determine “actual size.” Predictive equations were constructed for both femoral and tibial components and were tested at five different centers. Implant survivorship and patient characteristics were compared between those who did and did not receive an implant within one size of the prediction.
Results: The strongest predictors of component size were height, weight, and gender (p<0.01), followed by ethnicity (p=0.03) and age (p=0.03). Predictive equations were constructed for both tibial and femoral components. The model predicted the component fit within one size in 94% (r2=0.68) and 96% (r2=0.73) of femoral and tibial components. Cases beyond ±1 sizes did not have notable device-specific adverse events with Kaplan-Meier survivorship of 100% at five years.
Conclusion: Demographic models are an effective tool in component size prediction prior to TKA. This model has implications in reducing the need for preoperative radiographic templating, potentially resulting in increasing surgeon efficiency and possibly reducing hospital implant inventory. This may be particularly important for ambulatory or outpatient surgery centers.
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Surgical Treatment of Sacral Chordoma: En Bloc Resection with Negative Margins is a Determinant of the Long-Term Outcome
Simone Colangeli, MD, Surgeon, Antonio D’Arienzo, MD, Surgeon, Francesco Rosario Campo, MD, Surgeon, Rodolfo Capanna, MD, Director, Department of Orthopedic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, Francesco Muratori, MD, Surgeon, Leonardo Bettini, MD, Resident, Filippo Frenos, MD, Surgeon, Francesca Totti, MD, Resident, Guido Scoccianti, MD, Surgeon, Giovanni Beltrami, MD, Surgeon, Domenico Andrea Campanacci, MD, Director, Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
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Study Design: Retrospective case series.
Objective: To report the outcome of a series of patients with sacral chordoma who were surgically treated at a single center.
Summary: Chordomas are low-grade malignant tumors that arise from remnants of the notochord. They are most often found in the sacrum, spine and skull-base. These tumors have a slow clinical evolution and may eventually metastasize, even after adequate treatment. Rarely, they can dedifferentiate into high-grade sarcomas. Traditionally, chordomas were considered to be resistant to chemotherapy and standard radiation therapy. However, recently, adrotherapy has been shown to be effective for local and systemic control of the disease. In this study, clinical outcomes and local and systemic recurrence were reviewed to identify prognostic factors for local and systemic control.
Methods: Thirty-three patients with sacral chordoma (19 males, 14 females; median age 61 y, range 43-80) who were surgically treated at our institution between 1994 and 2015 were reviewed. In 24 patients, resection was performed above S2. No patients received pre-operative radiotherapy (RT). Three cases received RT (carbon ion therapy) as treatment for local recurrence. Wide (R0) surgical margins were achieved in 17 patients, marginal (R1) margins in 14 patients and intralesional (R2) margins in 2 patients.
Results: At a median follow-up of 53 months (range 0-198), 19 patients were continuously disease-free, 6 were disease-free after local recurrence (5) or metastases (1), 3 were alive with disease (2 local recurrence and 1 metastasis), 4 were dead of disease (1 patient died intraoperatively) and 1 was dead of another cause. Local recurrence was observed in 9 cases (27%); all 9 were treated surgically and 3 received carbon ion therapy after surgical intralesional excision. Overall survival at 10 years was 86.6%. Local recurrence-free survival at 10 years was 51%. A statistical analysis confirmed the importance of negative surgical margins (R0) to achieve local control of the disease (p = 0.0007). High resections (above S2) were associated with lower survival and higher risk of local recurrence.
Conclusion: Surgical en bloc resection is the primary treatment for sacral chordoma. Carbon ion therapy is used when it is difficult to obtain wide surgical margins. Due to morbidity and the disabling sequelae of surgery, adrotherapy may be considered an alternative to high (above S2-S3) sacral chordoma resections.
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