A preliminary evaluation of limb salvage surgery for osteosarcoma around knee joint

Objective

To evaluate the effectiveness and drawbacks of diversified procedures of limb salvage surgery (LSS), providing a reference of rational surgical criterion of LSS.

Methods

Fifty eight patients with stage IIB extremity osteosarcoma around knee joint area between 1992 and 2002 were studied retrospectively. Among them, 43 patients were treated by LSS followed by reconstruction. Reconstruction approaches included re-implantation of irradiation-devitalized tumor bone (n = 12), autoclaving-devitalized tumor bone (n = 8), prosthetic replacement (n = 11), allograft transplantation (n = 8) and vascularized fibula autograft implantation (n = 4). Amputations were performed in 15 patients. Patients were followed up for 6–16 years.

Results

There were no significant difference between LSS and amputation groups regarding disease free survival and local recurrence rates. The actuarial 5-year continuous disease free survival and local recurrence rate were 30.0% and 25.0% in patients of devitalized LSS group, whereas those were 56.5% and 8.7% in patients of non-devitalized reconstruction group. The complication rate was significantly higher in LSS group compared to amputation group (P = 0.003).

Conclusion

LSS with non-devitalized procedures is the optimal treatment for osteosarcoma around knee joint area. Prosthesis implantation is the preferred option for bone reconstruction following LSS. Prevention and treatment of post-operative complications should be paid more attention to get good long-term outcomes of surgery.     

Magnetic resonance imaging in the diagnosis of knee joint sarcomas

The purpose of the investigation was to study the potentialities of magnetic resonance imaging (MRI) in the diagnosis of knee joint sarcomas. The paper presents the results of examining 13 patients of different age, shows the potentialities of the technique in the identification of knee joint sarcomas, and describes the MRI semiotics of sarcomas in both the routine study and that using contrast enhancement in lesions of bone and soft tissue elements in the presence of regional metastases.     

Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee-four cases in the posterior region and three cases in the anterior region-were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects.     

Prefabricated superficial temporal fascia flap combined with a submental flap in noma surgery

The authors report their experience with a new procedure: the combination of a prefabricated superficial temporal fascia flap and a submental flap performed in an African hospital on five patients with cheek deformities caused by noma. The prefabricated superficial temporal fascia flap makes the inner lining of the cheek, which is anchored on the peripheral scar tissue. The submental flap is released during the second operation and makes the outer lining. The main advantages are the excellent aesthetic color of this last flap and the short distance between the donor site and the recipient site. Moreover, the submental flap is positioned in a single operation (when the outer-lining reconstruction is performed with a deltopectoralis flap, a third operation is necessary to cut the pedicle). None of the flaps failed, and the functional results were good. The prefabricated superficial temporal fascia flap and submental flap are versatile and reliable flaps, with reasonably long vascular pedicles, that can be used successfully, even under suboptimal conditions in weak patients with huge defects of the face.     

A New Approach to Assess the Gastrocnemius Muscle Volume in Rodents Using Ultrasound; Comparison with the Gastrocnemius Muscle Index

Introduction

The purpose of this study was to determine the reliability and validity of a new non-invasive ultrasound technique to measure gastrocnemius muscle atrophy after nerve denervation in an animal model.

Methods

In sixteen rodents an eight mm sciatic nerve gap was created. In the following 8 weeks, each week, two rodents were euthanized and the gastrocnemius muscle was examined using two different ultrasound systems and two investigators. The standardized ultrasound measurement protocol consisted of identifying pre-defined anatomical landmarks: 1) the fibula, 2) the fibular nerve, and 3) the junction between the most distal point of the semitendinosus muscle and gastrocnemius muscle. Consequently, we measured the muscle thickness as the length of the line between the fibula and the junction between the two muscles, perpendicular to the fibular nerve. After the ultrasound recording, the muscle mass was determined.

Results

A steep decline of muscle weight of 24% was observed after one week. In the following weeks, the weight further decreased and then remained stable from 6 weeks onwards, resulting in a maximal muscle weight decrease of 82%. The correlation coefficient was >0.96 between muscle diameter and weight using both ultrasound systems. The inter-rater reliability was excellent for both devices on the operated side (ICC of 0.99 for both ultrasound systems) and good for the non-operated site (ICC’s: 0.84 & 0.89). The difference between the muscle mass ratio and the muscle thickness ratio was not more than 5% with two outliers of approximately 13%.

Discussion

We have developed an innovative, highly reliable technique for quantifying muscle atrophy after nerve injury. This technique allows serial measurements in the same animal over time. This is a significant advantage compared to the conventional technique for quantifying muscle atrophy, which requires sacrificing the animal.     

Dose-intensive chemotherapy with stem cell support as a treatment strategy for bone and soft-tissue sarcomas

Whether high-dose chemotherapy with stem cell support improves the long-term outcome for patients with bone and soft-tissue sarcoma is debatable and controversial. Prognosis of patients with unresectable or advanced metastatic sarcoma remains poor with a disease-free survival at 5 years less than 10%; treatment is generally considered to be palliative. Doxorubicin, epirubicin and ifosfamide are the most active single agents with response rates above 20%. Although drug combinations result in higher response rates, superiority against single agent chemotherapy in terms of survival could not have been demonstrated yet. As a dose-response relationship has been shown for the anthracyclines and especially for ifosfamide, high-dose chemotherapy with stem cell support has been evaluated by several investigators. However, all studies were not randomized, comprised small patient numbers and included heterogeneous histological subtypes of soft-tissue sarcomas. Nevertheless, higher doses of chemotherapy result in higher remission rates, which could correlate with longer survival. Well-designed randomized trials should be performed. In this review article, we overview the literature and on the basis of our own data we emphasize the value of high-dose chemotherapy as a treatment option for younger patients with a good performance status in complete or partial remission prior to high-dose chemotherapy.     

The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle

The extensor digitorum brevis muscle flap, which has already been suggested as a local flap for the foot, has been applied by us in 2 cases with excellent results. This flap, as with other muscle flaps, provides an excellent bed for the skin graft. Furthermore, because of its width, it allows for covering an area of skin loss 5 X 7 cm in size in areas that are difficult to cover by other reconstructive means. The arch of rotation of this flap allows for coverage of the lateromedial and posterior surfaces of the ankle with no functional loss at the donor site. The relative ease of elevating this flap presents a reasonable justification for its wider application as a single local procedure for skin problems around the ankle.     

Distally based vastus lateralis muscle flap for coverage of wounds about the knee

The blood supply to the vastus lateralis muscle has been evaluated by dye injection techniques in fresh cadaver dissections. The main dominant blood supply is the descending branch of the lateral femoral circumflex artery. Vascular contributions from distal perforators of the superficial femoral artery, the superior geniculate artery, fill the main vascular pedicle in a retrograde fashion. Latex staining is observed consistently in the proximal third of the muscle. Five patients are presented in whom the distally based vastus lateralis muscle flap was successfully used to cover defects above the knee. Superficial muscle necrosis is a complication of this operation but has not precluded its usefulness. It is anticipated that this flap will be useful in the armamentarium of reconstructive surgeons treating such problematic patients.