Faculty Bibliography

BACKGROUND: A type III hemipelvectomy has been utilized for the resection of tumors arising from the superior or inferior pubic rami. METHODS: In eight patients, we incorporated a type III internal hemipelvectomy to achieve an en bloc R0 resection for tumors extending through the obturator foramen or into the ischiorectal fossa. The pelvic ring was reconstructed utilizing marlex mesh. This allowed for pelvic stability and abdominal wall reconstruction with obliteration of the obturator space to prevent herniations. RESULTS: All eight patients had an R0 resection with an overall survival of 88% and with average follow up of 9.5 years. Functional evaluation utilizing the Enneking classification system, which evaluates motion, pain, stability and strength of the affected extremity, revealed a 62% excellent result and a 37% good result. No significant complications were associated with the operative procedure. Marlex mesh reconstruction provided pelvic stability and eliminated all hernial defects. CONCLUSION: The superior and inferior pubic rami provide a barrier to a resection for tumors that arise in the extra-peritoneal pelvis extending through the obturator foramen or ischiorectal fossa. Incorporating a type III internal hemipelvectomy with a simple marlex mesh reconstruction allows for complete tumor resection without functional compromise, acute infectious issues, obturator or abdominal hernia defects.

With the advent of anterior lumbar interbody fusion (ALIF) and artificial discs as common procedures for the treatment many spinal problems such as pseudoarthrosis, degenerative disc disease and internal disc disruption from trauma, anterior exposure has become an increasingly popular procedure for the general, thoracic, urologic and vascular surgeon. Despite this, the body of literature describing this procedure is lacking. Dividing the approach for anterior spinal surgery into the thoracolumbar, mid-lumbar, and lumbosacral regions, we describe the basic techniques and anatomy needed to perform these open approaches, specifically, repairs of disc spaces T12-L2, L2-5, and L5-S1, respectively. The technique for the retroperitoneal approach will be discussed in detail; however, issues involved with indications for transperitoneal approach and technical 'pearls' will also be discussed

STUDY DESIGN: The results of short anterior rigid rod instrumentation used to treat thoracolumbar scoliosis in 24 patients were reviewed retrospectively. OBJECTIVE: To assess the safety and efficiency of anterior correction of thoracolumbar scoliosis using a single rigid rod with segmental fixation. SUMMARY OF BACKGROUND DATA: This method of treatment results from the historical difficulties noted in obtaining adequate correction in both planes for this particular type of curve while saving as many segments as possible. This approach seems to combine the advantages and avoid the limitations of posterior segmental and previous anterior segmental techniques. METHODS: For this study, 24 patients with thoracolumbar scoliosis underwent anterior spinal correction and fusion using a single rigid rod and segmental fixation. Additionally, in five patients, this construct was supplemented by interbody titanium cages. The patients were assessed for the amount of correction obtained in the main curve, and for the spontaneous correction of the compensatory curves above and below. Trunk balance was measured on standing radiographs. The average age of the patients was 17.3 years (range, 10-43 years), and the average follow-up period was 3.6 years (range, 2-4.5 years). RESULTS: Correction of the major curve at follow-up assessment was 54%, with a 73% correction of the instrumented area. The upper compensatory curve showed a 21% correction, and the lower curve a 59% correction. Over the duration of the follow-up period, the instrumented area showed kyphosis progression of 6.5 degrees. The five patients who had insertion of Harms cages tended to have a lower rate of correction. The average number of intervertebral mobile segments fused was 2.9 (range, 2-5 segments). No intraoperative complication occurred in relation to the anterior approach. A temporary sympathectomy effect on the side of the approach was noted in most patients. Two radiologic pseudarthrosis and one loss of fixation at the top of the construct were observed. CONCLUSIONS: Anterior correction and fusion using solid rod instrumentation constitute effective and safe treatment of thoracolumbar scoliosis. As compared with posterior systems, it provides correction and rebalance of the trunk through a shorter fusion segment.

Autolymphocyte therapy (ALT) is tumor-specific, adoptive cellular therapy of neoplastic disease using nonspecific ex vivo activation of autologous peripheral blood lymphocytes (PBL), which are composed primarily of memory T-cells (ALT-cells) and are active in patients with metastatic renal cell carcinoma and melanoma. Ex vivo pretreatment of tumor target cells with certain chemotherapeutic agents can enhance susceptibility to lysis by antitumor lymphocytes. To determine if cis-diamminedichloroplatinum(II) (CDDP) enhances ex vivo antitumor cytotoxicity of ALT-cells and if this lysis is mediated by T- and/or NK-cells and is human leukocyte antigen (HLA)-restricted, human soft tissue sarcoma (STS) target cells were derived from primary and metastatic surgical specimens and were incubated with and without CDDP. ALT-cells were prepared from autologous PBL obtained prior to surgery. Primary (PSTS) and metastatic (MSTS) target cells from each group were labelled with chromium 51 (51Cr) and used as targets for ALT-cells, CD45-depleted ALT-cells, CD56 (NK)-depleted ALT-cells, and PBL in a standard (4-hour) and delayed (18-hour) 51Cr release assay. Interferon-gamma (IFN-gamma) release was measured as an indication of antitumor effect and recognition by the noncytolytic lymphocytes in ALT-cells. Primary tumor target cells incubated in CDDP showed enhanced lysis as measured by the 51Cr release assay compared to non-CDDP-treated controls. Metastatic tumor target cells showed less lysis than the primary targets, although this was enhanced by pretreating metastatic tumor targets with CDDP. Lysis of all tumor targets was significantly greater when ALT-cells were used as the effector cells rather than PBL. Depletion of memory T-cells abrogated ex vivo lysis. Depletion of NK cells (CD56+) affected ex vivo lysis of autologous targets during the 4-hour but not the 18-hour assay. Ex vivo ALT-cell lysis and IFN-gamma release against only the autologous tumor targets confirmed tumor-specificity in one patient. Restriction of ALT-cell lysis and IFN-gamma release against HLA-A2+ autologous and one allogeneic HLA-A2+ STS tumor target, but not other non-STS targets, was demonstrated in another patient. These data suggest that CDDP may help render STS susceptible to tumor-specific, immune-mediated attack and that the combination of ALT and CDDP may lead to effective tumor-specific chemoimmunotherapy in patients with metastatic STS.

This paper reports on a case of hip joint sepsis complicated by a ruptured appendix in an intravenous drug user. A 41-year-old woman underwent open irrigation and debridement of her right hip joint for a methicillin-sensitive Staphylococcus aureus infection. Five days later the patient developed an intraperitoneal mass, requiring laparotomy and debridement of a periappendiceal abscess. The organisms infecting the abscess were different from those infecting the patient's hip. The patient recovered satisfactorily after 6 weeks of intravenous antibiotic therapy.

Fracture of the anterior iliac crest following bone grafting is an extremely rare occurrence. Five cases have been reported in the literature, none of which were internally stabilized. We are reporting a sixth case. Of the six cases, our harvest site is the furthest posterior from the anterior superior iliac spine. The fracture resulted in a large displaced anterior fragment that required open reduction and internal fixation with plates and screws. Osteoporosis increases the risk of anterior iliac crest fractures following bone grafting, but preventive procedures can be performed

A retrospective study was undertaken to characterize and compare the perioperative course of 91 cases of one- and two-stage combined anterior and posterior spinal fusions over a 7-year period. The two patient populations were similar regarding preoperative characteristics and the number of levels fused. Significantly decreased operative and anesthesia time, operative blood loss, and postoperative hospital days were seen in the one-stage population compared to the two-stage cases (P < 0.05). For the spinal deformity subgroup, a longer chest-tube duration, decreased anesthesia time, and decreased postoperative hospital stay in the one-stage group were the only significant differences. Surgical treatment delays were noted in 8% of one-stage cases and in 23% of two-stage cases. Complications occurred in 53% of all cases, with a significantly higher major complication rate in patients with preoperative medical comorbidities who underwent two-stage combined fusion versus one-stage reconstruction. Higher complication rates were also associated with an age greater than 40 years, the presence of medical comorbidities, and cases treated with a thoracoabdominal anterior approach.

Thrombotic occlusion of the left common iliac artery occurred in a 59-year-old man after an anterior and posterior spinal fusion. Preoperatively, the patient was known to have peripheral vascular disease. Symptoms of an L4-5 radiculopathy were noted postoperatively. After an iliac-iliac bypass, the symptoms completely resolved. Retraction of the vessels during the anterior retroperitoneal approach was the presumed cause. To the authors' knowledge, this is the first report of a thrombotic occlusion developing in a patient after an anterior retroperitoneal approach to the lumbar spine. It is their hope that through an increased awareness similar complication will be prevented.

Limb-sparing surgery has proven to be a feasible alternative to amputation for treatment of malignant tumors about the knee. Microvascular surgery and the possibility of providing healthy, stable soft-tissue coverage to the affected limb have expanded the possible role of limb-sparing techniques. Microvascular free flaps were utilized in 26 patients undergoing resection for large malignant tumors of the knee or adjacent to the knee. Patients were then followed for a minimum of 3 years to a maximum of 7 years and evaluated for tumor recurrence and limb function. Survival and disease-free interval were 68 and 77 percent, respectively, in stage II patients and only 50 and 0 percent, respectively, in stage III patients. Function, as determined by the MSTS functional evaluation system, was found to be fair to good in all patients. Microvascular free-tissue transfer has proven to be a valuable adjunct in limb-sparing surgery