Houdek, Matthew T.

Abstract Background and Objectives The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity. Methods A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed. Results In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm 2 . The mean follow‐up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap‐related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months. Conclusion The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft‐tissue coverage as a one‐step solution for massive oncologic defects.

AbstractBackgroundLocal recurrence (LR) of sacral chordoma is a difficult problem and the mortality risk associated with LR remains poorly described. The purpose of this study was to evaluate the risk of mortality in patients with LR and determine if patient age is associated with mortality.MethodsA total of 218 patients (144 male, 69 female; mean age 59 ± 15 years) with sacrococcygeal chordomas were reviewed. Cumulative incidence functions and competing risks for death due to disease and nondisease mortality were employed to analyze mortality trends following LR.ResultsThe 10‐year overall survival (OS) was 55%. Patients with LR had 44% 10‐year OS, similar to patients without (59%; P = .38). The 10‐year OS between those less than 55 compared with ≥55 years were similar (69% vs 48%; P = .52). The 10‐year death due to disease was worse in patients with LR compared with those without (44% vs 84%; P < .001). In patients without LR, patients ≥55 years were 1.6‐fold more likely to experience death due to other causes.ConclusionsPatients with an LR are more likely to die due to disease. Advanced patient age was associated with higher all‐cause mortality following resection of sacral chordoma. LR of chordoma was associated with increased disease‐specific mortality, regardless of age.

Case: Two young adult (aged 25 and 21 years) patients presented with sarcomas of the proximal ulna. To achieve an oncological margin, the proximal ulna required resection. Owing to the complex biomechanics of the elbow joint, reconstructive options are limited and have a high complication rate. The elbow was reconstructed with a transposition of the radial neck to the trochlea of the humerus in both patients. At over 2 years of follow-up, both patients have a stable and functional elbow. Conclusions: Transposition of the radial neck to the trochlea of the humerus provides a biological reconstruction in this complex problem.

Abstract Background Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. Methods We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999–2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Results Forty-six patients underwent flap reconstruction following APRS—28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22–660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. Conclusion The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

Purpose. Previous studies have grouped the treatment of axial and appendicular synovial sarcomas. The purpose of this study was to assess the prognostic variables of upper extremity synovial sarcomas (UESS) and compare the outcomes of those who underwent a nononcologic or inadvertent excision prior to definitive resection to those who underwent an initial oncologic resection. Methods. We reviewed the records of 23 UESS treated with definitive surgery at our institution between 1990 and 2014. There were 13 women and 10 men with a median age of 30 years (6–60) and median follow-up of 63 months (15–248). Prognostic variables, recurrence-free survival (RFS), and overall survival (OS) were then assessed. Results. Fifteen patients (65%) had a prior unplanned excision. Five patients required an amputation to obtain local control of disease. There were 3 observed local recurrences and 2 distant metastases at a median of 45 months from presentation. We found no difference in need for amputation, RFS, or OS between those who had undergone a planned excision and those who had an unplanned excision. Conclusion. While we were unable to find a significant difference in outcomes or amputation rates between those who underwent reexcision of a previously unplanned excision and those who underwent an initial planned resection, the high rate of unplanned excision is troubling and should remind practitioners to consider sarcoma in the differential of all upper extremity masses.

AbstractBackgroundWe reviewed the disease control and complications of the treatment of sacrococcygeal chordoma from four tertiary cancer centers with emphasis on the effects of radiotherapy in surgically treated patients.MethodsA total of 193 patients with primary sacrococcygeal chordoma from 1990 to 2015 were reviewed. There were 124 males, with a mean age of 59 ± 15 years and a mean follow‐up of 7 ± 4 years. Eighty‐nine patients received radiotherapy with a mean total dose of 61.8 ± 10.9 Gy.ResultsThe 10‐year disease‐free and disease‐specific survival was 58% and 72%, respectively. Radiation was not associated with local recurrence (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.59‐2.17; P = 0.71), metastases (HR, 0.93; 95% CI, 0.45‐1.91; P = 0.85) or disease‐specific survival (HR, 0.96; 95% CI, 0.46‐2.00; P = 0.91). Higher doses (≥70 Gy; HR, 0.52; 95% CI, 0.20‐1.32; P = 0.17) may be associated with reduced local recurrence. Radiotherapy was associated with wound complications (HR, 2.76; 95% CI, 1.64‐4.82;, P < 0.001) and sacral stress fractures (HR, 4.73; 95% CI, 1.88‐14.38; P < 0.001).ConclusionsIn this multicenter review, radiotherapy was not associated with tumor outcome but associated with complications. The routine use of radiotherapy with en‐bloc resection of sacrococcygeal chordomas should be reconsidered in favor of a selective, individualized approach with a radiation dose of ≥70 Gy.

Aims Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98.

Restoration of shoulder lateral rotation remains a significant challenge following brachial plexus injury. Transfer of the accessory nerve to suprascapular nerve (SSN) has been widely performed, although with generally poor outcomes for lateral rotation. A recent report suggested a selective infraspinatus reinnervation technique using a radial nerve branch for SSN transfer. This cadaveric study was performed in 7 specimens (14 shoulders). We present technical modifications to achieve additional length to the recipient nerve (suprascapular) that would facilitate direct repair. Key elements of the technique are (1) isolation of the SSN immediately distal to its motor branch to supraspinatus near the superior transverse scapular ligament; and (2) delivery of the transected SSN through the spinoglenoid notch and deep to the infraspinatus for emergence in the infraspinatus‐teres minor interval. Nerve overlap of at least 21 mm was observed in all 14 dissected shoulders between the harvested SSN and radial nerve branches. The mean nerve overlap between harvested branches was 26 mm (range 21–32 mm). The mean harvested SSN length was 59 mm (range 46–80 mm). The mean length of the harvested radial nerve branch was 72 mm (range 65–85 mm). No measurements were significantly different between left and right shoulders or between males and females (smallest P value = 0.1249). Nerve diameter of the two harvested branches was judged to be appropriately compatible for surgical coaptation in all 14 dissected shoulders. We present a variation on a described technique to increase recipient suprascapular nerve length. Additional length of the recipient nerve is achieved through utilization of a more proximal dissection of the suprascapular nerve near the level of the superior transverse scapular ligament and delivering the nerve through the teres minor‐infraspinatus interval. These surgical modifications are of clinical interest when selective reinnervation of the infraspinatus muscle is considered. We believe such a targeted approach can potentially increase shoulder lateral rotation function. Clin. Anat. 32:131–136, 2019. © 2018 Wiley Periodicals, Inc.